Uworld Adult Health

Describe Stage 3 pressure ulcers

full thickness skin loss

Acoustic nerve assessment

hearing and Romberg test

CN VIII

Acoustic

Fetal effects of syphilis during pregnancy

-hepatomegaly -jaundice -hemolytic anemia -decreased platelets -long bone abnormalities -failure to thrive

What are some risks associated with hormone replacement therapy?

-increased risk of thrombotic complications (DVT, stroke, MI) -cancer (breast and uterine)

Anterior and posterior leg rule of nines percentage

18%

anterior and posterior arm rule of nines percentage

9%

CN VI

Abducens

CN VII

Facial

CN III

Oculomotor

Which is cranial nerve I?

Olfactory

CN II

Optic

CN IV

Trochlear

Cloudy vision with a glare is associated with what visual disorder?

cataract, a non-emergency, age-related visual disorder.

Trigeminal nerve assessment

clench teeth and light touch

Define Dysphagia

difficulty swallowing

Broca aphasia involves damage to what area of the brain?

frontal lobe

Common causes of dementia is older adults

infection, medication, and hypoxia

Olfactory assessment involves

smell test

How is the facial nerve assessed?

by observing for symmetrical movements during facial expressions, such as a smile, frown, or closing the eyes.

What types of foods are included in a low residue diet?

easily digested foods such as enriched breads, rice, pasta, cooked vegetables, canned fruits, and tender meats.

Abducens nerve assessment

extraocular movements- lateral abduction

Describe the ictal phase of a seizure

period of active seizure activity

Risk factors for macular degeneration include

-advanced age -family history -hypertension -smoking -long-term poor intake of carotenoid-containing fruits and veggies

What can cause neutropenia?

-chemotherapy -medications (clozapine, methimazole)

Self-care for Meniere disease

-consuming a low-sodium diet to decrease the potential for fluid excess within the inner ear. -limiting/avoiding aggravating substances and stimuli -adhering to prescribed therapies for relief of symptoms -avoiding sudden changes in the position of the head -participating in vestibular rehabilitation therapy -Implementing safety measures during attacks

Treatment of tumor lysis syndrome

-continuous telemetry -aggressive electrolyte monitoring/treatment

symptoms of dumping syndrome

-diaphoresis -cramping -weakness -diarrhea within 30 minutes of eating

non-modifiable breast cancer risk facotrs

-female sex -age >50 -first-degree relative with history of breast cancer -BRCA1 and BRCA2 genetic mutations -personal history of endometrial or ovarian cancer -menarche before age 12 or menopause after age 55

Typical appearance of Parkinson disease

-stooped posture -masked facial expression -rigidity -forward tilt of trunk -reduced arm swinging -flexed elbows and wrists -slightly flexed hips and knees -trembling of extremities -shuffling, short-stepped gait

Rule of nines abdomen percentage

18%

What is the most common STI?

Chlamydia

Define Thrombocytopenia

low platelet count

The nurse is planning care for a client admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize? -assess vital capacity and total volume once per shift and PRN -perform passive range of motion exercises on affected joints every 4 hours -provide time during each shift for the client to express feelings -turn the client every 2 hours throughout the day and night

-assess vital capacity and total volume once per shift and PRN --Quadriplegia occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs. This is usually due to injury of the cervical spinal cord. Depending on the area of injury and extent of cord edema, the airway can be adversely affected. The priority assessment for this client is the status of the airway and oxygenation. The nurse should frequently assess breath sounds, accessory muscle use, vital capacity, tidal volume, and arterial blood gas values.

The nurse should plan to teach which client about the need for prophylatic antibiotics prior to dental procedures? -client who had a large anterior wall myocardial infarction with subsequent heart failure -client who had a mitral valvuloplasty repair -client with a mechanical aortic valve replacement -client with mitral valve prolapse with regurgitation

-client with a mechanical aortic valve replacement --Clients with any form of prosthetic material in their heart valves or who have unrepaired cyanotic congenital heart defect or prior history of IE should take prophylatic antibiotics prior to dental procedures to prevent development of IF

Nursing Management for the post-hemorrhoidectomy client includes:

--pain relief: pain is originally managed with pain medications, including nonsteroidal anti-inflammatory drugs and/or acetaminophen. opioids can be prescribed but may worsen constipation. Beginning 1-2 days postop, warm sitz baths are used as a means to relieve pain. --preventing constipation: encourage a high-fiber diet and adequate fluid intake. Administer docusate as prescribed.

Examination of a skin lesion involves

-Asymmetry -Border irregularity -Color change and variation -Diameter of 6 mm or larger -Evolving (changing appearance in shape, size, and color)

Risks for tumor lysis syndrome

-tumors with high burden or rapid turnover -cytotoxic chemotherapy or immunotherapy initiation

Rule of nines head percentage

4.5%

The warning signs of cancer can be remembered with what acronym?

CAUTION -change in bowel or bladder habits -a sore that does not heal -unusual bleeding or discharge from a body orifice -thickening or a lump in the breast or elsewhere -indigestion or difficulty in swallowing -obvious change in a wart or mole -nagging cough or hoarseness

CN V

Trigeminal

What diet modifications are recommended to reduce herniation?

avoiding high-fat foods and foods that decrease lower esophageal sphincter pressure, such as chocolate, peppermint, tomatoes, and caffeine --eat small, frequent meals --decrease fluid intake during meals to prevent gastric distension. --avoid consumption of meals close to bedtime and nocturnal eating.

The nurse on the medical-surgical unit receives report on assigned clients. Which client warrants immediate attention? -client experiencing abdominal cramps two hours after colonscopy -client reporting white stools 8 hours after barium swallow study -client with epigastric pain after endoscopic retrograde cholangiopancreatography -client with small bowel obstruction with copious, greenish-brown drainage from the nasogastric tube

-client with epigastric pain after endoscopic retrograde cholangiopancreatography --ERCP is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP. S/S include acute epigastric or left upper quadrant pain, often radiating o the back, and a rapid rise in pancreatic enzymes.

The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time? -client admitted with Gullian-Barre syndrome yesterday is paralyzed to the knees -client admitted with multiple sclerosis exacerbation has scanning speech -client with epilepsy puts on call light and reports having an aura -client with fibromyalgia reports pain in the neck and shoulders

-client with epilepsy puts on call light and reports having an aura --An aura is a sensory perception that occurs prior to a complex or generalized seizure. The client will most likely have a tonic-clonic seizure soon, and the nurse should attend to this client first to ensure safety measures are in place.

The nurse is counseling a client with obesity who is starting a weight reduction diet. The client reports consuming 4-5 regular cola beverages daily. Which of the following beverages should the nurse recommend as healthier substitutes? SATA -commercial fruit juice -flavored club soda -fresh vegetable juice -sports beverages -unsweetened tea

-flavored club soda -fresh vegetable juice -unsweetened tea --Sugary beverages, such as regular soft drinks, are key contributors to the excess consumption of calories and the obesity epidemic. Individuals who are attempting to lose weight should consume beverages with nutritional value and little-to-no caloric value, such as water, club soda, unsweetened tea/coffee, fresh vegetable juice, an nonfat/low-fat milk. A 12-oz serving in a typical can of regular cola-type beverage contains around 140 calories. For this client, the consumption of 5 cola beverages daily is contributing 255,500 kcal per year and accounts for 73 lb. This client could lose 73 lbs in a year simply by substituting zero-calorie beverages for cola.

The nurse is providing postoperative care to a client returning from a hemorrhoidectomy. Which action is the priority for the nurse to perform? -administer docusate and teach the client to avoid straining during defecation -give pain medications and instructions related to pain control -remove the rectal dressing and check the client for bleeding -teach the client how to self-administer a sitz bath 2-3 times daily

-give pain medications and instructions related to pain control --hemorrhoids are caused by increased anorectal pressure. Clients may experience symptoms such as rectal bleeding, pain, pruitus, and prolapse. Although removal of hemorrhoids is a minor procedure, the pain associated with it is due to spasms of the anal sphincter and is severe.

The nurse is caring for an adult client at the clinic who asks the nurse to look at a "black skin lesion". What assessment findings would be a classic indication of a potential malignant skin neoplasm? SATA -blanches with manual pressure -half of the lesion is raised and half is flat -history of prurlent drainage -lesion is the size of a nickle -various color shades are present

-half of the lesion is raised and half is flat -lesion is the size of a nickle -various color shades are present ---The examination for skin cancer follows the ABCDE rule: Asymmetry, Border irregularity, Color changes and variation; Diameter of 6 mm or larger; Evolving

The nurse assesses a client who is 2 days postoperative breast reconstruction surgery. The client has 2 closed-suction Jackson Pratt bulb drains in place. There is approximately 10 mL of serosanguineous fluid in each one. One hour later, the nurse notices the bulbs are full of bright red drainage and measures a total output of 200 mL. What is the nurse's priority action? -notify the HCP -open the collection bulb to release excessive negative pressure -record the amount in the output record as wound drainage -reposition the client on the right side

-notify the HCP --Although it depends on the type of surgical procedure performed, about 80-120 mL of serosanguineous or sanguineous drainage per hour for the first 24 hours following surgery can be expected. The nurse should notify the HCP if the drainage in the Jackson-Pratt closed-wound drainage device changes from serosanguineous to sanguineous and if the amount increases significantly after the first 24 hours following surgery.

A client with polycythemia vera comes to the clinic for a monthly treatment. The nurse knows that the treatment for this condition will consist of which of the following? -blood transfusion -fluid bolus -phlebotomy -steroid injection

-phlebotomy --Treatment of PV usually includes periodic phlebotomy, the removal of 300-500 mL of blood through venipuncture, to reduce the RBC count and achieve a hematocrit <45%. Initially, clients may require phlebotomy every other day until hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary.

CN IX

Glossopharyngeal

CN XII

Hypoglossal

CN XI

Spinal accessory

The most common clinical manifestations of any form of lymphoma

-presence of at least one painless, enlarged lymph node often found in neck, underarm, or groin

Manifestations of acute angle-closure glaucoma

-sudden onset of severe eye pain -reduced central vision -blurred vision -ocular redness -report of seeing halos around lights

During a camping trip, a camp counselor falls and gets a small splinter of wood embedded in the right eye. What action should the volunteer camp nurse take first? 1. Gently flush the eye with cool water 2. Instill optic antibiotic ointment 3. Patch both eyes with eye shields 4. Remove the splinter using tweezers

3. Patch both eyes with eye shields ---The camp nurse protects the injured eye using an eye shield, ensuring the shield does not touch the foreign body. The eyes work in synchrony with each other; therefore, the non-injured eye is patched to prevent further eye movement. The nurse also facilitates transport to the nearest emergency care center for assessment and treatment by an ophthalmologist. Flushing the eye with cool water is contraindicated as it may cause further damage by moving the splinter or introducing potential wound pathogens. Instilling optic antibiotic ointment would interfere wit h ophthalomologic medical examination.

What type of fluid (hyper,hypo,or iso) is 0.45% normal saline?

hypotonic solution

What is the danger with heparin-induced thrombocytopenia?

organ damage from local thrombi and/or embolization, leading to stroke and/or pulmonary embolism

What types of foods are avoided in clients with ulcerative colitis?

raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol

define apraxia

refers to loss of the ability to perform a learned movement (whistling, clapping, dressing) due to neurological impairment

Vagus nerve assessment

say "ah" and assess uvular and palate movement

Describe Stage 2 pressure ulcers

shallow, open wounds with partial-thickness skin loss of the dermis. --wound bed is red/pink

Broca aphasia is characterized by?

short, limited sentences with retained ability to comprehend speech

Hypoglossal nerve assessment

stick out tongue

What is a normal finding when performing the Babinski sign on an adult?

toes to point downward

Spinal accessory nerve assessment

turn head and lift shoulder to resistance

Optic nerve assessment

visual acuity and visual fields

Define dysarthria

weakness of the muscles used for speech. Pronunciation and articulation are affected. Comprehension and the meaning of words are intact, but speech is difficulty to understand.

When does infertility get diagnosed?

when a couple fails to conceive after 12 months (for females age <35) or 6 months (for females age >35)

What type of fluid is 5% dextrose in 0.9% normal saline?

hypertonic solution

What tissues are made with slow proliferating cells?

-cartilage -bone -kidney

Foods that are protein and/or calorie dense

-whole milk and dairy products -granola, muffins, biscuits -potatoes with sour cream and butter -meat, fish, eggs, dried beans, almond butter -pasta/rice dishes with cream sauce

Trocheal nerve assessment

extraocular movements- inferior adduction

Glossopharyngeal nerve assessment

gag reflex

Risk factors for cervical cancer

-HPV infection -hx of STI -early onset of sexual activity -multiple or high-risk sexual partners -immunosuppression -oral contraceptive use -low socioeconomic status -tobacco use

The nurse moves a finger in a horizontal and vertical motion in front of the client's face while directing the client to follow the finger with the eyes. Which cranial nerves is the nurse assessing? SATA -II -III -IV -V -VI

-III -IV -VI

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of packed red blood cells to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion? -"A drop in blood pressure is expected during the transfusion and getting up to void may cause a fall" -"Bedrest is required; therefore, voiding will prevent intermittent catheterization during the procedure" -"If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs" -"The urine is collected and analyzed prior to starting the transfusion to assess the client's baseline results"

"If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs" ---The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze form hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibilty. Early signs of a hemolytic reaction include red urine,fever, and hypotension; late signs include disseminated intravascular coagulation and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs.

The nurse assesses for cancer risk factors during a screening event at a gastroenterology clinic. Which of the following client statements include risk factors for esophageal cancer? SATA -"A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week" -"I am proud that I was able to lose 10 lb, but I'm still considered obese for my height" -"I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently" -"I have struggled with daily episodes of acid reflux for years, especially at nighttime" -"I snack on a lot of salted foods like popcorn and peanuts"

-"A few years ago, I switched from smoking cigarettes to smoking cigars 1 or 2 times a week" -"I am proud that I was able to lose 10 lb, but I'm still considered obese for my height" -"I drink 3 or 4 beers nightly to relax, but I did switch to light beer recently" -"I have struggled with daily episodes of acid reflux for years, especially at nighttime" --Esophageal cancer is a rare, rapidly malignancy of the esophageal lining with a low 5-year survival rate. Squamous cell carcinoma usually develops in the upper part of the esophagus, whereas adenocarcinoma usually develops in the lower part. Major risk factors include smoking and excessive alcohol consumption. Barrett esophagus is also a significant risk factor for esophageal cancer; this condition occurs when the distal portion of the esophagus develops precancerous changes. Obesity and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett esophagus.

The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer. The client is receiving patient-controlled analgesia with morphine. Which nursing diagnoses are appropriate to include in the client's care plan? SATA -acute pain -dysfunctional gastric motility -imbalanced nutrition, less than body requirements -ineffective self-health management -risk for infection

-acute pain -dysfunctional gastric motility -imbalanced nutrition, less than body requirements -risk for infection

The nurse is caring for an adolescent newly diagnosed with a chlamydial infection. After administering a one-time dose of azithromycin, the nurse understands that which of the following client statements indicate a correct understanding of client teaching? SATA -"A long-term consequence of an untreated chlamydial infection is infertility" -"I can resume sexual intercourse tomorrow, as I already received the antibiotic" -"I can still spread the infection, even if I do not have any of the symptoms" -"I should have screening yearly for chlamydia even if I do not have symptoms" -"I will make sure my partner gets checked and treated to prevent reinfection"

-"A long-term consequence of an untreated chlamydial infection is infertility" -"I can still spread the infection, even if I do not have any of the symptoms" -"I should have screening yearly for chlamydia even if I do not have symptoms" -"I will make sure my partner gets checked and treated to prevent reinfection" --Clients should be taught to abstain from sexual intercourse for 7 days after initiation of drug therapy.

The community health nurse provides an education program about risk factors for prostate cancer. Which of the following statements by program attendees indicate that teaching has been effective? SATA -"African American men have a higher risk for prostate cancer than other men" -"Eating large amounts of red meat may increase my risk for prostate cancer" -"I should avoid taking NSAIDs to prevent prostate cancer" -"My father had prostate cancer, so I have an increased risk for it" -"My risk for prostate cancer increases as I become older"

-"African American men have a higher risk for prostate cancer than other men" -"Eating large amounts of red meat may increase my risk for prostate cancer" -"My father had prostate cancer, so I have an increased risk for it" -"My risk for prostate cancer increases as I become older" ---Long-term use of NSAIDs can be a protective factor against certain types of cancer. However, before regularly taking NSAIDs, clients should speak with their healthcare providers because NSAIDs can increase the risk for adverse effects.

A nurse is making a presentation on skin cancer prevention with special focus on melanoma at a community health forum. Which statements should the nurse include? SATA -"Apply a broad-spectrum sunscreen before and during outdoor sports" -"Apply sunscreen a few minutes before starting outdoor activities" -"Reapply sunscreen after swimming, even if waterproof sunscreen was used earlier" -"serious sunburns can occur even on overcast days" -"Use tanning beds for <15 minutes for a base tan that is less likely to burn"

-"Apply a broad-spectrum sunscreen before and during outdoor sports" -"Reapply sunscreen after swimming, even if waterproof sunscreen was used earlier" -"serious sunburns can occur even on overcast days" ---To prevent sunburn, instruct clients to avoid sun exposure from 10 am to 4 pm, wear protective clothing, use sunscreen properly, and avoid non-solar exposure to ultraviolet radiation

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? SATA -"Avoid drinking alcoholic beverages" -"Do not abruptly stop taking your phenytoin" -"Go to the ED every time a seizure occurs" -"Wear an epilepsy medical identification bracelet" -"You may need to start using a nonhormonal birth control method"

-"Avoid drinking alcoholic beverages" -"Do not abruptly stop taking your phenytoin" -"Wear an epilepsy medical identification bracelet" -"You may need to start using a nonhormonal birth control method" --epilepsy is characterized by chronic seizure activity. Clients typically require lifelong anticonvulsant medication. The nurse should provide education about identifying and avoiding seizure triggers, such as excessive alcohol intake, sleep deprivation, and stress. Practicing relaxation techniques may help reduce the number of episodes. The client should also be encouraged to wear an epilepsy medical identification bracelet in case of emergency. Phenytoin, a hydration anticonvulsant, may decrease the effectiveness of some medications due to stimulation of hepatic metabolism. An alternate, nonhormonal birth control method should be used in addition to or instead of oral contraceptives. Clients should discuss pregnancy plans with their healthcare provider, as phenytoin can cause fetal abnormalities. Clients taking phenytoin should also receive education about practicing good oral hygiene as ginigval hyperplasia is a potential complication. Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure.

Which instructions should the nurse include when providing discharge teaching to a client with PUD due to H. pylori infection? SATA -"Avoid foods that may cause epigastric distress such as spicy or acidic foods" -"It is best if you refrain from consuming alcohol products" -"Report black tarry stools to your HCP immediately" -"Take our amoxicillin, clarithromycin, and omeprazole for the next 14 days" -"you may take over the counter drugs such as aspirin if you have mild epigastric pain"

-"Avoid foods that may cause epigastric distress such as spicy or acidic foods" -"It is best if you refrain from consuming alcohol products" -"Report black tarry stools to your HCP immediately" -"Take our amoxicillin, clarithromycin, and omeprazole for the next 14 days" --Treatment for H. pylori includes antibiotics and proton-pump inhibitors for acid suppression. The recommended initial treatment is 7-14 days of triple-drug therapy with omeprazole, amoxicillin, and clarithromycin. NSAIDs should be avoided as they inhibit prostaglandin synthesis, increase gastric secretion, and reduce the integrity of the mucosal barrier.

The nurse educator is completing a staff education conference about prenatal carrier screening. Which statement by a participant indicates a correct understanding of the genetic inheritance for cystic fibrosis? -"Both parents must be carriers of the abnormal gene for offspring to have the disorder" -"Female offspring are most often affected by the inheritance pattern of cystic fibrosis" -"If the female partner is a carrier, only male offspring will have the disorder" -"The inheritance pattern for cystic fibrosis does not skip generations"

-"Both parents must be carriers of the abnormal gene for offspring to have the disorder" --Carrier screening offers clients who are unaffected by a genetic disorder the option to discover whether they possess an abnormal gene that may affect health outcomes of future offspring. This type of genetic testing is frequently offered preconceptionally/prenatally to guide pregnancy decision-making. Cystic fibrosis follows an autosomal recessive inheritance pattern, meaning that offspring must receive two abnormal genes to be affected with the disorder.

A nurse is assessing a 58-year-old client with blurred vision and reduced visual fields. Which manifestation is of most concern to the nurse? -difficulty adjusting to dimmed lights -extreme eye pain -gradual loss of peripheral vision -opaque appearance of lens

-extreme eye pain --Acute angle-closure glaucoma is a form of glaucoma that requires immediate medical intervention. Glaucoma disorders are characterized by increased intraocular pressure due to decreased outflow of the aqueous humor resulting in compression of the optic nerve that can lead to permanent blindness.

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes? -"Breast changes that are not related to your cycle should be reported to your provider" -"If your breasts become sore during the month, you may take ibuprofen as needed" -"Schedule yearly clinical breast examinations with your health care provider" -"These cysts are benign, and research shows that they do not increase the risk of cancer"

-"Breast changes that are not related to your cycle should be reported to your provider" --One of the most common benign breast disorders is fibrocystic breast changes. Fibrocystic changes correlate to estrogen/progesterone hormone fluctuations during the menstrual cycle. Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. The condition typically resolves after menopause. The nurse instructs the client on breast self-awareness and emphasizes that any noncyclic breast changes and should be immediately reported to the healthcare provider.

The nurse is caring for a client with suspected pelvic inflammatory disease (PID). When the nurse is obtaining the client's health history, which of the following questions would provide pertinent data about the client's risk factors for PID? SATA -"Are you currently taking oral contraceptives" -"At what age did you experience your first menstrual cycle?" -"Do you engage in sexual intercourse with multiple partners?" -"Have you ever been diagnosed with a sexually transmitted infection?" -"Have you recently had an abortion or pelvic surgery?"

-"Do you engage in sexual intercourse with multiple partners?" -"Have you ever been diagnosed with a sexually transmitted infection?" -"Have you recently had an abortion or pelvic surgery?" --PID is a leading cause of ectopic pregnancy and infertility. The nurse assessing a client with suspected PID should assess for risk factors such as a history of PID or sexually transmitted infections; number of sexual partners; condom use during sexual intercourse; and recent abortion, pelvic surgery, or placement of an intrauterine device.

The HCP orders a small bowel follow-through for a client. Which instructions should the nurse include when teaching the client about this test? -"After the test, you may notice your stools are tarry black for a few days" -"During the test, a series of x-rays will be taken to assess the function of the small bowel" -"The HCP will use an endoscope to visualize your small bowel" -"Your examination is scheduled for 8am. Please drink all of the polyethylene glycol by midnight"

-"During the test, a series of x-rays will be taken to assess the function of the small bowel" --an SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine. Using this technique, decreased motility, increased motility, fistulas, or obstructions are identified.

The daughter of an 80 year old client recently diagnosed with Alzheimer disease says to the nurse, "I guess I can anticipate getting this disease myself at some point." What is an appropriate response by the nurse? -"Engaging in regular exercise decreases the risk of AD" -"Having a family hx of AD is not a risk factor" -"Try not to worry about this now as you can't do anything to prevent AD" -"You should avoid aluminum cans and cookware to prevent AD"

-"Engaging in regular exercise decreases the risk of AD" --The development of Alzheimer disease is related to a combination of genetic, lifestyle, and environmental factors. Clients with AD are usually diagnosed at ages greater than 65. Early-onset AD is a rare form of the disease that develops before age 60 and is strongly related to genetics. Children of clients with early-onset AD have a 50% chance of developing the disease. For late-onset AD, the strongest known risk factor is advancing age. Having a first-degree relative with late-onset AD also increases the risk of developing AD. Trauma to the brain has been associated with the development of AD in the future. Brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls. Research suggests that healthy lifestyle choices reduce the risk for developing AD.

A student nurse asks why enteral (tube) feedings, rather than total parenteral nutrition (TPN) are being administered to a client with sepsis and respiratory failure. Which is the best response by the RN? -"enteral feedings have no complications" -"Enteral feedings maintain gut integrity and help prevent stress ulcers" -"Enteral feedings provide higher calorie content" -"Risk of hyperglycemia is lower with enteral feedings than with TPN"

-"Enteral feedings maintain gut integrity and help prevent stress ulcers" --Stress ulcers are a common complication in critically ill clients because the GI tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. --complications associated with eneteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. -caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings along. TPN can be added. -illness-related stress hyperglycemia occurs in clients receiving both enteral feedings and TPN.

