Adult 1 Final Blueprint

care of patient in the PACU...

*INITIAL ASSESSMENT:* -airway patency -rate and quality of respirations -auscultate breath sounds in all fields -observe for emergence delirium (wake them gently) -O2 therapy -ECG monitoring -assess LOC *NOTIFY SURGEON WHEN:* 1. WOUND DRAINAGE... check every 15 mins but call surgeon is there is an increase in color or amount and change in vitals 2. VITALS... - drop in BP with rise in HR, restlessness, increase fluids if lungs are clear. Notify MD stat -if systolic BP <90 or >160 -if pulse <60 or >120 -if pain meds aren't working

dosage calculation

o 1g = 1000mg o 1mg = 1000mcg o 1Kg = 2.2lbs o 1mL = 1 c.c. o 1000mL = 1L = 1 quart o 30mL = 1oz o 5mL = 1tsp o 15mL = 1TBS o 1glass = 8oz = 240mL o 60gtt/mL • WHEN THE ANSWER IS LESS THAN 1, carry the decimal answer to the thousandths place and round to the hundredths place. • IF THE ANSWER IS GREATER THAN 1, carry to the hundredths place and round to the tenths place. • All IV problems having an answer in drops per minute are to be rounded to the nearest whole number. [gtt/min] • Any IV problem solving for [mL/hr] should be carried to the tenths decimal place.

DKA (diabetic ketoacidosis)

*DIABETIC KETOACIDOSIS* - acute complication associated with glucose in the blood & insufficient insulin (usually with Type I DM; serious; rapid) - when insufficient insulin, glucose cannot be properly used for energy → body breaks down fat as secondary source of fuel - Increased pulse, lowered plasma pH, breathing becomes shallow/rapid (Kussmaul) - KETONES: acidic by-products of fat metabolism - Alter pH balance → metabolic acidosis (lowered plasma pH) - KETONURIA: is a medical condition in which ketone bodies are present in the urine LABS: glucose > *300 mg; ABGs—pH < 7.30; serum bicarb <15 meq (norm 20-30) ; Ketones in blood & urine -electrolytes become depleted as cations are eliminated along with anionic ketones in an attempt to maintain electrical neutrality -insulin deficiency impairs protein synthesis→excessive protein degradation→ nitrogen losses from tissues - Insulin deficiency stimulates production of glucose from amino acids (proteins) in the liver→ further hyperglycemia IF DKA IS LEFT UNTREATED: Leads to severe depletion of: • sodium (norm 135 - 145) • potassium (norm 3.5-5) • chloride (norm 98 - 108) • magnesium • phosphate • Vomiting caused by acidosis (an increased acidity in the blood and other body tissue) → more fluid and electrolyte loss • Eventually hypovolemia (is a state of decreased blood volume) → shock will occur → renal failure → comatose (of or in a state of deep unconsciousness for a prolonged or indefinite period, esp. as a result of severe injury or illness) as result of dehydration, electrolyte imbalance, acidosis → death *MANIFESTATIONS* -dehydration → Poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension -early symptoms: Lethargy, weakness, Abdominal pain with anorexia and vomiting Later on: Kussmaul respirations (Rapid, deep breathing associated with dyspnea = body's attempt to reverse metabolic acidosis through exhalation of excess CO2; acetone is noted on breath as fruity/sweet) Lab findings for DKA: -blood glucose > 250 -arterial blood pH less than 7.30 The pH of blood is usually between 7.35 and 7.45. A pH of less than 7.0 is called acidic and a pH greater than 7.0 is called basic (alkaline). So blood is slightly basic. -serum bicarb levels less than 15 The bicarbonate ion acts as a buffer to maintain the normal levels of acidity (pH) in blood and other fluids in the body Norm 22-30 mmol/L -moderate to large Ketones in urine or blood Ketones Moderate: 30 - 40 mg/dL Large: > 80 mg/dL *TREATMENT* -ensure Patient airway and admin O2 -stablish IV access with large-bore catheter to begin fluid and electrolyte replacement -typical infusion: 0.45% or 0.9% NaCl at a rate to restore urine output to 30-60 mL/hr and to raise blood pressure - → When blood glucose approach 250, 5% dextrose is added to prevent hypoglycemia (low blood glucose) -regular Insulin withheld until: • fluid resuscitation • K is 3.5 or higher - Started at 0.1 unit/kg/hr by continuous infusion - If glucose lowered too quickly→ cerebral edema - Blood glucose reduction of 36-54 mg/dL/hr is ideal - To decrease glucose in blood and send it to starving cell = Ketones are decreased (b/c not needed anymore)

PUD (peptic ulcer disease)

*PEPTIC ULCER DISEASE* - injury to the mucosa of the esophagus, stomach, and/or duodenum leading to ulceration - H.pylori release ammonia (toxin), injure mucosa, expose mucosa to gastric acid. Injury to due digestive action of HCL acid and pepsin *CAUSES:* all causes breakdown in gastric mucosal barrier permitting acid-back diffusion into mucosa, destruction of mucosal cells followed by histamine release with increase in gastric acid and pepsin release -prolonged use of NSAIDS -smoking -prolonged alcohol consumption -corticosteroid/physiologic stress gastric mucosa protects and turns over every 2-3 days normally *CLINICAL MANIFESTATIONS* -pain is 1-2 hours after meals -located in the high left epigastrium and back and upper abdomen -aggravated by food if erosion is deeper -hematemesis DUODENAL ULCERS: (80%) -pain 2-4 hours after meals, midmorning, midafternoon, and middle of the night -located across midepigastrium (behind xiphoid) and upper abdomen, back pain with posterior ulcers; melena -pain may be minimal especially in older adults taking NSAIDs *COMPLICATIONS:* - hemorrhage (most common) - perforation (most lethal): penetrates serosa and spills contents; sudden abd pain, rapid/shallow respirations, no bowel sounds, N/V - gastric outlet obstruction: pylorus narrows due to edema, inflammation, pylorospasm, or scar tissue history of pain worsens with full stomach, vomiting of old food, weight loss, thirst, bad mouth, constipation, abd swelling, loud peristalsis, visible waves *DIAGNOSIS:* INVASIVE: EGD (esophagogastroduodenoscopy) for biopsy, rapid urase test, visualize ulcers and/or take tissue specimens to ID H.pylori and rule out cancer *NON-INVASIVE:* - test serum for IgG gor H. Pylori: does not distinguish if active or inactive - Urea Breath Test (by product of h. pylori): tests for an active infection - H&H - Stool for guaiac - serum amylase: detects pancreatic function when posterior duodenal ulcer penetration is suspected *DRUG THERAPY:* Medical (conservative) therapy Goal is to eradicate h.pylori, reduce acid secretions, and relieve pain - SAME MEDS AS GERD - 2-3 antibiotics + H2 blockers or PPI's ✨ cytoprotectives: bismuth subsalicylate (pepto-bismol); sucralfate ✨ antisecretory: H2 blockers (tagamet, pepcid, zantac); PPI's (nexium, prevacid, prilosec, protonix, aciphex) ✨ cytoprotective and antisecretory: cytotec ✨ Neutralizers: antacids ✨ Antibiotics: metronidazole (flagyl, biaxin, tetracycline, amoxicillin) ✨ others: TCAs (tofranil, sinequan), SSRIs; decrease afferent pain fiber transmission *LIFESTYLE CHANGES:* -avoid caffeine and alcohol -milk vs no milk -stop smoking -relaxation techniques -complications occur if untreated *SURGICAL THERAPY:* -less than 20% need surgery -needed when PUD does not heal and multiple ulcers; Hx of hemorrhage, possible malignancy; obstruction 1. PERFORATION: simple closure with omentum graft 2. GASTRIC OUTLET OBSTRUCTION: -pyloroplasty (enlarge sphincter to reduce stricture)-increases emptying -vagotomy: sever nerve, decrease motility and emptying-not desired 3. ULCER REMOVAL/REDUCTION: -subtotal gastrectomy -antrectomy with gastroduodenostomy (biliroth I)...50-70% of stomach removed -antrectomy and proximal duodenectomy with gastrojejunostomy (biliroth II)...50 of stomach removed -total gastrectomy: esophagus anastomosed to jejunum with duodenal stump *POST SURGERY CARE:* -pain relief -prevent atelectasis and DVT MANAGEMENT of NGT to LIWS: gastric aspirate bright red at first with gradual darkening during the first 12-24 hours after surgery; gradula return to yellow/green color 36-48 hours post op; NGT output about 1500ml/24hours; may be ordered due to gentle saline irrigations NGT must remain in pt so the gastric contents do not build up and cause distention=rupture, leakage into peritoneum, hemorrhage, and possible abcess if NGT comes out, it is replaced by surgeon

urinary calculi

*URINARY CALCULI* aka nephrolithiasis aka kidney stones *CAUSES* (no single theory): -Dehydration (high urinary concentration); super saturation of chemicals -Change in urinary pH that affects solubility of calcium -Lack of natural inhibitors to stone formation (nephrocalcin) *INTERVENTIONS:* -maintain fluids -turn q2h -assist to stand to void if possible -promote frequent and complete bladder emptying (dilute and free flowing urine) -give narcotics and heating pad for pain related irritation from stone -drink 3 L fluid daily to assure output of about 2,000ml per 24 hours -risk for infection -must diagnose type of stone = strain all urine! 24 hour urine test may be ordered -discard first specimen, collect every drop -keep urine in special container and on ice for 24 hours *TREATMENT:* ACUTE ATTACK -treating symptoms of pain, infection or obstruction -opioids at frequent intervals -many stones pass on own, but if larger than 4mm will require insertion of a ureteral stent to prevent obstruction from passage of stone SURGICAL TREATMENT 1. ENDOUROLOGIC PROCEDURE: - removal of stones with cystoscopy 2. NEPHROLITHOTOMY: -incision to remove kidney stone (open necessary for obese patient, otherwise can be done laparoscopically) 3. LITHOTRIPSY: -use of shock waves to pulverize urinary calculi -most frequently used, causes stones to break down into sand like particles that are easily passed through urinary tract into urine -post hematuria is common *how will you know if the lithotripsy treatment has been effective?* -CT scan and urinalysis shows it has passed *DIET:* -avoid dehydration; drink 3000 mL/day to void 2000 mL/day→ should void around the clock -avoid dietary oxalate (for calcium-oxalate formers) -water is best fluid, avoid caffeine, grapefruit/apple juice -avoid chocolate, nuts, beans, rhubarb, spinach, beets -limit sodium to 2 gm per day (high amounts increase calcium excretion in urine) -limit protein to 12 ounces per day if stones are from uric acid (also increases urinary calcium). -alter urine pH -if overweight, loose weight (BMI correlates with risk of calcium-oxalate stone formation) *PREVENTION* -maintain adequate fluids, turn q2h, assist to stand to void if possible; do what it takes to promote frequent and complete emptying of bladder. -KEEP URINE DILUTE AND FREE-FLOWING!

Hint: Why is a patient with diabetes at risk for poor wound healing?

defect in mobilization of inflammatory cells leading to impairment of phagocytosis by neutrophils and monocytes

What is general nursing care for the actual and potential nursing diagnoses of "ineffective airway clearance" and "impaired gas exchange"? What are post-op risks for the occurrence of these two nursing diagnoses?

*"ineffective airway clearance"* -monitor RR and O2 to determine change in status -elevate HOB and give table to lean onto -encourage DB, turn, coughing to promote effective breathing patterns -monitor for respiratory fatigue to provide additional support if needed -assist with incentive spirometer -administer bronchodilators, etc. *"impaired gas exchange"* -auscultate breath sounds -monitor rate/rhythm/depth/effort of respirations -monitor for increased restlessness, anxiety R/T hypoxemia -monitor patients ability to cough productively -administer O2 -Monitor ABGs *What are post-op risks for the occurrence of these two nursing diagnoses?* -atelectasis -aspiration pneumonia

complications after thyroidectomy

*AIRWAY COMPLICATIONS* -Recurrent laryngeal nerve damage → vocal cord paralysis→ if both cords then spastic airway obstruction will occur = require immediate tracheostomy -Other causes of labored respirations: excess edema of neck, hemorrhage, hematoma formation, laryngeal stridor (harsh, vibratory sound that occurs on inspiration and expiration as a result of edema on laryngeal nerve) -laryngal stridor may be treated with calcium (caused from damage to the parathyroid gland) *POST-OP CARE* -HOB elevated to semi-fowler's position. -support head with pillows, avoid neck flexion & suture lines tension. -assess for s/s hemorrhage or tracheal compression. -expect some hoarseness for 3-4 days post op -laryngeal stridor*** may occur d/t swelling or tetany. -note early, respond stat. -MD might order IV calcium gluconate to avoid an emergency. Long-term takes p. o. -monitor vital signs. check for tetany (paresthesia) for 72h; (Trousseau's sign and chvostek's sign should be monitored for 72 hours) -control post-op pain. -if day surgery, ambulate soon, go home same day, soft food next day.

aneurysm

*ANEURYSM* *CAUSE:* -most common cause is atherosclerosis -plaque formation causes degenerative changes in the media leading to loss of elasticity, weakening and dilation *COMPLICATIONS AFTER SURGERY:* GRAFT PATENCY: -adequate BP important to maintain -prolonged hypotension may result in graft thrombosis...give IV fluids and blood components; CVP readings or PA pressures and urinary output are monitored hourly -severe HTN can cause undue stress on arterial anastomoses=leakage of blood or rupture at suture lines; give IV diuretics, IV anti-HTNs CARDIOVASCULAR: -with CAD pt, myocardial ischemia or infarction may occur due to decreased O2 supply and increased O2 demands -dysrhythmias from electrolyte imbalances, hypoxemia, hypothermia, myocardial ischemia may occur INFECTION: -prosthetic vascular graft infection= rare but life threatening GI: -paralytic ileus (rare if 4+ days) -temporary ischemia or infarction of intestinal tissue (due to decreased blood flow, requires STAT surgery) NEURO: -ascending aorta or aortic arch surgery: assess LOC, all cranial nerves, upper limb assessment; stroke may occur -descending aorta surgery: neuro assessment of all lower extremities PERIPHERAL PERFUSION: -embolism/ graft occlusion (absent pulse, cool, pale, mottled, painful extremity); report STAT RENAL PERFUSION: -irreversible renal failure after aortic surgery (especially in diabetes pt) -decreased renal perfusion from embolism of aortic thrombus/plaque to one or both of the renal arteries; causes ischemia in 1 or both kidneys -hypotension, dehydration, prolonged aortic clamping during surgery, and blood loss can cause renal perfusion -minimal acceptable urinary output: 30ml/hr

aspiration pneumonia

*ASPIRATION PNEUMONIA* pneumonia from abnormal entry of secretions or substances into the lower airway R/T aspiration of material from the mouth or stomach into the trachea and subsequently the lungs *WHO IS AT RISK:* -decreased LOC (seizures, anesthesia, head injury, stroke, alcohol) -difficulty swallowing -NGT with or without tube feeding *NURSING CARE PRIORITIES:* -turn, cough, deep breath -turn q2h -hydration and nutrition -give O2 -pain meds *PATIENT POSITIONING:* -raise HOB 35-45 degrees -provide over-bed-table to lean on *How will you know if they aspirate?* -fever, shaking, chills, SOB, cough productive of purulent sputum, chest pain -in elderly may see confusion or stupor (RT hypoxia) -crackles, dullness to percussion, increased fremitus on auscultation

care for patients after *EYE TRAUMA*

*ASSESSMENT:* -determine mechanism of injury -assess A,B,C, safety -assess visual acuity *THERAPEUTIC INTERVENTIONS:* -no pressure on eye -stabilize foreign object, do not remove -chemical exposure → irrigate with normal saline -cover eye with dry sterile eye patch and eye shield -Keep patient NPO -elevate head 45 degrees (prevents edema/pressure) -administer analgesia as appropriate with minimal fluid

benign prostatic hyperplasia

*BENIGN PROSTATIC HYPERPLASIA (BPH)* enlargement of the prostate characterized by large, nodular lesions in the periurethral region (transitional zone) of the prostate *MANIFESTATIONS* SUBJECTIVE: -frequency of urination, nocturia -urgency, straining to urinate, -hesitancy, weak urinary stream (dribbling) -intermittent urinary stream -sensation of incomplete bladder emptying (retention) OBJECTIVE: -enlarged prostate on rectal exam (DRE); pt bends over table or lies on side for exam -lab tests: creatinine, urinalysis, PSA -prostate-specific antigen (PSA) - a protein in the prostate gland that liquifies semen. PSA escapes into the blood stream when prostate is disturbed by disease or instrumentation (norm <2.5 ng/ml—varies with age & race; 4-7—suspicious of cancer; almost all levels above 10 are cancer) -if needed: residual urine >100 ml (bladder scan) or measure urine flow with uroflowmetry *DRUG THERAPY* ALPHA ADRENERGIC RECEPTOR ANTACONIST: [terazin (hytrin)] -MOA: relaxes smooth muscles of bladder neck, prostate, arterioles, veins, decreases BPH and allows urine to flow -SE: orthostatic hypotension, dizziness, retrograde ejaculation, nasal congestion INTRAPROSTATIC ANDROGEN ANTAGONIST: [finasteride (proscar)] -MOA: blocks enzyme 5-a reductase which is necessary for conversion of testosterone → dihydroxytestosterone (principal intraprostatic androgen) -shrinks prostate, may take 3-6 months to improve -SE: decreased sexual desire, semen amount, and ability to achieve erection -If combined with ED drug, will cause orthostatic hypotension *POST-OP CARE* -maintain urinary drainage & observe for s/s hemorrhage -wound care -pain control, early ambulation -surveillance for complications of: infection, dehiscence, urinary obstruction, hemorrhage, thrombophlebitis, pulmonary embolism -urinary incontinence, sexual dysfunction HEMORRAGE -blood clots are expected first 24-36 hours, but large amounts of bright red blood in urine= hemorrhage -may use traction on catheter to apply counterpressure on bleeding site to DC -avoid activities that increase abdominal pressure (sitting or walking for prolonged periods, straining with BM) BLADDER SPASMS -if spasm develops, check catheter for clots, remove clots by irrigation -give analgesics and antispasmodics Have patient practice kegal exercises (stopping and starting flow) to help with incontinence WOUND CARE -watch for s/s infection -assess for redness, heat, swelling, purulent drainage -Esp. if perineal incision present→ proximity to anus -No rectal temps or enema, supp. okay *TEACHING AFTER TURP SURGERY* -care for indwelling catheter if left in place -drink 2 L fluid/day, urinate every 2-3 hours -avoid bladder irritants: caffeine, citrus juice, alcohol -keep having yearly DRE -observe for s/s UTI and wound infection -avoid heavy lifting (more than 10 lb) -refrain from driving or intercourse after surgery until physician says so -may have retrograde ejaculation -may take 1 year to get complete sexual function back

