Cardiac, Immune, Cancer, Endocrine, Sensory, Neuro Disorders
Plans and interventions for lupus
Instruct client to avoid prolonged exposure to sunlight Instruct client to clean the skin with mild soap Monitor and instruct client in administration of steroids - look out for Cushing's or Addison's, glucose levels
Chemotherapy
Involves the administration of cytotoxic medications and chemicals to promote tumor cell death
Head Injury Warning Signs
LOC, pupils, seizures, bleeding, visual problems, slurred speech, etc.
HIV complications
Opportunistic infections HIV wasting syndrome Neoplasms Premalignant diseases Organ-specific syndromes Immunodeficiency AIDS-associated dementia/encephalopathy Death
Neurovascular assessment
Pain Pulse Pallor Paresthesia Paralysis Pressure
Preload/Afterload
Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart.
ECG Heart Rate calculation
QRS complexes in 6 large blocks X 10
HIV/AIDS
Renders patients susceptible to opportunistic infections, unusual cancers, and other abnormalities Marked by progressive failure of the immune system
zone of injury
ST elevation occurs in the area of injury next to infarct; tissue is viable as long as circulation is adequate
Factors that trigger lupus
Sunlight Stress Pregnancy Drugs
Antiepileptic drugs
Suppress discharge of neurons within a seizure focus Suppress propagation of seizure activity from the focus to other areas of the brain
immune response
The body's defensive reaction to invasion by bacteria, viral agents, or other foreign substances.
expressive aphasia
The inability to produce language ( despite being able to understand language)
Radiation Safety
Time, distance, shielding
Zone of ischemia
Tissue that is oxygen deprived; ECG shows T-wave inversion
Stroke management
Use of Tissue Plasminogen Activator (tPA) within the first 3 hours -> thrombolysis -> reopen occluded arteries -> reperfusion of ischemic penumbra (Side effect: increased risk of hemorrhage, reperfusion injury). Following stroke -> cerebral autoregulation of perfusion is lost -> perfusion depended on (perfusion pressure)/(vascular resistance) -> Increase in vascular resistance after stroke therefore increased pressure is necessary to perfuse tissue adequately. DO NOT LOWER BLOOD PRESSURE FOLLOWING STROKE unless it reaches dangerous levels. Investigations: CT of head on admission -> exclude hemorrhage, tumor, subdural hematoma. Establish extent of infarct and presence of previous infact. CT Angiography -> demonstrate cerebral arterial stenosis or occlusion. Carotid and vertebral artery duplex U/S -> stenosis or occlusion. Echocardiogram -> where cardiac source is likely. CXR, ECG, FBC, Glucose, Coagulation. MRI -> sensitive in detecting and localizing acute ischemic brain lesions.
Radiation
Used to kill a tumor, reduce the tumor size, relieve obstruction Can destroy rapidly multiplying cancer cells as well as normal cells Can be internal or external
global aphasia
When both production and understanding of language is damaged
diabetes insipidus (DI)
antidiuretic hormone (ADH) is not secreted, or there is a resistance of the kidney to ADH
Left CVA
aphasia, apraxia, slow and cautious
P wave
atrial depolarization
DVT nursing interventions
bed rest, TPA, no pillow under knees or massaging of extremity, TPA within 5 days, heparin, analgesics, diuretics
Diagnosis of leukemia is made by...
biopsy, bone marrow aspiration, lumbar puncture, and frequent blood counts
HIV diet
bland, fruits/veggies, high protein, supplementation avoid dairy, spicy or acidic foods
deep vein thrombosis
blood clot forms in a large vein, usually in a lower limb
defibrillation
brief discharges of electricity are applied across the chest to stop dysrhythmias (ventricular fibrillation, V-tach); 120-200 joules
Cushing's syndrome
caused by prolonged exposure to high levels of cortisol
Leukemias
characterized by an abnormal overproduction of immature forms of any of the leukocytes. There is an interference with normal blood production that results in decreased numbers of erythrocytes, platelets, and mature leukocytes.
Leukemia is treated with...
chemotherapy and bone marrow transplant
HIV transmission means
contact with infected blood, secretions, or body fluids (semen, pre-seminal fluid, rectal or vaginal fluid, human milk) and associated with identifiable high-risk behaviors
Abnormal posturing
decorticate and decerebrate
Calcium Channel Blockers
decrease contractility, heart rate and conduction and they also cause vasodilation; used to control hypertension, angina, and dysrhythmias; do not administer medication if pulse is <50; does not treat acute attacks of angina; end in "dipine" or "pamiPr
Beta Blockers (__olol)
decrease heart rate and dilate arteries by blocking beta receptors
Increased afterload causes
decreased stroke volume; increased cardiac workload
dysphonia
difficulty producing speech sounds, usually due to hoarseness
ACE inhibitors side effects
dizziness, nonproductive cough, GI distress, orthostatic hypotension, headache, hyperkalemia
cor pulmonale, right ventricular failure
enlargement of the right ventricle, resulting from chronic disease within the lungs, that causes congestion within the pulmonary circulation and resistance of blood flow to the lungs
S-T segment
entire ventricular myocardium depolarized
tonic-clonic seizure
generalized seizure in which the patient loses consciousness and has jerking movements of paired muscle groups
The lack of mature leukocytes leads to _________________________________
immunosuppression and higher risk of infection
Apraxia
impaired ability to carry out motor activities despite intact motor function
receptive aphasia
inability to understand spoken or written words
Biggest complication in an immunocompromised patient is...
infection
bone marrow transplant
infusion of healthy bone marrow cells to a recipient with matching cells from a donor needs a neutropenic diet (nothing raw, no fresh fruit, etc.)
