Med Surge II Ch. 51, 62, 63
An unstable fracture of the ankle is diagnosed on radiographic assessment. Which statement by the nurse indicates adequate understanding of the principles of casting?
"Long-leg cast will be applied to immobilize the fracture." Rationale: Long-leg cast (LLC) is employed for unstable fractures of the ankle. Short-leg cast (SLC) is employed for fractures of the ankle, metatarsals, and foot. Leg cylinder cast is employed for stable fractures of the tibia, fibula, and knee. Long-leg cylinder cast is employed for stable fractures of the distal femur, proximal tibia, and knee.
The nurse is teaching a patient about thyroid replacement therapy. Which statement by the patient indicates a need for further teaching?
"If I continue to lose weight, I may need an increased dose." Rationale: Weight loss indicates a need for a decreased dose, not an increased dose. One of the symptoms of hypothyroidism is lack of energy; thyroid replacement therapy should help the patient have more energy. The correct time to take thyroid replacement therapy is in the morning. If the patient is gaining weight and continues to feel tired, that is an indication that the dose may need to be increased.
The nurse is educating a group of people at a community center about emergency care for physical trauma. What does the nurse teach this group? Select all that apply.
1. Call 911 and assess ABCs 2. Cut the clothing over the affected area 3. Remove jewelry on affected extremity 4. Immobilize extremity Rationale: The group should be instructed to first call 911 and then assess the injured person for the presence of adequate airway, breathing, and circulation. In an emergency, it is more important to provide lifesaving care before caring for the fracture. The clothing over the affected area should be cut or removed to inspect the area for the extent of damage and to check for bleeding. Jewelry on the affected extremity should be removed in case of swelling. The upper and lower end of the injury should be supported and splinted to immobilize the extremity. The person's shoes must not be taken off; it may add to the trauma.
Bleeding after thyroidectomy can cause: Select all that apply (there are 5 correct answers).
1. Difficulty swallowing 2. An increase in bleeding at the anterior of a client's neck dressing 3. An increase in bleeding at the posterior of a client's neck dressing 4. A tightening of the skin on the neck when a surgical adhesive is used as a wound closure 5. Changes in the client's voice
Thyroidectomy complication preventions
1. Head and neck support when she is resting in bed or a chair 2. Incentive spirometry 3. Use SCDs
Potential complications of thyroidectomy include which of the following? Select all that apply.
1. Hemorrhage 2. Thyroid crisis (from stimulation during surgery) 3. Respiratory obstruction 4. Laryngeal nerve damage *shouldn't talk after procedure *keep trach stuff available
Which of the following statements are true about the use of radioactive iodine (iodine 131) for treatment of hyperthyroidism? Select all that apply.
1. Hypothyroidism frequently occurs after treatment 2. In doses commonly used to treat hyperthyroidism, I-131 does not increase risk for cancer 3. Pregnancy and breastfeeding are contraindications to radioactive iodine treatment 4. Treatment with antithyroid drugs, such as PTU or Methimazole, are usually required before treatment with radioactive iodine ( to reduce risk for thyrotoxic crisis) ***this is given orally, NOT IV.
Lugol's solution
1. Is an iodide preparation 2. Inhibits production of thyroid hormones 3. Shrinks thyroid tissue 4. Reduces circulation through the thyroid gland 5 drops a day for 10 days
Fosamax, an osteoporosis medication...
1. Is better absorbed on an empty stomach 2. Need to sit up 30 min after taking to prevent esophageal irritation and heartburn
What statements about amputation are correct? Select all that apply.
1. Lower extremity amputations are more common than upper 2. In a Syme amputation, most of the foot is removed but the ankle remains 3. Lisfranc and Chopart amputations are types of mid foot amputations Rationale: Lower extremity amputations are performed more frequently than upper extremity amputations. In the Syme amputation, most of the foot is removed but the ankle remains. Lisfranc and Chopart amputations are types of midfoot amputations. Traumatic amputations usually result from accidents and are often upper extremity amputations. Lower extremity amputations are more common in black and Hispanic populations due to the high incidence of diabetes and arteriosclerosis.
Even at rest, Mrs. Schneider's heart rate is above 100 and she says she 'hears'' her heart beating. What should you advise Mrs. Schneider to do about her heart rate? Select all that apply.
1. Plan activities around heart rate (avoid straining) 2. Monitor her heart rate to see how well the drugs are working 3. As the thyroid gland returns to normal functioning, heart rate will return to normal
Which statements are true regarding the various types of casting materials for immobilization? Select all that apply.
1. Plaster is not commonly used for casting 2. Fiberglass can become rigid and dry within minutes Rationale: Plaster is the traditional material used for casting but is not as commonly used today for management of most fractures. Fiberglass can dry and become rigid within minutes and does not increase the risk of skin breakdown but instead decreases that risk. Fiberglass is the most common material used for casting.
The nurse is assessing a patient with a parathyroid disorder. Which laboratory values would be associated with a diagnosis of hypoparathyroidism? Select all that apply.
1. Serum magnesium of 1.0 2. Serum phosphorous of 6.5 3. Urine cyclic adenosine monophosphate (cAMP) level of 17 nmol/L Rationale: A normal serum magnesium level is 1.3 to 2.1 mEq/L; this level is decreased in patients with hypoparathyroidism. A normal serum phosphorus level lies between 3.0 to 4.5 mg/dL; this level is increased in patients with hypoparathyroidism. Normal urine cAMP level is between 18.3 to 45.4 nmol/L; this level would be decreased in patients with hypoparathyroidism. Thus a urine cAMP level of 17 nmol/L, serum magnesium level of 1 mEq/L, and serum phosphorus level of 6.5 mg/dL help diagnose hypoparathyroidism. The patient's serum calcium and serum parathyroid hormone levels are within the normal range of 9.0 to 10.5 mg/dL and 10 to 65 pg/mL respectively.
Arrange the following nursing actions pertaining to the emergency care of a patient who experiences fracture in the correct sequence.
1. assess airway 2. administer CPR if necessary 3. deal with bleeding 4. manage pain
What is the sequence of events, in their order of occurrence, pertaining to the action of the drug Cinacalcet?
1. binds to calcium sensitive receptors 2. reduces PTH production 3. lowered serum calcium 4. decreases the progression of PTH induced bone complications Rationale: Cinacalcet is the drug of choice to treat hyperparathyroidism. Cinacalcet binds to the calcium sensitive receptors and reduces the parathyroid hormone production. Decreased parathyroid hormone levels result in lowered serum calcium, which decreases the progression of parathyroid hormone induced bone complications.
Push residual limb against a hard surface to strengthen it every...
2 hours It MUST be a cone shape for prosthetics to fit *Stump, the tree, and other jokes mean coping
Grave's Disease Info
7-10x more common in women Autoimmune hyperthyroidism Occurs after puberty, pregnancy, or ages 30s-50s Waxy skin Tachycardia, palpitations, diarrhea, weight loss, anxiety, fatigue
A patient has undergone an elective below-knee amputation of the right leg as a result of severe peripheral vascular disease. In postoperative care teaching, the nurse instructs the patient to notify the health care provider if which change occurs?
A large amount of serosanguineous or bloody drainage Rationale: this may indicate hemorrhage or, if an incision is present, that the incision has opened. This requires immediate attention. Mild to moderate pain controlled with prescribed analgesics would be a normal finding for this patient. Absence of erythema and tenderness of the surgical site would also be normal findings for this patient. The patient should be able to flex and extend the right knee (limb) after surgery.
The nurse is assigned the following four patients. Which patient should the nurse see first?
A patient diagnosed w/ Conn's syndrome w/ a blood pressure of 210/106 and tremors
The nurse is assigned the following four patients. Which patient should the nurse see first???
A patient diagnosed with Addison's disease with a potassium level of 6.0 and a sodium level of 127 Rationale: The patient with Addison's disease is likely experiencing Addisonian crisis becasue the potassium level is extremely high and sodium level is very low. Both imbalances can lead to cardiac dysrhythmias. The patient who just returned from a CT scan can be seen initially by an unlicensed assistive personnel (UAP) for vital signs. The patient with hyperaldosteronism has an elevated blood pressure and should be seen but is not critical so is not priority. Metyrapone can be administered after the patient with Addison's disease is assessed and treated.
The nurse is reviewing the laboratory reports of a patient with hypercortisolism. Which finding should the nurse report immediately to the primary health care provider?
A serum sodium level increase from 138 to 154 Rationale: An increased level of sodium in the blood is seen in patients with hypercortisolism. If left untreated, this increase results in life-threatening problems such as renal failure; therefore, the nurse notifies the primary health care provider immediately to prevent further complications. An increase in a patient's serum cortisol level from 10 mcg/dL to 23 mcg/dL is within normal limits. A decrease in a patient's serum calcium level from 10.5 mg/dL to 9 mg/dL is within normal limits. The serum potassium level is normally low in patients with hypercortisolism and the given range is within normal limits; therefore, the nurse would not inform the primary health care provider.
Thyrotoxic crisis (thyroid storm)
A sudden, severe, increase in signs and symptoms associated with thyrotoxicosis - generally occurs in untreated or un-compliant patients Thyrotoxic crisis can also be triggered by stress or onset of infection. **Dehydration and extreme tachycardia** **Atrial dysrhythmia and heart failure**
A patient with a pelvic fracture is advised to undergo external fixation. Which part of the pelvis might have been involved in the fracture?