The nurse is obtaining a client's health history during a routine physical and wellness examination. Which of the following statements by the client should cause the nurse to suspect potential Hodgkin lymphoma? SATA -"For the past few weeks, I have noticed a pretty regular fever, but I do not have chills or feel bad" -"I have had a lump in my underarm for several weeks. I have not thought much about it because it doesn't hurt" -"My weight has gone down a lot in the past month. I have not changed my diet or exercise regimen, but it has been nice" - "Recently, my skin has been very itchy. I have had allergies in the past, but this feels different" -"Sometimes when I wake up, I find I have sweat so much while sleeping that I need to change the sheets"

-"For the past few weeks, I have noticed a pretty regular fever, but I do not have chills or feel bad" -"I have had a lump in my underarm for several weeks. I have not thought much about it because it doesn't hurt" -"My weight has gone down a lot in the past month. I have not changed my diet or exercise regimen, but it has been nice" - "Recently, my skin has been very itchy. I have had allergies in the past, but this feels different" -"Sometimes when I wake up, I find I have sweat so much while sleeping that I need to change the sheets" ---Lymphoma is a form of cancer that begins in the body's lymphatic system and is characterized by abnormal growth of lymphocytes. It is usually classified within two major subtyps, Hodgkin lymphoma and non-Hodgkin lymphoma and is further identified by numerous subcategories. To be diagnosed with Hodgkin lymphoma, malignant Reed-Sternberg cells must be found in the lymphatic tissue. Furthermore, Hodgkin lymphoma tends to follow a predictable path of metastasis, whereas NHL tends to be more widely disseminated. The most common clinical manifestation of any form of lymphoma is the presence of at least one painless, enlarged lymph node, often in the neck, underarm, or groin. Clients may also present with or develop fever; significant, unexplainable, and/or unintentional weight loss and/or drenching night sweats typically associate with a poor prognosis.

The nurse assessing a client with an upper GI bleed would expect the client's stool to have which appearance? -black tarry -bright red bloody -light gray "clay-colored" -small, dry, rocky-hard masses

-black tarry --black tarry --As blood passes through the GI tract, digestion of the blood ensures, producing the black tarry appearance. Bright red bloody stool would indicate a lower GI hemorrhage. Decreased bile flow into the intestine due to biliary obstruction would produce a light gray "clay-colored" stol. Small, dry, rocky-hard masses are an indication of constipation. Inactivity, slow peristalsis, low intake of fiber in the diet, decreased fluid intake, and some medications may contribute to constipation.

The nurse educates the caregiver of a client with Alzheimer disease about maintaining the client's safety. Current symptoms include occasional confusion and wandering. Which of the following responses by the caregiver show correct understanding? SATA -"Grab bars should be installed in the shower and beside the toilet" -"I will place a safe return bracelet on the client's wrist" -"Keyed deadbolts should be placed on all exterior doors" -"Medications will be placed in a weekly pill dispenser" -"Throw rugs and clutter will be removed from the floors"

-"Grab bars should be installed in the shower and beside the toilet" -"I will place a safe return bracelet on the client's wrist" -"Keyed deadbolts should be placed on all exterior doors" -"Throw rugs and clutter will be removed from the floors" --all medications should be out of the client's reach or locked away. A confused person may not remember the day of the week and take more or less medication than prescribed.

The nurse cares for an elderly client with type II diabetes who was diagnosed with diabetic retinopathy. Which statement by the client requires the most immediate action by the nurse? -"Half of my vision looks like it's being blocked by a curtain" -"I have to use reading glasses to see small print" -"My vision seems cloudy and I notice a lot of glare" -"The colors don't seem as bright as they used to be"

-"Half of my vision looks like it's being blocked by a curtain" --Chronic hyperglycemia can cause microvascular damage to the retina, leading to diabetic retinopathy, the most common cause of new blindness in adults. A partial retinal detachment may be painless and cause symptoms such as curtain blocking part of the visual field, floaters or lines, and sudden flashes of light

A 14-year-old is seen in the STD outpatient department and diagnosed with gonorrhea. The client tells the nurse of having sexual relations with only a 19-year-old partner. What is the best response by the nurse? -"Has your partner been evaluated and treated by a healthcare provider?" -"I have to report your situation to local law enforcement" -"One of your parents will need to consent to your treatment" -"You should use a condom when you have sex"

-"Has your partner been evaluated and treated by a healthcare provider?" --To avoid re-infection with gonorrhea, it is essential that the client's partner be tested and treated. During the visit, the nurse should counsel the client about the importance of partner evaluation and treatment and the likely recurrence of the infection if the partner refuses to be treated. The client should avoid sexual relations until treatment is completed and the client and partner no longer have symptoms.

A 78-year-old client recovering from a hip fracture tells the home health nurse, "I haven't had much of an appetite lately and have been really tired. I'm worried I'm not eating enough" Which question is the priority for the nurse to ask? -"Are you able to prepare your own meals?" -"Are you feeling lonely or depressed" -"Have you lost any weight unintentionally" -"How many meals do you eat each day?"

-"Have you lost any weight unintentionally" --Malnutrition occur when there is insufficient nutrient intake to meet body needs and relates to multiple factors. Malnutrition may impair critical physiological processes and can have rapid and potentially lethal implications. Therefore, nurses should frequently assess clients for malnutrition, particularly those at increased risk. Assessing for malnutrition involves collecting dietary data, lab values, physical measurements, and hx of recent weight loss. Reports of weight loss, especially unintentional, are critical findings often indicative of malnutrition. In addition, weight loss of greater than 5 percent in 1 month or greater than 10 percent in 6 months may indicate serious conditions.

The nurse is assessing a 2-year-old who has a blistered sunburn across the back and shoulders. Which of the following parent statements indicates an appropriate understanding of care for sunburn? SATA -"I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn" -"I am encouraging extra fluids since my child got sunburned" -"I have been giving my child acetaminophen to help relieve the pain" -"I have been placing cool, wet washcloths on my child's back" -"I have rubbed hydorcortisone cream on the area to help reduce inflammation and promote healing"

-"I am allowing my child to play outdoors only very early in the morning and late in the evening since the sunburn" -"I am encouraging extra fluids since my child got sunburned" -"I have been giving my child acetaminophen to help relieve the pain" -"I have been placing cool, wet washcloths on my child's back" ---Sunburn is a painful inflammatory skin reaction that results from overexposure to ultraviolet radiation. Care for minor sunburn is symptomatic and involves protecting the burn from further sun exposure, increasing fluid intake, taking mild oral analgesics, and applying cool compresses and soothing lotions.

The nurse is teaching a client with newly diagnosed lactose deficiency about dietary management. Which statements by the client indicate a correct understanding of this condition? SATA -"I can still eat cheese and yogurt as long as they don't make me feel sick" -"I should take a daily calcium and vitamin D supplement" -"Most diary products should be eliminated from my diet, but ice cream is okay" -"My lactose enzyme supplement should be taken with meals containing dairy" -"This means that I have developed an allergy to milk"

-"I can still eat cheese and yogurt as long as they don't make me feel sick" -"I should take a daily calcium and vitamin D supplement" -"My lactose enzyme supplement should be taken with meals containing dairy" --clients with lactase deficiency experience varying degrees of gastroinestinal symptoms after ingesting milk products, including flatulence, diarrhea, bloating, and cramping. This is due to a deficiency of the enzyme lactase, which is required for digestion of lactose. Treatment includes restricting lactose-containing foods in the diet. These clients may also take lactase enzyme replacement to decrease symptoms. Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified milk. Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual tolerance. Some dairy products, including aged cheeses and live-culture yogurts, contain little to no lactose and can be tolerated by most clients with lactase deficiency. --Lactase deficiency is not an immune reaction (allergy) to milk products. Rather, the GI symptoms are due to a deficiency of the enzyme lactase and the resultant inability to digest lactose.

Nausea and vomiting in which client is of greatest concern to the nurse? -client postoperative ophthalmic surgery -client receiving chemotherapy -client with Meniere disease -client with severe gastroenteritis

-client postoperative ophthalmic surgery --Vomiting can cause an increase in intraocular pressure, damage to the blood vessels and retina, and potential permanent vision loss. Antiemetic medication is administered as needed following ophthalmic surgery to prevent vomiting

The nurse provides home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? SATA -"I can use a humidifier to help prevent nosebleeds" -"I need to avoid contact sports such as soccer or hockey" -"I should use a soft-bristled toothbrush and floss carefully" -"I will call my healthcare provider if I soak a menstrual pad every hour" -"I will take naproxen to decrease inflammation if I am injured"

-"I can use a humidifier to help prevent nosebleeds" -"I need to avoid contact sports such as soccer or hockey" -"I should use a soft-bristled toothbrush and floss carefully" -"I will call my healthcare provider if I soak a menstrual pad every hour" --Von Willebrand disease is a genetic bleeding disorder caused by a deficiency of von Willebrand factor,which plays an important role in coagulation. Intranasal desmopressin or topical therapies may be prescribed to stop minor bleeding, whereas major bleeding may require replacement of vWF. Clients should wear medical identification bracelets in case of emergency.

A client with diabetes mellitus is admitted to the surgical unit after a vaginal hysterectomy. The client received 6 units of regular insulin subcutaneously and metoprolol 50 mg by mouth in the post-anesthesia care unit. Which statement by the unlicensed assistive personnel would require immediate action by the nurse? -"I changed the client's perineal pad 3 times in the last 2 hours" -"I have been encouraging the client to exercise the legs while in bed" -"I thought you should know the client voided 500 mL of straw-colored urine" -"I just took the client's vital signs, which are blood pressure 108/60 mm Hg, pulse 58, and respirations 12"

-"I changed the client's perineal pad 3 times in the last 2 hours" --The nurse should take immediate action when a client recovering from a vaginal hysterectomy saturates more than one perineal pad in an hour. The nurse should further assess the client and report these findings and excessive vaginal bleeding to the healthcare provider.

The nurse is preparing to discharge a client who is stable following a head injury. Which statement by the client indicates a need for further discharge instructions? -"I have a leftover prescription at home I can use if I have pain" -"I will cancel the wine tasting I have planned for this weekend" -"I will have someone drive me home and will take a couple of days off work" -"I will have someone stay with me and make sure I am okay"

-"I have a leftover prescription at home I can use if I have pain" --Opioid pain medications should be avoided following a head injury; therefore, the nurse should clarify what medication the client has at home. Any change in LOC, dizziness, nausea, or other side effects of opioids could be misinterpreted as symptoms of a worsening condition related to the head injury. Clients are typically advised to use non-narcotic or nonsteroidal anti-inflammatory pain medications. The client should also avoid driving, using heavy machinery, playing contact sports, or taking hot baths for 1-2 days.

A client comes to the ED with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency? -"I am very tired, and it's hard for me to keep my eyes open" -"I don't feel good, and I want to be seen" -"I have not taken my blood pressure medicine in over a week" -"I have the worst headache I've ever had in my life"

-"I have the worst headache I've ever had in my life" --a ruptured cerebral aneurysm is a surgical emergency with a high mortality rate. Cerebral aneurysms are usually asymptomatic unless they rupture; they are often called "silent killers" as they may go undetected for many years before rupturing without warning signs. The distinctive description of a cerebral aneurysm rupture is the abrupt onset of "the worst headache of my life" that is different from previous HAs. Immediate evaluation for a possible ruptured aneurysm is critical for any client experiencing a severe HA with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck. Early identification and prompt surgical intervention help increase the chance for survival

The home health nurse teaches an elderly clients with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching? -"I have to remember to raise my chin slightly upward when I swallow" -"I have to remember to swallow 2 times before taking another bite of food" -"I should avoid taking OTC cold medications when I'm sick" -"I should sit upright for at least 30-40 minutes after I eat"

-"I have to remember to raise my chin slightly upward when I swallow" --Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the lungs. Aspiration of foreign material into the lungs increases the risk for developing aspiration pneumonia. Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients includes: swallowing 2 times before taking another bite of food in order to clear food from the pharynx; thickening liquids to assist swallowing;avoiding OTC cold medications due to antihistamine cold preparation having anticholinergic properties, such as drowsiness and decreasing saliva production; sitting upright for at least 30-40 minutes after meals to allow gravity to move food/fluid through the tract, decrease gastroesophageal reflux, and decrease risk for aspiration; brushing teeth and using antiseptic mouthwash before and after meals to reduce bacterial count.

The nurse provides care for a client diagnosed with polycythemia vera. Which statement by the client would require immediate follow-up? -"I am trying to find makeup to cover my unattractive, ruddy facial complexion" -"I must have injured my leg in some way. It is sore, swollen, and red" -"I take a baby aspirin to relieve my occasional headaches" -"My skin itches so severely, and no lotion or cream seems to help"

-"I must have injured my leg in some way. It is sore, swollen, and red" ---Polycythemia vera is a hematological disorder in which too many RBCs are produced, causing increased blood viscosity, venous stasis,and increased risk for thrombus formation. The nurse should teach clients with PB measures to prevent thrombus. Clients should also learn to monitor for and report signs and symptoms of thrombus. Reports of possible thrombus require immediate intervention to avoid serious injury.

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? SATA -add a thickening agent to the fluids -avoid administering sedating medications before meals -place the client in an upright position during meals -restrict visitors who show signs of illness -teach the client to flex the neck while swallowing

-add a thickening agent to the fluids -avoid administering sedating medications before meals -place the client in an upright position during meals -teach the client to flex the neck while swallowing --aspiration pneumonia develops when aspirated material causes an inflammatory response and provides a medium for bacterial growth. At-risk conditions include cognitive changes, difficulty swallowing, compromised gag reflex, and tube feeding.

The nurse is reinforcing teaching about ulcer prevention with a client newly diagnosed with peptic ulcer disease. Which of the following client statements indicate appropriate understanding of teaching? SATA -"I need to avoid taking medicines like ibuprofen without a prescription" -"I should avoid drinking excess coffee or cola" -"I should enroll in a smoking cessation program" -"I should reduce or eliminate my intake of alcoholic beverages" -"I will eliminate whole wheat foods, like breads and cereals, from my diet"

-"I need to avoid taking medicines like ibuprofen without a prescription" -"I should avoid drinking excess coffee or cola" -"I should enroll in a smoking cessation program" -"I should reduce or eliminate my intake of alcoholic beverages" --Peptic ulcer disease is characterized by ulceration of the protective layers of the esophagus, stomach, and/duodenum. Mucosal "breaks" allow digestive enzymes and stomach acid to digest underlying tissues, leading to potential gastrointestinal bleeding and perforation. Risk factors for PUD include GI H. pylori infections, genetic predisposition, chronic NSAID (aspirin, ibuprofen, naproxen) use, stress, and diet/lifestyle choices. Nurses educating clients with PUD about ulcer prevention should focus on modifiable risk factors (NSAIDs; caffeine; smoking; alcohol; and meal timing). Chronic use of NSAIDs can damage the gastric mucosa and delay ulcer healing. Cola, tea, and coffee should be avoided as they stimulate stomach acid secretion. Tobacco increases secretion of stomach acid and delays ulcer healing. Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by increasing stomach acid secretion.

The nurse is providing discharge teaching to a client newly diagnosed with ulcerative colitis. Which of the following statements by the client indicate that teaching has been effective? SATA -"I need to eat a diet high in calories and protein so that I avoid losing weight" -"I need to take multivitamins containing calcium daily" -"I should avoid consuming alcoholic beverages" -"I should drink at least 2 liters of water daily and more when I have diarrhea" -"I will keep a symptom journal to note when I eat and drink during the day"

-"I need to eat a diet high in calories and protein so that I avoid losing weight" -"I need to take multivitamins containing calcium daily" -"I should avoid consuming alcoholic beverages" -"I should drink at least 2 liters of water daily and more when I have diarrhea" -"I will keep a symptom journal to note when I eat and drink during the day"

The nurse is reinforcing education about lifestyle modifications for a client diagnosed with Meniere disease. Which statement by the client indicates a need for further teaching? -"I need to enroll in a smoking cessation program" -"I need to restrict the amount of potassium in my diet" -"I will lie down and avoid walking unassisted during acute attacks" -"I will limit the amount of caffeine and alcohol that I consume"

-"I need to restrict the amount of potassium in my diet" --Meniere disease results from excess fluid accumulation in the inner ear. Attacks involve severe vertigo, nausea, and hearing loss. Clients with Meniere disease should be taught to adhere to a low-sodium diet; eliminate tobacco products; limit caffeine and alcohol; and limit or avoid exacerbating factors.

The long-term care nurse is caring for a client diagnosed with macular degeneration. Which client statement supports this diagnosis? -"I have been seeing small flashes of light" -"I have trouble threading my sewing needle. I have to hold it far away to see it" -"I notice that my peripheral vision is becoming worse" -"I see a blurry spot in the middle of the page when I read"

-"I see a blurry spot in the middle of the page when I read" ---Macular degeneration is a progressive, incurable eye disease that occurs when the central portion of the retina deteriorates, giving rise to distortion or loss in the center of the visual field. Macular degeneration has two different etiologies. Dry macular degeneration involves ischemia and atrophy of the macula that results from blockage of the retinal microvasculature. Wet macular degeneration involves the abnormal growth of new blood vessels in the macula that bleed and leak fluid, eventually destroying the macula. Progression of macular degeneration may be slowed with smoking cessation, intake of specific supplement, laser therapy, and injection of antineoplastic medications. Risk factors for macular degeneration include advanced age, family history, hypertension, smoking, and long-term poor intake of carotenoid-containing fruits and vegetables

The nurse provides discharge instructions to a client with cirrhosis who has portal hypertension, ascites, and esophageal varices. Which statement by the client indicates that the teaching was effective? -"I may have one alcoholic drink a day, but no more" -"I may take aspirin instead of acetaminophen for fever or pain" -"I should avoid straining while having a bowel movement" -"I should eat a protein and sodium restricted diet"

-"I should avoid straining while having a bowel movement" --Cirrhosis is a progressive, degenerative disease caused by destruction and subsequent disordered regeneration of the liver parenchyma. Clients with cirrhosis suffer from various complications that will progressively intensify without lifestyle modifications. --although a low-sodium diet is important to prevent worsening hypertension and ascites, a low-protein diet is not usually recommended. Many clients with cirrhosis suffer from protein-calorie malnutrition; therefore, an intake of 1.2-1.5 g/kg of protein a day is commonly prescribed

The nurse is providing discharge teaching for a client who suffered full-thickness burns. Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury? -"I should avoid using lotion to prevent infection" -"I should perform range-of-motion exercises daily" -"I will avoid direct sun exposure for at least 3 months" -"I will wear pressure garments to minimize scars"

-"I should avoid using lotion to prevent infection" --The rehabilitation phase begins after the clients wounds have fully healed and lasts about 12 months. The initiation of this phase depends on the extent of the burns and the client's ability to care for themselves.

The nurse is reinforcing instructions to a client being discharged from the clinic with a diagnosis of acute prostatitis. Which statement by the client indicates an understanding of the instructions? -"Having sex will make the infection worse" -"I enjoy iced tea, so I will drink more to stay hydrated" -"I should take ciprofloxacin until I feel better" -"I should take docusate to prevent straining"

-"I should take docusate to prevent straining" --Prostatitis is inflammation of the prostate gland, usually caused by a bacterial infection. Symptoms include rectogenital pain, burning, urinary hesitancy, and/or urinary urgency. Management of prostatitis includes antimicrobial and anti-inflammatory medications. Alpha-adrenergic blockers help relaxes the bladder and prostate. Suprapubic catheterization may be necessary for urinary retention in severe cases of acute prostatitis. Urethral catheterization is contraindicated due to the risk of exacerbating pain and urethral inflammation.

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider? -"I got short of breath this morning when I worked out" -"I have cut down on smoking to 1/2 pack per day" -"I haven't been feeling well, so I have been sleeping a lot" -"I took an acetaminophen in the waiting room for this bad headache"

-"I took an acetaminophen in the waiting room for this bad headache" --An arteriovenous malformation is a tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. AVMs are usually found in the brain and cause seizures, headaches, and neurologic deficits. Treatment depends on the location of the AVM, but blood pressure control is crucial. Clients with AVMs are at high risk for having an intracranial bleed as the veins can easily rupture because they lack a muscular layer around their lumen. Any neurologic changes, sudden severe headache, nausea, and vomiting should be evaluated immediately as these are usually the first symptoms of a hemorrhage. --The report of dyspnea may prompt further evaluation depending on the type of exercise performed, but it is not the priority. Clients with AVMs should avoid smoking to prevent hypertension. Reports of not feeling well and sleeping a lot may be related to the HA and possible hemorrhage, but this alone would not prompt a call to the HCP.

Which statement made by the client demonstrates a correct understanding of the homecare of an ascending colostomy? -"I will avoid eating foods such as broccoli and cauliflower" -"I will empty the pouch when it is one-half full of stool" -"I will irrigate the colstomy to promote regular bowel movements" -"I will restrict my fluid intake to 2,000 mL of fluid a day"

-"I will avoid eating foods such as broccoli and cauliflower" --A colostomy is a surgical procedure that creates an opening in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Colostomies can be performed on any part of the colon. Depending on the location of the colostomy, characteristics of the stool will vary, with the stool becoming more solid as it passes through the colon. Proper care of the ostomy and pouching device in clients with a colostomy includes ensuring sufficient fluid intake, preventing gas and odor, and changing the pouching system when it becomes one-third full to prevent leaks.

The clinic nurse provides teaching for a client scheduled for a barium enema the next day. Which statement by the client shows a need for further instruction? -"I can expect chalky-white stool after the procedure" -"I cannot eat or drink 8 hours before the procedure" -"I may have abdominal cramping during the procedure" -"I will avoid laxatives after the procedure"

-"I will avoid laxatives after the procedure" --A barium enema, or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause subsequent peritonitis.

The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes. Which statement by the client indicates a need for further teaching? -"I will be sure we use condoms during intercourse as long as I have lesions" -"I will not touch the lesions to prevent spreading the virus to other parts of my body" -"I will use a hair dryer on a cool setting to dry the lesions after taking a shower" -"I will use warm running water and mild soap without perfumes to wash the area"

-"I will be sure we use condoms during intercourse as long as I have lesions" --Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak.

The clinic nurse is reviewing the plan of care with a client who has phenylketonuria and plans to become pregnant this year. Which statement from the client requires the nurse to intervene? -"I will consume more high-protein, iron-rich foods, such as meat and eggs, before and during pregnancy" -"I will use a special, low-phenylalanine formula for infant feeding if my baby is also diagnosed with PKU" -"It would be beneficial for my partner and I to have genetic counseling even though he does not have PKU" -"My baby will need to have adequate milk intake after birth to help ensure the screening test for PKU is accurate"

-"I will consume more high-protein, iron-rich foods, such as meat and eggs, before and during pregnancy" --PKU is characterized by deficiency or absence of an enzyme required to metabolize phenylalanine, an amino acid found in protein foods. High levels of phenylalanine can cause intellectual disability by interfering with brain growth and development, which is particularly concerning for the developing fetus and infant. Clients with PKU should follow a low-phenylalanin diet before and during pregnancy to prevent potential teratogenic effects. Avoiding high-protein foods helps to maintain phenylalanine levels in a safe range. If the newborn is also diagnosed with PKU, special formulas with low-phenylalanine will likely be required. Exclusive breastfeeding may pose harm to the newborn with PKU because phenylalanine is transferred via breastmilk.

A client with a history of headaches is scheduled for a lumbar puncture to assess the cerebrospinal fluid pressure. The nurse is preparing the client for the procedure. Which statement by the client indicates a need for further teaching by the nurse? -"I may feel a sharp pain that shoots to my leg, but it should pass soon" -"I will go to the bathroom and try to urinate before the procedure" -"I will need to lie on my stomach during the procedure" -"The physician will insert a needle between the bones in my lower spine"

-"I will need to lie on my stomach during the procedure" --CSF is assessed for color, contents, and pressure. Normal CSF is clear and colorless, and contains a little protein, a little glucose, minimal white blood cells, no red blood cells, and no microorganisms. Normal CSF pressure is 60-150 mm H20. Abnormal CSF pressure or contents can help diagnose the cause of headaches in complicated cases. CSF is collected via lumbar puncture or ventriculostomy. Prior to a lumbar puncture, clients are instructed as follows: empty the bladder before the procedure; the procedure can be performed in the lateral recumbent position or sitting upright to help widen the space between the vertebrae and allow easier insertion of the needle; a sterile needle will be inserted between L3/4 or L4/5 interspace; pain may be felt radiating down the left, but it should be temporary. After the procedure, the client is instructed to lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache and increase fluid intake for at least 24 hours to prevent dehydration.

