Health and Illness Final
What position should the nurse use for the client with venous insufficiency to enhance blood supply?
lower extremities elevated
What is a late sign of respiratory distress in infants?
Cyanosis
The client has been managing angina episodes with nitroglycerin. Which finding indicates that the therapeutic effect of the drug has been achieved.
Decreased chest pain
RR of newborns, infants, adults
-30-60 -20-40 -12-20
The nurse recognizes that which client is most likely experiencing generalized anxiety disorder (GAD)
40 year old who has reported numerous absences from work, muscle aches, and difficulty falling asleep for the last 8 months
Stage II HTN
>140/>90
Crisis BP
>190/>120
Hamilton Anxiety Scale
Assessing anxiety symptoms in people who are ALREADY diagnosed with anxiety disorders. NOT for detecting or diagnosing. USEFUL IN HELPING MEASURE PATIENT IMPROVEMENT OVER TIME. Self-report - 0-17 MILD - 18-25 MILD TO MODERATE - 26-30 MODERATE TO SEVERE
A patient is admitted with fatigue, shortness of breath, pale skin, and dried cracked lips, tongue, and mouth. The hemoglobin is 9 g/dL and red blood cell count is 3.5 million cells/mm. Which of the following foods should the nurse teach the patient to include in the diet.
Beef, beets, cabbage for anemia
Yellow zone of asthma action plan
CAUTION -> first signs of cold, exposure to known trigger, cough, tight chest, mild wheeze, coughing at nigh, can do some (but not all) usual activities, continue with green zone meds and add quick-relief meds
Green zone of asthma action plan
GO -> breathing is good, no coughing/wheezing, sleeping through night, can do usual activities, use preventative medicine
Describe the dietary changes/feeding considerations that might be necessary when the patient is experiencing oxygenation problems.
Rest before eating, use bronchodilator 30 minutes before meal, oral care prior to eating, high protein, increased carb/fat diet, avoid dairy and chocolate, avoid dry food
The nurse is caring for an infant with RSV and monitoring for signs and symptoms of respiratory distress. Which one of the following is an early sign of respiratory distress?
Restlessness
Perfusion is best defined as..
The movement of oxygen and nutrients into and metabolic wastes out of cell
The nurse is interviewing a patient who is being treated for OCD. The patients compulsions involve cleanliness rituals, which the patient justifies by describing potential contaminants in great detail. The nurse interprets the patient's statement as implying that:
The patient may lack insight into the diagnosis
Schilling test
a diagnostic analysis for pernicious anemia, used to determine whether the body absorbs vitamin B12
flat affect
a lack of emotional responsiveness
Bipolar characteristics
bizarre, flamboyant eccentric, pressured speech, poor judgement, physical exhaustion with insomnia, elation, heightened sense and pleasure, lack of shame and guilt, manipulative, intrusive, distracted, grandiose, suspicious
How do Nitrates help central perfusion?
cause peripheral arterial and venous vasodilation
What is stable angina?
chest pain after exertion that lasts 5-15 minutes and relieved by rest/nitroglycerin, predictable and consistent
unknown etiological fatigue
chronic fatigue lasting 6+ months
Morphological shape of RBC: pernicious anemia
megaloblastic
Morphological shape of RBC: iron deficiency anemia
microcytic hypochromic
What is a subjective, emotional sustained state that influences one's whole personality and perception of the world?
mood
peripheral perfusion
movement of blood through vessels, must have open vessels and enough blood
What is oxygenation?
movement of oxygen from outside into alveoli into tissue (and carbon dioxide in the reverse manner)
What is perfusion?
movement of oxygen/nutrients into a cell and waste out of a cell
Dietary considerations for patients with pernicious anemia
oranges, carrots, cantaloupe, legumes, peanuts, peanut butter, whole grain cereal
Equation for # of pack years
packs smoked per day X years as a smoker
Defense mechanisms used by patients with: OCD
rationalization, avoidance, repression
Denial: Defense Mechanism
refusing to believe or even perceive painful realities
How is chronic fatigue syndrome recognized?
severe chronic fatigue for 6 or more consecutive months, interferes with daily activities and work, and 4/8 of (post-exertion malaise, unrefreshing sleep, significant impairment of short-term memory or concentration, muscle pain, multi-joint pain, headaches, tender lymph nodes, sore throat)
What is malignant HTN?
severely elevated BP that commonly damages small vessels
When evaluating the red cell indices of a patient, the nurse knows that a low mean corpuscular volume (MCV) indicates:
small size of RBC
What lab should be drawn with Lithium?
sodium
What is unstable angina?
sudden chest pain not relieved by rest/nitroglycerin, different than stable angina in frequency, duration, intensity
What is ECT?
