Med Surg I Final
AIDS nursing diagnosis: Imbalanced Nutrition related to:
* inability or altered ability to ingest, digest or metabolize nutrients * increased metabolic rate/ nutritional needs due to fever and infection
Peak incidence of appendicitis
10-12 yrs Mostly males 10-30 y/o
The nurse notes that a patient with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the significance of these symptoms? A. Patient my be developing hypocalcemia B. Patient is having a reaction to morphine C. Patient has a nutritional imbalance D. Patient needs a muscle relaxant to help him rest.
A. Patient my be developing hypocalcemia
Which age-related change in the gastrointestinal tract increases the risk for anemia?
Atrophy of the gastric mucosa
How do you diagnose GERD?
Barium swallow endoscopy/EGD for direct visualization via scope of upper GI tract Biopsy
A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?
Clay-colored stools
Main forms of inflammatory bowel disease (IBD):
Crohn disease and ulcerative colitis
Diverticulitis Treatment
Mild: Antibiotics Liquid diet with low fiber foods NPO/NGT (gastric decompression) Surgical intervention - removal of affected segment of colon
Precaution: Olistat for weight loss
Monitor renal function Clients with a history of renal sufficiency or liver disease should use caution while taking this medication as it has been linked to increase rates of cholelithiasis and liver failure.
Gastric Ulcer characteristics
Occurs in the stomach Epigastric pain 1-2 hours after eating Can cause hematemensis or melena Heartburn, chest discomfort and early satiety common Can cause gastric carcinoma in elderly
What severe complication does the nurse monitor for in a patient with ataxia-telangiectasia?
Overwhelming infection Ataxia-telangiectasia is an autosomal recessive neurodegenerative disorder characterized by cerebellar ataxia (loss of muscle coordination), telangiectasia (vascular lesions caused by dilated blood vessels), and immune deficiency. The immunologic defects reflect abnormalities of the thymus. The disorder is characterized by some degree of T-cell deficiency, which becomes more severe with advancing age. Immunodeficiency is manifested by recurrent and chronic sinus and pulmonary infections, leading to bronchiectasis.
What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?
Pentagastrin
The nurse is caring for a patient in the emergency department with complaints of acute abdominal pain, nausea, and vomiting. When the nurse palpates the patient's left lower abdominal quadrant, the patient complains of pain in the right lower quadrant. The nurse will document this as which of the following diagnostic signs of appendicitis?
Rovsing Sign In patients with suspected appendicitis, Rovsing sign may be elicited by palpation of the left lower quadrant, causing pain to be felt in the right lower quadrant
Peritonitis
Rupture of appendix abdomen distended with general pain
AIDS: Prevention of Transmission in Health Care setting
Standard precautions Hand washing/hygiene Do NOT recap needles & syringes Clean spills of Blood & Bodily fluids COnsider all bodily fluids contaminated Avoid contaminating outside of specimen containers Cleanse work surface areas with germicide
Causes of erosive gastritis
Stress; shock; severe trauma; major surgery; sepsis; burns (curling's ulcer); head injury (cushing's ulcer); excessive alcohol, NSAIDS,
Diverticulitis S/S
Sudden onset of LLQ abdominal pain Constipation/diarrhea Fever with elevated WBC Nausea & Vomiting
Postoperative therapy for hip replacement surgeries
The affected leg should not cross midline or be turned inward. The hip should not bend more than 90 degrees. Ambulation begins the day following surgery, and weight bearing ambulation may not be restricted, depending on the type of prosthesis.
T/F: When taking oral diabetic medication or insulin, people with DM can eat anything the want.
True There are no foods that cannot be consumed. However, oral medication and/or insulin are more effective when they do not have to work so hard to lower blood glucose, Combining medications with healthy eating and exercise results in better glucose control and perhaps less medication.
What test will the nurse assess to determine the client's response to antiretroviral therapy?
Viral load
A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?
Vitamin K
Scoliosis
a lateral curvature of the spine
A clinical manifestation of hepatic disease in a patient who can no longer compensate is: a) Esophageal varices b) Mild ascites c) Spider angiomas d) Palmar erythema
a) Esophageal varices This is a life threatening complication
Amphiarthrosis joints
allow limited movement e.g. vertebral joints
Lordosis
an increase in the lumbar curvature of the spine.
