Semester 2: Unit 4 Exam

In class discussion *** A patient had a TURP and is receiving continuous bladder irrigation. During your 12 hours shift, the patient's foley collect 5,320mL. The patient received 2500 mL of bladder irrigations. What is the patients urinary out put?

Whats in foley -bladder irrigation= true ouput 5,320ml-2500ml=2820ml (30ml = 1 oz..ice chips are recorded as half of what was ingested )

A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly? A. Bananas B. Strawberries C. Green beans D. Sweet potatoes

Strawberries

Match the following 1.Fracture hematoma 2. Granulation tissue 3. Callus formation 4. Ossification 5. Consolidation 6. Remodeling A. excess bone tissue is reabsorbed and union is complete B. distance between bone fragments diminishing C. prevents movement of fracture site D. forms the basis for new bone substance E. hematoma surrounds the ends of the bone fragments F. new bone is formed

1. E 2. D 3. F 4. C 5. B 6. A

Med surg Factors that most likely influence the development of pressure ulcers: A. amount of pressure (intensity) B. length of time the pressure is exerted on the skin (duration) C. ability of the patient's tissue to tolerate the externally applied pressure D. genetic factors E. shearing force F. exposure to sunlight G. excessive moisture

A. amount of pressure (intensity) B. length of time the pressure is exerted on the skin (duration) C. ability of the patient's tissue to tolerate the externally applied pressure E. shearing force G. excessive moisture

Powerpoints Skin mobility and turgor should be checked where (select all that apply) A. forearm B. back of hand C. under clavicle D. dorsum of the foot

A. forearm C. under clavicle DO NOT check skin turgor on hands bc older patients lose fat here first; thus you may get a false impression of dehydration

Power points What primary prevention measures are appropriate to implement to maintain optimum mobility? A. regular physical activity B. optimal nutrition C. Fall prevention measures D. PSA testing E. Mobile mammography

A. regular physical activity B. optimal nutrition C. Fall prevention measures

Med surg Most common site for pressure ulcers is the A. sacrum B. heels being C. shoulders D. back of head

A. sacrum

What categories are assessed in the Braden Scale? ( select all that apply) A. sensory perception B. cognition C. moisture D. activity E. hx of pressure ulcers F. mobility G. nutrition H. friction and shear

A. sensory perception C. moisture D. activity F. mobility G. nutrition H. friction and shear There are six (friction and shearing go together) (Some Monkys Abuse Many, Naughty Family members who Smoke)

Powerpoints Diet considerations for patient with Parkinson's (select all that apply) A. 7:1 diet B. Diet high in milk and milk products C. Diet high in protein D. Diet high in fiber, fluids, and easily chewed foods

A. 7:1 diet D. Diet high in fiber, fluids, and easily chewed foods high protein diet causes competition of amino acids in food vs levapoda... leading to decrease amount of levodopa reaching the brain..don't take meds too close to meal time and dont take with milk/milk products...Note: this does not happen to all patients The 7:1 diet balances carbohydrate and protein, allowing for 7 parts carbohydrate to 1 part protein. Parkinson's pt are at risk or constipation and dysphagia so it is important diets are high fiber, fluids, small bites of easily chewed foods

Power points Which labs would most likely be drawn if patient has issues with mobility (select all that apply) A. Alkaline phosphatase B. Thyroid panel C. Calcium D. lipid profile E. Troponin F. Phosphorus G. Uric acid H. Creatine kinase I. BUN/Creatinine

A. Alkaline phosphatase C. Calcium F. Phosphorus G. Uric acid H. Creatine kinase I. BUN/Creatinine

The nurse instructs the patient on possible side effects while taking finasteride, which includes A. Decreased interest in sexual activity B. Dizziness when getting out of bed quickly C. A greater risk for high BP D. Frequent urination

A. Decreased interest in sexual activity A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Orthostatic hypotension is a side effect of the α-blocking agents. Improvement in symptoms of obstruction takes 3 to 6 months. The medication does not cause hypertension.

A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take? A. Instruct the client to splint the wound with a pillow when coughing. B. Place the client in the supine position and inspect the site of the incision. C. Assess the intensity of the pain and administer the prescribed analgesic. D. Call the healthcare provider immediately and then check for wound dehiscence.

A. Instruct the client to splint the wound with a pillow when coughing. Supporting the wound with a pillow when coughing relieves some of the pain because it provides support to the incised chest wall. Pain at the incision site when coughing and deep breathing is expected; it does not indicate a need to place the client in the supine position and to inspect the wound site. Analgesics will not relieve the discomfort associated with coughing unless stress placed on the incision by coughing is relieved. Pain at the incision site just when coughing and deep breathing is expected; it does not indicate a need to call the healthcare provider and then check for wound dehiscence.

A patient is not certain whether she and her family should participate in a genetic screening plan. She asks the nurse why the X-linked recessive disorder that has been noted in some of her family members is expressed in males more frequently than in females. What is the nurse's best response? a. "The disease tends to show up in males because they do not have a second X chromosome to balance the expression of the gene." b. "One X chromosome of a pair is always inactive in females. This inactivity effectively negates the effects of the gene." c. "Females are known to have more effective DNA repair mechanisms than males, thus negating the damage caused by the recessive gene." d. "Expression of genes from the male's Y chromosome does not occur in females, so they are essentially immune to the effects of the gene."

ANS: A Because the number of X chromosomes in males and females is not the same (1:2), the number of X-linked chromosome genes in the two genders is also unequal. Males have only one X chromosome for any gene on the X chromosome. As a result, X-linked recessive genes have a dominant expressive pattern of inheritance in males and a recessive expressive pattern of inheritance in females. This difference in expression occurs because males do not have a second X chromosome to balance the expression of any recessive gene on the first X chromosome. It is incorrect to say that one X chromosome of a pair is always inactive in females or that females have more effective DNA repair mechanisms than males. Also, it is not true that females can be immune to the effects of a gene, because genes from the male's Y chromosome are not expressed in females.

The lack of weight bearing leads to what effects on the skeletal system? a. Demineralization, calcium loss b. Thickened bones c. Increased range of motion d. Increased calcium deposition in the bones

ANS: A Weight bearing helps to strengthen the bone. Lack of weight bearing means that the bone is losing minerals and calcium that strengthen it. Thickened bones will not occur with the lack of weight bearing. Range of motion may be decreased with a lack of weight bearing movements.

What is the priority nursing diagnosis for a patient experiencing chemotherapy-induced anemia? a. Risk for injury related to poor blood clotting b. Fatigue related to decreased cellular oxygenation c. Disturbed body image related to skin color changes d. Imbalanced nutrition, less than body requirements related to anorexia

ANS: B Decreased numbers of red blood cells (RBCs) result in decreased cellular oxygenation and less energy. Decreased numbers of RBCs alone do not change the patient's blood-clotting ability. Although skin color changes and altered nutrition also occur with anemia, fatigue due to decreased cellular oxygenation is a priority nursing diagnosis.

A patient who has been in the hospital for several weeks is about to be discharged. The patient is weak from the hospitalization and asks the nurse to explain why this is happening. What is the nurse's best response? a. "Your iron level is low. This is known as anemia." b. "Your immobility in the hospital is known as deconditioning." c. "Your poor appetite is known as malnutrition." d. "Your medications have caused drug induced weakness."