With polycythemia vera, increased RBC mass makes the blood abnormally viscous and __________ blood flow to the ________________________.
inhibits; microcirculation
diabetes mellitus (DM)
insulin is not secreted adequately or tissues are resistant to its effects
Leading causes of death in patients with lupus
kidney failure; heart failure
Right CVA
lack of insight, left side neglect, impulsive, short attention span,
ataxia
lack of muscle coordination
hemianopsia; hemianopia
lack of vision in half the visual field
Chemotherapy disrupts the cell cycle in various phases, interfering with cellular __________________ and ____________________.
metabolism, reproduction
Addison's disease
occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone
alpha blockers (__zosin) adverse effects
palpitations, orthostatic hypotension, tachycardia, edema, chest pain, dizziness, HA, anxiety, depression, weakness, numbness, fatigue, N&V, diarrhea, constipation, abdominal pain, incontinence, dry mouth and pharygitis, sexual dysfunction
In the immunocompromised patient, nursing care should focus on...
preventing infection and education
Cushing's triad
r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure)
polycythemia vera treatment
relies primarily on phlebotomy to reduce hematocrit - bleed them/ drain them (usually 1 or so a week or monthly) - prevent DVT and PE
cardioversion
synchronized elective restoration of a normal heart rhythm by electric shock; 50-100 joules
Intracranial Pressure (ICP)
the amount of pressure inside the skull
In polycythemia vera, diminished blood flow and _____________________ set the stage for intravascular thrombosis.
thrombocytosis
Antihypertensive drugs
used to lower blood pressure (see pic)
QRS complex represents
ventricular depolarization
T wave represents
ventricular repolarization
PVD peripheral vascular disease
"Bad blood flow to/from my legs"
ACE inhibitors
"PRIL" Captopril, Enalapril, Afosiopril Antihypertensive. Blocks Angiotensin Converting Enzyme (ACE) in lungs from converting angiotensin I to angiotensin II (powerful vasoconstrictor). Increases cardiac output, rate, and contractility; Decreases BP, Decreased Aldosterone secretions, Sodium and fluid loss. Check BP before giving (hypotension) *Orthostatic Hypotension
Autonomic Dysreflexia
(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)
DKA Nursing Interventions
- Assess: airway, LOC, hydration status, electrolytes, blood glucose level, temperature, urine output, mental status q1h, VS q 15 mins until stable, hourly blood glucose - Treat underlying cause - Monitor fluid status during aggressive replacement (1-2 L 0.9% NS over first 30 mins - 1 hour, 0.45% saline infused slower) - If BS = 250mg/dL add dextrose!! - Regular insulin IV (0.1 unit/kg bolus, 01 unit/kg/hr continuous drip) - Replace serum K - Infuse bicarb if severe acidosis occurs
type 1 diabetes symptoms
- Thirst - Extreme hunger - Frequent urination - N&V - Acetone Breath - Fatigue - Rapid weight loss - Unconsciousness
Left sided heart failure symptoms
-Left = lungs (and heart) -Crackles, increased HR, SOB, palpitations, dizzy, lightheaded, confused, restless, cough, dyspnea
Right sided heart failure symptoms
-Pitting Edema -Ascites -Hepatic enlargement -JVD -Parasternal lift -Nausea -Decreased appetite -Cold extremities -Diaphoresis
MI symptoms
-Shortness of breath, indigestion, nausea, anxiety -Cool, pale and moist skin. -Symptoms cannot always be distinguished .
Multiple Sclerosis Symptoms
-Weakness, numbness, tingling in a limb -Optic neuritis (amaoursis fugax) -Double vision -Loss of balance -Urinary frequency/urgency -Ataxia (lack of voluntary movements) -Hyper-reflexia -Fatigue -Hoffman sign (flicking middle finger causes thumb flexion) -Lhermittes sign (shock sensation down spine on neck flexion)
ARBs (__sartan) side effects
-dizziness -lightheadedness -diarrhea -insomnia -confusion *does not effect exercise response*
HIV/AIDS risk factors
-exposure to infected blood, body fluids, or tissue -unprotected sex, multiple sex partners, intravenous drug use -can go undiagnosed in older adults due to similarity of symptoms common with other illness in this age group (data collection and comprehensive assessment extremely important)
hypertensive crisis
180/110 urgency, days to weeks, no organ failure; 220/140 emergency, end organ failure, hours
A client who has experienced an ischemic stroke has been admitted to the medical unit. The client's family is adamant that she remain on bed rest to hasten her recovery and to conserve energy. What principle of care should inform the nurse's response to the family? a. The client should mobilize as soon as she is physically able. b. To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks. c. The client should remain on bed rest until she expresses a desire to mobilize. d. Lack of mobility will greatly increase the client's risk of stroke recurrence.
A
The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate response? a. Inform the care team and assess for further signs of possible increased ICP. b. Administer bronchodilators as prescribed and monitor the client's LOC. c. Increase the client's bed height and reassess in 30 minutes. d. Administer a bolus of normal saline as prescribed.
A
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? a. Check the equipment. b. Contact the physician to review the care plan. c. Continue the assessment because no actions are indicated at this time. d. Document the reading because it reflects that the treatment has been effective.
A
A patient is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic BP C. Tachycardia D. Decreasing body temperature
A Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
An unconscious client with multiple injuries arrives in the emergency department. Which nursing intervention receives the highest priority? A. Establishing an airway B. Replacing blood loss C. Stopping bleeding from open wounds D. Checking for a neck fracture
A The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.
