exam TWO medsurg II
A home care nurse assesses for disease complications in a client with bone cancer. Which laboratory value may indicate the presence of a disease complication?
Calcium level of 11.6 mg/dl Explanation: In clients with bone cancer, tumor destruction of bone commonly causes excessive calcium release. When the calcium-excreting capacity of the kidneys and GI tract is exceeded, the serum calcium level rises above normal, leading to hypercalcemia (a serum calcium level greater than 10.2 mg/dl). Hyperkalemia (a potassium level greater than 5 mEq/L) isn't caused by bone cancer and is seldom associated with chemotherapy. Hyponatremia (a sodium level less than 135 mEq/L) and hypomagnesemia (a magnesium level less than 1.3 mg/dl) are potential adverse effects of chemotherapy; these electrolyte disturbances don't result directly from bone cancer.
A nurse knows that a person with a 3-week-old femur fracture is at the stage where angiogenesis is occurring. What are the characteristics of this stage?
New capillaries producing a bridge between the fractured bones. Explanation: Angiogenesis and cartilage formation begin when fibroblasts from the periosteum produce a bridge between the fractured bones. This is known as a callus.
Which serum level indicates the rate of bone turnover?
Osteocalcin Explanation: Serum osteocalcin (bone GLA protein) indicates the rate of bone turnover. Serum myoglobin is assessed to evaluate muscle trauma. Serum enzyme levels of creatinine kinase and aspartate aminotransferase become elevated with muscle damage.
A nurse knows that more than 50% of clients with CVID develop the following disorder.
Pernicious anemia Explanation: More than 50% of clients with CVID develop pernicious anemia. Although chronic diarrhea may occur in clients with CVID, it does not happen in 50% of them. Hypocalcemia and neutropenia are not concerns for clients with CVID.
The nurse is caring for a client diagnosed with osteomyelitis. Which data noted in the client's record are supportive of this diagnosis? Select all that apply.
Pyrexia 3.Elevated white blood cell count 4.Elevated erythrocyte sedimentation rate 5.Bone scan impression indicative of infection
fiberglass cast
casts are light, water resistant, and dry within 30 minutes while plaster casts are heavy, can not get wet and take up to 3 days to completely dry; both casts give off heat when drying so prepare client for this feeling
nursing management for spinal cord compression
perform ongoing neuro assessments managed pain prevent complications managed muscle tone with ROM exercises institute intermittent urinary cath and bowel training program
T in TNM
the extent of the primary tumor: Tx-primary tumor can not be assessed T0-no evidence of primary tumor Tis- carcinoma in situ T1, T2, T3, T4-increasing size/local extent of primary tumor
A client who has osteoporosis is receiving calcitonin injections. The nurse considers the primary reason is
to increase calcium in the bone Principle: Calcitonin decreases serum calcium levels while parathyroid homorne increases serum calcium levels
A client with ataxia-telangiectasia is admitted to the unit. The nurse caring for the client would expect to see what included in the treatment regimen?
IV gamma globulin administration Explanation: Treatment for ataxia-telangiectasia includes IV gamma globulin, antimicrobial therapy, and bone marrow transplantation.
Adverse reaction to cryoprotectant dimethylsulfoxide (DMSO)
N/V, chills, dyspnea, cardiac dysrhythmias, hypotension progressing to cardiac/respiratory arrest
The nurse receives an order for enoxaparin (Lovenox) 40mg SQ daily on a client with a fractured hip. Which of the following is true?
The enoxaparin was ordered to prevent venous thromboembolism. Principle: Low molecular weight heparin (enoxaparin) may be prescribed to prevent venous thromboembolism
Type II hypersensitivity
involves IgG or IgM. Cytotoxic reaction, may lead to eventual cell/tissue damage Examples: myasthenia gravis, Goodpasture syndrome, pernicious anemia, hemolytic disease of newborn, transfusion reaction, thrombocytopenia
A client presents to the emergency department in anaphylactic shock after a bee sting. What should the nurse do? Select all that apply.
Administer Diphenhydramine. , Insert an intravenous line. , Have respiratory therapy provide an albuterol treatment.
Activation of a natural immunity response is enhanced by physical and chemical barriers. Which of the following is a physical barrier, which the nurse knows can be altered by illness, nutrition, or lifestyle?