A client with intestinal obstruction continues to have acute pain even though the NG tub is patent and draining. Which action by the nurse would be most appropriate? a) Reassure the patient that the NG tube is functioning b) Assess the patient for a rigid abd c) Administer an opioid as ordered d) Reposition the client on left side
b) Assess the patient for a rigid abd Concern is for Peritonitis—check for rigid abd, fever, increase in pain
The nurse is caring for a patient with C-Diff. Which intervention should the nurse implement to prevent nosocomial spread to other client? a) Wash hands with betadine for 2 minutes b) Wear non sterile gloves when handling GI secretions c) Clean the perineal area with soap and water after each stool d) Flush commode twice when disposing of stool
b) Wear non sterile gloves when handling GI secretions
The nurse would increase the comfort of the patient with appendicitis by: a. Having the patient lie prone b. Flexing the patient's right knee c. Sitting the patient upright in a chair d. Turning the patient onto his or her left side
b. Flexing the patient's right knee The patient with appendicitis usually prefers to lie still, often with the right leg flexed to decrease pain
Diverticulosis causes
congenital weakening of intestinal wall low intake of roughage and fiber straining on defecation chronic constipation age
Peritonitis S/S
rebound tenderness, muscular rigidity, laying still w/fast shallow breaths, distended abd, ascites, fever, Pain Inc. pulse, BP, WBC Decreased bowel sounds
Epiphysis
the end of a long bone, attached to shaft
Diaphysis
the shaft of a long bone
Gastritis S/S
vomiting stomach burn upset stomach loss of appetite blood vomiting black stool
You administer Intermediate acting insulin (NPH) at 5PM . The greatest risk of hypoglycemia will occur about what time?
10Pm while sleeping This is the peak time
A client with a spinal cord injury has full head and neck control when the injury is at which level?
C5
Pills for DM are oral insulin
False Oral medications for DM enhance the ability of the pancreas to produce insulin and/or utilize insulin more effectively. These medications are not insulin. Nsulin ingested orally would be destroyed by gastric acid.
The patient who has been diagnosed with Type 1 DM asks you if his body produces any insulin at all? You reply:
No, the insulin producing cells have stopped working and insulin injections will be needed for life.
Characteristics of Duodenal Ulcer
Occurs in duodenum Epigastric pain 2-5 hours after eating Can cause melena or hematochezia Heartburn & chest discomfort (less common) Pain may awaken patient during night
GERD Treatment
Relieve symptoms & heal esophageal irritation *Prilosec (proton pump inhibitor) * Antibiotic if H. pylori Avoid irritants Elevate HOB No meals 203 hrs b/f bedtime
The nurse is discussing the cardiac system with a client admitted with heart failure. The client asks "What determines the heart rate?" What is the nurse's best response?
The autonomic nervous system controls the heart rate.
A nurse is doing a physical assessment on a client with a GI disorder. Which position will the nurse most likely ask the client to assume when performing an abdominal examination?
The client should lie in a supine position with knees flexed slightly to assist in relaxing the abdominal muscles.
Ileostomy
a surgical operation performed when piece of the ileum is diverted to an artificial opening in the abdominal wall
A jaundiced patient has a gallstone blocking the bile duct. Upon assessment of the patient's laboratory studies, the nurse will expect to find a(n): a) Increased bilirubin level in the blood b) Decreased cholesterol level c) Increased BUN level d) Decreased serum alkaline phosphate level
a) Increased bilirubin level in the blood Understanding where the CBD is located
You are the nurse caring for a stable patient post an upper GI endoscopy. One hour later, he has a fever of 101.8 What would you do in response to this assessment data? a) Promptly assess for potential perforation b) Ask the PCA to change thermometers and retake temp c) Plan to give Tylenol to reduce fever d) Provide a tepid bath to assist with fever reduction
a) Promptly assess for potential perforation
The nurse is admitting a 55-year-old male with a diagnosis of acute pancreatitis is aware that acute pancreatitis occurs when: a) Toxic substances inflame the pancreas b) The patient abuses alcohol. c) Viruses digest the pancreas. d) Pancreatic enzymes digest the pancreas.
a) Toxic substances inflame the pancreas All answers are correct but a is the best answer
Diarthrosis joints
freely movable joints e.g. hip and shoulder.
The client with a hiatal hernia chronically experiences heartburn following meals. The nurse plans to teach the client to avoid which action because it is contraindicated with hiatal hernia? 1. Lying recumbent following meals 2. Taking in small, frequent, meals 3. Raising the head of the bed on 6-inch blocks 4. Taking H2-receptor antagonist medication
1. Laying recumbent following meals or at night will cause reflux and pain. Relief is usually achieved with the intake of small meals, use of H2 receptor antagonists and antacids, and elevation of the thorax after meals and during sleep
Peritonitis Risk Factors
Abdominal surgery Ectopic pregnancy Perforation - Trauma, ulcer, appendix rupture, diverticulum
Where does the bile and pancreatic enzymes enter the GI system?