9. The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. a. Contractures b. Hemorrhage c. Pressure ulcers d. Venous thromboembolism e. Pneumonia
A, C, D, E
A diabetic client with the flu asks why he should drink juices, check his fingerstick glucose every 4 hours, and take insulin when he is not eating and is vomiting. What would be the best explanation by the nurse? A. "You need to prevent dehydration and monitor for hyperglycemia and excessive breakdown of fats for glucose" B. "You need to check your blood glucose because vomiting could cause hypoglycemia and drinking fluids will prevent dehydration" C. "Your body uses protein for energy during times of illness, causing increased ketones and hypoglycemia" D. "If you can substitute water for the juices to prevent dehydration, then you won't need to check your blood glucose levels so often"
A. "You need to prevent dehydration and monitor for hyperglycemia and excessive breakdown of fats for glucose" Starvation-induced ketosis can be prevented by drinking juices that equal the prescribed carbohydrate meal pattern. Fluids are needed to prevent dehydration and hyperosmolality, which could result from large fluid losses from persistent vomiting. The liver breaks down fats, not proteins, to form glucose for energy and ketones, leading to DKA. Options B and D do not address the core issues of dehydration and hyperglycemia.
Which of the following evaluation data would best lead the nurse to conclude that the client with hyperglycemic hyperosmolar state (HHS) has demonstrated improvement during the first 24 hours? A. Alert and oriented, balanced intake and output, moist mucous membranes B. Intake equals output, denies pain and shortness of breath C. Alert and oriented blood and urine without ketones, no orthostatic BP D. Respirations easy and even, eats 50 to 75% of meals, vital signs stable
A. Alert and oriented, balanced intake and output, moist mucous membranes HHS results from hyperglycemia, causing excessive loss of water and retention of glucose that leads to dehydration, hypernatremia, and hypokalemia. Symptoms are dry, tenting skin, dry mucous membranes, altered level of consciousness, and hyperthermia. Ketones are not present in HHS. Pain and SOB are unrelated to HHS. Amount of dietary intake is unrelated to HHS.
A client has new onset type 1 diabetes mellitus (DM) and asks why he needs to check his blood glucose level so frequently. The nurse explains that frequent coverage with insulin to keep the blood glucose level between 80 and 155 mg/dL is important for which of the following reasons? A. Chronic elevated blood glucose levels damage cells and cause multiple organ damage B. High glucose levels cause the body to use proteins for energy, causing lactic acidosis C. Early identification of hypoglycemia before the onset of symptoms is easier to treat D. Carbohydrates are constantly being converted to glucose and transported in the blood by insulin
A. Chronic elevated blood glucose levels damage cells and cause multiple organ damage Research demonstrates a strong correlation between chronic hyperglycemia and complications of retinopathy, nephropathy, and neuropathy. Thus, there is damage to the eyes, kidneys, and peripheral nerves. Lactic acidosis occurs with diabetic ketoacidosis and the metabolism of fat. C is false rationale for the client in question. Insulin is needed to carry glucose across the cell membranes into the cell, not to e transported in the blood.
A nurse is caring for a client with heart failure. The nurse knows that the client has left-sided heart failure when the client makes which statement? A. "I sleep on three pillows each night." B. "My feet are bigger than normal." C. "My pants don't fit around my waist." D. "I don't have the same appetite I used to."
A. Orthopnea is a classic sign of left-sided heart failure. The client commonly sleeps on several pillows at night to help facilitate breathing. Swollen feet, ascites, and anorexia are signs of right-sided heart failure.
The nurse would prioritize that which of the following nursing diagnoses has highest priority for a client experiencing an attack of Meniere's disease? A. Risk for injury B. Risk for disturbed sleep patterns C. Impaired sensory perception: auditory D. Risk for ineffective individual coping
A. Risk for injury Meniere's disease is characterized by bouts of vertigo, which place the client at risk for falls and injury. The client may have manifestations of the other nursing diagnoses as well, but the highest priority is on preventing injury.
The nurse is caring for a client with type 1 diabetes mellitus. In developing a teaching plan, which of the following signs and symptoms of hypoglycemia should the nurse include? A. Shakiness B. Increased thirst C. Fever D. Fruity breath
A. Shakiness The signs of hypoglycemia include hunger, shakiness, sweating, pale and cool skin, and irritability. These signs may be manifestation of impaired cerebral function from the hypoglycemia. The other options are all signs of hyperglycemia.
When teaching a client about self-care following placement of a new permanent pacemaker to the upper left chest, the nurse should include which information? A. Take and record daily pulse rate B. Avoid air travel because of airport security alarms C. Immobilize the affected arm for 4 to 6 weeks D. Avoid using a microwave oven
A. The nurse must teach the client how to take and record the pulse daily. The pacemaker metal casing does not set off airport security alarms, so there are no travel restrictions. Prolonged immobilization is not required. Microwave ovens are safe to use and do not alter pacemaker function.
