Vocab

A client preparing to undergo a lumbar puncture states he doesn't think he will be able to get comfortable with his knees drawn up to his abdomen and his chin touching his chest. He asks if he can lie on his left side. Which statement is the best response by the nurse? "Lying on your left side will be fine during the procedure." "Although the required position may not be comfortable, it will make the procedure safer and easier to perform." "I'll report your concerns to the physician." "There's no other option but to assume the knee-chest position."

"Although the required position may not be comfortable, it will make the procedure safer and easier to perform."

A patient with a fractured left fibula is being taught how to use crutches. Which statement by the patient indicates that the teaching was effective? "I need to position the crutches even with my heels when standing." "I should make sure my underarms are supported by the tops of the crutches." "I need to allow my arms and hands to support my body weight." "I need to learn to use one type of gait for getting around."

"I need to allow my arms and hands to support my body weight." When using crutches, body weight is supported by the arms and hands. The top of the crutches should be approximately 2 inches below the axillae. The axillae should not support the weight of the body. Crutches should be positioned on either side of each foot, just slightly ahead of each foot. Patients should be taught two gaits so that they can change from one type to another to avoid fatigue. Additionally, a faster gait can be used when walking an uninterrupted distance, and a slower gait can be used for short distances or in crowded places.

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education? "I should participate in non-weight-bearing exercises." "I will stretch daily as directed by the physical therapist." "I will take hot tub baths to decrease spasms." "The exercises should be completed quickly to reduce fatigue."

"I will stretch daily as directed by the physical therapist."

The parents of a client intubated due to the progression of Guillain-Barré syndrome ask whether their child will die. What is the best response by the nurse? "It's too early to give a prognosis." "Don't worry; your child will be fine." "Once Guillain-Barré syndrome progresses to the diaphragm, survival decreases significantly." "There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive."

"There are no guarantees, but a large portion of people with Guillain-Barré syndrome survive." The survival rate of Guillain-Barré syndrome is approximately 90%. The client may make a full recovery or suffer from some residual deficits. Telling the parents not to worry dismisses their feelings and does not address their concerns. Progression of Guillain-Barré syndrome to the diaphragm does not significantly decrease the survival rate, but it does increase the chance of residual deficits. The family should be given information about Guillain-Barré syndrome and the generally favorable prognosis. With no prognosis offered, the parents are not having their concerns addressed.

Cerebellum components

- Cerebellar cortex (bulk of cerebellum) - Right and left hemispheres - Vermis, located centrally - Deep cerebellar nuclei.

Romberg test

-ask client to stand with feet at comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

Kubler-Ross stages of grief

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

The nurse is planning the care for a client at risk of developing pulmonary embolism. What nursing interventions should be included in the care plan? Select all that apply. Encouraging a liberal fluid intake Instructing the client to move the legs in a "pumping" exercise Using elastic stockings, especially when decreased mobility would promote venous stasis Instructing the client to dangle the legs over the side of the bed for 30 minutes, four times a day Applying a sequential compression device

1. Encouraging a liberal fluid intake 2. Instructing the client to move the legs in a"pumping" exercise 3. Using elastic stockings, especially when decreased mobility would promote venous stasis 4. Applying a sequential compression device The use of anti-embolism stockings or intermittent pneumatic leg compression devices reduces venous stasis. These measures compress the superficial veins and increase the velocity of blood in the deep veins by redirecting the blood through the deep veins. Having the client move the legs in a "pumping" exercise helps increase venous flow. Legs should not be dangled or feet placed in a dependent position while the client sits on the edge of the bed; instead, feet should rest on the floor or on a chair.

List Cranial Nerves

1. Olfactory 2. Optic 3. Oculomotor 4. Trochlear 5. Trigeminal 6. Abducens 7. Facial 8. Vestibulocochlear 9. Glossopharyngeal 10. Vagus 11. Accessory 12. Hypoglossal

A nurse is reviewing a patient's laboratory test results. Which serum albumin level would lead the nurse to suspect that the patient is at risk for pressure ulcers? 3.1 g/mL 2.5 g/mL 3.5 g/mL 4.0 g/mL

2.5 g/mL Serum albumin is a sensitive indicator of protein deficiency. Levels below 3 g/mL are associated with hypoalbuminemic tissue edema and increased risk of pressure ulcers.

Permanent brain injury or death will occur within which time frame secondary to hypoxia? 1 to 2 minutes 3 to 5 minutes 6 to 8 minutes 9 to 10 minutes

3 to 5 minutes

The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin?

3-5 days

A client who had a prosthetic valve replacement was taking warfarin to reduce the risk of postoperative thrombosis. The client visited the nurse at a clinic once a week. What INR level would alert the nurse to notify the health care provider? 3.4 3.0 2.6 3.8

3.8 Explanation:Coumadin patients usually have individualized target international normalized ratios (INRs) between 2 to 3.5 to maintain adequate anticoagulation. Levels below 2 to 2.5 can result in insufficient anticoagulation and levels greater than 3.5 can result in dangerous and prolonged anticoagulation.

A client is suspected to have bacterial meningitis. What is the priority nursing intervention? Administer prescribed antibiotics. Encourage oral fluid intake. Prepare the client for a CT scan. Assess the CSF fluid laboratory test results.

A client with suspected bacterial meningitis should receive antibiotic therapy within 30 minutes of arrival. Outcomes are usually better with early administration of antibiotics. Although the nurse should assess the CSF laboratory test results, antibiotic therapy should not be delayed waiting for the results. Encouraging oral fluids and preparing for a CT scan are appropriate interventions depending on the client, but the priority intervention is the early administration of antibiotics.

Seroma

A mass caused by the accumulation of serum within a tissue or an organ.Seromas may accumulate as a complication of surgery or after othertraumatic injuries to soft tissues.

A patient authorizes a son to make medical decisions and brings the completed forms for the nurse to place on the chart. What form does the nurse understand this is? A standard addendum to a will A living will An advance directive A proxy directive

A proxy directive Advance directives are written documents that allow competent people to document their preferences regarding the use or nonuse of medical treatment at the end of life, specify their preferred setting for care, and communicate other valuable insights into their values and beliefs. The addition of a proxy directive (the appointment and authorization of another person to make medical decisions on behalf of the person who created the advance directive when he or she can no longer speak for himself or herself) is an important addition to the living will or medical directive that specifies the signer's preferences.

Huntington's disease

A rare, dominant, genetic brain disorder caused by a defective gene on chromosomenumber 4 that has complete penetrance. The disease appears most often in middle-aged adults and leads to loss of nervecells and a buildup of the neurotransmitter dopamine. This causes involuntary twitching or jerking movements of the face andbody (chorea), alternating excitement and depression, and progressive DEMENTIA. The chorea can be controlled by drugsbut there is no treatment for the central problem. When the disease starts in childhood the inheritance is four times as likelyto be from the father than from the mother. The mechanism of the disease is unknown but it is thought that neural toxicityresults from the accumulation of amino-terminal fragments containing an expanded polyglutamine region.

Thyroid crisis

A sudden increase in the output of thyroxine and resultant extreme elevation of all body processes

Trendelenburg position

A supine position on the operating table, which is inclined at varying angles so that the pelvis is higher than the head; used during and after operations in the pelvis or for shock.

posterior pituitary hormones

ADH and oxytocin

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? Call the rapid response team because the patient is preparing to arrest. Place the patient in the supine position. Administer diphenhydramine (Benadryl) for the allergic reaction. Administer atropine to control the side effects of edrophonium.

Administer atropine to control the side effects of edrophonium.

The nurse is caring for a client in the early stages of sepsis. The client is not responding well to fluid resuscitation measures and has a worsening hemodynamic status. Which nursing intervention is most appropriate for the nurse to implement? Administer norepinephrine as prescribed. Begin a continuous IV infusion of insulin per protocol. Initiate enteral feedings as prescribed. Administer recombinant human activated protein C (rhAPC) as prescribed.

Administer norepinephrine as prescribed. Vasopressor agents are used if fluid resuscitation does not restore an effective blood pressure and cardiac output. Norepinephrine centrally administered is the initial vasopressor of choice. Ongoing research has found that rhAPC does not positively affect the outcome of clients with severe sepsis and it is no longer available for use. IV insulin may be implemented to treat hyperglycemia but is not indicated to improve hemodynamic status. Enteral feedings are recommended but not to improve hemodynamic status.

late signs of increased intracranial pressure (ICP)

Altered respiratory pattern Altered respiratory patterns are late signs of increased ICP and may indicate pressure or damage to the brainstem. Headache, irritability, and any change in LOC are early signs of increased ICP. Speech changes, such as slowed speech or slurring, are also early signs of increased ICP.

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?

An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.

Egophony

An extreme form of bronchophony, in which spoken words assume a nasal or bleating—goat-like—quality, which is most common when there is simultaneous lung consolidation and pleural fluid accumulation, but also heard in uncomplicated lobar pneumonia or pulmonary infarction

hydralazine

AntiHTN Vasodilator

Isosorbide dinitrate (Isordil)

Antianginal, Nitrates

A client with myasthenia gravis is admitted with an exacerbation. The nurse is educating the client about plasmapheresis and explains this in which of the following statements? Immune globulin is given intravenously. Mestinon therapy is initiated. Antibodies are removed from the plasma. The thymus gland is removed.

Antibodies are removed from the plasma. Plasmapheresis is a technique in which antibodies are removed from plasma and the plasma is returned to the client. The other three choices are appropriate treatments for myasthenia gravis, but are not related to plasmapheresis.