The nurse reinforces education to a female client about the use of a cervical cap to prevent pregnancy. Which statement by the client indicates a need for further teaching? -"I should apply spermicide to the cervical cap before inserting it" -"I should not use the cervical cap while I am on my period" -"I will remove and clean the cervical cap as soon as possible after intercourse" -"It is okay for me to insert the cervical cap several hours before I have sex"

-"I will remove and clean the cervical cap as soon as possible after intercourse" --The cervical cap is a barrier method of contraception used with spermicide. The reusable, cup-shaped cap is placed over the cervix before intercourse to block sperm from the uterus. To allow time for sperm to die, the cap should remain in place for > 6 hours after intercourse but should not remain for more than 48 hours. The cap may remain in place for multiple acts of intercourse, but clients should confirm correct placement and insert additional spermicide into the vagina each time.

The nurse is teaching general skin care guidelines to a client receiving teletherapy (external beam radiation therapy). Which statements does the client make that indicate proper understanding of the teaching? SATA -"I may apply an ice pack to the treatment site if it begins to burn" -"I will rub baby oil after each treatment to prevent dry skin" -"I will use extra measures to protect my skin from sun exposure" -"I will wash the treatment site with lukewarm water and mild soap" -"I will wear soft, loose-fitting clothing

-"I will use extra measures to protect my skin from sun exposure" -"I will wash the treatment site with lukewarm water and mild soap" -"I will wear soft, loose-fitting clothing" --Clients receiving teletherapy often experience significant effects to the skin of the treatment area. Teaching essential skin care standards to these clients is focused on preventing infection and promoting healing of the affected skin

A client is 1-day postoperative abdominoplasty and is discharged to go home with a Jackson-Pratt (JP) closed-wound system drain in place. The nurse teaches the client how to care for the drain and empty the collection bulb. Which statement indicates that the client needs further instruction? -"I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times" -"I'll pull the plug on the JP bulb and pour the drainage into the measurable specimen cup" -"I'll squeeze the JP bulb from side-to-side so I hold it in my hand" -"While the JP bulb is totally compressed, i'll clean the spout with alcohol and replace the plug'

-"I'll empty the JP bulb when it is totally full so that I don't have to unplug it so many times" --A closed-wound drain device is used to prevent fluid buildup at the surgical wound site and promote healing. Empty the device every 4-12 hours unless it is 1/2 to 2/3 full before then. Drainage tube patency and negative pressure in the reservoir (bulb) must be maintained to provide adequate drainage.

A client is being discharge home after an open radical prostatectomy. Which statement indicates a need for further teaching? -"I will drink lots of water" -"I will try to walk in my driveway twice a day" -"I will wash around my catheter twice a day" -"If I get constipated, I will use a suppository"

-"If I get constipated, I will use a suppository" --Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is particularly important while the client remains on opioid analgesics, which can cause constipation.

The nurse is providing education to a client with a new prescription for progestin-only pills (POPs). Which statement about POPs is appropriate for the nurse to include? -"If you begin vomiting any time within 24 hours of taking the pill, take an additional pill" -"If you take your pill 3 or more hours after your usual time, use a backup contraceptive" -"In your pill pack, there are 21 days of progestin pills and 7 days of inactive iron pills" -"The use of POPs increases your risk of developing deep venous thrombosis"

-"If you take your pill 3 or more hours after your usual time, use a backup contraceptive" --Progestin-only pills ,a form of oral contraception, work by thickening cervical mucus, thinning the endometrium, and preventing ovulation. Cervical mucus changes last only approximately 24 hours, so the client must take the pill at the same time every day for it to be effective. If the pill is taken > 3 hours late, a barrier method is advised until the pill is taken correctly for 2 days. An additional POP should be taken if diarrhea or vomiting occurs within 3 hours of the last dose. In a POP pack, there are no inactive pills. The client does not take a break from the hormone to menstruate.

During a routine clinic visit, the nurse is providing education to a 24-year-old female client with Marfan syndrome and aortic root dilation. Which statement made by the nurse is appropriate? -"Call the healthcare provider to stop your beta blocker if pregnancy occurs" -"If you plan to become pregnant, it is best to wait a few years and plan it at an older age" -"It is important to consistently use a reliable form of birth control" -"Your condition is not inheritable to your future children"

-"It is important to consistently use a reliable form of birth control" --Marfan syndrome is a connective tissue disorder that causes visual and cardiac defects and a distinct long, slender body type. In Marfan syndrome with aortic vessel involvement, the root of the aorta is dilated or weakened, increasing the risk of aortic dissection and aortic rupture. Increases in blood volume and cardiac workload that occur during pregnancy may worsen aortic root dilation and further increase the risk of aortic dissection/rupture. Pregnancy in clients with Marfan syndrome, especially those with aortic root dilation, poses a high risk of maternal mortality. Clients should be instructed about the importance of consistently using reliable birth control methods to prevent pregnancy. Clients with Marfan syndrome considering pregnancy should be counseled to complete childbearing in early adulthood because aortic root dilation and the risk of aortic dissection/rupture increase with time.

The nurse is reinforcing discharge instructions with a client following a partial gastrectomy. Which of the following instructions should the nurse include to prevent dumping syndrome? SATA -add high-protein foods to diet -consume high-carbohydrate meals -eat small, frequent meals -increase intake of fluids with meals -lie down after eating

-add high-protein foods to diet -eat small, frequent meals -lie down after eating --Following a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, N/V, dizziness, generalized sweating, and tachycardia. The symptoms usually diminish over time. --avoid meals high in simple carbohydrates because these may trigger dumping syndrome --avoid consuming fluids with meals to reduce the risk of dumping syndrome.

A nurse is screening clients at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? SATA -"for the past few years, I get a productive cough in the winter that goes away in spring" -"I occasionally have heartburn an hour after I eat fried foods and sausage" -"Last month when I was doing my breast self-examination, I noticed a marble-sized lump" -"My mole is itchy, and the borders have become uneven with a blackish to bluish color" -"Recently I have noticed that my bowel movements appear black"

-"Last month when I was doing my breast self-examination, I noticed a marble-sized lump" -"My mole is itchy, and the borders have become uneven with a blackish to bluish color" -"Recently I have noticed that my bowel movements appear black" -- A client report of occasional indigestion after specific triggers may indicate gastroesophageal reflux disease. However, indigestion that is persistent or chronic indigestion may indicate cancer.

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? -"I need to raise the head of my bed on blocks by at least 6 inches: -"I will remain sitting up for several hours after I eat my food" -"If my reflux and abdominal pain don't improve, I might need surgery" -"Losing weight may reduce my reflux, so I plan to take a weight-lifting class"

-"Losing weight may reduce my reflux, so I plan to take a weight-lifting class" --Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to a weakness in the diaphragm. although hiatal hernias may be asyptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess weight by performing light activities because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining. --sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches reduces upward movement of the hernia and decreases the risk of gastric reflux.

A nurse cares for a client with impairment of cranial nerve VIII. What instructions will the nurse provide the UAP prior to delegating interventions related to the client's activities of daily living? -"Be aware of the client's shoulder weakness and provide support as needed" -"Ensure that the client sits upright and tucks the chin when swallowing food" -"Explain all procedures in step-by-step detail before performing them" -"Make sure the items needed by the client are within reach"

-"Make sure the items needed by the client are within reach" --The client has an impairment of the vestibulocochlear nerve. Symptoms of impairment may include loss of hearing, dizziness, vertigo, and motion sickness, which place the client at a high risk for falls. Therefore, when instructing the UAP about helping the client with ADL's, the nurse emphasizes the need to keep items at the bedside within the client's reach. --weakness of the shoulder muscle occurs with impairment of CN XI, the spinal accessory nerve. Dysphagia may occur with impairment of CN IX (glossopharyngeal) and XN X (vagus), not CN VIII. Impairment of visual acuity occurs with disorders affecting CN II (optic).

The healthcare provider prescribes clomiphene for 5 days, beginning on the fifth day of menses, for treatment of infertility. After the nurse provides medication teaching, which client statement would indicate a need for further teaching? -"Clomiphene increase my risk of having more than one baby, such as twins or triplets" -"Hot flashes, mood swings,nausea, and headache are possible side effects of this medication" -"My partner and I should have sexual intercourse on the days that I am taking the medication" -"This medication will help my body release eggs and increase my chance of becoming pregnant"

-"My partner and I should have sexual intercourse on the days that I am taking the medication" --Clomiphene is a selective estrogen receptor modulator that is used as a first-line treatment for infertility for women and works by stimulating ovulation. This medication blocks estrogen receptors in the hypothalamus and pituitary, which causes the release of hormones that stimulate the ovaries to release an egg. The medication is taken orally for 5 days early in the menstrual cycle. Ovulation typically occurs 5-9 days after completing the medication. Therefore, it is necessary for the client to understand the importance of engaging in frequent sexual intercourse 5 days after completing the medication for the best chance of successful conception.

The nurse is providing education to a 32-year-old female client diagnosed with human papillomavirus. Which client statement indicates a need for further instruction? -"I can transmit the virus when I don't have symptoms" -"I know the virus can be spread through oral sex" -"I need to have a Papanicolaou test on an annual basis" -"My partner won't get HPV as long as we use a condom"

-"My partner won't get HPV as long as we use a condom" --HPV is associated with genital warts and cervical cancer. Condoms used during sex decrease, but do not completely eliminate, the risk of transmission. Prevention includes vaccination against HPV, preferably before sexual activity begins, and safe sex practices.

The nurse employed in a woman's healthcare clinic would be most concerned about which client statement? -"I recently noticed a small, round, painless, mobile lump in my left breast while showering" -"Last night while breastfeeding, my nipples were cracked and my breasts were painful" -"My right breast is red and warm with little tiny indented areas on the surface of the skin" -"Sometimes during my cycle, I notice breast nodules that are movable and feel soft to the touch"

-"My right breast is red and warm with little tiny indented areas on the surface of the skin" --The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In this aggressive form of cancer, breast lymph channels are blocked by cancer cells,creating breast tissue that becomes red, warm, and has an orange peel,pitting appearance on the skin surface. The nurse would be most concerned about this client and make an immediate referral to the healthcare provider for examination and evaluation.

The nurse is caring for a client with absence seizures. The UAP asks if the client will "shake and jerk" when having a seizure. Which response from the nurse is the most helpful? -"No, absence seizures can look like daydreaming or staring off into space" -"No, you are wrong. Don't worry about that" -"Yes, so please let me know if you see the client do that" -"You don't have to monitor the client for seizures"

-"No, absence seizures can look like daydreaming or staring off into space" --Absence seizures are brief periods of staring; there is no evidence of tonic-clonic activity or postictal confusion. The UAP should be educated about absence seizures when involed in the care of such clients.

The nurse is providing teaching about contraception to a group of clients. Which statement by the nurse is appropriate to include? -"Backup contraception is required for the first 3 months after initiation of oral contraceptives" -"Diaphragm contraceptive devices, when used with spermicide, also provide protection from HIV infection" -"OTC emergency contraceptives should be taken within 3 days of unprotected intercourse" -"Use of an intrauterine device should be avoided in sexually active adolescent clients"

-"OTC emergency contraceptives should be taken within 3 days of unprotected intercourse" --Emergency contraception prevents pregnancy after unprotected intercourse. OTC EC pills should be taken within 3 days of unprotected sexual intercourse. If taken after 3 days, levonorgestrel will not harm an established pregnancy but may be less effective. Copper intrauterine device insertion and oral ulipristal require a prescription and offer EC for up to 5 days after unprotected intercourse. --Backup contraception is required for 7 days after starting oral contraceptives; however, it is not required if the pill pack is started on the first day of menses.

The RN is supervising a graduate nurse providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene? -"Elevate your scrotum and apply an ice bag to reduce swelling" -"Practice coughing to clear secretions and prevent pneumonia" -"Stand up to use the urinal if you have difficulty voiding" -"Turn in bed and perform deep breathing every 2 hours"

-"Practice coughing to clear secretions and prevent pneumonia" --An inguinal hernia is the protrusion of abdominal contents through the inguinal canal, which appears as a bulge in the lateral groin. Herniation occurs spontaneously or results from increased intraabdominal pressure. Inguinal hernias occur most commonly in male clients and are usually repaired with minimally invasive surgery. If intestinal strangulation develops, the client requires emergency treatment to prevent bowel ischemia or perforation. Strangulation symptoms include abdominal distension, severe pain, N/V. To prevent hernia reoccurrence after surgical repair, the client is taught to avoid activities that increase intraabdominal pressure for 6-8 weeks. If sneezing or coughing are unavoidable, the client should splint incisions and keep the mouth open while sneezing.

The nurse is assessing the cranial nerves and begins testing the facial nerve (cranial nerve VII). Which direction should the nurse give the client to test this cranial nerve? -"close your eyes and identify this smell" -"Follow my finger with your eyes without moving your head" -"Look straight ahead and let me know when you can see my finger" -"Raise your eyebrows, smile, and frown"

-"Raise your eyebrows, smile, and frown" --This cranial nerve is tested by assessing exaggerated facial movements. The client is directed to raise the eyebrows, furrow the eyebrows, draw up the cheeks in a large smile, pull the cheeks down in a frown, and open the lips to show the teeth. Any asymmetrical movements are documented, and if unexpected, the healthcare provider is notified.

The nurse assesses a client who has followed a vegan diet for several years. Which client statement indicates a potential nutritional deficiency? -"I have had some visual disturbances while driving at night" -"I have had trouble falling asleep over the past few months" -"Scaly patches of skin are developing on my elbows and knees" -"Sometimes my hands and feet get a tingling sensation"

-"Sometimes my hands and feet get a tingling sensation" --Clients who follow a vegan diet eat only plant-based foods, omitting animal proteins and products. Clients who are vegan are at risk for deficiency of vitamin B12, which is primarily supplied by animal products. Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain. Manifestations of chronic deficiency includes peripheral neuropathy, neuromuscular impairment, memory loss/dementia. Clients who follow a vegan diet are encouraged to take supplemental vitamin B12 to prevent severe neurological complications. In addition, clients are taught to incorporate vitamin B12 fortified foods.

The clinic nurse is assessing a previously healthy 60-year-old client when the client says, "my hand has been shaking when I try to cut food. I did some research online. Could I have Parkinson's disease?" Which response from the nurse is the most helpful? -"It can't be Parkinson's disease because you aren't old enough" -"Make sure you tell the physician about your concerns" -"Parkinson's disease does not cause that kind of hand shaking" -"Tell me more about your symptoms. When did they start?"

-"Tell me more about your symptoms. When did they start?" --Parkinson's disease is a chronic, progressive neurodegenerative disorder that involves degeneration of the dopamine-producing neurons. Damage to dopamine neurons makes it difficult to control muscles through smooth movement. PD is characterized by a delay in initiation of movement (bradykinesia), increased muscle tone (rigidity), resting tremor, and shuffling gait. The most helpful response by the nurse is the one that acknowledges the concern of the client and also asks for more information. The nurse should assess for additional information and perform a more focused physical assessment given this new information.

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse? -"I will refer you to the dietitian" -"It should take about 6-8 weeks before you see improvement in your symptoms" -"Tell me what you had to eat yesterday" -You must not be following your diet"

-"Tell me what you had to eat yesterday" --The client with celiac disease continues to have symptoms. An assessment of the client's food intake must be obtained to determine if it includes foods that contain gluten, a protein in barley, rye oats, and wheats (BROW). The most common reason for non-responsiveness to a gluten-free diet in clients with celiac disease is that gluten has not been entirely eliminated from their food intake. --most people experience dramatic relief of GI symptoms within a few days of eliminating gluten from their diet.

The nurse is caring for a client with right upper quadrant pain and jaundice. The client's ALT/AST levels are 8 times the normal values. What questions would be most helpful regarding the etiology for these findings? SATA -do you have black tarry stool? -Do you use IV illicit drugs? -How much alcohol do you typically drink? -Were you recently immunized for pneumonia? -What OTC drugs do you take?

-Do you use IV illicit drugs? -How much alcohol do you typically drink? -What OTC drugs do you take? --ALT and AST are the enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues, but ALT/AST are used to diagnose hepatic disorders. Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake, some OTC medications (acetaminophen), and certain herbal and dietary supplements. IV illicit drug use increases the risk for hepatitis B and C infection.

The nurse is providing discharge education for a postoperative client who had a partial layrgnectomy for laryngeal cancer. The client is concerned because the healthcare provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? -"I will ask the healthcare provider to explain the consequences of your procedure" -"This is a common complication that will require you to have a hearing test every year" -"This is a common complication; your healthcare provider will order a consult for the speech pathologist" -"This is the reason you are using a special swallowing technique when you eat and drink"

-"This is the reason you are using a special swallowing technique when you eat and drink" --CN IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste. Postoperative partial laryngectomy clients will need to undergo evaluation by a speech pathologist to evaluate their ability to swallow safely to prevent aspiration. Clients are taught the supraglottic swallow, a technique that allows them to have voluntary control over closing the vocal cords to protect themselves from aspiration.

The nurse provides discharge instructions to a client one day after laparoscopic cholecystectomy. Which statement by the client indicates that further teaching is required? -"I can resume a regular diet but will avoid fatty foods for several weeks after surgery" -"I can return to work within a week of surgery" -"I will report to the HCP if my temperature is higher than 101 F" -"Tomorrow I can remove the puncture she bandages and take a bath"

-"Tomorrow I can remove the puncture she bandages and take a bath" --A laparoscopic cholecystectomy is the safest and most commonly used procedure for gallbladder removal. A laparoscope and grasping forceps are inserted through small punctures made in the abdomen. The procedure is associated with decreased postoperative pain, better cosmetic results, shorter hospital stays, and fewer days for recovery versus the open technique. postoperative teaching includes a low-fat diet (recommended). A regular diet can be resumed after a few weeks, although weight loss is often recommended. Resume normal activity slowly, as tolerated. Most individuals can return to work within a week. Dressings can be removed the day after surgery and showering is permitted at this time.

The nurse prepares a client for discharge following a vasectomy. The client asks "When can I have sexual intercourse with my wife without using a condom?" What is the best response by the nurse? -"Discontinue alternative birth control after at least 5 ejaculations" -"There is no need to use alternative birth control following today's procedure" -"Use alternative birth control for 6 months following today's procedure" -"Use alternative birth control until cleared by the health care provider"

-"Use alternative birth control until cleared by the health care provider" --A vasectomy is a surgical procedure performed for permanent male sterilization. During the procedure, the vasa deferentia are cut and sealed, preventing sperm from entering the ejaculate. The vasa deferentia are severed in the scrotum at the site before the seminal vesicles and prostate. As a result, the procedure should not affect the ability to ejaculate, amount and consistency of ejaculatory fluid, or other physiological mechanisms. Following a vasectomy, sperm continue to be produced but are absorbed by the body. Following the procedure, it can take sever months for the remaining sperm to be ejaculated or absorbed. Alternative birth control should be used until the healthcare provider confirms that semen samples taken at a follow-up appointment are free of sperm.

A 28-year-old client is seeking advice from the nurse about why she has not been able to conceive. The client is discouraged and states that she has been "trying to get pregnant for 4 months." Which statement by the nurse is best? -"Adoption or surrogacy are options for those who are unable to conceive" -"Consider talking to your HCP about fertility-enhancing medications that can help you conceive more quickly" -"There is no cause for concern unless you haven't been able to conceive for 1 year" -"Using an OTC urine ovulation detector kit to time sexual intercourse may improve your chances of conceiving"

-"Using an OTC urine ovulation detector kit to time sexual intercourse may improve your chances of conceiving"

The nurse provides discharge teaching for a client who is newly diagnosed with diabetes mellitus. Which statement by the client regarding sick-day rules indicates a need for further teaching? -"I will make sure that I monitor my blood glucose more frequently when I am sick" -"I will make sure to notify my health care provider when I am sick" -"When I am sick and not eating, I will not take my insulin until my appetite improves" -"When I am sick, I will drink 8-12 ounces of fluid every hour I am awake

-"When I am sick and not eating, I will not take my insulin until my appetite improves" --stress caused by illness, injury, or surgery causes increased secretion of corticosteroids that may result in impaired glycemic control and acute hyperglycemia in clients with diabetes mellitus. IF blood glucose is not controlled, the client can develop life-threatening ketoacidosis or hyperosmolar states. Therefore, the nurse should instruct clients with DM about sick-day DM management to detect and act on potentially dangerous hyperglycemic stats. Most importantly, the nurse should teach the client to frequently check blood glucose and to take insulin as prescribed during illness, even if there is no oral intake or it is poor, to avoid hyperglycemia and possible diabetic ketoacidosis.

The nurse iscaring for a client with increased ICP. Which statement by the UAP would require immediate intervention by the nurse? -"I will raise the HOB so it is easier to see the TV" -"I will turn down the lights when I leave" -"Let me move your belongings closer so you can reach them" -"You should do deep breathing and coughing exercises"

-"You should do deep breathing and coughing exercises" --Clients with elevated ICP should avoid anything that increases intrathoracic or intraabdominal pressure as these also indirectly increases ICP. These activities include straining, coughing, and blowing the nose. Respiratory interventions, if needed, may include deep breathing and incentive spirometry in the absence of coughing. The HOB should be maintained at 30 degrees, high enough to allow for CSF drainage, but low enough to maintain cerebral perfusion pressure. Clients should have minimal stimuli, including no bright lights or multiple visitors, so stimulation can increase ICP.

A client sustained a concussion after falling off a ladder. What are essential instructions for the nurse to provide when the client is discharged from the hospital? SATA -client should abstain from alcohol -client should remain awake all night -client should return if having difficulty walking -responsible adult should be taught neurological examination -responsible adult should stay with the client

-client should abstain from alcohol -client should return if having difficulty walking -responsible adult should stay with the client --A neurological assessment should be performed by a clinician. The responsible adult is taught the general indicative symptoms.

A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time? -"Avoid excess stretching of your lower extremities" -"Build strength by increasing the duration of daily exercise" -"Let me speak with you HCP about getting a wheelchair" -"You should keep your feet apart and use a cane when walking"

-"You should keep your feet apart and use a cane when walking" --Multiple sclerosis is a progressive, demyelinating disease of the central nervous system that interrupts nerve impulses, causing a variety of symptoms. Symptoms may vary, but muscle weakness, spasticity, incoordination, loss of balance, and fatigue are usually present, causing impaired mobility and risk for fall and injury. Walking with the feet apart increases the support base, improving steadiness and gait. Assistive devices, such as a cane or walker, are usually required as demyelination of the nerve fibers progresses. --fatigue is a common symptom with MS. Rather than increasing the duration, clients should balance exercise with rest. Clients should also exercise when the weather is cool and stay hydrated; dehydration and extremes in temperature cause symptom exacerbation.

A nurse is teaching home management to a client newly diagnosed with severe psoriasis. Which client statement indicates that further teaching is needed? -"exposure to sunlight will worsen my psoriasis" -"I should avoid drinking alcohol" -"I should use moisturizing creams frequently" -"Stress can worsen psoriasis"

-"exposure to sunlight will worsen my psoriasis" --Psoriasis is a chronic autoimmune disease that causes a rapid turnover of epidermal cells. Characteristic silver plaques on reddened skin may be found bilaterally on the elbows, knees, scalp, lower back, and/or buttocks. The goal of therapy is to slow epidermal turnover, heal lesions, and control exacerbations. There is no cure for psoriasis. Disease management includes avoidance of triggers, topical therapy, phototherapy, and systemic medications, including cytotoxic and biologic agents. The client should avoid alcohol as it can worsen psoriasis. In addition, the liver, kidneys, and bone marrow are specifically affected by the systemic medications commonly used to control psoriasis

The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond? -"genetic counseling is recommended. You will receive a referral before you leave" -"Huntington disease inheritance requires both biological parents to carry the gene" -"There are other ways to grow your family. You should consider adoption" -"This disease occurs spontaneously and is not likely to affect your children"

-"genetic counseling is recommended. You will receive a referral before you leave" --Huntington disease is an incurable autosomal dominant hereditary disease that causes progressive nerve degeneration, which results in impaired movement, swallowing, speech, and cognitive abilities. Chorea is a hallmark sign. The onset of active disease is usually at age 30-50, and death from neuromuscular and respiratory complications typically occurs within 20 years of diagnosis. HD is confirmed by genetic testing. Clients who have a parent with HD and are considering having biological children should receive genetic counseling. --autosomal dominant traits require only one copy of the affected gene to manifest.