-sartans
ARBs
Pathophysiology of polycythemia vera
Abnormal clonal stem cells interfere with or suppress normal stem cell growth. Uncontrolled and rapid cellular reproduction and maturation cause proliferation or hyperplasia of all bone marrow cells.
zone of infarction
Area of cell death and muscle necrosis; Q wave on ECG
Systemic Lupus Erythematosus
Autoimmune, inflammatory disorder of the connective tissue Can cause major body organs and systems to fail
A client exhibiting an altered level of consciousness (LOC) due to blunt force trauma to the head is admitted to the ED. The nurse should gauge the client's LOC on the results of what diagnostic tool? a. Monro-Kellie hypothesis b. Glasgow Coma scale c. Cranial nerve function d. Mental status examination
B
A client has recently begun mobilizing during the recovery from an ischemic stroke. To protect the client's safety during mobilization, the nurse should perform what action? a. Support the client's full body weight with a waist belt during ambulation. b. Have a colleague follow the client closely with a wheelchair. c. Avoid mobilizing the client in the early morning or late evening. d. Ensure that the client's family members do not participate in mobilization.
B
A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? a. Risk for impaired skin integrity b. Risk for injury c. Risk for autonomic dysreflexia d. Risk for suffocation
B
A nurse is caring for a client diagnosed with a hemorrhagic stroke. When creating this client's plan of care, what goal should be prioritized? a. Prevent complications of immobility. b. Maintain and improve cerebral tissue perfusion. c. Relieve anxiety and pain. d. Relieve sensory deprivation.
B
A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? a. Respiratory distress and projectile vomiting b. Bradycardia and hypertension c. Tachycardia and agitation d. Third-spacing and hyperthermia
B
The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipated administering to halt the seizure immediately? a. Intravenous phenobarbital b. Intravenous diazepam c. Oral lorazepam d. Oral phenytoin
B
While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state? a. Epileptic cry b. Confusion c. Urinary incontinence d. Body rigidity
B
For a patient who is experiencing expressive aphaisa, which nursing intervention is most helpful in promoting communication? A. Speaking loudly and slowly B. Using a "picture board" for the patient to point to pictures C. Writing directions so the patient can read them D. Speaking in short sentences
B Expressive aphasia is a condition in which the patient understand what is heard or written, but cannot say what he or she wants to say. A communication board helps the patient communicate with others in that the patient can point to objects or activates that he or she desires.
What is the priority nursing assessment in the first 24 hours after admission for the patient with a thrombotic stroke? A. Cholesterol level B. Pupil size and pupillary response C. Bowel sounds D. Echocardiogram
B It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves.
The nurse is assisting a patient with a stroke who has homonymous hemianopia. The nurse should understand that the patient will: A. Have a preference for foods high in salt B. Eat food on only half of the plate C. Forget the names of foods D. Not be able to swallow liquids
B. Homonymous hemianopia is blindness in half of the visual field; therefore the patient would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships.
On a medical-surgical floor, a nurse is caring for a cluster of clients with diabetes mellitus. Which client should the nurse assess first? A. A 20-year-old client with a blood glucose level of 70 mg/dl B. A 55-year-old complaining of chest pressure C. A 60-year-old client experiencing nausea and vomiting D. An 80-year-old client with a blood glucose level of 350 mg/dl
B. A 55-year-old complaining of chest pressure The nurse should assess the client with chest pressure first because that client might be experiencing a myocardial infarction. The blood glucose levels in 20-year-old client and 80-year-old client are abnormal, but not life threatening; therefore, these clients don't require immediate attention. After assessing the client with chest pressure, the nurse should assess the client experiencing nausea and vomiting.
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound? A. a first heart sound (S1). B. a third heart sound (S3). C. a fourth heart sound (S4). D. a murmur.
B. An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.
A client is 20 hours S/P colon resection with end-to-end anastomosis for ruptured diverticulum. The nurse has read in the medical record that the client has an 8-year history of Addison's disease. After noting new onset of lethargy with the current assessment, the nurse should take which action next? A. Review patient-controlled analgesia (PCA) record for dose history. B. Assess client for decreased urine output and blood pressure C. Check pupils for direct and consensual reaction D. Obtain pulse ox to check client's oxygen saturation level
B. Assess client for decreased urine output and blood pressure. Clients with Addison's disease should be assessed for signs of Addisonian crisis or adrenal insufficiency caused by an inadequate supply of corticosteroids. It frequently follows a stressful event such as surgery. Signs of Addisonian crisis include decreased urine output, decreased blood pressure, dry skin, and altered level consciousness. While excessive narcotic analgesia could cause lethargy, the Addison's disease must be addressed first because it is potentially life threatening. There is no indication of central nervous system disorder. A pulse oximetry reading would be done as a routine measure, but it is nonspecific for this client.
A client with type 2 insulin-requiring diabetes has the flu with nausea, body aches, and lack of appetite. The client's blood sugar is 180 mg/dL (10 mmol/L). The vital signs are temperature 101ºF (38.3ºC), pulse 88 bmp, and respirations 20 breaths/min. What should the nurse instruct the client to do? Select all that apply. A. Stop taking insulin. B. Check blood sugar every 4 hours. C. Drink 240 mL fluids every hour D. Check urine for ketones. E. Take two 325 mg aspirin.
B. Check blood sugar every 4 hours. D. Drink 240 mL fluids every hour. The nurse should instruct the client with insulin-requiring diabetes who has the flu to check the blood sugar every 4 hours. The client should try to drink 240 mL of fluid every hour. If the blood sugar levels become low, the client should drink liquids with sugar in them. The client should continue to take insulin. It is not necessary to check for ketones until the blood glucose level is above 240 mg/dL. The nurse cannot prescribe aspirin for this client. If the symptoms of the flu continue, the nurse should instruct the client to contact the health care provider.
