Med Surg Test 4 (Red Highlights)
A client seen in practice has rheumatoid arthritis and has been prescribed cyclophosphamide. What is the most common adverse event associated with this drug?
Bone Marrow Suppression
Anemia Nursing Diagnosis
Fatigue- related to decreased oxygen-carrying capacity (i.e. iron deficiency anemia) Fatigue related to decreased hemoglobin and diminished oxygen-carrying capacity of the blood
HIV Nursing Management
Teach patients and caregivers to report any slight changes in the client's health status
Review Page 1189
Thank you
Skin tests\ Emergency
( Emergency equipment must be readily available to treat anaphylaxis)
Improve self-care, self-esteem, anxiety, and grief with empathetic listening and realistic reassurance
(Ask if he would like you to sit with him while he collects his thoughts)
Left Shift
(increased number of band cells) neutrophil production increases, such as infection When a bacterial infection occurs, the neutrophils will increase in order to phagocytize the bacteria
compartment syndrome
(medical emergency, must notify provider immediately). Caused by increasing pressure in muscle compartment leading to nerve/muscle anoxia and necrosis
A client is brought in by ambulance to the emergency department after being involved in a motorcycle accident. The client has an open fracture on his tibia. The wound is highly contaminated and there is extensive soft tissue damage. How would you grade this client's fracture?
***
You are explaining a client's decreasing bone density in terms of the balance between bone resorption and formation. Discuss three dietary nutrients and/or hormones that play a role in the resorption and formation of adult bones?
*** physical activity; o dietary intake of certain nutrients, especially calcium; o and several hormones, including calcitriol (i.e., activated vitamin D), parathyroid hormone (PTH), calcitonin, thyroid hormone, cortisol, growth hormone, and the sex hormones estrogen and testosterone.
A clinic nurse is caring for a patient admitted with AIDS. The nurse has assessed that the patient is experiencing a progressive decline in cognitive, behavioral, and motor functions. What complication is the patient more than likely experiencing?
****
A patient presents with cellulitis and is experiencing an increase in WBC. During which process are pathogens engulfed by white blood cells capable of ingesting foreign particles?
****
Which leukocytes arrive at the inflammation site?
*Neutrophils arrive first at a site where inflammation occurs*
Educate patient and family in prevention of infection
.e. the importance of personal and environmental hygiene
How long does a patient taking bisphosphonates need to stay upright after administration?
30 minutes
When could a "rebound" anaphylactic reaction occur after an initial attack even when epinephrine has been given?
4 hr
Antiretroviral medications as post exposure prophylaxis for health care workers are started within ____ hours of exposure:
72 hours
How often must the nurse inspect the traction pin site for signs of inflammation and evidence of infection?
8 hrs
Bleeding disorders nursing management
: limit injury (a void activities that carry a risk for injury) , assess for bleeding, bleeding precautions
ULTIMATE GOAL in physical mobility
A client should be able to use assistive devices appropriately and safely prior to discharge.
Delayed Complications of Fractur
Delay union healing D/N occur w/in expected time frame Nonunion failure of the ends of fx bone to unite Malunion healing of fx bone in a misaligned position • Secondary to inadequate immobilization
You are caring for a client who has undergone a total hip replacement. What action should you take to ensure that the patient does not dislocate the new prosthesis?
Abduction of the hip helps to prevent dislocation of a new hip joint. Rotation and adduction should be avoided. While the hip may be flexed slightly, it shouldn't exceed 90 degrees and maintenance of flexion isn't necessary.
Cellular Immunity
Action by cytotoxic T cells-antibodies or cytotoxic T cells combine and destroy the invading microbes
A child is scheduled to have a vaccination for rubella. What type of immunity will develop following the vaccination?
Active Acquired Immunity
Rheumatic disease meds
Administer medications in modified doses as prescribed if complications occur
Assessment of Hematologic Health
Alcohol consumption increase risk for Anemia (effect on hematopoiesis, nutritional deficiency)
Which of the following is a type of leukemia?
All of the above
A patient with an autoimmune disorder is being seen in practice. How would a nurse describe the humoral immune response for this patient?