the use of electrical shock current delivered to the brain to induce a seizure that treats depression
modeling
therapist or s/o acts as role model to demonstrate appropriate behavior in feared situation and patient imitates it
Displacement: Defense Mechanism
transferring emotions associated with a particular person or event to another person, object, or situation that is less threatening
A client scheduled for a treadmill stress test. Prior to the stress test, the nurse reviews the results of the laboratory reports. The nurse should report which elevated laboratory values to the health care provider prior to the stress test.
troponin -> indicates myocardial infarction
When would the patient utilize medications such as Serevent (salmeterol)?
prevention of asthma attacks and exercise induced bronchospasms
An adolescent boy who is academically gifted is about to graduate from high school early since he has completed all courses needed to earn a diploma. Within the last 3 months he has begun to experience panic attacks that have forced him to leave class early and occasionally miss a day of school. He is concerned that these attacks may hinder his ability to pursue a college degree. What would be the best response by the school nurse who has been helping him deal with his panic attacks?
"It sounds like you have a real concern about transitioning to college. I can refer you to a health care provider for assessment and treatment."
What is the DSM-5 diagnosis for depression?
-One or more episodes of depressed mood or loss of interest/pleasure in nearly all activities for atleast 2 weeks. AND 4/7 of: - disruption in sleep, appetite, concentration, decreased energy, psychomotor agitation, excessive guilt, SI
Elevated BP
120-129/<80
Stage I HTN
130-139/80-89
During a physical assessment of a patient, the nurse suspects chronic, severe iron-deficiency anemia on finding:
Shiny, smooth, beefy tongue due to loss of papillae
When assessing your patient, you find out that he smokes 2.5 packages of cigarettes every day and has been smoking for 15 years. How many pack years is this?
37.5 pack years
A client comes to the emergency department reporting severe substernal chest pain radiating down the left arm. The client is admitted to the coronary care unit with a diagnosis of myocardial infarction (MI). WHich should the nurse do first when the client is admitted to the coronary care unit.
Begin telemetry monitoring
When would Benzo's be prescribed? Tricyclics?
Benzos: prescribed for anxiety disorders on as needed basis for performance anxiety Tricyclics: prescribed for panic attacks, panic disorders, GAD
The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumpolar cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation?
ABG
An appropriate nursing intervention for a patient with failure related to cancer treatment includes teaching the patient to:
Conserve energy by prioritizing activities to adapt to fatigue
A client with a specific phobia of spiders is seeing a therapist for the first session of treatment. The therapist hands the client a clear container with a large house spider inside. The activity is repeated continuously until the client's fear subsides. Which strategy is being used to treat the clients specific phobia
Flooding -> rapid desensitization
Warning Signs of Suicide
IS PATH WARM
A client is admitted to a healthcare facility for treatment of chronic obstructive pulmonary disease (COPD). Which nursing diagnosis is most important for this client
Impaired Gas Exchange r/t airflow obstruction
The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect.
Inspiratory and expiratory wheezing
The nurse assesses the family's ability to cope with the child's cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease.
Limiting interaction with extended family and friends.
What is low mean corpuscular hemoglobin?
Low levels of Hgb in RBC and hypocrhomic RBC
A female client who is 32 years of age has been diagnosis disorder with stage 1 hypertension. The client's height is 5 feet 5 inches, and her weight is recorded at 125 lbs; she reports that she frequently eating at "fast food" restaurants and enjoys a glass of wine to relax on weekends. In developing a teaching plan for this client, the nurse should address which topic?
Low-sodium choices
Nursing implications of bronchoscopy
NPO 6 hours prior to test, informed consent, test gag reflex before patient has anything to eat
left heart failure
PULMONARY CONGESTION, angina, confusion, hacking cough, crackles in lungs, frothy/pink-tinged sputum
An attorney who throws books and furniture around the office after losing a case is referred to the psychiatric nurse in the law firm's employee assistance program. The nurse knows that the client's behavior most likely represents the use of which defense mechanism?
Regressive behavior -> behavior that is appropriate at a younger age
relaxation training
Relaxation exercises for breathing or muscle groups are taught. The relaxation response is the opposite of the stress response and results in a reduced heart rate and breathing and relaxed muscles.
What is a shift to the right?
Return to normal, less bands and increased segs
Acute Coronary Syndrome
SOA, sweating, n/v, palpitations, pain in neck, left chest/left arm pain
A 45 year old single mother of three teenage boys has metastatic breast cancer. Her parents live 750 miles away and have only been able to visit twice since her initial diagnosis 14 months ago. The progression of her disease has forced the patient to consider high-dose chemotherapy. She is concerned about her children's welfare during the treatment. When assessing the patient's present and future needs, the nurse will be most concerned about which potential problem?