Acetabulum Rationale: A fractured acetabulum can be classified as a weight-bearing fracture, necessitating external fixation. A fractured fibula, iliac crest, and pubic rami fall are non-weight-bearing fractures and external fixation is not recommended.
Which bone fracture complication is also known as ischemia-edema cycle?
Acute compartment syndrome (ACS) Rationale: this is is a serious condition in which increased pressure within one or more compartments reduces circulation to the area. ACS is also called ischemia-edema cycle. Crush syndrome, fat embolism syndrome, and venous thromboembolism are complications of bone fractures, but ACS is the only complication called ischemia-edema cycle.
A patient presents to the emergency department with a history of adrenal insufficiency. The following laboratory values are obtained: Na 130 mEq/L, K 5.6 mEq/L, and glucose 72 mg/dL. Which is the first request that the nurse anticipates?
Administer insulin and dextrose in normal saline to shift potassium into cells Rationale: This patient is hyperkalemic. The nurse should anticipate a request to administer 20-50 units of insulin with 20-50 mg of dextrose in normal saline as an IV infusion to shift potassium into the cells. Spironolactone is a potassium-sparing diuretic that helps the body keep potassium, which the patient does not need. Although H2blocker therapy would be appropriate for this patient, it is not the first priority. Arterial blood gases are not used to assess for peaked T waves associated with hyperkalemia; an electrocardiogram (ECG) needs to be obtained instead.
Pathophysiology of Grave's Disease
An autoimmune process causes an abnormal thyroid-stimulator to affect the thyroid gland, increasing secretion of T3 and T4. TSH secretion is inhibited. This process is thought to be an autoimmune, familial disorder. Three forms of treatment to reduce hormone synthesis: radioactive iodine, antithyroid drugs, and a subtotal thyroidectomy
The nurse is caring for a patient who underwent kyphoplasty. Which nursing intervention is beneficial to the patient?
Applying ice pack to the insertion site Rationale: The nurse should apply an ice pack to the insertion site to relieve pain in patients who have undergone kyphoplasty. Monitoring the vital signs of the patient, discontinuing anticoagulant drugs, and assessing the patient's ability to lie prone for at least 1 hour are preoperative nursing interventions for the patient who is about to undergo kyphoplasty.
Elevating amputated limb on a pillow
Appropriate for the first 24 hours to reduce pain and edema NOT appropriate after 24 hours due to flexion contractors *Putting patients on their stomachs 2-3x a day prevents contractures
Lots of red drainage on amputation dressing
Assess BP and pulse If his BP is low and he's difficult to arouse, place a tourniquet
The nurse is caring for a patient who is diagnosed with adrenal insufficiency. The patient has the following lab results: potassium 5.9 mEq/dL, sodium 128 mEq/dL, and calcium 8.0 mg/dL. The patient reports palpitations. What action by the nurse is priority?
Assess cardiac rhythm Rationale: might be indicative of a dysrhythmia
The nurse prepares to perform a neurovascular assessment on a patient with closed multiple fractures of the right humerus. Which technique does the nurse use?
Assess sensation of the right upper extremity
The nurse reviews the vital signs of a patient diagnosed with Graves' disease and sees that the patient's temperature is up to 99.6° F. After notifying the health care provider, what does the nurse do next?
Assesses the patient's cardiac status completely Rationale: If the patient's temperature has increased by even one degree, the nurse's first action is to notify the provider. Continuous cardiac monitoring should be the next step. Administering a nonsalicylate antipyretic like acetaminophen is appropriate, but is not a priority action for this patient. Alerting the Rapid Response Team is not needed at this time. Asking visitors to leave would not be the next action, and if visitors are providing comfort to the patient, this would be contraindicated.
Through radiographic analysis of a patient, the primary health care provider confirms a displaced fracture of the femoral neck. Which complication should the nurse monitor for in the patient?
Avascular necrosis (AVN) Rationale: The disruption of blood supply in the area of the femoral neck can lead to ischemic or avascular necrosis (AVN) of the femoral head. AVN causes death and necrosis of the bone tissue, resulting in pain and decreased mobility. This condition is most common in patients with displaced fractures. Venous oozing is seen in pelvic fractures. Delayed union is most commonly seen in tib-fib fractures. Patients with chest trauma have an increased risk of puncture of the vital organs.
A patient diagnosed with hypothyroidism has been prescribed hormone replacement therapy. What does the nurse teach the patient about this therapy?
Avoid taking OTC drugs Rationale: The patient with hypothyroidism taking hormone replacement therapy should avoid OTC drugs because thyroid hormone preparations interact with many other drugs. The patient must assess sleep and bowel patterns for therapy effectiveness; when the patient requires more sleep and is constipated, the dosage may be increased. When the patient has difficulty getting to sleep and has more bowel movements than normal, the dose may be decreased. Hormone therapy is taken on an empty stomach. The patient must eat a well-balanced diet with adequate diet and fiber intake to prevent constipation; however, fiber supplements may interfere with the absorption of thyroid hormones
Increased risk for osteoporosis
BMI of 19 Excessive alcohol use Estrogen deficiency *Many people don't have symptoms *Walk at least 5x a week
Stress the important of reporting _____________ with osteoporosis
Bone pain (altered calcium)
The nurse admits an older adult patient who sustained a left hip fracture and is in considerable pain. The nurse anticipates that the patient will be placed in which type of traction?
Buck's traction Rationale: Buck's traction may be applied before surgery to help decrease pain associated with muscle spasm. Balanced skin traction is indicated for fracture of the femur or pelvis. Overhead traction is indicated for fracture of the humerus with or without involvement of the shoulder and clavicle. Plaster traction is indicated for wrist fracture.
While assessing a patient's bone fracture, the nurse finds that the fracture features a break across the entire width of the bone. The broken bone also extends through the skin. Which type of fracture does the nurse recognize?
Complete and open
A patient who had an ankle open reduction complains of intense, burning pain. The primary health care provider instructs the nurse to intravenously administer phentolamine. What condition is the health care team likely treating?
CRPS Rationale: A patient with CRPS may require a chemical sympathetic nerve block. This procedure can be done by an IV (intravenous) infusion of phentolamine, a drug that blocks sympathetic receptors. Phentolamine is not the drug of choice for managing CTS, FES, or ACS.
The nurse is caring for a patient after a fracture. Which complication of fractures manifests as a clinical triad of sensory perception abnormalities, motor dysfunction such as paresis and muscle spasm, and autonomic nervous system abnormalities?
CRPS Rationale: CRPS is a painful condition and includes a triad of sensory, motor, and autonomic abnormalities. CTS is a condition in which the median nerve in the wrist becomes compressed, causing pain and numbness. FES involves the release of fat globules from the yellow bone marrow into the bloodstream. These fat globules may get stuck in small blood vessels and block the blood flow. ACS is characterized by an increased pressure within one or more compartments, compromising the circulation to the areas distal to it.
Which complication of fractures can be treated with minimally invasive surgical sympathectomy?
CRPS Rationale: In patients with CRPS, minimally invasive surgical sympathectomy, or cutting of the sympathetic nerve branches via endoscopy through a small axillary incision, may be required. It is a pain management modality. Minimally invasive surgical sympathectomy is not indicated in CTS, FES, or ACS.
Grave's Disease
Cause of HYPERthyroidism, resulting in thyrotoxicosis. Other common causes of thyrotoxicosis include toxic goiter (more common in older persons), and thyroiditis (of autoimmune or viral etiology). *Blood is drawn for TSH (thyroid-stimulating hormone), free T4 (thyroxine), free T3 (triiodothyronine), and thyroid antibodies. A radioactive iodine uptake (RAIU) with thyroid scan is scheduled. No special precautions are needed after RAIU.
Glucocorticoids/corticosteroids, such as Prednisone
Cause osteoporosis over a prolonged time
A patient has had surgery for carpal tunnel syndrome (CTS). What does the nurse teach the patient before discharge?
Check neuromuscular status of the fingers every hour Rationale: The patient should be instructed to check the neurovascular status of the fingers every hour during the immediate postoperative period, and should be encouraged to move them frequently. This includes sensation, movement, temperature, color, and pain. Hand movements, including lifting heavy objects, may be restricted for 4 to 6 weeks after the surgery. If an NSAID is prescribed, it should be taken with or after meals to reduce gastric irritation. The affected arm must be elevated above the heart level for several days to reduce postoperative swelling.
A patient reports a history of wrist pain after an attempt to break a fall by landing on the heel of the hand with an extended wrist. Which type of fracture should the nurse suspect?
Colles' fracture Rationale: A Colles' fracture, or "dinner fork" injury, commonly occurs when a person attempts to break a fall by landing on the heel of the hand when the wrist is extended. Phalangeal, metacarpal, and proximal humerus fractures do not involve wrist fractures.
Which syndrome is described as a dysfunction of the central and peripheral nervous systems, leading to severe chronic pain?
Complex regional pain syndrome (CRPS) Rationale: CRPS is a dysfunction of the central and peripheral nervous systems that leads to severe, chronic pain. Carpal tunnel syndrome is a condition in which the median nerve in the wrist becomes compressed causing pain and numbness. In FES, fat globules are released from the yellow bone marrow into the bloodstream and block the flow of blood. Compartments are areas in the body in which muscles, blood vessels, and nerves are contained within fascia. In ACS, there is an increased pressure within one or more compartments, which in turn reduces circulation to that area.
Which complication resulting from a fracture might necessitate the use of an implanted device to block pain perception?