Know the difference in the terms "benign" versus "malignant" tumor

*BENIGN:* non cancerous and uniform in shape *MALIGNANT:* cancerous, capable of spreading, and irregular in shape

Lung Cancer

*DEFINITIVE DIAGNOSIS = biopsy obtained by bronchoscopy* - chest x-ray - mediastinoscopy is gold standard for staging. - needle biopsy may also be done. - X-ray, CT Scan, MRI, PET, sputum cytology, biopsy MEANING OF *CYTOLOGY* -identify malignant cells -results are only positive in 20%-30% of specimens because the malignant cells are not always present in the sputum -biopsy is necessary for definitive diagnosis

detached retina

*DETACHED RETINA* separation of sensory retina from the choroidal blood supply; fluid accumulated between layers; if untreated leads to blindness *RISK FACTORS:* -old age -family history -cataract or glaucoma surgery -severe myopia (nearsightedness) -aphakia (absence of lens in eye) -eye trauma *MANIFESTATIONS:* -photopsia: painless light flashes -sometimes there are flashes of light and spots that "float around"; "cobweb", "hairnet", "its like looking through a veil"; "floaters" -painless loss of peripheral central vision *NURSING INTERVENTIONS | PRE-TREATMENT:* -teach to wear eye protection to avoid tears and holes -do not put pressure on the eye -retina does not repair itself so that can't be treated PRE-OP: 1. mydriatrics: open eyes up 2. cycloplegics: dilates and paralyzes eye *SURGERY* GOALS OF SURGERY: -seal retinal tears -relieve traction on retina -create inflammation and scar to seal retina to the choroid...done with laser photocoagulation or cryoprexy (painful post-op) EXTRAOCULAR PROCEDURE: -scleral buckling -suture a silicone implant against the sclera causing it to buckle inward and fill gap of detachment INTRAOCULAR PROCEDURE: -pneumatic retinopexy: creates an air bubble to seal break OR -virectomy: surgical removal of the vitreous to relieve traction on retina *POST-OP CARE:* -positioning -expect watering of eyes and mild pain -do not rub eye -wear eye shield while sleeping -ice compresses to reduce edema -analgesics for mild pain -avoid activities that make you strain for 3-4wks -do not life over 50lb for 3-4wks -report to HCP s/s of inflammation, increases in pain, increased watering of eyes, or bloody discharge *TEACHING:* -report s/s of recurrence or infection -avoid infection -follow careful eye drop admin -continue with follow up care -proper hygiene and eye care techniques -importance of complying with post-op restrictions on head positioning, bending, coughing, and valsalva maneuver to optimize visual outcomes -teach how to instill eye medications with aseptic technique -how to monitor pain and report pain not relieved by medications

GERD

*GASTROESOPHAGEAL REFLUX DISEASE* - backflow of acidic gastric contents into the alkaline esophagus (bile salts, trypsin, pepsin) and cause esophagitis and tissue damage - caused by any factor that decreases the strength or efficacy of the lower esophageal sphincter or increases intra-abdominal pressure PREDISPOSING FACTORS: obesity, tight clothing, pregnancy, tumors, heavy lifting on a routine basis, certain foods decrease the LES (caffeine, chocolate, peppermint), hanging upside down - if persists greater than twice a week reflux episodes, severe, wake a person, or difficulty swallowing... should see HCP *MANIFESTATIONS* - backflow of acidic gastric contents into the alkaline esophagus (bile salts, trypsin, pepsin) and cause esophagitis and tissue damage - hot bitter sour liquid coming into throat or mouth - early fullness with meals; pc bloating - heartburn (pyrosis) - chest pain - disturbed sleep - nausea and vomiting *COMPLICATIONS* - erosive esophagitis - esophageal stricture (narrowing) - Barrett's esophagus...damaged esophageal cells esophageal cancer (precancerous) *MEDS:* INCREASE GASTRIC MOTILITY: ✨ metoclopramide (reglan)✨ - is a dopamine antagonist that increases the release of ACh to increase motility - warning can cause tardive dyskinesia NEUTRALIZE ACID: (antacids) ✨ maalox✨ ✨ mylanta✨ ✨ gelusil✨ - give 1-3 hours AFTER meals - space from other meds REDUCE GASTRIC ABSORPTION: histamine antagonists - H2 receptor blockers ✨ ranitidine/zantac✨ ✨ cimetidine/tagamet✨ ✨ famotidine/pepcid✨ PPI's (Proton pump inhibitors ) ✨ pantoprazole/protonix✨ ✨ Iansoprazole/prevacid✨ ✨ nexium✨ ✨ Gaviscon✨ -PPI's will make you more likely to get C-DIFF -can cause problems with bones = risk of fractures OTHERS: ✨ carafate/cytoprotection✨ -lines the stomach -take on an empty stomach *PREVENTION/TREATMENT* - no smoking (decreases acid clearance from LES) - avoid fatty foods, chocolate, coffee, tea, and milk can aggravate it - avoid late night snacking and stick to small frequent meals - NO lying down 2-3 hours after eating - drink fluids between meals - decrease weight if needed - avoid tight clothing around waist - elevate HOB 4-6 inches for sleep *Nissen Fundoplication* - wrap upper part of stomach around sphincter - reduces gastric acid reflux by enhancing the integrity of the LES - No NSAIDS for 10 days—might irritate & bleed

breast cancer

*BREAST CANCER* cancerous tumor of the breasts *MANIFESTATIONS:* -MASS: painless, hard, irregular shape, non-mobile -most often in upper, outer quadrant, unilateral -can have breast pain, lymph node swelling, nipple discharge, retraction, edema with peau d'orange skin, and dimpling *NURSING CARE & TEACHING AFTER MASTECTOMY:* POST-OP POSITIONG -semi-fowlers position with arm on affected side elevated on a pillow -flexing and extending the fingers should begin in the recovery room with progressive increases in activity encouraged -precautions important for arm on surgery side immediately post op and after discharge to home -post op discomfort minimized by admin of analgesics 30 min prior to exercising -shower with warm water = soothing effect and DC joint stiffness *TEACH* -affected arm should not be dependent, even in sleep -no needle sticks or BP readings on that arm -elastic bandages should not be used in early post op period= inhibit collateral lymph drainage -protect arm on operative side from minor trauma, sunburn etc. -if occurs, arm should be washed thouragly with soap/water -topical antibiotic ointment and bandage or other sterile dressing should be applied -AT RISK OF DEVELOPING FOR THE REST OF HER LIFE!!! *EXERCISES DESIGNED TO...* -prevent contractures and muscle shortening -maintain muscle tone -improve lymph and blood circulation exercises include: -brushing hair, moving arm in circular motions, moving arms up and down, clapping above your head, and pulling from above head down to the sides

HIV/AIDS opportunistic infections

*CANDIDASIS:* yeast affecting the GI tract (mouth to anus) *PNEUMOCYSTITIS CARINII*(P.jiroveci) *PNEUMONIA* (PCP): a fungus causing SOB, night sweats, fatigue, and weight loss *CRYPTOCOCCAL MENINGITIS:* a yeast causing altered mental status, stiff neck, visual disturbances, papilledema, ataxia, seizures, and sensitivity to light *CYTOMEGALOVIRUS:* (CMV): retinitis, decreased vision, floaters, and one sided visual loss *MYCOBACTERIUM AVIUM COMPLEX:* affecting the GI tract causing chronic diarrhea, fever, malaise, weight loss, anemia, neutropenia, malabsorption syndrome and obstructive jaundice *KAPOSI'S SARCOMA:* an opportunistic cancer, neoplasm of reticuloendothelial cells of vascual and lymph vessels...pink, purple, or brown spots with pain and edema of affected area; lesions can occur on skin or internally

care of patient with *CATARACTS*, pre and post op care

*CATARACTS* the lens of the eye becomes progressively opaque (cloudy/waxy), resulting in blurred vision. CAUSE: old age (senile) *PRE-OP care* -history and physical, insurance checks, planning for care to and from surgery and afterwards -administer topical mydriatic, cycloplegics and antibiotic agents, -GOOD HANDWASHING; oral antianxiety meds, NSAIDS *POST-OP care* -topical—EYE GTTS--Antibiotics, corticosteroids -mild analgesic prn; -eye patch/shield -GOOD -HANDWASHING -guided activity: avoid bending, stooping, coughing, of lifting---no driving for a couple days -return visit to surgeon

pancreatitis

*CAUSES* -alcohol = #1 reason -Obstruction (cholelithiasis, ampulla, or pancreatic tumor, duodenal obstruction, biliary disease) -Infection: bacterial, viral, or parasitic -Vascular: ischemia -Trauma: accidental or postoperative trauma, endoscopic retrograde cholangiopancreastography (ERCP), surgical procedures -Toxins and Drugs: alcohol, estrogen, furosemide, corticosteroids, NSAIDS -Hereditary factors -Miscellaneous: perforated peptic ulcer, lupus, pregnancy *MANIFESTATIONS* -Severe LUQ pain that can radiate to all quadrants caused by edema and distension of pancreatic capsule, pancreatic enzymes producing a chemical burn, release of kinins or cause obstruction of the biliary tree -Pain is sudden onset, described as severe, deep, piercing, and continuous or steady; aggravated by eating; frequently onset occurs when patient is recumbent, pain not relieved by vomiting -Pt is exhibiting fetal positioning/guarding. -Other: nausea and vomiting, abdominal distension (ileus), jaundice, tachycardia and hypotension, low-grade fever, leukocytosis, decreased breath sounds, crackles, decreased bowel sounds -in severe cases: Gray Turner sign- ecchymoses (bruising) of the flanks or Cullen's sign- in periumbilical area. (Seepage of blood-stained exudate from the pancreas) -Paralytic Ileus: slowing of the bowel (Atropine is used in this) *KEY LAB FINDINGS* Serum Tests: • ↑ amylase and lipase • ↑ WBC • ↑ glucose • ↑ liver function tests [AST or ALT (SGOT or SGPT)] ***************************** • ↓ calcium because trypsin inactivates parathyroid hormone • ↓ potassium, chloride, and sodium if vomiting • ↓ hemoglobin and hematocrit • ↑ Urinary Amylase *PRIORITY MANAGEMENT & TREATMENT* - Assure oxygenation [Auscultate lungs for decreased breath sounds; Cough and deep breathe, give oxygen] - Manage pain [treat early, ATC and bolus prn; Give morphine; remember pain and restlessness stimulates p. enzymes] - Rest the pancreas (pain relief) [NPO and NGT to low intermittent wall suction (LIWS) (give antacids in NGT); Give TPN (enteral, over parenteral chosen to decrease infection risk)] - Maintain hemodynamics (F & E) stability (prevent shock) [Assess BP, HR, urine output; Give IV fluids and albumin to restore vascular volume; Give dopamine to increase systemic vascular resistance; assess for tetany] - Maintain electrolyte balance • Calcium - assess Chvostek and Trousseau signs; give calcium • Potassium - auscultate for dysrhythmias, palpate for irregular pulses • Give K+ with M.D. order - Prevent Infection (administer antibiotic; respiratory infections are common) - Assess for glucose levels May need to administer insulin -PRIORITY IS TO REST THE GI TRACT!!! -NG Tube placement/management *SURGERY* PUESTOW PROCEDURE - (pancreaticojejunostomy) pancreas is filleted and connected to a loop of the jejunum to allow pancreatic enzymes to flow in to the jejunum

gallbladder

*CHOLECYSTITIS* inflammation of the gallbladder GENERAL: -indigestion, RUQ pain referred to R shoulder pain and scapula -acute [typically 3-6 hours after heavy meal, laying down]; recurs -restlessness, diaphoresis, nausea/vomiting, abdominal rigidity, fever, chills, leukocytosis > 10,000 WBC's. -Murphy's Sign: SOB (pericholecystic fluid accumulates due to congestion), pt is at risk for atelectasis → pain management is a priority!!! CHRONIC: history of fat intolerance, dyspepsia, heartburn, flatulence (abdominal distension) *CHOLELITHIASIS* gallbladder stones *CAUSE:* -imbalance of cholesterol, bile salts, calcium in solution -when stones are moving or lodge in duct, obstruction result -PAIN - severe to none; up to 1h then residual tenderness -SEVERE PAIN - aka biliary colic [but usually steady] -tachycardia, diaphoresis; may also see prostration *POST-OP* -manage acute pain from incisions & carbon dioxide in abdomen -lie in Sims position (left side, right knee flexed) -narcotic analgesics -decrease risk for atelectasis/pneumothorax (PREVENT!!!!) -deep breathe, ambulation, movement!!!!!!!! lowers DVT risk; assess lung sounds, O2 sat, IS -inspect incision/puncture sites (Redness? Purulent drainage? Bile colored drainage?) -may be at risk for bleeding due to vitamin K deficiency [decreased prothrombin production]; check mucous membranes of mouth, nose, gingiva, injection sites; check PT coagulation to guide assessment

chronic kidney disease (CKD)

*CHRONIC KIDNEY DISEASE* -fluid volume overload related to decreased GFR rate -progressive, irreversible *DIETARY* promote: high CHO, moderate fat, restrict fluids depending on output, monitor weight, balance activity/rest, emotional support *MEDS:* avoid aminoglycosides, amphotericin B, NSAIDs, ACE inhibitor and ARBs, IV contrast dye, (nephrotoxic) sodium polystryrene (Kayexalate) -lower K+ Erythropoietin alfa (Epogen, Procrit) -increase RBC Ferrous Sulfate (Feosol) -prevent iron def anemia Aluminum hydroxide gel (Amphojel) -with meals, bind food Furosemide (Lasix) -reduce edema TEACH: BP measurement, wt monitoring, diet, exercise, meds, community support group; nutrition consult; smoking cessation group OUTCOME: Dialysis or kidney transplant can maintain life, but do not cure CKD

compartment syndrome

*COMPARTMENT SYNDROME* pressure compromises the neuromuscular function of tissues within a confined space = reduced cap perfusion below a level necessary for tissue viability caused by: 1. decreased compartment size -restrictive dressings, splints, casts 2. increased compartment content: -bleeding, edema *MANIFESTATIONS:* 7 P'S -paresthesia (numb) -pressure -pallor -paralysis -pain = severe, not helped with relief measures -pulselessness = late ominous sign -puffiness myoglobinuria: dark red/brown urine (urine releases muscle biproduct from the break down of muscle) *NURSING CARE:* -prompt, accurate diagnosis is critical for STAT action -do NOT apply ice or elevate above heart level -remove/loosen bandage and bivalve the cast (MD does this) -reduce traction weight (MD) -surgical decompression (fasciotomy-the fascia is cut open to relieve pressure) (MD)

conscious sedation

*CONSCIOUS SEDATION* aka moderate sedation; twilight sleep; procedural sedation; MAC (monitored anesthesia care) *PURPOSE:* Used for procedures requiring patient assistance, e.g. Scoping procedures—gastroscopy, bronchoscopy • Sedative, anxiolytic, and/or analgesic medications used • Does not include use of inhalation agents • Patients responsive and maintain own airway, breathe on their own • Not expected to induce levels of sedation that would impair patients' ability to protect their airway • Most often used for minor therapeutic procedures (e.g., realignment of a fracture in the emergency department) *DRUGS USED:* combination of an anxiolytic med and an opioid are used to provide pain relief, anxiety relief, and amnesia ✨ Midazolam [versed]✨ - anxiolytic ✨ Fentanyl✨ - opioid

HTN drugs

*DIURETICS* (conserve K, lose Na): 1. thiazide/loop -inhibit NaCl reabsorption in loop of henle=increased excretion of NaCl 2. Potassium sparing -reduce K/Na exchange in distal and collecting tubules=reduce excretion of K, H, Ca, Mg 3. Aldosterone Receptor Blockers -inhibit Na-retaining and K-excreting effects of aldosterone in the distal and collecting tubules *ADRENERGIC INHIBITORS* (vasodilation): 1. central acting a-Adrenergic antagonist -reduce sympathetic outflow from CNS= vasodilation 2. peripheral acting a-Adrenergic antagonists -prevent peripheral release of epinephrine=vasodilation 3. a-adrenergic blockers -vasodilation 4. b-adrenergic blockers: -decrease CO and reduce sympathetic vasoconstrictor tone, decrease renin secretion by kidneys *ANGIOTENSIN INHIBITORS* (vasodilation and increased Na/H2O output): 1. ACE inhibitors: -decrease conversion of angiotensin I to angiotensin II=vasodilation 2. Angiotensin II receptor blockers -produce vasodilation and increase salt/water excretion 3. Renin inhibitors - prevent conversion of angiotensinogen to angiotensin *CALCIUM CHANNEL BLOCKERS:* -block movement of extracellular calcium into cells=vasodilation and DC heart rate, contractility, and SVR

diverticulitis

*DIVERTICULITIS* inflamed diverticula (outpouchings of colon) CAUSE: retention of stool and bacteria in diverticulum form hardened mass called fecalith. Inflammation develops and increased luminal pressures cause erosion of the bowel wall *TREATMENT* -rest the colon - NPO, bed rest, parenteral fluids, NG tube anticholinergic drugs to decrease distension from spasms -if perforation, exploratory laparotomy with possible colectomy MEDS: [dicyclomine (Bentyl)] and donnatal; IV antibiotics *DISCHARGE TEACHING* [nurse's role is crucial] -diet: High fiber -fluids: Increase water!! Fibers retain water, less for absorption -weight: reduce to decrease intra-abdominal pressure -meds: bulk laxatives [psyllium (metamucil)] -other: 30% require surgery to drain abscess or remove mass; surgery is typically a temporary diverting colostomy; then re-anastomosed after colon is healed

DVT (aka VTE)

