Unit 4: Adaptive Rationale

Risk for deep vein thrombosis (DVT) is increased with orthopedic, abdominal, thoracic, and genitourinary procedures. Trauma and swelling from surgery in the lower abdomen or pelvic region can

impede venous blood return from the lower extremities. This promotes venous stasis and increases the risk for deep vein thrombosis (DVT) in the postoperative period.

Protein helps

in the synthesis of immune factors.

Carbohydrates

increase the metabolic energy required for inflammation.

Loosening of sutures may occur after the initial wound edema subsides, but

is not a sign of failure of the suture line.

Contact dermatitis manifests as

localized eczematous eruption when the skin comes into direct contact with irritants or allergens.

It is uncommon for BPH to become

malignant.

Evisceration

occurs when wound edges separate to the extent that intestines protrude through the wound.

Carbidopa/levodopa is a metabolic precursor of dopamine; it reduces sympathetic outflow by limiting vasoconstriction, which may result in

orthostatic hypotension.

BPH develops

over the client's life span; it is not congenital.

After transurethral resection of the prostate (TURP), regular walking will

promote venous return from the lower extremities. Walking is preferred over sitting, which puts pressure on the surgical area and can cause bleeding. Strenuous exercise should initially be avoided.

Onychomycosis (fungal infection of toenail) is manifested as

scaliness under distal nail plate. Nails appear brittle, thickened, broken, or crumbling with yellowish discoloration.

Atopic dermatitis is characterized by

scaling and excoriation, which occurs due to food allergies, chemicals, or stress. (like Hallie's hands)

Serosanguineous drainage from the wound or on the dressing forewarns

separation of the wound edges (dehiscence);

Lipid soluble hormones are

steroid hormones

Drug eruptions are characterized by

bright-red erythematosus macules and papules on the skin, which occur because of an adverse reaction to a drug.

In the early stages of shock associated with hemorrhage, sympathetic nervous system responses cause

a compensatory peripheral vasoconstriction that shunts blood to vital organs. This vasoconstriction causes pallor.

A decrease in blood pressure occurs with shock due to hemorrhage, secondary to

a decreased circulating fluid volume.

A purplish incision is the expected coloration of

a healing wound.

A client is scheduled for an adrenalectomy. What does the nurse expect that the plan of care will include?

- Corticosteroids must be administered preoperatively to prevent adrenal insufficiency during surgery. Steroid therapy usually is given intravenously or intramuscularly preoperatively and continued intraoperatively to prepare for the acute adrenal insufficiency that follows surgery. - The diet must supply ample protein and potassium.

An ambulatory client with benign prostatic hyperplasia tells the nurse on morning rounds that he has not been able to void. The nurse assesses the client and determines that the bladder is distended. What should the nurse do? 1. Ask him to use a urinal. 2. Encourage increased fluids. 3. Assist him into a warm shower. 4. Exert pressure over the pubic area

Assist hin with a warm shower Warm water often will relax the urinary sphincter, enabling a client to void. The client already has indicated an inability to void, so asking him to use a urinal is inappropriate; plus the client is AMBULATORY so he is able to stand and go to the bathroom, a more natural method than the urinal. Because the bladder is already distended, increased fluid intake will increase pressure and may result in hydronephrosis. Pressure over a distended bladder induces pain, which causes muscular contraction of the urinary sphincter.

Post op TURP pt. complains of severe "cramping" and "tightness" in his abdomen. Which actions should the nurse implement? Select all that apply 1. Apply gentle massage over Mr. Sumo's lower abdomen 2. Tell pt. to lie in the fetal position 3. Encourage pt. to use relaxation techniques he learned preoperatively 4. Notify the HCP immediately 5. Check the urinary drainage tube for kinks and clots 6. Check the HCP's prescriptions to see if

Bladder spasms, due to surgical trauma, are common for 24-48 hours after TURP. Relaxation techniques can be a helpful, in conjunction with other pain-relief interventions. Obstruction to the flow of urinary drainage, from catheter kinks or clots, can contribute to bladder spasms after TURP. To maintain urinary flow and avoid clots, bladder irrigation should be constant. Also, fluid intake should be high to promote urine flow. Ditropan (oxybutynin) (oral or transdermal) OR Belladonna and opium rectal suppositories are prescribed to reduce bladder spasms.