The client is admitted with diabetic ketoacidosis (DKA). Which of the following does the nurse formulate as the priority nursing diagnosis? A. Impaired urinary elimination related to reduced output and muscle function B. Decreased cardiac output related to fluid and electrolyte imbalance C. Ineffective breathing pattern related to hyperventilation D. Anxiety related to fears of long-term outcomes and discomfort
B. Decreased cardiac output related to fluid and electrolyte imbalance. DKA is associated with excessive urine output, dehydration, and hypokalemia, placing the client at a risk for decreased cardiac output and cardiac dysrhythmias. The decreased urine output and muscle function do not address the metabolic problem. Anxiety and hyperventilation are not the priority needs.
A nurse is assessing a client with heart failure. What breath sound is commonly auscultated in clients with heart failure? A. tracheal. B. fine crackles. C. coarse crackles. D. friction rubs.
B. Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure. Tracheal breath sounds are auscultated over the trachea. Coarse crackles are typically caused by secretion accumulation in the airways. Friction rubs occur with pleural inflammation.
An older adult is admitted to the telemetry unit for placement of a permanent pacemaker because of sinus bradycardia. A priority goal for the client within 24 hours after insertion of a permanent pacemaker is to: A. Maintain skin integrity B. Maintain cardiac conduction stability C. Decrease cardiac output D. Increase activity level
B. Maintaining cardiac conduction stability to prevent arrhythmias is a priority immediately after artificial pacemaker implantation. The client should have continuous electrocardiographic monitoring until proper pacemaker functioning is verified. Skin integrity, while important, is not an immediate concern. The pacemaker is used to increase heart rate and cardiac output, not decrease it. The client should limit activity for the first 24 to 48 hours after pacemaker insertion. The client should also restrict movement of the affected extremity for 24 hours.
A nurse is caring for a client who has heart failure and reports increased shortness of breath. The nurse increases the client's oxygen per protocol. Which of the following actions should the nurse take first? A. Obtain the client's weight B. Assist the client into high-Fowler's position C. Auscultate lung sounds D. Check oxygen saturation with pulse oximeter
B. Using the airway, breathing, circulation priority approach to client care, the first action the nurse should take is to assist the client into high-Fowler's position. This will decrease venous return to the heart (preload) and help relieve lung congestion.
A client diagnosed with a hemorrhagic stroke has been admitted to the neurologic ICU. The nurse knows that teaching for the client and family needs to begin as soon as the client is settled on the unit and will continue until the client is discharged. What will family education need to include? a. How to differentiate between hemorrhagic and ischemic stroke b. Risk factors for ischemic stroke c. How to correctly modify the home environment d. Techniques for adjusting the client's medication dosages at home
C
A client diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy. The nurse explains that this procedure will be done for what purpose? a. To decrease cerebral edema b. To prevent seizure activity that is common following a TIA c. To remove atherosclerotic plaques blocking cerebral flow d. To determine the cause of the TIA
C
A client has had an ischemic stroke and has been admitted to the medical unit. What action should the nurse perform to best prevent joint deformities? a. Place the client in the prone position for 30 minutes/day. b. Assist the client in acutely flexing the thigh to promote movement. c. Place a pillow in the axilla when there is limited external rotation. d. Place the client's hand in pronation.
C
A client is brought to the ED by her family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? a. Insertion of an intracranial monitoring device b. Treatment with antihypertensives c. Making openings in the skull d. Administration of anticoagulant therapy
C
A client is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the client may have required surgery on what neurologic structure? a. Cerebellum b. Hypothalamus c. Pituitary gland d. Pineal gland
C
A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure? a. Sudden electrolyte changes throughout the brain b. A dysrhythmia in the peripheral nervous system c. A dysrhythmia in the nerve cells in one section of the brain d. Sudden disruptions in the blood flow throughout the brain
C
The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? a. Epistaxis b. Periorbital edema c. Bruising over the mastoid d. Unilateral facial numbness
C
The nurse is caring for a client diagnosed with an ischemic stroke and knows that effective positioning of the client is important. Which of the following should be integrated into the client's plan of care? a. The client's hip joint should be maintained in a flexed position. b. The client should be in a supine position unless ambulating. c. The client should be placed in a prone position for 15 to 30 minutes several times a day. d. The client should be placed in a Trendelenburg position two to three times daily to promote cerebral perfusion.
C
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? a. Shock b. Encephalitis c. Increased intracranial pressure (ICP) d. Status epilepticus
C
A patient arrives in the emergency department with an ischemic stroke and may receive t-PA. The nurse should first: A. Ask what medication the patient is taking B. Complete a history and health assessment C. Identify the time of onset of the stroke D. Determine if the patient is scheduled for any surgical procedures
C Studies show that clients who receive t-PA within 3 hours after the onset of a stroke have better outcomes and are eligible to receive the drug.
Cancer CAUTION
C - change in bowel/bladder A - sore won't heal U - unusual bleeding T - thickening/lump I - indigestion O - obvious change wart/mole N - nagging cough/hoarseness Unexplained weight loss, fatigue, night pain
The nurse is caring for a client who has just been told he is legally blind. Which of the following would be appropriate interventions for this client? (Select all that apply) A. Instructions regarding daytime driving only B. Immobility to promote retinal repair C. Home assessment prior to discharge D. Psychological support E. Placement in an assisted living facility
C, D - Home assessment prior to discharge, Psychological support Legal blindness can occur with glaucoma, cataracts, retinal disorders, trauma, or infections. Many of these disorders are not amenable to surgery or are diagnosed at late stages where surgery would be ineffective. Clients who are legally blind are capable of living alone, but the home must be assessed and appropriate accommodations made to minimize injury. Newly diagnosed clients must be supported as they grieve for the loss of certain aspects of their life and adjust to changes that will be required.