ANS: B When a person is ill and immobile the body becomes weak. This is known as deconditioning. Anemia, malnutrition, and medications may have an adverse effect on the body, but this is not known as deconditioning which is the most likely cause in this patient's situation.

An older patient is talking with the nurse about hip fractures. The patient would like to know the best approach to strengthen the bones. What is the nurse's best response? a."Walk at least 5 miles every day for exercise." b."Wear proper fitting shoes to prevent tripping." c."Talk with your physician about a calcium supplement." d."Stand up slowly so you don't feel faint."

ANS: C Calcium strengthens the bones. A calcium supplement will help strengthen bones as they may be affected by aging, illness, or trauma. Walking several miles will help strengthen the bones, but the patient should consult with the healthcare provider before any exercise regimen is implemented for the older adult. Wearing proper shoes and standing slowly to prevent dizziness is important but they will not prevent fractures.

While the nurse is obtaining the health history of a 75-year-old female patient, which of the following has the greatest implication for the development of cancer? a. Being a woman b. Family history of hypertension c. Cigarette smoking as a teenager d. Advancing age

ANS: D According to the American Cancer Society, the most important risk factor for cancer development is advancing age.

The nurse is caring for a patient who received a bone marrow transplant 10 days ago. The nurse would monitor for which of the following clinical manifestations that could indicate a potentially life-threatening situation? a. Mucositis b. Confusion c. Depression d. Mild temperature elevation

ANS: D During the first 100 days after a bone marrow transplant, patients are at high risk for life-threatening infections. The earliest sign of infection in an immunosuppressed patient can be a mild fever. Mucositis, confusion, and depression are possible clinical manifestations but are representative of less life-threatening complications.

Mobility for the patient changes throughout the life span. What is the term that best describes this process? a. Aging and illness b. Illness and disease c. Health and wellness d. Growth and development

ANS: D Growth and development happens from infancy to death. Muscular changes are always happening, and these changes affect the individual and his or her performance in life. Aging, illness, health, and wellness do have an effect on a person, but they don't always affect mobility.

The nurse is talking to the unlicensed assistive personnel about moving a patient in bed. The nurse knows the unlicensed assistive personnel understands the concept of mobility and proper moving techniques when making which statement? a. "Patients must have a trapeze over the bed to move properly." b. "Patients should move themselves in bed to prevent immobility." c. "Patients should always have a two-person assist to move in bed." d. "Patients must be moved correctly in bed to prevent shearing."

ANS: D Patients must be moved properly in bed to prevent shearing of the skin. Having a trapeze over the bed is only functional if the patient can assist in the moving process. A two-person assist is good, but the patient still needs to be moved properly. A patient may move himself or herself if he or she is able; but shearing may still occur

In caring for a patient following lobectomy for lung cancer, which of the following should the nurse include in the plan of care? a. Position the patient on the operative side only. b. Avoid administering narcotic pain medications. c. Keep the patient on strict bed rest. d. Instruct the patient to cough and deep breathe.

ANS: D Postoperative deep breathing and coughing is important to promote oxygenation and clearing of secretions. Pain medications will be given to lessen pain and allow for deep breathing and coughing. Strict bed rest is not instituted, because early ambulation will help lessen postoperative complications such as deep vein thrombosis. Prolonged lying on the operative side is avoided.

Nclex question A 5 year old has a fracture of the right upper arm. The x-ray showed that one side of the bone is bent while the other is broken. This known as a __________ fracture? A. Spiral B. Greenstick C. Oblique D. Transverse

B. Greenstick This is a greenstick fracture. These types of fractures are more common in the pediatric population because their bones tend to be more flexible and the periosteum is stronger than an adult.

Nclex question Which statement by a patient, who just received a cast on the right arm for a fracture, requires you to notify the physician immediately? A. "It is really itchy inside my cast!" B. "My pain is so severe that it hurts to stretch or elevate my arm." C. "I can feel my fingers and move them." D. "I've been using ice packs to reduce swelling."

B. "My pain is so severe that it hurts to stretch or elevate my arm." The answer is B. This statement is very concerning and may represent a condition called compartment syndrome. Compartment syndrome is where the nerves and blood vessels are becoming compromised due to increasing pressure in the compartments within the fascia (remember fascia doesn't expand, so if there is building pressure within the compartments of muscle from bleeding etc. it will compromise circulation and nerve function). Remember to monitor the 6 P's. (pain, pallor, paralysis, paresthesia, pulselessness (late sign), poikilothermia)

A pt with acute urinary retention associated with BPH is admitted to the ED. At home, the pt had no urine output for 12 hours. Labs reveal an elevated BUN and creatinine. The nurse will anticipate the HCP to order: A. Inpatient dialysis B. An indwelling foley catheter C. An IV for fluid replacement D. High dose diuretics

B. An indwelling foley catheter - permits release of urine Note nurse must monitor sings of infection

Power points: Why is it important to give medications on time and in the morning to a patient with parkinson's A. Agitations is worse in the morning B. Aspiration may occur C. they will quickly become confused D. puts them at a greater risk for compartment syndrome

B. Aspiration may occur pt with parkinson's typically suffer from dyphagia dysphagia→ diffulculty swallowing...meds must be given on time and in the morning so patient is not at risk for aspiration during their breakfast

Powerpoints How can the nurse decrease the risk of aspiration in a patient with Parkinson's (select all that apply) A. Place patient in low-folwers position for meal time B. Asses gag reflex C. Have patient sit in chair for meal time if tolerated D. Have patient walk floor prior to meal time E. Give medications on time

B. Asses gag reflex C. Have patient sit in chair for meal time if tolerated E. Give medications on time asses gag reflex, out of bed to chair for meals, or place patient in FULL fowlers for meal time, give medications on time to improve swallowing

Most effect drug for treating Parkinson's A. Benztropine (Cogentin) B. Carbidopa / Levodopa (Sinemet) C. Pramipexole (mirapex) D. Ropinirole(requip) E. Trihexyphenidyl (Artane)

B. Carbidopa / Levodopa ( Sinemet) Dopaminergic

While caring for an obese client who underwent a cholecystectomy, the nurse notices a separation in the surgical incision. Which complication does the nurse identify? A. Adhesions B. Dehiscence C. Evisceration D. Contractions

B. Dehiscence Dehiscence is the separation and disruption of previously joined wound edges; this condition typically occurs in obese clients. Adhesions are bands of scar tissue that form between or around organs. Evisceration occurs when wound edges separate to the extent that intestines protrude through the wound. Contractions are a normal part of healing, but excessive contractions result in deformity.

Powerpoints Anti parkinsonian drugs work by: (select all that apply) A. Increase in COMT (Catechol-O-methyltransferase) B. Enhance/release supply of dopamine C. Decrease the absorption of dopamine D. block the effects of overactive cholinergic neurons

B. Enhance/release supply of dopamine D. block the effects of overactive cholinergic neurons

Power Points: Which fractures are most common in geriatric population A. Humerus fx B. Hip fx C Femoral shaft fx D. Colle's fx

B. Hip fx

Nclex question Select all the signs and symptoms that will present in compartment syndrome? A. Capillary refill less than 2 seconds B. Pallor C. Pain relief with medication D. Feeling of tingling in the extremity E. Affected extremity feels cooler to the touch than the unaffected extremity

B. Pallor D. Feeling of tingling in the extremity E. Affected extremity feels cooler to the touch than the unaffected extremity These symptoms may present with compartment syndrome. Option A and C are normal findings. Remember in compartment syndrome nerve and blood vessel function is being compromised, so expect signs and symptoms that occur when these structures are affected.