*DVT (deep vein thrombosis) // VTE (vascular thromboembolism)* a blood clot that forms in a vein deep in the body. Blood clots occur when blood thickens and clumps together. Most deep vein blood clots occur in the lower leg or thigh *CLINICAL MANIFESTATIONS:* -tenderness over the vein -hardening of overlying muscle -venous distention -edema -mild to moderate pain -deep reddish color to area b/c of venous congestion some patients have no obvious changes *TREATMENT:* -bed rest to prevent emboli -umbrella filter implanted to prevent pulmonary emboli -thrombectomy to remove the clot -warm, moist heat -analgesics -anticoagulants -elevation to facilitate venous return to the heart -TEDs help edema lessen and coagulation levels achieved *PREVENTION:* TEDs, SCDs, ambulate, bed exercises, turn q2h *RISK FACTORS:* -Virchows triad venous stasis, endothelial damage, hypercoagulability -older age -increased BMI -decreased mobility -Surgery (orthopedic) -trauma -BCP: hormone state, pregnancy=higher risk -History of DVT -History of cancer -History if diabetes

endometrial cancer

*ENDOMETRIAL (uterine) CANCER* *RISK:* -age: 60+ -obesity: estrogen stores in adipose -hypertension -nulliparity -late menopause (after 50) -unopposed estrogen use -diabetes -lynch syndrome -family history of cancer Being pregnant or taking birth control can provide some protection b/c is causing shedding of uterine lining but in a controlled way; prevents overgrowth *MANAGEMENT:* remove uterus (hysterectomy) -as long as cancer is less than 1/3 into uterus then the removal will be a cure -if more than 1/3 into the lining of the uterus, may need chemo/radiation 5 year survival rate is 83%, most common reproductive tract cancer in women

endometriosis

*ENDOMETRIOSIS* when normal uterine tissue implants and grows outside the uterus, causing bleeding like a "mini-period" -common in peritoneal cavity but can occur in pleural cavity, liver, kidney, gluteal muscles, bladder, stomach, lungs, etc. -not life threatening but causes a lot of pain and decrease in quality of life THEORIES (actual cause unknown): 1. retrograde period passes through fallopian tubes and bring viable endometrial tissue into the pelvis where it attaches 2. undifferentiated peritoneal cells remain dormant in pelvic tissue until ovaries produce enough hormones to stimulate growth 3. possible genetic relationship

fat embolism

*FAT EMBOLISM* bone marrow fat globules are released and enter tissues and organs after a traumatic skeletal injury *CAUSE:* -fracture complication -fat globules block pulmonary capillaries and cause pulmonary edema and hemorrhage -surfactant production decreases=alveolar collapse, hypoxia, cerebral manifestations AKA fat globules are released when you break your bone and they enter the blood stream causing an emboli *MANIFESTATIONS:* -petechial rash appears in 2-3 days in sclera, posterior pharynx, chest, axilla -chest pain -tachypnea -cyanosis -decreased O2 -dyspnea -apprehension -tachycardia -rapid and acute course, feeling of impending disaster, may become comatose in a short period of time!!! -decreased LOC if fat travels to brain *NURSING CARE:* -careful immobilization of long bone fracture is most important preventative measure -symptom management -fluid resuscitation -oxygen -reposition as little as possible and encourage cough/ deep breathing

fibroadenoma

*FIBROADENOMA* benign brest lumps non cancerous, common breast tumor (women 15-40) *MANIFESTATIONS:* TUMORS... -painless -round -well delineated -firm, rubbery -1-3 cm in diameter -mobile (can be pushed around) -size not affected by menstruation but pregnancy can stimulate growth -growth is slow -NOT associated with cancer

fibrocystic breast disease

*FIBROCYSTIC BREASE DISEASE* -Cluster of benign tissues, most common lesions -Between ages 35-60 *MANIFESTATIONS:* -usually bilateral in upper, outer quadrant CYSTS: -round -well circumscribed (can palpate full edge) -movable -tender -painful (b/c press on nerves) -may be soft or firm transient: come and go with hormone cycles, pain is transient as well -nipple discharge: milky, yellow or green *TEACHING:* -recurrence till menopause -may increase with periods -reassure—does NOT turn into cancer -breast support with a firm bra -local application of heat/ice -teach interventions about fibrocystic breast changes and medical treatment -teach or remind to perform BSE each month (any new lump that stays through menstrual cycle should be seen by HCP promptly) -stress reduction

fractures

*FRACTURE* broken bone COMPOUND → open fx; break in skin [higher risk of infection] SIMPLE → closed fx; bone is broken inside the skin with no break in skin [less risk for infection] *MANIFESTATION:* -immediate localized pain - ↓ function -inability to bear weight or use affected part -guarding (tense immobility to protect against movement) -may not be accompanied by obvious bone deformity If fracture suspected... leave in position found to decrease risk for further injury while assessing history (what happened) and pulses.

glaucoma

*GLAUCOMA* group of conditions characterized by increased IOP leading to optic nerve atrophy and loss of peripheral vision *CAUSES:* -anything that dilates the eye can cause glaucoma -fight/flight meds -excitement -darkness -aging *PATHOPHYSIOLOGY:* NORMALLY... aqueous humor is made by the ciliary processes (2-3ml/min) and flows over the lens, thru the pupil, thru the trabecular meshwork, out the canal of schlemm thru the aqueous vein to the episcleral vein GLAUCOMA... aqueous humor cannot be drained from the anterior chamber; excessive pressure causes optic nerve degeneration and blindness normal pressure: 1-20mmHg open glaucoma pressure: 22-32 closed glaucoma pressure: 50 mmHg *MANIFESTATIONS:* OPEN ANGLE (clogged holes): -generally no clinical manifestations because it develops slowly CLOSED ANGLE (bulging or dilated pupil): -sudden intense pain 10/10 in/around eye often with n/v -halos around lights -blurred vision -ocular redness -cornea may appear frosted due to corneal edema *ACTION OF DRUGS:* 1. BETA ADRENERGIC ANTAGONISTS: [betaxolol (Betoptic)] -decrease aqueous humor production (rests the eye) -eyedrop -slows HR, pulmonary distress, h/a, depression 2. ALPHA & BETA AGONISTS: [dipivefrin (Propine)] -converts to epinephrine in the eye, enhances outflow -speeds HR, raises BP 3. CARBONIC ANHYDRASE INHIBITOR: [systemic (Diamox) or topical (Azopt)] -diuretic effect -stinging, blurred vision, redness; paresthesias, tinnitus, GI upsets; Do not give w ASA 4. CHOLINERGIC AGENTS: [pilocarine (Pilocar)] - eye drops -miotics -stimulate the iris sphincter contraction, pupil contraction -leads to decreased visual acuity 5. glycerin liquid: -increases extracellular osmolarity to move intracellular water to extracellular and vascular spaces -eye drops

diabetes mellitus - relevant laboratory values.

*GLUCOSE LEVELS:* -normal blood glucose level: 70-120 -prediabetes: 121-125 -considered diabetes when blood sugar goes above 126 when fasting ->300 is DKA *DIAGNOSIS:* 1. HEMOGLOBIN A1C (aka glycosylaed HgB) 6.5%+ in diabetes (confirm with repeat testing) 2. FASTING PLASMA GLUCOSE LEVEL (FPG): 126mg/dL+ in diabetes (confirmed by repeat test on another day) 3. two hour OGTT (oral glucose tolerance test) level 200+ mg/dL when a glucose load of 75g (give a sugary drink) is used...the accuracy of the test depends on patient prep and attention to the many factors (severe restriction of carbs, acute illness, meds, bed rest) that may influence the test outcomes (confirm with repeat testing) 4. random or casual plasma glucose 200+ mg/dL with symptoms ADDITIONAL DIAGNOSIS OF PRE DIABETES: Impaired glucose tolerance (IGT) as in type 2 when alteration in B cell function is mild- not as high as in diabetes: FPG >100mg/dL but less than 126mg/dL OTHER: -serum lipids (cholesterol, triglycerides, are high with Metabolic syndrome and are pre diabetic red flags) -high blood pressure -hypokalemia risk with diabetes and low phosphate bc glucose bring K+ and phosphate with it -exercise and stress raises glucose levels and without enough insulin can lead to DKA

herniated nucleus pulposus

*HERNIATED NUCLEUS PULPOSUS* *CAUSE:* -slipped intervertebral disc -can result from natural degeneration with age or repeated stress/ trauma to spine -may first bulge and then can herniate; places pressure on nearby nerves -can also occur from spinal stenosis -lower back pain -bowel/bladder incontinence (medical emergency) *POST-OP CARE:* with fusion: -healing time is longer than just with a laminectomy -rigid orthosis (back brace) used; Dr. order method of application and use (log roll?) -if the surgery is on the cervical spine, watch for spinal cord edema -no lifting, twisting, bending -firm mattress or bed board is used -focus on maintaining alignment without fusion: -place pillow under thighs of each leg when supine and btwn legs when side lying -opioid analgesics for 24-48 hours -potential for CSF leakage; report severe headaches, leakage immediately (drainage will be clear/ slightly yellow) -monitor peripheral neuro status during first 48 hours post op, report paresthesias -assess for paralytic ileus

hiatal hernia

*HIATAL HERNIA* aka diaphragmatic hernia or esophageal hernia - herniation (bulging) of the stomach into the esophagus through a hiatus (weakening in the diaphragm around the esophagus) and increased intra-abdominal pressure - cause unknown but predisposing factors are the same as GERD - Drug and surgical therapies the same as GERD -HERNIORRAPHY = closure of hiatal defect *DIFFERENT TYPES:* 1. SLIDING HH → stomach and intra-abdominal esophagus slide through the diaphragmatic hiatus...most common 2. ROLLING or PARAESOPHAGEAL hernia → Stomach herniates through the diaphragmatic hiatus, adjacent to the esophagus *DIAGNOSTIC TESTS:* consent! - barium swallow - esophagoscopy

hypertension

*HYPERTENTION* • Normal BP: <120/<80 • Prehypertension: 120-139/80-89 • Hypertension stage 1: 140-159/90-99 • Hypertension stage 2: 160+/100+ *TYPES:* 1. PRIMARY HTN: (90-95% cases) -elevated BP w/o known cause -contributing factors: increased SNS activity, overproduction of Na retaining substances, Increase Na intake, obesity, DM, high ETOH use 2. SECONDARY HTN: -elevated BP with a specific cause that can be identified and corrected -Causes: cirrhosis, endocrine disorders, drugs, neurologic disorders, pregnancy, renal disease, sleep apnea 3. HYPERTENSIVE CRISIS: -BP >220/140 -evidence of acute target organ damage: encephalopathy, cerebral hemorrhage, acute renal failure, MI, HF with edema) -use IV drug therapy titrated to Mean Arterial Pressure -decrease MAP by no more than 25% per min *HTN COMPLICATIONS:* 1. CORONARY ARTERY DISEASE: -cause: HTN induced atherosclerosis -these changes result in stiffened arterial wall and narrowed internal lumen 2. LEFT VENTRICULAR HYPERTROPHY: -cause: sustained HTN increasing the cardiac workload -over time, increased contraction (work) and O2 consumption cause heart to no longer meet O2 demands=heart failure 3. HEART FAILURE: -heart can no longer pump enough blood to meet metabolic needs of the body -contractility, stroke volume, and CO decreased -s/s: SOB, nocturnal dyspnea, fatigue -signs of enlarged heart present on Xray, ECG shows electrical changes

thyroid disorders pathophysiology, clinical manifestations, drug therapy, clinical manifestations of thyrotoxicosis and myxedema

*HYPOTHYROIDISM* *HYPERTHYROIDISM* A sustained increase in synthesis & release of thyroid hormones by thyroid gland *MANIFESTATIONS* -Related to effect of thyroid hormone excess - ↑ Metabolism - ↑ Tissue sensitivity to stimulation by sympathetic nervous system -Exophthalmos → enlarged, bulging eyes -Goiter → enlarged neck

*HINT:* From Dr. Frable's lecture distinguish incidence from prevalence (definitions)

*INCIDENCE* → new cases *PREVALENCE* → existing total cases (old cases + new cases) - (cause - specific death + those cured) -incidence has been relatively stable, about 50,000 new cases annually -prevalence is greater than ever before

leukemias

*MANIFESTATIONS:* -fatigue -weight loss -fever ACUTE LUMPHOCYTIC LEUKEMIA (ALL): -pallor -petechiae (in kids, this helps to differentiate from common cold) -bone/joint pain -CNS symptoms CHRONIC LYMPHOCYTIC LEUKEMIA: -decreased exercise tolerance -loss of appetite -splenomegaly -lymphadoenopathy -hepatomegaly -night swears -frequent infections ACUTE MYELOGENOUS LEUKEMIA (AML): -infection -bleeding/ bruising -anemia -Headache -mouth sores -sternal tenderness -bone pain CHRONIC MYELOGENOUS LEUKEMIA: -malaise -sweats -anorexia -increased splenomegaly *TESTS TO DIAGNOSE:* CBC: -very high WBC levels that causes pain b/c bone marrow is crowded from immature WBC -anemia -thrombocytopenia (late) bone marrow aspiration: 30%>blasts

lymphomas

*MANIFESTATIONS:*-fever -weight loss -myelosuppression -night sweats HODGKIN: -chills -pruritis -alcohol induced pain -respiratory problems -abdominal pain -N/V NON-HODGKIN: -malaise -painless swelling of nodes *TESTS TO DIAGNOSE:* node biopsy and scans: it almost always originates in the lymph nodes

metabolic syndrome

*METABOLIC SYNDROME* several things working hand in hand (syndrome) to use up the energy in the cell (metabolism) • cluster of abnormalities that increase the risk for cardiovascular disease (because it a vascular and nerve disease) and diabetes (type 2) • characterized by insulin resistance and obesity; others include hypertension, increased risk for clotting, abnormalities in cholesterol levels--> *DIAGNOSTIC CRITERIA* (3 must be present): 1. abdominal obesity 2. dyslipidemia (HDL=happy good lipids- want these, LDL and triclycerides=bad-dont want these) 3. elevated fasting glucose 4. HTN 6. pro-inflammatory states=elevated C-reactive protein *MANIFESTATIONS:* -impaired fasting blood glucose -hypertension -abnormal cholesterol levels -obesity -worse cognitive skills in teens *SIGNIFICANCE:* -patients are at increased risk of developing heart disease, stroke, diabetes, renal disease, polycystic ovary syndrome -smoking increases these risks -lifestyle modifications are first-line interventions to reduce the risk factors for metabolic syndrome: (reduce LDL, Stop smoking, lower BP, reduce glucose levels, weight loss, physical activity, healthy dietary habits)

neutropenia

*NEUTROPENIA* absolute neutrophil count <1000 norm: 4000-11,000 ANC=total WBC x % neutrophils *CAUSES:* -chemotherapy -immunosuppressive therapy -drug induced -hematologic disorders -autoimmune disorders -infections -misc.: severe sepsis, one marrow infiltration, hypersplenism, nutritional deficiencies, transfusion reaction, hemodialysis *NURSING INTERVENTIONS:* -isolation in HEPA room -hand hygiene is essential in minimizing risk of infection -antibiotics within one hour of attack -watch for s/s of infection (neutropenic fever>100.4 and neutrophil counts <500 is a medical emergency!!!) *PATIENT TEACHING:* -wash hands frequently, visitors too! -if at home, take temp as directed and follow instructions on when to call doctor -call Dr. with: fever>100.4, chills/ feel hot, redness/discharge/new body pain, changes in urination or bowel movement, cough, sore throat, mouth sores, blisters -avoid crowds, people with colds, flu, infection -wear a mask in public -avoid uncooked meats, seafood, eggs, unwashed fruits/veggies -bathe or shower daily -do not perform gardening or cleaning up after pets

CBC with differential findings indicate in relation to INFECTION *HINT:* What does an elevated neutrophil count indicate? Also, what does an elevated IgE level relate to generally?

*NEUTROPHILS:* -1st to arrive at site of injury (1.5-6.5 hours) -phagocytize bacteria, foreign material, and damaged cells -short life span (24-48hours); dead cells soon accumulate to make pus -bone marrow releases more neutrophils in response to infection=elevated WBC -shift to the left can occur when demand exceeds production rate *MONOCYTES:* -2nd to arrive (3-7 days after onset inflammation) -in tissue spaces, they transform into macrophages and assist with phagocytosis of inflammatory debris=cleans the area for healing -long life span and can multiply -may fuse to form a multinucleated giant cell=granuloma *LYMPHOCYTES:* -arrive later at the site of injury role: 1. cell mediated immunity-T cell 2. Humoral Immunity- B cell *INFECTION* WBC: -increased with a shift to the left PLASMA PROTEINS: -increased plasma proteins -increased C-reactive protein if acute -increased ESR if chronic NEUTROPHILS: -Body has a 6 day supply of mature cells, after they are used up, they are replaced by bands (baby neutrophils) -*increase indicates acute inflammation* -when band count is greater than 8%, there is a shift to the left, indicating severe inflammation (norm is 5% bands, 95% neutrophils) MONOCYTES: increased level = chronic inflammation EOSINOPHILS: -destroy parasites, control effects of histamine and leukotrienes -respond to allergic reactions IgE LEVELS: -elevated IgE = activation of the complement system which results in humoral immunity -humoral immunity mediates *allergic reactions*, autoimmune disorders, and antibody deficiencies

osteoarthritis

*OSTEOARTHRITIS* cartilage destruction *MANIFESTATIONS:* -no systemic manifestations like with RA -joint pain gets worse with use -pain relieved by rest; balance exercise with rest; do not be immobile -early a.m. stiffness goes away -crepitation *DEFORMITIES:* -heberden's nodes: joints of fingers appear as small nodes -bowlegged appearance from OA of the knee -one leg shorter than the other in OA of hip

paralytic ileus

*PARALYTIC ILEUS* paralysis of the small intestine *ASSESSMENT* • assess for bowel sounds in all 4 quadrants • abdominal distension • passing of flatus • N/V? *PREVENTATIVE & EARLY NURSING CARE* • early, frequent ambulation • NPO until bowel sounds return • NGT to decompress stomach and prevent N/V • dulcolax suppository to stimulate peristalsis

HIV-AIDS- pathophysiology, diagnosis, clinical manifestations, actions of drugs, diet teaching,

*PATHOPHYSIOLOGY* -virus binds to specific CD4 receptor sites and then enters the CD4 cell cytoplasm -reverse transcriptase assists RNA to make a single viral DNA and it copies itself to make a double-stranded viral DNA (enters cell nucleus) -using integrase the virus splices itself into genome to become part of the cell's genetic structure. HIV reproduces into long strands of HIV RNA—protease cuts into appropriate lengths during budding -consequences: all daughter cells from infected cell are infected -genetic codes can direct the cell to make HIV Note: A damaged CD4+ T helper cell has decreased ability to recognize and defend against pathogens 1. right virus 2. right dose of germ 3. right route (breast milk, semen, blood, pregnancy) 4. right host *DIAGNOSIS* -OraQuick: HIV Antibody Test uses oral secretion to test for HIV antibodies in 20 minutes. (suggests MIGHT have HIV) -rapid HIV antibody: fingerstick blood, results in 20 mins (requires follow-up beyond on the spot education; 3 out of 1,000 false positives) -4th generation: antigen/antibody test rarely used when + for antibodies requires a follow up test -Western Blot: confirms the HIV diagnosis; follow up test to confirm *MANIFESTATIONS* ACUTE INFECTION (retroviral syndrome): -starts 1-3wks after initial infection, lasts 2+wks -flu-like symptoms: fever, swollen lymph nodes, h/a, malaise, muscle/joint pain, diarrhea and/or diffuse rash -sometimes neuro complications are seen -symptoms could match many other diseases -antibodies occur (when enough antibodies form-seroconversion-the patient will become HIV+; 3 wks to 3 months CHRONIC INFECTION: -generally asymptomatic early on with T cell count >500 and low viral load -when CD4+ count drops to 200-500 and viral load increases, symptoms occur... -candidiasis (thrush/vaginal) -oral hairy leukoplakia (epstein-barr virus) -shingles (varicella-zoster virus) -persistent fever, drenching sweats, chronic diarrhea, recurring headaches -FATIGUE listen to patient!!! many psychological complaints: fear, anxiety, depression, worry, sadness LATE CHRONIC INFECTION (AIDS): -immune system severely compromised -CD4+ count <200 -opportunistic diseases develop -development of opportunistic cancer -wasting syndrome: loss of 10% or more of ideal body weight -dementia *DRUG ACTION* -suppress viral replication, avoid HIV med resistance, increase CD4 cell count, fewer adverse reactions -therapy is life long; patient must cooperate HAART DRUG THERAPY: combination therapy includes 2-3* meds; sometimes in one pill taken 1X day -recommended are two NRTIs and one PIs! NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITOR (NNRTI): [nevirapine (Viramune)] -Inhibit the action of reverse transcriptase -rash, erythema multiforme, hepatotoxicity, GI upset, h/a fatigue, neutropenia, pruritis, dizziness, trouble concentrating, unusual dreams, confusion anxiety, depression, diarrhea, encephalopathy NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITOR (NRTI): [zidovudine (AZT); Retrovir] -Insert a piece of DNA into developing HIV DNA chain, blocking further development of the chain and leaving the production of a new strand of HIV DNA incomplete -lactic acidosis, hepatic steatosis, lipodystrophy [fat atrophy], NV, anemia leukopenia, fatigue, h/a, insomnia, pancreatitis, peripheral neuropathy, skin discoloration NUCLEOTIDE REVERSE TRANSCRIPTASE INHIBITORS (NtRTI): [tenofovir DF (Viread)] -inhibit reverse transcriptase that normally facilitates the production of viral DNA from viral RNA -adverse effects: N, V, D PROTEASE INHIBITOR (PI): [indinavir (Crixivan)] -interferes with action of protease that normally cuts new strands of viral RNA so they can leave the initial cell; stops budding -AE: hyperglycemia, hyperlipidemia, lipodystrophy, diarrhea, nausea, h/a, hyper bilirubinemia, interstitial nephritis, kidney stones [should drink 2-4L of fluid a day], rash. DO NOT consume grapefruit juice. FUSION or ENTRY INHIBITORS (FI): [enfuvirtide (Fuzeon)] -inhibits binding of HIV to cells; -AE- injection site reactions, fatigue, nausea, diarrhea, insomnia, peripheral neuropathy, hypersensitivity reaction, pneumonia *DIET* DO NOT drink grapefruit juice; it interferes with the meds -lots of water!!!

peripheral arterial disease (PAD) *HINT:* How is the ankle-brachial index determined? What information does it provide?