What is the priority nursing intervention in the postictal phase of a seizure? A. Reorient the patient to time, person, and place B. Determine the patient's level of sleepiness C. Assess the patient's breathing patterns D. Position the patient comfortably
C. A priority for the patient in the postictal phase is to assess the patient's breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the patient as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the patient to time, person, and place. Determining the patient's level of sleepiness can be useful, but is not the priority. Positioning the patient comfortably promotes rest but is of less importance than establishing airway.
The nurse is providing information about foot care to a client with diabetes. Which of the following would the nurse include? A. "Wash your feet in hot water every day." B. "Use a razor to remove corns or calluses." C. "Be sure to apply a moisturizer to feet daily." D. "Wear well-fitting comfortable rubber shoes."
C. "Be sure to apply a moisturizer to feet daily." The nurse should advise the client to apply a moisturizer to the feet daily. The client should use warm water not hot water to bathe his feet. Razors to remove corns or calluses must be avoided to prevent injury and infection. The client should wear well-fitting comfortable shoes, avoiding shoes made of rubber, plastic or vinyl which would cause the feet to perspire.
A client has just been diagnosed with glaucoma. The nurse should place highest priority on teaching the client which of the following information? A. Fluid restriction is needed to reduce intraocular pressure B. Disorder often has no symptoms C. Adherence to medication therapy is essential to reduce risk of vision loss D. Disorder is typically diagnosed after episode of eye infection
C. Adherence to medication therapy is essential to reduce risk of vision loss It is important to share with the client that lifelong medication therapy is needed to preserve vision. Glaucoma typically does not have symptoms but since the client is already diagnosed, this is not a relevant issue. Options A an D are false statements.
The client is admitted with decreased level of consciousness (LOC) secondary to a closed head injury that resulted from a fall while roller-skating. Urine output is 500 mL from 0600 to 1100, 1000 mL from 1100 to 1400, and 350 mL from 1400 to 1500. which of the following actions by the nurse is appropriate? A. Realize that this is normal urine output and continue to monitor the patient B. Encourage the client to drink 8 to 10 glasses of fluid daily C. Check the urine specific gravity and report any abnormality as well as the urine output D. Decrease the IV rate from 100 mL/hr to 25 mL/hr suspecting fluid excess
C. Check the urine specific gravity and report any abnormality as well as the urine output. Diabetes insipidus can develop with head injury, tumors, and other conditions causing increased intracranial pressure. Excessive urine output of 350 mL/hr or more is a classic early symptom of DI. The specific gravity provides valuable information about renal function and response to ADH. Using critical thinking to analyze the urine output, specific gravity, and other characteristics of the urine, the nurse assesses for classic signs of DI that can occur following a head injury. The client is excreting large volumes of water and may actually need an increase in fluids to maintain an adequate circulating volume of water and ma actually need an increase in fluids to maintain adequate circulating volume. Giving oral fluids to someone with a decreased LOC increases the risk of aspiration.
A client is 12 hours status-post (S/P) partial thyroidectomy. When the nurse asks the client about any numbness or tingling of the face, mouth, or extremities, the client asks why this would be important. The nurse would include which of the following rationale in formulating the best response? A. Early identification of low thyroid hormone B. Detection of thyroid-inducing hypoglycemia C. Early identification of hypocalcemia D. Detection of nerve damage related to surgery
C. Early detection of hypocalcemia The parathyroid glands, located near the thyroid gland, may have been injured or accidentally removed, resulting in hypocalcemia. Hypocalcemia is life-threatening; thus it is important to identify early signs. Numbness and/or tingling of the mouth, face, or extremities are early symptoms of low serum calcium. Reduced thyroid hormone levels are an expected result of the surgery. Option B refers to the pituitary gland. Option D is possible, but could be detected by hoarseness or a weak voice.
The client is 8 hours S/P partial thyroidectomy for Graves' disease. What is the best documentation by the nurse of evaluation outcome criteria for the nursing diagnosis: Risk for ineffective airway clearance? A. Dressing is clean, dry, and intact, pain minimal and controlled, alert and oriented. B. Vital signs stable; client supports neck with hand during change of position C. No tracheal stridor, speaks clearly, and denies numbness or tingling D. Balanced intake and output, vital signs stable, and alert and oriented
C. No tracheal stridor, speaks clearly, and denies numbness or tingling Laryngeal nerve damage can occur as a result of a thyroidectomy manifested by stridor, a weak or harsh voice. An early sign of edema of the larynx leading to airway obstruction is a tight-fitting dressing. Numbness or tingling of the extremities, lips, or mouth is a sign of hypocalcemia that an lead to respiratory distress due to tetany. The data in the other options are important routine postoperative assessments, but they do not relate specifically to a thyroidectomy and the client's airway.
Cardiac output equation
CO = HR x SV (heart rate x stroke volume)
tumor lysis syndrome
Chemotherapy can cause massive destruction of cells leading the creation of uric acid which can be toxic to the kidneys leading to Acute Tubular Necrosis. You can try to prevent this with hydration and allopurinol.
Statins
Cholesterol drugs
Rheumatoid Arthritis involves...
Chronic, systemic, symmetrical autoimmune inflammatory disease Primarily attacks peripheral joints and surrounding muscles, tendons, ligaments, and blood vessels Extra-articular involvement of organs such as skin, heart, lungs, and eyes may occur Marked by spontaneous remissions and unpredictable exacerbations
A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? a. Hemiplegia b. Dry mucous membranes c. Signs of internal bleeding d. Loss of brain stem reflexes
D
A client is diagnosed with a right-sided stroke. The client is now experiencing hemianopsia. How might the nurse help the client manage her potential sensory and perceptional difficulties? a. Keep the lighting in the client's room low. b. Place the client's clock on the affected side. c. Approach the client on the side where vision is impaired. d. Place the client's extremities where she can see them.