The healthcare provider prescribes finasteride for a client with benign prostatic hyperplasia. What information does the nurse provide to the client?

Contact with the semen of a client taking finasteride can adversely affect a developing male fetus in a pregnant woman. Finasteride helps prevent male pattern baldness. Results may take 6 to 12 months. Finasteride is used to shrink an enlarged prostate. Other medications, such as tamsulosin, relax the muscles in the prostate and bladder neck, making it easier to urinate.

A 20-year-old carpenter falls from a roof and sustains fractures of the right femur and left tibia. The client reveals a history of substance abuse. What is the primary consideration for the nurse who is caring for this client?

Determining the amount and last use of the substance is the priority. Nurses should base their treatment of withdrawal symptoms on the time and amount of last use.

A residual urine test is prescribed for a client with benign prostatic hyperplasia. What should the nurse instruct the client to do?

Emptying the bladder before a urinary catheter is inserted measures how much urine remains in the bladder after voiding. Residual urine is the urine left in the bladder after urinating. After voiding, the client is catheterized, or a bladder scan can be used.

A primary healthcare provider is treating the red-color wound of a client caused by pressure ulcers. Which dressings are beneficial for wound recovery? Select all that apply. 1. Absorptive dressings 2. Hydrocolloid dressings 3. Transparent film dressings 4. Moist gauze dressings with antibiotics 5. Telfa dressings with antibiotic ointmen

Hydrocolloid dressings, transparent film dressings, and telfa dressings with antibiotic ointment are beneficial for the healing of a red wound caused by pressure ulcers. Absorptive dressings and moist gauze dressings with antibiotics are used to treat yellow wounds, such as wounds with nonviable necrotic tissue.

What is the etiology for the development of pressure ulcers in an 80-year-old client? 1. Atrophy of the sweat glands 2. Decreased subcutaneous fat 3. Stiffening of the collagen fibers 4. Degeneration of the elastic fibers

In older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers. Atrophy of the sweat glands will cause dry skin and decreased body odor. Stiffening of the collagen fibers and degeneration of the elastic fibers will result in the development of wrinkles.

Which monoamine oxidase inhibitor is used to treat Parkinson disease?

Selegiline

A nurse is caring for a client with a diagnosis of benign prostatic hyperplasia (BPH). Which information about this condition is important for the nurse to consider when caring for this client? 1. It is a congenital abnormality. 2. A malignancy usually results. 3. It predisposes to hydronephrosis. 4. Prostate-specific antigen decreases.

It predisposes hydronephrosis Inability to empty the bladder as a result of pressure exerted by the enlarging prostate on the urethra causes a backup of urine into the ureters and finally the kidneys (hydronephrosis).

A nurse in the pediatric clinic is caring for a child with lead poisoning (plumbism). For which associated complications should the nurse assess the child? Select all that apply. 1. Malnutrition 2. Liver damage 3. Marked anemia 4. Kidney damage 5. Encephalopathy

Lead blocks the formation of erythrocytes because it is toxic to the biosynthesis of heme; this leads to anemia. Damage to the proximal tubules causes proteinuria, glycosuria, and ketonuria. Encephalitis results from increased membrane permeability, which in turn causes increased intracranial pressure; increased intracranial pressure leads to tissue ischemia and atrophy, resulting in mental retardation.

A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Select all that apply. 1 . Resting tremors 2. Flattened affect 3. Muscle flaccidity 4. Tonic-clonic seizures 5. Slow voluntary movements

Resting (nonintention) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.

What blood test is done to monitor a client for TURP Syndrome?

Serum sodium is usually monitored in clients who have a TURP, to detect TURP syndrome. Serum osmolality may also be monitored. TURP syndrome occurs when irrigation fluid (usually sterile normal saline) is absorbed systemically. Irrigation fluid may be absorbed rapidly (through the prostate venous plexus) or gradually (from retroperineal spaces). TURP syndrome can occur during TURP surgery or up to 24 hours after surgery. With TURP syndrome, a severe hypervolemic, hyponatremic state occurs. Neurologic and hypovolemic changes occur. Signs and symptoms vary greatly and may change. These include nausea and vomiting, confusion, hypotension, hypertension, bradycardia, and visual disturbances. Treatment is symptomatic.