Duodenum
Factors that relax lower esophageal sphincter (LES) tone
Nicotine Caffeine Chocolate Fatty foods Milk ETOH Peppermint, spearmint Medications: Anticholinergics, beta adrenergic agonists, calcium channel blockers, nitrates, benzodiazepines
A client undergoes a colonoscopy for colorectal cancer screening. During the procedure three small polyps were removed. Which nursing actions are necessary when caring for the client immediately after the colonoscopy?
Observe for signs and symptoms of bowel perforation, monitor vital signs, and inform her that there may be a small amount of blood in her stool and to report excessive blood loss.
A nurse knows that more than 50% of clients with CVID develop the following disorder.
Pernicious anemia
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
Widened pulse pressure
Colostomy
a surgical procedure that brings one end of the large intestine out through the abdominal wall. During this procedure, one end of the colon is diverted through an incision in the abdominal wall to create a stoma
A client with UC has persistent diarrhea. He is thin and has lost 12lbs since the exacerbation started. Which of the following will be most effective in helping the client meet his nutritional needs? a) Continuous enteral feeding b) Following a high calorie, high protein diet c) TPN d) Eating 6 small meal per day
c) TPN The bowel needs rest with severe UC exacerbations
Battle's sign
ecchymosis over the mastoid process in patients with basilar skull fractures
Ileostomy nursing care
Pt. more at risk for nutritional deficiencies, dehydrations and electrolyte imbalance because of large amounts liquid stool- at risk for renal stones and gallstones Needs to drink approximately 2-3 L of fluid daily
The nurse administers lactulose to a client with hepatic encephalopathy. What is the expected clinical outcome from the administration of the lactulose? a) Stimulation of peristalsis b) Reduced ascites c) Reduced serum ammonia levels d) Prevention of hemorrhage
c) Reduced serum ammonia levels In the colon, Lactulose is broken down primarily to lactic acid by the action of colonic bacteria, which results in an increase in osmotic pressure and slight acidification of the colonic content
Gastritis treatment & prevention
eliminate irritant, antacids, H2 blocker treat H. pylori (non-erosive) NPO while symptomatic Avoid caffeine, ETOH, nicotine
The nurse is performing an admission assessment on a client diagnosed with gastroesophageal reflux disease. Which signs and symptoms would indicate GERD? 1. Pyrosis, pain on swallowing, and regurgitation 2. Weight loss, dysarthria, and diarrhea 3. Decreased abdominal fat, proteinuria, and constipation 4. Mid-epigastric pain, positive H. pylori test, and melena
1. Pyrosis, pain on swallowing, and regurgitation
The client with hepatic disease complicated by ascites is admitted to the hospital. The client reported a 10 lb weight gain over the past 7 days. The client has edema of the feet and ankles and his abdomen is distended, taut with striae and visible veins. Which nursing diagnosis is the most appropriate in this situation? A. Fluid volume excess B. Impaired gas exchange C. Impaired skin integrity D. Fluid volume deficit
A. Fluid volume excess
A 40-year-old male patient enters the emergency department complaining of nausea and vomiting and severe abdominal pain. While assessing the patient, the patient's wife informs the nurse that the patient had ingested copious amounts of alcohol last evening. The patient's abdomen is rigid, and there is bruising to the patient's flank. The patient is exhibiting signs of: A.Severe pancreatitis with possible peritonitis B.Acute cholecystitis C.Obstruction of the bowel D.Acute appendicitis
A. Severe abdominal pain is the major symptom of pancreatitis that causes patients to seek medical care. The pain of pancreatitis is accompanied by nausea and vomiting that does not relieve the pain or nausea. Abdominal guarding is present and a rigid or board-like abdomen may be a sign of peritonitis. Ecchymosis (bruising) to the flank or around the umbilicus may indicate severe peritonitis. Pain generally occurs 24 to 48 hours after a heavy meal or alcohol ingestion.
A client receiving antiretroviral therapy reports "not urinating enough." What is the nurse's best action?
Assess blood urea and creatinine Adverse effects associated with antiretroviral therapy include potential nephrotoxicity. Assessing blood urean nitrogen and creatinine for clients who have decreased urination is appropriate. The other answers will not assist the nurse in determining the client's problem, which should be assessed before intervention are administered.
