Semester 4 Unit 1 study

Pulomary embolism presents with

Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis.

A client with schizophrenia, undifferentiated type, is receiving a typical antipsychotic/neuroleptic drug. The nurse will assess for which extrapyramidal effects?

Shuffling gait, tremors, and restlessness are common extrapyramidal signs pseudoparkinsonism that occur as side effects of neuroleptics; they are usually controlled with antiparkinsonian drugs

A client who had a myocardial infarction develops cardiogenic shock despite treatment in the emergency department. Which client responses are related to cardiogenic shock? Select all that apply.

Tachycardia, Restlessness, Decreased urinary output.

A nurse is obtaining an admission history for a client who is scheduled for surgery to repair a ruptured abdominal aneurysm. Which type of shock should the nurse monitor for in this client?

Hypovolemic shock occurs when an abdominal aneurysm ruptures. Shock ensues because fluid volume becomes depleted as the heart continues to pump blood out of the ruptured vessel.

A client is admitted with a higher than expected red blood cell count. What physiologic alteration does the nurse expect will result from this clinical finding?

Increased blood viscosity. Rationale: Viscosity, a measure of a fluid's internal resistance to flow, is increased as the number of RBC's suspended in plasma increases.

A client is considered to be in septic shock when what changes are assessed in the client's labwork?

Increased serum lactate level. Rationale: Sepsis is an increasing serum lactate level, a normal or low total WBC count greater than 12,000 cells or less than 4,000 cells,decreasing segmented neutrophil level with a rising band neutrophil level. Blood glucose levels with sepsis are between 110 and >150 mg/dL.

While preforming nasotracheal suctioning, the nurse notices that the client has blood pressure of 90/70 and a heart rate of 50 beats per minute. What is the priority nursing intervention in this situation?

Stopping the suctioning procedure immediately. Rationale: Suctioning can result in vagal stimulation

A client is admitted with full-blown anaphylactic shock that developed due to a type 1 latex allergic reaction. Which findings will the nurse observe upon assessment? Select all that apply.

Strydor, dyspnea, hypotension. Rationale: Full-blown anaphylactic shock produces stridor, hypotension, and dyspnea.

The nurse is conducting triage under mass casualty conditions. Which tag should the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound?

Red. Rationale: Red tag: immediate threat to life. Black tag: expected to die and allowed to. Yellow tag: major injuries requiring treatment. Green tag: minor injuries that do not require immediate treatment.

The nurse notes that the client keeps interjecting sentences that have nothing to do with the main thoughts being expressed. The client asks whether the nurse understands. What is the best response by the nurse?

"I'd like to understand what you're saying, but I'm having difficulty following you."

How much does one liter of fluid weigh?

2.2 pounds.

Akathisia , motor restlessness, can usually be treated with antiparkinsonian or anticholinergic drugs while the antipsychotic medication is continued.

A Parkinsonian syndrome (a disorder featuring signs and symptoms of Parkinson disease such as resting tremors, muscle weakness, reduced movement, and festinating gait), and dystonia (impairment of muscle tonus)

Clozapine, an atypical antipsychotic, is prescribed for a client with psychosis. It is important for client to have frequent blood tests for which possible complication?

Agranulocytosis, a marked decrease in granulated white blood cells.

A client with schizophrenia who is being admitted to a psychiatric hospital for evaluation refuses to remove dirty clothing. What should the nurse do to best meet the client's needs?

Allow the client to undress when ready. Rationale: Any approach other than allowing the client to undress when ready will be seen as threatening, increase anxiety, and result in a physical confrontation.

Hemorrhagic shock presents with

Anxiety, tachycardia, and hypotension.

The nurse is developing a care plan for a client with postpartum psychosis. Which priority intervention should the nurse implement?

Assessment and management of postpartum psychosis are beyond the scope of a maternity nurse. A mother who experiences this condition must be referred to a specialist for comprehensive therapy.

Atrial fibrillation is a common dysrhythmia.

Atrial fibrillation may be chronic or intermittent. Antidysrhythmic medications are used initially; cardioversion is used only if the client does not respond to medication.

A client is admitted to the hospital with a diagnosis of heart failure and acute pulmonary edema. The healthcare provider prescribes furosemide 40 mg intravenous (IV) stat to be repeated in 1 hour. What nursing action will best evaluate the effectiveness of the furosemide in managing the client's condition?