Cilia of the respiratory tract Explanation: Cilia are considered a physical barrier, along with intact skin and mucous membranes.
A client visits an orthopedic specialist because of pain beginning in the low back and radiating behind the right thigh and down below the right knee. The doctor suspects a diagnosis of sciatica. The nurse knows that the origin of the pain is between which intervertebral disks?
L4, L5, and S1 Explanation: The lower lumbar disks, L4-L5 and L5-S1, are subject to the greatest mechanical stress and the greatest degenerative changes.
most at risk for osteoporosis
Thin, asian or caucasion women
IgE (.004% of total immunoglobulin)
appears in serum takes part in allergic/hypersensitivity combats parasitic infections
anaphylactoid reaction
caused by the release of mast cell and basophil mediators triggered by NON-IgE *can occur with medications, food, exercise, cytotoxic antibody transfusion 1
medical management of hypercalcemia
consume 2-4 L of fluid daily unless contraindicated by existing renal/cardiac disease stool softeners/laxatives antiemetic therapy
The nurse is taking care of a client with kyphosis. Which of the following pathological processes best explains the clinical manifestation?
Increased osteoclast activity and decreased osteoblast activity Principle: When osteoclastic activity is greater than osteoblastic activity bones become porous and brittle (Osteoporosis)
A client is receiving ganciclovir as part of the treatment for cytomegalovirus retinitis. What would the nurse monitor the results of the client's laboratory tests for?
Neutropenia Explanation: A common reaction to ganciclovir is severe neutropenia.
what needs to be stop and for how many hours before an skin test?
corticosteroids and antihistamines and must be stopped 48/96 hours before
A nurse is teaching a client about the side effects of ibuprofen. The client's learning is determined to be effective based on which statement by the patient describing the drug's effect on the immune system?
"Ibuprofen can cause neutropenia, which can increase my risk of infection." Explanation: Ibuprofen causes leukopenia and neutropenia.
Which cells present the antigen to T cells and initiate the immune response?
Macrophages
When an infection is bloodborne, the manifestations include which symptom?
Chills Explanation: Manifestations of bloodborne infection include chills, high fever, rapid pulse, and generalized malaise.
humoral responses (B cells)
-Bacterial phagocytosis and lysis -Anaphylaxis -Allergic hay fever and asthma -Immune complex disease -Bacterial and some viral infections
Leucovorin (Wellcovorin)
-often given with fluorouracil (5FU) to TX colorectal cancer because it assist %FU to bind with an enzyme inside cancer cells while enhancing the ability of the drug. -given with Methotrexate to rescue normal cells from the toxic effects of the drug
What treatment option does the nurse anticipate for the patient with severe combined immunodeficiency disease (SCID)?
Bone marrow transplantation Explanation: Treatment options for SCID include stem cell and bone marrow transplantation.
The nurse has just completed the administration of the client's first round of chemotherapy for treatment of Burkitt lymphoma. The nurse closely monitors for which clinical indicators of tumor lysis syndrome? Select all that apply.
Bradycardia. Hyperphosphatemia. Tented T waves. Principle: Clinical manifestations of tumor lysis syndrome include hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia; bradydysrhythmias, wide QRS complexes, tented T waves, tetany, seizures and flank pain
Which medication directly inhibits osteoclasts, thereby reducing bone loss and increasing bone mass density (BMD)?
Calcitonin Explanation: Calcitonin directly inhibits osteoclasts, thereby reducing bone loss and increased BMD.
What is the term for a rhythmic contraction of a muscle?
Clonus Explanation: Clonus is a rhythmic contraction of the muscle.
The nurse is asked to explain to the client the age-related processes that contribute to bone loss and osteoporosis. What is the nurse's best response?
Decrease in estrogen Explanation: Age related processes that contribute to loss of bone mass and osteoporosis are decreases in estrogen, calcitonin, and vitamin D and an increase in parathyroid hormone.
The nurse notes that the client's left great toe deviates laterally. This finding would be recognized as which condition?
Hallux valgus Explanation: Hallux valgus is commonly referred to as a bunion.
The nurse is performing an assessment on an older adult patient and observes the patient has an increased forward curvature of the thoracic spine. What does the nurse understand this common finding is known as?