*PERIPHERAL ARTERIAL DISEASE* *MANIFESTATION:* INTERMITTENT CLAUDICATION: -ischemic muscle ache or pain that is precipitated by a consistent level of exercise -resolves within 10 mins or less with rest, is reproducible -a result of accumulation of end products of anaerobic cellular metabolism like lactic acid ERECTILE DYSFUNCTION: -if internal iliac arteries are involved PARESTHESIA: -tingling from nerve tissue ischemia NEUROPATHY: -shooting or burning pain in extremity -patient may not notice lower extremity injury SKIN APPEARANCE: -thin, shiny, hair loss on lower legs -diminished leg pulses -pallor with leg elevation -reactive hyperemia (foot redness) when in dependent position CHRONIC REST PAIN: -occurs as PAD progresses and involves multiple arterial segments and there is insufficient flood flow to meet basic metabolic requirements of distal tissues -most often occurs at night->patient may try dangling the leg over the side of the bed, sleeping in a chair to allow gravity to maximize blood flow *ASSESSMENT:* SKIN: -loss of hair on legs and feet -thick toenails -pallor with elevation -dependent rubor -Thin, cool, shiny skin with muscle atrophy -skin breakdown with arterial ulcers (especially over bony areas) -gangrene CARDIOVASCULAR: -decreased, absent peripheral pulses -feel cool to touch -cap refill >3 sec -Bruits may be present at the pulse sites (turbulent sound when blood passes an obstruction) NEURO: -mobility or sensation impairment *Possible Diagnostic Findings:* -arterial stenosis evident with duplex imaging -decreased doppler pressures -decreased ankle brachial index -angiography indicative of peripheral atherosclerosis *how is ankle-brachial index determined?* -performed by using a hand held doppler -perform bilaterally -not good for diabetes ABI is calculated by dividing the ankle systolic BPs by the higher of the left and right brachial systolic BP -Normal ABI: 0.91-1.30 -Mild PAD ABI: 0.71-0.90 -Moderate PAD ABI: 0.41-0.70 -Severe PAD ABI: <.40 *what info does it provide?* -indicates adequate BP in the extremities -tells degree of difference of blood flow between upper and lower body

pneumonia

*PNEUMONIA* *MANIFESTATIONS:* -sudden onset of fever and chills -SOB -cough productive of purulent sputum -pleuritic chest pain -dullness to percussion -bronchial breath sounds, crackles' -take every dose of prescribed antibiotic -drug-drug, food-drug interactions -adequate rest to maintain progress toward recovery -may be several weeks before usual vigor and sense of well being return *TEACHING:* -teach about pneumococcal vaccine and influenza vaccine -teach nutrition, hygiene, rest, exercise to maintain natural resistance -prompt treatment of upper respiratory tract infection -strict asepsis -turn q2h -elevate HOB 30-45 degrees -TCDB

post-op care and patient teaching after total hip arthroplasty OR total knee arthroplasty.

*POST-OP HIP CARE:* -keep hips higher than knees when sitting -do not internally rotate and 90 degree flex the hip -use elevated toilet seats and chairs -foam abduction pillow between legs to prevent dislocation of new joint -no tub baths or driving for 4-6 wks -use grabber to assist patient and avoid bending over to pick something up -knees must be kept apart -physical therapy started first day post-op with ambulation and weight bearing *POST-OP KNEE CARE:* -isometric quadriceps setting post-op day 1 -continuous passive motion post op day 1 8-12 hours/ day -full weight bearing before discharge -use of stationary bike at home -use of shower chair, grab bars by commode and tub

NORMAL electrolyte levels

*POTASSIUM* 3.5-5 Increased levels indicate: -insulin, laxative, penicillin, diuretic use -tissue injury -kidney failure -metabolic or respiratory acidosis -RBC destruction Decreased levels indicate: -chronic diarrhea -diuretics -cushing syndrome -renal artery stenosis -vomiting *SODIUM* 135-145 *CHLORIDE* 96-106 *CALCIUM* 8.5-10.5 *BUN* 6-20 - used to identify renal problems - shows concentration of urea in blood which is regulated by rate at which the kidneys excrete urea - non-renal factors may also cause increase like rapid cell destruction from infection, fever, GI bleeding, trauma, athletic activity/excessive muscle breakdown, corticosteroid therapy *CREATININE* 0.6-1.2 - more reliable than BUN - creatinine is end product of muscle and protein metabolism which is liberated at a constant rate

pulmonary emboli

*PULMONARY EMBOLI* thrombus dislodged from peripheral venous system and lodged in pulmonary artery system. ventilation (gas exchange inhibited) without perfusion (blood flow) due to blocked pulmonary capillaries

radiation implants: nursing measures

*RADIATION IMPLANTS:* -implants mean you're emitting radioactivity -as low as reasonably possible -time, distance, shielding -minimize time spent in direct contact with patient-> radiation safety officer will indicate how much time at a specific distance can be spent -only care that MUST be delivered near the patient should be performed in close proximity -use shielding and wear a film badge to indicate cumulative radiation exposure (do not share badges, use only at work)

rheumatoid arthritis

*RHEUMATOID ARTHRITIS* chronic systemic autoimmune disease; inflammation of connective tissue in the synovial joints *PATHOPHYSIOLOGY:* autoimmune: -presence of autoantibodies (rheumatoid factor) against abnormal IgG -RF communes with IgG to form an immune complex that initially deposit on synovial membranes or superficial articular cartilage in the joints; this leads to the activation of complement and inflammatory response results -Joint changes from chronic inflammation begins when pannus (highly vascularized granulation tissue) forms within the joint -this eventually covers and erode the entire surface of the articular joint -genetic factors -systemically can spread *NURSING CARE:* -reduction of inflammation -management of pain -maintenance of joint function -and prevent/minimize joint deformity *DRUG THERAPY:* -rest -joint protection -heat/cold application -exercise -patient and caregiver teaching *ACTION OF DRUG:* -drugs have potential to lessen permanent effects of RA like joint erosion and deformity -choice of drug based on disease activity, patient level of function, lifestyle considerations (like desire to bear children) ✨prednisone✨ ✨naproxen✨ ✨humira✨ ✨remicade✨ ✨methotrexate✨

ovarian cancer

*RISK FACTORS:* -age -nulliparity (number of times ovary must release egg increases chances) -fertility drugs -age on menses onset and menopause -family history -BRCA and lynch -breast cancer history -askenasi jew *MANIFESTATIONS:* -vague abdominal discomfort and pain -GI symptoms -urinary frequency and urgency -enlargement of abdomen; bloating -ascites *TREATMENT:* -CA125 tumor marker is a detector -surgery mainstay: debulking with residual <1cm, spreads by seeding mostly; systemically -combination chemotherapy: platinum based plus taxane -palliative care

uterine cancer

*RISK FACTORS:* -age -obesity (store estrogen in fat) hypertension -nulliparity (no kids=no break from period) -late menopause (more periods=more opportunities for -maturation of cancer cells) -unopposed estrogen use -diabetes -lynch syndrome (HNPCC) *MANIFESTATIONS:* -vaginal bleeding (postmenopausal) -irregular bleeding (pre-menopausal) -pain -the uterus is generally fist size *TREATMENT:* -mainstay surgery (hysterectomy) -radiation sometimes prior to surgery -chemotherapy most often if further treatment needed

normal CBC ranges

*WBC* 5,000-10,000 post op: will go higher than 10,000 due to inflammation; if it goes higher than 12,000 there is an infection - know baseline before surgery *RBC* female: 3.8-5.1 male: 4.3-7.7 *PLATELETS* 150,000-400,000 measurement of number of platelets available to maintain platelet clotting factors *H&H* • hematocrit: measure of packed cell volume of RBC, expressed as a percentage of total blood volume female: 35-47% male: 39-50% low values indicate: anemia, bleeding, destruction of RBCs, leukemia, malnutrition, overhydration, nutritional deficit of iron, folate, fit B12 or B6 high values indicate: heart disease, dehydration, low blood oxygen levels (hypoxia) • hemoglobin: measurement of gas-carrying capacity of RBC female: 11.7-16 male: 13.2-17.3

cervical cancer

*RISKS:* -lack of regular screening -HPV***/STD/HIV (everyone that has had sex has been exposed to HPV) -early age with intercourse (earlier HPV exposure) -multiple partners (mens partners count towards number) -cigarette smoking -long term birth control use (more hormones) -race (blacks and hispanics high) *MANAGEMENT:* surgery and internal radiation together: -this is "brachy therapy" -internal radiation: puts rod in vagina -depending on tumor size, radiation may be done before or after surgery if after surgery/radiation they have recurrent disease=pelvic externation -extensive surgery, can be anterior, posterior, or total -total: removal of rectum, colon, small intestine, bladder, urethra, vagina, and sew up so no holes (no vagina or anus) -uterus, ovaries, fallopian tubes, cervix previously taken out -patient has colostomy and ileoconduit (for the urine, brings up the ureters) 5 year survival rate=71%, curable *TREATMENT:* 1st detect with pap smear! -surgery/radiation used together -stage O (pre invasive) is treated with laser, CKC, LEEP -stage I-IV treatment based on health, age, extent/co-morbidities -brachytherapy (internal radiation) -recurrent is treated with chemo or pelvic exeneration (take out all the remaining organs internally-bladder,ureter,rectum, etc. and leave with colostomy and urostomy->body image issues)

skin cancer prevention techniques

*SKIN CANCER PREVENTION TECHNIQUES* -avoid mid-day sun exposure -use protective clothing and sunscreens beginning in early life -examine skin on a monthly basis -ABCDE of melanoma (asymmetry, border irregularity, color change, diameter 6mm+, evolving) -no smoking -proper hygiene and nutrition

skin care after radiation therapy.

*SKIN DAMAGE:* -irritation may occur right away or even months to years after therapy (acute/ chronic) -erythema may develop 1-24 hours after a single treatment and can progress to wet desquamation (exposure of dermis and weeping of serous fluid) -skin reactions most likely occur in areas where skin is subject to pressure *INTERVENTIONS AFTER RADIATION:* -protect skin for temp extremes (no ice or heating packs, no hot water bottles) -avoid constricting garnets, rubbing, harsh chemicals, deodorants -for dry reactions, lubricate skin with nonirritating lotion emollient (aloe) with no metal, alcohol, perfume, or additives -for wet desquamation, keep tissue clean with normal saline compresses or modified Burow's solution soaks and dress with moisture vapor- permeable dressings or vaseline petroleum gauze -avoid direct sunlight exposure, use protective clothing and sunscreen -avoid swimming in saltwater or chlorinated pools during time of treatment

hysterectomy with bilateral salpingo-oopherectomy

*TAH-BSO* uterus, cervix, fallopian tubes, and ovaries removed using large abdominal incision. *TEACHING POST-OP* -patient is now in menopause and will never have another period -symptoms of menopause are more severe because of sudden withdrawal of all hormones -report all bleeding bc it should not occur -no sex for about 4-6 weeks (or until wound is healed) -temporary loss of vaginal sensation with vaginal hysterectomy → will return in several months -no heavy lifting or activities that may increase pelvic congestion -swimming is physically and mentally helpful -wearing a girdle is allowed and may provide comfort -once healing is complete, all previous activities may resume

NORMAL vital signs

*TEMPURATURE:* 12 hours post op: -risk for hypothermia (96.8) -they have been under anesthesia and have a slowed metabolism, the body was exposed to cold surgery room temp -use warm blankets, keep the PT moving and deep breathing 24-48 hours post op: -slight temp elevation is normal (100.4) - if elevated above 100.4 it could be related to lung congestion or atelectasis -deep breath, move, and give fluids -lung sounds will be deceased day 3 post op: -above 100=urinary infection, respiratory infection, phlebitis -balance rest with proper mobility to move secretions (if you move too much=hypermetabolism=higher fever) -fluids, nutrition, meds (help nausea) -may need sputum culture/antibiotic *RESPIRATIONS:* -want O2 about 92% -auscultate, cough/DB, incentive spirometry -pain meds to support deep breathing *CVD status:* -monitor vitals q15mins for an hour, then q30min for an hour, then q4h -watch for drop in BP and increased HR, cyanosis, decreed LOC=may indicate hemorrhage *FOLEY:* -should have at least 30ml/hr -first urination should be 200ml -input is more than output in first 48 hours

testicular cancer

*TESTICULAR CANCER* lump in scrotum - non-tender, firm, not transilluminated *SELF EXAM:* -perform in shower/bath → warm temp makes testes hang lower -use both hands to feel each testis, roll between thumb and first 3 fingers -identify the structures, should feel round and smooth. One may be larger than the other (okay!) -do on the same day each month -notify HCP if abnormalities are found *TEACHING:* -talk to patient about sterility and need to sperm retrieval BEFORE any surgery or chemo/radiation -may have ejaculatory dysfunction from certain surgeries -very treatable, 75% have complete remission when caught early!

tuberculosis *HINT:* What PPD finding indicates a positive result for health care workers? Why? What treatment is indicated (or not indicated) based on a positive mantoux test in the health care worker (you)?

*TUBERCULOSIS* -an infectious disease caused by mycobacterium tuberculosis (gram + acid fast bacillus). -spreads by very small airborne droplets when a person sneezes, coughs, speaks, or sings; Stays in air for hours -involves the lungs, but may spread (miliary TB) to larynx, kidneys, bones, adrenal glands, lymph nodes, and meninges. *Not infectious unless present here *SCREENING:* -tuberculin skin test (TST) aka mantoux test -intradermal injection of PDD on forearm that is read 48-72 hours after for presence or absence of induration -reaction will occur 2-12 wks after exposure - If skin test is +, do not do again levels of induration: 15mm: + for low risk and health 10mm: + for high risk groups 5mm: + for immunosuppressed *what PPD finding indicates a positive result for healthcare workers? Why?* -10mm because they are exposed more often *DIAGNOSIS:* ACID FAST BACILLUS TEST -microscopic examination of stained sputum smears for AFB -three consecutive sputum collections on different days -can take up to 8 weeks to grow and get definitive diagnosis HOW TO COLLECT: -early in the AM -rinse mouth with warm water -cough deeply -expectorate sputum, not saliva into sterile container -follow good mouth care -send to lab promptly *what treatment is indicated (or not indicated) based on a positive mantoux test in the health care worker?:* -9-12 months of daily isoniazid (INH), it reduces the risk of developing TB -monitor monthly for liver toxicity and adherence

What is the relevance of turn, cough, and deep breathe for the peri-operative patient? What do these procedures (when done correctly and often enough) prevent?

*TURN, COUGH, DEEP BREATHE* when done correctly and often enough it can prevent potential problems in the post operative period such as... -atelectasis -pneumonia -hypoxemia -delirium

nursing interventions to relieve side effects of chemotherapy that involve the mouth and esophagus.

*XEROSTOMIA* (dry mouth) -increased risk for cavities, use florida supplements, drink small amounts of water frequently *DYSGEUSIA* (taste loss) -may contribute to compromised nutritional status *ODYNOPHAGIA* aka dysphagia -give analgesics before meals *OVERALL ORAL CARE:* -assess routinely - teach pt to perform self exam -use soft bristle toothbrush -oral care before and after meals and at bedtime -can give saline solution w/ 1 tsp salt in 1 L water as effecting cleansing solution; 1 tsp sodium bicarb added to decrease odor, alleviate pain, dissolve mucin -topical analgesics for mucositis or pain in throat -offer feedings of soft, nonirritating high protein and high calorie foods frequently throughout the day

How spread of HIV is prevented

-abstinence -faithfulness -use condoms; even post menopause -promote early screening (even for low risk groups); CDC recommends all people between ages 13-64 be screen as a routine part of health care -have universal precautions of care, assume everyone is HIV+ -glove use when handling body fluid -get the facts, get tested, get involved -provide education for all patients about the disease, risk factors, and prevention -ID risks: sexual contact and injection drug use

Atherosclerosis - drug therapy

-atorvastatin: lowers cholestrol -anticoagulants: prevent blood build up near plaques -BP meds

CDC perspective on removing the stigma about HIV/AIDS

-its not about who we are, its about what we do -sexuality is in the brain, and does not have anything to do with disease spread

A postoperative client asks a nurse why it is so important to deep breathe and cough after surgery. When formulating a response, the nurse incorporates the understanding that retained pulmonary secretions in a postoperative client can lead to: a. pneumonia b. fluid imbalance c. pulmonary embolism d. carbon dioxide retention

A

An elderly patient asks the nurse what caused his cataract. The nurse's response should be based on which of the following? a. cataracts are most common in the elderly b. the usual cause of cataracts in elderly people is congenital. c. any type of chronic systemic disease can cause cataracts d. all cataracts result from eye injuries

A

Bronchial obstruction by retained secretions has contributed to a postoperative patient's recent pulse oximetry reading of 87%. Which of the following health problems is the patient experiencing? A. Atelectasis B. Bronchospasm C. Hypoventilation D. Pulmonary embolism

A

In planning postoperative interventions to promote ambulation, coughing, deep breathing, and turning, the nurse recognizes that which of the following actions will best enable the patient to achieve the desired outcomes? A. Administering adequate analgesics to promote relief or control of pain B. Asking the patient to demonstrate the postoperative exercises every 1 hour C. Giving the patient positive feedback when the activities are performed correctly D. Warning the patient about possible complications if the activities are not performed

A

Which of the following findings related to primary open-angle glaucoma would the nurse expect to find when reviewing a patient's history and physical examination report? A. Absence of pain or pressure B. Blurred vision in the morning C. Seeing colored halos around lights D. Eye pain accompanied with nausea and vomiting

A

What is the primary purpose of a three-way urinary catheter after a transurethral resection of the prostate (TURP)? A. Promote hemostasis and drainage of clots B. Relieve bladder spasms C. Reduce edema D. Increase bladder tone

A A large three-way indwelling catheter with a 30-mL balloon is inserted into the bladder after the procedure to provide hemostasis and to facilitate urinary drainage. The bladder is irrigated, either continuously or intermittently, usually for the first 24 hours to prevent obstruction from mucus and blood clots.