The nurse assessing a client's pain would expect the client to make which statement when describing the abdominal pain associated with appendicitis? -"my pain is a burning sensation in my upper abdomen" -"my pain is an 8 out of 10 and on my left side below my belly button" -"my pain is excruciating in my lower abdomen above my right hip" -"my pain is intermittent in my abdomen and right shoulder"

-"my pain is excruciating in my lower abdomen above my right hip" --The appendix is a bling pouch located at the junction of the ileum of the small intestine and the beginning of the large intestine. When infected or obstructed, the appendix becomes inflamed, causing acute appendicitis. Clients with acute appendicitis attempt to decrease pain by preventing increased intraabdominal pressure and lying still with the right leg flexed. --Pain in the left lower quadrant is associated with diverticulitis. Other signs/symptoms include a palpable, tender abdominal mass and systemic symptoms of infection.

A healthy 50 year old client asks the nurse, "What must I do in preparation for my screening colonscopy?" Which statements by the nurse correctly answer the client's question? SATA -"no food or drink is allowed 8 hours prior to the test" -"Prophylactic antibiotics are taken as prescribed" -"Smoking must be avoided after midnight" -"The day prior to the procedure your diet will be clear liquids" -"You will drink polyethylene glycol as directed the day before"

-"no food or drink is allowed 8 hours prior to the test" -"The day prior to the procedure your diet will be clear liquids" -"You will drink polyethylene glycol as directed the day before" --The instructions prior to a nuclear gastric emptying scan include teaching the client to avoid smoking the day of the examination as delay of gastric emptying occurs with tobacco use. Smoking cessation per se has no role in colonoscopy.

Acute care for diverticulitis

--focuses on allowing the colon to reset and inflammation to resolve --NPO status --IV fluids to prevent dehydration --pain relief through IV medications --prevention of increased intraabdominal pressure --prevention of increased intestinal motility by avoiding laxatives and enemas

What foods should a client with an ileostomy avoid?

--foods high in fiber (popcorn, coconut, brown rice, multigrain bread) -stringy vegetables (celery, broccoli, asparagus) -seeds or pits (strawberries, raspberries, olives) -Edible peels (apple slices, cucumber, dried fruit)

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives this report to the oncoming nurse as shift change and conveys that the client's current GCS score is a "10". Which client assessment is most important for the reporting nurse to include? -belief that the current surroundings are a racetrack -GCS score was "11" one hour ago -recent vital signs show blood pressure of 120/80 mm Hg and pulse of 82/min -reported allergy to penicillin and vancomycin

-GCS score was "11" one hour ago --The GCS quantities the LOC in a client with acute brain injury by measuring eye opening, verbal response, and motor response. The maximum score on the GCS is 15 and the lowest is 3. If a client is trending for deterioration, this should always be noted in neurological assessments. A numerical decline of a single number in 1 hour is significant. A criticism of the GCS score is that it is not that precise. --although it is important to be aware of allergies, the oncoming nurse can find that information on the chart if these medications are offered.

The clinic nurse educator is developing a teaching plan for the following 6 clients. The nurse should instruct which client to avoid the Valsalva maneuver when defecating? SATA -22 year old man with a head injury sustained during a college football game -30 year old woman recently hospitalized for reconstructive augmentation mammoplasty -56 year old man 2 weeks post myocardial infarction -68 year old woman recently diagnosed with pancreatic cancer -74 year old man with portal hypertension related to alcohol-induced cirrhosis -82 year old woman 1 week post cataract surgery

-22 year old man with a head injury sustained during a college football game -56 year old man 2 weeks post myocardial infarction -74 year old man with portal hypertension related to alcohol-induced cirrhosis -82 year old woman 1 week post cataract surgery --The Valsalva maneuver involves holding the breath while bearing down the perineum to pass a stool. Straining to have a bowel movement is to be avoided in clients recently diagnosed with increased intracranial pressure, stroke, or head injury as straining increases intra-abdominal and intrathoracic pressure, which raises the intracranial pressure. The vagus nerve is stimulated when bearing down; this temporarily slows the heart and decreases cardiac output, leading to potential cardiac complications in clients with heart disease. Straining increases intra-abdominal and intrathoracic pressure and should be avoided in clients diagnosed with portal hypertension related to cirrhosis due to the risk of variceal bleeding. The maneuver increases intraocular pressure and is contraindicated in clients with glaucoma and recent eye surgery.

The nurse is reviewing the history of four female clients. The nurse should recommend a Pap test to screen for cervical cancer in which client? -17-year-old who reports being sexually active for 2 years and uses condoms -26-year-old whose last Pap test screening at age 21 was negative -51-year-old who had a hysterectomy with cervix removal for benign reasons and whose previous pap tests were negative -72-year-old with a history of regular Pap test screening whose previous Pap tests were negative

-26-year-old whose last Pap test screening at age 21 was negative --Pap testing for cervical cancer allows early detection of cervical dysplasia and is initiated at age >21, regardless of sexual activity history. Women who have had their uterus and cervix removed for reasons unrelated to cervical cancer and th ose age >65-70 may usually discontinue screening. Women age 21-29 should be screened with Pap testing every 3 years in the United States

The nurse is caring for several clients in a women's health clinic. Based on the data collected, which client's history is most concerning for an increased risk of endometrial cancer? -40-year-old client who has been taking hormonalbirth control pills for the past 10 years -45-year-old client who reports a history of an ectopic pregnancy with a ruptured ovary and two preterm births -47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments -60-year-old client who recently had a colposcopy after testing positive for a high risk type of human papillomavirus

-47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments --Endometrial cancer arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth. Although typically slow growing, it can metastasize to the myometrium, cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific but the hallmark symptom is abnormal uterine bleeding. As with many cancers, the client's family and genetic history are significant risk factors; however, prolonged estrogen exposure without adequate progesterone is the greatest risk factor for developing endometrial cancer.

A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse? -25-year-old client who reports a fish-like vaginal odor for the past month -30-year-old client with an intrauterine device who reports heavy bleeding with menses -40-year-old client with endometriosis who reports persistent pain during intercourse -60-year-old client who reports bloating and pelvic pressure for the past 2 months

-60-year-old client who reports bloating and pelvic pressure for the past 2 months --Ovarian cancer results in more deaths than any other gynecologic cancer. Symptoms are often subtle and may include abdominal bloating; pelvic pain or pressure; abdominal girth increase; earl satiety; abdominal/back/leg pain;urinary urgency/frequency;and gastrointestinal disturbances.Due to the lack of routine screening and reports of vague symptoms, ovarian cancer may not be diagnosed until an advanced stage. A fish-like vaginal odor is often caused by bacterial vaginosis, an overgrowth of vaginal bacterial flora. This condition is not usually serious and is treated with oral or vaginal antibiotics.

A client tells the nurse of wanting to lose 20 lb in time for the client's daughter's wedding, which is 16 weeks away. How many calories will the client have to eliminate from the diet each day to meet this goal? -450 kcal/day -625 kcal/day -860 kcal/day -1,000 kcal/day

-625 kcal/day --A reduction or energy expenditure of 3,500 calories will result in a weight loss of 1 lb. To lose 20 lb, the client needs to reduce intake by a total of 70,000 kcal. Over a period of 16 week, this results in 625 kcal/day. Adding an exercise regimen to the client's daily routine will facilitate additional weight loss and/or reduce the need for severe caloric restriction.

The nurse receives report for 4 clients in the ED. Which client should be seen first? -30 year old with a spinal cord injury at L3 sustained in a motor cycle accident who reports lower abdominal pain and difficulty urinating -33 year old with a seizure disorder admitted with phenytoin toxicity who reports slurred speech and unsteady gait -65 year old with suspected brain tumor waiting to be admitted for biopsy who reports throbbing headache and had emesis of 250 mL -70 year old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL

-70 year old with atrial fibrillation and a closed-head injury waiting for brain imaging who reports a headache and had emesis of 200 mL --A client with a neurological injury is at risk for cerebral edema and increased intracranial pressure, a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants, making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment immediately.

The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer? SATA -HIV -HPV -multiple sex partners -nulliparity -sexual activity before age 18

-HIV -HPV -multiple sex partners -sexual activity before age 18 -HPV is the most common sexually transmitted infection and is a primary risk factor for cervical cancer. Other cervical cancer risk factors include sexual activity at an early age, multiple sexual partners, and weakened immune system function.

A client is brought to the emergency department after sustaining third-degree burns over 50% of the body. Which solution is the best choice for fluid resuscitation in this client? -0.45% normal saline -5% dextrose in 0.9% normal saline -5% dextrose in water -Lactated Ringer's Solution

-Lactated Ringer's Solution --The greatest immediate threat to a client with severe and extensive burn injuries is hypovolemic shock and electrolyte imbalance. This is due to cellular damage and increased capillary permeability caused by direct thermal trauma, which result in fluid loss. In the emergent phase of burn management, it is critical to establish an airway and replenish lost intravascular fluid, proteins, and electrolytes. Lactated Ringer's is the solution of choice for fluid resuscitation of a burned client due to its similarity in chemical composition to human plasma. Lactated Ringer's remains the in intravascular space longer than other solutions, which helps to stabilize blood pressure and avert shock.

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The healthcare provider requests that the nurse prepare the client for paracentesis. Which nursing actions would the nurse implement prior to the procedure? SATA -educate client about the procedure and obtain informed consent -initiate NPO status 6 hours prior to the procedure -Obtain baseline vital signs, abdominal circumference, and weight -place client in high Fowler position or as upright as possible -request that the client empty the bladder

-Obtain baseline vital signs, abdominal circumference, and weight -place client in high Fowler position or as upright as possible -request that the client empty the bladder --Paracentesis is performed to remove excess fluid from the abdominal cavity or to collect a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Prior to a paracentesis, nursing actions include verifying that the client received necessary information to give consent and witness informed consent; instruct the client to void to prevent puncturing the bladder; assess the client's abdominal girth, weight, and vital signs; place the client in the high Fowler position or as upright as possible.

The oncology nurse is caring for a client with tumor lysis syndrome. Which prescription should the nurse question? -allopurinol 200 mg PO every 24 hours -normal saline IV at 150 m/hr continuous -Sevelamer 800 mg PO3 times daily with meals -Spironolactone 25 mg PO every 12 hours

-Spironolactone 25 mg PO every 12 hours --Tumor lysis syndrome is an oncologic emergency that occurs when cancer treatment successfully kills cancer cells, resulting in the release of intracellular components. Clients with TLS develop significant imbalances of serum electrolytes and metabolites. Potassium-sparing medications can worsen hyperkalemia.

The nurse is caring for a client in the intensive care unit who suffered partial-thickness burns to 36% of the body. During the first 24 hours, the nurse would anticipate which of the following assessments? -hemoglobin 10.2 g/dL -hyperactive bowel sounds -serum sodium 152 mEq/L -Tall, peaked T waves on ECG

-Tall, peaked T waves on ECG --Burn injuries cause tissue damage that leads in increased vascular permeability and fluid shifts. In the emergent phase after a burn (first 24-72 hours)fluid, proteins, and intravascular components leak into the surrounding interstitium,causing decreased intravascular oncotic pressure and decreased intravascular volume, and resulting in fluid shifts and hypovolemia. Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting in hyperkalemia. Clients with hyperkalemia experience muscle weakness, ECG changes, and cardiac arrhythmias. Hematocrit and hemoglobin values will be elevated due to hypovolemia. The sympathetic nervous system is activated in response to a burn,causing decreased peristalsis. N/V, gastric distension, and paralytic ileus may occur. Sodium is the most abundant extracellular cation. Hyponatremia occurs as sodium is lost via fluid shifts and insensible losses.

The RN is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client? -the client will contact the United Ostomy Associated of America -The client will look at and touch the stoma -The client will read the materials provided on ostomy care -the client will verbalize methods to control gas and odor

-The client will look at and touch the stoma --A client who has undergone ostomy surgery must become independent in self-care. This requires adaptation to a significant alteration in body image and dealing with a number of psychosocial issues that are associated with a change in appearance and the loss of bowel control. The client looking at and touching the stoma is an indication that the client has accepted or begun to accept the change in body image and functioning and can begin participating in self-care.

The public health nurse identifies which of the following clients as being at high risk for developing colorectal cancer? -a 28-year-old female client with a body mass index of 38 kg/m3 -a 38-year-old male client with a 15-year history of ulcerative colitis -a 48-year-old male client whose father has a history of colorectal cancer -a 58-year-old male client who consumes a diet high in fruits and vegetables -a 68-year-old female client with a 40-year history of cigarette smoking

-a 28-year-old female client with a body mass index of 38 kg/m3 -a 38-year-old male client with a 15-year history of ulcerative colitis -a 48-year-old male client whose father has a history of colorectal cancer -a 68-year-old female client with a 40-year history of cigarette smoking

Which client is at greatest risk for pulmonary embolism? -a client 6 hours postoperative cesarean section - a client in atrial fibrillation -a client with a subdural hematoma -a client with pneumonia

-a client 6 hours postoperative cesarean section --Death from pulmonary embolism is often attributed to a missed diagnosis. Nurses must recognize any condition or situation that predisposes a client to venous stasis, hypercoagulability of blood, and endothelial damage, as these factors increase the risk for PE.In atrial fibrillation, stasis and turbulence of blood increases risk of thrombus formation. Once mobilized, emboli can get trapped in blood vessels, causing ischemia. Smaller vasculature and increased blood flow in the brain increases the probability of a stroke, rather than PE>

A clinic nurse is reviewing charts for clients who have appointments later in the day. Which of the following clients should the nurse recognize as appropriate recipients of a prescription of emtricitabine/tenofovir? SATA -a client who reports current recreational IV drug use -a client with a latent tuberculosis infection -a female client whose spouse has HIV -a male client who has intercourse with men and women -a phlebotomist at an outpatient blood bank

-a client who reports current recreational IV drug use -a female client whose spouse has HIV -a male client who has intercourse with men and women --HIV is a viral infection of CD4 cells that results in progressive immune system impairment. It is most frequently transmitted via blood, unprotected sexual contact, shared needles, and parenteral equipment, or perinatally from mother to child. Primary prevention and modification of risky behaviors are essential health care strategies for HIV because there is no known cure. Preexposure prophylaxis is a preventive strategy in which antiretroviral therapy is prescribed for clients whose risk for contracting HIV is high. Entricitabine/tenofovir (Truvada) is a commonly used combination therapy for PrEP in high-risk individuals (clients using recreational IV drugs, clients whose spouses have HIV, men who have sex with men). PrEP should be combined with other prevention methods such as safer sex practices, regular HIV testing and counseling for risk reduction. -Tuberculosis infection does not increase the risk of contracting HIV. However, HIV infection places clients at risk for opportunistic infections. Antiretroviral therapy can lower the risk for opportunistic infections in clients with HIV.

The nurse completes a neurological examination on a client who has suffered a stroke to determine if damage has occurred to any of the cranial nerves. The nurse understands that damage has occurred to cranial nerve IX based on which assessment finding? -a tongue blade is used to touch the client's pharynx; gag reflex is absent -only one side of the mouth moves when the client is asked to smile and frown -the absence of light touch and pain sensation on the left side of the client's face -when the client shrugs against resistance, the left shoulder is weaker than the right

-a tongue blade is used to touch the client's pharynx; gag reflex is absent --Cranial nerve IX (glossopharyngeal) and X (vagus) are related to the movement of the pharynx and tongue. To evaluate cranial nerves X and IX, the nurse assesses for the presence of a gag reflex and symmetrical movements of the uvula and soft palate, and listens to voice quality. A tongue blade can be used to touch the posterior pharyngeal wall to assess for a gag reflex. Asking the client to say "ah" will allow assessment of the uvula and soft palate. Harsh or brassy voice quality indicates dysfunction with the vagus nerve.

During the admission assessment of a client with a small-bowel obstruction, the nurse anticipates which clinical manifestations? SATA -abdominal distension -absolute constipation -colicky abdominal pain -frequent vomiting -pain during defecation

-abdominal distension -colicky abdominal pain -frequent vomiting --Small-bowel obstruction can have mechanical or non-mechanical causes. Mechanical obstruction is commonly caused by obstruction of the bowel resulting from surgical adhesions, hernias, intussuscpetion, or tumors. Paralytic ileus, a non-mechanical obstruction, may occur after abdominal surgery or narcotic use. When a small-bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid onset of N/V; colicky intermittent abdominal pain, and abdominal distension. The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise, bowel ischemia, or perforation. Nursing management of an obstruction includes placing the client on NPO status, inserting a NG tube, administering prescribed IV fluids, and instituting pain control measures.

An older client comes to the outpatient clinic for a routine physical examination and health screening. Which findings does the nurse recognize as possible indications of colorectal cancer? SATA -abdominal pain -blood in the stools -change in bowel habits -low hemoglobin level -unexplained weight loss

-abdominal pain -blood in the stools -change in bowel habits -low hemoglobin level -unexplained weight loss --Colorectal cancer occurs most often in adults over age 50. Risk factors include history of colon polyps; family history of colorectal cancer; inflammatory bowel disease; and history of other cancers. --Symptoms of colorectal cancer may include blood in stool from fragile, bleeding polyps or tumors; abdominal discomfort and/or mass; anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion; change in bowel habits due to obstruction by polyps or tumors; unexplained weight loss due to impaired nutrition from altered intestinal absorption. Colorectal cancer often goes unnoticed, as many of the symptoms are painless and nonspecific. Clients should be assessed for these symptoms and receive regular routine colorectal cancer screening tests.

The nurse who is caring for a client with acute diverticulitis will immediately report which finding to the healthcare provider? -abdominal pain has progressed to the left upper quadrant -hemoglobin of 11.2 g/dL -lying on the side with knees drawn up to abdomen and truck flexed -white blood cell count of 12,000/mm3

-abdominal pain has progressed to the left upper quadrant --Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure. The left colon is the most common area for diverticula to develop. When these diverticula become inflamed, the client may experience acute pain and systemic signs of infection. Complications that can occur in some clients are abscess formation and intestinal perforation resulting in diffuse peritonitis. The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum. Peritonitis is a potentially lethal complication and should be reported immediately.

The post-anesthesia care unit nurse receives report on a client after abdominal surgery. What sounds would the nurse expect to hear when auscultating the bowel? -absent bowel sounds -borborygmi sounds -high pitched and gurgling sounds -swishing or buzzing sounds

-absent bowel sounds --Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent, high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4 quadrants. Cardiovascular bruits are rarely benign and usually arterial narrowing or dilation. Procedures that require bowel manipulation cause a temporary halting of peristalsis for the first 24-48 hours, resulting in absent bowel sounds. For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalss will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds.

A hospitalized client develops acute hemorrhagic stroke and is transferred to the intensive care unit. Which nursing interventions should be included in the plan of care? SATA -administer PRN stool softeners daily -administer scheduled enoxaparin injection -implement seizure precautions -keep client NPO until swallow screen is performed -perform frequent neurological assessments.

-administer PRN stool softeners daily -implement seizure precautions -keep client NPO until swallow screen is performed -perform frequent neurological assessments. --a hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure. During the acute phrase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits. The nurse should perform neurological assessments at regular intervals and report any acute changes. Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should reduce stimulation by maintaining a quiet and dimly lit environment and limit visitors; administer stool softeners to reduce strain during bowel movements; reduce exertion, maintain strict bed rest, and assist with activities of daily living; maintain head in midline position to improve jugular venous return to the heart --enoxaparin is an anticoagulant used to prevent venous thromboembolism. Anticoagulants are contraindicated in clients with hemorrhagic stroke; the nurse should question any prescriptions that increase risk for bleeding. A client with hemorrhagic stroke should instead receive nonpharmacologic interventions to prevent VTE.

A client who suffered a burn injury has received fluid resuscitation and is now diuresing, indicating the end of the emergency phase. Which prescription is the highest priority at this time? -administer enteral feedings at the return of bowel sounds -assist the client in activities of daily living as tolerated -contact the client's religious advisor for spiritual support -educate the client's family about dressings and medications

-administer enteral feedings at the return of bowel sounds --The nurse should consider Maslow's Hierarchy of Needs to determine the importance of various interventions. This client is in the acute phase of burn management continues to have increased physiological needs. Clients with burns have increased metabolism and calorie requirements that must be met for healing to occur. The nutrition needed for healing increases proportionally with he percentage of burned tissue. Therefore, providing proper nutrition as soon as possible is the highest priority.

A hospitalized client with acute pancreatitis has nausea, vomiting, epigastric pain, and tachycardia. Laboratory results show elevated serum lipase levels. Which interventions would the nurse anticipate being prescribed for the client? SATA -administer hydromorphone IV PRN for pain -administer intravenous fluids -insert a nasogastric tube for nasogastric suction -maintain client in a supine position, with head of bed flat -provide small, frequent, high-carbohydrate, high-calorie meals

-administer hydromorphone IV PRN for pain -administer intravenous fluids -insert a nasogastric tube for nasogastric suction --Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. NPO status is maintained to prevent stimulation of excretion of pancreatic enzymes. A NG tube is used to suction out gastric secretions; this reduces nausea and lessens stimulation of the pancreas. IV opioids are frequently utilized for pain management. Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing. --the client should maintain positions that flex the trunk and draw the knees up to the abdomen to decrease tension on the abdomen. A side-lying position with the head elevated to 45 degrees will help relieve the pain even better.

The nurse is caring for a client with acute diverticulitis who has N/V and rates pain as 8 on a scale of 0-10. Which of the following interventions should be included in the plan of care? -administer morphine sulfate as prescribed for pain control -insert a rectal tube to protect the client's skin from diarrhea -instruct the client to avoid straining -maintain NPO status -start IV infusion of normal saline

-administer morphine sulfate as prescribed for pain control -instruct the client to avoid straining -maintain NPO status -start IV infusion of normal saline --Diverticulosis is a condition in which saclike protrusions develop in the large intestine, caused by increased intraabdominal pressure and/or chronic constipation. When diverticula become infected and inflamed, the individual has diverticulitis.

The nurse cares for a client with ulcerative colitis who is having abdominal pain and greater than 10 bloody stools per day. Which of the following interventions should be included in the client's plan of care? SATA -administer prescribed analgesic medications as needed -encourage the client to discuss feelings about illness -initiate strict, hourly intake and output monitoring -investigate the client's compliance with the medication regimen -offer the client high-protein foods during meals and snacks

-administer prescribed analgesic medications as needed -encourage the client to discuss feelings about illness -initiate strict, hourly intake and output monitoring -investigate the client's compliance with the medication regimen -offer the client high-protein foods during meals and snacks --Ulcerative colitis is a chronic inflammatory bowel disease characterized by bouts of bloody diarrhea, abdominal pain, anorexia, and anemia. Nurses caring for clients with UC should provide pain management, promote adequate nutrition and hydration, address psychosocial needs, and evaluate client compliance with treatment.

A nurse is caring for a client admitted to the intensive care unit for toxic epidermal necrolysis. Which interventions should be included in this client's care plan? SATA -administer prescribed eye lubricants on schedule -apply sterile, moist dressings and ointments to denuded areas of skin -implement reverse isolation precautions and strict aseptic technique -keep room temperature warm to prevent shivering -provide gentle massage as needed to relieve pain

-administer prescribed eye lubricants on schedule -apply sterile, moist dressings and ointments to denuded areas of skin -implement reverse isolation precautions and strict aseptic technique -keep room temperature warm to prevent shivering --toxic epidermal necrolysis is an acute skin disorder, most commonly associated with a medication reaction that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion. It is a severe form of Stevens-Johnson syndrome. The major cause of death related to toxic epidermal necrolysis is sepsis; therefore, infection prevention is critical

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first? -administer rectal diazepam -assess for neck stiffness and Brudzinski sign -draw blood for lab studies -transport the client to CT for assessment of shunt malfunction

-administer rectal diazepam --This client is in status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer. Grunting and a dazed appearance are 2 common signs. A client with hydrocephalus and a ventriculoperitoneal shunt is at a higher risk for seizures. Stopping seizure activity is the first nursing priority. IV benzodiazepines are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department. --a VP shunt drains excess fluid in the brain down to the abdomen, where it is absorbed by the body. A CT scan can accurately assess shunt malfunction. Any malfunction would need to be treated promptly to prevent future seizures and damage. Finding the cause of the seizure is important and should be done as soon as seizing has stopped.