Kyphosis Explanation: Common deformities of the spine include kyphosis, which is an increased forward curvature of the thoracic spine that causes a bowing or rounding of the back, leading to a hunchback or slouching posture. The second deformity of the spine is referred to as lordosis, or swayback, an exaggerated curvature of the lumbar spine. A third deformity is scoliosis, which is a lateral curving deviation of the spine (Fig. 40-4). Osteoporosis is abnormal excessive bone loss.
The nurse administers subcutaneous filgrastim (Neupogen) to a client. Which laboratory value does the nurse monitor to evaluate this drug's effectiveness?
Leukocyte count. Principle: Colony-stimulating factors stimulate red blood cell production decreasing the need for blood transfusions (erythropoietin) or stimulate neutrophil production to decrease the risk for infection (neupogen)
Assessment of a client reveals signs and symptoms of Paget's disease. Which of the following would be most likely?
Long bone bowing Explanation: Some clients with Paget's disease are asymptomatic with only some mild skeletal deformity. Other clients have marked skeletal deformities which may include enlargement of the skull, bowing of the long bones, and kyphosis.
Which intervention should the nurse implement with the client who has an external fixator? Select all that apply.
Perform pin care as ordered. Supervise the client during transfers. Perform neurovascular assessment. Inspect pin sites for signs of infection. Explanation: Nursing care of the client with an external fixator includes pin care, inspection of pin sites for signs of infection, neurovascular assessment, and supervision of the client during transfers. The nurse does not adjust the clamps on the external fixator frame; this is the responsibility of the physician.
When creating a plan of care for a client who has tumor lysis syndrome, the nurse focuses on which of the following goals?
Preventing renal failure and achieving electrolyte balance is a priority in the setting of tumor lysis syndrome
Which term refers to a disease of a nerve root?
Radiculopathy When the client reports radiating pain down the leg, the client is describing radiculopathy.
Which stage of the immune response occurs when the differentiated lymphocytes function in either a humoral or a cellular capacity?
Response stage Explanation: In the response stage, the differentiated lymphocytes function in either a humoral or a cellular capacity.
The nurse is preparing to administer a enoxaparin (Lovenox) injection to a client. Which of the following should the nurse assess prior to administering the medication?
Signs of bleeding Principle: Low molecular weight heparin does not require laboratory monitoring of bleeding times.
M in TNM
The absence/present of distal metastasis: Mx-distant metastasis cannot be assessed M0-no distant metastasis M1-distant metastasis
Myeloablative
consist of giving PTs high dose chemo and sometimes total body irradiation
Typical clinical manifestations of human immunodeficiency virus are
fever, chills, nightsweat, weight loss, lymphadenopathy, and fatigue
Allogeneic HSCT (AlloHSCT)
from a donor other than PT; a family member or matched donor -used primarily for disease of bone marrow and dependent on leukocyte antigen matched donor
Signs of hip dislocation
include limb shortening, acute groin pain, external or internal rotation, limb deformity, crepitus and reduced mobility
what improves engraftment syndrome?
initiation of corticosteroid therapy with support from blood products and hematopoietic growth factors
systemic reactions to type I hypersensitivity
laryngeal stridor, angioedema, hypotension, bronchial/GI/uterine spasm; local reactions hives
Nonmyeloablative
mini transplant, does not completely destroy bone marrow cells
The nurse is caring for a client with bone cancer. Which of the following labs are most likely to be elevated?
Alkaline phosphatase Principle: Alkaline phosphatase can be elevated in liver disease or bone disorders
The nurse is aware that the most prevalent cause of immunodeficiency worldwide is
Malnutrition Explanation: The most prevalent cause of immunodeficiency worldwide is severe malnutrition.
Which of the following is the most common and most fatal primary malignant bone tumor?
Osteogenic sarcoma (osteosarcoma) Explanation: Osteogenic sarcoma (osteosarcoma) is the most common and most often fatal primary malignant bone tumor.
A client presents to the emergency department with fever, chills, restlessness, and limited movement of a fractured jaw. What complication should the nurse interpret as the findings?
Osteomyelitis Explanation: Clinical manifestations of osteomyelitis include signs and symptoms of sepsis and localized infection.
The nurse is caring for a client with a right femoral shaft fracture.The nurse considers that the client has a high risk for which of the following complications? Select all that apply
Pulmonary embolism Compartment syndrome Principle: Complications following fractures include hypovolemic shock (hemorrhage), fat embolism (long bones) and compartment syndrome
After a fracture, during which stage or phase of bone healing is devitalized tissue removed and new bone reorganized into its former structural arrangement?