Which of the following is NOT a nursing intervention for impaired mobility A. Positioning patient with appropriate body alignment B. Reposition patient at least every 3-4 hour C. Keeping skin clean, dry, and protected D. Encouraging coughing, deep breathing, and bed exercises E. Encouraging patient to stand at the side of the bed to promote weight bearing

B. Reposition patient at least every 3-4 hour pt should turned at least every 2 hours

A client has a laryngectomy and radical neck dissection for cancer of the larynx. Two tubes from the area of the incision are connected to portable wound drainage systems. Inspection of the neck reveals moderate edema even though the drainage systems are functioning. Which clinical indicator should the nurse assess in the client? A. Crackles B. Restlessness C. Loss of the gag reflex D. Cloudy wound drainage

B. Restlessness The client has a high risk for airway obstruction from the edema; restlessness and dyspnea indicate cerebral hypoxia. Crackles come from the alveoli, part of the lower airway; the surgery involves the upper airway. There is no evidence of abdominal distention. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed, and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Cloudy drainage may indicate infection; however, this is not an immediate postoperative complication.

Power points The nurse suspect yellow purulent discharge from a wound, however, when she irrigates wound it does not go away. What should the nurse suspect this is A. Eschar B. Slough C. Undermining D. Tunneling

B. Slough

Med surg Loss of dermis with a shallow red-pink wound bed, without slough or bruising. What stage of pressure ulcer? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable .

B. Stage 2 (Bruising indicates deep tissue injury) May also present as an intact or open/ruptured serum-filled or serosanguineous-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.

A patient with a fracture of the left femoral neck has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should: A. turn the patient partially to each side with the assistance of another nurse B. have the patient lift the buttocks slightly by using a trapeze over the bed C. loosen the traction and help the patient turn onto the unaffected side D. place a pillow between the patient's legs & turn gently to each side

B. have the patient lift the buttocks slightly by using a trapeze over the bed Traction : alligns the bone with a steady pullling action . Weights should hang freely..NEVER ON THE FLOOR...never remove weights unless instructed by MD. Make sure patient has overhead trapezius to help them move slightly ..monitor for compartment syndrome

Powerpoints What are typical complications of antiparksonian medications that the nurse should asses for (select all that apply) A. anorexia B. orthostatic hypotension C.dyskinesia D psychiatric changes

B. orthostatic hypotension C.dyskinesia D psychiatric changes Medications can cause orthostatic hypotension, dyskinesia, and psychiatric changes (aka personality changes)

A 55-year-old female arrives to the ER with a right leg fracture. An x-ray is performed and shows a closed tibia fracture. A closed reduction is performed and a cast is put in place. The patient is ordered Morphine 2 mg IV every 4-6 hours as needed for pain. The patient calls on the call light to tell you the pain medication is not working and that it even hurts to slightly stretch the leg. What is your response to this statement by the patient? Select all that apply: A. Reassure the patient that this is normal after a bone fracture, and reposition the cast. B. Re-adjust the cast to ensure it fits snugly against the fracture. C. Perform neurovascular checks. D. Elevate the leg above heart level. E. Loosen and remove restrictive items. F. Notify the physician.

C. A. Reassure the patient that this is normal after a bone fracture, and reposition the cast. ELIMINATED! This is not normal and should be investigated/reported to the physician along with performing some nursing interventions. B. Re-adjust the cast to ensure it fits snugly against the fracture. ELIMINATED! We definitely don't want to do this because this will increase the muscle's compartment pressure even more. We want to decrease pressure and re-adjusting the cast to fit more snugly will cause more problems. C. Perform neurovascular checks. CORRECT! As discussed above in detail, we want to check the 6 P's....pain (early sign), paresthesia, pallor, paralyisis, poikilothermia, pulselessness (late sign). D. Elevate the leg above heart level. ELIMINATED! We want to keep the leg AT HEART LEVEL, not above it. Keep the extremity at heart level helps maintain arterial pressure, which is very important because the muscle compartment is experiencing ischemia. E. Loosen and remove restrictive items. CORRECT! Yes, we most definitely want to do this to help alleviate any extra pressure on the compartment! F. Notify the physician. CORRECT! Of course, we will be doing this while simultaneously doing all the other things. The MD may order bivalvement of the cast (cutting it in half) or performing a fasciotomy in severe cases.

Med surg Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed; slough, undermining and tunneling may be present. What stage of pressure ulcer? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable .

C. Stage 3 Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure depth of tissue loss. May include undermining and tunneling. The depth of a category/stage III pressure ulcer varies by anatomic location.

Power Points Which type of fracture would cause the most concern for impaired perfusion A. Non displaced closed fx B. Incomplete fx C. Displaced fx D. Non displaced femoral shaft fx

C. Displaced fx

Power points Home health nurse is assessing a patient who was recently treated with abx. The nurse notices disperse redness in sacral area and in between thighs. The nurse should suspect ? A. Stage 1 pressure ulcer B. Stage 2 pressure ulcer C. Fungal infection D. Second degree burn

C. Fungal infection recent abx use, redness is disperse and typically you are not going to see pressure ulcers in-between the thighs

How do you determine the extent of injury to the growth plate ? A. Break index B. Braden Scale C. Salter harries classification D. FRAX test

C. Salter harries classification

A nurse is evaluating a client's understanding regarding postoperative concerns after a mastectomy. Which unanticipated development near and around the incision noted by the client should be reported to her primary healthcare provider? A. Persistent itching B. Decreased sensation C. Swelling with erythema D. Irregular-appearing skin

C. Swelling with erythema Swelling and erythema are signs of infection and should be reported to the primary healthcare provider immediately. Itching is a sign of healing that is expected. Decreased sensation results from the severing of nerves and formation of scar tissue and is expected. There is little subcutaneous fat in the thoracic area, and the skin may be taut at the operative site, appearing irregular; this commonly occurs.

The following exam results in accurate determination of prostate size as well as dx of BPH or prostate cancer. A.Digital rectal exam B. Uro flow meter C. Transrectal ultrasound scan D. X - Ray

C. Transrectal ultrasound scan

Nclex question What is a late sign of compartment syndrome? A. Paralysis B. Pain C. Parethesia D. Pulselessness

D. Pulselessness Pulselessness is a late sign of compartment syndrome.....nurse can mark where he/she felt pulse in affected extermity) NOTIFY PROVIDER RIGHT AWAY AND KEEP EXTREMITY ELEVATED...remove any restrictive clothing Pain is an early sign

The nurse is caring for a client who underwent intestinal surgery 3 days ago and notices brownish pus with a fecal odor draining from the incision. What should the nurse infer from this finding? A. Colonization with Proteus B. Colonization with Pseudomonas C. Colonization with Staphylococcus D. Colonization with aerobic coliform and Bacteroides

D. Colonization with aerobic coliform and Bacteroides A client who underwent intestinal surgery is more susceptible to developing colonization of aerobic coliform and Bacteroides, which results in brown pus with a fecal odor. Beige pus that has a fishy odor is formed due to colonization with Proteus. Greenish-blue pus that has a fruity smell is formed due to colonization with Pseudomonas. Creamy-yellow pus indicates a colonization of Staphylococcus.