Interventions and prescriptions for a client with sepsis and meningitis may include:

-administering vasopressors -obtaining relevant labs and blood cultures prior to administering antibiotics -administer empiric antibiotics, preferably within 30 minutes of admission -prior to lumbar puncture, obtain a head CT scan as increased ICP or mass lesions may contraindicate an LP due to the risk of brain herniation -assist with a lumbar puncture for CSF examination and cultures. CSF is usually purulent and turbid in clients with bacterial meningitis.

The nurse is caring for aclient with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? SATA -administers coagulation factor replacement IV push -administers ibuprofen PO PRN for pain -applies ice packs to the affected joint hourly for 15 minutes -elevates the affected leg in the extended position -performs neurologic assessment every 30 minutes for 6 hours

-administers coagulation factor replacement IV push -applies ice packs to the affected joint hourly for 15 minutes -elevates the affected leg in the extended position -performs neurologic assessment every 30 minutes for 6 hours. --for acute bleeding, clients with hemophilia are treated with supplemental IV clottingfactors. Hemarthrosis is managed with rest, ice,compression, and elevation, and the affected joint should remain extended to prevent contractures. NSAIDs increased bleeding risk and should be avoided for clients with hemophilia.

What can cause thrombocytopenia?

-alcohol use -HIV infection -medications (heparin)

The nurse is conducting an educational community outreach program on melanoma screening. Which statement by a resident would indicate the need for further education? -abrupt changes in the size or color of a mole are warning signs -all new growths and pigmentations must be biopsied to rule out cancer -melanoma can occur as any color -melanoma does not always occur as a new mole

-all new growths and pigmentations must be biopsied to rule out cancer --Client education on early detection of skin cancer is important as most cases of malignant melanoma are discovered by the client. A full medical workup of every mole is unnecessary. Routine self-evaluation followed by medical assessment of questionable growths is sufficient. Clients with advanced age or reduced mobility may need to see a dermatologist for a full body skin survey.

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? SATA -albumin -ammonia -bilirubin -prothrombin time -sodium

-ammonia -bilirubin -prothrombin time --Cirrhosis, the end stage of many chronic liver disease, is characterized by diffus hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes after blood flow through the liver and decrease the liver's functionality. Elevated bilrubin results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin. Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result coagulation studies (PT, INR, PTT) are usually elevated. Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy. --albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to syntehsize albumin, so hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of the vascular spaces into interstitial spaces. The kidneys perceive this as low perfusion and try to reabsorb both sodium and water. The large amount of water in the body results in a dilutional effect.

Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit? -aphasia -apraxia -dysarthria -dysphagia

-aphasia --Aphasia refers to impaired communication due to a neurological condition. The term aphasia is interchangeable with dysphasia, although aphasia is used more commonly. Receptive aphasia refers to impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, as simple "yes" or "no" questions, and use gestures and pictures to increase understanding. Expressive aphasia refers to impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice. The nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or a combination of both, and the severity will vary with the individual.

The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include? SATA -arrange furniture to allow for free movement -keep frequently used items within easy reach -lock doors leading to stairwells and outside areas -place an identifying symbol on the bathroom door -provide a dark room free of shadows for sleeping

-arrange furniture to allow for free movement -keep frequently used items within easy reach -lock doors leading to stairwells and outside areas -place an identifying symbol on the bathroom door --When a client with Alzheimer disease is being cared for in the home, the caregiver should be instructed regarding safety modifications to ease the burden of caregiving and promote the client's independence and dignity

A client admitted 3 days ago with upper GI bleed underwent an endoscopic procedure to stop the bleeding. The client is started on a clear liquid diet today. Which foods are appropriate for the nurse to offer the client? SATA -apple juice -cherry popsicle -chicken broth -frozen yogurt -unsweetened tea -vanilla ice cream

-apple juice -chicken broth -unsweetened tea --A client recovering from abdominal surgery first consumes ice chips after demonstrating adequate bowel function. After ice chips, postoperative diet progression continues to clear liquids, full liquids, soft diet, and then regular diet. -popsicles are part of a clear liquid diet. However, red dyes in clear liquids should not be given to clients with recent GI bleeding. If a client vomits, the vomitus may appear red and falsely lead the nurse to believe that the client is bleeding. It is important to implement prudent nursing judgment and fully consider the client's condition when making care decision. -frozen yogurt and vanilla ice cream are appropriate food choices for a client on a full liquid diet.

A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? SATA -apply a patch to the right eye at night -avoid driving -chew on the left side -maintain meticulous oral hygiene -use a cane on the left side

-apply a patch to the right eye at night -chew on the left side -maintain meticulous oral hygiene --Bell's palsy is an inflammation of cranial nerve VII that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. --Client teaching should include using glasses during the day and wearing a patch at night to protect the exposed eye; using artificial tears during the day as needed to prevent excess drying of the cornea; chew on the unaffected side to prevent food trapping; soft diet is recommended; maintain good oral hygiene after every meal to prevent problems from accumulated residual food.

A client diagnosed with head and neck cancer has developed mouth sores related to external radiation therapy. The nurse teaches the client to use which of the following oral hygiene practices? SATA -apply a water-soluble lubricating agent to moisturize mouth tissues -brush teeth with a soft-bristle toothbrush -cleanse the mouth with normal saline after meals and at bedtime -do not drink hot liquids or eat foods that are spicy or acidic -rinse with alcohol-based antiseptic mouthwash to decrease mouth odor -use palifemin as prescribed to alleviate oral pain

-apply a water-soluble lubricating agent to moisturize mouth tissues -brush teeth with a soft-bristle toothbrush -cleanse the mouth with normal saline after meals and at bedtime -do not drink hot liquids or eat foods that are spicy or acidic --Measures to minimize oral mucositis from chemoradiotherapy include rinsing the mouth with normal saline, brushing with a soft-bristle toothbrush, using a water-soluble lubricating agent, avoidance of hot liquids and spicy/acidic foods, and application of prescribed viscouslidocaine.

A client diagnosed with cirrhosis is experiencing pruritus. Which strategies are appropriate for the nurse to teach the client to promote comfort and skin integrity? SATA -apply cool, moist washcloths to the affected areas -keep the fingernails trimmed short to minimize skin scratching -take a hot bath or shower to alleviate itching sensations -use skin protectant or moisturizing cream over unbroken skin -wear cotton gloves or long-sleeved clothing to avoid scratching

-apply cool, moist washcloths to the affected areas -keep the fingernails trimmed short to minimize skin scratching -use skin protectant or moisturizing cream over unbroken skin -wear cotton gloves or long-sleeved clothing to avoid scratching ---Cholestyramine may be prescribed to increase the excretion of bile salts in feces, thereby decrease pruritus. it is packaged in powdered form, must be mixed with food or juice, and should be given 1 hour after all other medications.

The nurse is caring for a client in the postanesthesia care unit following a gastroduodenostomy. Which of the following nursing interventions are appropriate? SATA -applying bilateral sequential compression devices -encouraging splinting of the incision with a pillow when coughing -keeping the client NPO until bowel sounds return -maintaining supine positioning at all times -repositioning and irrigating a clogged nasogastric tube

-applying bilateral sequential compression devices -encouraging splinting of the incision with a pillow when coughing -keeping the client NPO until bowel sounds return --A gastroduodenostomy involves removing the distal two-thirds of the stomach with anastomosis of the remaining stomach to the duodenum. Following a partial gastrectomy, clients should remain NPO until bowel sounds return. Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome. Postoperative clients are at risk for developing venous thromboembolism due to reduced mobility levels and require VTE prophylaxis. Clients are also at risk for hypoventilation and respiratory compromise due to sedation, pain, and immobility. Encourage clients to turn, cough, and deep breathe while splinting the surgical site to prevent development of atelectasis. --in the postoperative period, the nurse should elevate the head of the bed to improve ventilation and reduce the risk of aspiration. Only clients who experience dumping syndrome should lay supine for a short period after eating.

A client with blunt head injury is admitted for observation, including hourly neurologic checks. At 01:00 AM, the client reports a headache; the nurse obtains a normal neurologic assessment and administers the PRN acetaminophen. At 02:00 AM, the client appears to be sleeping. Which action should the nurse take? -arouse the client and ask what the current month is -document "relief apparently obtained" and recheck at 03:00 AM -let the client sleep but verify respiratory rate -wake the client up and check for paresthesia

-arouse the client and ask what the current month is --Serial neurologic assessments are important as neurologic abnormalities are often initially subtle, making it important to note the trend. Interventions for neurologic issues are most effective when made early. The client is admitted due to the need for serial neurologic assessments by a professional nurse, and that is the priority. --although pain relief has probably been achieved, this option does not involve any neurologic assessment. One of the early signs of increased ICP is change in LOC.

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the client's condition has progressed to hepatic encephalopathy? SATA -ask if the client knows what day it is -ask the client to extend the arms -assess for telangiectasia -determine if the conjunctiva is jaundiced -note amylase and lipase serumlevels

-ask if the client knows what day it is -ask the client to extend the arms --hepatic encephalopathy is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, GI hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances to lethargy and coma. Mental status is altered and clients are not oriented to time, place, or person. A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists. Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. --Spider angiomas, gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. --jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy. --amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferease and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis

The nurse is caring for a client who had a stroke two weeks ago and has moderate receptive aphasia. Which interventions should the nurse include in the plan of care to help the client follow simple commands regarding activities of daily living? SATA -ask simple questions that require "yes" or "no" answers -if the client becomes frustrated, seek a different care provider to complete ADL -remain calm and allow the client time to understand each instruction -show the client pictures of ADL or use gestures -speak slowly but loudly while looking directly at the client

-ask simple questions that require "yes" or "no" answers -remain calm and allow the client time to understand each instruction -show the client pictures of ADL or use gestures --Receptive aphasia refers to impairment or loss of language comprehension that is caused by a neurological condition. The terms "aphasia" and "dysphasia" can be used interchangeably as both refer to impaired communication; however, "aphasia" is more commonly used. When assisting a client with receptive aphasia to complete activities of daily living, the nurse should avoid completing tasks for the client and should instead encourage independence using appropriate communication techniques.

During morning rounds, the nurse notices that a client admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? SATA -assess the client's hand movements with the arms extended -compare current mental status findings with those from previous shifts -contact the HCP to request a blood draw for ammonia level -encourage the client to ambulate in the hallway -hold the client's morning dose of lactulose

-assess the client's hand movements with the arms extended -compare current mental status findings with those from previous shifts -contact the HCP to request a blood draw for ammonia level --Hepatic encephalopathy is a serious complication of end-stage liver disease that results from inadequate detoxification of ammonia from the blood. Symptoms include lethargy, confusion, and slurred speech; coma can occur if this condition remains untreated. Asterixis, or a flapping tremor of the hands when the arms are extended with the hands facing forward, may also be noted in the client with encephalopathy. The client with ESLD exhibiting confusion and lethargy should be evaluated for worsening encephalopathy by assessing for asterixis and comparing current mental status and ammonia level to previous findings. If encephalopathy continues to worsen, medical treatment should include higher doses of lactulose and rifaximin, and discharge should be delayed until the client is stable. --Lactulose is the primary drug used for hepatic encephalopathy treatment. It helps to excrete ammonia through the bowels as soft or loose stools. Lactulose should not be held if the client's hepatic encephalopathy continues to worsen.

A client with end-stage liver disease is admitted for a transplant workup. The client's spouse states that the client has not stopped drinking alcohol and may be unable to quit for 6 months before the transplant. Which is the most appropriate action for the nurse to implement? -ask the transplant team to place a palliative care referral so the client can learn about the option of hospice instead of transplant -assess the client's motivation to make the necessary self-care changes before and after the transplant -schedule a meeting to enlist the help of family members in encouraging the client to stay sober until the transplant -tell the nurse manager that the client may not be an appropriate transplant candidate

-assess the client's motivation to make the necessary self-care changes before and after the transplant --The client may not be an appropriate transplant candidate due to his alcohol use. However, additional facts are needed to determine the new situation as the only information obtained came from the client's spouse. The nurse should assess the client's drinking habits and motivation to stop drinking before and after the transplant by speaking with the client directly. In addition, a transplant requires many other self-care regimens. The nurse should be alert for indicators of the client's ability to take prescribed medications, follow dietary restrictions, and attend medical appointments.. The information obtained from this assessment should be communicated to the interdisciplinary team members responsible for determining transplant eligibility.

The UAP assists a client with cirrhosis who underwent paracentesis 4 hours ago. The UAP reports to the nurse that the client was lightheaded and unsteady while ambulating to the chair. Which action should the nurse implement first? -ask the UAP to take a set of vital signs -assess the symptoms reported by the UAP -hold the prescribed diuretic medications -instruct the UAP to assist the client to bed

-assess the symptoms reported by the UAP --paracentesis is a procedure that involves removal of excess fluid from the peritoneal cavity and is performed to relieve dyspnea and discomfort related to increased intra-abdominal pressure and fluid volume. Hypovolemia is an associated complication related to intravascular fluid shifts that occur during and post-procedure and also to high volume peritoneal fluid removal. The nurse should first validate the presence of light-headedness and unsteady gait, monitor vital signs, and assess for manifestations of hypovolemia, as decreased circulating volume can lead to hemodynamic instability

After performing a physical assessment and obtaining vital signs for a client immediately after a laparoscopic cholecystectomy, which nursing intervention is the priority? -apply anti-embolism stockings -assist with early ambulation -offer stool-softeners -provide low-fat foods

-assist with early ambulation --postoperative nursing care after a laparoscopic cholecystectomy focuses on prevention of complications. Carbon dioxide is used to inflate and expand the abdominal cavity during laparoscopic procedures to allow insertion of surgical instruments and better visualization of the abdominal organs. CO2 can initiate the phrenic nerve and diaphragm, causing shallow breathing and referred pain to the right shoulder. The nurse should assist the client with early ambulation and deep breathing to facilitate dissipation of the CO2 used during surgery. Early ambulation not only improves breathing but also decreases the risk of thromboembolism and stimulates peristalsis. --stool softeners may prevent postoperative constipation caused by surgical anesthetics and opioids, which contribute to decreased peristalsis. However, early ambulation is more important due to promoting bowel motility and reduces constipation.

The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required? -attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place. -fills irrigation container with 500-1000 mL of lukewarm tap water and flushes the irrigation tubing -hands the irrigation container on a hook at the level of the shoulder approximately 22 inches above the stoma -slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs

-attaches an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holds it in place. --A colostomy is a surgical procedure that creates an opening in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Clients with a descending or sigmoid colostomy drain stool that is more formed and similar to a normal bowel movement. Although less common, some clients choose to irrigate their colostomy in order to create a bowel regimen that allows them to wear a smaller pouch or a dressing over the stoma. When irrigated daily, the client gains increased control over the passage of stool. --a cone-tip applicator is used to instill the irrigation solution into the stoma. An enema set should never be used to irrigate a colostomy. A cone-tip applicator is specifically made to avoid damage to the sensitive colostomy opening.

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring? -auscultate breath sounds to assess for crackles -monitor for >50 mL/hr urine output -monitor GCS increasing from 8/15 to 9/15 -press over the tibia to assess for pitting edema

-auscultate breath sounds to assess for crackles --Mannitol is an osmotic diuretic used to treat cerebral edema and acute glaucoma. When administered, mannitol causes an increase in plasma oncotic pressure that draws free water from the extravascular spaced into the intravacular space, creating a volume expansion. This fluid, along with the drug, is excreted through the kidneys, thereby reducing cerebral edema and intracranial pressure. However, if a higher dose of mannitol is given or it accumulates, fluid overload that may cause life-threatening pulmonary edema results. An early sensitive indicator of fluid overload is new onset of crackles auscultated in the lungs. To prevent these complications, clients require frequent monitoring of serum osmolarity, input and output, serum electrolytes, and kidney function. --urine output would be expected to increase from the diuretic effect of mannitol and is not a complication.

A client with throat cancer receives radiation therapy to the head and neck. Which strategies are appropriate to increase oral intake? SATA -avoid irritants such as acidic, spicy foods -discourage the use of topical analgesics -encourage liquid nutritional supplements -perform oral hygiene once a day -use artificial saliva to control dryness

-avoid irritants such as acidic, spicy foods -encourage liquid nutritional supplements -use artificial saliva to control dryness --Radiation therapy to the head and neck can cause mucositis and xerostomia, leading to decreased nutrition.Care includes avoiding irritants, consuming supplements, using artificial saliva or sipping water, and performing frequent oral hygiene. Clients on radiation therapy need to maintain more frequent oral hygiene due to the drying effects of mucositis.

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client? SATA -avoid massaging the area -avoid receiving vaccinations in the affected arm -elevate the arm above the heart -perform isometric exercises -use an intermittent pneumatic compression sleeve

-avoid receiving vaccinations in the affected arm -elevate the arm above the heart -perform isometric exercises -use an intermittent pneumatic compression sleeve

The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? SATA -avoid rubbing or scratching the affected eye -avoid straining when having a bowel movement -expect occasional flashes of light during recovery -report any sudden pain to the healthcare provider -rest the eyes by refraining from reading and writing

-avoid rubbing or scratching the affected eye -avoid straining when having a bowel movement -report any sudden pain to the healthcare provider -rest the eyes by refraining from reading and writing ---Retinal detachment is separation of the sensory retina from the underlying pigment epithelium. Clients experiencing retinal detachment may report a gradual, curtain-like loss of the visual field. Traumatic retinal detachment may also result in abrupt vision loss. Retinal detachment requires emergency surgery to attempt to restore vision. Surgical repair involves rebinding the choroid and retina. After repair, interventions focus on promoting retinal reattachment.

Disease management of psoriasis involves

-avoidance of triggers: stress, trauma, infection -topical therapy: corticosteroids, moisturizers -phototherapy: UV lights -systemic medications: cytotoic and biologic agents

Postoperative teaching after retinal detachment repair involves...

-avoiding activities that increase intraocular pressure -reporting sudden pain, flashes of light, vision loss, or bleeding (indicates detachment or infection) -avoiding focused activities that can cause rapid eye movements and increase risk of detachment -wearing an eye patch or shield as directed to prevent rubbing/scratching of the eye -ensuring appropriate positioning as instructed by surgeon.

The nurse understands that which of these body substances are modes of transmission for hepatitis B? SATA -blood -feces -semen -urine -vaginal secretions

-blood -semen -vaginal secretions --Viral hepatitis isa disease of the liver characterized by inflammation, necrosis,and cirrhosis. One of the most common viral strains that causes hepatitis is hepatitis B. The transmission of hepatitis B is primarily through contact with blood, semen, and vaginal secretions, commonly through unprotected sexual intercourse and intravenous illicit drug use. Infants born to infected mothers are also at risk for vertical transmission of hepatitis B. Although kissing, sneezing, sharing drinks/utensils, and breastfeeding are not known routes of transmission, hepatitis B could possibly be transmitted through saliva entering the bloodstream via sharing a toothbrush or receiving a bite. Hepatitis B has an insidious onset of illness, and clients may be asymptomatic carriers. Early symptoms are often nonspecific. Hepatitis B may produce jaundice, weight loss, clay-colored stools, and thrombocytopenia in late stages of illness. An effective vaccine is widely available for hepatitis B.

The nurse is preparing to administer 40 mg of IV furosemide. Prior to administering the medication, the nurse should assess which parameters? SATA -blood pressure -blood urea nitrogen -liver enzymes -potassium -white blood cell count

-blood pressure -blood urea nitrogen -potassium --Loop diuretics are used to treat fluid retention, such as that found in clients with heart failure or cirrhosis. When administering loop diuretics, the nurse can expect the client's kidneys to excrete a significant amount of water and potassium. When potassium is excreted at a fast rate, the client could develop hypokalemia, medical emergency that can result in other life-threatening complications such as heart arrhythmias, as well muscle cramps and weakness. Blood pressure should also be assessed prior to administration of loop diuretics as excess diuresis may cause intravascular volume depletion that results in low blood pressure. A client with baseline hypotension may develop a critically low blood pressure. Excess diuresis can also affect kidneys, and the blood urea nitrogen and creatinine levels can become elevated as well. Therefore, these levels should be assessed.

The emergency department nurse performs an admission assessment for a client with priapism of about 3 hours duration who also has sickle cell anemia. What assessment finding is of most concern and warrants immediate notification of the healthcare provider? -bluish discoloration of the erect penis -drank a 6-pack of beer 8 hours ago -extreme penile pain rated as 9 on a 0-10 scale -has not voided for atleast 6 hours

-bluish discoloration of the erect penis --Priapism is a sustained, painful erection that lasts for more than 2 hours. Common associated clinical manifestations includes intense pain, rigid penis, difficulty voiding, and anxiety/embarassment. Bluish discoloration is of the most concern as it can be a sign of ischemia to the penis.

The ED nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? SATA -breath smells of alcohol -client disoriented to place -client reports eyes burning -history of multiple sclerosis -point tenderness over spine

-breath smells of alcohol -client disoriented to place -point tenderness over spine --Indications for spinal immobilization include abnormal neurological findings, significant mechanism of injury, change in orientation or LOC, intoxication, distracting injury, and point tenderness over the spine.

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? SATA -asymmetrical pupillary constriction -brief loss of consciousness -headache -loss of vision -retrograde amnesia

-brief loss of consciousness -headache -retrograde amnesia --A concussion is considered a minor traimatic brain injury and results from blunt force or an acceleration/deceleration head injury. These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and a light diet are encouraged during this time. The following manifestations indicate more serious brain injury and are not expected with simple concussion: Worsening headaches and vomiting; sleepiness and/or confusion; visual changes; weakness or numbness of part of the body.

The nurse is providing nutritional teaching for a client with a new ileostomy. Which foods should the nurse instruct the client to avoid? SATA -bananas -broccoli with cheese -multigrain bagel -popcorn -spaghetti with sauce

-broccoli with cheese -multigrain bagel -popcorn --An ileostomy is a surgically created opening in the abdominal wall that connects the small intestine to the external abdomen. Stool from the small intestine bypasses the colon and exits through the ileostomy. Functions of the colon do not occur, resulting in liquid stool that drains into an external ostomy appliance attached to the skin. In the immediate postoperative period of an ileostomy, a low-residue diet is prescribed to prevent obstruction of the narrow lumen of the small intestine and stoma. After the ileostomy heals, the client reintroduces fibrous foods one at a time. The client is instructed to thoroughly chew food and monitor for changes in stool output.

The nurse is caring for a client admitted for a seizure disorder. The nurse witnesses the client having a tonic-clonic seizure with increasing salivation. Which actions should the nurse take? SATA -call for help -hold down the client's arm -insert a tongue depressor to move the tongue -preparing for suctioning -turn the client on the side

-call for help -preparing for suctioning -turn the client on the side --During an active seizure, the nurse should call for additional help, turn the client on the side if possible, and have suction equipment ready to clear any excessive secretions that may block the airway. However, during an active seizure it is dangerous to attempt to insert anything in the client's mouth, especially if the teeth are clenched. The client should not be restrained as this could cause an injury.

A client admitted with acute myocardial infarction suddenly displays air hunger, dyspnea, and coughing with frothy, pink-tinged sputum. What would the nurse anticipate when auscultating the breath sounds of this client? -bronchial breath sounds at lung periphery -clear vesicular breath sounds at lung bases -diffuse bilateral crackles at lung bases -stridor in upper airways

-diffuse bilateral crackles at lung bases --Acute-onset dyspnea and cough productive of pink, frothy sputum indicate severe pulmonary edema, likely a complication from myocardial infarction. Pink sputum results from ruptured bronchial veins due to high back pressure. The mix of blood and airway fluids creates the pink tinge. On assessment, crackles can be heard at the lung bases.