Remodeling Explanation: Remodeling is the final stage of fracture repair. During inflammation, macrophages invade and debride the fracture area. Revascularization occurs within about 5 days after a fracture. Callus forms during the reparative stage but is disrupted by excessive motion at the fracture site.
The nurse is teaching a client about a recent order for loratadine to help with seasonal allergies. What client statements indicate no further teaching is required? Select all that apply.
Taking my medication on an empty stomach is a must. "Sucking on ice chips will help if my mouth is dry. "Being careful driving is important after taking the medication." "It is recommended that I buy a humidifier for my bedroom."
Type IV hypersensitivity
delayed/cellular reaction occurring 1-3 days after exposure to antigen. The resulting tissue damage involves activity by lymphokines, macrophages, and lysozymes Example: contact dermatitis, graft-versus-host disease, Hashimoto's thyroiditis, sarcoidosis
RAST
detects free antigens-specific IgE in serum (NOT bound to mast cells) performed on blood samples Major disadvantages: limited allergen selection, reduced sensitivity, lack of immediate results, cost more
Tumor Lysis Syndrome (TLS)
emergency! occurs spontaneously or commonly after radiation, biotherapy, or chemo that goes after rapidly growing cancer (leukemia/lymphoma/small cell lung) Releasing the contents of a tumor leads to rapidly induced electrolyte imbalances}hyperkalemia/hyperphosphatemia(hypocalcemia follows) hyperuricemia having life threatening end-organ effects on myocardium/kidney/cns
rheumatic disease
encompass autoimmune, degenerative, inflammatory, systemic conditions affecting joints, muscles, soft tissues. Most common symptoms are arthritis and pain
clinical manifestations of hypercalcemia
fatigue, weakness, confusion, decreased level of responsiveness, hyporeflexia, n/v, constipation, ileus, polyuria, polydipsia, dehydration, dysrhythmias
Syngeneic
from an identical twin
nursing management for SVCS
identify PTs at risk educate PT on s/s monitor for clinical manifestations avoid upper extremity venipuncture and blood pressure avoid completely supine or prone position to promote comfort and reduce anxiety monitor for complications
incisional biopsy
performed if tumor mass is too large to be removed; so a wedge of tissue from the tumor is removed to be analysis. --if specimen doesn't contain representative tissues/cells negative results DO NOT guarantee absence of cancer
A client who was injured while playing basketball reports an extremely painful elbow, which is very edematous. What type of injury has the client experienced?
sprain Explanation: Sprains are injuries to the ligaments surrounding a joint. A strain is an injury to a muscle when it is stretched or pulled beyond its capacity. A contusion is a soft tissue injury resulting from a blow or blunt trauma. Sprains are injuries to the ligaments surrounding a joint.
needle biopsy
to sample suspicious masses easily/safely accessible; masses in breast/thyroid/lung/liver/kidney
positive reaction of skin test
urticarial wheal(round/reddened skin elevation), localized erythema (diffused redness) in the area of inoculation/contact/pseudopodia
clinical manifestations of TLS
(depends on extent of metabolic abnormalities) Neuro: fatigue/weakness/memory loss/ altered mental status, muscle cramps, tetany, paresthesias, seizures Cardiac: hypertension, shorten QT complexes, widened QRS waves, altered T waves, dysrhythmias, cardiac arrest GI: anorexia, n/v, abdominal cramps
s/s of type III hypersensitivitiy
urticaria, joint pain, fever, rash, adenopathy
excisional biopsy
used for small easily accessible tumors of Skin/U/L GI and upper respiratory removes entire tumor and surrounding marginal tissues. Advantages: entire specimen can be used for staging/grading and decreases chances of seeding tumor cells
at what time is the PT no longer consider high risk for death from sepsis and bleeding?
when the engraftment of new marrow occurs
what guidelines are used for the interpretation of skin test results?
*skin test are used most frequently with the diagnosis of allergic rhinitis *negative test results are helpful in ruling out food allergy *positive skin test correlate highly with food allergy
The nurse is caring for a client with myasthenia gravis. The nurse generates a plan of care for the client based on which type of hypersensitivity reaction?
Cytotoxic
The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing:
Fat embolism syndrome Explanation: The clinical manifestations described in the scenario are characteristic of fat embolism syndrome.