Which medication classification should be avoided in the treatment of brain tumors? Anticoagulants Osmotic diuretics Anticonvulsants Corticosteroids

Anticoagulants

A patient has been diagnosed with hyphema. Which of the following medicationclassifications stabilizes clot formation at the site of hemorrhage? Antiplatelets Antifibrinolytics Corticosteroids Diuretics

Antifibrinolytics

Which method to induce hemostasis after sheath removal after percutaneous transluminal coronary angioplasty (PTCA) is most effective? Direct manual pressure Application of a vascular closure device such as Angio-Seal or VasoSeal Application of a pneumatic compression device (e.g., FemoStop) Application of a sandbag to the area

Application of a vascular closure device such as Angio-Seal or VasoSeal Explanation :Application of a vascular closure device has been demonstrated to be very effective. Direct manual pressure to the sheath introduction site and application of a pneumatic compression device after PTCA have been demonstrated to be effective; the former was the first method used to induce hemostasis after PTCA. Several nursing interventions frequently used as part of the standard of care, such as applying a sandbag to the sheath insertion site, have not been shown to be effective in reducing the incidence of bleeding.

For the client who is taking aspirin, it is important to stop taking this medication at least how many day(s) before surgery? 7 5 1 3

Aspirin should be stopped at least 7 to 10 days before surgery. The other time frames are incorrect.

A client with AML has pale mucous membranes and bruises on the legs. What is the primary nursing intervention? Assess the client's skin. Assess the client's pulse and blood pressure. Assess the client's hemoglobin and platelets. Check the client's history.

Assess the client's hemoglobin and platelets. Clients with AML may develop pallor from anemia and a tendency to bleed because of a low platelet count. Assessing the client's hemoglobin and platelets will help to determine whether this is the cause of the symptoms. This would be the priority above assessing pulses, blood pressure, history, or skin.

The client takes naproxen for arthritic pain and is now prescribed warfarin for persistent atrial fibrillation. Due to the interactions of the medications, what is the nurse's best response? Assess the client's stool for color Inform the client to decrease alcohol to one glass each day Administer both medications with food to increase absorption Teach the client to ingest foods high in vitamin K

Assess the client's stool for color Clients who take NSAIDs, such as naproxen (Aleve), with warfarin (Coumadin) may experience gastrointestinal bleeding. The nurse will need to monitor for this. Clients are to ingest a consistent level of vitamin K. Administering the medications with food does not increase absorption. Ingesting food with the medications may decrease gastrointestinal upset. Clients are instructed to not ingest alcohol.

The nurse is assessing a male client with multiple sclerosis (MS). What education would the nurse provide to assist the client in managing this disease? Select all that apply. Avoidance of hot temperatures Recommend bone mineral density testing Participation in occupational therapy Effective treatment of anemia Treatment of any episodes of depression

Avoidance of hot temperatures] Participation in occupational therapy Effective treatment of anemia Treatment of any episodes of depression Multiple sclerosis (MS) is an immune-mediated, progressive demyelinating disease of the central nervous system (CNS). Fatigue affects most people with MS and is often the most disabling symptom. Heat, depression, anemia, deconditioning, and medication may contribute to fatigue. Avoiding high temperatures, effective treatment of depression and anemia, a change in medication, as well as occupational and physical therapy may help manage fatigue. Pain is another common symptom of MS. Bone mineral testing is recommended for women with MS who are perimenopausal. This group of clients are likely to have pain related to osteoporosis.

The nurse is caring for a client diagnosed with unstable angina who is receiving IV heparin. The client requires bleeding precautions. Bleeding precautions include which measure? Avoid the use of nail clippers Avoid subcutaneous injections Avoid continuous BP monitoring Use an electric toothbrush

Avoiding continuous BP monitoring Explanation:The patient receiving heparin is placed on bleeding precautions, which can include: applying pressure to the site of any needle punctures for a longer time than usual, avoiding intramuscular injections, avoiding tissue injury and bruising from trauma or constrictive devices (e.g. continuous use of an automatic BP cuff). SQ injections are permitted; a soft toothbrush should be used, and the patient may use nail clippers, but with caution.

Which of the following tests confirms the diagnosis of myasthenia gravis (MG)? Computed tomography (CT) scan Serum studies Tensilon test Electromyogram (EMG)

B, Edrophonium chloride (Tensilon) is an acetylcholinesterase inhibitor that stops the breakdown of acetylcholine. The drug is used because it has a rapid onset of 30 seconds and a short duration of 5 minutes. Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis. The presence of acetylcholine receptor antibodies is identified in serum. Repetitive nerve stimulation demonstrates a decrease in successive action potentials. The thymus gland may be enlarged in MG, and a T scan of the mediastinum is performed to detect thymoma or hyperplasia of the thymus.

The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following? Virus Lymphoma Bacteria Leukemia

Bacteria Septic meningitis is caused by bacteria. In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.

The nurse is using a measurement tool to determine a patient's level of independence in activities of daily living, such as continence, toileting, transfers, and ambulation. What would be the appropriate tool for the nurse to use? Barthel Index The Braden Scale Patient evaluation conference system The Pulses Profile

Barthel Index The Barthel Index (Mahoney & Barthel, 1965) is used to measure the patient's level of independence in ADLs, continence, toileting, transfers, and ambulation (or wheelchair mobility). This scale does not address communicative or cognitive abilities. The Patient Evaluation Conference System (PECS) (Harvey, Hollis, & Jellinek, 1981), which contains 15 categories, is a comprehensive assessment scale that includes such areas as medications, pain, nutrition, use of assistive devices, psychological status, vocation, and recreation. The PULSES profile (Granger, Albrecht, & Hamilton, 1979) is used to assess physical condition (e.g., health/ illness status), upper extremity functions (e.g., eating, bathing), lower extremity functions (e.g., transfer, ambulation), sensory function (e.g., vision, hearing, speech), bowel and bladder function (i.e., control of bowel or bladder), and situational factors (e.g., social and financial support). Each of these areas is rated on a scale from one (independent) to four (greatest dependency). Scales such as the Braden scale (Table 10-3) or Norton scale (Norton, McLaren, & Exon-Smith, 1962) may be used to facilitate systematic assessment and quantification of a patient's risk for pressure ulcer

A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA). Which action should the nurse take first in the management of DKA?

Begin fluid replacements. Explanation: Management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin.

The nurse is assessing a client with advanced gastric cancer. The nurse anticipates that the assessment will reveal which finding? Weight gain Bloating after meals Increased appetite Abdominal pain below the umbilicus

Bloating after meals Symptoms of progressive disease include bloating after meals, weight loss, abdominal pain above the umbilicus, loss or decrease in appetite, and nausea or vomiting.

hyphema

Blood in anterior chamber of the eye, as seen during the fundoscopic exam

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Extreme thirst Intake and output Nutritional status Body temperature

Body temperature

The nurse is reviewing the initial laboratory test results of a client diagnosed with DKA. Which of the following would the nurse expect to find?A. Serum bicarbonate of 19 mEq/LB. Blood glucose level of 250 mg/dLC. Blood pH of 6.9D. PaCO2 of 40 mm Hg

CR: With DKA, blood glucose levels are elevated to 300 to 1000 mg/dL or more. Urine contains glucose and ketones. The blood pH ranges from 6.8 to 7.3. The serum bicarbonate level is decreased to levels from 0 to 15 mEq/L. The compensatory breathing pattern can lower the partial pressure of carbon dioxide in arterial blood (PaCO2) to levels of 10 to 30 mm Hg.

During the preoperative assessment, the nurse learns that the client has been taking prednisone. The nurse realizes that the client is at risk for: Decreased blood pressure. Cardiovascular collapse. Respiratory depression. Increased blood loss.

Cardiovascular collapse. Prednisone, a corticosteroid, can result in cardiovascular collapse if suddenly discontinued. A bolus of corticosteroid may be given intravenously immediately before and after surgery. Hydrochlorothiazide and anesthetics may interact, resulting in respiratory depression. Phenothiazines may potentiate the hypotensive action of anesthetics. Anticoagulants can increase the risk of bleeding.

In which location are most brain angiomas located? Thalamus Brainstem Cerebellum Hypothalamus

Cerebellum

A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L, serum sodium level 140 mEq/L, and urine specific gravity 1.025. The client has two IV lines in place with normal saline solution infusing through both. Over the past 4 hours, his total urine output has been 50 ml. Which physician order should the nurse question?

Change the second I.V. solution to dextrose 5% in water. Explanation: The nurse should question the physician's order to change the second I.V. solution to dextrose 5% in water. The client should receive normal saline solution through the second I.V. site until his blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client's urine output is low and his specific gravity is high, which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level places the client at risk for life-threatening cardiac arrhythmias.

labile

Changing rapidly and often

A client presents with severe diarrhea and a history of chronic renal failure to the emergency department. Arterial blood gas results are as follows: pH 7.30 PaO2 97 PaCO2 37 HCO3 18 The nurse would expect which of the following sets of assessment findings?

Clammy skin, blood pressure 86/46, headache Metabolic acidosis, a common clinical disturbance, is characterized by decreased pH and plasma bicarbonate concentration. Common causes of metabolic acidosis include diarrhea, chronic renal failure, use of diuretics, intestinal fistulas, and ureterostomies. The client will experience the following signs and symptoms: headache, confusion, increased respiratory rate, nausea, vomiting, cold and clammy skin, and decreased blood pressure.

Rhinorrhea

Clear nasal discharge, "runny nose"

The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. What instruction should the nurse give to the parents? Use nasal packing for any nose bleeds Encourage the toddler to participate in playground activities with other toddlers Administer factor VIII intravenously at the first sign of bleeding Administer over-the-counter preparations for a cold

Clients and families are taught to administer factor VIII intravenously. This helps to prevent bleeding episodes. Activities that minimize trauma are allowed for the toddler, however, playground activities may place the toddler at risk for increased bleeding. Over-the-counter cold preparations are to be avoided because they will interfere with platelet aggregation. Nasal packing is avoided because when the nasal packing is removed, bleeding may occur.