Of the following choices, which is the most reliable test used in diagnosing Type 1 and 2 DM? A. Oral Glucose Tolerance Test (OGTT) B. Hemoglobin A1C C. Urine dextrostix (dip stick) D. Serum cortisol
B. Hemoglobin A1C Blood test that reflects average blood glucose levels over 2-3 months When blood glucose levels are elevated, glucose molecules attach themselves to red blood cells (life span of 120 days) The longer the amount of glucose in the blood remains above normal, the higher the glycated hemoglobin level. Also fasting blood glucose level is used to daignose DM
T/F: AIDS is a primary immunodeficiency disorder
False Primary immune deficiencies should be not be confused with AIDS. They are not the same condition. In addition, a primary immune disorder does not increase the child's risk for developing AIDS later in life. Primary immune deficiency diseases are serious, but they are rarely fatal and can be controlled. Testing will reveal the evidence of a primary immune disease, not AIDS. AIDS is classified as a secondary immunodeficiency.
T/F: Once one begins taking oral diabetic medications or insulin for Type 2 DM, these medications must be taken for life.
False Temporary circumstances such as glucocorticoid therapy may cause elevated serum glucose and medication and/or insulin is required OR weight loss through exercise and healthy eating may decrease blood glucose levels and the need to insulin and/or oral diabetic agents may decrease.
Symptoms of GERD
Pyrosis-burning sensation in esophagus Dyspepsia Regurgitation of stomach contents Pain when swallowing
Appendicitis S/S
RLQ abdominal pain or cramping, nausea, vomiting, chills, low grade fever, rebound pain @ McBurney's Point
The admitting RN is monitoring client laboratory values. Which value is expected in the client with cholecystitis who has chronic inflammation? a) An elevated WBC b) A decrease in serum amalyse c) An elevated alkaline phosphate d) A decrease in direct bilirubin
a) An elevated WBC
The pt is 2 hrs postoperative laproscopic cholecystectomy is c/o severe pain in the right shoulder. Which nsg intervention should the nurse implement? a) Apply a heating pad to the shoulder for 15-20 minutes b) Administer morphine IV after diluting with saline c) Contact the surgeon to order an Xray of the shoulder d) Apply a sling to the right arm, which was injured during surgery
a) Apply a heating pad to the shoulder for 15-20 minutes A heating pad should be applied for 15-20 minutes to assist the migration of the CO2 used to insufflate the abd. This shoulder pain is a common occurence with laproscopic procedures
The nurse is preparing a client for a paracentisis. The nurse should: a) Have the client void immediately before the procedure b) Place the client in a side-lying position c) Initiate an IV line to administer sedatives d) Place the client on NPO status for 6hrs before the procedure
a) Have the client void immediately before the procedure Need to empty the bladder d/t risk for perforation Needs to be in high fowlers or seated on side of bed Not usually need sedatives No need to be NPO
A health care provider has been exposed to hepatitis B through a needle stick. Which of the following drugs should the nurse anticipate administering as post-exposure prophylaxis? a) Hepatitis B immune gamma globulin b) Interferon c) Hepatitis B vaccine d) Insulin
a) Hepatitis B immune gamma globulin
The client has end stage liver disease secondary to ETOH cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? a) Increased Amnonia Levels and GI Bleed b) Hypoalbuminemia c) Splenomegaly d) Hyperaldosteronism
a) Increased Amnonia Levels and GI Bleed Blood in the GI tract is digested as a protein which increases serum ammonia levels and increase the risk of encephalopathy
Your Patient is admitted for acute diverticulitis. His BP is 110/70 with a heart rate of 85. His RR is 18 with an O2 sat of 96% on RA. The patient has sudden onset of severe abd pain with a temp of 102... What is the first nursing intervention? a) Call MD b) Give pain meds c) Reposition pt d) Give pt PO Fluids
a) call MD Concern is peritonitis from ruptured diverticulum. Severe abd pain and fever are s/s of peritionits
What are interventions to prevent acute exacerbation of diverticulitis? (SATA) a) eat a low fiber diet b) Drink 2, 500 cc of water daily c) Avoid eating foods with seeds d) Walk 30 minutes a day e) Take an antacid every 2 hours
b) Drink 2, 500 cc of water daily c) Avoid eating foods with seeds d) Walk 30 minutes a day
A 36 year old female with Type 1 DM is admitted to the ED. Which of the following respiratory patterns requires immediate attention? a) Rapid and shallow b) Deep and irregular c) Short inspiration, long expiration d) Regular depth with frequent pauses
b) deep irregular Deep, irregular but not labored respirations may occur with Diabetic Ketoacidosis. Called Kussmaul respirations—they are the body's attempt to decrease metabolic acidosis but exhaling carbon dioxide.
