N340. Med Surg. Test #2
Answer Key: A Feedback: Good job! The nurse will want to assess the patients concerns first
A patient who has had a colectomy with a permanent ileostomy tells the nurse, "I cannot bear to even look at the stoma. I do not think I can manage all these changes." Which is the best action by the nurse? A. Ask the patient more about the concerns with stoma management. B. Postpone any patient teaching until the patient adjusts to the ileostomy. C. Reassure the patient that care for the ileostomy will become easier. D. Develop a detailed written plan for ostomy care for the patient.
Answer Key: A Feedback: Good job! Assessing the breath sounds is the best first step. If you hear nothing with asthma, it's REALLY BAD! It would mean that everything has already closed up!
A patient who is experiencing an acute asthma attack is admitted to the emergency department. The nurse's first action should be to: A. listen to the patient's breath sounds. B. ask about inhaled corticosteroid use. C. determine when the dyspnea started. D. obtain the forced expiratory volume (FEV) flow rate.
Answer Key: A Feedback: Good job! Pursed lip breathing is an excellent tool for patients to control anxiety.
A patient with chronic bronchitis has a nursing diagnosis of impaired breathing pattern related to anxiety. Which nursing action is most appropriate to include in the plan of care? A. Teach the patient how to effectively use pursed lip breathing. B. Suggest the use of over-the-counter sedative medications. C. Discuss a high-protein, high-calorie diet with the patient. D. Titrate oxygen to keep saturation at least 90%.
Answer Key: B Feedback: Tripod-ing is a good way to improve gas exchange. - high Fowler's = placed when the head of the bed needs to be elevated as high as possible. The upper half of the patient's body is between 60 degrees and 90 degrees in relation to the lower half of their body. - Trendelenburg = the body is laid flat on the back (supine position) with the feet higher than the head by 15-30 degrees. Used for abdominal and gynecological surgery.
A patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best position the patient to improve gas exchange? A. Resting in bed with the head elevated to 45 to 60 degrees B. Sitting up at the bedside in a chair and leaning slightly forward C. Resting in bed in a high-Fowler's position with the knees flexed D. In the Trendelenburg position with several pillows behind the head
Answer Key: C Feedback: Good job! Noncompliance is common with CPAP users, especially early on before the patient is used to it. Assessing if the patient has been compliant is the correct first step.
A patient with sleep apnea who received a new prescription for a continuous positive airway pressure (CPAP) device a week ago returns to the clinic and says that severe daytime fatigue is still a problem. Which action should the nurse take first? A. Teach about radiofrequency ablation. B. Plan to schedule a night time sleep study. C. Ask the patient whether the CPAP is being used every night. D. Discuss the possible surgical approaches used for sleep apnea.
- For someone who doesn't have diabetes, a NORMAL A1C level can range from 4.5 to 6 percent. - Someone who's had uncontrolled diabetes for a long time might have an A1C level ABOVE 8 percent. - When the A1C test is used to DIAGNOSE diabetes, an A1C level of 6.5 percent or higher on two separate tests indicates you have diabetes. - A result between 5.7 and 6.4 percent is considered prediabetes, which indicates a high risk of developing diabetes.
A1C ranges...what do the ranges mean??
Diabetic Ketoacidosis - Complication resulting from absolute or relative deficiency in insulin. - Characterized by hyperglycemia, ketosis, acidosis and dehydration - Can occur with hyperglycemia >250mg/dL
DKA ... stands for? What causes it? Characterized by ... 4 things Blood sugar at??
DKA - diabetic ketoacidosis is more common in TYPE 1 DIABETICS (HHS is NOT as common with them)
DKA more common in type 1 or type 2 diabetics?
- Dehydration - intravascular depletion - Hypothermia - Hyperpnea - Kussmaul respirations (fast breathing) - Acetone breath - fruity odor - "juicy fruit" - Acute abdomen - painful - Mentation changes (mental activity) - Hyporeflexia - decreased reflexes
Diabetic Ketoacidosis - CLINICAL SIGNS Thirsty? Temp? Breathing? Breath? Abdomen? Mentation? Reflexes?
- Correct fluid and electrolyte disturbances - Provide adequate insulin to restore and maintain normal glucose metabolism and correct acidosis - Prevent complications resulting from treatment - Provide patient and family education and follow up
Diabetic Ketoacidosis - TREATMENT GOALS Anything with fluid? Anything with insulin?
- life threatening emergency with high mortality rate - Severe hyperglycemia >600 mg/dL, - absence of ketosis, - profound dehydration, - neurologic signs ranging from depressed sensorium to coma
HHS & HHNS - Hyperosmolar Hyperglycemic Nonketotic Syndrome Dangerous? Blood sugar at? Ketosis? Thirsty? Mentation?
HHS most commonly occurs in patients with type 2 DM who have some concomitant illness that leads to reduced fluid intake. Infection is the most common preceding illness, but many other conditions can cause altered mentation, dehydration, or both. Once HHS has developed, it may be difficult to differentiate it from the antecedent illness. The concomitant illness may not be identifiable. HHS has also been reported in patients with type 1 DM.