When providing discharge instructions to a client undergoing treatment for cancer, the nurse includes which of the following reportable symptoms of hypercalcemia? Select all that apply.
Increase in lethargy. Fatigue and weakness. Increased thirst and urination. Principle: Hypercalcemia is an oncologic emergency and is marked by a progressive change in level of consciousness, hyporeflexia, ileus, constipation, polyuria and polydipsia
Which condition is a metabolic bone disease characterized by inadequate mineralization of bone?
Osteomalacia Explanation: Osteomalacia is a metabolic bone disease characterized by inadequate mineralization of bone.
A nurse practitioner assesses a patient's movement in his left hand after a cast is removed. The nurse asks the patient to turn his wrist so the palm of his hand is facing up. This movement is known as:
Supination
swollen glands
adenopathy
Clinical Manifestations of GVDH
diffused rash progressing to blistering and desquamation similar to second degree burns, mucosal inflammation of eyes/entire GI with subsequent diarrhea which can exceed 2 L per day, biliary stasis w abdominal pain, hepatomegaly, elevated liver enzymes heading to obstructive jaundice
type III hypersensitivity
immune complex reaction marked by acute inflammation resulting from formation and deposition of immune complexes Examples: systemic lupus, erythematosus, serum sickness, nephritis, RA
Cellular responses (Tcells)
transplant rejection delayed hypersensitivity (tuberculin reaction) graft-versus-host-disease tumor surveillance/destruction intracellular infections viral, fungal, parasitic infections
intradermal skin testing
0.5-1 ml sterile syringe with 26/27 gauge intradermal needle, syringe parallel to skin, small amount of allergen solution approximately 5 mm in diameter
A patient is diagnosed with osteogenic sarcoma. What laboratory studies should the nurse monitor for the presence of elevation?
Alkaline phosphatase Explanation: Serum alkaline phosphatase levels are frequently elevated with osteogenic sarcoma or bone metastasis. Hypercalcemia is also present with bone metastases from breast, lung, or kidney cancer. Symptoms of hypercalcemia include muscle weakness, fatigue, anorexia, nausea, vomiting, polyuria, cardiac dysrhythmias, seizures, and coma. Hypercalcemia must be identified and treated promptly.
The nurse is administering Alendronate (Fosamax) to a client with osteoporosis. Which of the following is true?
It works by inhibiting bone resorption. Bisphosphonates (alendronate) inhibit osteoclastic activity and promote calcium deposition into bone
The nurse is preparing to discharge a client with a casted right wrist fracture. Which of the following should be included in the discharge teaching?
Range of motion exercises of the fingers and shoulder Principle: Encourage range of motion to the fingers and shoulder following a wrist fracture
When caring for a client who underwent bone marrow transplantation, the nurse knows that the client is at risk for which early major complication? Select all that apply.
Sepsis. Hemorrhage. Principle: Sepsis and bleeding are major complications following bone marrow transplantation until new marrrow engraftment occurs
T-cell and B-cell lymphocytes are the primary participants in the immune response. What do they do?
T-cell and B-cell lymphocytes distinguish harmful substances and ignore those natural and unique to a person. Explanation: T-cell and B-cell lymphocytes are the primary participants in the immune response. They distinguish harmful substances and ignore those natural and unique to a person.
The home health nurse is preparing a teaching plan on alendronate (Fosamax) therapy for one of her clients. Which of the following instructions would the nurse give the client?
Take the medication with 8 oz of water. Principle: Instruct patients to take oral bisphosphonates on an empty stomach, with 8 ounces of water and to sit upright for at least 30 - 60 minutes (risk for esophageal ulcers)
The nurse is caring for a client with hyperphosphatemia. The nurse would assess the client for which of the following clinical manifestations?
Tetany Principle: When phosphorous levels rise the calcium level decreases and the patient may present with signs of hypocalcemia
The nurse is caring for a client with a fever, sore throat and swollen cervical lymph nodes. The complete blood count shows a normal neutrophil count and an elevated lymphocyte count. Which of the following microorganisms is the most likely etiology for the client's symptoms?