Antibodies
Platelet defects
Aspirin may induce a platelet disorder
Prevention and Management of Anaphylaxis
Assess respiratory status (breath sounds, respiratory patterns and rate and oximetry) Protect the airway
Steps in the Life Cycle of HIV
Attachment/Binding- glycoproteins of HIV bind with the host's uninfected CD4+ receptor and chemokine coreceptors, which results in fusion of HIV with the CD4+ T- cell membrane
When having a reaction to a blood transfusion, patients will present with the same symptoms and assessment changes
False
Increase eosinophil count
CBC - Allergic DIsorder
Factors That Affect Fracture Healing
Chart 42 - 2 Infection
Significant risk of hematopoietic malignancy
Clonal stem cell disorders occur when the control mechanism fails and "indolent" clone cells may evolve to more aggressive clone cells.
Anaphylaxic common causes
Common Causes; Refer to Chart 37-2 o Antibiotics most common; penicillin o Foods, medications, insect bites and latex o Other Pharmaceutical/Biologic Agents
A client has recently been admitted to the orthopedic unit following total hip arthroplasty. The client has a closed suction device in place and the nurse has determined that there were 320 mL of output in the first 24 hours. How would you report this in the patient's chart?
Drainage of 200 to 500 mL in the first 24 hours is expected. Consequently, the nurse does not need to inform the health care provider.
Scoliosis
Evidenced by an abnormal lateral curve in the spine, shoulders that aren't level, an asymmetric waistline, and a prominent scapula which is accentuated by bending forward.
Education Needs of the Patient with a Cast, Brace, or Splint
Extremity needs to be elevated above the Heart level • Do not stick foreign objects into the cast
A patient's unrelieved pain should be reported to the physician 30 minutes after administered pain medication.
False
An antigen is a protein substance developed by the body in response to and interacting with a specific antibody
False
Avascular necrosis is prolongation of expected healing time for a fracture.
False
Epiphysis is the bone-forming cell.
False
Immunity refers to the body's nonspecific protective response to an invading foreign agent or organism.
False
Polycythemia is a form of anemia
False
Primary immune deficiency disorders result from external factors such as infection
False
What is pes cavus?
Foot with an abnormally high arch and a fixed equinus deformity of the forefoot
octreotide acetate (Sandostatin)
For Bowel Patterns
Methotrexate, cyclophosphamide (Cytoxan), and azathioprine (Imuran)
For Rheumatic disease are highly toxic and can produce bone marrow suppression, anemia, gastrointestinal disturbances, severe birth defects, and rashes
What findings can be identified with the use of radiography of the spine?
Fracture, dislocation, infection, osteoarthritis, or scoliosis
is a clinical syndrome that is characterized by a progressive decline in cognitive, behavioral, and motor functions as a direct result of HIV infection:
HIV encephalopathy
Nursing Interventions Skeletal Traction #2 Skeletal Traction #2
Have patient perform deep breathing and coughing exercises
What type of anemia results from red blood cell destruction?
Hemolytic
Nutrtion and Immune system
Inadequate intake of protein increases a client's susceptibility to infection
A client with a documented history of allergies presents to the clinic. She states that she is frustrated by her chronic nasal congestion, anosmia (inability to smell) and inability to concentrate. What would an appropriate nursing diagnosis be for this patient?
Ineffective coping with chronicity of condition
Allergic Rhinitis Diagnosis
Ineffective individual coping with chronicity of condition and need for environmental modifications (i.e. chronic nasal congestion, anosmia (inability to smell) and inability to concentrate)
A client from the ward is being discharged to be treated at home. What should be emphasized with this patient when engaging in self-care activities?
Infection Control; Hygiene
What is bursitis?
Inflammation of a fluid-filled sac in the joint
To prevent skin breakdown and lower the risk for impaired skin integrity
Inspect skin at least three times a day
Arthroscopy Assessment afterwatrds
Instruct family to monitor signs and symptoms of complications (fever, excessive bleeding, swelling, numbness, cool skin)
Preventing Dislocation of Hip Prosthesis
Instruct patient not to bring knees together Correct positioning using splint, wedge, pillows ( To prevent the affected extremity from Internal rotation )
Complementary, Alternative, and Integrative Health Therapies
Many clients with HIV use some type of alternative therapy and, as with most health treatments, there are benefits and risks
A patient presents with a laceration to her forearm as a result of falling through a glass patio door. At the wound site, what types of cells are invading?
Monocytes
You are assessing a client who reports a throbbing, burning sensation in the right foot. The client states that the pain is worst during the day but notes that the pain is relieved with rest. These symptoms are indicative of what health problem?
Motor neuroma
What should any older adult patient be evaluated for whose chief complaint is back pain and who has an elevated total protein level?