Med surg Exposed bone, tendon, or muscle is visible or directly palpable, slough and eschar may be present, osteomyelitis may occur. What stage of pressure ulcer? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable .

D. Stage 4 exposed bone, tendon, or muscle is visible or directly palpable Slough or eschar may be present. Often includes undermining and tunneling. Depth of pressure ulcer varies by anatomic location . Ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis or osteitis likely to occur.

Alpha blockers in the treatment of BPH are associated with all of the following except: A. Improvment in symptoms in 2-3 weeks B. Minimal changes in blood pressure C. Once daily dosing D. Side effects of dizziness and fatigue E. 25% decrease in prostate size

E. 25% decrease in prostate size

Med surg Actual depth of ulcer is completely obscured by slough and/or eschar in wound bed. What stage of pressure ulcer? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable

E. Unstageable actual depth of ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in wound bed . Until enough slough and/or eschar are removed to expose the base of wound, the true depth cannot be determined; but it will be either a stage III or stage IV. Stable (dry, adherent, intact without erythema, or fluctuance) eschar on the heels serves as "the body's natural (biologic) cover" and should not be removed.

Which physiologic activity is associated with the "proliferative phase" of normal wound healing? White blood cells migrate into the wound Epithelial cells grow over the granulation tissue bed Scar tissue gradually becomes thinner and pale in color Vasodilation occurs with increased capillary permeability

Epithelial cells grow over the granulation tissue bed During the "proliferative phase" of normal wound healing, the epithelial cells grow over the granulation tissue bed. The white blood cells are migrated into the wound during the inflammatory phase. In the maturation phase, the scar tissues gradually become thinner and pale in color. The vasodilation with the increased capillary permeability may occur during the inflammatory phase.

True or False Alpha-adrenergic antagonists decrease the size of the prostate?

FLASE Relax muscles around prostate 5-alpha-reductase inhibitors --> Helps with decreasing prostate size Ex/ Finasteride (Proscar)...conservative approach ( may cause decreased libido) **reductase --> reduce size

True or False: Time heals all wounds

False Time does not heal all wounds. Chronic wounds are those that do not heal within the normal time (approximately 3 months). If a wound fails to heal in a timely manner, assess and identify factors that may delay healing. Refer the patient to an HCP specializing in wound management. .

Nclex question Fractured bone that breaks through the skin. A. Closed Fracture B. Compound Fracture C. Greenstick Fracture D. Transverse Fracture

The answer is B. This is known as a compound fracture (also called an open fracture)

Nclex question Fractured bone is broken into many fragments (3 or more). A. Open Fracture B. Greenstick Fracture C. Oblique Fracture D. Comminuted Fracture

The answer is D. This is known as a comminuted fracture

What question would be most important to ask a male client who is in for a digital rectal examination? a. "Have you noticed a change in the force of the urinary system?" b. "Have you noticed a change in tolerance of certain foods in your diet?" c. "Do you notice polyuria in the AM?" d. "Do you notice any burning with urination or any odor to the urine?"

a. "Have you noticed a change in the force of the urinary system?" This change would be most indicative of a potential complication with (BPH) benign prostate hypertrophy.

How common is BPH? a. 50% of men in their 60s b. 10% of men in their 60s c. 90% of men in their 60s d. 30% of men in their 60s

a. 50% of men in their 60s

A patient scheduled for a transurethral resection of the prostate (TURP) for BPH tells the nurse that he has delayed having surgery because he is afraid it will affect his sexual function. When responding to his concern, the nurse explains that a. with this type of surgery, erectile problems are rare, but retrograde ejaculation may occur. b. information about penile implants used for ED is available if he is interested. c. there are many methods of sexual expression that can be alternatives to sexual intercourse. d. sterility will not be a problem after surgery because sperm production will not be affected.

a. with this type of surgery, erectile problems are rare, but retrograde ejaculation may occur. Rationale: Erectile problems are rare, but retrograde ejaculation may occur after TURP. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns.

Med surg (end of chapter questions) Which one of the orders should a nurse question in the plan of care for an elderly immobile stroke patient with a stage III pressure ulcer? a. Pack the ulcer with foam dressing. b. Turn and position the patient every hour. c. Clean the ulcer every shift with Dakin's solution. d. Assess for pain and medicate before dressing change.

c. Clean the ulcer every shift with Dakin's solution

A patient with irritative and obstructive bladder symptoms has an enlarged prostate on digital rectal examination (DRE) and an elevated PSA level. The nurse will anticipate that the patient will need teaching about a. uroflometry studies. b. cystourethroscopy. c. transrectal ultrasonography (TRUS). d. magnetic resonance imaging (MRI).

c. transrectal ultrasonography (TRUS). In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to help differentiate BPH from prostatic cancer. Uroflowmetry studies will help determine the extent of urine blockage and treatment, but a differential diagnosis will be obtained first. Cystourethroscopy may be used after TRUS if the diagnosis is still uncertain. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the diagnostic process.

Nclex question An older patient has developed age spots and is concerned about skin cancer. How would the nurse instruct the patient to perform skin checks to assess for signs of skin cancer? a."Limit the time you spend in the sun." b."Monitor for signs of infection." c."Monitor spots for color change." d."Use skin creams to prevent drying."

c."Monitor spots for color change." The ABCD method (check for asymmetry, border irregularity, color variation, and diameter) should be used to assess lesions for signs associated with cancer. Color change could be a sign of cancer and needs to be looked at by a dermatologist. Limiting time spent in the sun is a preventative measure but will not assist the patient in checking the skin or detecting skin cancer. Infection is usually not found in skin cancer. Skin creams have not been shown to prevent cancer nor would they assist in detecting skin cancer.

Which of the following signs and symptoms would indicate that a client has benign prostatic hypertrophy (BPH)? a. Hematuria b. Flank pain c. Impotence d. Difficulty starting the urinary stream

d. Difficulty starting the urinary stream The symptoms of BPH are related to obstruction as a result of an enlarged prostate. Difficulty in starting the urinary stream is a common symptom, along with dribbling, hesitancy and urinary retention.

In class discussion What congenital disease will affect children's bones breaking? A. Osteogenesis imperfecta B. Rickets C. Paget's disease D. Osteoporosis

A. Osteogenesis imperfecta Osteogenesis imperfecta is caused by defective genes. These genes affect how the body makes collagen, a protein that helps strengthen bones. The condition can be mild, with only a few fractures during a person's lifetime. In more severe cases, it can involve hundreds of fractures that occur without any apparent cause. Treatments include bone-strengthening medications, physical therapy, and orthopedic surgery

When a client who has had a mastectomy sees her incision for the first time, she exclaims, "I look horrible! Will it ever look better?" What is the nurse's best response? A. "You seem shocked by the way you look now." B. "Now that the tumor is gone, the area will heal quickly." C. "After it heals, others won't even know you had surgery." D. "You will feel better about it when the swelling subsides."

A. "You seem shocked by the way you look now." Reflection of feelings provides an opportunity to express emotions, which may promote eventual acceptance of body image changes. Saying that the area will heal quickly now that the tumor is gone, that others won't know that the client had surgery, or that the client will feel better once the swelling subsides negates the client's feelings and is not an honest or realistic response; false reassurance does not promote trust.