Complex regional pain syndrome (CRPS) Rationale: Pain in patients with CRPS can be managed by peripheral or spinal cord neurostimulation using an external or internal implanted device that delivers electrical pulses to block pain from reaching the brain. This actually blocks the pain perception. CTS, FES, and ACS are not managed with an implanted device to block the pain perception.
A patient with a fracture asks the nurse about the difference between a compound fracture and a simple fracture. Which statement by the nurse is correct?
Compound fracture involves a break in the bone, with damage to the skin Rationale: *also, a simple fracture does not extend through the skin whereas a compound fracture is accompanied by damage to blood vessels
What assessment finding indicates a possibility of hyperthyroidism in a patient?
Considerable loss of weight without dieting
Symptom of hypothyroidism
Decreased cardiac output
Which finding does the nurse identify as contributing to the potential for infection in the patient with hypercortisolism?
Decreased lymphocyte count Rationale: Excess cortisol reduces the number of circulating lymphocytes and increases the risk for infection. The patient should restrict sodium intake because of increased serum sodium levels to prevent fluid overload. Glucose metabolism is disturbed by hypercortisolism and the patient's fasting blood glucose is increased. The patient also has decreased serum potassium level. Dysrhythmias can occur from potassium imbalance.
High levels of T3, T4
Difficulty climbing stairs Diaphoresis Hyperactive bowel sounds Tremors Enlargement of thyroid
Which is the most commonly occurring upper extremity fracture?
Distal radius fracture (DRF) Rationale: A distal radius fracture (DRF) is the most common upper extremity fracture. Younger adults experience this injury from high energy (high-impact) trauma as a result of motor vehicle crashes and sports. Older adults, particularly women with osteopenia, typically have low-impact DRFs as a result of falls. Phalangeal, metacarpal, and proximal humerus fractures are not as common as DRF.
Patient needs to report ____________ when taking propanolol
Dizziness, which could be hypotension
Ask _________ to evaluate patient's comfort with movement
Do you feel safer walking when using crutches?
DXA or DEXA
Doesn't use iodine or dyes
During RAI therapy,
Drink lots of fluids. Teach that hypothyroidism may be a long term side effect
The nurse teaches a patient with hyperparathyroidism about actions the patient can take specifically aimed at reducing the incidence of renal calculi. Which action by the patient indicates effective learning?
Drinks large amounts of water and fluids Rationale: The nurse instructs the patient to increase the intake of oral fluids to prevent kidney stones (calculi) that are caused by the excessive secretion of parathyroid hormone. The nurse instructs the patient to reduce alcohol ingestion to promote parathyroid hormone function. The nurse instructs the patient to increase the intake of fiber-containing foods to minimize constipation, which may be caused by hypercalcemia. The nurse instructs the patient to reduce the consumption of caffeinated drinks to decrease impaired mentation changes.
The nurse expects what assessment findings in a patient with thyroid cancer? Select all that apply.
Dyspnea Dysphagia Hoarseness Rationale: Dyspnea (difficulty breathing) and dysphagia (difficulty swallowing) can be caused by the invasion of thyroid cancer into the trachea and neck muscles. The patient may also have a hoarse voice because of recurrent involvement of the tumor with the laryngeal muscles. Heat intolerance is characteristic of hyperthyroidism. Muscle weakness and muscle wasting are also common signs of hyperthyroidism.
The nurse is caring for a patient with complex regional pain syndrome (CRPS). Which clinical sign of CRPS is a manifestation of autonomic nervous system dysfunction seen in this complication?
Edema Rationale: Edema, or the accumulation of fluid, in the extracellular spaces is an abnormality of the autonomic nervous system seen in this complication. Paresis, muscle spasm, and loss of function are all motor manifestations of complex regional pain syndrome (CRPS).
A patient has a short-leg cast following a fracture of the ankle. What does the nurse teach the patient about managing the fracture?
Elevate the affected leg on several pillows Rationale: The patient should elevate the leg on several pillows to reduce the swelling. The patient can attach a cast shoe or a rubber walking pad to the cast to prevent damaging the cast. Ice is applied for the first 24 to 36 hours to reduce swelling and inflammation. The patient must ensure that the cast is not too tight; the patient should be able to insert a finger between the cast and the skin.
A patient has been diagnosed with hyperaldosteronism. What laboratory finding is used to confirm this diagnosis?
Elevated blood pH Rationale: In hyperaldosteronism, increased aldosterone levels affect the kidney tubules and cause loss of hydrogen ions. This leads to metabolic alkalemia or elevated blood pH level. It also causes excretion of potassium leading to low potassium levels. Sodium retention causes a HIGH, not low, level of serum sodium. Blood volume increases along with the blood pressure. The urine is dilute and has a specific gravity lower than 1.005.
If wound looks infected,
FIRST obtain a culture of incisional drainage You'll give antibiotics for this later, and tell them to notify you about diarrhea or white patches in the mouth.
A 30-year-old patient suffers a pelvic fracture. His partial oxygen concentration (PaO2) drops to 70 mm hg. There is an increase in the erythrocyte sedimentation rate (ESR) and serum lipid levels. The serum calcium level drops to 7 mg/dL. Which complication should the nurse suspect?
Fat embolism syndrome (FES) Rationale: The abnormalities that can occur in an FES may include decreased PaO2 level (often below 60 mm Hg), increased ESR, decreased serum calcium levels, and increased serum lipids. Hypovolemic shock, venous thromboembolism, and acute compartment syndrome may not manifest with increased ESR and serum lipids, and there is no decrease in serum calcium level.
Which type of fracture is seldom immobilized by casting and requires surgical treatment with nails, rods, or screws?
Femoral Rationale: A femur (pelvic) fracture is seldom immobilized by casting because the powerful muscles of the thigh become spastic. These muscles cause displacement of the bone ends, resulting in displacement of the fragments. Extensive hemorrhage can occur with a femur fracture. The surgical treatment used is open reduction and internal fixation (ORIF) with nails, rods, or a compression screw. In rare cases in which extensive bone fragmentation, or severe tissue trauma is found, external fixation may be employed. Ankle, tib-fib, and phalangeal fractures can be immobilized with casting.
With severe hypocalcemia and tetany, Chvostek's sign and Trousseau's sign are usually present. How does the nurse assess for Chvostek's sign?
For Chvostek's, tap one side of the client's face over the area of the facial nerve and observe for local spasm For Trousseau's, inflate a blood pressure cuff on the client's upper arm and observing for muscle spasm in the hand.
Which type of fracture is most commonly complicated by delayed union because of poor perfusion?
Fractures of the tibia and fibula Rationale: Fractures of both the tibia and the fibula, particularly the lower third, is often referred to as a "tib-fib" fracture. Because of poor perfusion to parts of the tibia and fibula, delayed union is not unusual. It is uncommon for pelvic, spinal, and femoral fractures to be complicated and have a delay in union.
What assessment finding typically indicates there is a fracture of the hip?
Groin pain
Which autoimmune disorder is usually triggered by a bacterial or viral infection?
Hashimoto's disease Rationale: Chronic thyroiditis, which is also known as Hashimoto's disease, is an autoimmune disorder that is usually triggered by a bacterial or viral infection. Graves' disease is also an autoimmune disorder that results in hyperthyroidism. Thyroid cancer may be congenital or may be caused by various factors such as infections or surgical injury. Myxedema coma is a complication of untreated hypothyroidism; it is not an autoimmune disorder.
What to do with an unknown patient's personal items
Have two nurses put them in a bag and document
A patient presents to the emergency department with hypertension and fatigue. The patient reports weight loss and vomiting over the past several days. The nurse suspects the patient may be experiencing an Addisonian crisis. What question by the nurse is priority?
Have you recently been on steroids or pain medication? Rationale: Asking whether the patient has been on steroids or pain medication is priority because it may help to determine the cause of adrenal insufficiency if it is present. It is good to ask about salt cravings because it is a manifestation of adrenal insufficiency; however, the nurse already suspects the patient has this diagnosis. The priority would not be further assessing symptoms but determining the cause. Low calcium is not a finding in adrenal insufficiency, high calcium is. Excess cortisol production is not related to Addisonian crisis.
Patient develops fatigue, constipation, and weight gain after using Synthroid
Increase dose of levothyroxine *Too much Synthroid can make you feel like you did prior to surgery
A patient who has been on long-term corticosteroid treatment calls the health care provider's office to report fatigue, nausea, and salt cravings. What question by the nurse is priority?
Have you stopped taking your corticosteroid? Rationale: Patients who are on long-term corticosteroid treatment should not abruptly stop taking their medication. They will have symptoms of Addison's disease; therefore, it is important to ask if the patient is taking it when the patient exhibits Addisonian symptoms. Salt substitutes would not cause these symptoms. The patient would not have swelling in the abdomen. Swelling in the back or shoulders is not a priority question.
A patient is taking fludrocortisone for adrenal hypofunction. The nurse instructs the patient to report which symptom while taking this drug?
Headache Rationale: A side effect of fludrocortisone is hypertension. New onset of headache should be reported, and the patient's blood pressure should be monitored. Anxiety is not a side effect of fludrocortisone and is not associated with adrenal hypofunction. Nausea is associated with adrenal hypofunction; it is not a side effect of fludrocortisone. Sodium-related fluid retention and weight GAIN, not loss, are possible with fludrocortisone therapy.
A patient had a parathyroidectomy 18 hours ago. Which finding requires immediate attention?