A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

ANS: D Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing. The other nursing actions are also important to implement but are not as high a priority as ensuring adequate ventilation

As a precaution for vocal cord paralysis from damage to the recurrent laryngeal nerve during thyroidectomy surgery, what equipment should be in the room in case it is needed for this emergency situation? a. Tracheostomy tray b. Oxygen equipment c. IV calcium gluconate d. Paper and pencil for communication

A A tracheostomy tray is in the room to use if vocal cord paralysis occurs from recurrent laryngeal nerve damage or for laryngeal stridor from tetany. The oxygen equipment may be useful but will not improve oxygenation with vocal cord paralysis without a tracheostomy. IV calcium salts will be used if hypocalcemia occurs from parathyroid damage. The paper and pencil for communication may be helpful, especially if a tracheostomy is performed, but will not aid in emergency oxygenation of the patient.

The nurse is caring for a 62-year-old man after a transurethral resection of the prostate (TURP). Which instructions should the nurse include in the teaching plan? A. Avoid straining during defecation. B. Restrict fluids to prevent incontinence. C. Sexual functioning will not be affected. D. Prostate exams are not needed after surgery.

A Activities that increase abdominal pressure, such as sitting or walking for prolonged periods and straining to have a bowel movement (Valsalva maneuver), should be avoided in the postoperative recovery period to prevent a postoperative hemorrhage. Instruct the patient to drink at least 2 L of fluid every day. Digital rectal examinations should be performed yearly. The prostate gland is not totally removed and may enlarge after a TURP. Sexual functioning may change after prostate surgery. Changes may include retrograde ejaculation, erectile dysfunction, and decreased orgasmic sensation.

In teaching a postcoronary bypass patient about the risk of venous thromboembolism (VTE), it is important to stress: a. Early ambulation b. Turning every 2 hours c. Splinting chest while coughing d. Importance of taking pain medication

A Activity has proven vital in helping to prevent postoperative VTEs. Other forms of treatment include anticoagulants and sequential compression devices (SCDs). Splinting the chest while coughing, taking pain medication, and turning every 2 hours are important for the recovery of the coronary bypass patient, but have little impact on preventing VTE.

A patient with advanced AIDS has a nursing diagnosis of impaired memory related to neurologic changes. In planning care for the patient, what should the nurse set as the highest priority? a. Maintain a safe patient environment b. Provide a quiet, nonstressful environment to avoid overstimulation c. Use memory cues such as calendars and clocks to promote orientation d. Provide written instructions of directions to promote understanding and orientation

A All of the nursing interventions are appropriate for a patient with impaired memory but the priority is the safety of the patient when cognitive and behavioral problems impair the ability to maintain a safe environment.

The nurse is caring for a 76-year-old man who has undergone left knee arthroplasty with prosthetic replacement of the knee joint to relieve the pain of severe osteoarthritis. Postoperatively the nurse expects what to be included in the care of the affected leg? a. Progressive leg exercises to obtain 90-degree flexion b. Early ambulation with full weight bearing on the left leg c. Bed rest for 3 days with the left leg immobilized in extension d. Immobilization of the left knee in 30-degree flexion for 2 weeks to prevent dislocation

A Although early ambulation is not done, the patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible. Because this is painful after surgery, the patient requires good pain management and often the use of a CPM machine. The patient's knee is unlikely to dislocate.

A 28-year-old woman with a fracture of the proximal left tibia in a long leg cast complains of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which action should the nurse take? a. Notify the health care provider immediately. b. Elevate the left leg above the level of the heart. c. Administer prescribed morphine sulfate intravenously. d. Apply ice packs to the left proximal tibia over the cast.

A Clinical manifestations of compartment syndrome include (1) paresthesia, (2) pain distal to the injury that is not relieved by opioid analgesics and pain on passive stretch of muscle traveling through the compartment, (3) pressure increases in the compartment, (4) pallor, coolness, and loss of normal color of the extremity, (5) paralysis or loss of function, and (6) pulselessness or diminished/absent peripheral pulses. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Pulselessness and paralysis (in particular) are later signs of compartment syndrome. Notify the health care provider immediately of a patient's changing condition. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome.

Which of the following characteristics should the nurse include when teaching the client about moderate sedation? a) Ability to respond to verbal commands b) Unable to maintain airway c) Loss of consciousness d) Paralysis of the lower extremities

A Explanation: The client receiving moderate sedation will be able to respond to verbal commands.

What is the effect of finasteride (Proscar) in the treatment of BPH? a. A reduction in the size of the prostate gland b. Relaxation of the smooth muscle of the urethra c. Increased bladder tone that promotes bladder emptying d. Relaxation of the bladder detrusor muscle promoting urine flow

A Finasteride results in suppression of androgen formation by inhibiting the formation of the testosterone metabolite dihydroxytestosterone, the principal prostatic androgen, and results in a decrease in the size of the prostate gland. α-Adrenergic blockers are used to cause smooth muscle relaxation in the prostate that improves urine flow. Drugs affecting bladder tone are not indicated.

A surgical patient's premedication regimen includes midazolam (Versed). What are the most likely desired effects of this medication? a) Monitored anesthesia care and amnesia b) Potentiates volatile agents to speed induction c) Analgesia and prevention of intraoperative vomiting d) Relaxation of skeletal muscles and facilitation of endotracheal intubation

A Midazolam is a benzodiazepine that is widely used for its ability to induce amnesia and provide moderate sedation (conscious sedation). Nitrous oxide is a gaseous agent that potentiates volatile agents to speed induction and reduce total dosage and side effects. Antiemetics prevent intraoperative vomiting. Neuromuscular blocking agents facilitate endotracheal intubation

The nurse is teaching clinic patients about risk factors for testicular cancer. Which individual is at highest risk for developing testicular cancer? A. A 30-year-old white male with a history of cryptorchidism B. A 48-year-old African American male with erectile dysfunction C. A 19-year-old Asian male who had surgery for testicular torsion D. A 28-year-old Hispanic male with infertility caused by a varicocele

A The incidence of testicular cancer is four times higher in white males than in African American males. Testicular tumors are also more common in males who have had undescended testes (cryptorchidism) or a family history of testicular cancer or anomalies. Other predisposing factors include orchitis, human immunodeficiency virus infection, maternal exposure to DES, and testicular cancer in the contralateral testis.

Following a gastrectomy performed for peptic ulcer disease, the patient has recovered and is ready for discharge. What instructions should the nurse include in discharge teaching to prevent dumping syndrome? a. Divide meals into six small feedings. b. Take fluids along with meals. c. Use concentrated sweets like honey, jam, and jelly. d. Reduce protein and fats in the diet.

A To prevent dumping syndrome after gastrectomy, the patient should avoid large meals, instead dividing meals into six small meals to avoid overloading the intestines at mealtimes. Fluids should not be taken with meals. Fluids can be taken at least 30 to 45 minutes before or after meals. This helps prevent distension or a feeling of fullness. Concentrated sweets should be avoided because they sometimes cause dizziness, diarrhea, and a sense of fullness. Protein and fats should be increased in the diet to help rebuild body tissue and to meet energy needs.

What preoperative instruction should the nurse give to the patient scheduled for a subtotal thyroidectomy? a. How to support the head with the hands when turning in bed b. Coughing should be avoided to prevent pressure on the incisionm c. Head and neck will need to remain immobile until the incision heals d. Any tingling around the lips or in the fingers after surgery is expected and temporary

A To prevent strain on the suture line postoperatively, the patient's head must be manually supported while turning and moving in bed but range-of-motion exercises for the head and neck are also taught preoperatively to be gradually implemented after surgery. There is no contraindication for coughing and deep breathing and these should be carried out postoperatively. Tingling around the lips or fingers is a sign of hypocalcemia, which may occur if the parathyroid glands are inadvertently removed during surgery. This sign should be reported immediately.

Postoperative orders for a pt after cataract surgery state, apply pressure dressing to left eye. Which nursing action is most appropriate? a. call the dr to verify the order because pressure dressing ar usually contraindicated after eye surgery. b. call the dr to verify the order because dressings are usually applied bilaterally after eye surgery c. carry out the order by applying four eye pads and covering them lightly with Elastoplast tape d. ask another nurse to read the order and carry it out

A pressure on suture lines should be avoided

An adolescent is brought to the emergency room after being hit on the head while playing ball. After examination, a diagnosis of detached retina of the left eye is made. Which of the following signs & symptoms does the nurse expect to observe? a. the pt states he sees quick flashes of light b. the pt complains of severe pain in the affected eye c. the pt has decreased peripheral vision d. the nurse observes orbital edema

A the retina perceives light and transmits impulses from nerve cells to the optic nerve; symptoms include flashes of light or blurred, sooty vision, sensation of particles moving in the line of vision, the visual field may be blank, or have a veil like coating and eventually a loss of vision.

A 33-year-old patient noticed a painless lump in his scrotum on self-examination of his testicles and a feeling of heaviness. The nurse should first teach him about what diagnostic test? A. Ultrasound B. Cremasteric reflex C. Doppler ultrasound D. Transillumination with a flashlight

A. Ultrasound When the scrotum has a painless lump, scrotal swelling, and a feeling of heaviness, testicular cancer is suspected, and an ultrasound of the testes is indicated. Blood tests will also be done. The cremasteric reflex and Doppler ultrasound are done to diagnose testicular torsion. Transillumination with a flashlight is done to diagnose a hydrocele.

Which menu choice by the patient with diverticulosis is best for preventing diverticulitis? a. Navy bean soup and vegetable salad b. Whole grain pasta with tomato sauce c. Baked potato with low-fat sour cream d. Roast beef sandwich on whole wheat bread

ANS: A A diet high in fiber and low in fats and red meat is recommended to prevent diverticulitis. Although all of the choices have some fiber, the bean soup and salad will be the highest in fiber and the lowest in fat

The nurse admitting a patient with acute diverticulitis explains that the initial plan of care is to a. administer IV fluids. b. give stool softeners and enemas. c. order a diet high in fiber and fluids. d. prepare the patient for colonoscopy.

ANS: A A patient with acute diverticulitis will be NPO and given parenteral fluids. A diet high in fiber and fluids will be implemented before discharge. Bulk-forming laxatives, rather than stool softeners, are usually given, and these will be implemented later in the hospitalization. The patient with acute diverticulitis will not have enemas or a colonoscopy because of the risk for perforation and peritonitis.

A patient is scheduled for a right cataract extraction and intraocular lens implantation at an ambulatory surgical center in 2 weeks. During the preoperative assessment of the patient in the physician's office, it is most important for the nurse to assess a. the visual acuity of the patient's left eye. b. for a white pupil in the patient's right eye. c. how long that the patient has had the cataract. d. for a history of reactions to general anesthetics.

ANS: A Because it can take several weeks before the maximum improvement in vision occurs in the right eye, patient safety and independence are determined by the vision in the left eye. Cataract surgery is done using local anesthetics rather than general anesthetics. A white pupil in the operative eye would not be unusual for a patient scheduled for cataract removal and lens implantation. The length of time that the patient has had the cataract will not impact on the perioperative care

A patient with a right retinal detachment had a pneumatic retinopexy procedure. Which information will be included in the discharge teaching plan? a. The purpose of maintaining the head in a prescribed position b. The use of eye patches to reduce movement of the operative eye c. The need to wear dark glasses to protect the eyes from bright light d. The procedure for dressing changes when the eye dressing is saturated

ANS: A Following pneumatic retinopexy, the patient will need to position the head so the air bubble remains in contact with the retinal tear. The dark lenses and bilateral eye patches are not required after this procedure. Saturation of any eye dressings would not be expected following this procedure.

Which patient arriving at the urgent care center will the nurse assess first? a. Patient with acute right eye pain that occurred while using home power tools b. Patient with purulent left eye discharge, pruritus, and conjunctival inflammation c. Patient who is complaining of intense discomfort after an insect crawled into the right ear d. Patient who has Ménière's disease and is complaining of nausea, vomiting, and dizziness

ANS: A The history and symptoms suggest eye trauma with a possible penetrating injury. Blindness may occur unless the patient is assessed and treated rapidly. The other patients should be treated as soon as possible, but do not have clinical manifestations that indicate any acute risk for vision or hearing loss

A 56-year-old woman is concerned about having a moderate amount of vaginal bleeding after 4 years of menopause. The nurse will anticipate teaching the patient about a. endometrial biopsy. b. endometrial ablation. c. uterine balloon therapy. d. dilation and curettage (D&C).

ANS: A A postmenopausal woman with vaginal bleeding should be evaluated for endometrial cancer, and endometrial biopsy is the primary test for endometrial cancer. D&C will be needed only if the biopsy does not provide sufficient information to make a diagnosis. Endometrial ablation and balloon therapy are used to treat menorrhagia, which is unlikely in this patient.

An elderly male patient is experiencing difficulty in initiating voiding and a feeling of incomplete bladder emptying. What causes these symptoms in benign prostatic hyperplasia (BPH)? A. Obstruction of the urethra B. Untreated chronic prostatitis C. Decreased bladder compliance D. Excessive secretion of testosterone

Answer: A BPH is a benign enlargement of the prostate gland. The enlargement of the prostate gradually compresses the urethra, eventually causing partial or complete obstruction. Compression of the urethra ultimately leads to the development of clinical symptoms.

When caring for a patient the second postoperative day after abdominal surgery for removal of a large pancreatic cyst, the nurse obtains an oral temperature of 100.8° F. Which action should the nurse take first? a. Have the patient use the incentive spirometer. b. Assess the surgical incision for redness and swelling. c. Administer the ordered PRN acetaminophen (Tylenol). d. Ask the health care provider to prescribe a different antibiotic.

ANS: A A temperature of 100.8° F in the first 48 hours is usually caused by atelectasis, and the nurse should have the patient cough and deep breathe. This problem may be resolved by nursing intervention, and therefore notifying the health care provider is not necessary. Acetaminophen will reduce the temperature, but it will not resolve the underlying respiratory congestion. Because a wound infection does not usually occur before the third postoperative day, a wound infection is not a likely source of the elevated temperature.

A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate? a. "The cancer involves only the cervix." b. "The cancer cells look almost like normal cells." c. "Further testing is needed to determine the spread of the cancer." d. "It is difficult to determine the original site of the cervical cancer."

ANS: A Cancer in situ indicates that the cancer is localized to the cervix and is not invasive at this time. Cell differentiation is not indicated by clinical staging. Because the cancer is in situ, the origin is the cervix. Further testing is not indicated given that the cancer has not spread.

A 54-year-old patient is on the surgical unit after a radical abdominal hysterectomy. Which finding is most important to report to the health care provider? a. Urine output of 125 mL in the first 8 hours after surgery b. Decreased bowel sounds in all four abdominal quadrants c. One-inch area of bloody drainage on the abdominal dressing d. Complaints of abdominal pain at the incision site with coughing

ANS: A The decreased urine output indicates possible low blood volume and further assessment is needed to assess for possible internal bleeding. Decreased bowel sounds, minor drainage on the dressing, and abdominal pain with coughing are expected after this surgery.

Which topic will the nurse include in the preoperative teaching for a patient admitted for an abdominal hysterectomy? a. Purpose of ambulation and leg exercises b. Adverse effects of systemic chemotherapy c. Decrease in vaginal sensation after surgery d. Symptoms caused by the drop in estrogen level

ANS: A Venous thromboembolism (VTE) is a potential complication after the surgery, and the nurse will instruct the patient about ways to prevent it. Vaginal sensation is decreased after a vaginal hysterectomy but not after abdominal hysterectomy. Leiomyomas are benign tumors, so chemotherapy and radiation will not be prescribed. Because the patient will still have her ovaries, the estrogen level will not decrease.

A patient develops neutropenia after receiving chemotherapy. Which information about ways to prevent infection will the nurse include in the teaching plan (select all that apply)? a. Cook food thoroughly before eating. b. Choose low fiber, low residue foods. c. Avoid public transportation such as buses. d. Use rectal suppositories if needed for constipation. e. Talk to the oncologist before having any dental work done.

ANS: A, C, E Eating only cooked food and avoiding public transportation will decrease infection risk. A high-fiber diet is recommended for neutropenic patients to decrease constipation. Because bacteria may enter the circulation during dental work or oral surgery, the patient may need to postpone dental work or take antibiotics.

The charge nurse observes a newly hired nurse performing all of the following interventions for a patient who has just arrived in the postanesthesia care unit after having right cataract removal and an intraocular lens implant. Which one requires that the charge nurse intervene? a. The nurse leaves the eye shield in place. b. The nurse encourages the patient to cough. c. The nurse elevates the patient's head to 45 degrees. d. The nurse applies corticosteroid drops to the right eye.

ANS: B Because coughing will increase intraocular pressure, patients are generally taught to avoid coughing during the acute postoperative time. The other actions are appropriate for a patient after having this surgery.

To prevent recurrence of uric acid renal calculi, the nurse teaches the patient to avoid eating a. milk and cheese. b. sardines and liver. c. legumes and dried fruit. d. spinach, chocolate, and tea.

ANS: B Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.

To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse can evaluate the patient for improvement by a. questioning the patient about blurred vision. b. noting any changes in the patient's visual field. c. asking the patient to rate the pain using a 0 to 10 scale. d. assessing the patient's depth perception when climbing stairs.

ANS: B POAG develops slowly and without symptoms except for a gradual loss of visual fields. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.