Multiple myeloma
While providing care in this setting you notice that a colleague puts on a second pair of gloves over soiled gloves while performing a procedure. Why would this be a problem?
Must be changed in between encounters
Which type of cells increase in number when the patient is exposed to a bacterial infection?
Neutrophils
Compartment syndrome
Notify physician
Osteomyelitis—
Osteomyelitis with vascular insufficiency is more common with DM & peripheral vascular disease. More common to affect the feet
Chronic Myeloid Leukemia (CML) treatment
Patient adherence to therapy is critical for optimal outcomes to be achieved.
Stage 1 : Primary/acute HIV
Period from infection with HIV to the development of HIV- specific antibodies
Patients usually begin ambulation within 1 day after surgery using walker or crutches.
Physical Therapy will ambulate patient the day after the surgery
A client is being seen in practice who has developed a nutritional deficit. When it comes to an immune response inadequate intake of what nutrient will increase the client's susceptibility to infection?
Protein
The malignant cell of Hodgkin lymphoma is the Reed-Sternberg cell
Reed--Sternberg cell
A patient seen in practice appears to be having a severe allergic reaction. What should be done to assess the patient's respiratory status?
Respiratory Rate, Pattern, Low Oxygen Sat, Breathing difficulties; abnormal lung sounds
It is noted in a patient's chart that he is at risk for infection due to protein loss. How does protein loss inhibit the immune response?
Results in atrophy of lymphoid tissues
What is a cast?
Rigid external immobilizing device molded to contours of body part
Morton Neuroma:
S/S: throbbing burning pain relived with rest and massage
You notice that a client with a leg cast is using a pencil to scratch under the edge of the cast. What action should you take to help the client?
Scratching should be discouraged because of the risk for skin breakdown or damage to the cast. Most clients can be discouraged from scratching if given a mild antihistamine, such as diphenhydramine, to relieve itching.
Early complications
Shock • Fat embolism • Compartment syndrome elevated compartment pressure that is above normal perfusion pressure • Incr. volume space (edema & swelling) • Decr. space (restrictive cast) • 5 P's: pain, pallor, pulselessness, paresthesias paralysis • VTE, PE
What is atrophy?
Shrinkage-like decrease in the size of the muscle
Transfusion Process: PRBC
Take patient's temperature, pulse, respiration, blood pressure and assess fluid volume status (e.g., auscultate lungs, assess for jugular venous distention) to serve as a baseline for comparison during transfusion.
a full bladder interferes with accurate scanning of the pelvic bones)
The nurse should encourage the patient to empty their bladder prior to completing their bone scan**
You suspect the presence of compartment syndrome in a patient that had a cast placed for a humeral fracture. What action should you take?
This major neurovascular problem is caused by pressure within a muscle compartment that increases to such an extent that microcirculation diminishes, leading to nerve and muscle anoxia and necrosis. Function can be permanently lost if the anoxic situation continues for longer than 6 hours. Therefore, immediate medical care is a priority over further nursing assessment.
Hormones for Bone Formation
Thyroid Hormone Growth Hormone Estrogen
Assess neurovascular status before and after splinting
To prevent compartment syndrome REMOVE THE CAST/SPLINT
Which statement is false about magnetic resonance imaging?
Transdermal patches that have a thin layer of aluminized back must be covered with gauze.
Pain with brace use
Treat with elevation, ice packs, and analgesics
Bone is in a constant state of turnover.
True
Disseminated intravascular coagulation is not a disease but a sign of an underlying condition
True
Phantom limb pain is perceived in the amputated limb.
True
Polyarticular refers to a rheumatic disease affecting more than one joint
True
Proper standing posture occurs when the abdominal muscles contract, giving a feeling of upward pull, and the gluteal muscles contract, giving a downward pull.
True
Testing for crepitus can produce further tissue damage and should be avoided.
True
The nurse must never remove weights from skeletal traction unless a life-threatening situation occurs.
True
The nurse never adjusts the clamps on the external fixator frame.
True
Autoimmune disorders are more common in women than men
True *Autoimmune disorders are more common in women than men*
Steroids and Osteoporosis
Use of steroids for more than 3 months at doses higher than 5mg puts patients at risk (Prednisone)
A client's primary infection with HIV has subsided and an equilibrium now exists between HIV levels and the client's immune response. What physiologic state is this?