Hoarseness Rationale: Hoarseness or stridor is an indication of respiratory distress and requires immediate attention. Edema at the surgical site of any surgery is an expected finding. Pain when the patient moves the head or attempts to lift the head off the bed is an expected finding after a parathyroidectomy. Any time a patient has been intubated for surgery, a sore throat is a common occurrence in the postoperative period. This is especially true for patients who have had surgery involving the neck.
What clinical finding does the nurse expect in a patient with reduced aldosterone secretion?
Hyperkalemia Rationale: Reduced aldosterone secretion causes potassium, sodium, and water imbalances. Potassium excretion is decreased causing hyperkalemia. Insufficiency of adrenocortical steroids causes problems through the loss of aldosterone and cortisol steroids. Impaired secretion of cortisol results in hypoglycemia. There is an increased excretion of sodium and water causing hyponatremia and hypovolemia.
What finding does the nurse expect to see in a patient with hyperaldosteronism?
Hypernatremia Rationale: Hyperaldosteronism, or increased aldosterone levels, affects the kidney tubules and causes sodium retention with excretion of potassium and hydrogen ions. As a result, hypernatremia, hypokalemia, and metabolic alkalosis result. The patient has elevated blood pressure, which may cause strokes, heart attacks, and kidney damage.
What effect can starting a dose of levothyroxine sodium too high or increasing a dose too rapidly have on a patient?
Hypertension and heart failure Rationale: Levothyroxine would essentially put the patient into a hyperthyroid state. The patient would be tachycardic, not bradycardic. The patient may have an increased respiratory rate. Shock may develop, but only as a late effect and as the result of "pump failure."
While assessing a patient with an endocrine disorder, the nurse hears an audible bruit over the thyroid gland. The presence of mass or cyst is noted on the patient's ultrasound report. The primary health care provider prescribes radioactive iodine. The nurse suspects that the patient is experiencing what condition?
Hyperthyroidism Rationale: An audible bruit heard over the thyroid gland because of increased blood flow is an indication of hyperthyroidism. A mass or cyst indicates an enlarged thyroid gland, which may be a goiter. The primary health care provider prescribes radioactive iodine therapy to ablate the enlarged thyroid gland. Hypothyroidism is characterized by weight gain and impaired cardiac and respiratory functions and is treated with levothyroxine, which is a thyroid hormone supplement. Hypoparathyroidism is characterized by excessive or inappropriate muscle contractions and is treated with parathormone. Hyperparathyroidism is characterized by weight loss, an increased risk of fracture, and renal calculi. It is treated with calcitonin.
The electrolyte imbalance of ______________ is a possible complication after a subtotal thyroidectomy. This complication occurs secondary to inadvertent damage to or removal of the parathyroid gland(s) during surgery.
Hypocalcemia *Numbness and tremors occur *Tetany: numbness and tingling, muscle spasms, tremors and twitching, and convulsions *So keep calcium gluconate at bedside Also keep suction, trach, and O2 at bedside
Which condition should the nurse suspect in a patient who has undergone parathyroidectomy?
Hypocalemia Rationale: Excision of the parathyroid gland (parathyroidectomy) leads to hypoparathyroidism. Due to the absence of parathyroid hormone, calcium reabsorption in the kidneys is hindered. This leads to hypocalcemia, which occurs due to a decrease in the serum calcium levels. Hyponatremia occurs when levels of sodium in the blood are very low, which is not at issue since parathyroid hormone does not regulate the serum sodium levels. The serum phosphorus level increases in hypoparathyroidism, resulting in hyperphosphatemia.
Which electrolyte disturbance causes hypoparathyroidism?
Hypomagnesemia Rationale: Hypomagnesemia is a decreased serum magnesium level, which causes impairment of parathyroid hormone secretion. This results in hypoparathyroidism. Hyperkalemia is characterized by increased serum potassium levels and is not a cause of hypoparathyroidism. Hyponatremia is characterized by decreased serum sodium levels, which are seen in patients with impaired thyroid and parathyroid hormone function. Hypercalcemia is characterized by increased serum calcium levels, which are seen in patients with hyperparathyroidism.
PVD Characteristics
I didn't feel anything when I cut my foot and it doesn't hurt now. Intermitment claudication, or pain when walking that's relieved by rest YOU CANNOT USE HEATING PADS WITH PVD
What does the nurse identify as a sign of infection for a patient who underwent an adrenalectomy?
Increase in 1 degree F in body temperature Rationale: this is significant for an immunosuppressed patient and could suggest infection
Amputation goal
Increased blood supply to extremity Intervention: Counsel to prevent emotional upsets
The nurse is providing discharge instructions to a patient on spironolactone therapy. Which comment by the patient indicates a need for further teaching?
I should eat a banana every day Rationale: this is b/c spironolactone is a potassium sparing diuretic, and this could increase risk for hyperkalemia While taking spironolactone, symptoms of hyponatremia such as drowsiness and lethargy must be reported; the patient may need increased dietary sodium. Spironolactone will not have an effect on the patient's heart rate.
The registered nurse is teaching a student nurse about the care plan for a patient with hypoparathyroidism. Which statement made by the student nurse indicates a need for further teaching?
I will explain to the patient that hypocalcemia therapy is short term Rationale: Hypocalcemia therapy in a patient with hypoparathyroidism is long-term, not short-term. The nursing care plan includes teaching the patient to reduce anxiety. The patient should be advised to wear a medical alert bracelet for easy identification. Patients with parathyroidism should avoid processed cheese, milk, and yogurt because of their high phosphorus content. Foods rich in calcium and low in phosphorous should be eaten.
The nurse is providing teaching to a patient scheduled for a unilateral adrenalectomy. What statement by the patient indicates that the teaching was effective?
I will still have one adrenal gland left Rationale: Patients who have a unilateral adrenalectomy will still have one adrenal gland. They will likely have the surgery laparoscopically. The surgery cannot be done until potassium is stabilized; potassium levels are normally low (not high) with this diagnosis. The patient may need temporary glucocorticoid therapy but should not need long-term replacement.
A patient with thyroid cancer has just received iodine131 ablative therapy. Which statement by the patient indicates a need for further teaching?
I'm ready to hold my newborn grandson now Rationale: Patients undergoing131I therapy should avoid close contact with pregnant women, infants, and young children for 1 week after treatment. Patients should remain at least 1 meter (39 inches or roughly 3 feet) away, and limit exposure to less than 1 hour per day. Some radioactivity will remain in the patient's salivary glands for up to 1 week after treatment. Care should be taken to avoid exposing others to the saliva. Flushing the toilet three times after use will ensure that all urine has been diluted and removed. Clothing needs to be washed separately and the washing machine then needs to be run empty for a full cycle before it is used to wash the clothing of others.
Administer blood from
IV control pump. Verify this with another nurse to make sure it's a match
What does the nurse teach a patient with hypoparathyroidism about treating hypocalcemia?
Include foods that are high in calcium Rationale: The patient with hypocalcemia should include foods high in calcium to overcome calcium deficiency. However, foods such as milk, yogurt, and cheese must be avoided in the daily diet because of their phosphorus content. Long-term oral therapy for calcium is 0.5 to 2 g daily in divided doses. Hypocalcemia requires lifelong therapy; if the patient adheres to the prescribed drug and diet regimen, calcium levels should remain high enough to prevent hypocalcemic crisis.
Which physiological change related to compartment syndrome is responsible for symptoms of flexed posture and unequal pulses in a patient?
Increased production of lactic acid Rationale: Increased production of lactic acid may result in flexed posture and unequal pulses. Anaerobic metabolism may cause cyanosis. Pain may result due to pressure on nerve endings. Increased capillary permeability would result in edema.
A patient with hypothyroidism is being discharged. Which environmental change may the patient experience in the home?
Increased thermostat setting Rationale: Manifestations of hypothyroidism include cold intolerance. Increased thermostat settings or additional clothing may be necessary. A patient with a diagnosis of hypothyroidism can be safely managed at home with adequate discharge teaching regarding medications and instructions on when to notify the health care provider or home health nurse. In general, hypothyroidism does not cause mobility issues. Activity intolerance and fatigue may be an issue, however. A patient with hypothyroidism is not immune-compromised or contagious, so no environmental changes need to be made to the home.
The nurse has determined that a patient diagnosed with Cushing's disease is at risk for injury. What intervention is necessary??
Instruct patient to use an electric razor Rationale: The patient should be encouraged to use an electric razor to prevent breaking the skin. A high-calorie, not a low-calorie, diet is indicated. The patient should walk with required assistive devices or assistance. Histamine receptor blockers are indicated.
What are the common manifestations seen in patients with hypothyroidism?
Intolerance to cold Constipation Weight Gain DECREASED respiratory rate Rationale: they may also have a body temperature lower than 97 F, so extra clothes are needed even in warm weather
The nurse instructor is educating nursing students about compartment syndrome. What statement made by a nursing student indicates a need for further instruction?
It causes an absence of pulses Rationale: Acute compartment syndrome is a complication of fractures in which increased pressure within one or more compartments reduces circulation to the area. Plasma proteins leak into the interstitial fluid space and edema occurs. Edema increases pressure on nerve endings and causes pain. Sensory perception deficits or paresthesia generally appears before changes in vascular or motor signs. The color of the tissue pales, and pulses begin to weaken but rarely disappear.
A patient with hyperparathyroidism is prescribed calcitonin with glucocorticoids. How does this drug work to lower serum calcium levels?