Which medication is given to clients who are diagnosed with angina but are allergic to aspirin? Amlodipine Clopidogrel Diltiazem Felodipine

Clopidogrel

The nurse caring for a client is providing instructions for an upcoming renal angiography. Which nursing action, explained in the preoperative instructions, is essential in the postprocedure period? Complete a pulse assessment of the legs and feet. Encourage voiding following the procedure. Assess cognitive status. Assess renal blood work.

Complete a pulse assessment of the legs and feet. A renal angiography provides details about the arterial blood supply to the kidney. A catheter is passed up the femoral artery into the aorta in the area of the renal artery. After the procedure, a pressure dressing remains in place for several hours. It is essential that the nurse palpates pulses in the legs and feet at least every 1 to 2 hours for signs of arterial occlusion. Reviewing lab work is completed in the preoperative period. Voiding assesses renal status that provides additional data in the post procedural period. Assessing cognitive status is completed due to the sedative that is administered in the preprocedural period.

The nurse plans care for a client with obesity. What does the nurse recognize is the primary pathophysiological reason clients with obesity are at greater risk for developing thromboembolism?

Compromised peripheral blood flow A client with obesity is at increased risk for developing thromboembolism due to compromised blood flow and resulting venous stasis. Although the client with obesity is at risk for high cholesterol levels, increased fat in the blood does not directly impact the risk for developing thromboembolism. Increased blood viscosity and impaired clotting do not typically occur in obesity and are not the reason a client with obesity would be at greater risk for developing thromboembolism.

Volkmann's contracture

Condition in which the muscles in the palm side of the forearm shorten, causing the fingers to form a fist and the wrist to bend

Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Tetany and increased blood urea nitrogen (BUN) levels Sunken eyeballs and spasticity Confusion and seizures Flaccidity and thirst

Confusion and seizures Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur. Sunken eyeballs, thirst, and increased BUN levels indicate fluid volume deficit. Spasticity, flaccidity, and tetany are unrelated to water intoxication.

The nurse is caring for an older client whose chart reveals that the client has a reversible cause of urinary incontinence. The nurse creates a plan of care for which condition? Asthma Constipation Bladder cancer Decreased progesterone levels

Constipation Constipation is a reversible cause of urinary incontinence in the older adult. Other reversible causes include acute urinary tract infection, infection elsewhere in the body, decreased fluid intake, a change in a chronic disease pattern, and decreased estrogen levels in the menopausal woman. The other answers do not apply.

A vasoactive medication is prescribed for a patient in shock to help maintain MAP and hemodynamic stability. A medication that acts on the alpha-adrenergic receptors of the SNS is ordered. Its purpose is to: Vasodilate the skeletal muscles. Relax the bronchioles. Constrict blood vessels in the cardiorespiratory system. Decrease heart rate.

Constrict blood vessels in the cardiorespiratory system. Alpha- and beta-adrenergic receptors work synergistically to improve hemodynamic stability. Alpha receptors constrict blood vessels in the cardiorespiratory and gastrointestinal systems, as well as in the skin and kidneys.

A nurse is providing in-home hospice care to a terminally ill client. The client experiences a medical crisis requiring monitoring and medication administration. Which level of hospice care would the nurse implement? Routine home care Continuous care General inpatient care Inpatient respite care

Continuous care

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?

Contusions can be characterized by loss of consciousness associated with stupor and confusion. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brainstem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

The nurse is caring for a client who is in neurogenic shock. The nurse knows that this is a subcategory of what kind of shock? Obstructive Carcinogenic Hypovolemic Distributive

Correct response: Distributive Explanation: Three types of distributive shock are neurogenic, septic, and anaphylactic shock. There is no such thing as carcinogenic shock. Obstructive and hypovolemic shock do not have subcategories.

When the nurse observes that the client's systolic blood pressure is less than 80 mm Hg, respirations are rapid and shallow, heart rate is over 150 beats per minute, and urine output is less than 30 cc/hour, the nurse recognizes that the client is demonstrating which stage of shock? Compensatory Progressive Irreversible Refractory

Correct response: Progressive Explanation: In progressive shock, the client's skin appears mottled and mentation demonstrates lethargy; the client will be clinically hypotensive. In compensatory shock, the client's blood pressure is normal, respirations are above 20, and heart rate is above 100 but below 150. In refractory or irreversible shock, the client requires complete mechanical and pharmacologic support.

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, would not be manifested by which of the following?

Cranial nerve demyelination can result in a variety of clinical manifestations. Optic nerve demyelination may result in blindness. Bulbar muscle weakness related to demyelination of the glossopharyngeal and vagus nerves results in the inability to swallow or clear secretions. Vagus nerve demyelination results in autonomic dysfunction, manifested by instability of the cardiovascular system. The presentation is variable and may include tachycardia, bradycardia, hypertension, or orthostatic hypotension.

The nurse is caring for a client who was admitted to the telemetry unit with a diagnosis of "rule/out acute MI." The client's chest pain began 3 hours earlier. Which laboratory test would be most helpful in confirming the diagnosis of a current MI? Creatine kinase-myoglobin (CK-MB) level Troponin C level Myoglobin level CK-MM

Creatine kinase-myoglobin (CK-MB) level Elevated CK-MB assessment by mass assay is an indicator of acute MI; the levels begin to increase within a few hours and peak within 24 hours of an MI. If the area is reperfused (due to thrombotic therapy or PCI), it peaks earlier. CK-MM (skeletal muscle) is not an indicator of cardiac muscle damage. There are three isomers of troponin: C, I, and T. Troponin I and T are specific for cardiac muscle, and these biomarkers are currently recognized as reliable and critical markers of myocardial injury. An increase in myoglobin is not very specific in indicating an acute cardiac event; however, negative results are an excellent parameter for ruling out an acute MI.

Spinal Shock

Critical care Neurogenic shock A clinical complex caused by trauma to the vertebral column andspinal cord, resulting in a transient-3-6 wk in duration-loss of reflex activity due to functional or anatomic interruption of thecorticospinal tracts; SS is seen immediately after complete injury at the T6 level or above, and is accompanied by arreflexia,loss of sensation, flaccid paralysis below the level of the lesion, flaccid bladder with urine retention, and lax anal sphincterObstetrics An idiopathic postpartum vasomotor collapse that follows spinal anesthesia, 2º to various stressants of delivery-eg, acute blood loss, electrolytic imbalance, adrenocortical insufficiency, pre-eclampsia, anesthetics, amniotic fluid embolism.

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

Damage to the midbrain causes decerebrate posturing that's characterized by abnormal extension in response to painful stimuli. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.

A nurse is caring for a client who has suffered a hip fracture and who will require an extended hospital stay. The nurse should ensure that the client does what action to prevent common complications associated with a hip fracture?

Deep vein thrombosis (DVT) is among the most common complications related to a hip fracture. To prevent DVT, the nurse encourages intake of fluids and ankle and foot exercises. The patient should not be told to endure pain; a proactive approach to pain control should be adopted. While respiratory complications commonly include atelectasis and pneumonia, the use of deep-breathing exercises, changes in position at least every 2 hours, and the use of incentive spirometry help prevent the respiratory complications more than using supplementary oxygen. Bed rest may be indicated in the short term, but is not normally required for 14 days.

granulocytopenia

Deficiency of granulocytes (white blood cells).

A client nearing the end of life is experiencing delirium. Which action will the nurse take to help this client?

Delirium can develop in the client who is near the end of life and may be due to an underlying treatable condition or the effects of the disease process. Actions should be taken to identify the underlying cause and provide appropriate interventions. The presence of familiar faces helps reduce the anxiety caused by the delirium. Restraints are not identified as an appropriate intervention for the client with delirium. Environmental stimuli should be reduced and harsh lighting avoided as these can increase the anxiety associated with delirium.

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is Salt-poor albumin Plasma Dextran Packed red blood cells

Dextran

A client is hemorrhaging following chest trauma. Blood pressure is 74/52, pulse rate is 124 beats per minute, and respirations are 32 breaths per minute. A colloid solution is to be administered. The nurse assesses the fluid that is contraindicated in this situation is

Dextran may interfere with platelet aggregation in clients who are in hypovolemic shock as a result of a hemorrhage. The other options are appropriate solutions to administer in this situation.

After the patient has received tPA, the nurse knows to check vital signs every 30 minutes for 6 hours. Which of the following readings would require calling the provider? Respiration of 22 Systolic pressure of 130 mm Hg Heart rate of 100 Diastolic pressure of 110 mm Hg

Diastolic pressure of 110 mm Hg A diastolic pressure reading of over 105 mm Hg warrants notifying the health care provider. The other choices are within normal range. Refer to Table 47-5 in the text.

DASH diet

Dietary Approaches to Stop Hypertension

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe? Numbness Diplopia and ptosis Patchy blindness Loss of proprioception

Diplopia and ptosis The initial manifestation of myasthenia gravis involves the ocular muscles, such as diplopia and ptosis. The remaining choices relate to multiple sclerosis.

The nurse received a patient from a motor vehicle accident who is hemorrhaging from a femoral wound. What is the initial nursing action for the control of the hemorrhage?

Direct, firm pressure is applied over the bleeding area or the involved artery at a site that is proximal to the wound (Fig. 72-3). Most bleeding can be stopped or at least controlled by application of direct pressure. Otherwise, unchecked arterial bleeding results in death. A firm pressure dressing is applied, and the injured part is elevated to stop venous and capillary bleeding, if possible. If the injured area is an extremity, the extremity is immobilized to control blood loss. A tourniquet is applied to an extremity only as a last resort when the external hemorrhage cannot be controlled in any other way and immediate surgery is not feasible.