Support systems and coping strategies
When doing a physical assessment of a patient, the nurse should expect which of these findings related to mononucleosis (mono)
Swollen lymph nodes
A nurse or providing discharge instructions to a patient with peripheral vascular disease that include stress-reduction techniques. The patient asks the nurse, "Why is reducing stress so important?" What is the nurse's best response?
The stress-induced release of vasoactive catecholamines, such as epinephrine
You are working in a cardiac telemetry unit and are providing patient education regarding the importance of taking all prescribed cardiac mediation. The patient appears annoyed with the new medication and states, "Well i am already taking aspirin and metoprolol. I do not understand how furosemide will help my heart." How would you describe the benefit of this medication?
This mediation is a diuretics which will reduce blood volume and workload of the heart
After stabilization of Addison's disease, the nurse teaches the client about stress management. What should the nurse instruct the client to do?
Use relaxation techniques such as music
central perfusion
ability to move the blood to major body organs and determined by cardiac output (stroke volume + HR)
What is the observable verbal/nonverbal expression of one's feelings?
affect
Inadequate number of RBC's is..
anemia
MODERATE level of anxiety
associated with narrowed perceptual field that permits individual to concentrate on the imminent problem, tension, pounding heart, increased pulse, increased pulse/RR, perspiration, mild somatic symptoms (GI discomfort, headache, urinary frequency)
MILD level of anxiety
associated with stress of daily life, patient is alert and perceptual field/senses heightened, productive in nature, slight discomfort, restlessness, irritable, nail biting, finger tapping, fidgeting
Defense mechanisms used by patients with: phobia
avoidance, isolation, passive aggression, regression
How is HTN diagnosed?
based on the average of 2+ accurate blood pressure measurements during 2+ contacts with a healthcare provider
What is peripheral arterial disease?
disease of blood vessels supplying the arms and legs, painful cramping after activity (hip, thigh, calf muscle), leg numbness/weakness, coldness in lower leg, shiny skin on leg
What lifestyle changes can the nurse teach the patient to improve perfusion in someone with peripheral arterial disease?
dependent structures below level of heart, Trendelenburg, HOB on 6 in. blocks
How can a patient prevent vasoconstriction?
do not cross legs, no vaso occlusive devices, no long car rides
therapuetic communication techniques
encourage patient to share feelings, set small-short term goals, empathetic listening/supportive encouragement, avoid blanket reassurances, reinforce that depression is a treatable illness
Impaired gas exchange
excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
Specific phobia
fear of a single object, activity, situation
Agoraphobia
fear of being alone in open/public spaces
Mysophobia
fear of dirt and germs
What does a FEV1.0 tell us?
forced expiratory volume in 1 second, gold standard
Why does pursed lips help breathing?
helps slow expiration, prevents collapse of small airways and helps patient control the rate and depth of respiration, promotes relaxation and enables the patient to gain control of dyspnea and reduce feelings of panic
What is secondary HTN?
high BP from identified cause -> renal disease
What is essential HTN?
high BP from unidentified cause
physiological fatigue
imbalance of physical/cognitive/emotional activity -> sleep/diet
ineffective airway clearance
inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
What is a shift to the left?
increase in number of bands or "baby" neutrophils in blood smear..indicative of active infection
Signs of ineffective airway clearance
ineffective cough, wheezing, crackles, sputum, difficulty vocalizing
primary prevention for HTN
low sodium/low fat/high fish diet, exercise, stop smoking, maintain BP
What factors put a person more at risk for perfusion problems?
males, african americans, american indian, hyperlipidemia, diabetes, lifestyle (diet, exercise, smoking, alcohol consumption, smoking)
The nurse assesses a child after heart surgery to correct tetralogy of Fallow. Which finding would the nurse report to the health care provider as an indication that the client has low cardiac output?
pale, cool extremities; cyanosis; weak; thready pulses; delayed capillary refill; and decrease in level of consciousness
What is reaction formation characterized by?
patient acts in opposition to feelings
What is projection characterized by?
patient blames someone/something other than the source of the anger/frusturation/pain
What is intellectualization characterized by?
patient over-relies on rational explanations/abstract thinking to diminish the significance of a feeling or event
What is a tet spell?
period of cyanosis, position child in knee to chest position because it keeps the blood in the periphery -> less preload on the heart
What is afterload?
pressure/resistance the heart has to overcome to eject blood
PANIC level of anxiety
striking dread and terror accompanied with feelings of loss of control; can be life threatening and cause death; rapid/disorganized speech, trembling, shaking, impaired memory, confusion, disorientation, inability to concentrate, lack of insight, poor judgment, hallucinations
Defense mechanisms used by patients with: PTSD
suppression
symptoms of TOF
tachycardia, ejection murmur, diminished 2nd heart sound, mild respiratory distress, cyanosis, grunting, mild IC/SC retractions, delayed capillary refill
How should iron be administered?
take it with no food and plenty of fluids (OJ), through a straw to avoid staining teeth, not taken with milk/antacid, sit upright 30 minutes after, stools may be black and tarry
response prevention
technique in which therapists prevent clients from performing their typical avoidance behaviors
What is preload?
volume of blood received by heart (adequate preload to prime pump)
Which of the following clients should the nurse assess first?
