MS 2 Exam 2

The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply

1. Instruct the client about thyroid replacement therapy. 2. Encourage the client to eat foods high in fiber and lots of fluids. 3. Instruct the client to contact the HCP if episodes of chest pain occur. -Cold intolerance so need a warmer environment.

Symptoms of Upper GI obstruction

Colicky pain tinkly sounds severe vomiting (vomiting relieves pain)

DKA and HHS blood glucose levels

DKA: <800 HHS: >800

Signs of compensation for metabolic acidosis include

Deep rapid respirations

Signs of hypoglycemia

Diaphoresis Tachycardia Fatigue Excessive hunger Tremors

Diagnostics for Cushing's Disease

Increased plasma cortisol levels low dose dexamethasone suppression 24 hour urine sample = cortisol in urine -always discard first void CT scan for tumors

Symptoms of DI

Increased serum osmolality, increased serum sodium and potassium (less volume to dilute) -dehydration can lead to seizures, coma, and or death

Cause of HHS

Infection, corticoids, phenytoin, thiazides

Characteristics and causes of pancreatitis

Inflammation + auto digestion Alcohol abuse + cholecystitis

What is Addisonian crisis?

Insufficient adrenocortical hormones- sudden drop Caused by: Stress, sudden withdrawal of meds, surgery -Shock= priority Treat with: Fluid replacement + steroids

The nurse should teach the client who is receiving warfarin sodium that:

International Normalized Ratio (INR) is used to assess effectiveness.

A client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose level was 950mg/dL. A continuous intravenous infusion of short acting insulin is initiated along with intravenous rehydration with normal saline. The serum glucose level is now 240mg/dl. The nurse would next prepare to administer which item?

Intravenous fluids containing dextrose - used to avoid tanking them into hypoglycemia.

A client is brought to the ED in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar nonketotic (HHNC) syndrome is made. The nurse would immediately prepare to initiate which anticipated health care providers' prescription?

Intravenous infusion of normal saline- fluid resuscitation

What is located in the pancreas houses beta cells that produce insulin and amylin

Islets of Langerhans

Signs of pancreatitis

Left upper quadrant pain not relieved by vomiting Hypocalcemia= tetany (shaky, spasms)

Treatment for hypothyroidism (Hashimotos)

Levothyroxine (Synthroid) -Life long treatment -Report chest pain, weight loss, irritability and tremors -increased oxygen demand

Diagnostics and Treatment for GI bleeding and Complications

Upper GI bleed: Endoscopy Lower GI bleed: Colonoscopy Treat: Endoscopic hemostasis therapy -stops vessels - cauterize to stop bleeding -H2 blockers and meds Complications: Shock and hemorrhage

Why are patients with pancreatitis NPO?

You don't want to stimulate the pancreas

What is thyroid storm?

acute, life-threatening form of thyrotoxicosis that may present w/ Afib, fever, and delirium -Excessive amounts of thyroid hormones -thyroidectomy is a risk factor

Signs of DKA

extremely high glucose levels, acidic pH of arterial blood gas, starving, weight loss, fruity breath, isotonic dehydration, kussmaul respirations

A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is an expected outcome of the medication?

Achieve normal thyroid hormone levels.

Symptoms of Lower GI obstruction

*Abdominal distention May not have vomiting

Acidosis Treatment

-Assess LOC and respiration's -give sodium bicarbonate if ph is <7.1 -corrected bug fluids and insulin

Cause of DKA

-little to no insulin -stress and infection —> hyperglycemia (Polyuria, blurred vision, polydipsia, dehydration)

Treatment for DKA and HHS

-risk for fluid volume deficit -manage airway -fluid replacement + insulin therapy -when glucose @ 250-> change to D5W w/ .45% NS with glucose because we don't want to deplete them. -potassium labs -regular insulin = continuous -patient teaching: know signs of hypoglycemia. -if stressed: still take insulin (even if not eating because their body needs insulin because of the increased stress)

The nurse is caring for a client admitted to the ED with DKA. In the acute phase, the nurse plans for which priority intervention?

Administer short-duration insulin intravenously.

The pernicious anemia that may accompany gastritis is due to which of the following?

A lack of intrinsic factor normally produced by acid-secreting cells of the gastric mucosa. -Acid secreting cells are lost or nonfunctioning.