A post op pt.'s urinary catheter has been removed. Plans are made for his discharge this evening, provided he is able to void. You assess the pt to determine if he has urinary retention. How would you assess for urinary retention? A. inspect for edema of the penis B. inspect the suprapubic area for distention C. palpate the suprapubic area for distention D. percuss the suprapubic area for tympany

Suprapubic distention is common with urine retention. It may be observed as "swelling" in the lower abdomen. Palpation over the suprapubic area will reveal distention of the bladder if urine is being retained.

A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 120/76 to 60/40, and the heart rate has risen from 82 to 121. Which does the nurse recognize as the most likely reason for the assessment findings?

The client has become hypotensive and tachycardic in response to hypovolemic or hemorrhagic shock related to acute blood loss from the long bone and pelvic fractures.

A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing? 1. Vitamin C aids in the process of epithelialization. 2. Vitamin C helps in the synthesis of immune factors. 3. Vitamin C increases the metabolic energy required for inflammation. 4. Vitamin C is required for collagen production by fibroblasts.

Vitamin C aids in capillary synthesis and collagen production by fibroblasts.

Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult? 1. The nurse should minimize the use of tape on the skin. 2. The nurse should keep the client adequately hydrated. 3. The nurse should change the dressings as soon as they get wet. 4. The nurse should provide rest for the client throughout the day.

adequate hydration

Restlessness and confusion can be signs of shock from hemorrhage. These are a result of

cerebral hypoxia related to a decreased circulating fluid volume.

All lipid-soluble hormones are synthesized from

cholesterol (type of steroid)

An increase in heart rate occurs with shock due to hemorrhage. This increase in heart rate is a

compensatory effort to perfuse cells and tissues with blood when circulating fluid volume is decreased.

A deficiency of iodine results in a

deficiency in thyroid hormone production.

After transurethral resection of the prostate (TURP), a high fluid intake will

ensure adequate urine output, which will flush the bladder, keep it free of clots, and reduce risk of ascending urinary tract infection. Residual bleeding and clots may occur up to six weeks after surgery.

dehiscence may progress to movement of abdominal organs outside of the abdominal cavity. this is called

evisceration

Nonspecific eczematous dermatitis results in

evolution of lesions from vesicles to weeping papules and plaques.

Thyrotoxic crisis (thyroid storm) is the body's response to

excessive circulating thyroid hormones.

Carbidopa/levodopa should be administered with

food to minimize gastric irritation.

Carbidopa-levodopa should be

taken with meals to reduce the nausea and vomiting that commonly are caused by this drug. Multivitamins are contraindicated; vitamins may contain pyridoxine (vitamin B 6), which diminishes the effects of levodopa. Moderate amounts of alcohol will antagonize the drug's effects; a rare, occasional drink is not harmful. A high-protein diet is contraindicated. Sinemet contains levodopa, an amino acid that may increase blood urea nitrogen levels. Also, some proteins contain pyridoxine, which increases peripheral metabolism of levodopa, decreasing the amount of levodopa crossing the blood-brain barrier.

A decreased serum calcium causes

tetany

Cortisol, a lipid-soluble hormone, is secreted by

the adrenal cortex.

Insulin is secreted by

the pancreas.

Prolactin and growth hormone are secreted by

the pituitary gland.

Vitamin A aids in

the process of epithelialization.

Dehiscence is

the separation and disruption of previously joined wound edges; this condition typically occurs in obese clients.

Tinea cruris is a fungal infection of the skin near the genitals, buttocks, and thighs and is also known as

jock itch

Water soluble hormones are

protein hormones

Insulin, prolactin, and growth hormone are

water-soluble hormones.

The patient verifies that he knows what transurethral resection of the prostate (TURP) involves and that there are possible complications. Which statement by the patient indicates that he understands the implications of surgery on his sexual function?