A patient who uses injectable illegal drugs asks the nurse about preventing acquired immunodeficiency syndrome (AIDS). Which response by the nurse is best? a. "Avoid sexual intercourse when using injectable drugs." b. "It is important to participate in a needle-exchange program." c. "You should ask those who share equipment to be tested for HIV." d. "I recommend cleaning drug injection equipment before each use."

ANS: B Participation in needle-exchange programs has been shown to decrease and control the rate of HIV infection. Cleaning drug equipment before use also reduces risk, but it might not be consistently practiced. HIV antibodies do not appear for several weeks to months after exposure, so testing drug users would not be very effective in reducing risk for HIV exposure. It is difficult to make appropriate decisions about sexual activity when under the influence of drugs.

The health care provider prescribes finasteride (Proscar) for a 56-year-old patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that a. he should change position from lying to standing slowly to avoid dizziness. b. his interest in sexual activity may decrease while he is taking the medication. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

ANS: B A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Although orthostatic hypotension may occur if the patient also is taking a medication for erectile dysfunction (ED), it should not occur with finasteride alone. Improvement in symptoms of obstruction takes about 6 months. The medication does not cause hypertension.

The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

ANS: B After a laparoscopic cholecystectomy, the patient will have Band-Aids in place over the incisions. Patients are discharged the same (or next) day and have few restrictions on activities of daily living. Drainage from the incisions would be abnormal, and the patient should be instructed to call the health care provider if this occurs. A low-fat diet may be recommended for a few weeks after surgery but will not be a life-long requirement.

The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require an intervention? a. The UAP flushes the toilet once after emptying the patient's bedpan. b. The UAP stands by the patient's bed for 30 minutes talking with the patient. c. The UAP places the patient's bedding in the laundry container in the hallway. d. The UAP gives the patient an alcohol-containing mouthwash to use for oral care.

ANS: B Because patients with temporary implants emit radioactivity while the implants are in place, exposure to the patient is limited. Laundry and urine/feces do not have any radioactivity and do not require special precautions. Cervical radiation will not affect the oral mucosa, and alcohol-based mouthwash is not contraindicated.

Which information will the nurse include for a patient with newly diagnosed gastroesophageal reflux disease (GERD)? a. "Peppermint tea may reduce your symptoms." b. "Keep the head of your bed elevated on blocks." c. "You should avoid eating between meals to reduce acid secretion." d. "Vigorous physical activities may increase the incidence of reflux."

ANS: B Elevating the head of the bed will reduce the incidence of reflux while the patient is sleeping. Peppermint will decrease lower esophageal sphincter (LES) pressure and increase the chance for reflux. Small, frequent meals are recommended to avoid abdominal distention. There is no need to make changes in physical activities because of GERD.

A hospitalized patient who has received chemotherapy for leukemia develops neutropenia. Which observation by the nurse would indicate a need for further teaching? a. The patient ambulates several times a day in the room. b. The patient's visitors bring in some fresh peaches from home. c. The patient cleans with a warm washcloth after having a stool. d. The patient uses soap and shampoo to shower every other day.

ANS: B Fresh, thinned-skin fruits are not permitted in a neutropenic diet because of the risk of bacteria being present. The patient should ambulate in the room rather than the hospital hallway to avoid exposure to other patients or visitors. Because overuse of soap can dry the skin and increase infection risk, showering every other day is acceptable. Careful cleaning after having a bowel movement will help prevent skin breakdown and infection.

A client has been taking finasteride (Proscar) for 4 weeks and reports that he has not yet seen a reduction in symptoms. Which response by the nurse is most appropriate? a. "Have you been taking the medication as ordered?" b. "It may take several months to see results." c. "It may not be the right drug for you." d. "We can try dutasteride (Avodart) next."

ANS: B So that he does not become discouraged, the nurse should first reassure the client that this class of medications may take up to 6 months to be effective. The nurse then can assess for compliance, but asking that question first may put the client on the defensive. The client needs to try the medication for several more months before the health care team changes it. Avodart is in the same class of medications, and its use for up to 6 months of therapy may be required before results are seen.

Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)? a. "You will need to remain on a bland diet." b. "Avoid foods that cause pain after you eat them." c. "High-protein foods are least likely to cause you pain." d. "You should avoid eating any raw fruits and vegetables."

ANS: B The best information is that each individual should choose foods that are not associated with postprandial discomfort. Raw fruits and vegetables may irritate the gastric mucosa, but chewing well seems to decrease this problem and some patients may tolerate these foods well. High-protein foods help neutralize acid, but they also stimulate hydrochloric (HCl) acid secretion and may increase discomfort for some patients. Bland diets may be recommended during an acute exacerbation of PUD, but there is little scientific evidence to support their use.

A 44-year-old man admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take? a. Irrigate the NG tube. b. Check the vital signs. c. Give the ordered antacid. d. Elevate the foot of the bed.

ANS: B The patient's symptoms suggest acute perforation, and the nurse should assess for signs of hypovolemic shock. Irrigation of the NG tube, administration of antacids, or both would be contraindicated because any material in the stomach will increase the spillage into the peritoneal cavity. Elevating the foot of the bed may increase abdominal pressure and discomfort, as well as making it more difficult for the patient to breathe.

A patient with Hodgkin's lymphoma who is undergoing external radiation therapy tells the nurse, "I am so tired I can hardly get out of bed in the morning." Which intervention should the nurse add to the plan of care? a. Minimize activity until the treatment is completed. b. Establish time to take a short walk almost every day. c. Consult with a psychiatrist for treatment of depression. d. Arrange for delivery of a hospital bed to the patient's home.

ANS: B Walking programs are used to keep the patient active without excessive fatigue. Having a hospital bed does not necessarily address the fatigue. The better option is to stay as active as possible while combating fatigue. Fatigue is expected during treatment and is not an indication of depression. Minimizing activity may lead to weakness and other complications of immobility.

A 32-year-old patient has oral contraceptives prescribed for endometriosis. The nurse will teach the patient to a. expect to experience side effects such as facial hair. b. take the medication every day for the next 9 months. c. take calcium supplements to prevent developing osteoporosis during therapy. d. use a second method of contraception to ensure that she will not become pregnant.

ANS: B When oral contraceptives are prescribed to treat endometriosis, the patient should take the medications continuously for 9 months. Facial hair is a side effect of synthetic androgens. The patient does not need to use additional contraceptive methods. The hormones in oral contraceptives will protect against osteoporosis.

The nurse designs a program to decrease the incidence of human immunodeficiency virus (HIV) infection in the adolescent and young adult populations. Which information should the nurse assign as the highest priority? a. Methods to prevent perinatal HIV transmission b. Ways to sterilize needles used by injectable drug users c. Prevention of HIV transmission between sexual partners d. Means to prevent transmission through blood transfusions

ANS: C Sexual transmission is the most common way that HIV is transmitted. The nurse should also provide teaching about perinatal transmission, needle sterilization, and blood transfusion, but the rate of HIV infection associated with these situations is lower.

The nurse is caring for a young adult who just got married and has been diagnosed with testicular cancer. To which community resource does the nurse refer him? a. American Cancer Society b. Red Cross c. Sperm bank d. Public Health Department

ANS: C The young man with testicular cancer should be referred to a sperm bank, so that he will have the option to have children in the future if he so desires. The other resources listed will not provide assistance in this area. The American Cancer Society does offer several resources for clients with cancer and their families, but referral to a sperm bank would be the priority owing to the man's age and his newly married status.

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

ANS: C Amylase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be useful in evaluating whether the prescribed therapies have been effective.

A 68-year-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), the nurse will plan to do frequent assessments of the patient's a. apical pulse. b. bowel sounds. c. breath sounds. d. abdominal girth.

ANS: C Because GERD may cause aspiration, the unconscious patient is at risk for developing aspiration pneumonia. Bowel sounds, abdominal girth, and apical pulse will not be affected by the patient's stroke or GERD and do not require more frequent monitoring than the routine.

A patient returned from a laparoscopic Nissen fundoplication for hiatal hernia 4 hours ago. Which assessment finding is most important for the nurse to address immediately? a. The patient is experiencing intermittent waves of nausea. b. The patient complains of 7/10 (0 to 10 scale) abdominal pain. c. The patient has absent breath sounds in the left anterior chest. d. The patient has hypoactive bowel sounds in all four quadrants.

ANS: C Decreased breath sounds on one side may indicate a pneumothorax, which requires rapid diagnosis and treatment. The nausea and abdominal pain should also be addressed but they are not as high priority as the patient's respiratory status. The patient's decreased bowel sounds are expected after surgery and require ongoing monitoring but no other action.

A 46-year-old female with gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement indicates that additional teaching about GERD is needed? a. "I take antacids between meals and at bedtime each night." b. "I sleep with the head of the bed elevated on 4-inch blocks." c. "I eat small meals during the day and have a bedtime snack." d. "I quit smoking several years ago, but I still chew a lot of gum."

ANS: C GERD is exacerbated by eating late at night, and the nurse should plan to teach the patient to avoid eating at bedtime. The other patient actions are appropriate to control symptoms of GERD.

Which patient choice for a snack 2 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective? a. Chocolate pudding b. Glass of low-fat milk c. Cherry gelatin with fruit d. Peanut butter and jelly sandwich

ANS: C Gelatin and fruit are low fat and will not decrease lower esophageal sphincter (LES) pressure. Foods such as chocolate are avoided because they lower LES pressure. Milk products increase gastric acid secretion. High-fat foods such as peanut butter decrease both gastric emptying and LES pressure.

An 80-year-old who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration? a. Sucralfate (Carafate) b. Omeprazole (Prilosec) c. Metoclopramide (Reglan) d. Aluminum hydroxide (Amphojel)

ANS: C Metoclopramide can cause central nervous system (CNS) side effects ranging from anxiety to hallucinations. Hallucinations are not a side effect of proton-pump inhibitors, mucosal protectants, or antacids.

At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. The nurse will teach the patient to a. increase the amount of fluid with meals. b. eat foods that are higher in carbohydrates. c. lie down for about 30 minutes after eating. d. drink sugared fluids or eat candy after meals.

ANS: C The patient is experiencing symptoms of dumping syndrome, which may be reduced by lying down after eating. Increasing fluid intake and choosing high carbohydrate foods will increase the risk for dumping syndrome. Having a sweet drink or hard candy will correct the hypoglycemia that is associated with dumping syndrome but will not prevent dumping syndrome.

When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.

ANS: C The patient with acute pancreatitis is at risk for hypocalcemia, and the assessment data indicate a positive Trousseau's sign. The health care provider should be notified after the nurse checks the patient's calcium level. There is no indication that the patient needs to have the BP rechecked or that there is any arm pain

The nurse teaches a 64-year-old woman to prevent the recurrence of renal calculi by a. using a filter to strain all urine. b. avoiding dietary sources of calcium. c. choosing diuretic fluids such as coffee. d. drinking 2000 to 3000 mL of fluid a day.

ANS: D A fluid intake of 2000 to 3000 mL daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.

A 73-year-old patient with diverticulosis has a large bowel obstruction. The nurse will monitor for a. referred back pain. b. metabolic alkalosis. c. projectile vomiting. d. abdominal distention.

ANS: D Abdominal distention is seen in lower intestinal obstruction. Referred back pain is not a common clinical manifestation of intestinal obstruction. Metabolic alkalosis is common in high intestinal obstruction because of the loss of HCl acid from vomiting. Projectile vomiting is associated with higher intestinal obstruction

When the nurse is caring for a patient who has had left-sided extracorporeal shock wave lithotripsy, which assessment finding is most important to report to the health care provider? a. Blood in urine b. Left flank pain c. Left flank bruising d. Drop in urine output

ANS: D Because lithotripsy breaks the stone into small sand, which could cause obstruction, it is important to report a drop in urine output. Left flank pain, bruising, and hematuria are common after lithotripsy.

The nurse cares for a patient who is human immunodeficiency virus (HIV) positive and taking antiretroviral therapy (ART). Which information is most important for the nurse to address when planning care? a. The patient's blood glucose level is 142 mg/dL. b. The patient complains of feeling "constantly tired." c. The patient is unable to state the side effects of the medications. d. The patient states, "Sometimes I miss a dose of zidovudine (AZT)."

ANS: D Because missing doses of ART can lead to drug resistance, this patient statement indicates the need for interventions such as teaching or changes in the drug scheduling. Elevated blood glucose and fatigue are common side effects of ART. The nurse should discuss medication side effects with the patient, but this is not as important as addressing the skipped doses of AZT.

A patient with human immunodeficiency virus (HIV) infection has developed Mycobacterium avium complex infection. Which outcome would be appropriate for the nurse to include in the plan of care? a. The patient will be free from injury. b. The patient will receive immunizations. c. The patient will have adequate oxygenation. d. The patient will maintain intact perineal skin.

ANS: D The major manifestation of M. avium infection is loose, watery stools, which would increase the risk for perineal skin breakdown. The other outcomes would be appropriate for other complications (pneumonia, dementia, influenza, etc.) associated with HIV infection

Which client statement indicates understanding about post-orchiectomy care for testicular cancer? a. "I will avoid contact sports to prevent injury and development of cancer in my remaining testis." b. "I will always use a condom because I am at increased risk for acquiring a sexually transmitted disease." c. "I will wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle." d. "I will continue to perform testicular self-examination (TSE) monthly on my remaining testicle."

ANS: D Treatment (e.g., surgery, radiation, chemotherapy) for testicular cancer does not protect the person from development of testicular cancer in the remaining testicle. A monthly TSE should be performed to monitor for changes in size, shape, or consistency of the testis. The other statements are inaccurate. Testicular cancer is not caused by trauma, cannot be prevented by an athletic cup, and does not cause increased risk for sexually transmitted diseases.

The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.

ANS: D Alcohol use is one of the most common risk factors for pancreatitis in the United States. Cigarette smoking, diabetes, and high-protein diets are not risk factors.

The nurse will anticipate teaching a patient experiencing frequent heartburn about a. a barium swallow. b. radionuclide tests. c. endoscopy procedures. d. proton pump inhibitors.

ANS: D Because diagnostic testing for heartburn that is probably caused by gastroesophageal reflux disease (GERD) is expensive and uncomfortable, proton pump inhibitors are frequently used for a short period as the first step in the diagnosis of GERD. The other tests may be used but are not usually the first step in diagnosis.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbness

ANS: D Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. The nurse will teach the patient to take a. sucralfate at bedtime and antacids before each meal. b. sucralfate and antacids together 30 minutes before meals. c. antacids 30 minutes before each dose of sucralfate is taken. d. antacids after meals and sucralfate 30 minutes before meals.

ANS: D Sucralfate is most effective when the pH is low and should not be given with or soon after antacids. Antacids are most effective when taken after eating. Administration of sucralfate 30 minutes before eating and antacids just after eating will ensure that both drugs can be most effective. The other regimens will decrease the effectiveness of the medications.

A patient receiving head and neck radiation for larynx cancer has ulcerations over the oral mucosa and tongue and thick, ropey saliva. Which instructions should the nurse give to this patient? a. Remove food debris from the teeth and oral mucosa with a stiff toothbrush. b. Use cotton-tipped applicators dipped in hydrogen peroxide to clean the teeth. c. Gargle and rinse the mouth several times a day with an antiseptic mouthwash. d. Rinse the mouth before and after each meal and at bedtime with a saline solution

ANS: D The patient should rinse the mouth with a saline solution frequently. A soft toothbrush is used for oral care. Hydrogen peroxide may damage tissues. Antiseptic mouthwashes may irritate the oral mucosa and are not recommended.

The nurse explaining esomeprazole (Nexium) to a patient with recurring heartburn describes that the medication a. reduces gastroesophageal reflux by increasing the rate of gastric emptying. b. neutralizes stomach acid and provides relief of symptoms in a few minutes. c. coats and protects the lining of the stomach and esophagus from gastric acid. d. treats gastroesophageal reflux disease by decreasing stomach acid production.

ANS: D The proton pump inhibitors decrease the rate of gastric acid secretion. Promotility drugs such as metoclopramide (Reglan) increase the rate of gastric emptying. Cryoprotective medications such as sucralfate (Carafate) protect the stomach. Antacids neutralize stomach acid and work rapidly.

After the nurse completes discharge teaching for a patient who has had a left modified radical mastectomy and lymph node dissection, which statement by the patient indicates that no further teaching is needed? a. "I will avoid reaching over the stove with my left hand." b. "I will need to do breast self-examination on my right breast monthly." c. "I will keep my left arm elevated until I go to bed." d. "I will remember to use my right arm and to rest the left one."

Answer: A Rationale: The patient should avoid any activity that might injure the left arm, such as reaching over a burner. Breast self-examination should be done to the right breast and the left mastectomy site. The left arm should be elevated when the patient is lying down also. The left arm should be used to improve range of motion and function.

A patient with benign prostatic hyperplasia is scheduled for TURP. After you assess the patient's knowledge of the procedure and its effects on reproductive function, you determine a need for further teaching when the patient says, A. "It is possible that I'll be sterile after this procedure." B. "I understand that some retrograde ejaculation may occur." C. "I will have a catheter for several days to keep my urinary system open." D. "It is unlikely that I would become impotent from this procedure."

Answer: A The patient will not be sterile; he may experience retrograde ejaculation and some erectile dysfunction. It is unlikely he will become impotent. He will need a catheter.

A 20-year-old student comes to the student health center after discovering a small painless lump in her right breast. She is worried that she might have cancer because her mother had cervical cancer. The nurse's response to the patient is based on the knowledge that the most likely cause of the breast lump is a. fibrocystic complex. b. fibroadenoma. c. breast abscess. d. adenocarcinoma.

Answer: B Rationale: Fibroadenoma is the most frequent cause of breast lumps in women under 25 years of age. Fibrocystic changes occur most frequently in women ages 35 to 50. Breast abscess is associated with pain and other systemic symptoms. Breast cancer is uncommon in women younger than 25.

A 33-year-old patient tells the nurse that she has fibrocystic breasts but reducing her sodium and caffeine intake and other measures have not made a difference in the fibrocystic condition. An appropriate patient outcome for the patient is a. calls the health care provider if any lumps are painful or tender. b. states the reason for immediate biopsy of new lumps. c. monitors changes in size and tenderness of all lumps in relation to her menstrual cycle. d. has genetic testing for BRCA-1 and BRCA-2 to determine her risk for breast cancer.

Answer: C Rationale: Because fibrocystic breasts may increase in size and tenderness during the premenstrual phase, the patient is taught to monitor for this change and to call if the changes persist after menstruation. Pain and tenderness are typical of fibrocystic breasts, and the patient should not call for these symptoms. New lumps may be need biopsy if they persist after the menstrual period, but the biopsy is not done immediately. The existence of fibrocystic breasts is not associated with the BRCA genes.