Occlusive dressing is placed for 5-7 days to allow for the patients enzymes to break down the necrotic tissue or slough is known as what type of debridement A. Autolytic B. Chemical C. Mechanical D. Whirlpool E. Surgical

A. Autolytic Autolytic → the body's own enzymes to remove dead, sloughy and necrotic tissues. occlusive dressing is placed for 5-7 days to allow for the patients enzymes to break down the necrotic tissue or slough) Chemical → involves enzyme debridement via medication Mechanical → wet to dry dressing... when you remove dressing you are removing debris with it Whirlpool → action of whirl removes debris Surgical → removed with scalpel

Powerpoints Which drug used for parkinson's decrease the effects of acetylcholine A. Benztropine (Cogentin) B. Carbidopa / Levodopa (Sinemet) C. Pramipexole (mirapex) D. Ropinirole(requip) E. Trihexyphenidyl (Artane)

A. Benztropine (Cogentin) E. Trihexyphenidyl (Artane)

NCLEX question Which of the following items are used to perform wound care irrigation? Select all that apply. A. Clean gloves B. Sterile gloves C. Refrigerated irrigating solution D. 60-mL syring

A. Clean gloves B. Sterile gloves D. 60-mL syring To irrigate a wound, the nurse uses clean gloves to remove the old dressing and to hold the basin collecting the irrigating fluid plus sterile gloves to apply the new dressing. A 60-mL syringe is the correct size to hold the volume of irrigating solution plus deliver safe irrigating pressure. The irrigation fluid should be at room or body temperature-- certainly not refrigerated

Nclex question Your patient is 2 hours post-op from a cast placement on the right leg. The patient has family in the room. Which action by the significant other requires you to re-educate the patient and family about cast care? A. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying. B. Positioning the cast at heart level with pillows. C. Checking the color and temperature of the right foot. D. Using a hair dryer on the cool setting to help with drying.

A. Gently moving the cast with the fingertips of the hands every 2 hours to help with drying. The cast should always be moved with the palms of the hands (NOT finger tips) during the drying period to prevent dent formation because this can cause the development of ulcers under the skin where the dents develop....pt should never stick anything into their cast to itch..instead an antihistamine may be prescribed

Adaptive quiz What are the functions of a client's subcutaneous layer of skin? Select all that apply. A. It provides insulation. B. It acts as an energy reservoir. C. It prevents systemic dehydration. D. It provides cells for wound healing. E. It acts as a mechanical shock absorber

A. It provides insulation. B. It acts as an energy reservoir. E. It acts as a mechanical shock absorber The subcutaneous layer provides insulation and acts as an energy reservoir and mechanical shock absorber. The epidermal layer prevents systemic dehydration. The dermal layer provides cells for wound healing.

Power points Which statements are true about the granulation phase of wound healing ( select all that apply) A. Migration of fibroblasts B. Secretion of collagen C.Migration of epithelial cells D. Clot serving as meshwork for starting capillary growth E. Scar formation F. Abundance of capillary buds G. Wound is fragile H.Collagen fibers remodel I. Contraction of the skin/wound occur

A. Migration of fibroblasts B. Secretion of collagen F. Abundance of capillary buds G. Wound is fragile Inflammation→ 3-5 days. Homeostasis develops and macrophages remove debri..Approximation of incision edges..Migration of epithelial cells...Clot serving as meshwork for starting capillary growth Granulation→ 5-21days...new blood vessels are formed...Migration of fibroblasts. Secretion of collagen. Abundance of capillary buds. Wound fragile Maturation→ lasts months....collagen fibers remodel, scar formation, and contraction of the skin/wound occur

Allowing the patient and their family to be included to plan of care falls under which concept of QSEN A. Patient Centered Care B. Teamwork and Collaboration C. Evidence-based Practice D. Quality Improvement E. Safety F.Informatics

A. Patient Centered Care Teamwork and Collaboration: Ex: Pharmacy getting meds to nurse on time, Social service planning proper discharge, PT came up with plan for patient, Dietitian making sure diet is tolerated well Evidence-based Practice: Ex: 7:1 diet and new surgical intervention Quality Improvement Ex: Nurse is monitoring for changes in patient if medication was adjusted Safety Ex: nurse assess risk for falls and apply non skid socks to patient Informatics Ex: Assessments being recorded in EMR.

Powerpoints Pt is being treating for parkinson's...what cardio pulmonary issues should the nurse be concerned with (select all that apply) A. Postural hypotension B. Aspiration C. Pneumothorax D. Aortic aneurysm

A. Postural hypotension B. Aspiration -postural hypotension due to medication--> instruct patient to change positions slowly and obtain orthostatic blood pressure at admission -Asses lungs bc patient is at risk for aspriations due to weakness of their muscles

Powerpoints Why is a patient why parkinson's at risk for fall (select apply that apply) A. Shuffling gait B. Leaning posture C. Increased coordination D. speed of gait changes

A. Shuffling gait B. Leaning posture D. Speed of gait changes pt with parkinson's will have a shuffling gait...which will cause their gait to speed up and they are unable to catch themselves/slow down...thus, shuffling gait, speeding up of gait, and leaning forward puts them at risk for fall.

Med surg Intact skin with nonblanchable redness of a localized area usually over a bony prominence would be what stage of a pressure ulcer? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 E. Unstageable

A. Stage 1 The area may also be painful, firm, soft, warmer, or cooler as compared to adjacent tissue...Note: if patient has darker skin it may be hard to notice blanching

Nclex question: Which assessment finding found while assessing a patient with a fracture who has traction requires immediate intervention? A. The weights are freely hanging on the floor. B. Pin sites are free from drainage. C. Patient uses the overhead trapeze bar to move around in the bed. D. Patient's extremities have a capillary refill of less than 2 seconds.

A. The weights are freely hanging on the floor. Weights used for traction should freely hang but NOT on the floor. All the other options are expected findings.

In class discussion How can the nurse help prevent pressure ulcers (select all that apply) A. Turning the patient every 2 hours B. elevating the bed no more than 60 degrees C. Place the body in a 30 degree laterally inclined position D. use of devices such as foam mattress, wheelchair cushion, and left shift

A. Turning the patient every 2 hours C. Place the body in a 30 degree laterally inclined position D. use of devices such as foam mattress, wheelchair cushion, and left shift Use devices such as→ low-air-loss mattresses, foam mattresses, wheelchair cushions, padded commode seats, boots [foam, air], lift sheets) "Rule of 30" (means the head of the bed is elevated at no more than 30 degrees and the body is placed in a 30-degree, laterally inclined position) Turn every 2 hours

Med Surg Nondisplaced fractures are usually: (select all that apply) A. transverse B. spiral C. oblique D. greenstick E. comminuted

A. transverse B. spiral D. greenstick In a displaced fracture, the two ends of the broken bone are separated from one another and out of their normal positions. Displaced fractures are often comminuted (more than two fragments) or oblique. In a nondisplaced fracture, the periosteum is intact across the fracture and the bone fragments are still in alignment. Nondisplaced fractures are usually transverse, spiral, or greenstick.