Which of the following is a disorder due to a lesion in the basal ganglia? Multiple sclerosis Guillain-Barré Myasthenia gravis Parkinson's disease

Disorders due to lesions of the basal ganglia include Parkinson's disease, Huntington's disease, and spasmodic torticollis.

What is the major clinical use of dobutamine?

Dobutamine (Dobutrex) increases cardiac output for clients with acute heart failure and those undergoing cardiopulmonary bypass surgery. Physicians may use epinephrine hydrochloride, another catecholamine agent, to treat sinus bradycardia. Physicians use many of the catecholamine agents, including epinephrine, isoproterenol, and norepinephrine, to treat acute hypotension. They don't use catecholamine agents to treat hypertension because catecholamine agents may raise blood pressure.

Immediately on cessation of vital functions, the body begins to change. The nurse would expect which physical change to occur following death?

Dusky appearance The body becomes dusky or bluish, waxen-appearing, and cool; blood darkens and pools in dependent areas of the body, and urine and stool may be evacuated.

emphysema

Emphysema is a chronic respiratory disease where there is over-inflation of the air sacs (alveoli) in the lungs, causing adecrease in lung function, and often, breathlessness.

A client underwent a continent ileostomy. Within which time frame should the client expect to empty the reservoir? At least once every 2 days Every 4 to 6 hours Three or four times daily At least once a day

Every 4 to 6 hours

Bell palsy is a disorder of which cranial nerve? Vestibulocochlear (VIII) Vagus (X) Facial (VII) Trigeminal (V)

Facial (VII) Bell palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia, a disorder of the trigeminal nerve, causes facial pain. Ménière syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barré syndrome is a disorder of the vagus nerve.

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? Chest pain on inspiration Clubbing of fingers and toes Respiratory acidosis Paradoxical chest movement

Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.

A nurse is developing a teaching plan for a patient with urinary incontinence who will be performing intermittent self-catheterization. Which of the following would be most important for the nurse to emphasize? Cleaning the client's used catheters with water and allowing to air dry Maintaining sterility of the equipment Following a regular emptying schedule Using bladder distention to signal need for insertion

Following a regular emptying schedule When intermittent self-catheterization is used, the nurse would emphasize regular emptying of the bladder rather than sterility. The catheter is inserted for the length of time it would take to empty the bladder. A regular schedule, not evidence of bladder distention, is used to guide the frequency of the procedure.

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use? PULSES profile Functional Independence Measure Patient Evaluation Conference System Barthel Index

Functional Independence Measure One of the most frequently used tools to assess the patient's level of independence is the Functional Independence Measure (trade marked- FIM), a minimum data set consisting of 18 items. The PULSES profile, Barthel Index, and Patient Evaluation Conference System also are used, but these are more generic measures.

Nursing students are reviewing the various types of brain tumors. The students demonstrate understanding of the material when they identify which of the following as the most common type? Acoustic neuromas Meningiomas Pituitary adenomas Gliomas

Gliomas are the most common type of intracerebral brain tumor. Meningiomas account for approximately 15% of all primary brain tumors. Pituitary adenomas represent approximately 10% to 15% of all brain tumors. Acoustic neuromas are less common.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? Nausea, vomiting, and profuse sweating Difficulty breathing or swallowing Tachycardia, tachypnea, and hypotension Hemiplegia, seizures, and decreased level of consciousness

Hemiplegia, seizures, and decreased level of consciousness Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.

A client's electronic health record states that the client receives regular transfusions of factor IX. The nurse would be justified in suspecting that this client has what diagnosis? Hypoproliferative anemia Hodgkin lymphoma Leukemia Hemophilia

Hemophilia Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.

Which condition may occur during the postoperative period in a client who underwent adrenalectomy because of sudden withdraw of excessive amounts of catecholamines?

Hypotension and hypoglycemia may occur in the postoperative period because of the sudden withdrawal of excessive amounts of catecholamines.

Which stage of anesthesia is referred to as surgical anesthesia? IV II III I

III Stage III may be maintained for hours with proper administration of the anesthetic. Stage I is beginning anesthesia, where the client breathes in the anesthetic mixture and experiences warmth, dizziness, and a feeling of detachment. Stage II is the excitement stage, which may be characterized by struggling, singing, laughing, or crying. Stage IV is a state of medullary depression and is reached when too much anesthesia has been administered.

Asthma is cause by which type of response?

IgE-mediated Atopy, the genetic predisposition for the development of an IgE-mediated response to allergens, is the most common identifiable predisposing factor for asthma. Chronic exposure to airway allergens may sensitize IgE antibodies and the cells of the airway.

arthrogram

Imaging of a joint following the introduction of a contrast agent into the joint capsule to enhance visualization of theintraarticular structures.

Morphine sulfate has which of the following effects on the body?

In addition to relieving pain, morphine dilates the blood vessels. This reduces the workload of the heart by both decreasing the cardiac filing pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload).

Myasthenia gravis occurs when antibodies attack which receptor sites? Serotonin Acetylcholine Dopamine Gamma-aminobutyric acid

In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and gamma-aminobutyric acid are not receptor sites that are attacked in myasthenia gravis.

A comatose client is being cared for by a critical care nurse who documents that the client responds only to very painful stimuli by fragmentary, delayed reflex withdrawal. The nurse knows that reflexes in the body are centered where? In the medulla oblongata In the spinal cord In the midbrain In the pons

In the spinal cord The spinal cord functions as a passageway for ascending sensory and descending motor neurons. Its two main functions are to provide centers for reflex action and to serve as a pathway for impulses to and from the brain. Reflex centers are not in the pons, the medulla, or the midbrain.

The nurse is caring for a critically ill client. Which of the following is the nurse correct to identify as a positive effect of catecholamine release during the compensation stage of shock? a) Regulation of sodium and potassium b) Increase in arterial oxygenation c) Decreased white blood cell count d) Decreased depressive symptoms

Increase in arterial oxygenation Catecholamines are neurotransmitters that stimulate responses via the sympathetic nervous system. A positive effect of catecholamine release increases heart rate and myocardial contraction as well as bronchial dilation improving the efficient exchange of oxygen and carbon dioxide. They do not decrease WBCs or decrease the depressive symptoms. They do not regulate sodium and potassium.

A patient with a brain tumor is complaining of headaches that are worse in the morning. What does the nurse know could be the reason for the morning headaches? The tumor is shrinking. Increased intracranial pressure Migraines Dehydration

Increased intracranial pressure

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? Decreased heart rate Decreased level of consciousness (LOC) Increased restlessness Increased blood pressure

Increased restlessness

Guillain-Barré syndrome

Inflammation of the myelin sheath of peripheral nerves, characterized by rapidly worsening muscle weakness that may lead to temporary paralysis; also known as infectious polyneuritis.

Calcitonin (CT)

Inhibits the breakdown of bone; causes a decrease in blood calcium concentration

An emergency department nurse is interviewing a client who is presenting with signs of an ischemic stroke that began 2 hours ago. The client reports a history of a cholecystectomy 6 weeks ago and is taking digoxin, warfarin, and labetalol. What factor poses a threat to the client for thrombolytic therapy? Taking digoxin Two hour time period of the stroke International normalized ratio greater than 2 Surgery 6 weeks ago

International normalized ratio greater than 2; She is taking coumadin. To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit thrombolytic therapy.

A nurse practitioner provides health teaching to a patient who has difficulty managing hypertension. This patient is at an increased risk of which type of stroke?

Intracerebral Hemorrhage

Nystagmus

Involuntary rapid eye movements

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area? Scapula Lateral malleolus Greater trochanter Ischial tuberosity

Ischial tuberosity For a client who sits for prolonged periods, such as in a wheelchair, the ischial tuberosity would be highly susceptible to pressure ulcer development. Areas such as the greater trochanter and lateral malleolus would be susceptible for clients lying on their side. The scapula would be considered a high risk area for clients lying on their back.

Which nutritional deficiency may delay wound healing? Lack of vitamin D Lack of vitamin E Lack of calcium Lack of vitamin C

Lack of vitamin C

A client has experienced an ischemic stroke that has damaged the frontal lobe of his brain. Which of the following deficits does the nurse expect to observe during assessment? Limited attention span and forgetfulness Visual and auditory agnosia Hemiplegia or hemiparesis Lack of deep tendon reflexes

Limited attention span and forgetfulness Damage to the frontal lobe may impair learning capacity, memory, or other higher cortical intellectual functions. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and a lack of motivation. Damage to the motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes. Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia.

Calcitonin

Lowers blood calcium levels

Myasthenia gravis

MG affects the neuromuscular junction, interrupting the communication between nerve and muscle, and thereby causing weakness. A person with MG may have difficulty moving their eyes, walking, speaking clearly, swallowing, and even breathing, depending on the severity and distribution of weakness. Increased weakness with exertion, and improvement with rest, is a characteristic feature of MG. About 30,000 people in the United States are affected by MG. It can occur at any age, but is most common in women who are in their late teens and early twenties, and in men in their sixties and seventies.

Creutzfeldt-Jakob disease (vCJD)

Mad cow disease in humans. Caused by prions, mis-folded form of normal brain cell protein. Terminal illness.

Vomiting results in which of the following acid-base imbalances?

Metabolic Alkalosis Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

Monro-Kellie

Which of the following is considered a central nervous system (CNS) disorder? Guillain-Barré Multiple sclerosis Myasthenia gravis Bell's palsy

Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.