What is Addison's Disease?

Adrenal insufficiency -give some steroids and take away Addisonian crisis -all three classes lowered (adrenocorticosteroids, other adrenal gland products) -No symptoms until severe damage

What is ACTH and what does it stimulate?

Adrenocorticotropic hormone, stimulates adrenal gland, from anterior pituitary.

Labs for pancreatitis

Amylase and lipase INCREASED

The nursing instructor asks a student to describe the patho that occurs in Cushings disease. Which statement by the student indicated an accurate understanding of this disorder? Cushing's disease results from....

An increased pituitary secretion of adrenocorticotropic hormone (ACTH)

A patient with SIADH has a serum sodium level of 129. The nurse is concerned about potential complication form this laboratory finding and implements safety measures. What would be the priority?

Pad the side rails in case of seizures.

Description of nonmechanical obstruction

Paralytic ileus (bowel not working), vascular, neurogenic

In preparing a client for a colonoscopy, the nurse should explain that:

1. A signed informed consent in necessary 2. Sedation may be used during the procedure 3. Bowel cleansing is necessary for preparation

The nurse places a priority on which of these interventions to care for a client with an NG tube.

1. Frequent oral care for dry oral mucosa. 2. Use of low intermittent suctioning. 3. Frequent assessment of bowel sounds.

A patient with chronic gastritis associated with the presence of H. pylori is treated with triple-drug therapy. The nurse explains to the patient that the drugs commonly included in this regimen include

1. Amoxicillin (Amoxil) 2. Clarithromycin (Biaxin) 3. Omeprazole (Prilosec)

Select all the statements that apply to the proper administration of total parenteral nutrition

1. Can hang for only 24 hours 2. Required glucose monitoring every 6 hours and PRN 3. Label should contain all nutrients as well as date, time, and expiration date.

In caring for a client with cholelithiasis and a possible biliary obstruction, what clinical findings would you expect?

1. Clay colored or light colored bowel movements. 2. Abdominal pain 3. Jaundice

A client is diagnosis of diabetic ketoacidosis (DKA) is being treated in the ED. Which findings would the nurse expect to note as confirming this diagnosis?

1. Deep, rapid breathing 2. Elevated blood glucose levels 3. Low plasma bicarbonate level

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understand discharge instructions if the client states that which symptoms are associated with the diagnosis?

1. Feeling cold 2. Loss of body hair 3. Persistent lethargy 4. Puffiness of the face

A client has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder (extreme of this disorder)?

1. Fever 2. Nausea 3. Tremors 4. Confusion

Signs and symptoms of a bowel perforation might include:

1. Free air under the diaphragm on Xray 2. A sudden change in pain and new pain in the shoulder 3. Changes in vital signs including elevated temp.

Important nursing interventions when caring for a client with Cushing syndrome include

1. Monitoring blood glucose levels 2. Protecting patient from exposure to infection

The nurse performs a detailed assessment of the abdomen of a patient with a possible bowel obstruction, knowing that a manifestation of an obstruction in the small intestines is...

1. Projectile vomiting 2. Persistent, colicky abdominal pain 3. Increased, tinkling bowel sounds above the blockage.

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrate an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop?

1. Shakiness 2. Palpitations 3. Light headedness

The nurse anticipates a patient will need an esophagastroduodenoscopy (EGD). Select all the actions that are appropriate in this patients care.

1. Signed informed consent 2. Teaching related to conscious sedation 3. Full set of vitals before the procedure 4. Keep the patient NPO until gag reflex returns post-procedure.

What is SIADH and what is it characterized by?

Excess ADH dilutional hyponatremia, low serum osmolality Concentrated Urine—> dark color Mental status changes, seizures, headache, cerebral edema (can be related to low or high sodium)

What is Cushing's Disease and what is the main cause?

Excess corticosteroids (glucocorticosteroids) Main cause: exogenous- excess administration

What is Hyperthyroidism (Graves Disease) including the pathophysiology behind it

Exophthalmos: protruding eyes Everything increased Patho: Antibodies attach to TSH receptors and stimulate thyroid to release T3 and T4. Leads to excess release.