HHS more common type 1 or type 2 diabetics? When does it usually happen?
- Can occur with DMT1 or DMT2 - Typically occurs with type 2 DM - Seen most often in elderly patients not receiving adequate fluid intake - Usually preceded by illness or infection - Mortality of HHNS greater than DKA due to severe metabolic changes, delay in diagnosis, or other medical complications of elderly - Not very common
Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS) Occur with DM 1 and DM 2? Typically occurs with DM __ ? Seen most often in ___ patients who ______. Usually preceded by _______ . Mortality of HHNS is ____ than DKA. Common?
Benign dietary KETOSIS is a controlled, insulin regulated process which results in a mild release of fatty acids and ketone body production in response to low carbohydrate intake, and higher fat consumption. DIABETIC KETOACIDOSIS is a condition in which abnormal quantities of ketones are produced in an unregulated biochemical situation. In order to reach a state of ketoacidosis, the body has to be in a state of not producing enough insulin to regulate the flow of fatty acids and the creation of ketone bodies. The danger of keto-acidosis is in the amounts of the ketone bodies being released. Because KETONE BODIES ARE SLIGHTLY ACIDIC IN NATURE, and so many are released at once in a ketoacidosis situation, they build up in the bloodstream. The sheer volume quickly overwhelms the delicate acid-base buffering system of the blood, and the blood pH drops to become more acidic than normal.
Ketoacidosis vs. Ketosis
- a state of elevated levels of ketone bodies in the body. It is almost always generalized throughout the body, with hyperketonemia, that is, an elevated level of ketone bodies in the blood. - Ketone bodies are formed by ketogenesis when liver glycogen stores are depleted. - During starvation or a long physical training session, the body starts using fatty acids instead of glucose. The brain cannot use long-chain fatty acids for energy because they are completely albumin-bound and cannot cross the blood-brain barrier.
Ketosis - think AKTINS !!
Answer Key: D Feedback: Good job! Keeping the head of the bed elevated to 30 degrees will help prevent the discomfort associated with GERD.
Question 3 of 10 0.5 Points You are caring for a hospitalized patient with a history of GERD. The patient complaints that his symptoms seem to be worse while in the hospital. Which of the following nursing interventions would you recommend to the patient at this time? A. Drink at least 10-12 ounces of fluid with each meal B. Give the patient TUMS to help minimize GERD symptoms C. Lie down on your right side and rest after each meal D. Sleep with the head of the bed elevated at 30 degrees
Answer Key: C Feedback: Good job! The best option is a non-red cool clear food, like lemon flavored gelatin.
Question 4 of 10 0.5 Points A patient who had previously been NPO for nausea and vomiting from a bleeding peptic ulcer has received an order to advance the diet as tolerated. Which of the following should the nurse offer to the patient first? A. Hot chicken broth B. Cherry flavored gelatin C. Lemon flavored gelatin D. Coffee with creamer and sugar
1. Diabetic ketoacidosis (DKA) 2. Hyperosmolar hyperglycemic syndrome (HHS)
Prolonged hyperglycemia can lead to two acute metabolic crisis:
Answer Key: C Feedback: Good job! The nursing assistant can help with draining and measurement of output
Question 10 of 10 0.5 Points Which of these nursing activities included in the care of a patient with a new colostomy should the nurse delegate to the nursing assistive personnel (NAP)? A. Place the pouching system over the ostomy. B. Check the skin around the ostomy for breakdown. C. Drain and measure the output from the ostomy. D. Document the appearance of the stoma.
Answer Key: A Feedback: Good job! NPO status is used to allow the bowels to rest and heal.
Question 2 of 10 0.5 Points A patient hospitalized with an acute exacerbation of ulcerative colitis is having 10 to 14 bloody stools a day. The physician orders the patient to be NPO on admission. The nurse recognizes that this order is MOST important because it: A. Promote bowel rest and healing B. Prevents nausea and vomiting C. Decreases abdominal distention and pain D. Allows for laboratory testing to be performed
Answer Key: B Feedback: Good job! Emesis can be either bright red or partially digested and "coffee ground" in appearance. [NIH: Although H. pylori infection is common, peptic ulcer disease and gastric cancer occur in only a small minority of infected persons.]
Question 5 of 10 0.5 Points A patient is hospitalized with the diagnosis of peptic ulcer disease. The nurse may anticipate to find which of the following signs and symptoms: A. Positive H+ Pylori serum test B. Vomiting of "coffee-ground" emesis C. Pain on abdominal palpation over the right lower quadrant D. Pain on abdominal palpation over the left lower quadrant
Answer Key: C Feedback: Good job! It is important that someone with active C Diff is placed in contact enteric isolation to prevent the spread of this disease.
Question 6 of 10 0.5 Points A patient who is hospitalized with watery, incontinent diarrhea is diagnosed with Clostridium difficile (C Diff). Which action will the nurse include in the plan of care? A. Educate the patient about proper food handling and storage. B. Order a diet with no dairy products for the patient. C. Place the patient in a private room with contact enteric precautions. D. Teach the patient about why antibiotics are not being used.
Answer Key: A Feedback: Good job! The first step is to ASSESS the patient's risk factor.