D
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? a. Copes with sensory deprivation. b. Registers normal body temperature. c. Pays attention to grooming. d. Obeys commands with appropriate motor responses.
D
What should be included in the client's care plan when establishing an exercise program for a client affected by a stroke? a. Schedule passive range of motion every other day. b. Keep activity limited, as the client may be overstimulated. c. Have the client perform active range-of-motion (ROM) exercises once a day. d. Exercise the affected extremities passively four or five times a day.
D
Which of the following will the nurse observe in a client in the ictal phase of a generalized tonic-clonic seizure? A. Jerking in one extremity that spreads gradually to adjacent areas B. Vacant staring and abruptly ceasing all activity C. Facial grimaces, patting motions, and lip smacking D. Loss of consciousness, body stiffening, and violent muscle contractions
D A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupuls, and muscular stiffening or contraction, which lasts about 20-30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration.
DVT diagnostic tests
D Dimer ESR Venous Duplex Venogram Ultrasound MRI
Hypertension Nursing Care (DIURETIC)
D-aily Weight I- ntake and Output (I & O) U- rine Output R-esponse of BP E-lectrolytes T-ake Pulses I-schemic Episodes (TIA) C-omplications: 4C's
The nurse is teaching the family and a client newly diagnosed with type 1 diabetes how diet and exercise affect insulin requirements. Which statement made by the client indicates understanding of the teaching? A. "I will need more insulin and food when exercising." B. "Exercise will decrease my insulin need and decrease my food requirements." C. "An exercise regimen may cause me to eliminate my bedtime snack." D. "I can remove my insulin pump when exercising."
D. "I can remove my insulin pump when exercising." The nurse should advise the client that exercise will lower blood sugar and a snack should be eaten prior to exercise. It is recommended that the insulin pump be removed during exercise because it can become dislodged. The diabetic client will typically need less insulin and more food during times of exercise as exercise decreases insulin resistance.
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus? A. Respirations of 12 breaths/minute B. Cloudy urine C. Blood sugar 170 mg/dL D. Fruity breath
D. Fruity breath The rising ketones and acetone in the blood can lead to acidosis and be detected as a fruity odor on the breath. Ketoacidosis needs to be treated to prevent further complications such as Kussmaul respirations (fast, labored breathing) and renal shutdown. A blood sugar of 170 mg/dL is not ideal but will not result in glycosuria and/or trigger the classic symptoms of diabetes mellitus. Cloudy urine may indicate a UTI.
The nurse has been teaching the client with new onset of syndrome of inappropriate antidiuretic hormone (SIADH) about the disorder. Which statement by the client best indicates the correct understanding of how to manage this disease? A. "I should limit my sodium intake to 2 grams daily" B. "I should report constipation or fatigue to the doctor" C. "I should drink at least 3,000 mL or 10 glasses of water daily" D. "I should limit my fluid intake to approximately 800 mL or 4 glasses of water daily"
D. I should limit my fluid intake to approximately 800 mL or 4 glasses of water daily. In SIADH there is excess secretion of ADH, which causes fluid retention, dilutes the plasma, causing fluid retention, dilutes the plasma, causing suppression of aldosterone, and increases renal excretion of sodium. Water then moves into the cells from the plasma and interstitial spaces causing cellular edema, and dilutional hyponatremia results. The treatment is fluid restriction and hypertonic saline infusion rather than sodium restriction.
A post-surgical client is brought back to the nursing until following a thyroidectomy. Which of the following methods should be used to assess for bleeding? A. Inspect the dressing for signs of hemorrhage B. Change dressing applied in the operating room C. Check latest hemoglobin to determine if there has been a drop in value D. Palpate back of neck and shoulders for evidence of bleeding
D. Palpate back of neck and shoulders for evidence of bleeding The danger of hemorrhage is greatest during the first 24 hours following thyroid surgery. The tendency is for blood to follow gravity and flow down at the sides and posteriorly if hemorrhage occurs in the area of the neck. Inspecting the dressing for signs of hemorrhage may not reveal bleeding. Changing dressing immediately after surgery is not appropriate. A drop in hemoglobin may be a clue to bleeding, but is not the best initial assessment action.
A client is admitted with a newly diagnosed detached retina. The nurse should place highest priority on doing which of the following? A. Limiting visitors and providing clear liquids B. Allowing the client to get out of bed but keeping the room darkened C. Giving eye drops every hour and allowing bathroom privileges only D. Placing the client on bedrest and patching the eyes
D. Placing the client on bedrest and patching the eyes The client wit a detached retina should have activity restricted with eyes patched to reduce eye movement and prevent worsening of the detachment. The client may be prepared for surgery quickly, and thus may be placed on NPO status rather than clear liquids. Eye drops are not necessary.