Which "awareness context" is characterized by the client, family, and health care professionals understanding that the client is dying, but all pretend otherwise? Mutual pretense awareness Suspected awareness Closed awareness Open awareness SUBMIT ANSWER

Mutual pretense awareness In mutual pretense awareness, the client, the family, and the health care professionals are aware that the client is dying, but all pretend otherwise. In closed awareness, the client is unaware of his or her terminal state, whereas others are aware. In suspected awareness, the client suspects what others know and attempts to find it out. In open awareness, all are aware that the client is dying and are able to acknowledge that reality openly.

When the patient has lost the ability to compensate for the insult, vital organs begin to show signs of dysfunction. Which of the following is one of the first signs of organ failure?

Myocardial depressionThe body's inability to meet increased oxygen requirements produces ischemia, and biochemical mediators cause myocardial depression. This leads to failure of the cardiac pump, even if the underlying cause of the shock is not of cardiac origin.

Best time of day to schedule your patient's BM?

Natural gastrocolic and duodenocolic reflexes occur about 30 minutes after a meal; therefore, after breakfast is one of the best times to plan for bowel evacuation.

A client comes to the emergency department complaining of vision changes, nausea, vomiting, diarrhea, and tightness in the chest. The client reports that he was out on his farm spraying some pesticides. Based on the client's information, the nurse would suspect exposure to which of the following? Vesicant Blood agent Pulmonary agent Nerve agent

Nerve agent The client was working with pesticides, organophosphates, which are considered nerve agents. The client's signs and symptoms also reflect exposure to a nerve agent.

Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock? Neurogenic Septic Anaphylactic Cardiogenic

Neurogenic The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.

A nurse reviews a client's medication history before administering a cholinergic blocking agent. Adverse effects of a cholinergic blocking agent may delay absorption of what medication? Digoxin Amantadine Diphenhydramine Nitroglycerin

Nitroglycerin

A client is admitted to the hospital with acute hemorrhage from esophageal varices. What medication should the nurse anticipate administering that will reduce pressure in the portal venous system and control esophageal bleeding? Vasopressin Octreotide Epinephrine Vitamin K

Octreotide (Sandostatin) Acute hemorrhage from esophageal varices is lifethreatening. Resuscitative measures include administration of IV fluids and blood products. IV octreotide (Sandostatin) is started as soon as possible. Sandostatin is preferred because of fewer side effects. Octreotide reduces pressure in the portal venous system and is preferred to the previously used agents, vasopressin (Pitressin) or terlipressin. Vitamin K promotes blood coagulation in bleeding conditions, resulting from liver disease.

The nursing instructor is teaching the senior nursing class about neuromuscular disorders. When talking about Multiple Sclerosis (MS) what diagnostic finding would the instructor list as being confirmatory of a diagnosis of MS? An elevated acetylcholine receptor antibody titer Oligoclonal bands IV administration of edrophonium Episodes of muscle fasciculations

Oligoclonal bands

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: NS at 60 mL/hr via an intravenous line Morphine 2 mg intravenously Dopamine (Intropin) intravenous solution Oxygen at 2 L/min by nasal cannula

Oxygen at 2 L/min by nasal cannula

Which term is used to describe a tachycardia characterized by abrupt onset, abrupt cessation, and a QRS of normal duration? Atrial flutter Atrial fibrillation Paroxysmal atrial tachycardia Sinus tachycardia

Paroxysmal atrial tachycardia

Vision and visual fields are altered in disorders of which of the following endocrine glands? Pituitary Parathyroid Thyroid Pancreas

Pituitary

Decerebrate prognosis

Poor

Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced? Photophobia Positive Brudzinski sign Positive Kerning sign Nuchal rigidity

Positive Brudzinski sign A positive Brudzinski sign occurs when the client's neck is flexed (after ruling out cervical trauma or injury) and flexion of the knees and hips is produced. Photophobia is sensitivity to light. A positive Kerning sign occurs when the client is lying with the thigh flexed on the abdomen and the leg cannot be completely extended. Nuchal rigidity is neck stiffness.

The nurse is assessing a newly admitted client with a diagnosis of meningitis. On assessment, the nurse expects to find which of the following? Hyper-alertness Positive Kernig's sign Negative Brudzinski's sign Positive Romberg sign

Positive Kernig's sign A positive Kernig's sign is a common finding in the client with meningitis. When the client is lying with the thigh flexed on the abdomen, the leg cannot be completely extended. A positive Brudzinski's sign is usual with meningitis. The Romberg sign would not be tested in this client. The client will develop lethargy as the illness progresses, not hyper-alertness.

pericardiotomy syndrome

Postcommissurotomy syndrome A condition of acute onset characterized by fever, pericarditis, pleuritis that develops ≥ 2 wks after cardiac surgery, in which the pericardium has been 'violated' by wide incision and manipulation Clinical Malaise, fever, pericarditis, friction rub, chest pain, pleuritis Management Aspirin, NSAIDs, if unresponsive, corticosteroids Prognosis PPS is usually self-limited, but often recurs and may be disabling.

A rehabilitation nurse is preparing a presentation for clients and caregivers about issues that clients with disabilities may face. Which of the following would be most appropriate for the nurse to include in the presentation? Fatigue primarily results from physical demands. Most care tasks required after discharge focus on the physical care. Priority setting is helpful in dealing with the impact of the disability. A loss of sexual functioning correlates with a loss of sexual feeling. SUBMIT ANSWER

Priority setting is helpful in dealing with the impact of the disability. For clients with disabilities, the nurse would emphasize the use of coping strategies and teach the patient how to cope with the disability through priority setting. A loss of sexual functioning does not necessarily correspond to a loss of sexual feeling. Rather, the physical and emotional aspects of sexuality, despite the physical loss of function, continue to be important for people with disabilities. The fatigue associated with disabilities results from numerous factors, such as the physical and emotional demands, as well as the ineffective coping, unresolved grief, disordered sleep patterns, and depression. Although the most obvious care tasks after discharge involve physical care, other elements of the caregiving role include psychosocial support and a commitment to this supportive role.

cachexia

Profound protein loss a condition of physical wasting away due to the loss of weight and muscle mass that occurs in patients with diseases such as advanced cancer or AIDS Cachexia is associated with anabolic and catabolic changes in metabolism that relate to activity of neurohormones and proinflammatory cytokines, resulting in profound protein loss. Although anorexia may exacerbate cachexia, it is not a primary cause. Starvation refers to simple food deprivation and is not cachexia. Anorexia-cachexia syndrome, characterized by disturbances in carbohydrate, protein, and fat metabolism, endocrine dysfunction, and anemia results in severe asthenia (loss of energy).

A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? Protamine sulfate Phytonadione (vitamin K) Plasma protein fraction Thrombin

Protamine sulfate is the antidote specific to heparin. Phytonadione (vitamin K) is the antidote specific to oral anticoagulants such as warfarin. (Heparin isn't given orally.) Thrombin is a hemostatic agent used to control local bleeding. Plasma protein fraction, a blood derivative, supplies colloids to the blood and expands plasma volume; it's used to treat clients who are in shock.

The nurse is caring for a client who is scheduled for a percutaneous liver biopsy. Which diagnostic test is obtained prior? Prothrombin time (PT) Complete blood count (CBC) Erythrocyte sedimentation rate (ESR) Blood chemistry

Prothrombin time (PT) The client must have coagulation studies before the procedure such as a PT or PTT because a major complication after a liver biopsy is bleeding. Clients at risk for serious bleeding may receive precautionary vitamin K. A complete blood count and blood chemistry may be completed for baseline values. Typically, an ESR is not associated with the procedure.

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome? Psychosis, disorientation, delirium, insomnia, and hallucinations Severe dementia and myoclonus Choreiform movement and dementia Tremor, rigidity, and bradykinesia

Psychosis, disorientation, delirium, insomnia, and hallucinations Advances in technology have led to the introduction of interventional neuroradiology for the treatment of aneurysms. Endovascular techniques may be used in selected clients to occlude the blood flow from the artery that feeds the aneurysm with coils or other techniques to occlude the aneurysm itself. Postoperative complications are rare but can occur. Potential complications include psychological symptoms such as disorientation, amnesia, and Korsakoff syndrome (disorder characterized by psychosis, disorientation, delirium, insomnia, hallucinations, and personality changes). Creutzfeldt-Jakob disease results in severe dementia and myoclonus. The three cardinal signs of Parkinson disease are tremor, rigidity, and bradykinesia. Huntington disease results in progressive involuntary choreiform (dancelike) movements and dementia.

A nurse has taught a client how to perform quadriceps-setting exercises. The nurse determines that the client has understood the instructions when he demonstrates which of the following? Pushes the popliteal area against the mattress while raising the heel Raises the body by pushing the hands against the chair seat Lifting the body off the bed while holding on to a trapeze Contracts the buttocks together for a count of five

Pushes the popliteal area against the mattress while raising the heel

Which of the following is the first-line therapy for myasthenia gravis (MG)? Azathioprine (Imuran) Lioresal (Baclofen) Deltasone (Prednisone) Pyridostigmine bromide (Mestinon)

Pyridostigmine bromide (Mestinon)

McBurney's point

RLQ point (1/3 of the way from the ASIS to the umbilicus) tenderness indicative of appendicitis

FEV1/FVC

Ratio that is useful in distinguishing between restrictive & obstructive diseases

idioventricular

Related to only the ventricles; produced by the ventricles.

The nurse in collaboration with the rehabilitation team is working with a patient on performing therapeutic exercises. Which of the following would the nurse expect to encourage to increase the patient's muscle power? Active exercises Isometric exercises Passive exercises Resistive exercises

Resistive exercises Resistive exercises provide resistance to increase muscle power. Passive exercises are used to retain as much joint range of motion as possible and to maintain circulation. Isometric exercises are used to maintain strength when a joint is immobilized. Active exercises are used to increase muscle strength.