"My sexual relations should not be affected. I will still be able to have an erection, but I will ejaculate less semen." Transurethral resection of the prostate (TURP), when done for treatment of symptomatic benign prostatic hyperplasia (BPH), involves removal of some prostate tissue to reduce its size. When done for treatment of cancer, cancerous tissue is removed. TURP is done through the urethra. Abdominal incision is not required. It is unlikely that the nerves responsible for erection would be damaged or removed during TURP. Impotence (inability to have an erection) is not a side effect. However, ejaculate may contain less semen, and retrograde ejaculation may occur (discharge of semen into the bladder and urine).

When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client? 1. Avoid leaning forward. 2. Hesitate between steps. 3. Rest when tremors are experienced. 4. Keep arms close to the center of gravity.

- The client with Parkinson disease often has a stooped posture because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. - Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. - The tremors of Parkinson disease occur at rest (resting tremors). - The client must consciously attempt to maintain a natural arm swing for balance.

Urea, the end product of protein metabolism, and creatinine, a result of skeletal muscle use, are normally excreted by the kidney. When kidney function is impaired...

BUN and creatinine are elevated.

A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What increased risk does the nurse consider when assessing this client? 1. Weight loss 2. Hypoglycemia 3. Decreased blood pressure 4. Inadequate wound healing

Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of clients receiving long-term corticosteroid therapy tend to heal slowly. A common finding associated with long-term corticosteroid use is weight gain, caused not only by fluid retention but also by alterations in fat, carbohydrate, and protein metabolism.

Prostate cancer is the most common occurring cancer in men. Early detection increases the chance of cure. What yearly screenings are recommended for early detection of prostate cancer?

Blood test for prostate-specific antigen (PSA) for all men over 50 years of age The presence of prostate-specific antigen (PSA), which is secreted only by prostate tissue, suggests prostate disease. Levels are extremely high with advanced prostate cancer. Low levels reflect prostate hyperplasia or early prostate cancer. PSA levels are generally higher in older men than in younger men, even when cancer is not present. The American Cancer Society recommends PSA blood test yearly for all men over age 50. Men in high-risk groups (African Americans and those with a first degree relative diagnosed with prostate cancer at an early age) should be tested earlier. Digital rectal exam for all men over 50 years of age Anatomically, the prostate surrounds the urethra and bladder neck. Positioned in the pelvic cavity, it rests upon the rectum. The American Cancer Society recommends annual digital rectal exam for all men over age 50. Palpation of hard, irregular nodes on the prostate suggests cancer. Men in high-risk groups (African Americans, those with a family history) should be tested earlier. The prostate cancer screening blood test can be falsely elevated if the blood is drawn immediately after a digital rectal exam is done.

A nurse administers carbidopa-levodopa to a client with Parkinson disease. Which therapeutic effect does the nurse expect the medication to produce? 1. Increase in acetylcholine production 2. Regeneration of injured thalamic cells 3. Improvement in myelination of neurons 4. Replacement of a neurotransmitter in the brain

Carbidopa-levodopa is used because levodopa is the precursor of dopamine. It is converted to dopamine in the brain cells, where it is stored until needed by axon terminals; it functions as a neurotransmitter.

When assessing a client with Graves disease (hyperthyroidism), what would the nurse expect to find in the client's history?

Diaphoresis. Increased basal metabolic rate, increased circulation, and vasodilation result in warm, moist skin.

What are the manifestations of hypoestrogenism? Select all that apply. 1. Hot flashes 2. Amenorrhea 3. Gynecomastia 4. Hypermenorrhea 5. Reduced bone density

Low levels of estrogen may cause hot flashes, amenorrhea, and reduced bone density. Gynecomastia and hypermenorrhea are manifestations of excess estrogen production.

A client returns from a radical neck dissection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? 1. Cloudy wound drainage 2. Absence of the gag reflex 3. Decreased urinary output 4. Restlessness with dyspnea

Restlessness and dyspnea

The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern? 1. Decreased physical mobility related to stooped posture 2. Risk for injury related to gait disturbances 3. Impaired skin related to drooling 4. Pain related to headache

Risk for injury related to gait disturbances - The client with Parkinson disease may fall because of gait disturbances. - Decreased mobility and impaired skin are problems but not the priority. - Pain is usually not a manifestation of Parkinson disease.

