NCLEX Studying
Where is ADH found?
pituitary
Treatment of FVD
- prevent further losses of fluid - replace volume (po fluids, iv fluids) - fall risks - monitor for overload with IV fluid replacement
Hypermagnesemia causes
- renal failure - antacids
Hypomagnesemia causes
- diarrhea (lots of Mg in intestines) - alcoholism - alcohol suppresses ADH and it's hypertonic (not eating and drinking too much)
Hypercalcemia s/s
- bones are brittle - kidney stones
Vasopressiin or desmopressin
ADH replacement medication given as nasal spray in DI.
A child with acute lymphocytic leukemia (ALL) is receiving chemotherapy through a single lumen Groshong catheter. During the infusion, the child reports nausea and has vomited. The primary healthcare provider has prescribed ondansetron IV. What action should the nurse take?
A Groshong catheter is implanted when other venous access sites are no longer useable. The child has begun to react to the chemotherapy and needs medicated now. Because this implanted device has only one lumen, the nurse must stop the chemotherapy infusion temporarily, flush the port, administer the ondansetron, flush again and restart the chemotherapy infusion.
A client who has been receiving care for cirrhosis arrives to the clinic for follow-up care. Which new signs and symptoms noted by the nurse would indicate that the client has developed hepatic encephalopathy?
A musty or sweet breath odor, poor concentration, slow movement, asterixis (an abnormal tremor consisting of involuntary jerking movements, especially in the hands).
Disease with too little aldosterone
Addison's Disease
The nurse is caring for a client who is wheezing and struggling to breathe. Which inhaled medications might be indicated at this time?
Albuterol and levalbuterol are both rapid acting bronchodilators, that will quickly relieve shortness of breath, chest tightness and wheezing. This client is in distress now. Either medication would be indicated.
A client diagnosed with hypothyroidism has been taking levothyroxine in increasing doses over the past week. Which findings, if present, would indicate to the nurse that the drug dosage is too high?
If the levothyroxine dose is too high, the client may experience an tachycardia, dysrhythmias, tremors, and a headache. When the levothyroxine level is too high, the symptoms are the same as hyperthyroidism.
A client awaiting discharge for a broken left tibia is to be sent to physical therapy for crutches and crutch walking. The client reports having brought a pair of crutches borrowed from a family member. What is the most appropriate action for the nurse to take now?
The physical therapy department is best qualified to assist a client in adjusting to the use of crutches prior to discharge. Because the client wants to use older crutches, it is even more important for a physical therapist to determine whether it is safe for the client to do so. Physical therapy can evaluate the condition of the old crutches, the client's ability to manage that equipment and to walk safely with those crutches.
Potential ADH problems
craniotomy, head injury, sinus surgery, transsphenoidal hypophysectomy, or any condition that can lead to an increased ICP (all head injuries/surgeries)
Fluid Volume Excess/Hypervolemia
too much fluid in the vascular space
What is the action of aldosterone?
when blood volume gets low (vomiting, hemorrhage, etc.) it increases and retains sodium/water and blood volume goes up
Which nursing intervention represents secondary prevention level?
Providing care for clients in a shelter for abused women indicates that a problem has been identified and is being monitored to prevent the problem from getting worse. The focus of secondary prevention is early detection, use of referral services, and rapid initiation of treatment to stop the progress of the disease.
Renal failure
kidneys aren't working
A client with renal failure has returned to the unit post kidney transplant. Which postoperative interventions should the nurse provide?
- administer furosemide (diuresis) - Measure abdominal girth - weight daily - measure urine output every 30-60 minutes
What does ADH do?
makes you retain water
Hypermagnesemia s/s
- flushing and warmth - vasodilation - think muscles
Hypomagnesemia treatment
- give some Mg - check renal function (before and during IV Mg). - seizure precautions - eat Mg
FVE causes what?