Virus Principle: An increase in neutrophils indicates a bacterial infection while an increase in lymphoctyes indicate a viral infection (although lymphocytes are also elevated in some bacterial infections as well)
Diagnostic for SVCS
clinical findings, chest xray, CT, MRI
clinical manifestations of spinal cord compression
local inflammation, edema, venous stasis, impaired blood supply to nerve tissues local/radicular back/neck pain along the dermatomal areas pain exacerbated with movement, supine recumbent position, coughing, sneezing, or valsalva numbness, tingling, feelings of coldness in affected areas, inability to detect vibrations, loss of positional sense subtle weakness to flaccid paralysis
phagocytosis will include:
neutrophils and monocytes. Explanation: Neutrophils and monocytes are phagocytes, cells that perform phagocytosis.
engraftment syndrome may occur during the neutrophil recovery phase and s/s are:
noninfectious fever associated with skin rash, weight gain, diarrhea, pulmonary infiltrates
A client with an immunodeficiency disorder was admitted with pneumonia two days ago. The nurse suspects acute respiratory failure after reviewing which of the following arterial blood gas (ABG) values?
pH 7.30, PaO2 70 mm Hg, HCO3 32 mEq/L, PaCO2 50 mm Hg Principle: Acute respiratory failure is manifested by a decrease in PaO2 (less than 50 mm Hg) and an increase in PaCO2 (greater than 50 mm Hg) with respiratory acidosis
medical management for spinal cord compression
radiation to reduce tumor size/corticosteroid to reduce inflammation and swelling surgery to debulk tumor vertebral augmentation to attain stability of bone, prevent nerve compression, decreases pain (Vertebroplasty-percutaneous injection of polymethyl methacrylate bone cement Kyphoplasty-inserts a balloon where damage is located and inflated to create cavity within bone filled with bone cement; helps compress the fracture fragments together)
A client is treated in the emergency department for acute muscle strain in the left leg caused by trying a new exercise. During discharge preparation, the nurse should provide which instruction?
"Apply ice packs for the first 24 to 48 hours, then apply heat packs." Explanation: The nurse should instruct the client to apply ice packs to the injured area for the first 24 to 48 hours to reduce swelling and then apply heat to increase comfort, promote reabsorption of blood and fluid, and speed healing. Applying ice for only 12 to 18 hours may not keep swelling from recurring. Applying heat for the first 24 to 48 hours would worsen, not ease, swelling. Applying ice 48 hours after the injury would be less effective because swelling already has occurred by that time.
Superior vena cava syndrome
*most often associated with lung cancer, lymphoma/thymoma/testicular/mediastinal metastases from breast cancer Gradually/sudden impaired venous drainage giving rise to: dyspnea, cough, horaseness, chest pain, facial swelling, edema of neck/arms/hands/thorax, sensation of skin tightness, difficulty swallowing and stridor engorged/distended jugular, temporal, arm veins dilated thoracic vessels causing prominent venous pressure on chest wall ICP associated with visual disturbances, headache, altered mental status
Which statement describes external fixation?
The surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. Explanation: In external fixation, the surgeon inserts metal pins into the bone or bones from outside the skin surface and then attaches a compression device to the pins. In internal fixation, the surgeon secures the bone with metal screws, plates, rods, nails, or pins. A cast or other mode of immobilization is applied. In closed reduction, the bone is restored to its normal position by external manipulation. In open reduction, the bone is surgically exposed and realigned.
A female client is at risk for developing osteoporosis. Which action will reduce the client's risk?
Initiating weight-bearing exercise routines Explanation: Performing weight-bearing exercise increases bone health. A sedentary lifestyle increases the risk of developing osteoporosis.
The nurse is caring for a client with colon cancer and receives an order to draw a CEA. Which of the following is the most likely reason the physician ordered the test?
It will help to evaluate treatment response Principle: Tumor markers (for example, CEA, CA 125) are monitored to help determine the effectiveness of chemotherapy
Nursing students are reviewing the pathophysiology of human immunodeficiency virus (HIV). They demonstrate understanding of the information when they state which of the following as the form of the genetic viral material?
Ribonucleic acid (RNA) Explanation: HIV is a retrovirus that carries its genetic material in the form of RNA rather than DNA. HIV consists of a viral core containing the viral RNA, surrounded by an envelope consisting of protruding glycoproteins.
A client with arterial insufficiency undergoes below-knee amputation of the right leg. Which action should the nurse include in the postoperative care plan?