Nursing diagnosis for DI

Fluid deficit, priority is fluid replacement

What is the level for hypoglycemia, signs, and treatment

<60. Sweaty, pallor, dilated pupils If on BB: signs might not show up Tx: give 15g of carbs, D5W, oral glucose -should improve rapidly when they get glucose

Levothyroxine (Synthroid) is prescribed for a client diagnosed with hypothyroidism. Upon review of the clients record, the nurse notes that the client is taking warfarin. Which modification to the plan of care should the nurse review with the clients health care provider?

A decreased dosage of warfarin sodium.

Treatment of DI

ADH replacement: desmopressin acetate -effective?: urine output should decrease ADH stimulants Thiazides for kidney problems—> diuretic (slows filtration rate) -decreases GFR (keep fluid, dump bad stuff) Indocin: NSAID, increase response to ADH IV fluids Low sodium/ potassium diets—> no salt substitutes

You are a nurse caring for a client that has just returned from a cholecystectomy. What are appropriate interventions for this patient and what is one that is NOT.

Appropriate -Encourage early ambulation -Deep breathe and cough every hour -Splint abdomen when moving and coughing INappropriate -regular diet

A client presents to the ED with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?

Assessment of vital signs

Which of the following would be the most important for a nurse to teach a client who is hospitalized with acute pancreatitis prior to discharge?

Avoidance of alcohol use for up to a year. -alcohol can precipitate future flares or turn it into chronic pancreatitis.

What is melena?

Black stools -Iron supplements may cause this -Indicative of upper GI bleed

The physician orders dopamine at 4mcg/kg/min for a 210lb patient. Supplied 400mg in 250ml of D5W. Calculate the COS and IR

COS: 400,000 mcg/250 ml= 1600 mcg/ml IR: (4mcg X 94.45 kg X 60 min) / 1600mcg/ml = 14 ml/hr

NG tube insertion

Check tube placement = xray + push air in and listen with stethoscope. Only do xray the first time unless indicated. -Elevate head of bed to prevent aspiration -Risk of aspiration -Reduce nostril irritate by taping the tube down -Use water soluble lubricant -Residual volume-> pull back and replace contents

What is Hematemesis and what to do if this occurs

Coffee ground throw up -Do an endoscopy to see where the bleed is -Been in there a while and is being digested that is why its black and coffee texture

Description of mechanical obstruction

Common, physical most are in small bowel

How to relieve pancreatitis pain

Cough and deep breathe

Treatment for SIADH

Fluid restriction w/ normal saline -declomycin (demeclocyline)= block affect of ADH on renal. (Increases urine output) -Lithium= not for confusion, blocks renal response -hypertonic solution= slow over time -supplement with sodium and potassium -weigh DAILY- especially with fluid problems -avoid opioids (can increase salt) —don't have to restrict Na or K

Insulin is released in the pancreas in response to ?

Glucose

In DKA, are there high or low levels of potassium?

HIGH

Symptoms of Cushing's Disease

Hypertension (sodium and water retention), hypokalemia (alkalosis), hyperglycemia.

The nurse is taking the patients blood pressure, while inflating the cuff the nurse notices jerking motions of the patients arm and hands. The nurse suspects the patient has

Hypocalcemia -Trousseau's sign

Signs of Addison's Disease

Hypotension and hypovolemia Hyperkalemia Weight loss, fatigue, bronze skin

Complications of DI

Hypovolemia: circulatory collapse Shock Hypernatremia

The nurse teaches the client that the best time to take corticosteroids for replacement purposes is? What is the patients diagnosis?

In divided doses in the morning and late afternoon. Addison's Disease

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data should alert the nurse to this occurrence?

Inability to pass flatus

What is DI and the two types?

Inadequate ADH Neurogenic: lack of ADH (trauma/tumor) Nephrogenic: insensitivity to ADH (genetic)

Labs for Cushing's Disease

Increased BP, Decreased potassium, Increased plasma cortisol, increased levels of ACTH, increased pH.

Signs and Symptoms of Graves Disease (hyperthyroidism)

Increased metabolism -Weight loss and muscle wasting -Rapid pulse -increased appetite -Dyspnea and insomnia -Increased bowel -Increased respirations -Fine/thin nails and clubbing -Intolerance to heat, elevated basal temp -Hypertension

Where are the Adrenal glands located and what do they produce

Located on top of the kidneys -Adrenal cortex: corticosteroids hormones -cortisol, aldosterone, androgens, estrogen -Adrenal medulla -Epinephrine and norepinephrine

A client with a head injury develops SIADH. Symptoms the nurse would expect to find include

Low urine output and thirst.