- heart failure - renal failure
Heart Failure
- heart is weak - cardiac output goes down - kidney perfusion goes down - urinary output goes down - volume stays in the vascular space
FVD causes
- loss of fluid from anywhere (thoracentesis, paracentesis, vomiting, diarrhea, and hemorrhage) - can cause shock!! - third spacing (burns, ascites) - polyuria
Treatment of FVE
- low sodium diet/restrict fluids - I&O and daily weights (same time, same scale, same clothing, void first) - Diuretics (furosemide, bumetanide, hydrochlorothiazide, spironolactone) - bed rest (induces diuresis) - physical assessment - Give IVFs slowly to the elderly and very young and clients with a history of heart and kidney problems
The nurse would make which recommendations when conducting community health teaching about obesity to a group of adolescents?
- 60 minutes of moderate-intensity physical activity 7 days a week - Girls should take a least 13,000 steps daily and boys should take 11,000 steps daily - TV viewing and video game playing should be 2 or fewer hours each day.
The nurse is caring for a client with cirrhosis of the liver and suspects that the client may be developing hepatic encephalopathy. Which assessments by the nurse suggest that the client is developing this complication?
- Asterixis - Lethargy - Amnesia - Behavioral changes
Hypercalcemia causes
- Hyperparathyroidism (too much PTH) **When serum calcium gets low, the PTH kicks in and pulls Ca from the bone and puts it into the blood, therefore the serum Ca goes ↑ - thiazides (retain calcium) - immobilization ( you have to bear weight to keep Ca in the bones)
The nurse providing palliative care to a client would include which outcomes in the teaching plan?
- Maintaining the client's quality of life - Minimizing family caregiver stress - Managing the client's pain - Managing the client's and family's emotional needs - Attending to the client's spiritual needs
The nurse has determined that a bedridden client diagnosed with a stroke is at risk for venous thromboembolism (VTE). What interventions should the nurse initiate?
- Measure the calf and thigh daily - Apply sequential compression devices to the legs - Position paralyzed leg with each distal joint higher than the proximal joint - Passive range of motion several times a day
Treatment for hypocalcemia
- PO calcium - IV Ca (GIVE SLOWLY) and always make sure the client is on a heart monitor - Vitamin D - Phosphate binders: sevelamer hydrochloride and calcium acetate
Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery?
- Positive Trousseau's sign - Leg cramps
The nurse is preparing to teach a client about post percutaneous transluminal coronary angioplasty (PTCA) care. Which teaching points should the nurse include?
- Reporting any chest discomfort following percutaneous intervention - Avoid lifting more than 10 pounds until approved by healthcare provider. - remain on bed rest for a minimum of 4 hours - Fluids need to be increased to flush the dye used during the procedure from the kidneys
What signs of cannula displacement should the nurse monitor for at an arterial line insertion site?
- Swelling - Fluid leakage - Blanching - Poor arterial waveform
The client reports intense headaches with increasing pain for the past month. A magnetic resonance imaging (MRI) is prescribed. In reviewing the client's history, which information is of concern to the nurse?
- coronary artery stent - cardiac pacemaker - extreme obesity - history of working with metal fragments
Diseases with too much aldosterone
- cushing's disease - hyperaldosteronsism (Conn's syndrome)
Hypocalcemia causes
- hypoparathyroidism - radical neck - thyroidectomy - NOT ENOUGH PTH
Treatment for hypercalcemia
- move! - fluids prevent kidneys stones - Ca has an inverse relationship with phosphorus (add phosphorus to the diet) - steroids - safety precautions - medications that decrease serum Ca: biphosphates (etidronate), calcitonin.
DI (diabetes insipidus)
- not enough ADH - lose (diurese) water - Fluid volume DEFICIT (can go into shock) - urine is diluted (specific gravity goes down) - blood is concentrated (H&H goes up)
S/S of hypomagnesemia and hypocalcemia
- think muscles 1st! NOT SEDATED - muscle tone rigid and tight - seizures - stridor/laryngospasm - airway is smooth muscle - positive Chvostek's signs (cheek twitching) - positive Trousseau's (BP cuff causes tremor of hand) - arrhythmias - DTRs increased - Mind changes up or down - swallowing problems
SIADH (syndrome of inappropriate antidiuretic hormone)
- too much ADH (too many letters too much water) - Retains water - Fluid volume EXCESS - urine is concentrated (specific gravity goes up) - blood is diluted (H&H goes down)
Treatment for hypermagnesemia
- ventilator - dialysis - calcium gluconate = antidote for toxicity - safety precautions
FVD s/s
- weight loss - decreased skin turgor - dry mucous membranes - decreased urine output - BP decreases (less volume, less pressure) - Pulse increased (weak and thready) - respirations increased - CVP decreased - cool extremities - urine specific gravity is up (concentrated)
How should a nurse prepare to administer a Measles, Mumps, Rubella (MMR) vaccination to a 6 year old child?