Med Surg Which stage of fracture healing does the basis of osteoid form and occurs 3-14 days after injury A. Fracture hematoma B. Granulation C. Callus formation D. Ossification E. Consolidation F. Remodeling

B. Granulation Granulation tissue: 3 to 14 after injury→ active phagocytosis absorbs the products of local necrosis. The hematoma converts to granulation tissue. Granulation tissue (consisting of new blood vessels, fibroblasts, and osteoblasts) forms the basis for new bone substance (osteoid)

Three days after bariatric surgery, the client puts the call light on and states, "I felt a 'pop' in my belly after I had a coughing spell." The nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? A. Loosening of the sutures B. Sharp increase in serosanguineous drainage C. Purplish color of the incision D. Protrusion of organs through an open incision

B. Sharp increase in serosanguineous drainage Serosanguineous drainage from the wound or on the dressing forewarns separation of the wound edges (dehiscence); dehiscence may progress to movement of abdominal organs outside of the abdominal cavity (evisceration). Loosening of sutures may occur after the initial wound edema subsides, but is not a sign of failure of the suture line. A purplish incision is the expected coloration of a healing wound.

Cardinal Manifestations of Parkinson's A. Anorexia B. Tremor C. Muscle rigidity D. Bradykinesia

B. Tremor C. Muscle rigidity D. Bradykinesia Termor → "pill rolling", pronation and supination of hands at rest, tremors increase during stress and anxiety Muscle rigidity→ "cogwheel rigidtiy" ( a "stop and go" effect during a range of motion maneuver) due to involunatry contraction of all skeletal muscles Bradykinesia→ slow movement causing problems with swallowing, facial expression ( mask like face) , gait, postural adjustment issues

A patient was given a patch test to determine what allergen was responsible for their atopic dermatitis. The provider prescribes a steroid cream. What important instructions should the nurse give to the patient? a.Apply the cream generously to affected areas. b.Apply a thin coat to affected areas, especially the face. c.Apply a thin coat to affected areas; avoid the face and groin. d.Apply an antihistamine along with applying a thin coat of steroid to affected areas.

C. Apply a thin coat to affected areas; avoid the face and groin. The patient should avoid the face and groin area as these areas are sensitive and may become irritated or excoriated. An antihistamine cream would also excoriate the area if the pruritus is cause by an allergen. There may be a need to administer oral steroid if the rash is generalized.

Med Surg Which stage of fracture healing typically occurs 2 weeks after initial injury and new bone is formed A. Fracture hematoma B. Granulation C. Callus formation D. Ossification E. Consolidation F. Remodeling

C. Callus formation Fracture hematoma: first 72 hours after injury→ hematoma surrounds the ends of the bone fragments Granulation tissue: 3 to 14 after injury→ active phagocytosis absorbs the products of local necrosis. The hematoma converts to granulation tissue. Granulation tissue (consisting of new blood vessels, fibroblasts, and osteoblasts) forms the basis for new bone substance (osteoid) Callus formation: end of second week of injury→ new bone is formed (composed of cartilage, osteoblasts, calcium, and phosphorus) Ossification: 3 weeks to 6 months → prevents movement of fracture site However, the fracture is still evident on x-ray. During this stage, the patient may be allowed limited mobility or the cast may be removed. Consolidation: can occur up to 1 year after injury→ distance between bone fragments diminishing and eventually closes Remodeling: excess bone tissue is reabsorbed and union is complete

Med Surg What is the UAP able to do in wound care A. Evaluate whether wound care is effective in promoting wound healing B. Assess and monitor patient's nutritional status C. Empty wound drainage containers and document drainage on intake and output record. D. Apply prescribed dressings or medications for wound debridement

C. Empty wound drainage containers and document drainage on intake and output record. RN--> Evaluate whether wound care is effective in promoting wound healing LPN/LVN--> Apply prescribed dressings or medications for wound debridement Dietitian--> Assess and monitor patient's nutritional status.

Nclex question A patient sustained a fracture to the femur. The patient has suddenly become confused, restless, and has a respiratory rate of 30 breaths per minute. Based on the location of fracture and the presenting symptoms, this patient may be experiencing what type of complication? A. Compartment Syndrome B. Osteomyelitis C. Fat embolism D. Hypovolemia

C. Fat embolism Patients who experience a fracture of the long bones (such as the femur) are at risk for a fat embolism. The patient will become confused and restless along with an abnormal respiratory status.

Powerpoints Which wounds would you notice undermining and/or tunneling ( select all that apply) A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

C. Stage 3 D. Stage 4

Med surg What is the nurse most likely to do if she notices stable eschar on the heels of a patient's foot A. Remove eschar so she is able to stage wound B. this is life threatening and the provider should be notified right away C. continue to monitor for changes D. apply wet sterile dressing

C. continue to monitor for changes Stable (dry, adherent, intact without erythema, or fluctuance) eschar on the heels serves as "the body's natural (biologic) cover" and should not be removed if eschar is noticed anywhere else it is removed to allow for healing...however the heels are a special case

Med Surg The nurse notices the patients wound is clean and granulation and re-epithelialization is occurring. What should the nurse do next A. Let the wound air out B. Change dressing C. maintain slight moisture to wound D. apply liberal amount of hydrogen peroxide

C. maintain slight moisture to wound Clean wounds that are granulating and re-epithelializing: Keep slightly moist (Do not let a wound that has the potential to heal dry out. Dryness is an enemy of wound healing. "Airing out" a wound is a great mistake. Wounds need a moist environment to heal.) Protected from further trauma until they heal naturally. Avoid unecessary manipulation during dressing changes ( may destroy new granulation tissue and break down fibrin formation) Never use anitmicrobials and antibactericidals such as Betadine, Dakin's solution, hydrogen peroxide, and chlorhexidine in a clean granulating wound...they can cause damage to the new healing tissues....Only use caustionly if wound is not clean

After a motorcycle accident, a patient arrives in the ED with severe swelling of the left lower leg. Which action will the nurse take FIRST? A. elevate the leg on 2 pillows B. apply a compression bandage C. place ice packs on the lower leg D. assess leg pulses and sensation

D. assess leg pulses and sensation It is important to catch compartment syndrome earlier to prevent permanent damage

(Med surg) How does a deficiency in vitamin C affect wound healing? A. Impairs epithelization B. it does not affect wound healing C. decreases supply of amino acids for tissue repair D. delays formation of collagen fibers and capillary development

D. delays formation of collagen fibers and capillary development Nutritional deficiencies and effects on wound healing Vitamin C→ delays formation of collagen fibers and capillary development Protein→ decreases supply of amino acids for tissue repair Zinc→ impairs epithelization Note: Vitamin A is also needed in healing because it aids in the process of epithelialization

A pt with a braden score of 10 is at what risk? A. not at risk B. mild risk C. moderate risk D. high risk

D. high risk the lower the score the higher the risk for pressure sore development) 19-23 - not at risk 15-16 - mild risk (15-18 is considered to be at mild risk if 75 or older) 12-14 - moderate risk > 12 - high risk

A client returns from a radical neck dissection with two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? A..Cloudy wound drainage B. Absence of the gag reflex C.Decreased urinary output D.Restlessness with dyspnea

D.Restlessness with dyspnea The client is at risk for airway obstruction; restlessness and dyspnea indicate hypoxia. Cloudy drainage may indicate infection, which is not an immediate postoperative complication. Loss of the gag reflex is unimportant. The pharyngeal opening is sutured closed, and a tracheal stoma is formed; the trachea is anatomically separate from the esophagus. Decreased urinary output needs to be monitored but does not take priority.

Nclex question When caring for a patient who has experienced a compound fracture, what nursing intervention will you take with this type of fracture? A. Cover the fracture with a sterile dressing B. Place the arm below the heart level. C. Attempt bone reduction by manually readjusting the bone. D. Place a tight compression bandage over the fracture.