The nurse assesses a newly admitted adult client on a neurological inpatient unit. Which assessment findings require immediate follow-up by the nurse? SATA -cannot flex the chin toward the chest -eyes move in opposite direction of head when head is turned to side -new onset of right arm drift -pupils 8 mm in diameter bilaterally -toes point downward when side of foot is stimulated

-cannot flex the chin toward the chest -new onset of right arm drift -pupils 8 mm in diameter bilaterally --the neck should be supple and able to be flexed toward the chest. Nuchal rigidity requires follow-up due to possible meningeal irritation related to infection. A new-onset of unilateral drift of a limb could indicate a stroke. The nurse assesses for other stroke-like symptoms, activates the facility stroke protocol, and notifies the HCP accordingly. Normal pupils are 3-5 mm in diameter. Pupil dilation can be the result of medication use of neurological causes. --oculocephalic reflex is an expected finding indicating an intact brainstem. It is tested by rotating the head and watching for the eyes to move simultaneously in the opposite direction.

Clinical manifestations of hypovolemic shock

-change in LOC -tachycardia with thready pulse -cool,clammy skin -oliguria -tachypnea

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? SATA -change in lacrimation on the affected side -electric shock-like pain in the lips and gums -flattening of the nasolabial fold -inability to smile symmetrically -severe pain along the cheekbone

-change in lacrimation on the affected side -flattening of the nasolabial fold -inability to smile symmetrically

A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action from the nurse to take? -assess the client's vital signs -check the client's blood glucose -report the findings to the HCP -slow down the rate of infusion

-check the client's blood glucose --A complication of total parenteral nutrition is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision. The development of hyperglycemia is related to the following: excessive dextrose infusion; a low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones; high infusion rate; administration of medications such as steroids; infection. Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the TPN solution, slowing down the infusion rate, and administering subcutaneous insulin.

A nurse precepting a new graduate nurse who is caring for a client with a paralytic ileus and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions? SATA -checks for residual every 4 hours -places client in semi-Fowler's position -plugs the air vent if gastric content refluxes -provides mouth care every 4 hours -turns off suction when auscultating bowel sounds

-checks for residual every 4 hours -plugs the air vent if gastric content refluxes --Continuous suction can be applied to decompress the stomach if a double lumen Salem sump tube is in place. The larger lumen is attached to suction and the smaller lumen is open to the atmosphere. Checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous suction for decompression and is not being used to administer enteral feeding. The air vent must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa. If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level of the client's stomach to prevent reflux.

The nurse is reviewing lifestyle and nutritional strategies to help reduce symptoms in a clinet with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? SATA -choose foods that are low in fat -do not consume any foods containing dairy -eat three large meals a day and minimize snacking -limit or eliminate the use of alcohol and tobacco -try to avoid caffeine, chocolate, and peppermint

-choose foods that are low in fat -limit or eliminate the use of alcohol and tobacco -try to avoid caffeine, chocolate, and peppermint --GERD occurs when chronic reflux of stomach contents causes inflammation of the esophagus mucosa. The lower esophageal sphincter normally prevents stomach contents from entering the esophagus. Any factor that decreases the tone of the lower esophageal sphincter (caffeine, alcohol) delays gastric emptying (fatty foods) or increases gastric pressure (large meals) can precipitate GERD.

The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? SATA -client coughs and gasps when swallowing food and liquids -client is easily frustrated while attempting to speak -client is unable to understand speech and is completely nonverbal -client misunderstands and inappropriately responds to verbal instruction -client's speech is limited to short phrases that require effort

-client is easily frustrated while attempting to speak -client's speech is limited to short phrases that require effort --Broca aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short, limited phrases that make sense but display great effort and frequent omission of smaller words. Clients with Broca aphasia are aware of their deficits and can become frustrated easily. Clients with Wernicke aphasia are unaware of their speech impairment. --Wernicke aphasia involves the inability to comprehend the spoken and/or written words

After receiving report, which client should the nurse assess first? -client on a heparin infusion with platelet count of 86,000/mm3 -client with dehydration with blood urea nitrogen of 24 mg/dL -client with myelodysplastic syndrome with white blood cell count of 2,000/mm3 -client with sickle cell disease with hemoglobin of 7.9 g/dL and hematocrit of 24%

-client on a heparin infusion with platelet count of 86,000/mm3 --thrombocytopenia is a serious complication of heparin products. Regardless of its cause, thrombocytopenia usually results in bleeding complications. However, in heparin-induced thrombocytopenia usually leads to paradoxical venous and/or arterial thrombosis and less commonly in bleeding. The mechanism for thrombosis is unclear. The danger of HIT is risk of organ damage from local thrombi and/or embolization, leading to stroke and/or pulmonary embolism. HIT occurs over several days. The nurse should monitor platelet levels of clients on heparin and report a decrease of >50% from baseline or a drop below 150,000/mm3 to the HCP.

The nurse receives the assigned clients for today on a neurology unit. The nurse should check on which client first? -client with hx of head injury whose GCS changes from 13 to 14 -client with hx of myasthenia gravis who had ptosis in the evening -client with hx of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension -client with hx of transverse myelitis with 2+ bilateral lower extremity muscle strength

-client with hx of T2 spinal injury who has diaphoresis, pulse 54/min, and hypertension --autonomic dysreflexia is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system in a spinal injury at T6 or higher. Due to the injury, the parasympathetic nervous system cannot counteract the SNS stimulation below the injury. Classic triggers are distended bladder or rectum. Classic manifestations include severe hypertension, throbbing HA, marked diaphoresis above the level of injury, bradycardia, piloerection, and flushing. This is an emergency condition requiring immediate intervention. Management includes raising the head of the bed and then treating the cause

A nurse working in a neurology clinic receives the following telephone messages. Which client should the nurse call back first? -client prescribed sumatriptan who has throbbing left temple pain preceded by an aura -client taking carbidopa-levodopa who has dizziness when rising from a sitting or lying position -client with myasthenia gravis who has a fever and increasing difficulty swallowing -client with trigeminal neuralgia who reports burning cheek pain after eating ice cream

-client with myasthenia gravis who has a fever and increasing difficulty swallowing --Myathenia gravis is an autoimmune disease of the neuromuscular junction resulting in fluctuating muscle weakness. Autoantibodies are formed against the acetylcholine receptors, so fewer receptors are available for acetylcholine to bind. It is treated with pyridostigmine, which increases the amount of acetylcholine at the synaptic junction, augmenting neuromuscular signals and improving muscle strength. Infection, undermedication, and stress can precipitate a life-threatening myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure. This client's infection and increasing difficulty swallowing indicate the need for immediate intervention. -Sumatriptan is prescribed for moderate to severe, acute migraine headaches that are characterized by severe pulsatile, throbbing unilateral head pain with or without auras, photophobia, nausea, and vomiting. The client with uncontrolled migraine headaches requires a change in treatment regimen. --trigeminal neuralgia is characterized by intermittent severe, unilateral facial pain precipitated by light touch, hot or cold foods, chewing, and swallowing.. This client may require a change in treatment regimen for improved pain relief.

Which client finding is most important for the nurse to follow up? -client with distinct liver edge even with right costal margin -client with pyelonephritis who has costovertebral angle tenderness -client with rash that has purplish blotches that do not blanch -client with spinal cord injury whose toes point downward with the Babinski test

-client with rash that has purplish blotches that do not blanch --Purpura refers to reddish-purple blotches on the skin that do not blanch with pressure due to bleeding underneath the skin. Further assessment must be done to evaluate for a potentially serious etiology, such as blood dyscrasia.

For which client is it most important for the nurse to provide teaching on ways to prevent the spread of the condition? -client with eczema on upper torso -client with oral candidiasis -client with psoriasis on hands -client with tinea corporis

-client with tinea corporis --Tinea Corporis is a fungal infection of the skin often transmitted from one person to another or from an infected animal to human. It appears as a scaly, pruritic patch that is often circular or oval in shape. It is highly contagious and can be spread via items such as grooming tools, hats, towels, and bedding. Tinea corporis often spreads via shared athletic equipment or in athletic locker rooms due to the proximity of infected gear.

The nurse is assessing 4 clients in the ED. Which client should the nurse prioritize for care? -client with liver cirrhosis and ascites who has increasing abdominal distension and needs therapeutic paracentesis -client with new-onset asscites from a suspected ovarian mass who needs paracentesis for diagnostic studies -client with ulcerative colitis who has fever, blood diarrhea, and abdominal distension and needs an abdominal x-ray -nursing home client with dementia who has stool impaction and abdominal distension and needs stool disimpaction.

-client with ulcerative colitis who has fever, blood diarrhea, and abdominal distension and needs an abdominal x-ray --The client with ulcerative colitis who has abdominal distension, blood diarrhea, and fever likely has toxic megacolon. This is a common, life-threatening complication of inflammatory bowel disease and is seen more frequently in ulcerative colitis that in Crohn disease. Toxic megacolon can also be associated with C. difficile infection and other forms of infectious colitis. Severe colonic inflammation causes release of inflammatory mediators and bacterial products which contribute to colonic smooth muscle paralysis. Rapid colonic distension ensues, thinning the intestinal wall and making it prone to perforation. Imaging confirms the diagnosis --This client with liver cirrhosis and ascites need periodic paracentesis for relief of distension in addition to diuretics for advanced-stage disease. This client is not priority. --this client needs paracentesis for fluid cytology to evaluate for malignancy, but is not priority. --clients with dementia have decreased mobility, drink less fluid, and often take medications with anticholinergic properties. Such factors make these clients prone to severe constipation, and they often need manual disimpaction but this does not make the client priority.

S/S of cataract

-cloudiness of the lens -painless, gradual loss of visual acuity with blurry vision -scattered light on the lens producing glares and halos -decreased color perception

A nurse is preparing a presentation about behavioral modifications to support weight loss for clients at an obesity clinic. Which of the following points should the nurse include in the teaching plan? SATA -avoid social gatherings that occur in restaurants or around meals -create multiple small goals with rewards for achievement -identify a list of desired outcomes not directly related to weight loss -perform anxiety-reducing activities rather than using food to cope with stress -utilize visual cues such as motivational quotes to encourage positive behavior

-create multiple small goals with rewards for achievement -identify a list of desired outcomes not directly related to weight loss -perform anxiety-reducing activities rather than using food to cope with stress -utilize visual cues such as motivational quotes to encourage positive behavior --avoiding social activities in a food setting promotes isolation and negative perceptions. Clients who struggle to make healthy choices in these settings should plan ahead for what will be eaten or bring a separate meal.

A client with diabetes receiving peritoneal dialysis experiences chills and abdominal discomfort. The nurse assesses the client's abdomen by pressing one hand firmly on the abdominal wall. The client experiences pain when the nurse quickly withdraws the hand. The client's most recent blood glucose level is 210 mg/dL. What is the priority action by the nurse? -collect peritoneal fluid for culture and sensitivity -heat the remaining dialysate fluid and increase the dwell time -place the client in high Fowler's position -prepare to administer regular insulin intravenously

-collect peritoneal fluid for culture and sensitivity --Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effuent. Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity. The nurse should collect peritoneal effuent from the drainage bag for culture and sensitivity. Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously.

Factors increasing estrogen exposure and endometrial cancer risk includes:

-conditions associated with infrequent or anovulator menstrual cycles (polycystic ovary syndrome, infertility, late menopause, early menarche) -obesity -tamoxifen

A client on a medical-surgical unit is receiving heparin therapy. Platelet levels decreased from 230,000/mm3 2 days ago to 80,000/mm3 today. Which nursing actions are appropriate? SATA -confirm validity of platelet result with new blood specimen -hold the scheduled morning dose of heparin -notify the HCP of the platelet count -obtain a full set of vital signs -request change of prescription for heparin to enoxaparin

-confirm validity of platelet result with new blood specimen -hold the scheduled morning dose of heparin -notify the HCP of the platelet count -obtain a full set of vital signs ---The nurse should suspect heparin-induced thrombocytopenia in a client who is receiving or has recently received heparin and has a sudden reduction of >50% in platelet count. The nurse should stop heparin immediately, assess vital signs and neurovascular status, draw blood for repeat testing, and report findings to the HCP. Clients who are suspected of having HIT or who have a history of HIT should never receive heparin or low-molecular-weight heparni. Only non-heparin anticoagulants may be given

The nurse is making follow-up phone calls to clients who had cataract surgery with intraocular lens implantation the previous day. The nurse receives which client report that requires priority intervention? -blurry vision in the affected eye -constipation -itching in the affected eye -sleeping on 2 pillows at night

-constipation --Following cataract surgery, the client should be instructed to avoid coughing, sneezing, lifting over 5 lbs, bending, rubbing the eye, or straining during bowel movements for several days to prevent increased intracocular pressure. IT is common for the client to experience itching, photophobia, and mild pain for several days following surgery

Which of these instructions is appropriate teaching for a 60-year-old woman? SATA -consume adequate sources of calcium and vitamin D and take supplements -increase intake of food sources of iron and take supplements -observe for unilateral leg swelling when taking hormone replacement therapy -remain upright for 30 minutes when taking a bisphosphonate -vaginal spotting after menopause is a common, insignificant sign of aging

-consume adequate sources of calcium and vitamin D and take supplements -observe for unilateral leg swelling when taking hormone replacement therapy -remain upright for 30 minutes when taking a bisphosphonate --A postmenopausal woman is at risk for osteoporosis and heart disease. Clients should remain upright after taking a bisphosphonate and consume calcium and vitamin D for bone health. Clotting disorder is a risk with HRT. Intermittent vaginal spotting after menopause can be a sign of endometrial cancer. Anemia in older adults is usually not related to lack of iron intake, especially once menstruation has stopped. Excessive iron intake can lead to iron overload, and the risk of excess iron tends to be higher with aging.

S/S of acute appendicitis

-continuous pain that begins in the periumbilical region and then moves to the right lower quadrant centering at McBurney's point -anorexia, N/V -rebound tenderness and guarding

Interventions involved in the rehabilitation phase of burns

-counseling or other psychosocial support -gentle massage with water-based lotion to alleviate itching and minimize scarring -planning for reconstructive surgery -Pressure garments to prevent hypertrophic scars and promote circulation -range-of-motion exercises to prevent contractures -sunscreen and protective clothing to prevent sunburns and hyperpigmentation

Which group of food selections would be the best choice for a client advancing to a full liquid diet 3 days after bariatric surgery? -apple juice, mashed potatoes, chocolate pudding -chicken broth, low-fat cheese omelet, strawberry ice cream -creamy wheat cereal, blended cream of chicken soup, protein shake -low-fat vanilla yogurt, smooth peanut butter, vegetable juice

-creamy wheat cereal, blended cream of chicken soup, protein shake --Bariatric surgery reduces stomach capacity. A client's bariatric postoperative diet is restricted to foods that are low in simple carbohydrates and high in nutrients. After gastric surgery, consumption of simple carbohydrates can lead to dumping syndrome. The client will tolerate only small meals of clear liquids at first, advance to full liquids 24-48 hours after surgery and then progress gradually to solid foods as the gastrointestinal tract heals. Small, frequent meals are recommended to avoid overstretching of the pouch and to prevent N/V and regurgitation. The best food choices for a bariatric full liquid diet are cream soups, refined cooked cereals, sugar-free drinks, and low-sugar protein shakes and dairy foods.

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the HCP. Which assessment data is most important for the nurse to report to the HCP? -blood pressure of 140/86 mm Hg -difficulty swallowing -dry, hacking cough -low back pain

-difficulty swallowing --Difficulty swallowing is the most important symptom to report to the HCP. A thoracic aortic aneurysm can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate that the aneurysm has increased in size and may need further diagnostic evaluation and treatment. --low back pain would be a concern if the client had a hx of abdominal aortic aneurysm.

The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority? -contact the HCP -cut the tube with scissors -increase gastric suction level -place the client in high Fowler position

-cut the tube with scissors --A balloon tamponade tube (Sengstaken-Blakemore or Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal.

What disorders follow the autosomal recessive inheritance pattern?

-cystic fibrosis -phenylketonuria -Tay-Sachs disease -sickle cell disease

A client with a blood pressure of 250/145 mm Hg is admitted for hypertensive crisis. The healthcare provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? -decrease mean arterial pressure by no more than 25% -keep blood pressure at or below 120/80 mm Hg -maintain heart rate of 60-100/min -maintain urine output of at least 30 mL/hr

-decrease mean arterial pressure by no more than 25% --Hypertensive crisis is a life-threatening emergency due to the possibility of severe organ damage. If not treated promptly, complications such as intracranial hemorrhage, heart failure, myocardial infarction, renal failure, aortic dissection, or retinoathy may occur. Emergency treatment includes IV vasodilators such as nitroprusside sodium. It is important to lower th blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart, and kidneys. This may result in stroke, renal failure, or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 100-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure and double the diastolic blood pressure, and then dividing the resulting value by 3. A blood pressure of 120/80 mm Hg is too low for an initial goal and could result in organ damage.

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? SATA -complete activities such as bathing and dressing as quickly as possible -decrease the client's anxiety by limiting the number of choices offered -redirect the client if agitated by asking for help with a task or going for a walk -remember to interact with the client as an adult, regardless of childlike affect -use open-ended questions when communicating with the client

-decrease the client's anxiety by limiting the number of choices offered -redirect the client if agitated by asking for help with a task or going for a walk -remember to interact with the client as an adult, regardless of childlike affect --Caregivers for clients with Alzheimer disease should communicate with the client using yes or no questions and simple, step-by-step instruction; treat the client as an adult; limit the number of choices; and allow plenty of time for task completion. Agitated clients can be redirected with new activities.

Clinical manifestations of DI

-decreased urine specific gravity -elevated serum osmolality -hypernatremia -hypovolemia and potential hypotension -polydipsia -polyuria

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? SATA -administer an analgesic as needed -determine if there is bladder distension -measure the client's blood pressure -place the client in the Sims' position -remove constrictive clothing

-determine if there is bladder distension -measure the client's blood pressure -remove constrictive clothing --Clients with a high (T6 or above) spinal cord injury are at risk for autonomic dysreflexia. It is an uncompensated sympathetic nervous system stimulation. Classic signs include hypertension, throbbing headache, diaphoresis above the level of injury, bradycardia, ploerection, flushing, and nausea. This is life-threatening condition that requires immediate intervention to prevent complications. Clients with a spinal cord injury should have their blood pressure checked when they report a headache, The most common cause of autonomic dysreflexia is bladder irritation due to distension. The client needs to be catheterized or the possibility of a kink in the existing catheter must be assessed. Bowel impaction can also be a cause; a digital rectal examination should be performed. Constrictive clothing should be removed to decrease skin stimulation. --HAs associated with autonomic dysreflexia are typically due to severe hypertension and often resolve after blood pressure has been treated. --the client should have the head of the bed elevated 45 degrees or higher Fowlers to lower blood pressure. The Sims' position is flat and side-lying.

Priority nursing actions when caring for a client who recently experienced sexual assault

-determine whether the client has bathed, showered, or douched -educate victim on recommendation for a pelvic exam to collect evidence -obtain date of last menstrual period and current method of birth control -perform head-to-toe assessment to identify physical injuries -thoroughly document all injuries on a body map -provide prophylactic therapies for sexually transmitted infections and pregnancy.

S/S of primary open-angle glaucoma

-develop slowly -painless impairment of peripheral vision -normal central vision - difficulty with vision in dim light -increased sensitivity to glare -halos observed around bright lights

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? SATA -diarrhea -difficulty breathing -difficulty swallowing -muscle weakness -resting tremor

-difficulty breathing -difficulty swallowing -muscle weakness --Amyotrophic lateral sclerosis is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. Most clients survive only 3-5 years after the diagnosis as there is no cure.

The nurse is giving a presentation at a community health event. The nurse should provide which instruction on how to prevent botulism? -boil water if unsure of its source -discard canned food with a bulging end -keep milk cold -wash hands

-discard canned food with a bulging end --Botulism is caused by the GI absorption of the neurotoxin produced by Clostridium botulinum. The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting in muscle paralysis. The organism is found in the soil and can grow in any food contaminated with the spores. Manifestations include descending flaccid paralysis, dysphagia, and constipation. The main source is improperly canned or stored food. A metal can's swollen/bulging end can be caused by the gases from C botulinum and should be discarded. The infant form of botulism can occur in children under age 1 year if they eat honey, particularly raw honey. The immature gut system in these children makes them more susceptible.

A client with a history ofmdiverticular disease is being discharged after an episode of acute diverticulitis. Which instructions should be included in the discharge teaching plan to reduce the risk of future episodes? SATA -drink plenty of fluids -exercise regularly -follow a low-residue diet -include whole grains, fruits, and vegetables in the diet -increase intake of red meat

-drink plenty of fluids -exercise regularly -include whole grains, fruits, and vegetables in the diet --Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine. Diverticulosis is characterized by the presence of these protrusions: the client is asymptomatic and may not even be aware of the condition. Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool. The etiology of diverticular disease has been liked to chronic constipation, a major cause of excess intracolonic pressure. Preventing constipation may help reduce to risk of diverticula forming and becoming inflamed. Measures to prevent constipation include a diet high in fiber daily intake of at least 8 glasses of water or other fluids, and exercise. A fiber supplement such as psyllium or bran may be advised. In the past, clients have been taught to avoid consuming seeds, nuts, and popcorn; however, current evidence does not indicate that avoidance of these foods will prevent an episode of diverticulitis. --a low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes. --increased consumption of red meat and other high-fat foods can increase the risk of diverticulitis.

During the immediate postoperative period after a colostomy, which stoma appearance requires the nurse to contact the HCP immediately? -brick red with slight moisture noted -dusky with moderate edema present -pink with slight oozing of blood -rosy with no stool produced

-dusky with moderate edema present --A colostomy is a surgical procedure that creates an opening in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. The stoma should be pink to brick red, indicating vascularity and viability. Minor bleeding and oozing may occur and mild to moderate swelling is normal for 2-3 weeks after surgery. In the immediate postoperative period, stool will be absent. If the bowel is cleansed prior to surgery, the draining of stool will be delayed by several days. Otherwise, stool appears when peristalsis resumes.

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL. The nurse should anticipate which findings? SATA -coarse crackles -dyspnea -pallor -respiratory depression -tachycardia

-dyspnea -pallor -tachycardia ---A normal hemoglobin level for an adult male is 13.2-17.3 g/dL and female is 11.7-15.5 g/dL. A client with severe anemia will have tachycardia, which will maintaincardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor occurs from reduced blood flow to the skin. Respiratory depression does not occur with anemia, but may occur post-administration of a narcotic or during oversedation.

The nurse is developing teaching materials for a client diagnosed with ulcerative colitis. The client will receive sulfasalazine. Which of the following instructions are included in the discharge teaching plan? SATA -avoid small, frequent meals -can have a cup of coffee with each meal -eat a low-residue, high-protein, high-calorie diet -increase fluid intake to at least 2000 mL/day -medication should be continued even after the resolution of symptoms -take daily vitamin and mineral supplements

-eat a low-residue, high-protein, high-calorie diet -increase fluid intake to at least 2000 mL/day -medication should be continued even after the resolution of symptoms -take daily vitamin and mineral supplements --A low-residue, high-protein, high-calorie diet, along with daily vitamin/mineral supplements is encourage to meet the nutritional and metabolic needs of the client with ulcerative colitis. The low-residue diet limits trauma to the inflamed colon and may lessen symptoms. Easily digested foods such as enriched breads, rice, pastas, cooked vegetables, canned fruits, and tender meats are included in the diet. Raw fruits and vegetables, whole grains, highly seasoned foods, fried foods, and alcohol are avoided. The well-balanced diet includes at least 2000-3000 mL/day of fluid to maintain fluid and electrolyte balance and hydration. --Small, frequent meals are encouraged to lessen the amount of fecal material present in the GI tract and to decrease stimulation --caffeine, alcohol, and tobacco are gastric irritants that stimulate the intestine and should be avoided

A client at 32 weeks gestation has been diagnosed with syphilis. The client expresses to the nurse her belief that antibiotic therapy is harmful and refuses treatment. What is the nurse's appropriate response at this time? -educate the client about potential fetal harm or death if antibiotics are refused -explain that the fetus's right to receive appropriate treatment is prioritized during pregnancy -express respect for the client's beliefs and discuss natural treatment alternatives -inform the client about the symptoms of a Harisch-Herxheimer reaction,which may potentially occur after treatment

-educate the client about potential fetal harm or death if antibiotics are refused --Nurses have an ehtical responsibility to respect the pregnant client's authority to make decisions for herself and on behalf of her fetus, authority known as the principle of autonomy. A client's autonomy and right to make decisions do not change during pregnancy.The nurse should assist the client by providing education about the need for treatment and the consequences of refusing treatment for herself and the fetus,which ensures that the client's refusal of treatment is an informed decision. Syphilis is a STI that crosses the placenta. Refusing treatment for syphilis may cause fetal harm or death. The only adequate treatment available during pregnancy is an IM penicillin injection. Treatment should resolve the maternal infection and prevent or successfully treat fetal infection.