A client is admitted to an ED, and a diagnosis of myxedema coma is made. Which action would the nurse prepare to carry out initially?

Maintain a patent airway

Signs of DI

Mental status changes, dehydration, POLYURIA, low urine osmolality, diluted urine

Information for acute abdominal pain

NPO ALWAYS do vitals first Can be many different problems so do full history second -could be bleeding, pregnant, etc

Does HHS have ketones and is it acidic or basic?

No ketones NOT acidic—> basic (PH is either normal or increased)

Are there ketones or lipolysis in HHS?

No! No lipolysis= no ketones

What is Hypothyroidism (Hashimoto's) along with signs and symptoms

Patho: deficiency in thyroid hormones Decreased metabolism -weight gain, slowed movements, lethargy -decreased appetite, constipation -thick nails -intolerance to cold -decreased HR and force

GI bleeding- what to do first and risk factors

Perform vitals first to assess for shock. -Shock= decreased BP and tachycardia Risk factors: -Inappropriate NSAID use -previous bleed -alcohol use -older adults

Diabetes insipidus is what type of problem

Pituitary problem

After several diagnostic tests, a client is diagnosed with diabetes insipidus (DI). The nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder?

Polydipsia

What to do before thyroidectomy and what are the risks

Pre: Iodine, anti-thyroid, beta blockers -Risk for airway obstruction (swelling) -Laryngeal stridor (loud sound) -Risk for low calcium if damage to parathyroid -check calcium using Trousseu (shaking hand) or Chovestek (cheek) signs. -carpal spasms, tetany = give calcium

The nurse knows that an important role of the pancreas that may be diminished during pancreatitis is

Release of bicarbonate to decrease acidity of gastric chyme.

Teaching points for Addison's Disease

Report stressful events to titrate med dosage Dont stop meds suddenly - greater than a week Risk for infection Monitor blood glucose Side Effects: Same as Cushing's Risk for osteoporosis = vitamin D and Calcium Take meds in morning (2/3) and (1/3) in late afternoon

Goal of pancreatitis

Rest, NPO, decrease stimulation, pain control

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Where should the nurse anticipate the location of the pain?

Right upper quadrant, radiating to the right scapula and shoulder.

With acute pancreatitis, what lab value rises within 12 hours and stays elevated for 4 days?

Serum amylase

Signs of HHS

Severe dehydration, hyperglycemic signs, more mental status changes

Signs of thyroid storm and how to treat it

Severe tachycardia -HF & Shock -Hyperthermia Iodine: decreases vascularity of thyroid, inhibits synthesis of T3 and T4. Use Beta-Blocker

What is occult bleeding and what test confirms this?

Small amounts of blood -cant see, need to do occult blood test *Guaiac Test

Treatment for Addison's Disease

Steroids - prednisone and hydrocortisone (immunosuppressant)

Signs of GI Obstruction

Strangulation = pain rapid onset, decreased blood flow Above obstruction = bowel sounds present Below obstruction = bowel sounds not present

The nurse is changing the subclavian dressing of a client. When assessing the catheter insertion site, the nurse notes the presence of yellow drainage from around the sutures that are anchoring the catheter. What should the nurse obtain before cleaning the site?

Swab and culture of the exudate to send to the lab.

Interventions for Cushing's Disease

They are immunosuppressed so.. -Prevent infection -BP control -Potassium treatment

Signs of Cushing's Disease

Thinning of hair, buffalo hump, moon face, fat pads, slowed healing, striae, thin skin -If you fix problem or stop medication administration these signs will go away, they are not life long.

A client admitted with a GI bleed has an initial hemoglobin of 12.5g/dL and hematocrit of 40%. Four hours later the patient has a hemoglobin of 9.8g/dL and hematocrit of 24%. The patient has stable vital signs, is receiving lactated ringers at 150ml/hr and has had drainage but no sign of blood from the nasogastric tube. You interpret these findings as

This decrease in hemoglobin and hematocrit was caused by hemodilution from fluid replacement therapy.