Auscultate breath sounds. Rationale: Furosemide, or Lasix minimizes hypoxia associated with pulmonary edema.

A client who is in hypovolemic shock has a hematocrit value of 25%. What does the nurse anticipate that the primary healthcare provider will prescribe?

Blood replacement. Rationale Blood replacement is needed to increase the oxygen-carrying capacity of the blood.

Vagal stimulation can result in

Bronchospasm. hypotension, bradycardia, heart block, ventricular tachycardia, or other dysrhythmias and require immediate intervention

A nurse is caring for a client who has had multiple myocardial infarctions and has now developed cardiogenic shock. Which clinical manifestations support this diagnosis?

Cold, clammy cyanotic, or mottled skin, Increased Heart rate, Low blood volume ,weak, thready pulses due to peripheral vasoconstriction, Hypotension, absent or hypoactive bowel sounds.

How does consuming water help with arterial insufficiency?

Consuming water will decrease the viscosity of blood, possibly preventing the formation of thrombi.

Digoxin's negative inotropic effect:

Digoxin decreases, not increases, cardiac impulses through the conduction system of the heart.

A client with heart failure is to receive digoxin and asks the nurse why the medication is necessary. What physiologic response will the nurse include when answering the client's question?

Digoxin increases the strength of the contractions but decreases the heart rate.

A client is admitted to the emergency department with profuse vomiting. The client reports that the vomitus was bright red in color. What does the nurse identify as the priority intervention?

Draw blood for typing and cross match. Rationale: Immediate blood replacement is indicated.

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify? Select all that apply.

Flaccid paralysis, Lack of reflexes below the injury

How does Furosemide or Lasix work?

Furosemide inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule, causing diuresis.

What are the symptoms of autonomic dysreflexia?

Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia.

What side effects are considered late extra pyramidal side effects?

Late extrapyramidal side effects include fine, worm-like tongue movements.

A client is in profound (late) hypovolemic shock. The nurse assesses the client's laboratory values. What does the nurse know that clients in late shock develop?

Metabolic acidosis. Rationale: Decreased oxygen increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis.

During the progressive stage of shock, anaerobic metabolism occurs. The nurse expects that initially the anaerobic metabolism will cause what?

Metabolic acidosis. Rationale: Metabolic acidosis occurs during the progressive stage of shock as a result of accumulated lactic acid.

A client with C8 tetraplegia is admitted to the emergency room. Vital signs: blood pressure of 80/40 ,pulse 48, and respiratory rate 18. The nurse suspects which condition?

Neurogenic shock

Arterial insufficiency. What is the cause?

Nicotine causes vasoconstriction and spasm of the peripheral arteries.

Why is daily weight important in the patient on diuretics?

Oneliter of fluid weighs approximately 2.2 pounds, 1 kilogram and weight loss will reflect the amount of fluid lost.

A young adult client is admitted to the hospital with a diagnosis of schizophrenia, paranoid type. The client has been saying, "The voices in heaven are telling me to come home to God." What should initial nursing care be focused on?

Potential for self-harm. Rationale: Client safety always is the priority over any other client need, and command hallucinations increase the risk of injury.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness. RATIONALE: In the early stage of shock, the client has increased epinephrine secretion. This, in turn, causes the client to become restless, anxious, nervous, and irritable.

A client undergoes a bowel resection. When assessing the client 4 hours postoperatively, the nurse identifies which finding as an early sign of shock?

Restlessness. Rationale: In the early stage of shock, the client has increased epinephrine secretion. The client to becomes restless, anxious, nervous, and irritable.

What is the purpose for prescribed serum albumin?

Serum albumin helps maintain volume.

A client with schizophrenia, undifferentiated type, is receiving a typical antipsychotic/neuroleptic. The nurse will assess for which extrapyramidal effects?

Shuffling gait, tremors, and restlessness

Spinal shock

Spinal shock syndrome s immediate after a transection of the spinal cord; results in flaccid paralysis of all skeletal muscles and lasts for 48 hours to for several weeks.

On reviewing the data of a client with thyroid disorder, the primary healthcare provider prescribed atenolol. Which assessment findings would indicate the need for atenolol therapy? Select all that apply.

Tachycardia, Atrial Fibrillation, Systolic hypertension. Rationale: Tachycardia, atrial fibrillation, and systolic hypertension are cardiac manifestations associated with hyperthyroidism.