Viral Set Point
Response Stage of immune response
Viral rather than bacterial antigens induce a cellular response
Open or compound/complex Fracture Risk for infection
Wound extends to the bone • Grade I: 1 cm long clean wound • Grade II: larger wound without extensive damage • Grade III: highly contaminated, extensive soft tissue injury, may have amputation
Antimalarials-
a ssess for visual changes, GI upset, skin rash, headaches, photosensitivity, bleaching of hair
Eosinophil chemotactic factor of anaphylaxis
affects the movement of eosinophils (granular leukocytes) to the site of allergens
Post-HIV Exposure Prophylaxis for Health Care Providers-
after initiating the emergency reporting system, the nurse should report as quickly as possible to the employee health services, the emergency department, or other designated treatment facility
Viral set point:
amount of virus present in the blood after the initial burst of viremia and the immune response that follows
Salycilate therapy
assess for tinnitus, gastric intolerance, GI bleeding, and purpura
Vitamin B 12
because vitamin B12 is found only in foods of animal origin, strict vegetarians (vegans) may ingest little vitamin B 12
A client has been identified as being in the primary infection stage of HIV. What does this mean?
between the first signs of symptoms
The goal in the treatment of Hodgkin lymphoma is
cure Has a high cure rate
Multiple myeloma
decreased bone density, osteoporosis may be seen on bone imaging. Long-acting opioids are often prescribed to afford adequate pain relief
Acute hemolytic reaction
donor blood is incompatible with that of the recipient
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be rodded in surgery. Identify three complications that may occur for this patient.
dvt; compartment syndrome; fat embolism
A client is being seen in practice following anaphylaxis as a result of a bee sting. Following this event, what alteration in laboratory values should be present?
eosinophils
You are seeing a patient with diabetes who is attempting to prevent disease-related complications. What action will you instruct the client to perform to reduce the risk of developing osteomyelitis?
foot care
Patients with anemia should be assessed for signs and symptoms of
heart failure (SOB and peripheral edema)
Age and gender and Imune system
higher incidence in females than in males
A client has come to the orthopedic clinic for a follow-up appointment 6 weeks after fracturing his ankle. Diagnostic imaging reveals that bone union is not taking place. What factor may have contributed to this complication?
inadequate immobilization
Humoral or antibody response
is characterized by the production of antibodies by B lymphocytes in response to a specific antigen
Hemophilia A
is caused by a genetic defect that results in deficient or defective factor VIII. Tx?
Persistent leukocytosis
is hematologic malignancy (i.e., Leukemia)
A client with rheumatoid arthritis comes to the clinic reporting pain in the joint of his right great toe and is eventually diagnosed with gout. What dietary advice should be given to this patient?
less purine
Phagocytosis
monocytes *( phagocytic cells )* responsible for engulfing and destroying foreign bodies and toxins.
Maintaining fluid and electrolyte balance in Leukemia patient (SATA
o Intake and output, daily weights o Assess for dehydration and overload ( Auscultating the client's lungs frequently) o Laboratory studies including electrolytes, blood urea nitrogen, creatinine, and hematocrit o Replacement as necessary
Acquired immunity :
pecific against a foreign antigen
You are caring for a client who has just had an arthroscopy as an outpatient and is getting ready to go home. You should teach the client to monitor closely for what postprocedure complication? Why?
physical activity; o dietary intake of certain nutrients, especially calcium; o and several hormones, including calcitriol (i.e., activated vitamin D), parathyroid hormone (PTH), calcitonin, thyroid hormone, cortisol, growth hormone, and the sex hormones estrogen and testosterone.
HIV encephalopathy
progressive decline in cognitive, behavioral, and motor functions
How to protect from candidiasis
provide oral care before and after meals
Transfusion Reaction
reaction must be recognized promptly and the transfusion discontinued immediately
A hospital nurse has experienced percutaneous exposure to an HIV-positive patient's blood as a result of a needlestick injury. The nurse has informed the supervisor and identified the client. What action should the nurse take next?
report to employee health services; ER
Gout-
severe dietary restriction is not necessary; however, the nurse encourages the patient to restrict consumption of foods high in purines, especially organ meats, and to limit alcohol intake
Contusion
soft tissue injury produced by blunt force • Pain, swelling, and discoloration: ecchymosis • r/o-blow, kick, or fall
primary hemostasis
the severed blood vessel constricts
Another client seen in practice is also diagnosed with rheumatoid arthritis. She is prescribed antimalarials for treatment. What side effect should the nurse educate the patient about with these medications?
visual changes
Rheumatic Disease education
watch for signs and symptoms of infection, monitor body temperature) (requires frequent check-ups)