A client who is a child with stridor and nasal flaring -> nasal flaring indicates child is struggling to breathe and in critical condition
A client experiencing an acute panic attack develops respiratory alkalosis. Vital signs are as follows: RR:46, HR: 110, BP: 162/90, and temperature of 98.6. Which action will the nurse implement first to help improve respiratory alkalosis
Instruct the client to breath into a paper bag
The nurse is assessing a 4-month old client. For what finding will the nurse take immediate action
Intercostal retractions on inspiration
right heart failure
JVD, dependent edema, distended abdomen, weight gain, increased BP
Red zone of asthma action plan
DANGER -> medical alert if other treatments not working, breathing hard and fast, very SOA, nose opens wide, ribs showing, cannot talk
Dietary considerations for patients with iron deficiency anemia
beans, dark green leafy veggies, eggs, dried fruit, breads/pastas, peas, pork, poultry, red meat, seafood
Ineffective breathing pattern
Altered depth/rate, decreased minute ventilation, decreased vital capacity
A health care provider has entered orders for a client with COPD, which order should the nurse question
Oxygen increased to 3 L./min if oxygen saturation is less than 94% RA
Tetralogy of Fallot is a combination of which four cardiac defects?
Ventricular septal defect, pulmonary stenosis, overriding of the aorta, and right ventricular hypertrophy
Signs of impaired gas exchange
abnormal ABGS, confusion, restlessness, irritability, somnolence
SEVERE level of anxiety
can become a clinical problem, crippling/paralyzing experience, judgment is impaired, perceptual field is reduced, may focus one one particular detail or scattered details, learning/problem solving NOT possible at this level, insomnia, trembling/pounding heart, hyperventilation
Conversion: Defense Mechanism
unconscious transformation of anxiety into a physical symptom with no organic cause
A nurse is seeing a patient prior to discharge after being admitted to hospital for suicidal ideation. As the nurse begins the discharge process, the patient closes her eyes and begins rapid, shallow breathing. The patient also begins to shake and perspire profusely. Which actions should the nurse take? Select all that apply
-Take the client to a quiet space -Reassure the patient of being safe -Talk to the patient in a comforting manner
A nurse is teaching a patient with mono about how to manage fatigue associated with disease. Which statement by the patient indicates she understands how to manage the fatigue.
I schedule afternoon rest periods for myself in addition to sleeping 10 hours every night
A patient with iron deficiency anemia reports increased fatigue. The patient reports, "I am even too tired to eat what I should. Based on this information, the most appropriate intervention to combat this nutritional problem is to:
Divide daily food intake into five or six smaller meals to minimize energy expenditure associated with consuming three larger meals
Which manifestation is characteristically associated with anemia?
Fatigue
Which of the following nursing diagnosis would be the most appropriate for a patient with mono
Fatigue
A nurse is caring for a patient admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the patient?
Pallor, tachycardia, sore tongue, gait disturbances
A client tells the nurse he is experiencing dyspnea. Which action by the nurse is the most appropriate?
Place the patient in high fowler's position
An adolescent who is immobilized in a cast to stabilize a recent fractured femur suddenly develops chest pain, dyspnea, diaphoresis, and tachycardia. The nurse should further assess the client for which condition
Pulmonary emboli
What does oxygenation rely on?
adequate ventilation (movement of gas), diffusion (movement across membrane) and perfusion (circulation of blood)
Which symptoms should the nurse teach the client with unstable angina to report immediately to the health care provider?
change in pattern of chest pain as it can indicate an increasing severity of CAD
secondary fatigue
underlying medical condition lasting 1-6 months -> medication
Signs of infants in respiratory distress
use of accessory muscles, retractions, nasal flaring, stridor, grunting, crackles, LOC changes, cyanosis, thoracic shape, positioning
Compensation : Defense Mechanism
used to make up for perceived deficiencies and cover up shortcomings in order to protect the conscious mind from recognizing them
Dissociation: Defense Mechanism
usually integrated functions of consciousness, memory, identity, or perception of the environment; may result in separation between feeling and thought
RSV
viral bronchiolitis, use airborne precautions, rhinorrhea, febrile, tachypneic, wheezing/crackles