A client with the diagnosis of schizophrenia is given antipsychotic drugs. Antipsychotic drugs can cause extra pyramidal side effects. Which effect may be irreversible?

Tardive dyskinesia

A client on a telemetry unit develops paroxysmal atrial fibrillation. When planning care for this client, what should the nurse consider?

That it may be life threatening. Rationale: Atrial fibrillation increases the risk for a stroke even without underlying heart disease; the risk is greater with structural heart disease, hypertension, and increasing age.

A client with a 40-year history of drinking two alcoholic beverages and smoking two packs of cigarettes daily comes to the outpatient clinic with an ischemic left foot. It is determined that the cause is arterial insufficiency. What is the cause?

The nurse concludes that the pain in the client's foot is a result of inadequate blood supply.

The nurse is caring for victims of a bomb blast in the emergency department who are receiving different pain medications. Which client must be placed on electrocardiogram equipment?

The patient taking Naproxen. Rationale: N S A I D medications such as naproxen may result in cardiovascular events such as myocardial infarction, stroke, and heart failure.

What side effects are considered early extra pyramidal side effects?

Tremors, restless movements, and muscle spasms of the neck, back, tongue, or face are early extrapyramidal side effects.

How long after clozapine is discontinues will the patient need to be tested for agranulocytosis?

Up to 4 weeks.

To prevent septic shock in the hospitalized client, what should the nurse do?

Use aseptic technique during all invasive procedures. Septic shock occurs as a result of an uncontrolled infection, which may be prevented by using correct infection control practices.

Tardive dyskinesia

Vermicular movements and protrusion of the tongue, chewing and puckering movements of the mouth, and puffing of the cheeks, is irreversible, even when the medication is withdrawn.

The nurse cares for a client who has schizophrenia and is taking chlorpromazine. Which side effects are considered late extrapyramidal side effects?

Worm-like tongue movements.

A client with schizophrenia who has auditory hallucinations is withdrawn and apathetic. What should the nurse say to involve this client in an activity?

Would you like to participate in the group walk today? : is a declarative statement that invites the client to walk, and the client can comply without making a verbal decision.

A Parkinsonian syndrome

a disorder featuring signs and symptoms of Parkinson disease such as resting tremors, muscle weakness, reduced movement, and festinating gait

A client with schizophrenia is often

ambivalent, rendering decision-making difficult.

Tachycardia, urine retention, and constipation are common side effects that occur with

antidepressants.

How are extra pyramidal side effects treated?

antiparkinsonian and or anticholinergic drugs

Digoxin's positive inotropic effect:

by altering the electrophysiological properties of the heart, slows the heart rate.

Cardiogenic shock causes the urine output drops to less than 30 mL/hr because of

decreased arterial perfusion to the kidneys and the compensatory mechanism of reabsorbing fluid to increase the circulating blood volume.

Neurogenic shock results from

decreased neuromuscular tone, which reduces vasoconstriction.

Cardiogenic shock results

from a decrease in cardiac output.

What are the symptoms of neurogenic shock?

hypotension, bradycardia, and warm, dry skin caused by the loss of adrenergic stimulation below the level of the lesion.

Distant heart sounds are associated with:

hypothyroidism

Women with signs of postpartum psychosis need

immediate medical attention to prevent suicide or infanticide. Postpartum psyhosis is a psychiatric emergency.

Acute dystonic reaction

impairment of muscle tonus.

The cardiac output is __________________ in hyperthyroidism.

increased

Nausea, vomiting, and muscle cramps are signs of

lithium toxicity.

Restlessness in cardiogenic shock

occurs because of cerebral hypoxia.

Obstructive shock occurs from

physical obstruction impeding the filling or outflow of blood, such as cardiac tamponade or pulmonary embolism.

Drowsiness, disorientation, and slurred speech are common side effects

that occur with central nervous system depressants.

A type and crossmatch will ensure

that the correct blood type will be administered to the client, preventing a transfusion reaction.

What is the normal range for hematocrit?

the expected hematocrit for women is 37% to 47% and for men is 42% to 52%.

Cardiogenic shock causes the skin

to become cool and pale as blood shunts from the peripheral blood vessels to the vital organs.

Spinal shock is caused by

transection of the spinal cord and results in a loss of reflex activity below the level of the injury.