Elevating the stump for the first 24 hours Explanation: Stump elevation for the first 24 hours after surgery helps reduce edema and pain by increasing venous return and decreasing venous pooling at the distal portion of the extremity. Bed rest isn't indicated and could predispose the client to complications of immobility.
The nurse is caring for a client undergoing an incisional biopsy. Which statement does the nurse understand to be true about an incisional biopsy?
It removes a wedge of tissue for diagnosis. Explanation: The three most common biopsy methods are excisional, incisional, and needle. In an incisional biopsy, a wedge of tissue is removed from the tumor and analyzed. In an excisional biopsy, the surgeon removes the tumor and the surrounding marginal tissues. Needle aspiration biopsy involves aspirating tissue fragments through a needle guided into the cancer cells.
rhinitis medicamentosa
rebound reaction from the overuse of sympathomimetic nose drops/sprays worsen the congestion, resulting in PT using more medication leading to more nasal congestion. DO NOT mistake this for tolerance to drug
The nurse determines the client has extravasation of a chemotherapeutic agent. Which of the following nursing interventions would follow. Select all that apply.
Administer the prescribed antidote. Perform a neurovascular assessment to the affected extremity. Aspirate for residual medication from site. Principle: Following an extravasation, neurovascular assessments of the affected extremity should be performed
When caring for a client with a fractured wrist and a plaster of paris cast that was just placed, the nurse should perform which of the following actions?
Elevate the limb above the level of the heart Principle: Elevate the limb above the level of the heart for the first 24-48 hours following the application of a cast, splint or brace, to limit edema
The nurse is caring for a client who is on bedrest. Which action performed by the unlicensed assistive personnel increases the client's risk for complications?
Keeping a pillow under the knees Principle: Pressure on the back or side of the knee increases the risk for peroneal nerve damage and could result in footdrop (neurovascular assessments is a priority)
After reviewing the various primary immunodeficiencies, nursing students demonstrate understanding of the information when they identify what as complement system deficiencies? Select all that apply.
Angioneurotic edema , Paroxysmal nocturnal hemoglobinuria
This type of T lymphocyte is responsible for altering the cell membrane and initiating cellular lysis. Choose the T lymphocyte.
Cytotoxic T cell Explanation: The cytotoxic T cells (also known as killer T cells) attack the antigen directly and release cytotoxic enzymes and cytokines.
term means a lack of one or more of the five immunoglobulins?
Hypogammaglobulinemia Explanation: Hypogammaglobulinemia is a lack of one or more of the five immunoglobulins. Agammaglobulinemia is a disorder marked by an almost complete lack of immunoglobulins or antibodies. Panhypoglobulinemia is a general lack of immunoglobulins in the blood. Telangiectasias are vascular lesions caused by dilated blood vessels.
Type 1 hypersensitivity
Involves IgE antibodies, Mast cells -Anaphylactic reaction characterized by vasodilation, increased capillary permeability, smooth muscle contraction, eosinophilia Examples: extrinsic asthma, allergic rhinitis, systemic anaphylaxis, bee stings
The nurse is educating the patient with low back pain about the proper way to lift objects. What muscle should the nurse encourage the patient to maximize? Rectus abdominis Gastrocnemius Latissimus dorsi Quadriceps
Quadriceps Explanation: The nurse instructs the patient in the safe and correct way to lift objects using the strong quadriceps muscles of the thighs, with minimal use of weak back muscles
The nurse suspects that a client with an arm cast has developed a pressure ulcer. Where should the nurse assess for the presence of the ulcer?
Ulna styloid Explanation: Casts or inappropriately applied splints can put pressure on soft tissues, causing tissue anoxia and pressure ulcers. Lower extremity sites most susceptible are the heel, malleoli, dorsum of the foot, head of the fibula, and anterior surface of the patella. The main pressure sites on the upper extremity are located at the medial epicondyle of the humerus and the ulnar styloid.
A client is experiencing pain, joint instability, and difficulty walking due to an injury to the knee ligaments. The injury was judged not to require surgery. Which intervention would not be included in this client's care?
traction Explanation: Joint immobilization, limited weight bearing, ice, and NSAIDs would be included in the initial treatment.
IgG (75% of Total Immunoglobulin)
• Appears in serum and tissues (interstitial fluid) • Assumes a major role in bloodborne and tissue infections • Activates the complement system • Enhances phagocytosis • Crosses the placenta
staging
determines the size of the tumor, the existence of local invasion, lymph node involvement, distant metastasis. One system is the TNM (tumor, nodes, metastasis)
The home health nurse is preparing a teaching plan for a client who is receiving an oral dose of alendronate (Fosamax). Which of the following instructions must the nurse give the client?