A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?

Respiratory alkalosis Pt with PNA will hyperventilate to increase oxygen, which blows off too much carbon dioxide.

The nurse is assessing a patent with polycythemia vera. What skin assessment data would the nurse determine is a normal finding for this patient? Jaundice skin and sclera Pale skin and mucous membranes Bronze skin tone Ruddy complexion

Ruddy complexion Polycythemia vera (sometimes called P vera), or primary polycythemia, is a proliferative disorder of the myeloid stem cells. Patients typically have a ruddy complexion and splenomegaly.

A nurse is admitting a new client with a deep vein thrombosis in her left leg. During the admission process, which information provided by the client would be a contraindication to anticoagulant therapy? Three vaginal births, the most recent 18 months ago A cerebral vascular bleed 10 years ago Diet that includes many green, leafy vegetables every day Scheduled eye surgery in 1 week

Scheduled eye surgery in 1 week Contraindications to anticoagulant therapy include recent or impending eye surgery, recent cerebral vascular bleeds, and recent childbirth. A diet including green leafy vegetables is not a contraindication.

s/s of autonomic dysreflexia

Severe HTN, headache, bradycardia, nasal stuffiness, flushing, sweating, blurred vision and anxiety

Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis? Calcium gluconate Furosemide Magnesium sulfate Sodium bicarbonate

Sodium bicarbonate

The nurse has just received report on a client in the ED being transferred to the acute stroke unit with a diagnosis of a right hemispheric stroke. Which findings does the nurse understand is indicative of a right hemispheric stroke? Altered intellectual ability Slow, cautious behavior Spatial-perceptual deficits Aphasia

Spatial-perceptual deficits. Explanation: Patients with right hemispheric stroke exhibit partial perceptual deficits, left visual field deficit, and paralysis with weakness on the left side of the body. Left hemispheric damage causes aphasia, slow, cautious behavior, and altered intellectual ability.

The surgical client has been intubated and general anesthesia has been administered. The client exhibits cyanosis, shallow respirations, and a weak, thready pulse. The nurse recognizes that the client is in which stage of general anesthesia? Stage III Stage II Stage IV Stage I

Stage IV

A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to be identified as the causative factor? Hemophilus influenzae Streptococcus pneumoniae Escherichia coli Staphylococcus aureus

Streptococcus pneumoniae The bacteria Streptococcus pneumoniae and Neisseria meningitides are responsible for 80% of cases of meningitis in adults.

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient? Suggest applying cool compresses on the face several times a day to tighten the muscles. Tell the patient to smile every 4 hours. Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Inform the patient that the muscle function will return as soon as the virus dissipates.

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. After the sensitivity of the nerve to touch decreases and the patient can tolerate touching the face, the nurse can suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone. Facial exercises, such as wrinkling the forehead, blowing out the cheeks, and whistling, may be performed with the aid of a mirror to prevent muscle atrophy. Exposure of the face to cold and drafts is avoided.

A nurse is providing care to a client recently diagnosed with a brain tumor. When planning this client's care, the nurse anticipates which therapy as providing the best outcome for the client? Radiation therapy Chemotherapy Immunotherapy Surgery

Surgery

A nurse has been providing in-home hospice care to an older adult client with lung cancer for more than six months. The family asks the nurse how long the Medicare hospice services will continue. What is the nurse's best response? The client must begin to pay for other home health services since six months of hospice care have been received. The hospice services need to end now that the client has had the services for six months. The Medicare hospice services can continue as long as the physician and hospice director agree about the client's terminal condition. Medicare hospice services end at the seventh month of care.

The Medicare hospice services can continue as long as the physician and hospice director agree about the client's terminal condition.

A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. What will the nurse specify about this client's target blood pressure?

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) specifies a lower goal pressure of 130/80 for people with diabetes mellitus.

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence? The client ambulates with the assistance of one. The client uses a mechanical lift to climb steps. The client arranges a community service to deliver meals. The client grasps the affected arm at the wrist and raises it.

The client grasps the affected arm at the wrist and raises it. The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance.

Following a motor vehicle collision, a client is admitted to the emergency department with a blood pressure of 88/46, pulse of 54 beats/min with a regular rhythm, and respirations of 20 breaths/min with clear lung sounds. The client's skin is dry and warm. The nurse assesses the client to be in which type of shock?

The client in neurogenic shock experiences hypotension, bradycardia, and dry, warm skin. A client experiencing septic shock would exhibit tachycardia. A client in anaphylactic shock would experience respiratory distress. A client in cardiogenic shock would exhibit cardiac dysrhythmias and adventitious lung sounds.

The nurse is caring for a 35-year-old man whose severe workplace injuries necessitate bilateral below-the-knee amputations. How should the nurse anticipate that the client will respond to this news? The client will progress sequentially through five stages of the grief process. The client will require psychotherapy to process his grief. The client will experience grief in an individualized manner. The client will go through the stages of grief over the next week to 10 days.

The client will experience grief in an individualized manner. Loss of limb is a profoundly emotional experience, which the client will experience in a subjective manner, and largely unpredictable, manner. Psychotherapy may or may not be necessary. It is not possible to accurately predict the sequence or timing of the client's grief. The client may or may not benefit from psychotherapy.

Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting? The client will take the seizure medication at the same time daily. The client will verbalize an understanding of feelings that preempt seizure activity. The client will post emergency numbers on the refrigerator for ease of obtaining. The client will remain free of injury if a seizure does occur.

The client will remain free of injury if a seizure does occur. All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.

Which client would the nurse recognize as having the greatest risk for complications during the intraoperative or postoperative period? The 28-year-old client who occasionally smoked marijuana in high school. The 35-year-old client with non-insulin dependent diabetes. The 72-year-old client who takes no routine medications. The 47-year-old client who stopped smoking 2 years ago.

The client with diabetes is at risk for complications during the intraoperative or postoperative period. Hypoglycemia can develop during anesthesia or from inadequate carbohydrate intake or excess insulin administration postoperatively. Hyperglycemia can increase the risk for wound infection and delay wound healing. Smokers are encouraged to stop 4 to 8 weeks before surgery. Recent illicit drug use can increase the risk for adverse reactions to anesthesia. Healthy older adults are not at increased risk.

A client with polycythemia vera reports gouty arthritis symptoms in the toes and fingers. What is the nurse's best understanding of the pathophysiological reason for this symptom? Excess red blood cells produce extracellular toxins that build up. The dead red blood cells release excess uric acid. Excess red blood cells cause vascular injury in the joints. The dead red blood cells occlude the small vessels in the joints.

The dead red blood cells release excess uric acid.

lumbar laminectomy

The excision of a vertebral posterior arch in the part of the back between the thorax and pelvis.

The initial sign of skin pressure is erythema, which normally resolves in less than 15 minutes. 45 minutes. 1 hour. 30 minutes.

The initial sign of pressure is erythema caused by reactive hyperemia, which normally resolves in less than 1 hour. All of the other time frames are incorrect.

Modified Trendelenburg

The modified Trendelenburg position is when the individual laying flat on their back with their head level to their body and their legs are passively raised. This position is often used to help venous return to the heart and restore adequate brain perfusion in individuals with hypotension.

The nurse is caring for a client at the end of life. The client is prescribed a regularly scheduled dose of narcotics and short-acting narcotic for breakthrough pain. Which action should the nurse take when administering the narcotics to manage this client's pain?

The nurse who is administering narcotics at the end of life still must realize that any side effects must be addressed. In end-of-life care there is no need to assess for signs of drug dependence. The nurse will also reassure the client that frequent use of opioid analgesia will not cause addiction when administered in a life-limiting illness. In this case, dosing will not be restricted and medications will be administered on a routine schedule not a PRN basis. Administering the narcotic on routine schedule around the clock avoids causing intense discomfort followed by a period of heavy sedation.

A patient has been diagnosed with a brain tumor, a glioblastoma multiforme. The nurse met with the family after the diagnosis to help them understand that: Radiation is not an option because of the tumor's location near the brainstem. Surgery can improve survival time but the results are not guaranteed. Chemotherapy, following surgery, has recently been shown to be a highly effective treatment. The tumor rarely spreads to other parts of the body.

The overall prognosis for this type of aggressive brain tumor is poor but surgery can improve survival time.

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care? The patient The nurse The physical therapist The physician

The patient The evidence-based plan of care that nurses develop must be approved by the patient and family and is an integral part of the rehabilitation process.

Digoxin

Ther. Class. antiarrhythmics inotropics Pharm. Class. digitalis glycosides

A client is on bed rest after sustaining injuries in a car accident. Which nursing action helps prevent complications of immobility? Decreasing fluid intake to ease dependent edema Bathing and feeding the client to decrease energy expenditure Turning the client every 2 hours and providing a low-air-loss mattress Raising the head of the bed to maximize the client's lung inflation

To avoid pressure ulcers in an immobilized client, the nurse must assess the skin thoroughly and use such preventive measures as regular turning, a low-air-loss mattress, and a trapeze (if the client's condition allows). The nurse should increase, not decrease, the client's fluid intake to help prevent renal calculi, which may result from immobility. To prevent atelectasis, another complication of immobility, having the client cough, deep breathe, and use an incentive spirometer would be more effective than raising the head of the bed. Instead of bathing and feeding the client, the nurse should promote independent self-care activities whenever possible to prepare the client for a return to the previous health status.

The client has had biomarkers tested after reporting chest pain. Which diagnostic marker of myocardial infarction remains elevated for as long as 2 weeks? Myoglobin CK-MB Total creatine kinase Troponin

Troponin

The nurse is fitting a patient for crutches that are required for an ankle injury. What quick method can the nurse use to measure so that the crutches will be of appropriate height? Use the patient's height and add 12 inches. Use the patient's height and subtract 8 inches. Use the patient's height and add 6 inches. Use the patient's height and subtract 16 inches.