MMR is given Sub-Q. Subcutaneous injections are administered in the fat layer, underneath the skin. When administering SQ injections use a 23-25 gauge needle, needle length for infants (1- 12 months) is 5/8", children 12 months and older 5/8" - ¾".
A client who has chronic renal failure has been prescribed synthetic erythropoietin for the prevention of anemia. Which assessment finding should be reported to the primary healthcare provider?
Swelling of feet and ankles may indicate the beginning of a cardiovascular problem. Clients taking this drug are at risk for myocardial infarctions and risk of blood clots.
Where is aldosterone found?
adrenal glands (on top of kidneys)
A nurse is planning a health fair in a Hispanic community composed of primarily young adults. What would be essential for the nurse to provide to this community at the health fair?
- Blood pressure screening - Glucose monitoring - Influenza vaccine - BMI calculation - Test urine for protein Hispanics have a higher incidence of death from heart disease and stroke. Blood pressure monitoring is essential to detect and control hypertension. Diabetes is prevalent in the Hispanic community. Early diagnosis is critical to manage and control for the risk of complications. Flu vaccination is recommended for all ethnic groups. Obesity is very high among Hispanic Americans at >70%. Chronic renal failure is a high risk for Hispanic Americans particularly since diabetes is prevalent. Early testing for protein in urine is recommended.
An elderly client living in a long-term care facility fell 8 hours ago causing a laceration on the occipital area of the skull and steri-strips were applied for closure. Which signs/symptoms would indicate to the nurse that the client should be transferred to the emergency department?
- Sudden emotional outbursts. - Client report of blurred vision. - Headache unrelieved by acetaminophen.
Which interventions should the nurse include in the plan of care for a client following chest tube placement for a spontaneous pneumothorax?
- Tape all connections between the chest tube and drainage system. - Perform pulmonary assessment every two hours. - water seal chamber kept below client's chest - change when full
The nurse is caring for a client diagnosed with Addison's disease. Which finding would indicate to the nurse that a client has received excessive mineralocorticoid replacement?
- Weight gain of 4 pounds in one week - Serum potassium of 3.2 mEq
S/S of hypermagnesemia and hypercalcemia
- act like SEDATIVES - DTRs decreased - Muscle tone weak and flaccid - arrhythmia - LOC decreased - pulse decreased - respirations decreased
A client arrives at the emergency department after being removed from a burning building. The nurse suspects carbon monoxide poisoning when the client exhibits which signs and symptoms?
- chest pain - confusion - palpitations
S/S of FVE
- distended neck veins - peripheral edema/third spacing - CVP is increased (2-6 is normal) - Lung sounds wet (SOB) - Polyuria - pulse increases (full and bounding) - BP increases (more volume more pressure) - weight increases
Three things with a lot of sodium?
- effervescent soluble medications - canned/processed foods - IVF with sodium
A client who has been taking phenytoin for several years arrives to the clinic for follow-up care. During the nurse's history and physical of the client, which findings indicate a possible side effect to the phenytoin?
An adverse effect of phenytoin is aplastic anemia. Phenytoin is an anticonvulsant. Aplastic anemia is a blood disorder where not enough new blood cells are produced in the bone marrow. The blood cells include red blood cells, white blood cells and platelets. The most common symptom of decreased RBC's is fatigue and dyspnea upon exertion because RBC's are responsible for oxygen transport throughout the body. A common sign/symptom of aplastic anemia is also skin rashes. Collectively, these are signs/symptoms of aplastic anemia caused by this medication.
A client who is 20 weeks pregnant and diagnosed with pelvic inflammatory disease is given a prescription for metronidazole. What should the nurse inform the client to avoid in order to prevent an interaction with metronidazole?
Metronidazole is an antibiotic used for the treatment of vaginal infections. Metronidazole and alcohol can interact with each other, causing severe nausea and vomiting as well as cramping and flushed appearance.