A patient returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. An appropriate intervention for the nurse to include in implementing postoperative care for the patient includes a. teaching the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes for the best pain relief. b. insisting that the patient examine the surgical incision when the dressings are removed. c. posting a sign at the bedside warning against blood pressures or venipunctures in the right arm. d. encouraging the patient to obtain a permanent breast prosthesis as soon as she is discharged from the hospital.

Answer: C Rationale: The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right arm. The patient is taught to use the PCA as needed for pain control rather than at a set time. The nurse allows the patient to examine the incision and participate in care when the patient feels ready. Permanent breast prostheses are usually obtained about 6 weeks after surgery.

In assessing a patient for testicular cancer, you understand that the manifestations of this disease often include A. acute back spasms and testicular pain. B. rapid onset of scrotal swelling and fever. C. fertility problems and bilateral scrotal tenderness. D. painless mass and heaviness sensation in the scrotal area.

Answer: D Clinical manifestations of testicular cancer include a painless lump in the scrotum, scrotal swelling, and a feeling of heaviness. The scrotal mass usually is not tender and is very firm. Some patients complain of a dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum.

While the nurse is obtaining a nursing history from a 52-year-old patient who has found a small lump in her breast, which question is most pertinent? a. "Do you currently smoke cigarettes?" b. "Have you ever had any breast injuries?" c. "Is there any family history of fibrocystic breast changes?" d. "At what age did you start having menstrual periods?"

Answer: D Rationale: Early menarche and late menopause are risk factors for breast cancer because of the prolonged exposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibrocystic breast changes are not associated with increased breast cancer risk.

Parents express concern to the nurse about their child's detached retina. The parents ask the nurse if a retinal detachment could be hereditary. Which of the following responses by the nurse is best? a. yes, it is. did any of your other children ever have a detached retina? b. the cause of retinal detachment is not certain, but there are usually a number of contributing factors c. while there may be a hereditary tendency, the immediate cause of your child's retinal detachment was severe trauma d. I think we had better concentrate on how to prevent a detached retina in your child's other eye as there is a strong hereditary tendency.

B

The nurse identifies which of these symptoms are characteristic of acute (closed-angle) glaucoma? a. Eye fatigue, photophobia, loss of peripheral vision b. blurred vision, headache, rainbows around lights c. tunnel vision, malaise, flashing lights d. nausea, orbital edema, blindness

B

When teaching a patient about the pathophysiology related to open-angle glaucoma, which of the following statements is most appropriate? A. "The retinal nerve is damaged by an abnormal increase in the production of aqueous humor." B. "There is decreased draining of aqueous humor in the eye, causing pressure damage to the optic nerve." C. "The lens enlarges with normal aging, pushing the iris forward, which then covers the outflow channels of the eye." D. "There is a decreased flow of aqueous humor into the anterior chamber by the lens of the eye blocking the papillary opening."

B

The results of a patient's recent endoscopy indicate the presence of peptic ulcer disease (PUD). Which teaching point should the nurse provide to the patient based on this new diagnosis? a. "You'll need to drink at least two to three glasses of milk daily." b. "It would likely be beneficial for you to eliminate drinking alcohol." c. "Many people find that a minced or pureed diet eases their symptoms of PUD." d. "Your medications should allow you to maintain your present diet while minimizing symptoms."

B Alcohol increases the amount of stomach acid produced so it should be avoided. Milk may exacerbate PUD, so two to three glasses would not be recommended. There is no reason to puree or mince food, and a current diet is likely to be altered to minimize symptoms.

A patient with hypothyroidism is treated with levothyroxine (Synthroid). What should the nurse include when teaching the patient about this therapy? a. Explain that alternate-day dosage may be used if side effects occur. b. Provide written instruction for all information related to the drug therapy. c. Assure the patient that a return to normal function will occur with replacement therapy. d. Inform the patient that the drug must be taken until the hormone balance is reestablished.

B Because of the mental sluggishness, inattentiveness, and memory loss that occur with hypothyroidism, it is important to provide written instructions and repeat information when teaching the patient. Replacement therapy must be taken for life and alternate-day dosing is not therapeutic. Although most patients return to a normal state with treatment, cardiovascular conditions and psychoses may persist

A 73-year-old male patient admitted for total knee replacement states during the health history interview that he has no problems with urinary elimination except that the "stream is less than it used to be." The nurse should give the patient anticipatory guidance that what condition may be developing? A. A tumor of the prostate B. Benign prostatic hyperplasia C. Bladder atony because of age D. Age-related altered innervation of the bladder

B Benign prostatic hyperplasia is an enlarged prostate gland because of an increased number of epithelial cells and stromal tissue. It occurs in about 50% of men over age 50 and 80% of men over age 80. Only about 16% of men develop prostate cancer. Bladder atony and age-related altered innervations of the bladder do not lead to a weakened stream.

The nurse has identified the nursing diagnosis of fatigue for a patient who is hypothyroid. What should the nurse do while caring for this patient? a. Monitor for changes in orientation, cognition, and behavior. b. Monitor for vital signs and cardiac rhythm response to activity. c. Monitor bowel movement frequency, consistency, shape, volume, and color. d. Assist in developing well-balanced meal plans consistent with level of energy expenditure.

B Cardiorespiratory response to activity is important to monitor in this patient to determine the effect of activities and plan activity increases. Monitoring changes in orientation, cognition, and behavior are interventions for impaired memory. Monitoring bowels is needed to plan care for the patient with constipation. Assisting with meal planning will help the patient with imbalanced nutrition: more than body requirements to lose weight if needed

A nurse performs discharge teaching for a 58-year-old woman after a left hip arthroplasty (posterior approach). Which statement, if made by the patient to the nurse, indicates teaching is successful? a. "I should not try to drive a motor vehicle for 2 to 3 weeks." b. "Leg-raising exercises are necessary for several months." c. "I will not have any restrictions now on hip and leg movements." d. "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

B Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.

The anesthesiologist will use moderate (conscious) sedation during the client's surgical procedure. The circulating nurse will expect the client to: a) Need pain control throughout the procedure b) Respond verbally during the procedure c) Be anxious throughout the procedure d) Need an endotracheal tube

B Explanation: Clients can respond to verbal and physical stimuli and maintain an oral airway and protective reflexes during moderate sedation.

After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements? a) "I won't feel it, but I'll have a tube to help me breathe." b) "I'll be sleepy but able to respond to your questions." c) "I'm so glad that I will be unconscious during the surgery." d) "Only the surgical area will be numb."

B Explanation: With moderate sedation, the patient can maintain a patent airway (ie, doesn't need a tube to help breathing), retain protective airway reflexes, and respond to verbal and physical stimuli. The patient is not unconscious with moderate sedation. Local anesthesia involves anesthetizing or numbing the area of the surgery

A patient has a right ureteral catheter placed following a lithotripsy for a stone in the ureter. In caring for the patient after the procedure, what is an appropriate nursing action? a. Milk or strip the catheter every 2 hours. b. Measure ureteral urinary drainage every 1 to 2 hours. c. Irrigate the catheter with 30-mL sterile saline every 4 hours. d. Encourage ambulation to promote urinary peristaltic action

B Output from ureteral catheters must be monitored every 1 to 2 hours because an obstruction will cause overdistention of the renal pelvis and renal damage. The renal pelvis has a capacity of only 3 to 5 mL and if irrigation is ordered, no more than 5 mL of sterile saline is used. The patient with a ureteral catheter is usually kept on bed rest until specific orders for ambulation are given. Suprapubic tubes may be milked to prevent obstruction of the catheter by sediment and clots.

While completing an admission history for a 73-year-old man with osteoarthritis admitted for knee arthroplasty, the nurse asks about the patient's perception of the reason for admission. The nurse expects the patient to relate which response to this question? a. Recent knee trauma b. Debilitating joint pain c. Repeated knee infections d. Onset of "frozen" knee joint

B The most common reason for knee arthroplasty is debilitating joint pain despite attempts to manage it with exercise and drug therapy. Recent knee trauma, repeated knee infections, and onset of "frozen" knee joint are not primary indicators for a knee arthroplasty.

An older patient who had knee replacement surgery 2 days ago can only tolerate being out of bed with physical therapy twice a day. Which collaborative problem should the nurse identify as a priority for this patient? a. Potential complication: hypovolemic shock b. Potential complication: venous thromboembolism c. Potential complication: fluid and electrolyte imbalance d. Potential complication: impaired surgical wound healing

B The patient is older and relatively immobile, which are two risk factors for development of deep vein thrombosis. The other potential complications are possible postoperative problems, but they are not supported by the data about this patient.

What medication is used with thyrotoxicosis to block the effects of the sympathetic nervous stimulation of the thyroid hormones? a. Potassium iodide b. Atenolol (Tenormin) c. Propylthiouracil (PTU) d. Radioactive iodine (RAI)

B The β-adrenergic blocker atenolol is used to block the sympathetic nervous system stimulation by thyroid hormones. Potassium iodide is used to prepare the patient for thyroidectomy or for treatment of thyrotoxic crisis to inhibit the synthesis of thyroid hormones. Antithyroid medications inhibit the synthesis of thyroid hormones. Radioactive iodine (RAI) therapy destroys thyroid tissue, which limits thyroid hormone secretion.

The nursing instructor is discussing benign versus malignant cells in the pathophysiology class. What distinguishes malignant cells from benign cells of the same tissue type? A) Slow rate of mitosis of cancer cells B) Proteins in the cell membrane C) Size of cells D) Stability of cells

B Feedback: The cell membrane of malignant cells also contains proteins called tumor-specific antigens (eg, carcinoembryonic antigen [CEA] and prostate-specific antigen [PSA]), which develop over time as the cells become less differentiated (mature). These proteins distinguish malignant cells from benign cells of the same tissue type.

A patient is one day postoperative following a transurethral resection of the prostate (TURP). Which event is not an expected normal finding in the care of this patient? A. The patient requires two tablets of Tylenol #3 during the night. B. The patient complains of fatigue and claims to have minimal appetite. C. The patient has continuous bladder irrigation (CBI) infusing, but output has decreased. D. The patient has expressed anxiety about his planned discharge home the following day.

C A decrease or cessation of output in a patient with CBI requires immediate intervention. The nurse should temporarily stop the CBI and attempt to resume output by repositioning the patient or irrigating the catheter. Complaints of pain, fatigue, and low appetite at this early postoperative stage are not unexpected. Discharge planning should be addressed, but this should not precede management of the patient's CBI.

When performing teaching with a patient with glaucoma while administering a scheduled dose of pilocarpine, the nurse would include which of the following statements? A. "Prolonged eye irritation is an expected adverse effect of this medication." B. "This medication needs to be continued for at least 5 years after your initial diagnosis." C. "This medication will help to raise intraocular pressure to a near normal level." D. "It is important not to do activities requiring visual acuity immediately after administration."

D

The patient is receiving an IV vesicant chemotherapy drug. The nurse notices swelling and redness at the site. What should the nurse do first? A. Ask the patient if the site hurts. B. Turn off the chemotherapy infusion. C. Call the ordering health care provider. D. Administer sterile saline to the reddened area.

B. Turn off the chemotherapy infusion. Because extravasation of vesicants may cause severe local tissue breakdown and necrosis, with any sign of extravasation the infusion should first be stopped. Then the protocol for the drug-specific extravasation procedures should be followed to minimize further tissue damage. The site of extravasation usually hurts, but it may not. It is more important to stop the infusion immediately. The health care provider may be notified by another nurse while the patient's nurse starts the drug-specific extravasation procedures, which may or may not include sterile saline.

gastrectomy surgery what patient teaching is relevant to the dumping syndrome?

BILLROTH I: 50-75% of stomach removed BILLROTH II: 50% of stomach removed *DUMPING SYNDROME (1/2 -1/3 patients experience) -normally gastric chyme enters duodenum in small amounts with minimal shift of fluid from extracellular space. -after surgery, a large bolus of hypertonic gastric chyme enters small intestine. This pulls in fluid. -results in weakness, sweating, palpitations, & dizziness lasting an hour after meal; cramps; hyper-peristalsis—urge to defecate

The nurse expects a patient with a cataract to complain about which symptom? a. eye pain when doing close work b. double vision c. blurred vision d. halos around lights

C

When administering eye drops to a patient with glaucoma, which of the following nursing measures is most appropriate to minimize systemic effects of the medication? A. Apply pressure to each eyeball for a few seconds after administration. B. Have the patient close the eyes and move them back and forth several times. C. Have the patient put pressure on the inner canthus of the eye after administration. D. Have the patient try to blink out excess medication immediately after administration.

C

When planning care for a patient with disturbed sensory perception related to increased intraocular pressure caused by primary open-angle glaucoma, which of the following elements should you focus on? A. Recognizing that eye damage caused by glaucoma can be reversed in the early stages. B. Giving anticipatory guidance about the eventual loss of central vision that will occur. C. Encouraging compliance with drug therapy for the glaucoma to prevent loss of vision. D. Managing the pain experienced by patients with glaucoma that persists until the optic nerve atrophies.

C

The nurse is providing care for a patient who has been living with HIV for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? A. A new onset of polycythemia B. Presence of mononucleosis-like symptoms C. A sharp decrease in the patient's CD4+ count D. A sudden increase in the patient's WBC count

C A decrease in CD4+ count signals an exacerbation of the severity of HIV. Polycythemia is not characteristic of the course of HIV. A patient's WBC count is very unlikely to suddenly increase, with decreases being typical. Mononucleosis-like symptoms such as malaise, headache, and fatigue are typical of early HIV infection and seroconversion.

A patient is admitted to the hospital with thyrotoxicosis. On physical assessment of the patient, what should the nurse expect to find? a. Hoarseness and laryngeal stridor b. Bulging eyeballs and dysrhythmias c. Elevated temperature and signs of heart failure d. Lethargy progressing suddenly to impairment of consciousness

C A hyperthyroid crisis results in marked manifestations of hyperthyroidism, with severe tachycardia, heart failure, shock, hyperthermia, restlessness, irritability, abdominal pain, vomiting, diarrhea, delirium, and coma. Although exophthalmos may be present in the patient with Graves' disease, it is not a significant factor in hyperthyroid crisis. Hoarseness and laryngeal stridor are characteristic of the tetany of hypoparathyroidism and lethargy progressing to coma is characteristic of myxedema coma, a complication of hypothyroidism.

The patient is told that the adenoma tumor is not encapsulated but has normally differentiated cells and that surgery will be needed. The patient asks the nurse what this means. What should the nurse tell the patient? A. It will recur. B. It has metastasized. C. It is probably benign. D. It is probably malignant.

C Benign tumors usually are encapsulated and have normally differentiated cells. They do not metastasize and rarely recur as malignant tumors do.

A postoperative patient has a nursing diagnosis of ineffective airway clearance. The nurse determines that interventions for this nursing diagnosis have been successful if which is observed? a. Patient drinks 2 to 3 L of fluid in 24 hours. b. Patient uses the spirometer 10 times every hour. c. Patient's breath sounds are clear to auscultation. d. Patient's temperature is less than 100.4° F orally.

C One characteristic of ineffective airway clearance is the presence of adventitious breath sounds such as rhonchi or crackles, so clear breath sounds are an indication of resolution of the problem. Spirometer use and increased fluid intake are interventions for ineffective airway clearance but may not improve breath sounds in all patients. Elevated temperature may occur with atelectasis, but a normal or near-normal temperature does not always indicate resolution of respiratory problems

Which characteristics describe Pneumocystis jiroveci infection, an opportunistic disease that can be associated with HIV? a. May cause fungal meningitis b. Diagnosed by lymph node biopsy c. Pneumonia with dry, nonproductive cough d. Viral retinitis, stomatitis, esophagitis, gastritis, or colitis

C Pneumocystis jiroveci infection is characterized by pneumonia with a dry, nonproductive cough. Cryptococcus infection may cause fungal meningitis. Non-Hodgkin's lymphoma is diagnosed by lymph node biopsy. Cytomegalovirus infection is characterized by viral retinitis, stomatitis, esophagitis, gastritis, or colitis.

A patient who is scheduled for a right breast biopsy asks the nurse the difference between a benign tumor and a malignant tumor. Which answer by the nurse is correct? a. "Benign tumors do not cause damage to other tissues." b. "Benign tumors are likely to recur in the same location." c. "Malignant tumors may spread to other tissues or organs." d. "Malignant cells reproduce more rapidly than normal cells."

C The major difference between benign and malignant tumors is that malignant tumors invade adjacent tissues and spread to distant tissues and benign tumors never metastasize. The other statements are inaccurate. Both types of tumors may cause damage to adjacent tissues. Malignant cells do not reproduce more rapidly than normal cells. Benign tumors do not usually recur.

When performing preoperative care for a patient diagnosed with a detached retina, the nurse should take which action? a. apply ice packs to the affected eye b. irrigate the eye with warm normal saline c. maintain the pt on bed rest d. instruct the pt to lay on the unaffected side

C bed rest minimizes movement of the eyes and head to facilitate settling of the detached retina

A 33-year-old patient has recently been diagnosed with stage II cervical cancer. What should the nurse understand about the patient's cancer? A. It is in situ. B. It has metastasized. C. It has spread locally. D. It has spread extensively.

C. It has spread locally. Stage II cancer is associated with limited local spread. Stage 0 denotes cancer in situ; stage I denotes tumor limited to the tissue of origin with localized tumor growth. Stage III denotes extensive local and regional spread. Stage IV denotes metastasis.

What is a cause of primary hypothyroidism in adults? a. Malignant or benign thyroid nodules b. Surgical removal or failure of the pituitary gland c. Surgical removal or radiation of the thyroid gland d. Autoimmune-induced atrophy of the thyroid gland

D Both Graves' disease and Hashimoto's thyroiditis are autoimmune disorders that eventually destroy the thyroid gland, leading to primary hypothyroidism. Thyroid tumors most often result in hyperthyroidism. Secondary hypothyroidism occurs as a result of pituitary failure and iatrogenic hypothyroidism results from thyroidectomy or radiation of the thyroid gland.

A 51-year-old woman has recently had a unilateral, right total mastectomy and axillary node dissection for the treatment of breast cancer. Which of the following interventions should the nurse include in the patient's care? A. Immobilize the patient's right arm until postoperative day 3. B. Maintain the patient's right arm in a dependent position when at rest. C. Administer diuretics prophylactically for the prevention of lymphedema. D. Promote gradually increasing mobility as soon as possible following surgery.

D Mobility should be encouraged beginning in postanesthetic recovery and increased gradually throughout the patient's recovery. Immobilization is counterproductive to recovery and the limb should never be in a dependent position. Diuretics are not used to prevent lymphedema but may be used in active treatment of the problem.

A patient with a stable, closed fracture of the humerus caused by trauma to the arm has a temporary splint with bulky padding applied with an elastic bandage. The nurse suspects compartment syndrome and notifies the physician when the patient experiences a. increasing edema of the limb. b. muscle spasms of the lower arm. c. rebounding pulse at the fracture site. d. pain when passively extending the fingers.