Use the patient's height and subtract 16 inches.

Bullectomy

Used for emphysema Large bullae are resected to improve lung function

A newly graduated nurse is admitting a client with a long history of emphysema. The nurse learns that the client's PaCO2 has been between 56 and 64 mm Hg for several months. Why should the nurse be cautious administering oxygen?

Using oxygen may result in the client developing carbon dioxide narcosis and hypoxemia. When PaCO2 chronically exceeds 50 mm Hg, it creates insensitivity to CO2 in the respiratory medulla, and the use of oxygen may result in the client developing carbon dioxide narcosis and hypoxemia. No information indicates the client's calcium will rise dramatically due to pituitary stimulation. No feedback system that oxygen stimulates would create an increase in the client's intracranial pressure and create confusion. Increasing the oxygen would not stimulate the client to hyperventilate and become acidotic; rather, it would cause hypoventilation and acidosis.

Which is the most common cause of acute encephalitis in the United States? St. Louis virus West Nile virus Herpes simplex virus Western equine virus

Viral infection is the most common cause of encephalitis. Herpes simplex virus is the most common cause of acute encephalitis in the United States. The Western equine encephalitis virus, West Nile virus, and St. Louis virus are types of arboviral encephalitis that occur in North America, but they are not the most common causes of acute encephalitis.

During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin? Vitamin E Vitamin D Vitamin A Vitamin K

Vitamin K

Vomiting results in which of the following acid-base imbalances?

Vomiting results in loss of hydrochloric acid (HCl) and potassium from the stomach, leading to a reduction of chlorides and potassium in the blood and to metabolic alkalosis.

A patient is scheduled to have an auditory brain stem response in 2 days. What does the nurse instruct the patient to do in preparation for the test? Do not eat or drink 8 hours prior to testing. Wash and rinse hair before test but do not apply any other hair products. Shave several areas on the scalp where the electrodes will be placed. Omit daily medications prior to testing.

Wash and rinse hair before test but do not apply any other hair products.

A young client is diagnosed with a mild form of hemophilia and is experiencing bleeding in the joints with pain. In preparing the client for discharge, what instructions should the nurse provide? Undergo genetic testing and counseling if the client is male. Take ibuprofen for joint pain. Take warm baths to lessen pain. Wear a medical identification bracelet.

Wear a medical identification bracelet. Explanation: Clients with hemophilia should wear a medical identification bracelet about having this disease. Ibuprofen interferes with platelet aggregation and may increase the client's bleeding. A warm bath may lessen pain but increase bleeding. Genetic testing and counseling are not necessary for male clients, because females are the carriers of the genetic material for hemophilia.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient? Within 48 hours after exposure Therapy is not necessary prophylactically and should only be used if the person develops symptoms. Within 24 hours after exposure Within 72 hours after exposure

Within 24 hours after exposure

myasthenia gravis

a chronic autoimmune disease that affects the neuromuscular junction and produces serious weakness of voluntary muscles

Kernig's sign

a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down

Phenylketonuria (PKU)

a disorder related to a defective recessive gene on chromosome 12 that prevents metabolism of phenylalanine

narcosis

a drug-induced sleep from which the patient is not easily aroused and that is most often associated with the administration of narcotics

prognosis

a forecast of the probable course and outcome of a disease or situation

A nurse is teaching a client who has facial muscle weakness and has recently been diagnosed with myasthenia gravis. The nurse should teach the client that myasthenia gravis is caused by: genetic dysfunction. upper and lower motor neuron lesions. a lower motor neuron lesion. decreased conduction of impulses in an upper motor neuron lesion.

a lower motor neuron lesion Myasthenia gravis is characterized by a weakness of muscles, especially in the face and throat, caused by a lower motor neuron lesion at the myoneural junction. It isn't a genetic disorder. A combined upper and lower motor neuron lesion generally occurs as a result of spinal injuries. A lesion involving cranial nerves and their axons in the spinal cord would cause decreased conduction of impulses at an upper motor neuron.

Hypertensive urgency

a situation in which blood pressure is severely elevated but there is no evidence of target organ damage

Antagonist

a substance that tends to nullify the action of another, as a drug that binds to a cellular receptor for a hormone,neurotransmitter, or another drug blocking the action of that substance without producing any physiologic effect itself. Seealso blocking agent.

Mantoux test

a tuberculin skin test in which a solution of 0.1 mL of PPD-tuberculin containing 5 tuberculin units is injected intradermally into either the anterior or posterior surface of the forearm. The test is read 48 to 72 hours after injection. The size of the area of any induration at the site of injection, in combination with patient risk factors, is used to determine whether the test is positive, that is, whether exposure to or infection with Mycobacterium tuberculosis (the agent causing tuberculosis) or a related organism has occurred.

Diathesis

a vulnerability or predisposition to developing a disorder

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions? Renal Integumentary Musculoskeletal Hepatic

a) Renal Explanation: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.

bronchiectasis

abnormal dilation of the bronchi with accumulation of mucus

induration

abnormal hard spot(s) or area of skin; may include underlying tissue

Cardiac tamponade

acute compression of the heart caused by fluid accumulation in the pericardial cavity

AML

acute leukemia of the myelogenous type, one of the two major categories of acute leukemia; most types affect primarily middle-aged to elderly people. Symptoms include anemia, fatigue, weight loss, easy bruising, thrombocytopenia, and granulocytopenia that leads to persistent bacterial infections. Several types are distinguished, named according to the stage in which abnormal proliferation begins: acute undifferentiated l., acute myeloblastic l., acute promyelocytic l., acute myelomonocytic l., acute monocytic l., acute erythroleukemia, andacute megakaryocytic l. Called also acute myelocytic l. and acute nonlymphocytic l.

A nurse is teaching a client with a long leg cast how to use crutches properly while descending a staircase. The nurse should tell the client to transfer body weight to the unaffected leg, and then: advance both crutches. advance the unaffected leg. advance both legs. advance the affected leg.

advance both crutches. The nurse should instruct the client to advance both crutches to the step below, then transfer his body weight to the crutches as he brings the affected leg to the step. The client should then bring the unaffected leg down to the step.

Inotropic

affecting the contractility of cardiac muscle

Asterixis

aka Liver Flap, a flapping tremor of the hands. When the client extends the arms & hands in front of the body, the hands rapidly flex & extend. a motor disturbance marked by intermittent lapses of an assumed posture as a result of intermittency of sustainedcontraction of groups of muscles; called liver flap because of its occurrence in coma associated with liver disease, but alsoobserved in other conditions.

pleurisy

an inflammation of the pleura that produces sharp chest pain with each breath

A client has an irregular heart rate of around 100 beats/minute and a significant pulse deficit. What component of the client's history would produce such symptoms? atrial flutter heart block bundle branch block atrial fibrillation

atrial fibrillation Explanation: In atrial fibrillation, several areas in the right atrium initiate impulses resulting in disorganized, rapid activity. The atria quiver rather than contract, producing a pulse deficit due to irregular impulse conduction to the AV node. The ventricles respond to the atrial stimulus randomly, causing an irregular ventricular heart rate, which may be too infrequent to maintain adequate cardiac output. Atrial flutter, heart block, and bundle branch block would not produce these symptoms.

Autonomic dysreflexia

autonomic dysreflexia an uninhibited and exaggerated reflex of the autonomic nervous system to stimulation; called alsohyperreflexia. The response occurs in 85 per cent of all patients who have spinal cord injury above the level of the sixththoracic vertebra. It is potentially dangerous because of attendant vasoconstriction and immediate elevation of bloodpressure, which in turn can bring about hemorrhagic retinal damage or stroke syndrome. Less serious effects includesevere headache; changes in heart rate; sweating, flushing, and "goose bumps" or piloerection above the level of thespinal cord injury; and pallor below that level.

Pulsus paradoxus

beats have weaker amplitude with respiratory inspiration, stronger with expiration

Hemianopia

blindness in one-half of the visual field

Contusion

bruise

Bulbar weakness

can't talk, swallow

CVP

central venous pressure

A client in a short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should: remove the dressing on the puncture site after vital signs stabilize. keep the client's knee on the affected side bent for 6 hours. apply pressure to the puncture site for 30 minutes. check the client's pedal pulses frequently.

check the client's pedal pulses frequently. After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse should leave this dressing in place for several hours — and only remove it if instructed to do so.

Polycythemia vera

condition characterized by too many erythrocytes; blood becomes too thick to flow easily through blood vessels

CRRT

continuous renal replacement therapy

Spasticity

continuous resistance to stretching by a muscle due to abnormally increased tension, with increased deep tendon reflexes

The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is lymphangiography. lymphoscintigraphy. air plethysmography. contrast phlebography.

contrast phlebography.

Cerebellum function

coordination of voluntary movements and balance

hemoptysis

coughing up blood

Which is a component of the nursing management of the client with new variant Creutzfeldt-Jakob disease (vCJD)? Administering amphotericin B Providing supportive care Initiating isolation procedures Preparing for organ donation

d) Providing palliative care Explanation:The vCJD is a progressive fatal disease with no treatment available. Due to the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although patient isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.

hypoxemia

deficient amount of oxygen in the blood

Dysphonia

difficulty producing speech sounds, usually due to hoarseness

Dysphasia

difficulty speaking

Dysphagia

difficulty swallowing

Digoxin antidote

digoxin immune FAB

otorrhea

discharge from the ear

myopathy

disease of the muscle

While repositioning an immobile client, a nurse notes that the client's sacral region is warm and red. Further assessment confirms that the skin is intact. Based on these findings, it's most appropriate for the nurse to: give the client a donut ring to reduce pressure on the affected area. contact the client's family. do nothing; the client's skin is intact. document the condition of the client's skin.

document the condition of the client's skin.