It reduces the release of skeletal calcium Rationale: Calcitonin is a short-acting drug. The therapeutic effect is greatly enhanced when given along with glucocorticoids. Calcitonin decreases the release of skeletal calcium and increases the excretion of calcium by the kidneys. Oral phosphates inhibit bone resorption and interfere with calcium absorption. Calcium chelators, such as mithramycin, lower the calcium level by binding calcium. This reduces the level of free calcium.
A patient has been diagnosed with hypothyroidism. What medication is usually prescribed to treat this disorder?
Levothyroxine sodium Rationale: Levothyroxine is a synthetic form of T4 that is used to treat hypothyroidism. Atenolol is a beta blocker that is used to treat cardiovascular disease. Methimazole and propylthiouracil are used to treat hyperthyroidism.
Ophthalmopathy
Lid retraction, which is due to excess sympathetic stimulation from thyrotoxicosis. Lids can't approximate completely and eyes dry out. Staring appearance, eye grittiness, discomfort, tearing, and exophthalmos (the eye is forced forward). When exophthalmos is severe, the condition can threaten vision. May not be able to treat these patients with I-131 as it can make this condition worse.
Which type of cast may be applied for a patient who sustains an unstable fracture of the ulna?
Long arm Rationale: A long-arm cast stabilizes an unstable fracture of the ulna. A short-arm cast immobilizes a stable fracture of the distal radius. A thumb spica cast immobilizes a fractured thumb. A hanging-arm cast is used for fractures of the humerus that cannot be aligned by a long-arm cast.
What is the major concern related to pelvic injury?
Loss of blood volume Rationale: Pelvic injury most commonly results in venous oozing or arterial bleeding. Loss of blood volume due to pelvic injury leads to hypovolemic shock. AVN may cause death and necrosis of bone tissue, resulting in pain and decreased mobility. This problem is most likely seen in patients with displaced fractures of the femur. Chest trauma might increase the risk for developing pneumonia. Neurologic dysfunction can be seen when trabecular, or cancellous, bone within the vertebra becomes weakened and causes the vertebral body to collapse, resulting in compression fractures.
What is an early manifestation of fat embolism syndrome?
Low arterial oxygen Rationale: The earliest manifestations of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea (increased respirations). Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Nonpalpable, red-brown petechiae—a macular, measles-like rash—may appear over the neck, upper arms, and/or chest.
The nurse is assisting the orthopedic surgeon in the management of nonunion of a fracture of a patient. The patient receives low-intensity pulsed ultrasound and allografts from cadavers, which are frozen or freeze dried and stored under sterile conditions in a skin bank. Which procedure is the patient receiving?
Low-intensity pulsed ultrasound Rationale: One of the newest modalities for healing fractures is the use of low-intensity pulsed ultrasound, or exogen therapy. Allografts from cadavers may also be used. These grafts are frozen or freeze dried and stored under sterile conditions in a bone bank. Autografts are chips of bone taken from the iliac crest, or other site, packed between the bone ends to facilitate union. A noninvasive, external electrical bone stimulation system delivers a small continuous electrical charge directed toward the non-healed bone.
The nurse is providing emergency care to a patient experiencing thyroid storm. What actions does the nurse take? Select all that apply.
Maintain a patent airway and adequate ventilation Administer antithyroid drugs as prescribed Monitor continually for cardiac dysrhythmias Rationale: The nurse must ensure that the patient experiencing thyroid storm has a patent airway and adequate ventilation because the patient is likely to have respiratory distress. Thyroid storm occurs mainly in patients with uncontrolled hyperthyroidism; antithyroid drugs are prescribed to control the manifestations that include fever, tachycardia, and systolic hypertension. The patient must be monitored continually for cardiac dysrhythmias. The patient is given normal saline infusions to correct dehydration and provided a cooling blanket or ice packs to reduce fever.
An older patient with an elevated serum calcium level is receiving IV furosemide and an infusion of normal saline at 150 mL/hr. Which nursing action can the RN delegate to unlicensed assistive personnel (UAP)?
Measure the patient's I&O hourly Rationale: Measuring intake and output is a commonly delegated nursing action that is within the UAP scope of practice. Numbness and tingling is part of the patient assessment that needs to be completed by a licensed nurse. Bony deformities can be due to pathologic fractures; physical assessment is a complex task that cannot be delegated. An older patient receiving an IV at 150 mL/hr is at risk for congestive heart failure; careful monitoring for shortness of breath is the responsibility of the RN.
While assessing bone density,
Measure their height
Which type of thyroid cancer often occurs as part of multiple endocrine neoplasia (MEN) type II?
Medullary Rationale: Medullary carcinoma commonly occurs as part of MEN type II, which is a familial endocrine disorder. Anaplastic carcinoma is an aggressive tumor that invades surrounding tissue. Follicular carcinoma occurs more frequently in older patients and may metastasize to bone and lung. Papillary carcinoma is the most common type of thyroid cancer. It is slow-growing and, if the tumor is confined to the thyroid gland, the outlook for a cure is good with surgical management.
A 70-year-old male patient who underwent open reduction internal fixation (ORIF) surgery experiences a seizure after 24 hours. Which drug can cause seizures related to its toxic metabolites?
Meperidine Rationale: Meperidine should not be used for pain management. Its toxic metabolites cause seizures and other adverse drug events, especially among older adults. Tramadol, ketorolac, and morphine are all employed in the management of post-operative pain. These do not cause any adverse reactions if administered in safely tolerated amounts.
What medication is used for the treatment of Cushing's disease?
Metyrapone Rationale: Metyrapone is used for treatment of Cushing's disease. Kayexalate and phenoxybenzamine are not indicated for Cushing's disease. Hydrocortisone is contraindicated in patients with Cushing's disease.
Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a patient who has just arrived after a total thyroidectomy?
Monitor oxygen sat using pulse oximetry Rationale: Airway assessment and management is always the first priority with every patient. This is especially important for a patient who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, although this is not the first priority. Pain control and supporting the head and neck with sandbags are important priorities, but can be addressed after airway assessment.
The nurse is caring for an older patient post hip-repair surgery. What postoperative care must the nurse perform for this patient?
Monitor patient frequently to prevent falls Rationale: After hip repair, the older patient is at risk to experience acute confusion and delirium. The patient must be monitored frequently to prevent falls, especially when trying to get out of bed. The patient is encouraged to begin ambulating the day after surgery to prevent complications associated with immobility. The patient must be repositioned every 1 to 2 hours to prevent pressure ulcers. The heels of the patient must be kept off the bed at all times to prevent ulcer formation. The heels and other bony prominences should be inspected every 8 to 12 hours.
A patient recently admitted with hyperparathyroidism has a very high urine output. Of these actions, what does the nurse do next?
Monitors I&O Rationale: Diuretic and hydration therapies are used most often for reducing serum calcium levels in patients with hyperparathyroidism. Usually, a diuretic that increases kidney excretion of calcium is used together with IV saline in large volumes to promote renal calcium excretion. The health care provider does not need to be notified in this situation, given the information available in the question. Cardiac assessment is part of the nurse's routine evaluation of the patient. Slowing the rate of IV fluids is contraindicated because the patient will become dehydrated because of the use of diuretics to increase kidney excretion of calcium.
What manifestations should the nurse expect to find in a patient with Cushing's syndrome? Select all that apply.
Moon face Truncal obesity Loss of bone density Rationale: The patient with Cushing's syndrome has increased total body fat which is redistributed, producing moon face and truncal obesity. Depletion of nitrogen and mineral loss leads to loss of bone density. The patient with acromegaly has a barrel-shaped chest and enlarged hands and feet because of an excess of growth hormone.
The nurse is assessing a patient for hypothyroidism. What findings indicate the presence of hypothyroidism in the patient? Select all that apply.
Muscle aches Difficulty in speech Intolerance to cold Rationale: The patient with hypothyroidism has generalized weakness and muscle aches because of decreased metabolism. The patient also has a thick tongue and edema in the larynx, which causes difficulty in speech. Hypothyroidism also causes intolerance to cold because of decreased metabolism. The patient sleeps for about 14 to 16 hours a day. Hypothyroidism leads to a decreased metabolism, which causes the patient to be lethargic, not hyperactive.
The nurse is caring for a patient receiving hydration therapy. What does the nurse expect if there is a sudden drop in calcium levels?
Muscle numbness Rationale: Mild to moderate hypoglycemia or a sudden drop in calcium levels causes tingling or muscle numbness. Nausea, constipation, and epigastric pain are some of the gastrointestinal problems associated with increased levels of serum calcium.
The nurse is monitoring a patient who had a thyroidectomy. What manifestation indicates injury to the parathyroid gland?
Muscle twitching Rationale: Due to low calcium; Muscle twitching is a sign of calcium deficiency. Injury to the parathyroid gland results in hypocalcemia or low serum calcium levels. Hemorrhage is most likely to occur in the first 24 hours after surgery but is not related to damage to the parathyroids. Hoarseness and weak voice may occur as a result of laryngeal nerve damage during the surgery.
A patient suspected of having Cushing's disease is scheduled for dexamethasone suppression testing. What statement by the patient indicates a need for further teaching?
My blood will be drawn over 3 days Rationale: The patient will not have blood drawn for this test. The urine will be collected over 24 hours. The test will determine if the patient has high cortisol levels. Dexamethasone suppression testing involves the administration of dexamethasone given over 3 hours.
Which complication is associated with compartment syndrome?