A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection. Which nursing intervention is the priority in caring for this client? -apply an ice pack to the left shoulder -elevate the affected arm on a pillow -help the client ambulate frequency -obtain a pneumatic compression sleeve

-elevate the affected arm on a pillow --After a mastectomy, an important goal is restoring function in the client's affected arm. Measures to promote function are initiated immediately after surgery. Elevating the affected arm to heart level is crucial to reduce fluid retention and prevent lymphedema in the affected arm. Hand and arm exercises are implemented gradually, beginning with finger flexion and extension. These activities maintain muscle tone, prevent contractures, and improve lymph and blood circulation, which promote function and also prevent lymphedema. The return of full range of motion in the affected arm is desired within-6 weeks.Additional nursingcare for clients after a mastectomy includes keeping the client in semi-Fowler position and placing a sign over the bed that specifies, "no blood pressure, venipuncture, or injections on left arm"

The nurse will implement which nursing actions when caring for a client recently diagnosed with a hiatal hernia? SATA -elevate the head of the hospital bed -instruct the client to avoid tobacco and caffeine -offer small, frequent, low-fat meals -provide a girdle to reduce the hernia -teach the client to avoid lifting or straining

-elevate the head of the hospital bed -instruct the client to avoid tobacco and caffeine -offer small, frequent, low-fat meals -teach the client to avoid lifting or straining --Conditions that increase intraabdominal pressure and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm, causing a hiatal hernia. A sliding hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm. A paraesophageal hernia occurs when the gastroesophageal junction remains in place but a portion of upper stomach folds up along the esophagus and forms a pocket. Paraesophgeal hernias are a medical emergency. Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated with gastroesophageal reflux disease, including heartburn, dysphasia, and pain caused by increased intraabdominal pressure or supine positioning. Interventions to reduce herniation includes: diet modifications, lifestyle changes, avoiding lifting or straining, elevated the HOB approximately 30 degrees. --wearing a girdle or tight clothes increases intrabdominal pressure and should be avoided

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? SATA -elevate the legs and feet when sitting -increase dietary intake of foods rich in iron -increase fluid intake during exercise and hot weather -increase water temperature to reduce post-bath itching -report swelling or tenderness in the legs

-elevate the legs and feet when sitting -increase fluid intake during exercise and hot weather -report swelling or tenderness in the legs --Clients with polycythemia vera are at risk of developing thrombosis and should be taught preventive measures and symptoms to report. They should take measures to prevent dehydrate, and avoid iron-rich foods and hot showers/baths. Increasing intake of iron-containing foods and supplements can further increase hemoglobin production and is not recommended. Clients with PV need periodic phlebotomy to remove excess blood.

The nurse educates a group of clients in the infertility clinic about risk factors contributing to infertility. Which factors should the nurse include in the teaching? SATA -BMI of 22 kg/m2 -endometriosis -maternal age > 35 -polycystic ovarian syndrome -recurrent chlamydial infections

-endometriosis -maternal age > 35 -polycystic ovarian syndrome -recurrent chlamydial infections ---Infertility is the inability to conceive after unprotected intercourse for > 12 months. Female fertility declines as women age, with the first significant decrease seen after age 35.Hormonal dysfunction can cause ovarian cysts and anovulatory cycles which impair fertility. Some sexually transmitted infections may be asymptomatic in females, which can delay treatment. Untreated or recurrent infections cause inflammation, scarring, and damage to the reproductive tract, leading to infertility. Endometriosis is characterized by endometrial tissue depositing outside the uterus. These endometrial lesions can result in chronic inflammation, pelvic pain, menstrual cycle abnormalities, and infertility.

The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? SATA -decreased serum sodium -excess oral water intake -high urine output -increased serum osmolality -increased urine specific gravity

-excess oral water intake -high urine output -increased serum osmolality --Transphenoidal hypophysectomy is the surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones. Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus, a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys; therefore, loss of circulating ADH results in massive diuresis of dilute urine.

Postprocedure instructions for a barium enema includes

-expect the passage of chalky, white stool until all barium contrast has been expelled -take a laxative to assist in expelling the barium. Retained barium can lead to fecal impaction -drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent constipation.

A speeding driver sustained a closed-head injury in an acceleration/deceleration accident from striking a tree front end first. Based on the coup-countrecoup phenomenon, which assessments are most likely to be affected related to the involved areas of the brain? -expressive speech, vision -light touch, hearing -sense of position, graphesthesia -weber tuning fork test, cranial nerve

-expressive speech, vision --Coup-contrecoup injury occurs when a body in motion stops suddenly, causing contusions of brain tissue as the brain moves back and forth within the skull. First, the soft tissue strikes the hard skull in the same direction as the momentum (coup). As the body bounces back, the brain strikes the opposing side of the skull (contrecoup). When the forward collision occurred, the frontal lobe most likely suffered the primary impact (coup). Executive function, memory, speech, and voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital lob, where vision is processed.

The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL compared to 13 g/dL a year ago. What should be the nurse's initial action? -encourage intake of over-the-counter iron pills -encourage intake of red meat and egg yolks -facilitate a screening colonoscopy -facilitate another blood test in 6 months

-facilitate a screening colonoscopy --Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients shouldhave regular screening colonscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment.

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? SATA -family history of skin cancer -high number of moles -history of severe adolescent acne -immunosuppressant medication use -outdoor occupation

-family history of skin cancer -high number of moles -immunosuppressant medication use -outdoor occupation --skin cancers are most often linked to damage of skin cells DNA by overexposure to ultraviolet radiation. The three most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanoma grow rapidly and are highly metastatic, making them the deadliest form of skin cancer. Basal cell and squamous cell carcinomas generally have a much lower risk of metastasis. Clients should be taught to avoid overexposure to sunlight, perform monthly skin checks with the ABCDE assessment, and immediately report any abnormal findings to their healthcare provider. Early detection and treatment significantly improve outcomes.

Client instructions for a small bowel follow-through (SBFT)

-fast 8 hours prior to the examination -test lasts 60-120 minutes, but if obstruction or decreased motility is present, it can take longer -drink plenty of fluids after the examination to facilitate barium removal. Chalky stools may be present 24-72 hours after the examination. If brown stools do not return after 72 hours or abdominal pain or fullness is present, contact HCP.

The nurse is caring for a client with a hx of HAs. The client has talked to the nurse, smiled at guests, and maintained stable vital signs. The nurse notes the following changes in the client's status. Which assessment finding is critical to report to the HCP? -blood pressure 136/88 mm Hg -flat affect and drowsiness -poor appetite -respiratory rate 12/min

-flat affect and drowsiness --The level of consciousness is the most important, sensitive, and reliable indicator of the client's neurological status. Changes in the level of consciousness can represent increased intracranial pressure and reduced cerebral blood flow. Changes in vital signs usually do not appear until intracranial pressure has been elevated for some time, or they may be sudden in cases of head trauma.

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility? -genital herpes and HIV -gonorrhea and chlamydia -human papillomavirus and syphilis -year and trichomoniasis

-gonorrhea and chlamydia --Gonorrhea and chlamydia can lead to pelvic inflammatory disease and infertility. They are referred to as "silent infections" because many affected women show no symptoms. Infections of the fallopian tubes and uterus can lead to permanent damage and infertility. The centers for Disease Control and Prevention recommend annual chlamydia and gonorrhea screening for all sexually active females age <25 and older females with risk factors. Both chlamydia ad gonorrhea are treatable. The use of latex condoms is recommended to reduce the risk of contracting chlamydia and gonorrhea.

Manifestations of chronic open-angle glaucoma

-gradual loss of peripheral vision -difficulty adjusting to different lighting

The nurse teaching a group of clients about celiac disease will include which meal in the teaching plan? -baked salmon with rice, steamed vegetables, and dinner roll -breaded pork chops, corn on the cob, and steamed snow peas -grilled chicken, green beans, and mashed potatoes -spaghetti with italian tomato sauce and meatballs

-grilled chicken, green beans, and mashed potatoes --Celiac disease is an autoimmune disorder in which chronic inflammation caused by gluten damages the small intestine. It is important to teach this client that all gluten-containing products should be eliminated from the diet (wheat, barley, rye, and oats); rice, corn, and potatoes are gluten free and allowed in their diet; processed foods may contain "hidden" sources of gluten; clients will need to be gluten-free for the rest of their lives; eating even small amounts of gluten will damaged the intestinal villi, even if they do not experience symptoms. --marinated and breaded protein sources should be avoided

A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma. Which clinical finding warrants immediate intervention? -hairnet-like effect across vision -loss of memory about the collision -temporal headache -tongue laceration oozing blood

-hairnet-like effect across vision --Retinal detachment is a separation of the retina from the posterior wall of the eye, and may result from blunt-force trauma. If not promptly recognized and treated, permanent blindness may occur. Signs of detachment include lighting flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect throughout the field of vision.

A client is receiving an infusion of total parenteral nutrition with 20% dextrose through a central line at 75 mL/hr. The nurse responds to the client's IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action? -hang 0.9% normal saline until new bag arrives, then increase TPN to 150 mL/hr for 1 hour -hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr -hang dextran in saline until the new bag arrives, then resume TPN at 75 mL/hr -hang lactated Ringer's until the new bag arrives, then resume TPN at 75 mL/hr

-hang 10% dextrose in water until the new bag arrives, then resume TPN at 75 mL/hr --TPN is administered via central venous catheter to meet the nutritional needs of clients who cannot digest nutrients via the GI tract. The nurse should hang 10% dextrose in water at the same infusion rate of 75 mL/hr until the new bag arrives. If the 20% dextrose solution is temporarily replaced with an infusion lacking dextrose, the pancreas will continue to produce insulin in response to the residual glucose, which may cause hypoglycemia. --dextran in saline solution is a colloid use to expand intravascular volume in clients with hypovolemia. It can cause fluid overload and is not an appropriate action.

A highly intoxicated client was brought to the ED after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? -administer atropine for bradycardia -administer nifedipine for hypertension -have CT scan performed to rule out an intracranial bleed -perform hourly neurologic checks with Glasgow coma scale

-have CT scan performed to rule out an intracranial bleed --Cushing's triad is related to increased ICP. Early Signs include change in level of consciousness. Later signs include bradycardia, increased systolic blood pressure with a widening pulse pressure and slowed irregular respirations. Cushing's triad is a later sign that does not appear until the ICP is increased for some time. It indicates brain stem compression. The client's intoxication could blunt an accurate history or presentation of a head injury --atropine is used to stimulate the sinoatrial node in bradycardia with systemic symptoms. An ECG should be obtained prior to administering atropine. --Nifedipine is a CCB that is a potent vasodilator. However, all components must be considered in this scenario as to the etiology of the HTN rather than just treating that sign

The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? SATA -helps prevent colorectal cancer -improves glycemic control -promotes weight loss -reduces risk of vascular disease -regulates bowel movements

-helps prevent colorectal cancer -improves glycemic control -promotes weight loss -reduces risk of vascular disease -regulates bowel movements --Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods improves stool elimination, which helps prevent constipation and decreases the risk of colorectal cancer. --fiber-rich foods tend to have a low glycemic load, and are nutrient dense, yet have lower caloric density. Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss. --fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke.

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms? -brain natiuretic peptide 70 pg/mL -hematocrit 21% -Leukocytes 3,500//mm3 -platelets 105,000/mm3

-hematocrit 21% --Hematocrit is a component of red blood cells that carries oxygen to the body's tissues. In the presence of decreased hematocrit and hemoglobin,decreased oxygen-carrying capacity and transport occur. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia.

The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? -assess mental status and orientation -give on an empty stomach for rapid effect -hold if 3 soft stools occur in a day -mix with fruit juice to improve flavor

-hold if 3 soft stools occur in a day --Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood-brain barrier, leading to neurological dysfunction. Lactulose is the most common treatment for hepatic encephalopathy. Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an acidic environment and a hyperosmotic effect. In this acidic environment, ammonia is converted to ammonium and excreted rapidly. Lactulose can be given orally with water, juice, or milk or it can be administered via enema. For faster results, it can be administered on an empty stomach. The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movement each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached. The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia.

Modifiable breast cancer risk factors

-hormone therapy with estrogen and/or progesterone -postmenopausal weight gain and obesity (fat cells store estrogen) -hx of smoking/alcohol consumption -dietary fat intake -sedentary lifestyle

Risk factors for Pelvic inflammatory disease (PID)

-hx of PID -multiple sexual partners -previous STI -unprotected sexual intercourse -placement of an intrauterine device within the past 3 weeks -recent abortion or pelvic surgery

Client education with prostatitis

-hydrate with CLEAR liquids -complete full course of antibiotics -engage in sexual intercourse or masturbation to reduce discomfort (use condoms) - take stool softeners as prescribed to reduce straining during defecation -take sitz baths to help relieve symptoms

A nurse is caring for a client who developed paralytic ileus after a stroke. The client reports nausea, abdominal discomfort, and distension; bowel sounds are absent. Which prescription does the nurse question? -hydrocodone 5/325 mg 1 tab every 4 hours PRN for moderate pain -increase continuous IV normal saline rate from 75 to 100 mL/hr -insert nasogastric tube and attach to wall suction -ondansetron 4 mg IVP every 4 hours PRN for nausea

-hydrocodone 5/325 mg 1 tab every 4 hours PRN for moderate pain --paralytic ileus is characterized by temporary paralysis of a portion of the bowel, which affects peristalsis and bowel motility. S/S include abdominal discomfort, distension, and N/V. Risk factors include abdominal surgery, perioperative medications, and immobility. To prevent further abdominal distension and resulting nausea, the client should remain NPO. Nasogastric tube to wall suction may be necessary to decompress the stomach. IV fluid replacement may be necessary to correct losses that occur from nasogastric suction. Nausea is treated with prescribed antiemetics. --The client should not take medications by mouth and opioid medications should be avoided as they prolong paralytic ileus.

A client admitted with severe acute pancreatitis. While obtaining the client's blood pressure, the nurse notices a carpal spasm. What laboratory result would the nurse assess in response to this symptom? -decreased albumin -elevated troponin -hyperkalemia -hypocalcemia

-hypocalcemia --Pancreatitis is an acute inflammation of the pancreas that results in autodigestion. The most common causes are cholelithiasis and alcoholism. Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the pancreas. The pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include hyperglycemia, hypovolemia, latent hypoxia or acute respiratory distress syndrome, peritonitis, and hypocalcemia. Pancreatitis can cause hypocalcemia, but the etiology is unclear. Chvostek's (facial twitching) and Trousseau's (carpal spasm) signs are an indication of hypocalcemia from the decrease in threshold for contraction. Sustained muscle contraction and decreased cardiac contractility are concerns related to hypocalcemia.

Nursing interventions for a blood transfusion reaction include

-immediately stopping transfusion and disconnecting tubing -maintain IV access with NS using new tubing -notify HCP and blood bank -monitor VS -recheck labels, numbers, and client's blood type -treat symptoms -collect blood and urine specimens to evaluate for hemolysis -return blood and tubing set to blood bank for additional testing -complete necessary facility paperwork

The graduate nurse cares for several poststroke clients. Which of the following nursing interventions are appropriate? SATA -implement fall precautions for the client with cerebellar stroke -increase lighting for the client with cranial nerve VII affected -initiate swallow precautions for the client with cranial nerves IX and X affected -place spoon within field of vision for the clinet with homonymous hemianopsia -speak louder in front of the client who has receptive aphasia

-implement fall precautions for the client with cerebellar stroke -initiate swallow precautions for the client with cranial nerves IX and X affected -place spoon within field of vision for the client with homonymous hemianopsia --Strokes causes different neurological deficits depending on the location of the affected area within the brain and the extent of injury. Cerebellar deficits affect balance and equilibrium; fall precautions are appropriate. Cranial nerves IX and X control the gag and swallowing mechanisms, making swallow precautions necessary. Blindness in the same half of each visual field, homonymous hemianopsia, is suspected when clients ignore objects on one side. Initially, the nurse assists, but the client must learn to turn the head to scan the environment. --a stroke affecting cranial nerve VII, the facial nerve, can cause an asymmetrical smile or inability to raise one eyebrow. Increased light is unnecessary as vision is not affected. --clients experiencing receptive aphasia, impair comprehension of speech and writing, typically have injury to the Wernicke area of the brain, located in the left temporal lob. The nurse would not speak louder as this does not aid comprehension.

Manifestations of Bell palsy includes

-inability to completely close the eye on the affected side -alteration in tear production due to weakness of the lower eyelid muscle -flattening of the nasolabial fold on the side of the paralysis -inability to smile or frown symmetrically

The nurse is caring for a client diagnosed with Gullian-Barre syndrome after a recent GI illness. Monitoring for which of the following is a nursing care priority for this client? -diaphoresis with facial flushing -hypoactive or absent bowel sounds -inability to cough or lift the head -warm, tender, and swollen leg

-inability to cough or lift the head --GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep-tendon reflexes. Many clients have a hx of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure includes inability to cough, shallow respirations, dyspnea and hypoxia, and inability to lift the head or eye brows. Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation.

The emergency nurse admits a client who was rescued from a burning building. The client's arms and chest are covered with dry, leathery, charred skin that does not blanch. Which new prescription should the nurse implement first? -administer 50-100 mcg fentanyl IV push q30min, PRN for pain -apply topical bacitracin ointment to burn wounds, twice daily -infuse 150 mL/hr lactated ringer solution IV continuously -obtain equipment and prepare client for escharotomy

-infuse 150 mL/hr lactated ringer solution IV continuously ---Burn injuries are caused by direct tissue damage from exposure to caustic sources. These injuries may be life-threatening, depending on the extent of tissue injury and organ damage. To prioritize the initial management of burn injuries, nurses should use the ABCs. Circulatory compromise is common after sustained a burn, as extensive tissue injury combined with the systemic inflammatory response cuases increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. These intravascular losses begin rapidly after a burn and may lead to hypovolemic shock and death. Therefore, the nurse should prioritize initiation of fluid resuscitation

An adult client with altered mental status and fever has suspected bacterial meningitis with sepsis. Blood pressure is 80/60 mm Hg. Which prescribed intervention should the nurse implement first? -administer IV antibiotics -infuse bolus of IV normal saline -prepare to assist with lumbar puncture -transport client for head CT scan

-infuse bolus of IV normal saline --Meningitis is an inflammation of the meninges covering the brain and spinalcord. The key clinical manifestations of bacterial meningitis includes fever, severe HA, N/V, and nuchal rigidity. Other symptoms include photophobia, altered mental status, and other signs of increased ICP. In a hypotensive client with sepsis, the priority of care is fluid resuscitation to increase the client's blood pressure.

An adolescent client seen in the ambulatory care center is going on a one-week fasting regimen of water and juice to jump start weight loss. The nurse's response is based on an understanding of which of the following? -fasting for 7 days is not likely to cause health problems -fasting spares protein in favor of fat metabolism -fasting will help control hunger pangs in the long term -initial weight loss during fasting is primarily from fluid loss

-initial weight loss during fasting is primarily from fluid loss

The nurse receives new prescriptions for a client with right lower quadrant pain and suspected acute appendicitis. Which prescription should the nurse implement first? -administer 0.25 mg hydromorphone IV push for pain -draw blood for CBC and electrolyte levels -initiate IV access and infuse normal saline 100 mL/hr -obtain urine specimen for urinalysis

-initiate IV access and infuse normal saline 100 mL/hr --Appendicitis is inflammation of the appendix and often result from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. When prioritizing care of a client with appendicitis, the nurse should utilize the ABCs. Fluid resuscitation with IV crystalloids is an important intervention aimed at preventing circulatory collapse resulting from fluid losses and NPO status. --blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse should prioritize circulatory status over obtaining lab specimens.

The nurse is admitting a client from the post-anesthesia care unit who just received a permanent atrioventricular pacemaker for a complete heart block. Which action should the nurse implement first? -assess incision for bleeding or hematoma formation -auscultate bilateral anterior and posterior lung sounds -initiate continuous cardiac monitoring -reestablish IV fluids and postoperative antibiotics

-initiate continuous cardiac monitoring --When the client arrives in the post-anesthesia care unit after pacemaker placement, the nurse should attach the cardiac monitor to assess the function of the pacemaker. If the atrioventricular pacemaker is working properly, pacer spikes should be visible prior to the P waves and QRS complexes. If the pacemaker is not working properly, the HCP should be contacted immediately. The nurse should also assess for mechanical capture by palpating the client's pulse rate and comparing it with the electrical rate displayed on the cardiac monitor, and check the client's vital signs to assess stability following the procedure.

A client comes to the emergency department reporting alkaline drain cleaner splashed into the eye. The conjunctiva of the affected eye is erythematous, and the client reports a burning sensation. What action is appropriate at this time? -administer PO analgesic medication -cover the affected eye with an eye patch -initiate continuous eye irrigation -perform a Snellen vision test

-initiate continuous eye irrigation --Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. Fr all types of ocular chemical burns, copious eye irrigation with sterile saline or water should begin immediately to flush the chemical irritant out of the eye. Irrigation is continued until the pH of the eye returns to normal (6.5-7.5) , which typically takes 30-60 minutes.

The nurse is planning care for a client experiencing an acute attack of Meniere disease. Which action is a high priority to include in the plan of care? -initiate fall precautions -keep the emesis basin at bedside -provide a quiet environment -start intravenous fluids

-initiate fall precautions --Clients with Meniere disease can have severe vertigo, tinnitus, hearing loos, and aural fullness. It is a priority for the nurse to institute safety measures, such as fall precautions, for these clients. they will require a salt-restricted diet.

The nurse admits a client with cirrhosis who has an upper gastrointestinal bleed from suspected gastroesophageal varices. Which new prescription should the nurse question? -administer pantoprazole IV piggyback every 12 hours -initiate continuous octreotide IV infusion -insert and maintain a nasogastric tube -maintain NPO status except for PO medications

-insert and maintain a nasogastric tube --Upper GI bleeding is a potentially life-threatening condition commonly caused by bleeding gastroesophageal varices or peptic ulcers. Gastroesophageal varices are distended, fragile blood vessels within the stomach and/or esophagus that frequently occur secondary to cirrhosis. Due to the fragility of these veins, clients are closely monitored for variceal rupture. Rupture of gastroesophageal varices is an emergency complication that rapidly results in massive GO bleeding, hypovolemic shock, and death. Variceal rupture commonly occurs due to a sudden increase in portal venous pressure and from mechanical injury. In upper gastrointestinal bleeding, nasogastric tube insertion may be prescribed for gastric decompression or evacuation. However, nasogastric tube insertion without visualization of the esophagus may traumatize and rupture varices, causing hemorrhage. --Octreotide may be used to help control upper GI bleeding related to bleeding gastroesophgeal varices, as it reduces portal venous pressure, which reduces bleeding.

The nurse is caring for a client after a lumbar puncture. Which client assessment is most concerning and requires a nursing response? -consumes 600 mL liquid over 4 hours -insertion site dressing saturated with clear fluid -observed lying in the right-sided Sim's position -reports a HA rated 6/10

-insertion site dressing saturated with clear fluid --Elevated ICP is a contraindication to performing a lumbar puncture. The client is placed in the fetal position or sitting and leaning over a table. Continued leaking fluid indicates that the site did not seal off and a blood patch is required. --The client should lie flat for atleast 4 hours. The prone or supind position is recommended to help prevent a HA. --5%-30% of clients have the common complication of HA. It is thought to be a result of leakage of fluid through the dural puncture site. The symptom is treated and is normally self-limiting.

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. Which meal dose the client choose to indicate that teaching has been effective? -chicken salad with lettuce on French bread, chocolate pudding, and milk -fat-free yogurt, carrot sticks, apple slices, and diet soda -Ham, steamed carrots, green beans, gelatin dessert, and iced tea -kale salad with boiled eggs and dried fruit, a brownie, and orange juice

-kale salad with boiled eggs and dried fruit, a brownie, and orange juice --Clients with iron-deficiency anemia should be taught to eat iron-rich foods such as meats, shellfish, eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal.