A client who experienced shock is now nonresponsive and having cardiac dysrhythmias. The client is being mechanically ventilated, receiving medications to maintain renal perfusion, and is not responding to treatment. In this stage, it is most important for the nurse to

encourage the family members to touch and talk to the client.

cardiomegaly

enlargement of the heart

ESR

erythrocyte sedimentation rate

polyphagia

excessive hunger

myxedema coma

extreme hypothyroidism(abrupt med cessation), rare with a high mortality rate = decreased cardiac output leads to decreased tissue perfusion which leads to brain and organ depletion leading to multi-organ failure Maintenance of adequate airway is crucial, since most patients have depressed mental status along with respiratory failure. Mechanical ventilation is commonly required during the first 36-48 hours, but some patients require prolonged respiratory support for as long as 2-3 weeks.

pyrexia

fever

FEV1

forced expiratory volume in 1 second

FVC

forced vital capacity - amount of gas that can be forcibly and rapidly exhaled after a full inspiration

In planning care for a patient with an extrapyramidal disorder, the nurse recognizes that a major difference between Parkinson disease and Huntington disease is the development of what symptom in clients with advanced Huntington disease? hallucinations and delusions muscle fasciculations depression bradykinesia

hallucinations and delusions As Huntington's disease progresses, hallucinations, delusions, and impaired judgment develop due to degeneration of the cerebral cortex. Depression is a likely symptom for clients with both Parkinson's disease and Huntington's disease. Bradykinesia, slowness in performing spontaneous movement, is commonly associated with Parkinson's disease. Muscle fasciculations, or twitching, are commonly associated with ALS.

otosclerosis

hardening of the bony tissue of the middle ear The middle ear consists of the eardrum and a chamber which contains three bones called the hammer, the anvil, and thestirrup (or stapes). Sound waves passing through the ear cause the ear drum to vibrate. This vibration is transmitted tothe inner ear by the three bones. In the inner ear, the vibrations are changed into impulses which are carried by thenerves, to the brain. If excessive bone growth interferes with the stapes ability to vibrate and transmit sound waves,hearing loss will result.

h/o

history of

Hepatic encephalopathy

impaired ammonia metabolism causes cerebral edema. s/s: change in LOC, memory loss, asterixis (flapping tremor) impaired handwriting, hyperventilation w/ resp alkalosis. Rx: lactulose, low protein, safety, rest

Aortic insufficiency

inability of the aortic valve to perform at the proper levels, which results in blood flowing back into the left ventricle from the aorta. inadequate closure of the aortic valve, permitting aortic regurgitation.

Functional urinary incontinence

inability of usually continent person to reach toilet in time to avoid unintentional loss of urine

Apraxia

inability to perform particular purposive actions, as a result of brain damage.

apraxia

inability to perform particular purposive actions, as a result of brain damage.

aphasia

inability to speak

Agraphia

inability to write

Parathyroid hormone

increases blood calcium levels

intrathecal

injection into the meningeal space surrounding the brain and spinal cord

The nurse cares for a client prescribed warfarin orally. The nurse reviews the client's prothrombin time (PT) level to evaluate the effectiveness of the medication. Which laboratory values should the nurse also evaluate? Sodium complete blood count (CBC) partial thromboplastic time (PTT) international normalized ratio (INR)

international normalized ratio (INR)

asthenia

lack of strength

LVAD

left ventricular assist device

Akathisia

motor restlessness

As a client approaches death, respirations become noisy. This is the result of which type physical event? central nervous system alterations gastrointestinal impairment cardiac dysfunction musculoskeletal change

musculoskeletal change As death approaches, a client's reflexes become hypoactive. The jaw and facial muscles also relax. As the tongue falls to the back of the throat, respirations become noisy.

NIV

noninvasive ventilation

Epistaxis

nosebleed

Addison's disease

occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone

aural

of or related to the ear or the sense of hearing

Homan's sign

pain in *calf upon dorsiflexion* of foot and may indicated thrombophlebitis

Precordial Pain

pain in the anterior chest overlying the heart

intermittent claudication

pain in the leg muscles that occurs during exercise and is relieved by rest

claudication

pain, tension, and weakness in a leg after walking has begun, but absence of pain at rest

Hemiplegia

paralysis of one side of the body

Hemiplegic

paralysis of one side of the body

PTCA

percutaneous transluminal coronary angioplasty

PEEP

positive end expiratory pressure; keeps the alveoli open

parathyroid hormone (PTH)

raises blood calcium level

fasciculation

rapid continuous twitching of resting muscle without movement of limb

gastric dumping syndrome

rapid gastric emptying, is a condition where ingested foods pass through the stomach very rapidly and enter the small intestine largely undigested --> usually happens in bypass surgeries --> occurs when food especially sugar moves from your stomach into your small bowel too quickly. Presents:==> *abdominal cramps,N/V diarrhea, 10-30 mins after eating* DX--> modified oral glucose tolerance test TX-> dietary changes

Ischial tuberosity

receives the weight of the body when sitting

adenoidectomy

removal of the adenoids

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: increase the dose of muscle relaxants. avoid naps during the day. rest in an air-conditioned room. take a hot bath.

rest in an air-conditioned room. Explanation:Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity

A nursing assessment of a client with peritonitis reveals hypotension, tachycardia, and signs and symptoms of dehydration. What else would the nurse expect to find? severe abdominal pain with direct palpation or rebound tenderness jaundice and vomiting tenderness and pain in the right upper abdominal quadrant rectal bleeding and a change in bowel habits

severe abdominal pain with direct palpation or rebound tenderness Peritonitis decreases intestinal motility and causes intestinal distention. A classic sign of peritonitis is a sudden, diffuse, severe abdominal pain that intensifies in the area of the underlying causative disorder (i.e., appendicitis, diverticulitis, ulcerative colitis, a strangulated obstruction). The client may also have rebound tenderness. Tenderness and pain in the right upper abdominal quadrant suggest cholecystitis. Jaundice and vomiting are signs of cirrhosis of the liver. Rectal bleeding or a change in bowel habits may indicate colorectal cancer.

paroxysmal nocturnal dyspnea (PND)

shortness of breath that occurs suddenly during sleep

Micrographia

small and often illegible handwriting

Refractory

stubbornly resistant to authority or control

A client has a heart rate greater than 155 beats/minute and the ECG shows a regular rhythm with a rate of 162 beats/minute. The client is intermittently alert and reports chest pain. P waves cannot be identified. What condition would the nurse expect the physician to diagnose? sinus tachycardia atrial flutter supraventricular tachycardia heart block

supraventricular tachycardia

escharotomy

surgical incision of the eschar and superficial fascia of the chest or a circumferentially burned limb in order to permit the cutedges to separate and restore blood flow to unburned tissue. Edema may form beneath the inelastic eschar of a full-thickness burn and compress arteries, thus impairing blood flow and necessitating an escharotomy. The incision is protectedfrom infection with the same antimicrobial agent being used on the burn wound.

Maze procedure

surgical procedure to treat atrial fibrillation in which a new conduction pathway is created that eliminates the rapid firing of ectopic pacemaker sites in the atria

Laryngectomy

surgical removal of the larynx

Papilledema

swelling of the optic disc

Chemosis

swelling of the tissue that lines the eyelids and the surface of the eye

instrumental activities of daily living (IADLs)

tasks necessary to conduct the business of daily life and also requiring some cognitive competence, such as telephoning, shopping, food preparation, housekeeping, and paying bills

ptosis

term used for a drooping upper eyelid. Ptosis, also called blepharoptosis, can affect one or both eyes.

A nurse is caring for a young female adult client diagnosed with atrial fibrillation who has just had a mitral valve replacement. The client is being discharged with prescribed warfarin. The client mentions to the nurse that she relies on the rhythm method for birth control. What education will be a priority for the nurse to provide to this client? foods to limit (green leafy vegetables) while taking warfarin the high risk for complications if she becomes pregnant while taking warfarin instructions for using the rhythm method symptoms to report of worsening tachycardia related to atrial fibrillation

the high risk for complications if she becomes pregnant while taking warfarin

Agnosia

the inability to recognize familiar objects.

agnosia

the inability to recognize familiar objects.

myoclonus

the sudden, involuntary jerking of a muscle or group of muscles

Bronchoscopy

the visual examination of the bronchi using a bronchoscope

Cushing's Triad

three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation

Source of calcitonin

thyroid gland

A client has a blockage in the proximal portion of a coronary artery and decides to undergo percutaneous transluminal coronary angioplasty (PTCA). What medication will the nurse expect to administer during the procedure? hydrochlorothiazide ticagrelor metoprolol ceftriaxone

ticagrelor During PTCA, the client receives heparin, an anticoagulant (ticagrelor), as well as calcium agonists, nitrates, or both, to reduce coronary artery spasm. Nurses do not routinely give antibiotics such as ceftriaxone during this procedure; however, because the procedure is invasive, the client may receive prophylactic antibiotics to reduce the risk of infection. An antihypertensive like metoprolol and a diuretic like hydrochlorothiazide may cause hypotension, which should be avoided during the procedure.

Palliation

to relieve or lessen without curing

allograft

transplantation of healthy tissue from one person to another person; also called homograft

Virchow's triad

venous stasis, endothelial injury, hypercoagulable state

Hemiparesis

weakness on one side of the body

S/S of cardiogenic shock

↑ HR, ↑ RR, ↓ BP, ↓ urinary output, restless, diaphoretic, cool/clammy skin change in mental status