Myoglobinuria renal failure Rationale: This results from compartment syndrome. Osteomyelitis is bone infection, which occurs with open fractures in which skin integrity is lost. Pulmonary edema is seen in fat embolism syndrome and may result in respiratory failure. Retinal hemorrhage is a rare complication that is associated with fat embolism.
Which assessment finding would be considered a grade 1 goiter?
No visible thyroid enlargement when the neck is in a normal position Rationale: The patient with a grade 1 goiter does not have thyroid enlargement, which normally is visible when the neck is in normal position. However, the mass can be palpated and moves up and down when the patient swallows. When swallowing movements are not visible or felt on palpation, the patient has a grade 0 goiter. This is further confirmed by the absence of bruits when the neck is auscultated. The patient with a grade 2 goiter has a thyroid enlargement that is easily palpable and usually asymmetric.
After thyroidectomy,
Observe neck dressing for bleeding Watch for tachycardia, fever, and altered mental status (thyroid storm)
Which condition is the biggest risk factor for hip fracture?
Osteoporosis Rationale: Osteoporosis is the biggest risk factor for hip fractures. Osteoporosis is characterized by the demineralization of the bones, making them porous and brittle. Anemia, atherosclerosis, and diabetes mellitus are not risk factors for hip fractures since these conditions may not show any effect on the demineralization of bones.
A 60-year-old male patient who underwent open reduction internal fixation (ORIF) complains of constipation. Which drug may have caused this complication?
Oxycodone Rationale: Patients who have open reduction internal fixation (ORIF) surgery are usually prescribed analgesics. Constipation is a common side effect of opioid analgesics such as oxycodone, especially for older adults. Ketorolac, naproxen, and acetaminophen may also be used for analgesia but are not known to cause constipation.
Which motor clinical manifestation may be seen in a patient with complex regional pain syndrome (CRPS)?
Paresis Rationale: Paresis, or weakness of the extremities, is a manifestation of abnormal motor perception in patients with complex regional pain syndrome (CRPS). Edema, a change in color of the affected skin, and excessive sweating are manifestations of the autonomic nervous system dysfunction seen in CRPS.
The nurse is reviewing the clinical data of four patients. Which patient is at high risk for bone fractures?
Patient A: increased serum calcium, increased PTH, decreased Vitamin D, increased serum phosphorous Rationale: Excessive parathyroid hormone (PTH) levels increase bone resorption by decreasing the osteoblastic activity and increasing osteoclastic activity; this releases calcium and phosphorus into the blood and leads to bone fractures. Therefore, patient A with increased serum calcium levels, increased PTH levels, and increased serum phosphorous levels is at high risk for bone fracture. Patient B has normal PTH levels, decreased serum calcium levels, and increased serum phosphorous levels and may not be at high risk for bone fractures. Patient C with normal PTH levels, normal serum calcium levels, increased vitamin D levels, and increased serum phosphorous levels also may not be at a risk for bone fractures. Additionally, patient D with decreased PTH levels, decreased serum calcium levels, and normal serum phosphorous levels is not at risk for bone fractures.
The nurse is reviewing the clinical data of four patients. Which patient is at high risk for peptic ulcers?
Patient C: Increased serum calcium, increased PTH, increased serum gastrin, and decreased serum phosphorous Rationale: Excessive levels of parathyroid hormone (PTH) may increase the levels of serum calcium levels. Hypercalcemia causes elevated serum gastric levels which causes gastrointestinal (GI) problems such as peptic ulcers. Therefore, patient C with hyperparathyroidism, increased serum calcium levels, and increased serum gastrin levels is at high risk for developing peptic ulcers. Patient A has normal serum gastrin levels, so this patient may not be at risk of developing peptic ulcers. Patient B has normal serum gastrin levels, so this patient also may not be at risk of developing peptic ulcers. Additionally, patient D with decreased levels of serum gastrin levels may not be at a risk of developing peptic ulcers.
An older adult patient has multiple tibia and fibula fractures of the left lower extremity after a motor vehicle crash. Which pain medication does the nurse anticipate will be requested for this patient?
Patient controlled anesthesia (PCA) with morphine Rationale: Morphine is an opioid narcotic analgesic; given through PCA, it is the most appropriate mode of pain management for this type of acute pain associated with multiple injuries. Muscle relaxants are effective for treating pain related to muscle spasms, but they are not adequate for this type of acute pain. Ibuprofen is a nonsteroidal anti-inflammatory that is used to treat mild to moderate pain; bone pain is very acute, so ibuprofen would not be sufficient. Meperidine should never be used for older adults because it has toxic metabolites that can cause seizures.
After receiving a change-of-shift report about these four patients, which patient does the nurse attend to first?
Patient with acute adrenal insufficiency who has a blood glucose of 36 Rationale: A glucose level of 36 mg/dL is considered an emergency; this patient must be assessed and treated immediately. Although it is important to maintain medications on schedule, the patient requiring a dose of desmopressin is not the first patient who needs to be seen. A serum potassium of 3.4 mEq/L in the patient with hyperaldosteronism may be considered normal (or slightly hypokalemic), based on specific hospital levels. The patient reporting a severe headache needs to be evaluated as soon as possible after the patient with acute adrenal insufficiency. As an initial measure, the RN could delegate obtaining vital signs to unlicensed assistive personnel (UAP).
The nurse manager for the medical-surgical unit is making staff assignments. Which patient will be most appropriate to assign to a newly graduated RN who has completed a 6-week unit orientation?
Patient with chronic hypothyroidism and dementia who takes levothyroxine daily Rationale: The patient with chronic hypothyroidism and dementia is the most stable of the patients described and would be most appropriate to assign to an inexperienced RN. A patient with vocal hoarseness and difficulty swallowing is at higher risk for complications and requires close observation by a more experienced nurse. Increasing anxiety and diaphoresis in a patient with Graves' disease can be an indication of impending thyroid storm, which is an emergency; this is not a situation to be managed by a newly graduated RN. A patient who has just arrived on the unit after a parathyroidectomy requires close observation for bleeding and airway compromise and requires assessment by an experienced nurse.
What type of anemia is associated with idiopathic hypoparathyroidism?
Pernicious anemia Rationale: Evidence-based practice has identified a clear link between pernicious anemia and idiopathic hypoparathyroidism. There is no known link between idiopathic hypoparathyroidism and sickle cell anemia, megaloblastic anemia, or iron deficiency anemia.
What manifestation is usually seen in fat embolism but not in blood clot embolism?
Petechiae Rationale: Petechiae is a macular, measles-like rash, and may occur over the neck, upper arms, or chest and abdomen. Petechiae is not seen in blood clot embolism. Altered mental status, increased pulse, and dyspnea are seen in both cases.
Sensation that is felt in an amputated part immediately after surgery is known as which of the following?
Phantom limb pain
A chemical sympathetic nerve block may be used to manage complex regional pain syndrome (CRPS). Which drug, administered intravenously, is used to block sympathetic nerve receptors?
Phentolamine Rationale: A chemical sympathetic nerve block may be used in patients with complex regional pain syndrome (CRPS). This procedure can be done by an IV (intravenous) infusion of phentolamine, a drug that blocks sympathetic receptors. Bupivacaine (a topical analgesic), prednisolone (a corticosteroid), and amitriptyline (an anti-depressant) are used for general pain management.
Which statement is accurate about the types of tractions used for musculoskeletal trauma of the upper extremities?
Plaster traction may be employed for fractures of the wrist Rationale: Plaster traction, or pins, inserted through the bone are fixed in the cast for fractures of the wrist. Skeletal traction is used for fractures of the humerus, with or without involvement of the shoulder and clavicle. 90-90 traction is employed for fractures of the humerus. Plaster traction is not employed for fractures of the humerus, but for the wrist.
What post-operative assessment finding in a patient who underwent a parathyroidectomy indicates potential tetany?
Positive for Trusseau's test Rationale: A patient who has undergone parathyroidectomy is at a high risk for hypocalcemic crisis. This may lead to tetany, an involuntary contraction of the muscles. Serum calcium deficiency can be assessed with Trousseau's test; a positive response indicates potential tetany. Voice pattern changes and hoarseness in a patient who had a parathyroidectomy may be due to laryngeal nerve damage. A serum calcium level of 9.5 mg/dL is normal. Tingling in the extremities and face is due to mild hypocalcemia, which does not lead to tetany.
Which long-term drug therapy increases the risk of developing ischemic bone necrosis?
Prednisone Rationale: Patients on long-term corticosteroid therapy, such as prednisone, are at risk for ischemic necrosis. Ketorolac, ibuprofen, and acetaminophen do not increase the risk for developing ischemic necrosis.
What manifestation does the nurse expect to find in a patient with hyperparathyroidism?
Presence of renal calculi Rationale: X-rays for the patient with hyperparathyroidism show the presence of renal calculi and deposits of calcium in the soft tissue of the kidney because of hypercalcemia. Increased serum calcium levels lead to an elevated serum gastrin level, which leads to peptic ulcer. Serum calcium levels are generally greater than 12 mg/dL. Fatigue and lethargy become more severe as serum calcium levels rise. The patient with high serum calcium levels develops gastrointestinal problems, such as anorexia, nausea, and weight loss.
What is the nursing priority for a patient with chronic hyperparathyroidism?
Preventing injury Rationale: The nursing priority for a patient with chronic hyperparathyroidism is preventing injury. The patient has loss of bone density and is at risk for pathologic fractures. The patient with hyperthyroidism cannot tolerate heat, and the nursing priority for this patient is to reduce room temperature. The nurse does not encourage the patient with chronic hyperparathyroidism to exercise because the patient is susceptible to injury. The patient with hyperthyroidism requires a stress-free environment to prevent risk for cardiac complications. The nursing priority for this patient is to reduce stimulation.