Question 7 of 10 0.5 Points A 67 year-old patient tells the nurse, "I have problems with constipation now that I am older so I use a suppository every morning." Which action should the nurse take first? A. Assess the patient for individual risk factors for constipation. B. Encourage the patient to increase oral fluid intake. C. Inform the patient that a daily bowel movement is unnecessary. D. Suggest that the patient increase daily intake of high-fiber foods.
Answer Key: B Feedback: Good job!
Question 9 of 10 0.5 Points A patient calls the clinic and tells the nurse about a new onset of severe and frequent diarrhea. The nurse anticipates that the patient will need to: A. Prepare for a colonoscopy. B. Collect a stool sample. C. Schedule a barium enema. D. Have blood cultures drawn.
Answer Key: C Feedback: Good job! An increased BMI and snoring are both signs of sleep apnea.
The nurse takes the health history for four patients in the clinic. Which information regarding the patients' sleep is most important to communicate to the health care provider? A. A 21-year-old student takes melatonin to assist in sleeping when traveling from the United States to Europe. B. A 32-year-old who is experiencing a stressful week uses diphenhydramine (Benadryl) for several nights. C. A 41-year-old with a body mass index (BMI) of 42 kg/m2 says that the spouse complains about the patient's snoring. D. A 64-year-old nurse who works the night shift reports drinking hot chocolate before going to bed in the morning.
Primary treatment goals: 1. Rehydration to restore circulating plasma volume 2. Correct electrolyte deficits 3. Additional treatment goals similar to those for DKA
Treatment of HHNS - Hyperosmolar Hyperglycemic Nonketotic Syndrome Liquid? Electrolytes?
1 Not enough insulin Maybe you did not inject enough insulin. Or your body could need more insulin than usual because of illness. 2. Not enough food When you're sick, you often don't feel like eating, sometimes resulting in high ketone levels. High levels may also occur when you miss a meal. 3. Insulin reaction (low blood glucose) If testing shows high ketone levels in the morning, you may have had an insulin reaction while asleep.
What Causes DKA? Here are three basic reasons for moderate or large amounts of ketones:
Answer: D. Feedback: Good job! Pursed-lip breathing should be used before, during and after any activity that causes dyspnea.
When giving instructions to a patient with COPD on Pursed-Lip Breathing (PLB) the nurse instructs the patient on all of the following EXCEPT: A. Inhale slowly and deeply through the nose. B. Exhale slowly through pursed lips, almost as if one were whistling. C. The amount of time spent on exhalation should be 3 times a long as inhalation. D. Use PLB all the time when you are not experiencing dyspnea.
Answer Key: B Feedback: Use of a bronchodilator can ease lungs prior to exercise.
When teaching the patient with chronic obstructive pulmonary disease (COPD) about exercise, which information should the nurse include? A. "Stop exercising if you start to feel short of breath." B. "Use the bronchodilator before you start to exercise." C. "Breathe in and out through the mouth while you exercise." D. "Upper body exercise should be avoided to prevent dyspnea."
Answer Key: D Feedback: Good job! Productive cough is often seen in patients with COPD caused by Chronic Bronchitis.
When the nurse is interviewing a patient with a new diagnosis of chronic obstructive pulmonary disease (COPD), which information will help most in confirming a diagnosis of chronic bronchitis? A. The patient tells the nurse about a family history of bronchitis. B. The patient's history indicates a 40 pack-year cigarette history. C. The patient denies having any respiratory problems until the last 6 months. D. The patient complains about a productive cough every winter for 3 months.
Answer Key: B Feedback: Barrel chest is typically seen with patient's with COPD due to air trapping. - Kyphosis is seen in elderly patients with oseopenia/osteoporosis. roundback or Kelso's hunchback. - Pectus excavatum is a normal alteration of the chest wall not associated with COPD. - Scoliosis is also not associated with COPD although if severe could impair proper oxygenation.
Which of the following findings will the nurse expect to find when performing an assessment of the respiratory system of a patient with chronic COPD? A. Kyphosis B. Barrel chest C. Pectus excavatum D. Scoliosis
Answer Key: D Feedback: Good job! Bradycardia is a LATE sign of inadequate oxygenation.
Which of the following is NOT an early sign of inadequate oxygenation? A. Tachypnea B. Tachycardia C. Dyspnea on exertion D. Bradycardia
Answer Key: A Feedback: Patients with Crohn's Disease may be at increased risk for developing fistula formations which may lead to peritonitis. [Crohn's disease may cause sores,or ulcers,that tunnel through the intestine and into the surrounding tissue,often around the anus and rectum.] Bloody diarrhea is a commonly seen sign and symptom of this disorder. However, diverticulitis is not normally seen in conjunction with Crohn's Disease. [Diverticulitis is a common digestive disease which involves the formation of pouches (diverticula) within the bowel wall.]
You are caring for a patient being admitted with an exacerbation of Crohn's disease. It is important to fully assess this patient every 4 hours because patients with this condition may be at increased risk for all of the following complications EXCEPT: A. Diverticulitis B. Bloody diarrhea C. Fistula formation D. Peritonitis