The answer is A. Compound fracture (also called an open fracture). Due to the nature of this fracture, the patient is at major risk for infection because the skin is no longer intact. Therefore, the nurse should cover the fracture site with a sterile dressing. NEVER attempt a bone reduction. In addition, avoid a tight compression bandage due to the development of ischemia. Instead, you would want to immobilize the extremities and splint it.

Nclex question/Med surg reading A 85 year old patient has an accidental fall while going to the bathroom without assistance. It appears the patient has sustained a bone fracture to the left leg. The leg's shape is deformed and the patient is unable to move it. The patient is alert and oriented but in pain. What will you do FIRST after confirming the patient is safe and stable? A. Apply an ice pack covered with a towel to the site. B. Immobilize the fracture with a splint. C. Administer pain medication. D. Elevate the extremity above heart level.

The answer is B. After confirming the patient is safe and stable, the nurse would immobilize the fracture with a splinting device. This will prevent the accidental movement of the extremity by the patient. Immobilization is important because it prevents further pain or bleeding along with more damage that can occur to the surrounding tissues. In addition, if a bone is not immobilized but moved after it has been fractured this can affect the healing process. **Nursing interventions is order of importance..Is patient safe?yes→ immobilize fx→ stop bleeding with clean cloth→ if fx is open you want to cover with sterile dressing→ elevate extremity to decrease swelling and apply ice→ keep patient NPO until evaluated by MD bc patient may need surgery → pain management ( monitor and document closely bc it is important to catch compartment syndrome early to prevent irreversible damage )

The client with BPH undergoes a transurethral resection of the prostate. Postoperatively, the client is receiving continuous bladder irrigations. The nurse assesses the client for signs of transurethral resection syndrome. Which of the following assessment data would indicate the onset of this syndrome? a. Bradycardia and confusion b. Tachycardia and diarrhea c. Decreased urinary output and bladder spasms d. Increased urinary output and anemia

a. Bradycardia and confusion Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.

Med surg (end of chapter questions) An 85-year-old patient is assessed to have a score of 16 on the Braden Scale. Based on this information, how should the nurse plan for this patient's care? a. Implement a 1-hr turning schedule with skin assessment. b. Place DuoDerm on the patient's sacrum to prevent breakdown. c. Elevate the head of bed to 90 degrees when the patient is supine. d. Continue with weekly skin assessments with no special precautions.

a. Implement a 1-hr turning schedule with skin assessment.

While working with a 72-year-old male undergoing treatment for benign prostatic hyperplasia (BPH), the nurse is questioned by the family about the incidence of BHP in males over 70. Which of the following percentages of males over 70 will the nurse say has BHP? a. More than 90% b. Slightly under 75% c. 50% d. 60%

a. More than 90% More than 90% of males over 70 have BHP.

Which of the following alpha-blocking agents are currently prescribed for persons with BPH? (Select all that apply.) a. Tamsulosin (Flomax) b. Doxazosin mesylate (Cardura) c. Verapamil (Calan) d. Tamoxifen (Nolvadex)

a. Tamsulosin (Flomax) b. Doxazosin mesylate (Cardura) Rationale: Alpha-adrenergic blocking medications such as tamsulosin and doxazosin may be prescribed for patients with BPH. These medications function by constricting the prostate gland, which results in reduction of urethral pressure and the improvement of urine flow.

A nurse is educating a 21-year-old lifeguard about the risk of skin cancer and the need to wear sunscreen. Which statement by the patient indicates that they need further teaching? a. "I wear a hat and sit under the umbrella when not in the water." b. "I don't bother with sunscreen on overcast days." c. "I use a sunscreen with the highest SPF number." d. "I wear a UV shirt and limit exposure to the sun by covering up."

b. "I don't bother with sunscreen on overcast days." The sun's rays are as damaging to skin on cloudy, hazy days as on sunny days. The other options will all prevent skin cancer.

Med surg (end of chapter questions) A patient in the unit has a 103.7° F temperature. Which intervention would be most effective in restoring normal body temperature? a. Use a cooling blanket while the patient is febrile. b. Administer antipyretics on an around-the-clock schedule. c. Provide increased fluids and have the UAP give sponge baths. d. Give prescribed antibiotics and provide warm blankets for comfort.

b. Administer antipyretics on an around-the-clock schedule.

Med surg (end of chapter questions) A 65-year-old stroke patient with limited mobility has a purple area of suspected deep tissue injury on the left greater trochanter. Which nursing diagnoses are most appropriate (select all that apply)? a. Acute pain related to tissue damage and inflammation b. Impaired skin integrity related to immobility and decreased sensation c. Impaired tissue integrity related to inadequate circulation secondary to pressure d. Risk for infection related to loss of tissue integrity and undernutrition secondary to stroke e. Ineffective peripheral tissue perfusion related to arteriosclerosis and loss of blood supply to affected area

b. Impaired skin integrity related to immobility and decreased sensation c. Impaired tissue integrity related to inadequate circulation secondary to pressure

Med surg (end of chapter questions) A nurse is caring for a patient with diabetes who is scheduled for amputation of his necrotic left great toe. The patient's WBC count is 15.0 × 106/µL, and he has coolness of the lower extremities, weighs 75 lb more than his ideal body weight, and smokes two packs of cigarettes per day. Which priority nursing diagnosis addresses the primary factor affecting the patient's ability to heal? a. Imbalanced nutrition: obesity related to high-fat foods b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking c. Ineffective peripheral tissue perfusion related to narrowed blood vessels secondary to diabetes and smoking d. Ineffective individual coping related to indifference and denial of the long-term effects of diabetes and smoking

b. Impaired tissue integrity related to decreased blood flow secondary to diabetes and smoking

Med surg (end of chapter questions) A nurse is caring for a patient who has a pressure ulcer that is treated with debridement, irrigations, and moist gauze dressings. How should the nurse anticipate healing to occur? a. Tertiary intention b. Secondary intention c. Regeneration of cells d. Remodeling of tissues

b. Secondary intention

Med surg (end of chapter questions) A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5° F temperature, slight erythema at the incision margins, and 30 mL serosanguineous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The abdominal incision shows signs of an infection. b. The patient is having a normal inflammatory response. c. The abdominal incision shows signs of impending dehiscence. d. The patient's physician must be notified about her condition.

b. The patient is having a normal inflammatory response.

Med surg (end of chapter questions) The nurse assessing a patient with a chronic leg wound finds local signs of erythema and the patient complains of pain at the wound site. What would the nurse anticipate being ordered to assess the patient's systemic response? a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound

b. WBC count and differential

A patient in the outpatient setting was diagnosed with atopic dermatitis. What interventions will the plan of care focus primarily on? a.Decreasing pain b.Decreasing pruritus c.Preventing infection d.Promoting drying of lesions

b.Decreasing pruritus Pruritus is the major manifestation of atopic dermatitis and causes the greatest morbidity. The urge to scratch may be mild and self-limiting, or it may be intense, leading to severely excoriated lesions, infection, and scarring.

The nurse is taking the history of a client who has had benign prostatic hyperplasia in the past. To determine whether the client currently is experiencing difficulty, the nurse asks the client about the presence of which of the following early symptoms? a. Urge incontinence b. Nocturia c. Decreased force in the stream of urine d. Urinary retention

c. Decreased force in the stream of urine Decreased force in the stream of urine is an early sign of BPH. The stream later becomes weak and dribbling. The client then may develop hematuria, frequency, urgency, urge incontinence, and nocturia. If untreated, complete obstruction and urinary retention can occur.