The nurse prepares to give a bath and change the bed linens on a client with cutaneous Kaposi's sarcoma lesions. The lesions are open and draining a scant amount of serous fluid. Which of the following would the nurse incorporate into the plan during the bathing of this client? a) wearing gloves b) wearing a gown and gloves c) wearing a gown, gloves, and a mask d) wear a gown and gloves to change the bed linens and gloves only for the bath
b) gown and gloves Gowns and gloves are required if the nurse anticipates contact with soiled items such as those with wound drainage or is caring for a client who is incontinent with diarrhea or a client who has an ileostomy or colostomy. Masks are not required unless droplet or airborne precautions are necessary. Regardless of the amount of wound drainage, a gown and gloves must be worn.
The physician orders oral neomycin for a pt with cirrhosis. The expected outcome of this therapy is: a) Reduce abd pressure b) Prevent straining during on defecation c) Block ammonia formation d) Reduce bleeding within the intestine
c) Block ammonia formation Neomycin decreases the bacterial action of protein in the intestine, which results in ammonia production. This ammonia, if not detoxified by the liver, can results in hepatic encephalopathy
A patient is admitted with increasing ascites. The patient's vital signs are: temperature: 98.8 F; heart rate: 118; BP: 128/72, SaO2: 89% on room air. Which action should be a priority for the nurse? a) Assess heart sounds. b) Obtain an order for blood cultures for a suspected infection. c) Raise the head of the bed and position patient as upright as possible d) Prepare for a paracentesis
c) Raise the head of the bed and position patient as upright as possible Positioning will assist with breathing
The client is admitted to the medical department with a dx of r/o acute pancreatitis. Which lab values should the nurse monitor to confirm this dx? a) Creat and BUN b) Troponin and CK-MB c) Serum amylase and lipase d) Serum bilirubin and calcium
c) Serum amylase and lipase Serum amylase and lipase are elevated with acute pancreatitis Bilirubin can be elevated but amylase and lipase elevation are pancreatitis specific
A client with acquired immunodeficiency syndrome (AIDS) is suspected of having cutaneous Kaposi's sarcoma. The nurse prepares the client for which test that will confirm the presence of this type of sarcoma? a) sputum culture b) liver biopsy c) punch biopsy of the lesion d) white blood cell count
c) punch biopsy of the lesion Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate, or open, and drain. The lesions spread by metastasis through the upper body then to the face and oral mucosa. They can also move to the lymphatic system, lungs, and gastrointestinal tract. Late disease results in swelling and pain in the lower extremities, penis, scrotum, or face. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.
Your patient is diagnosed with UC. Which S/S warrants immediate intervention from the nurse? a) Patient has 8 bloody stools per day b) Pt's oral temp is 99.8 c) The patients abd is hard and rigid d) The patient complain of urinating when coughing
c) the patient's abd is hard and rigid sign of peritonitis a complication of UC 20 bloody stools is common, 99.8 is not febrile, stress incontinence is not a symptom of UC
The patient with type 1 DM is taught to take NPH (intermediate) insulin at 5pm each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time a) 11AM - shortly before lunch b) 1pm shortly after lunch c) 6pm- shortly after dinner d) 1 am - while sleeping
d) 1 am - while sleeping NPH will peak 4-12 hrs which will be in middle of the night- can avoid by giving snack at bedtime
The client is in the preicteric phase of hepatitis. Which signs/symptoms should the nurse expect the client to exhibit during this phase? a) Clay colored stools and jaundice b) Normal appetite and pruritus c) Being afebrile and left upper quadrant pain d) Complaints of fatigue and diarrhea
d) Complaints of fatigue and diarrhea
The client with hepatic disease receives 100 mL of salt-poor albumin IV. Which finding would best indicate that the albumin is having its desired effect? a) Increased urine output b) Increased temperature c) Decreased anorexia d) Decreased ascites
d) Decreased ascites
Diverticulosis treatment
high fiber diet avoid nuts, corn, seeds (can cause diverticulitis) exercise Not curable but manageable with self care
Synarthrosis joints are
immovable e.g. skull
A client has been diagnosed with cancer of the rectum. While completing the preoperative checklist the client asks the nurse "Where will my stoma be?" The nurse's best response is
left lower quadrant Rationale: A client with cancer of the rectum will have an abdominoperineal resection. The anal canal will be closed and a stoma will be formed from the proximal sigmoid colon in the left lower quadrant of the abdomen.
gastroesophageal reflux disease (GERD)
often involves relaxation of the lower esophageal sphincter, allowing stomach contents to back up into the espophagus
Diverticulosis S/S
ongoing bowel irregularities (constipation, diarrhea) nausea anorexia bloating abdominal distention