Which description accurately defines a closed reduction?
Process where the ends of the bones are manually pulled and realigned Rationale: Closed reduction involves applying a manual pull or traction to move the ends of a fractured bone to realign them. This is the most common nonsurgical method for managing a simple fracture. A commercial immobilizer or an elastic bandage is used to keep the scapula or clavicle bone in place during healing. A fiberglass synthetic cast is used to immobilize the extremity if the fracture is complex. Moderate sedation or analgesia is used during a closed reduction to reduce pain.
Which part of the pelvis is non-weight bearing?
Pubic rami Rationale: The pubic rami or the iliac crest is a non-weight bearing part of the pelvis. The sacrum, pelvic ring, and acetabulum are weight-bearing parts of the pelvis.
The nurse is caring for a patient with hypocalcemia due to hypoparathyroidism. What is the cause of iatrogenic hypoparathyroidism?
Removal of the parathyroid glands Rationale: Iatrogenic hypoparathyroidism is caused by the removal of all parathyroid tissue during total thyroidectomy or by deliberate surgical removal of the parathyroid glands. Patients with malabsorption syndromes, malnutrition, and chronic kidney disease have hypomagnesemia or decreased serum magnesium levels. Hypomagnesemia may also cause hypoparathyroidism. Also, Iatrogenic means 'caused by treatment'
What is the most common cause of hypothyroidism in the United States?
Radioactive iodine treatment Rationale: The most common cause of hypothyroidism in the United States is radioactive iodine (RAI) treatment and thyroid surgery for hyperthyroidism. Hypothyroidism was common in the Midwest region of the U.S. before iodide was added to table salt and saltwater fish was widely available. Tyrosine and iodide are compounds essential to produce thyroid hormones. Saltwater fish is a good source of iodide and prevents hypothyroidism. Endemic goiter due to hypothyroidism is found in areas where soil and water have little natural iodide.
What skin change does the nurse expect to find in a patient with hypercortisolism?
Reddish purple striae
The nurse delegates the task of providing comfort to a patient with Graves' disease to an unlicensed assistive personnel (UAP). What does the nurse instruct the UAP to do? Select all that apply.
Reduce room temperature Ensure that the patient always has a fresh pitcher of ice water Change the bed linen whenever it becomes damp from diaphoresis Rationale: The UAP may reduce the patient's room temperature to decrease any discomfort caused by heat intolerance, and must ensure that the patient has a fresh pitcher of ice water to provide relief from excessive heat. The UAP should change bed linen that becomes wet from diaphoresis to prevent skin breakdown and provide comfort. The patient with Graves' disease experiences heat intolerance, so the UAP would provide cool showers or cold sponge baths for comfort. A noisy, stressful environment can increase the manifestations of hyperthyroidism and increase the risk for cardiac problems, so the environment must be as calm and quiet as possible, and visitors should be restricted.
Which is the priority intervention in the management of a patient with complex regional pain syndrome (CRPS)?
Relieving pain Rationale: Complex regional pain syndrome (CRPS) is a musculoskeletal disorder that manifests as unrelenting pain, possibly interfering with a patient's daily activities. Therefore, the priority intervention in CRPS management is pain relief so that the patient can resume normal activities. Paresis, edema, and muscle spasms can be managed once the pain is managed.
A patient with a possible adrenal gland tumor is admitted for testing and treatment. Which nursing action is most appropriate for the charge nurse to delegate to the nursing assistant?
Remind the patient to avoid drinking coffee and changing position suddenly Rationale: Drinking caffeinated beverages and changing position suddenly are not safe for a patient with a potential adrenal gland tumor because of the effects of catecholamines. Reminding the patient about previous instructions is an appropriate role for a nursing assistant who may observe the patient doing potentially risky activities. Patient assessment, patient teaching, and environment planning are higher-level skills that require the experience and responsibility of the RN, and are not within the scope of practice of the nursing assistant.
The nurse assigns an unlicensed assistive personnel (UAP) to monitor the temperature of a patient with Graves' disease. What does the nurse instruct the UAP to do?
Report even a 1 degree F increase in temperature immediately Rationale: any increase in temperature may indicate a rapid worsening of the patient's condition and the onset of a thyroid storm. The patient's temperature should be measured at least every 4 hours, documented, and reported to the nurse as soon as it is obtained. The patient with Graves' disease experiences diaphoresis and has heat intolerance, so an elevated temperature must be reported to the nurse immediately
A patient is brought to the emergency department (ED) via ambulance after a motor vehicle crash. What condition does the nurse assess for first?
Respiratory distress Rationale: In order: respiratory, bleeding, head injury, pain
What type of fracture is most common in adults?
Rib fractures Rationale: Rib fractures are the most common fracture in the adult population. The incidence of proximal femur (hip) fractures is highest in older adults. Wrist (Colles') fractures are seen in middle and late adulthood. Humeral fractures are common in adults.
The x-ray report of a patient shows a fracture at the femur. The nurse anticipates that which type of traction will be prescribed to reduce muscle spasm and tissue damage?
Russel's traction Rationale: Russell's traction: stabilizes and aligns the lower extremities after a fracture, reduces muscle spasm and tissue damage, and the affected lower extremity is extended and a sling under the knee suspends the leg. - A 90-90 (aka Overhead) traction is used for humerus fractures (upper extremities), where the elbow is flexed and the arm is at a right angle to the body over the upper chest. - Cervical halter traction is used for cervical muscle spasms. - Plaster traction is beneficial for a patient who has a wrist fracture. - A pelvic belt is a type of pelvic traction in which a strap around the hips at the iliac crests is attached to weights at the foot of the bed. - A pelvic sling is a type of pelvic traction where a wide strap around the hips is attached to an overhead bar to keep the pelvis off the bed.
Which statement is true regarding the types of traction used for musculoskeletal trauma of the lower extremities?
Russell's traction is used for fractures of the hip Rationale: Russell's traction is used for fractures of the hip or the distal end of the femur. Fractures of the femur or pelvis are treated with skeletal traction. Buck's traction is used for fractures of the hip or femur, preoperatively.
Which organism is commonly responsible for hospital-acquired infections and is often the causative agent in osteomyelitis?
S. aureus Rationale: Staphylococcus aureus is the organism most commonly involved in nosocomial infections (hospital-acquired), such as methicillin-resistant Staphylococcus aureus (MRSA). Bone infection, or osteomyelitis, is most common with open fractures, when skin integrity is lost after surgical repair of a fracture. For patients experiencing this type of trauma, the risk for hospital-acquired infections is increased. These infections are common, and many are from multidrug-resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA). Streptococcus mutans, salivarius, and lactobacillus acidophilus are not commonly associated with nosocomial infections.
While assessing a patient with hypoparathyroidism, the nurse observes severe muscle cramps and elbow flexion. Which condition does the nurse suspect?
Severe hypocalcemia Rationale: Severe muscle cramps indicate severe hypocalcemia. Moderate hyperkalemia is associated with arrhythmias and muscle weakness. Severe hypomagnesemia is associated with malnutrition. Moderate hyperphosphatemia damages the skeletal muscle tissues.
A patient has sustained a metatarsal fracture. Which type of cast would be used to immobilize a patient who has a metatarsal fracture?
Short leg cast Rationale: A short-leg cast (SLC) is used for fractures of the ankle, metatarsals, and foot. A leg cylinder cast immobilizes stable fractures of the tibia, fibula, and knee. A long-leg cast (LLC) is used for unstable fractures of the tibia, fibula, and ankle. A long-leg cylinder cast immobilizes stable fractures of the distal femur, proximal tibia, and knee.
Which type of cast is used to immobilize an unstable fracture of the humerus?
Shoulder spica cast Rationale: A shoulder spica cast is considered ideal for an unstable fracture of the humerus for proper support. A long-arm cast stabilizes an unstable fracture of the ulna. A short-arm cast immobilizes a stable fracture of the distal radius. A hanging-arm cast is used for fractures of the humerus that cannot be aligned by a long-arm cast.
Agranulocytosis is an uncommon but serious adverse effect of antithyroid drugs. To detect agranulocytosis, you teach Mrs. Schneider that it is important to immediately report:
Sore throat Mouth Sores Fever *all indications of infection *also look for Hepatitis with antithyroid therapy
A patient diagnosed with Cushing's disease has received teaching about nutrition. What food selection by the patient indicates effective teaching?
Spinach Rationale: Spinach is a food choice that is high in potassium and is indicated for patients with Cushing's disease. Cabbage is low in potassium, and patients with Cushing's may be taught to eat foods high in potassium. Saltines and canned soup are high in sodium. Nutrition therapy for patients with hypercortisolism may involve sodium restriction.
A patient with bone cancer is most susceptible to what type of fracture?
Spontaneous fracture Rationale: A patient with bone cancer is prone to spontaneous, or pathologic, fractures. Spontaneous fracture occurs after minimal trauma to a bone that has been weakened by disease. A simple fracture is a fracture in which there is no external or visible wound and it does not extend through the skin. A compound fracture is a fracture in which the skin surface over the broken bone is disrupted causing an external wound. A stress fracture is caused from excessive strain and stress on the bone, which is commonly seen among athletes.