HCTZ (hydrochlorothiazide)
Diuretic
ICP nursing interventions
Elevate HOB 35-45 deg Neck in neutral pos. Avoid flexion of hips Avoid isometric or resistive exercises Restrict fluid intake Avoid valsalva maneuvers Foley O2 Control body temp
Radiation side effects
Fatigue Anorexia Immunosuppression Tissue damage Ulcerations GI effects
Assessment for suspected HIV
History of one or more risk factors Infection Myalgia Headache Nausea, anorexia Dry cough Chronic diarrhea Involuntary weight loss
Blood sugar mnemonic
Hot and dry = sugar high Cold and clammy = need some candy
Beta blocker side effects
Bradycardia, HF, contra with asthma, reflex tach, GI disturbance
When teaching the client about complications of atrial fibrillation, the nurse should instruct the client to avoid which of the following? A. Stasis of blood in the atria B. Increased cardiac output C. Decreased pulse rate D. Elevated blood pressure
A. Atrial fibrillation occurs when the SA node no longer functions as the heart's pacemaker and impulses are initiated at sites within the atria. Because conduction through the atria is disturbed, atrial contractions are reduced and stasis of blood in the atria occurs, predisposing to emboli. Some estimates predict that 30% of clients with atrial fibrillation develop emboli. Atrial fibrillation is not associated with increased cardiac output, elevated BP, or decreased pulse rate.
A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60. The nurse should take which of the following actions first? A. Prepare for transcutaneous pacing B. Prepare to defibrillate the client at 200 J C. Administer an IV lidocaine infusion D. Schedule the operating room for insertion of a permanent pacemaker
A. Transcutaneous pacemaker therapy provides an adequate heart rate to a client in an emergency situation. Defibrillation and a lidocaine infusion are not indicated for the treatment of third-degree heart block. Transcutaneous pacing is used temporarily until a transvenous or permanent pacemaker can be inserted.
Nursing Assessment for suspected lupus
Joint pain and decreased mobility Fever - also heart rate Nephritis - urine output, gravity Pleural effusion - lung sounds Pericarditis - friction rub, pain, fever Abdominal pain - auscultate, palpate, BM Photosensitivity - wear shades, dim lights in room
During physical assessment, the nurse should further assess the client for signs of atrial fibrillation when the palpation of the radial pulse reveals: A. Two regular beats followed by one irregular beat B. An irregular rhythm with pulse greater than 100 C. Pulse rate below 60 D. A weak, thread pulse
B. Characteristics of atrial fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm, and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and should report it to the physician. A weak, thread pulse is characteristic of a client in shock. Two regular beats followed by an irregular beat may indicate a premature ventricular contraction.
Which of the following is the most appropriate diet for a client during the acute phase of an NSTEMI? A. Liquids as desired B. Small, easily digested meals C. Three regular meals a day D. Nothing by mouth
B. Recommended dietary principles in the acute phase of MI include avoiding large meals because small, easily digested foods are better tolerated. Fluids are given according to the client's needs, and sodium restrictions may be prescribed, especially for clients with manifestations of heart failure. Cholesterol restrictions may be prescribed as well. Clients are not prescribed diets of liquids only or restricted to NPO unless their condition is very unstable.
Hypertension formula
BP = CO x PR increased cardiac output AND increased peripheral resistance
Side effects of chemotherapy
Bone marrow suppression (immunosuppression, thrombocytopenia, anemia) GI effects (anorexia, N/V, diarrhea) Stomatitis, mucositis Alopecia (hair loss, leads to altered body image) Fatigue Xerostomia (dry mouth)
Which of the following is an expected outcome for a client on the second day of hospitalization after an MI? the client: A. Continues to have severe chest pain B. Can identify risk factors for MI C. Participates in a cardiac rehabilitation walking program D. Can perform personal self-care activities without pain
D. By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the client may be sitting up in a chair as part of the cardiac rehab program.
type 2 diabetes
Diabetes of a form that develops especially in adults and most often obese individuals and that is characterized by high blood glucose resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production.
Clinical manifestations of RA...
Fatigue, general malaise, anorexia/weight loss Persistent joint pain Characteristic morning stiffness lasting >1 hour Tenderness, swelling, restricted ROM of joints Joint deformities, nodules
Hypothyroidism symptoms
Fatigue, lethargy. Modest weight gain with anorexia. Dry, coarse skin and cold intolerance. Swelling of face, hands, and legs. Constipation. Weakness, muscle cramps, arthralgias, paresthesias, impaired memory and hearing.
Polycythemia vera complications
Hemorrhage (GI, hematuria, intracranial) Vascular thromboses Secondary gout Uric acid calculi Myelofibrosis Stroke Acute leukemia Myocardial infarction
While caring for a client who has sustained a myocardial infarction, the nurse notes 8 premature ventricular contractions in 1 minute on the cardiac monitor. The client is receiving an IV infusion of 5% dextrose in water and oxygen at 2 L/min. The nurse's first course of action should be to: A. Increase the IV infusion rate B. Notify the physician promptly C. Increase the oxygen concentration D. Administer a prescribed analgesic
B. PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post-MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.
Hyperthyroidism symptoms
Nervousness, weight loss despite increased appetite, excessive sweating and heat intolerance, palpitations, frequent bowel movements, muscular weakness of the proximal type and tremor
Oncologic emergencies
Superior vena cava syndrome - partial occlusion of SVC, SOB, JVD, decreased perfusion Spinal cord compression - lead to permanent neuro impairment (secondary spinal injury), check reflexes and full neuro assessment Pericardial effusion & cardiac tamponade - need immediate drainage, prepare for pericardocentesis or drain Disseminated intravascular coagulation (DIC) - clotting and bleeding simultaneously Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Tumor lysis syndrome - may need emergent dialysis
U.N.L.O.A.D. F.A.S.T. ...tx for HF...
Upright position Nitrates Lasix Oxygen ACE inhibitors Digoxin Fluids (decrease) Afterload (decrease) Sodium restriction Test (Dig level, ABGs, potassium level)