Visit your dentist annually. Principle: Osteonecrosis of the jaw is a potential risk with bisphosphonates so encourage yearly dental evaluations
The nurse is assessing a young client during an annual sports physical at school. The assessment reveals that the client has lateral curving of the spine. The nurse reports to the health care professional that the assessment revealed
scoliosis. Explanation: Scoliosis is a lateral curvature of the spine. Lordosis is an increase in the lumbar curvature of the spine. Diaphysis is the shaft of a long bone. Epiphysis is the end of a long bone.
N in TNM
the absence/presence and extent of regional node metastasis: Nx-Regional lymph nodes cannot be assessed N0- No regional lymph node metastasis N1, N2, N3- increasing involvement of regional lymph nodes
Amifostine (Ethyol)
used in PTs with head/neck cancer to reduce acute/chronic xerostomia
The nurse is caring for a client with a hip fracture. The physician orders the client to start taking a bisphosphonate. Which medication would the nurse document as given?
Alendronate
A client who has extremity right wrist fracture complains of severe burning pain, frequent changes in the skin from hot and dry to cold, and feeling clammy skin that is shiny and growing more hair in the injured extremity. The nurse should anticipate providing care for what complication?
Complex regional pain syndrome Explanation: The symptoms reported by the client are consistent with complex regional pain syndrome.
Which blood test confirms the presence of antibodies to HIV?
Enzyme immunoassay (EIA) Explanation: EIA and Western blotting identify and confirm the presence of antibodies to HIV.
Drugs that can prevent GVDH
PTs receive immunosuppressant drugs: cyclosporine (Sandimmune), methotrexate, tacrolimus (Prograf) or mycophenolate mofetil (MMF)
A client has just undergone arthrography. What is the most important instruction for the nurse to include in the teaching plan?
Report joint crackling or clicking noises occurring after the second day. Explanation: After undergoing arthrography, the client must be informed that he or she may hear crackling or clicking noises in the joints for up to 2 days, but if noises occur beyond this time, they should be reported. These noises may indicate the presence of a complication, and therefore should not be ignored or treated by the client. Massage is not indicated. The client need not be asked to avoid sunlight or dairy products.
hypercalcemia
Total serum calcium level: greater than 10.5 Ionized serum calcium: greater than 1.29mmol medical emergency (oncologic) calcium that is released from the bones is more than what the kidney can excrete or than what the bones can reabsorb -can result from production of cytokines, hormonal substances and growth factors by cancer cells, or by the body in response to the cancer cells -most commonly seen in breast, lung, renal cancers; myeloma, and some types of leukemia
A patient falls while skiing and sustains a supracondylar fracture. What does the nurse know is the most serious complication of a supracondylar fracture of the humerus?
Volkmann's ischemic contracture Explanation: The most serious complication of a supracondylar fracture of the humerus is Volkmann contracture (an acute compartment syndrome), which results from antecubital swelling or damage to the brachial artery.
IgA (%15 of total immunoglobulin)
appears in body fluids protects against pulmonary, gastrointestinal, genitourinary infections prevents absorption of antigens from food passes to neonate to breast milk for protection
Kaposi sarcoma (KS) is diagnosed through
biopsy. Explanation: KS is diagnosed by biopsy of the suspected lesions. Prognosis depends on the extent of the tumor, the presence of other symptoms of HIV infection, and the CD4+ count.
spinal cord compression
caused by compression or the cord and its nerve roots by a metastatic paravertebral tumor extending into epidural space. -can lead to significant and permanent neurologic impairment -most often associated with cancer that metastasize -70% occurs at thoracic level, 20% lumbosacral level
Autologous
from the PT
fine needle aspiration
involves aspirating cells rather than intact tissue through a needle thats guided into suspected diseased area Can ONLY be analysis by cytological exam
A nurse would most likely expect the need for open reduction for a client with which of the following?
joint fracture Explanation: An open reduction is required when soft tissue is caught between the ends of the broken pieces of bone, the bone has a wide separation, open fractures are evident, comminuted fractures are present, and the patella or other joints are fractured. It is also done when wound debridement or internal fixation is needed.