Correct answer: d Rationale: One or more of the following are characteristic of compartment syndrome: (1) paresthesia (i.e., numbness and tingling sensation); (2) pain distal to the injury that is not relieved by opioid analgesics and, on passive stretch of muscle, pain that travels through the compartment; (3) increased pressure in the compartment; (4) pallor, coolness, and loss of normal color of the extremity; (5) paralysis or loss of function; and (6) pulselessness, or diminished or absent peripheral pulses. The examination also includes assessment of peripheral edema, especially pitting edema, which may occur with severe injury.

The patient is in the preoperative holding area, having been brought to surgery from the Emergency Department because of a detached retina. The tear has occurred in the right posterior aspect of the retina. The nurse places the patient in which of the following positions? a. At a 45-degree angle (semi-Fowler's position) b. At a 90-degree angle (high Fowler's position) c. Prone d. Supine

D

The patient will be placed under moderate sedation to allow realignment of a fracture in the emergency department. When the family asks about this anesthesia, what should the nurse tell them? a. includes inhalation agents b. induces high level of sedation c. frequently used for traumatic injuries d. patients remain responsive and breathe without assistance

D

The nurse explains to the patient with gastroesophageal reflux disease (GERD) that this disorder a. results in acid erosion of the esophagus from frequent vomiting. b. will require surgical wrapping or repair of the pyloric sphincter to control the symptoms. c. is the protrusion of a portion of the stomach into the esophagus through an opening in the diaphragm. d. often involves relaxation of the lower esophageal sphincter, allowing stomach contents to back up into the esophagus.

Correct answer: d Rationale: Gastroesophageal reflux disease (GERD) results when the defenses of the esophagus are overwhelmed by the reflux of acidic gastric contents into the lower esophagus. An incompetent lower esophageal sphincter (LES) is a common cause of gastric reflux.

The nurse is caring for a 75-year-old woman who underwent left total knee arthroplasty and has a new order to be "up in chair today before noon." What action should the nurse take to protect the knee joint while carrying out the order? a. Administer a dose of prescribed analgesic before completing the order. b. Ask the physical therapist for a walker to limit weight bearing while getting out of bed. c. Keep the continuous passive motion machine in place while lifting the patient from bed to chair. d. Put on a knee immobilizer before moving the patient out of bed and keep the surgical leg elevated while sitting.

D The nurse should apply a knee immobilizer for stability before assisting the patient to get out of bed. This is a standard measure to protect the knee during movement following surgery. Although an analgesic should be given before the patient gets up in the chair for the first time, it will not protect the knee joint. Full weight bearing is begun before discharge, so a walker will not be used if the patient did not need one before the surgery. The CPM machine is not kept in place while the patient is getting up to the chair.

The nurse is completing a neurovascular assessment on the patient with a tibial fracture and a cast. The feet are pulseless, pale, and cool. The patient says they are numb. What should the nurse suspect is occurring? a. Paresthesia b. Pitting edema c. Poor venous return d. Compartment syndrome

D The nurse should suspect compartment syndrome with one or more of the following six Ps: paresthesia, pallor, pulselessness, pain distal to the injury and unrelieved with opioids, pressure increases in the compartment, and paralysis. Although paresthesia and poor venous return are evident, these are just some of the manifestations of compartment syndrome.

The nurse is completing discharge teaching with an 80-year-old male patient who underwent right total hip arthroplasty. The nurse identifies a need for further instruction if the patient states the need to a. avoid crossing his legs. b. use a toilet elevator on toilet seat. c. notify future caregivers about the prosthesis. d. maintain hip in adduction and internal rotation.

D The patient should not force hip into adduction or force hip into internal rotation as these movements could displace the hip replacement. Avoiding crossing the legs, using a toilet elevator on a toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching

The patient is brought to the emergency department after a car accident and has a femur fracture. What nursing intervention should the nurse implement to prevent a fat embolus in this patient? a. Administer enoxaparin (Lovenox). b. Provide range-of-motion exercises. c. Apply sequential compression boots. d. Immobilize the fracture preoperatively

D To prevent fat emboli, the nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus from the bone before surgical reduction. Enoxaparin is used to prevent blood clots not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient

When providing discharge instructions to a patient who had a subtotal thyroidectomy for hyperthyroidism, what should the nurse teach the patient? a. Never miss a daily dose of thyroid replacement therapy. b. Avoid regular exercise until thyroid function is normalized. c. Use warm saltwater gargles several times a day to relieve throat pain. d. Substantially reduce caloric intake compared to what was eaten before surgery.

D With the decrease in thyroid hormone postoperatively, calories need to be reduced substantially to prevent weight gain. When a patient has had a subtotal thyroidectomy, thyroid replacement therapy is not given because exogenous hormone inhibits pituitary production of TSH and delays or prevents the restoration of thyroid tissue regeneration. Regular exercise stimulates the thyroid gland and is encouraged. Saltwater gargles are used for dryness and irritation of the mouth and throat following radioactive iodine therapy.

A patient identified as HIV antibody-positive 1 year ago manifests acute HIV infection but does not want to start antiretroviral therapy at this time. What is an appropriate nursing intervention for the patient at this stage of illness? a. Assist with end-of-life issues b. Provide care during acute exacerbations c. Provide physical care for chronic diseases d. Teach the patient about immune enhancement

D After a patient has positive HIV antibody testing and is in acute disease, the overriding goal is to keep the viral load as low as possible and to maintain a functioning immune system. The nurse should provide teaching regarding ways to enhance immune function to prevent the onset of opportunistic diseases in addition to teaching about the spectrum of the infection, options for care, signs and symptoms to watch for, ways to prevent HIV spread, and ways to adhere to treatment regimens.

hypoglycemia

Glucose= <50mg/dL Cool and Clammy give them candy -follow ADA 15/15 rule; eat or drink 15g CHO (1/2c OJ, 1/2 regular soft drink, 1c milk, etc) then retest in 15 mins -patients taking acarbose or miglitol pure glucose (dextrose) in tab or gel to raise glucose fast enough, these drugs slow the digestion of other CHO -dont give food/drink if LOC down..can give sublingual icing, sugar, paste Can cause brain damage if don't have enough glucose; cells cant get what they need so they become damaged leads to cell inflammation or death over time; an urgent thing and does not self correct, stays and worsens so body parts die; can lead to death within minutes (3-5 minutes) so nurses need to be fast acting and know what it looks like; THIS IS URGENT profuse perspiration anxiety nervous tremors irritable mental confusion seizures coma weakness double or blurred vision hunger tachycardia palpitations Ketones negative

white blood cell differentiation

INCREASED LEVELS... -Neutrophils = acute inflammation -Bands = shift to the left; prolonged acute inflammation -Monocytes = chronic inflammation -Eosinophils = destroy parasites, control effects of histamine & leukotrienes; respond to allergic reactions

What are priority nursing measures when administering vesicant chemotherapeutic agents?

IV ROUTE: may cause severe tissue breakdown or necrosis NURSING ACTION: stop infusion immediately *S/S EXTRAVASATION:* -pain -swelling -redness -presence of vesicles in the skin *COMPLICATIONS:* -tissue may ulcerate and necroses -may cause full thickness skin loss -may need surgical intervention (skin grafting) -sepsis, scarring, contractures, joint pain, nerve loss may occur

meds for diabetes

MEDS: TYPE 1 DM INSULIN: -action: activates transport mechanism for carrying glucose and other products of digestion into cells -used for type 1 and 2 -do not heat/freeze -in use vials left at room temp for 4 weeks (lantus only 28 days) -extra insulin should be refrigerated -avoid exposure to direct sunlight regimen that mimics endogenous insulin production is basal-bolus: 1. long-acting (basal) once a day 2. rapid/short acting (bolus) before meals RAPID ACTING -lispro (humalog) -aspart (novolog) -glulisine (apidra) onset: 10-30 min peak: 30min-3hr duration: 3-5 hr SHORT ACTING -regular (humalin R, novolin R) onset:30min-1hr peak: 2-5hr duration: 5-8hr INTERMEDIAT ACTING -NPH (humalin N, novolin N) onset: 1.5-4hr peak: 4-12hr duration: 12-18hr LONG ACTING -glargine (lantus) -detemir (levemir) onset: 0.8-4hr peak: n/a duration 24+hr MEDS: TYPE 2 DM ORAL AGENTS: 1. DPP-4 inhibitors (januvia): suppress glucagon secretion in response to meals 2. sulfonylureas: stimulate release of insulin, decrease gluconeogenesis, increase receptor sensitivity) 3. meglitinides: stimulates rapid, short insulin release 4. Biguanides: decrease glucose production, increase tissues glucose uptake, increases insulin sensitivity 5. Thiazolidinediones: increases muscles glucose uptake and decreases glucose production 6. gamma- glucosidase inhibitors: decrease CHO absorption Other agents: 1. incretin mimetic: synthetic peptide that stimulated release of insulin from Beta cells; do not use with insulin 2. amylin analog: slows gastric emptying, recudes post meal glucagon secretion, increases satiety

nursing care priorities during the different phases of HIV/AIDS

Medication regimens are very complex, expensive, interactive with many other medications, and have many side effects. -Assess for understanding of schedule. -Offer ideas for reminders to take meds. -Assess compliance. -Encourage adherence—resistance to HIV occurs quickly [within few days to weeks] with non-compliance. - Meds will never be effective for this patient again in the future. -Monitoring HIV disease progression and immune function -Initiating and monitoring antiretroviral therapy (ART) -Preventing and detecting opportunistic infections -Preventing and treating complications of therapies -Ongoing health assessment -Teaching/ Education about spectrum of HIV, treatment, preventing transmission, improving health, and family planning -Repeating and clarifying information is necessary due to shock and denial AMBULATORY & HOME CARE: -often experience anxiety, fear, diarrhea, depression peripheral neuropathy, pain, nausea, vomiting, and fatigue -symptom management similar to other chronic illness -metabolic disorders have emerged (fat distribution, sunken face) -detect early and deal with symptoms Hyperlipidemia, insulin resistance, and bone disease common -as HIV/AIDS becomes chronic there are increases in long term complications: CVD, chronic renal disease and cancers (anal and lung cancers) -nursing interventions focus on safety, self-care, and to help caregivers support those activities -prevent confusion by maintaining meaningful environment, frequent re-orientation, and stress reduction measures -emphasis is placed on providing support to family members and significant others who may have difficulty dealing with deterioration of mental and physical status TERMINAL CARE: -dementia often present in final stages of HIV "AIDS-dementia complex" and cognitive motor complex -results from HIV infection in the brain, CNS lymphoma, toxoplasmosis, CMV, herpes virus, Cryptococcus, progressive multi-focal leukoencephalopathy, dehydration, or drug side effects -reversible if a cause is diagnosed For ALL persons, ask: Received blood transfusion or blood clotting factors before 1985? Shared needles, syringes, or other injection equipment with another person? Have you had a sexual experience with your penis, vagina, rectum, or mouth in contact with these areas of another person? Have you ever had a sexually transmitted disease (STD)? DEPENDENT UPON THE STAGE OF THE DISEASE: -prevention -treatment -terminal phase SOCIAL FACTORS: -self-esteem -sexuality -family interactions -finances

HHNK (hyperosmolar hyperglycemia syndrome)

PATHOPHYSIOLOGY -Extreme hyperglycemia -Severe osmotic diuresis -Fluid volume deficit -Decreased Na+, K+, phosphorus -Electrolyte imbalance -Profound dehydration -Hyperosmolality -Hypovolemia -Decreased renal perfusion-> Oliguria, Anuria -Hypotension-->Tissue anoxia, Increased lactic acid -Hemoconcentration-> Hyperviscosity, Thrombosis -All leads to seizures, shock, coma, death -Occurs in patients with diabetes who are able to produce enough insulin to prevent DKA but not enough to prevent severe hyperglycemia, osmotic diuresis and extracellular fluid depletion -Less common than DKA, often in patients over 60 with Type 2 DM COMMON CAUSES -Infection: UTI, pneumonia -Sepsis -Any acute illness -Newly diagnosed type 2 DM -Often related to impaired thirst sensation and/or functional inability to replace fluids *MANIFESTATIONS* -Presents fewer earlier symptoms due to some pancreas function -Then boom→ very severe hyperglycemia -More severe neuro symptoms (somnolence, coma, seizures, hemiparesis: weakness in one side of body, aphasia: trouble speaking and understanding written and verbal language) -*Symptoms resemble a stroke (cerebrovascular accident) so immediate determination of glucose level is critical for correct diagnosis and treatment -The hyperosmolality calls for major fluid replacement -BG may be 600 mg/dL LAB VALUES -Blood glucose > 600 -Marked increase in serum osmolarity -Ketone bodies are absent or minimal in both blood and urine *TREATMENT* similar to DKA -immediate IV fluids of NS or ½ NS -then regular insulin by infusion after fluid replacement -then switch to D5W when glucose levels around 250 mg to avoid hypoglycemia

Know the tumor/cancer staging system meanings, i.e. TNM communicates what information?

T/Tumor: T0: no evidence of tumor Tis: carcinoma in situ T1-4: ascending degrees of tumor size and involvement Tx: tumor cannot be measured or found N/Node involvement: N0: no evidence of disease in lymph nodes N1-4 ascending degrees of nodal involvement Nx: regional lymph nodes unable to be assessed clinically M/Metastasis to distant nodes, organs, etc. M0: no metastases M1-4: ascending degrees of metastatic involvement of the host, including distant nodes Mx: cannot be determined

Contrast the acute complications of Types 1 and 2 diabetes mellitus including pathophysiology, clinical manifestations (including arterial blood gas values), and treatment. Hint: What is priority care for the patient experiencing DKA? Hint: What are patient clinical manifestations of HHS?

acute: -DKA -HHNK -hypoglycemia DKA: -Kussmaul respirations -Ketones in urine -glucose levels <400 HHNK: -presents with fewer earlier symptoms due to some pancreatic function, then boom! very severe hyperglycemia -more severe neuro symptoms (somnolence, coma, seizures) -calls for major fluid replacement! Treatments are similar: 1. Fluids (NS or 1/2 NS) 2. insulin 3. Switch to D5W to avoid hypoglycemia when glucose around 250

The nurse determines that the patient may be suffering from an acute bacterial infection based upon which laboratory test result? a) Increased platelet count b) Increased blood urea nitrogen c) Increased number of band neutrophils d) Increased number of segmented myelocytes

c) Increased number of band neutrophils The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is commonly found in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. The mature neutrophils are segmented.

Causes of chronic complications of diabetes mellitus and the resulting clinical manifestations

angiopathy: 1. Macrovascular (CVA, PVD, CAD) 2. Microvascular (capillary basement membrane thickens Leads to: -neuropathy -gastroparesis -gangrene -erectile dysfunction -neurogenic bladder -nephropathy Other chronic non antipathy related: -depression -sleep apnea -celiacs disease -hypothyroidism -hyperthyroidism (type 1) -with addisons disease you get worse cognitive skills in teams bc high glucose levels clog membrane and smaller hippocampus Causes of diabetes related angiopathy insulin is in your cells--> with diabetes, the cells are the problem and the patient--> the cells are wondering where the insulin is and the glucose (energy source) is so the cells and blood vessels change--> capillary basement membrane thickens and weakens causing poorly nourished cells and nerves--> Phagocytosis can't occur, oxygen and nutrients don't leave to get to sites that are in need--> angiopathy clinical manifestations of diabetes related angiopathy 1. angiopathy: negative changes in the blood) (causes all other chronic complications) 2. neuropathy: something is going wrong with the nerves because something is wrong with the blood vessels 3. gastroparesis: slowing down of the stomach, results from neuopathy so the food just sits there and you have poor digestion so glucose can't get to the blood stream even if insulin is present (has nothing to work on); causes hypoglycemia 4. Gangrene: must remove all dead tissue immediately bc can cause systemic infection 5. erectile dysfunction: can't keep it up long enough 6. Neurogenic bladder: nerve problems, the bladder gets lazy and messages don't get to the bladder to tell you that its full; leads to UTI 7. Nephropathy: kidney infection from neurogenic bladder UTI

A patient with osteoarthritis is scheduled for a total hip arthroplasty. The nurse explains that the purpose of this procedure is to (select all that apply) a. fuse the joint. b. replace the joint. c. prevent further damage. d. improve or maintain ROM. e. decrease the amount of destruction in the joint.

b, d Rationale: Arthroplasty is the reconstruction or replacement of a joint. This surgical procedure is performed to relieve pain, improve or maintain range of motion, and correct deformity. Total hip arthroplasty (THA) provides significant relief of pain and improvement of function for a patient with osteoarthritis (OA).

When teaching how lisinopril (Zestril) will help lower the patient's blood pressure, which mechanism of action should the nurse use to explain it? a) Blocks β-adrenergic effects. b) Relaxes arterial and venous smooth muscle. c) Inhibits conversion of angiotensin I to angiotensin II. d) Reduces sympathetic outflow from central nervous system.

c) Inhibits conversion of angiotensin I to angiotensin II. Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. Beta blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central acting α-adrenergic antagonists reduce sympathetic outflow from the CNS to produce vasodilation and decreased SVR and BP.

patient teaching for managing diabetes

holistic approach to maintain diabetes and prevent progression: -exercise -insulin/antidiabetic meds -diet (low fat with BP control) -rest/ skin care-without can lead to infections, FOOT CARE *RISK FACTORS:* -obesity -sendentary lifestyle -smoking -HTN -high fat intake -family history (ask 3 generations) -ethnicity: blacks, mexicans and native indians have highest frequency -increasing age -secondary diabetes causes: cushings (high cortisol), hyperthyroidism, pancreatitis, cystic fibrosis, parenteral nutrition, hematochromatosis *WHEN SICK:* -continue drug therapy and eating -min 4oz/hr fluids -assess BG q1-2h (contact HCP with BG>250, fever, ketonuria, N/V) -If on insulin, more may be needed -go to ER/Call HCP with hyper/hypoglycemia -being sick is a stressor and may raise BG and cause fluid loss -tight glucose control may delay atheroscleotic process -avoid alcohol; can cause severe hypoglycemia -preventative care practices for eyes, kidneys, feet, teeth, and gums can be accomplished with regular checkups and lab work -routine screening for overweight adults over age 45 (check child too) -some risk factors can be addressed in childhood (e.g. check for dark ring around neck-acanthosis nigricans-dark, coarse, thickened skin-correlates with vascular changed associated with diabetes)-preventable

NORMAL urinalysis findings

patient should be voiding 30mL/h 6-8 hours post op *protein in the urine is NEVER considered normal*; it can be caused from pregnancy, physical exertion, increased protein consumption, meds Color: amber yellow Odor: aromatic Protein: random protein (dipstick) <150/day for 24 hour protein Glucose: none Ketones: none Bilirubin: none pH: 4-8 (avgerage=6) Organism culture: none; <10,000 result of normal flora

vital signs indicating *HEMORRHAGE*

• ↓ blood pressure; ↑ heart rate • cyanosis • ↓ level of consciousness