A nursing supervisor sends an unlicensed healthcare worker to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to the health care worker? Select all that apply. 1. Taking routine vital signs 2. Applying a sterile dressing 3. Answering clients' call lights 4. Administering saline infusions 5. Changing linens on an occupied bed 6. Assessing client responses to ambulation

Taking routine vital signs is a universal activity that all healthcare workers are taught to perform regardless of the setting Answering call lights is a universal activity that all unlicensed healthcare workers are taught to perform regardless of the setting Making an occupied bed is a universal activity that all unlicensed healthcare workers are taught to perform regardless of the setting.

A client has a laryngectomy and radical neck dissection for cancer of the larynx. Two tubes from the area of the incision are connected to portable wound drainage systems. Inspection of the neck reveals moderate edema even though the drainage systems are functioning. Which clinical indicator should the nurse assess in the client? 1. Crackles 2. Restlessness 3. Loss of the gag reflex 4. Cloudy wound drainage

The client has a high risk for airway obstruction from the edema; restlessness and dyspnea indicate cerebral hypoxia. Crackles come from the alveoli, part of the lower airway; the surgery involves the upper airway. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed, and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Cloudy drainage may indicate infection; however, this is not an immediate postoperative complication.

A client is admitted after a motor vehicle crash. The primary healthcare provider has diagnosed the presence of pelvic fractures and bilateral femur fractures. The client's blood pressure has fallen from 121/78 to 62/44 mm Hg and the heart rate has risen from 78 to 128 beats/min. The nurse knows that which parenteral replacement fluids is the most appropriate for this client? 1. 5% Dextrose and lactated Ringer solution 2. 0.9% normal saline solution 3. Total parenteral nutrition 4. Whole blood products

The client has experienced acute blood loss from the long bone and pelvic fractures and is tachycardic and hypotensive.` Therefore the most appropriate parenteral fluid is whole blood.

A client is admitted to the hospital with a tentative diagnosis of urinary retention related to benign prostatic hyperplasia. The primary healthcare provider notes a secondary diagnosis of delirium related to urosepsis and prescribes the insertion of an indwelling urinary retention catheter. Which nursing action is most important at this time? 1. Secure a prescription for wrist restraints. 2. Orient the client to time, place, and person. 3. Involve family members in the client's care. 4. Determine whether any unsafe behavior patterns exist.

The nurse should determine whether the client is a danger to self or others before planning and implementing care. No pattern of unsafe behavior has been identified requiring the use of wrist restraints. Pulling on the retention catheter is a concern because this may cause an injury. However, less restrictive alternatives to wrist restraints should be tried first. A restraint is used as a last resort. Orienting a client to time, place, and person is appropriate for a client with delirium; however, this will not protect the client from attempting to pull out the urinary catheter or from engaging in other unsafe behaviors. Although family members should be involved in a client's care, it is not the responsibility of a family member to assess a client or protect a client from injury.

Mineralocorticoids secreted by the __________ regulate the sodium and potassium levels, which __________.

adrenal cortex regulates water balance

All water-soluble hormones are formed from

amino acids (proteins)

A client with cancer of the prostate who develops bone metastasis will generally have

an elevated alkaline phosphatase.

A keloid is

an overgrowth of collagenous tissue at the site of a skin injury.

Contractions

are a normal part of healing, but in excess can result in deformity.

Adhesions

are bands of scar tissue that form between or around organs.

Tinea pedis is an intradigital fungal infection of the feet, also known as

athlete's foot

The metabolic rate is regulated by triiodothyronine, which is secreted by the

thyroid gland.

Parathormone is secreted by the parathyroid gland and calcitonin is secreted by the

thyroid gland; these hormones regulate calcium and phosphorus levels in the blood.

Bleeding is common immediately after transurethral resection of the prostate (TURP), since surgery has caused trauma. Bloody urine with clots is not unusual. Gradually, urine

will fade to pink as bleeding diminishes. Urine drainage is likely reddish-pink with some small clots.