Which of the following responses would be accurate if given to the nurse during an initial interview from a patient with benign prostatic hypertrophy (BPH)? a. "I have pain and swelling of my both ankles." b. "I frequently drink wine with my evening meals." c. "I have difficulty starting a stream of urine, and it is a weak stream." d. "My bladder doesn't feel empty after I urinate, and I have to strain to pass the urine."

c. "I have difficulty starting a stream of urine, and it is a weak stream." The symptoms of BPH are sometimes referred to as "nuisances," and include difficulty starting a stream of urine that is described as weak and the need to strain to urinate. Ultimately, in advanced cases, azotemia and renal failure can occur. Red wine is not a direct causative agent here.

A client asks the nurse what will eventually happen if he does not have his benign prostatic hypertrophy treated. The most accurate answer by the nurse will be which of the following? a. "Staghorn renal calculi or small calcium stones can occur as a result of untreated BPH." b. "Untreated BPH will lead to malignant hypertension." c. "Urine reflux and possibly hydronephrosis can result from untreated BPH." d. "If BPH is not treated, the client can develop pyelonephritis."

c. "Urine reflux and possibly hydronephrosis can result from untreated BPH." Untreated BPH will lead to increased pressure in the bladder, which causes urine reflux into the ureters and can eventually lead to hydronephrosis, which can affect kidney function. These complications rarely occur, as BPH symptoms force most men to get treatment earlier.

After undergoing a transurethral resection of the prostate to treat benign prostatic hypertrophy, a patient is retuned to the room with continuous bladder irrigation in place. One day later, the patient reports bladder pain. What should the nurse do first? a. Increase the I.V. flow rate b. Administer meperidine (Demerol) as prescribed c. Assess the irrigation catheter for patency and drainage d. Notify the doctor immediately

c. Assess the irrigation catheter for patency and drainage Although postoperative pain is expected, the nurse should ensure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic such as meperidine as prescribed. Increasing the I.V. flow rate may worse the pain. Notifying the doctor isn't necessary unless the pain is severe or unrelieved by the prescribed medication.

The client is admitted to the hospital with BPH, and a transurethral resection of the prostate is performed. Four hours after surgery the nurse takes the client's VS and empties the urinary drainage bag. Which of the following assessment findings would indicate the need to notify the physician? a. Red bloody urine b. Urinary output of 200 ml greater than intake c. Blood pressure of 100/50 and pulse 130. d. Pain related to bladder spasms.

c. Blood pressure of 100/50 and pulse 130. Frank bleeding (arterial or venous) may occur during the first few days after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 ml of greater than intake is adequate. Bladder spasms are expected to occur after surgery. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The physician should be notified.

The nurse is reviewing a medication history of a client with BPH. Which medication should be recognized as likely to aggravate BPH? a. Metformin (Glucophage) b. Buspirone (BuSpar) c. Inhaled ipratropium (Atrovent) d. Ophthalmic timolol (Timoptic)

c. Inhaled ipratropium (Atrovent) Atrovent is a bronchodilator, and its anticholinergic effects can aggravate urinary retention. Glucophage and BuSpar do not affect the urinary system; timolol does not have a systemic effect.

Which of the following herbal preparations might a patient with a diagnosis of BPH disclose during the initial interview? a. Hawthorne (Crataegus) b. Licorice (Glycyrrhiza) c. Saw palmetto extract (Serenoa repens) d. Ma Huang (Ephedra sinica)

c. Saw palmetto extract (Serenoa repens) Rationale: Saw palmetto is a popular over-the-counter medication that appears to be effective in improving BPH symptoms, and has relatively few side effects.

Med surg (end of chapter questions) An 82-year-old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage I b. Stage II c. Stage III d. Stage IV

c. Stage III

Nclex question A patient is to receive phototherapy for the treatment of psoriasis. What is the nursing priority for this patient? a.Obtaining a complete blood count (CBC) b.Protection from excessive heat c.Protection from excessive ultraviolet (UV) exposure d.Instructing the patient to take their multivitamin prior to treatment

c.Protection from excessive ultraviolet (UV) exposure Protection from excessive UV exposure is important to prevent tissue damage. Protection from heat is not the most important priority for this patient. There is no need for vitamins or a CBC for patients with psoriasis.

To help decrease the threat of a melanoma in a blonde-haired, fair-skinned patient at risk, the nurse would advise the patient to do which of the following? a. Apply sunscreen 1 hour prior to exposure. b. Drink plenty of water to prevent hot skin. c. Use vitamins to help prevent sunburn by replacing lost nutrients. d. Apply sunscreen 30 minutes prior to exposure.

d. Apply sunscreen 30 minutes prior to exposure. Wearing sunglasses and sunscreen are recommended by the National Cancer Institute. Drinking water will help with heat exhaustion but will not prevent melanoma. Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the risk of developing melanoma; however, vitamins do not prevent burn.

A client had a transurethral prostatectomy for benign prostatic hypertrophy. He's currently being treated with a continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. Which of the interventions should be done first? a. Administer an oral analgesic b. Stop the irrigation and call the physician c. Administer a belladonna and opium suppository as ordered by the physician. d. Check for the presence of clots, and make sure the catheter is draining properly.

d. Check for the presence of clots, and make sure the catheter is draining properly. Blood clots and blocked outflow if the urine can increase spasms. The irrigation shouldn't be stopped as long as the catheter is draining because clots will form. A belladonna and opium suppository should be given to relieve spasms but only after assessment of the drainage. Oral analgesics should be given if the spasms are unrelieved by the belladonna and opium suppository.

The client who has a cold is seen in the emergency room with inability to void. Because the client has a history of BPH, the nurse determines that the client should be questioned about the use of which of the following medications? a. Diuretics b. Antibiotics c. Antitussives d. Decongestants

d. Decongestants In the client with BPH, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention can also be precipitated by other factors, such as alcoholic beverages, infection, bedrest, and becoming chilled.

A client is admitted to the hospital with benign prostatic hyperplasia, the nurse most relevant assessment would be: a. Perineal edema b. Flank pain radiating in the groin c. Urethral discharge d. Distention of the lower abdomen

d. Distention of the lower abdomen This indicates that the bladder is distended with urine, therefore palpable.

Romeo Diaz, age 78, is admitted to the hospital with the diagnosis of benign prostatic hyperplasia (BPH). He is scheduled for a transurethral resection of the prostate (TURP). It would be inappropriate to include which of the following points in the preoperative teaching? a. Expect bloody urine, which will clear as healing takes place. b. TURP is the most common operation for BPH. c. Explain the purpose and function of a two-way irrigation system. d. He will be pain free.

d. He will be pain free. Surgical interventions involve an experience of pain for the client which can come in varying degrees. Telling the pain that he will be pain free is giving him false reassurance.

Powerpoints/in class discussion Which drugs are dopamine receptor agonist ? (select all that apply) A. Benztropine (Cogentin) B. Carbidopa / Levodopa (Sinemet) C. Pramipexole (mirapex) D. Ropinirole(requip) E. Trihexyphenidyl (Artane)

dopamine receptor agonist--> mimic dopamine effects in the brain C. Pramipexole (mirapex) D. Ropinirole(requip)