The primary health care provider prescribes intravenous phosphates to a patient with hyperparathyroidism. The patient reports tingling and numbness in the muscles after the treatment. What could be the reason behind this?
Sudden drop in serum calcium levels Rationale: Patients with hyperparathyroidism are prescribed oral and intravenous phosphates. Intravenous phosphates are used only when the serum calcium levels need to be lowered rapidly. This rapid decrease in the serum calcium levels causes tingling and numbness in the muscles. Intravenous administration of phosphates does not alter the serum magnesium levels. Decreased serum phosphorous levels may not cause tingling and numbness in the muscles. Intravenous administration of phosphates does not decrease the serum parathyroid hormone (PTH) levels.
PTU
Suppresses immunity, so report symptoms of sickness
Thyroid gland produces
T3, T4, and calcitonin
A patient's preliminary thyroid function test reveals a decrease in serum triiodothyronine (T3) and tetraiodothyronine (T4) hormone levels, which might indicate hypothyroidism. What other parameter should be assessed to determine the origin of hypothyroidism as primary or secondary?
TSH stimulation test
Calcium supplements
Take 1 tablet with each meal Take 3 tablets a day
A 30-year-old patient sustains a fractured hip and experiences hypoxemia, dyspnea, and tachypnea. What complication due to fracture should the nurse suspect from these findings?
The patient may have Fat Embolism Syndrome (FES) Rationale: FES may be a complication due to the fracture of long bones. Fat emboli can lodge in small blood vessels, compromising the circulation to the areas distal to the blockage. The earliest manifestations of FES are a low arterial oxygen level or hypoxemia, dyspnea, and tachypnea (increased respirations). Venous thromboembolism, acute compartment syndrome, and complex regional pain syndrome do not manifest hypoxemia, dyspnea, and tachypnea.
A patient with Cushing's disease begins to laugh loudly and inappropriately, causing the family in the room to be uncomfortable. What is the nurse's best response?
The disease can sometimes affect emotional responses
Incidence of fractures
The incidence of hip or proximal femur fracture is highest in older adults. Wrist fractures are usually seen in middle and late adulthood. Rib fractures are the most common type of fractures in adults. Femoral shaft fractures occur most often in young and middle-aged adults.
The nurse is caring for four patients with endocrine disorders. Which patient is likely to present with nonpitting mucinous edema around the neck and on the hands and feet?
The patient with hypothyroidism Rationale: Hypothyroidism is characterized by nonpitting edema everywhere on the body, including around the neck and on the hands and feet. This edema is mucinous and changes the patient's appearance. Graves' disease is an autoimmune disorder characterized by goiter, exophthalmos, and pretibial myxedema. Thyroid crisis, also known as thyroid storm, is a life-threatening event that occurs as a result of untreated hyperthyroidism. It is characterized by high fever and severe hypertension. Thyroid cancer is caused by a bacterial or viral infection and is characterized by pain, neck tenderness, and thyroid gland enlargement.
What changes does the nurse note in a patient with hypercortisolism upon physical assessment?
The presence of fat pads on the shoulders Rationale: The patient with hypercortisolism has fat pads on the neck, back, and shoulders because of fat redistribution. The patient develops extremely thin and translucent skin following increased blood vessel fragility. Excessive cortisol secretion causes acne; coats of fine hair cover the face and the body. The patient develops muscle atrophy or muscle wasting and weakness, especially at the extremities. The patient also has truncal obesity following changes in fat distribution.
Purpose of "Time Out"
To ensure client safety All members of a surgical team take the time to identify correct patient, procedure, and site
A patient sustains a tibial fracture and a cast is applied. The primary health care provider advises that a window is cut on the cast. What is the objective of this action?
To inspect the skin Rationale: An open window cut in the cast helps with skin inspection. The piece of that cast removed to make the window must be kept and replaced after wound care to prevent localized edema in the area. Cutting a window may not cause skin dryness. The cast can be cut with a cast cutter to relieve pressure or allow for tissue swelling.
Amputated limbs go where?
To the incinerator to be burned
A patient has hyperparathyroidism. Which incident witnessed by the nurse requires the nurse's intervention?
UAP pulling the patient up in the bed by the shoulders Rationale: The patient with hyperparathyroidism is at risk for pathologic fracture. All members of the health care team must move the patient carefully. A lift sheet should be used to reposition the patient. The patient with hyperparathyroidism is not restricted from eating and should maintain a balanced diet. The patient can benefit from moderate exercise and physical therapy, and is not restricted from having visitors.
Which clinical sign of complex regional pain syndrome (CRPS) does the nurse know to be a manifestation of the sensory perception abnormalities seen in this syndrome?
Unrelenting burning pain Rationale: Intense burning pain is a characteristic feature of complex regional pain syndrome (CRPS) and is considered an abnormality in the sensory perception caused by disease pathology. Change in color, excessive sweating, and change in temperature over the affected area are manifestations of the autonomic nervous system dysfunction seen in CRPS.
A patient with hypercortisolism is at risk for bone fractures. What does the nurse instruct the unlicensed assistive personnel (UAP) to do when caring for this patient?
Use a gait belt to assist the patient when walking
For exophthalmos,
Use natural tears Wear sunglasses when outside Use an eye shield at night Take anti-inflammatories
A patient with Graves' disease can potentially develop thyroid storm. What factor can trigger thyroid storm in the patient?
Vigorous palpation of the goiter Rationale: this will release TH in large amounts thyroid storm is also caused by exposure to iodine
A patient is prescribed 50,000 units of ergocalciferol daily. What disorder does this drug treat?
Vitamin D deficiency Rationale: The nonsurgical management of hypoparathyroidism involves correcting vitamin D deficiency. Ergocalciferol is prescribed as long-term therapy for vitamin D deficiency. Long-term oral therapy for hypocalcemia involves the intake of calcium, 0.5 to 2 g daily, in divided doses. Acute hypomagnesemia is corrected with 50% magnesium sulfate in 2 mL doses (up to 4 g daily) either intramuscular or intravenous. Thionamides are prescribed for hyperthyroidism.
A physician suspects an autoimmune basis to be the cause of idiopathic hypoparathyroidism in a patient. From which other conditions is the patient likely to be already suffering? Select all that apply.
Vitiligo Hypothyroidism Adrenal insufficiency Rationale: These might occur due to an autoimmune etiology accompanying hypoparathyroidism. Chronic kidney disease and malabsorption syndrome cause hypomagnesemia, which may also result in hypoparathyroidism.
What integumentary change does the nurse expect while assessing the skin of a patient with hyperparathyroidism?
Waxy pallor Rationale: The patient with long-standing hyperparathyroidism may have a waxy pallor. Hyperthyroidism causes diaphoresis or excessive sweating because of heat intolerance. The patient also has soft body hair with hyperthyroidism. Cool, dry skin is found in the patient with hypothyroidism as a result of intolerance to cold.
The nurse is instructing a local community group about ways to reduce the risk for musculoskeletal injury. What information does the nurse include in the teaching plan?
Wear helmets when riding a motorcycle Rationale: Those who ride motorcycles or bicycles should wear helmets to prevent head injury. Telling the general public to avoid contact sports or to avoid driving in inclement weather is not realistic. Telling the general public to avoid rigorous exercise is not only unrealistic; it is also opposed to what many health care professionals recommend to maintain health.
The nurse is caring for a patient with hypercortisolism. The nurse begins to feel the onset of a cold but still has 4 hours left in the shift. What does the nurse do?
Wears a face mask when caring for the patient Rationale: A patient with hypercortisolism will be immune-suppressed. Anyone with a suspected upper respiratory infection who must enter the patient's room must wear a mask to prevent the spread of infection. Although asking another nurse to care for the patient might be an option in some facilities, it is not generally realistic or practical. The nurse, not the patient, feels the onset of the cold, so monitoring the patient for coldlike symptoms is part of good patient care for a patient with hypercortisolism. Refusing to care for the patient after starting care would be considered abandonment.
Antidepressents will or will not affect a thyroid scan?
Will not, since they don't contain iodine
A patient has been prescribed radioactive iodine (RAI) therapy for hyperthyroidism. What does the nurse teach the patient about this therapy?
You will receive RAI in the form of oral131 Rationale: The dosage depends on the size of the thyroid gland and its sensitivity to radiation. Some of the cells that produce thyroid hormone are destroyed. However, the thyroid gland also stores thyroid hormones to an extent. Therefore, the patient may not have complete relief of symptoms until 6 to 8 weeks after RAI therapy. Radioactivity is present in the patient's body fluids and stool for a few weeks even after the therapy is complete. The patient must take radiation precautions to prevent exposure to family members and other people. RAI treatment is done on an outpatient basis; most patients require only one sitting, whereas some may require two or three sittings.
Transsphenoidal hypophysectomy
a surgical procedure most commonly used to remove a tumour of the pituitary gland. Transsphenoidal means through the sphenoid sinus. This is the air sinus (cavity) at the back of your nose. The pituitary tumour is removed through the nose.
PTU (propylthiouracil)
blocks the conversion of T4 to T3, the more potent thyroid hormone. Antithyroid drugs are usually administered for 12-24 months, with the dose decreased as the hyperthyroid state improves.
Before a thyroid scan,
check hCG levels to verify the patient is not pregnant
Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
hyponatremia and hypo-osmolality resulting from an excess of water rather than a deficiency of sodium... *due to inappropriate, continued secretion or action of the hormone despite normal or increased plasma volume, which results in impaired water excretion. *requires fluid restriction
5 mL
is 1 tsp