A client with stroke symptoms has a blood pressure of 240/124 mm Hg. The nurse prepares the prescribed nicardipine intravenous infusion solution correctly to yield 0.1 mg/mL. The nurse then administers the initial prescription to infuse at 5 mg/hr by setting the infusion pump at 50 mL/hr. What is the nurse's priority action at this time? -assess hourly urinary output -increase pump setting to correct administration rate to 100 mL/hr -keep systolic blood pressure above 170 mm Hg -monitor for a widening QT interval

-keep systolic blood pressure above 170 mm Hg --A client with an acute stroke presentation requires "permissive hypertension" during the first 24-48 hours to allow for adequate perfusion through the damaged cerebral tissues. However, the blood-brain barrier is no longer intact once the blood pressure is greater than 220/120 mm Hg. Therefore, "mild" lowering is required, usually to a systolic pressure that is not below 170 mm Hg. Nicardipine is a prototype of nifedipine and is a potent calcium channel blocking vasodilator. It takes effect within 1 minute of IV administration. It is essential to monitor that the blood pressure is not being lowered too quickly or too slowly as this would extend the stroke. Hypotension can occur with or without reflex tachycardia. The drug must be discontinued if hypotension or reflex tachycardia occurs. --widening of the QT interval can increase the risk of life-threatening torsades de pointes. It is most commonly seen with haloperidol, methadone, ziprasidone, and erythromycin. However, this is not an expected complication of nicardipine.

The nurse is caring for a client in the immediate postoperative period following a carotid endarterectomy. The client is drowsy with slurred speech. Which assessment finding would cause the nurse to notify the HCP immediately? -diminished gag reflex after endotracheal tube removal -increased agitation level and pulling at linens -left arm drift during bilateral arm extension -responds to verbal commands with eyes closed

-left arm drift during bilateral arm extension --a carotid endarterectomy is a surgical procedure performed to remove plaque from the carotid artery to improve cerebral perfusion. The nurse must closely assess for signs of new or worsening alterations in neurologic status, as surgical manipulation of arteries and blood flow increases the risk of stroke. Monitoring the client's neurologic status post-operatively can --diminished gag reflex is common after anesthesia and endotracheal tube removal. The gag reflex should return as the client awakens. Individuals recovering from anesthesia may have alterations in mood or affect that will resolve as anesthesia wears off. Drowsiness and somnolence during purposeful interactions are expected after anesthesia.

The nurse assesses a client with suspected acute pancreatitis and anticipates the client reporting pain in which anatomical area? -left flank radiating to the left groin area -left upper quadrant radiating to the back -periumbilical area shifting to the right lower quadrant -right upper quadrant radiating to the right shoulder

-left upper quadrant radiating to the back --The client with acute pancreatitis will report a sudden onset of unrelenting, severe pain in the left upper quadrant or midepigastric area of the abdomen that often radiates to the back. The pain is referred to the back as the pancreas is a retroperitoneal organ. Pain improves with leaning forward and worsens with lying flat. The pain is often preceded or made worse by a high-fat meal. N/V are common due to severe pain. Clients are at risk of developing hypovolemia (third spacing of fluids), acute respiratory distress syndrome (due to intense systemic inflammatory response), and hypocalcemia (necrosed fat binding calcium) --kidney stones cause sudden, excruciating pain in the flank, back, or lower abdomen due to stretching of the ureter. The pain will radiate to the groin area --appendicitis presents as periumbilical pain progressing to the right lower quadrant. Tenderness at McBurney's point is present as pressure is applied, and rebound tenderness occurs when pressure is released. -Cholecystitis causes pain in the right upper quadrant that often radiates to the right shoulder area.

During assessment of a client who had major abdominal surgery a week ago, the nurse notes that the incision has dehisced and evisceration has occurred. The nurse stays with the client while another staff member gets sterile gauze and saline. How should the nurse position the client while waiting to cover the wound? -low Fowler's position with knees bent -prone to prevent further evisceration -side-lying lateral position -supine with head of the bed flat

-low Fowler's position with knees bent --wound evisceration is the protrusion of internal organs through the wall of an incision. It typically occurs 6-8 days after surgery and is more common in clients who have had abdominal surgery, those with poor wound healing, and those who are obese. IT is considered a medical emergency. The nurse should remain with the client while calling for help. The HCP should be notified immediately and supplies brought to the room by another staff member. The wound should be covered with sterile normal saline dressings. While the nurse remains in the room, the client should be positioned in low Fowler's position with the knees bent.. This position lessens abdominal tension on the suture line and can prevent further evisceration. The client should be prepared for immediate return to surgery.

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination? SATA -bitter almond smell on breath -fever and raised skin pustules -low blood cell counts -oral mucosal ulcerations -vomiting and diarrhea

-low blood cell counts -oral mucosal ulcerations -vomiting and diarrhea ---Radiation changes the DNA, which causes cell destruction. Radiation usually affects tissues with rapidly proliferating cells first,followed by tissues with slowly proliferating cells. As a result, early manifestations of radiation damage include oral mucosal ulcerations, vomiting/diarrhea, and low blood cell counts. The extent of radiation exposure can be monitored indirectly by measuring blood cell counts.

The nurse is preparing a client who had Roux-en-Y gastric bypass for discharge from the hospital. What information should the nurse plan to include related to the prevention of dumping syndrome? -meals should be small and low in carbohydrate content -fluids should be encouraged with each meal -take a multivitamin with iron and calcium supplements daily -you will need to take your cobalamin injection monthly

-meals should be small and low in carbohydrate content --A RYGB procedure uses a small proximal portion of the stomach to create a gastric pouch that is anastomosed to the Roux limb of the small intestine, bypassing most of the stomach and a portion of the duodenum. Dumping syndrome, the rapid emptying of gastric contents into the small intestine, is a potential complication. The presence of a large quantity of hyperosmolar intestinal contents causes fluids to shift out of the vascular system into the intestines, leading to symptoms such as N/V, diarrhea, weakness, and hypotension. To prevent dumping syndrome, clients should eat multiple small meals, eat a low-carbohydrate diet, and separate their consumption of food and fluids.

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? SATA -flank pain radiating to the groin -high-protein food ingestion before the onset of pain -low-grade fever with chills -pain at the umbilicus -right upper quadrant pain radiating to the right shoulder

-low-grade fever with chills -right upper quadrant pain radiating to the right shoulder --cardinal symptoms of acute cholecystitis from cholelithiasis include pain in the RUQ with referred pain to the right shoulder and scapula. Clients often report fatty food ingestion 1-3 hours before the initial onset of pain. Associated symptoms include low-grade fever, chills, N/V, and anorexia. During an acute attack, inflammation of the mucous lining and wall of the gallbladder occurs as a result of gallstone obstruction of the cystic bile duct. The inflammation and increased pressure in the gallbladder from the blocked bile duct results in Murphy's sign; palpation over the RUQ causes pain and inability to take a deep breath. Laboratory results show leukocytosis. --it is not dietary protein but food with significant fat content that signals the gallbladder to contract, emptying bile into the duodenum to help digestion. Gallstones normally harmlessly floating around the gallbladder are squeezed into the bile duct, causing the pain of biliary colic. Gallstones stuck further down the bile duct may become colonized by a bacterial infection.

A 70-year old client is admitted to the hospital with a lower GI bleed. After assisting the client back to bed, the nurse finds approximately 600 mL of frank red blood in the commode. The client is now pale and diaphroetic and reports dizziness. Which action should the nurse perform first? -check the vital signs -draw blood for hemoglobin and hematocrit -lower the head of the bed -maintain an IV line with normal saline

-lower the head of the bed --Acute blood loss is a medical emergency, and the nurse needs to carry out interventions rapidly. Lowering the head of the bed or placing the client in the supine position maintains blood perfusion to the brain and other vital organs. This can be done quickly to help stabilize the client before performing other interventions. --assessing and recording vital signs is appropriate after lowering the head of the bed --monitoring hemoglobin and hematocrit levels is appropriate to assess to severity of blood loss and need for possible blood transfusion. Blood loss typically takes a few hours to reflect on the client's laboratory report; thus, not a priority. --ensuring IV access and continuing fluid administration is appropriate. This maintains fluid volume due to blood loss and corrects or reduces potential for hypovolemic shock. Not a priority and can be done after lowering the head of the bed

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns of the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next? -check vital signs -maintain IV access with normal saline -notify the HCP -recheck identification labels and numbers

-maintain IV access with normal saline --During a blood transfusion reaction, the nurse should immediately stop the transfusion and initiate normal saline to maintain IV access and prevent hypotension and vascular collapse.

The nurse is admitting a client with choleslithasis and acute cholecystitis. Suddenly, the client vomits 250 mL of greenish-yellow stomach contents and reports severe pain in the right upper quadrant with radiation to the right shoulder. Which intervention would have the highest priority? -administer promethazine 25 mg suppository -infuse normal saline 100 mL/hr -insert nasogastric tube to low suction -maintain NPO status

-maintain NPO status --the highest priority intervenetion for an actively vomiting with cholelithiasis is maintenance of strict NPO status to avoid additional gallbladder stimulation. Additional collaborative interventions for cholecystitis should also be taken into account. --Promethazine 25 mg suppository is the second priorty. Promethazine promotes the relief of nausea and vomiting and minimizes further fluid loss.

A client is brought to the ED by emergency medical services with a flaccid right arm and leg and lack of verbal response. The stroke alert team is initiated. The nurse takes which priority action? -determine onset of symptoms -ensure that the client has 2 large-bore IV lines -maintain patent airway -prepare for head CT scan

-maintain patent airway --A flaccid extremity and change in verbal ability are symptoms of a stroke, which is considered an emergency. Clients with stroke symptoms are immediately triaged using a special team and set of tools to determine the correct course of action with the goal of preventing further brain damage. In any emergency, the first priority nursing action is to maintain a patent airway. Depending on the mechanism of injury, the symptoms may include changes in airway clearance, which is a priority. The nurse, or another member of the ED or stroke alert team, will prepare the client for an immediate head CT scan to rule out a hemorrhagic stroke and determine the location and extent of the injury. This person will also ensure that the client has 2 large-bore IV lines for rapid infusion of fluids or medications as needed.

A client calls the primary care clinic reporting diarrhea for 4 days and a low grade fever. What instruction is most important for the nurse to give to the client? -encourage client to eat bulk-forming foods such as whole grain bread -encourage rest, fluids, and acetaminophen for the fever -make an appointment for the client with the healthcare provider today -take 2 tablets of loperamide followed by 1 tablet after each loose stool.

-make an appointment for the client with the healthcare provider today --Most bouts of diarrhea are self-limiting and lasts <48 hours. Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by a HCP. Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication side effects, or laxative overuse. The HCP will need to assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea that may require further treatment. -Instructions on eating bulk-forming foods may be helpful with diarrhea but does not address the underlying problem causing the diarrhea and fever. -Instructions on rest, fluids, and acetaminophen are helpful and would be the primary choice if the diarrhea had been occurring <48 hours without other symptoms.

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L. Which assessment finding does the nurse anticipate? -constipation and polyuria -increased thirst and dry mucous membranes -leg weakness and soft, flabby muscles -tremors and brisk deep-tendon reflexes

-tremors and brisk deep-tendon reflexes --Hypomagnesemia, a low blood magnesium level, is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the GI and renal systems. It is associated with ventricular arrhythmias (most serious concern) and neuromuscular excitability. --constipation and polyuria indicate hypercalcemia.

The nurse is caring for a client with an acute ischemic stroke who has a blood pressure of 178/95 mm Hg. The HCP prescribes as-needed antihypertensives to be given if the systolic pressure is >200 mm Hg. Which action by the nurse is most appropriate? -give the antihypertensive medication -monitor the blood pressure -notify the HCP -question the prescription

-monitor the blood pressure --An ischemic stroke is a loss of brain tissue perfusion due to blockage in blood flow. Elevated blood pressure is common and permitted after a stroke and may be a compensatory mechanism to maintain cerebral perfusion distal to the area of blockage. This permissive hypertension usually autocorrects within 24-48 hours and does not require treatment unless the hypertension is extreme (Systolic pressure >220 mm Hg or diastolic blood pressure >120 mm Hg) or contraindicated due to the presence of another illness requiring strict blood pressure control. A blood pressure of 178/95 mm Hg should be monitored, along with the client's other vital signs and status.

The nurse is caring for a client in the medical-surgical unit who has delirium according to the Confusion Assessment Method assessment tool. Which of the following assessment findings are likely contributing to the client's delirium? SATA -multiple doses of IV hydromorphone administered in the past 12 hours -serum sodium of 123 mEq/L -SpO2 of 82% on room air -temperature of 103.1 F -urine culture positive for gram-positive cocci in chains

-multiple doses of IV hydromorphone administered in the past 12 hours -serum sodium of 123 mEq/L -SpO2 of 82% on room air -temperature of 103.1 F -urine culture positive for gram-positive cocci in chains --Nursing interventions include treating the underlying cause as prescribed to resolve delirium, maintaining a safe environment, reorienting the client frequently, promoting a regular sleep cycle, providing familiar items from hone, and encouraging family and friends to stay with the client.

Need for spinal immobilization (think NSAIDS)

-neurological examination (focal deficits include numbness and decreased strength) -significant traumatic mechanism of injury -altertness (client may be disoriented or have an altered LOC) -intoxication (client could have impaired decision-making ability or lack awareness of pain) -distracting injury (another significant injury could distract the client from spinal pain) -spinal examination (point tenderness over the spine or neck pain on movement may be present)

The nurse receives report on the assigned team of clients on the oncology unit. All are receiving chemotherapy. Which client should the nurse check on first? -alopecia and oral mucositis noted on assessment -morning hemoglobin result is 8 g/dL -new-onset back pain and weakness in legs -persistent vomiting and potassium result is 3.4 mEq/L

-new-onset back pain and weakness in legs --A new onset finding is more concerning than chronic or expected findings. There is a risk of spinal cord compression from a metastatic tumor in the epidural space. The classic symptoms are localized, persistent back pain; motor weakness; and sensory changes. There can also be autonomic dysfunction, reflected by bowel or bladder dysfunction. Neurologic changes are a priority because the symptoms are subtle and time sensitive for permanent negative outcomes. Bone is a common site for metastasis due to its vascularity. This is the highest risk of the 4 options.

Thrombotic thrombocytopenic purpura is suspected due to the client's current platelet count of 2,000/mm3. Which client sign or symptom is the most concerning and requires immediate further nursing action? -current oozing epistaxis -ecchymosis on leg since yesterday -new-onset confusion -reported history of hematuria

-new-onset confusion --A priority assessment in a client with low platelets is any change in level of consciousness. This can indicate intracranial bleeding and increased intracranial pressure.

Client teaching for von Willberand disease includes:

-notify HCP of signs of bleeding -use a humidifier or nasal spray to keep mucosa moist, reducing nosebleeds -avoid aspirin and NSAIDs -maintain gum integrity to minimize bleeding -report heavy menstrual bleeding, which can be managed with hormonal therapies and intranasal desmopressin

A client is admitted to the hospital for severe HAs. The client has a hx of increased ICP, which has required lumbar punctures to relieve the pressure by draining cerebrospinal fluid. The client suddenly vomits and states, "That's weird, I didn't even feel nauseated." Which action by the nurse is the most appropriate? -document the amount of emesis -lower the head of the bed -notify the HCP -offer anti-nausea medication

-notify the HCP --Unexpected and projectile vomiting without nausea can be a sign of increased ICP, especially in the client with a hx of increased ICP. The unexpected vomiting is related to pressure changes in the cranium. The vomiting is related to pressure changes in the cranium. The vomiting can be associated with HA and gets worse with lowered head position. The most appropriate action is to obtain a full set of vital signs and contact the HCP immediately.

The nurse is caring for a debilitated client with a percutaneous endoscopic gastrostomy tube that was inserted 3 days ago for the long-term administration of enteral feedings and medications. While the nurse is preparing to administer the feeding, the tube becomes dislodged. What is the most appropriate intervention? -insert a Foley catheter into the existing tract and inflate the balloon -insert a small-bore nasointestinal tube to administer feedings and medications -notify the HCP who inserted the PEG tube -reinsert the PEG tube into the existing tract immediately

-notify the HCP who inserted the PEG tube --A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to clsoe within hours of tube dislodgement. The nurse should notify the HCP who placed the PEG tube as early dislodgement (less than 7 days from placement) requires either surgical or endoscopic replacement. --the insertion of a Foley catheter or immediate reisertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. --Small-bore nasointestinal tubes are used for short-term rather than long-term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention.

The nurse admits a client who fell of a 20 ft ladder. On arrival in the ED, the client is arousable but lethargic. What is the nurse's priority action? -ask about client's chronic medical conditions -assess for level and duration of pain -obtain a GCS score -perform a head-to-toe assessment

-obtain a GCS score --After trauma to a client, the nurse performs an emergency or trauma assessment that includes a primary and secondary survey. The primary assessment determines the status of the airway, breathing, and circulation. Next, the nurse evaluates disability of neurological function using the GCS. The GCS measures the client's LOC by assessing the best eye opening response, best verbal response, and best motor response. The lower the GCS score, the higher the risk for the client to develop complications.

The nurse is planing care for a client with suspected stroke who has just arrived at the ED with slurred speech, facial drooping, and right arm weakness that began 1 hour ago. Which of the following interventions should the nurse anticipate including in the initial plan of care? SATA -arrange for a speech pathologist consult -discuss community resources with family -obtain a STAT CT scan of the head -perform a baseline neurologic assessment -prepare to initiate alteplase within the next 3 hours

-obtain a STAT CT scan of the head -perform a baseline neurologic assessment -prepare to initiate alteplase within the next 3 hours --Strokes may be either ischemic or hemorrhagic. Ischemic stroke occurs when circulation to parts of the brain is interrupted by occlusion of cerebral blood vessels by a thrombosis or embolus. Hemorrhagic stroke occurs when a cerebral blood vessel ruptures and bleeds into the cranial vault. Both types of stroke result in brain tissue death without prompt treatment. A client with stroke symptoms must have an immediate CT scan or MRI of the head to determine the type and location of the stroke. Determining exactly when symptoms began is essential for diagnosis and planning treatment. Thrombolytic therapy is used to dissolve blood clots and restore perfusion to brain tissue in clients with an ischemic stroke unless contraindicated. It must be administered within 4.5 hours from onset of symptoms. A baseline neurologic assessment is essential for tracking ongoing neurologic symptoms that indicate improvement or complications which guide later treatments. --Consultation with a speech pathologist and providing the family with information about community resources are important later but not during the initial phase of stroke management.

Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral hepatitis B? SATA -offer small, frequent meals to prevent nausea -promote rest periods between periods of activity -provide a diet high in fat and low in carbs -teach the client not to share razors or toothbrushes with others -teach the client to abstain from drinking alcohol

-offer small, frequent meals to prevent nausea -promote rest periods between periods of activity -teach the client not to share razors or toothbrushes with others -teach the client to abstain from drinking alcohol --Hepatitis is often caused by infection, toxins, or trauma resulting in impairment of liver function. Nursing interventions for clients with acute viral hepatitis includes: alternate periods of rest and activity to reduce metabolic demands and avoid fatigue; avoid hepatotoxins as they worsen injury to liver cells; medications metabolized in the liver should be used cautiously to allow hepatocytes to head; encourage a low fat, small, frequent meals to decrease nausea and promote intake in clients with anorexia--anorexia is lowest in the morning so promote eating a larger breakfast; provide oral care and avoid extremes in food temperature to increase appetite; promote water consumption and diets adequate in carbohydrates and calories; hepatitis B is transmitted through sexual contact and infected blood, therefore a condom should be used during sexual intercourse; clients should not share razors or toothbrushes

What are some rapidly proliferating cells commonly first affected by radiation and chemotherapy?

-oral mucosa -GI tract -bone marrow

A client with a C3 spinal cord injury has a HA and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially? -administer PRN analgesic medication -adminsiter PRN antihypertensive medication -lower the HOB -palpate the client's bladder

-palpate the client's bladder --Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke. Noxious stimuli may include bladder distention, fecal impaction, and tight clothing.

General procedure for emptying the JP drainage device

-perform hand hygiene -pull the plug on the bulb (opens the device) -pour the drainage into a small, calibrated container -empty the device every 4-12 hours (unless 1/2 or 2/3 full) ----as the small capacity bulb fills, the amount of negative pressure in the bulb decreases. -compress the empty bulb by squeezing it from side-to-side with 1 or 2 hands until it is totally collapsed. -clean the spout on the bulb with alcohol and replace the plug when it is totally collapsed to restore negative pressure.

A homeless man known to have chronic alcoholism and who has not eaten for 8 days in undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome? -phosphorus 2.0 mg/dL, potassium 2.9 mEq/L, magnesium 1.0 mEq/l -phosphorus 4.0 mg/dL, potassium 3.5 mEq/L, magnesium 2.0 mEq/L -random blood glucose 60 mg/dL, sodium 120 mEq/L, calcium 7.0 mg/dL -random blood glucose 100 mg/dL, sodium 140 mEq/dL, calcium 10.0 mg/dL

-phosphorus 2.0 mg/dL, potassium 2.9 mEq/L, magnesium 1.0 mEq/l --Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphorus, potassium, and/or magnesium. Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency.

The nurse prepares to administer IV albumin to a client with severe liver disease who has a low serum albumin level of 1.5 g/dL. Which characteristic finding associated with hypoalbuminemia should the nurse anticipate assessing? -altered mental status -easy bruising -loss of body hair -pitting edema

-pitting edema --Oncotic pressure is a form of osmotic pressure exerted by plasma proteinsin the blood that pulls water into the circulatory system. Albumin is a large plasma protein that remains in the vascular compartment. Albumin plays a role in maintaining intravascular oncotic pressure and prevents fluid from leaking out of the vessels. Clients with severe liver disease can develop hypoalbuminemia because the liver manufactures albumin, and damaged hepatocytes are unable to synthesize it. When serum albumin is low, oncotic pressure decreases and fluid leaks from the intravascular compartment into the interstitial spaces, causing pitting edema of the lower extremities, periorbital edema, and ascites. --all other options are manifestations of liver disease. Altered mental status is due to elevated serum ammonia levels. Easy bruising is caused by an inability to produce prothrombin and other clotting factors. Loss of body hair is due to altered hormone metabolism.

The nurse is caring for a client with cirrhosis. Assessment findings include ascites, peripheral edema, SOA, fatigue, and generalized discomfort. Which interventions would be appropriate for the nurse to implement to promote the client's comfort? SATA -encourage adequate sodium intake -place client in semi-Fowler position -place client in Trendelenburg position -provide alternating air pressure mattress -use music to provide a distraction

-place client in semi-Fowler position -provide alternating air pressure mattress -use music to provide a distraction --In a client with cirrhosis and ascites, discomfort is often due to pressure of the fluid on the surrounding organs. SOA occurs due to the upward pressure exerted by the abdominal ascites on the diaphragm, which restricts lung expansion. Positioning the client in semi-Fowler or Fowler position can promote comfort, as this position can reduce the pressure on the diaphragm. In semi-Fowler position, the head of the bed is elevated 30-45 degrees. Side-lying with the head elevated can also be a position of comfort for the client with ascites as it allows the heavy, enlarged abdomen to rest on the bed, reducing pressure on internal organs and allowing for relaxation. Meticulous skin care is a priority due to the increased susceptibility of skin breakdown from edema, ascites, and pruitus. It is important to use a specialty mattress and implement a turning schedule of every 2 hours. A distraction can take the client's mind off the current symptoms and may also help promote comfort in many different situations. Some of these distractions include listening to music, watching television, playing video games, or taking part in hobbies. --Client with ascites and peripheral edema should decrease their fluid or sodium intake, not increase. In Trendelenburg position, the bed is tilted with the head lower than the legs. This position is contraindicated in the client with ascites, as it may exacerbate SOA by causing the abdominal ascites to push upward on the diaphragm, restricting lung expansion.

General interventions to maintain gastric suction using a Salem sump tube includes

-place client in semi-Fowler's position (helps keep the tube from lying against the stomach wall to help prevent gastric reflux) -provide mouth care every 4 hours to help maintain moisture of oral mucosa and promote client comfort -turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds -inspect the drainage system for patency

A nurse is evaluating an acutely ill client with suspected meningitis. The nurse should take what action first? -check for Kernig's and Brudzinski's signs -establish IV access -place the client on droplet precautions -prepare the client for lumbar puncture

-place the client on droplet precautions --The client with suspected bacterial meningitis should be placed on droplet precaution isolation until the causative agent has been identified and appropriate treatment is initiated. Meningococcal meningitis and Haemophilus influenzae type B meningitis are highly transmissible to others, and the client must remain on droplet isolation until these can be ruled out. Precautions can usually be discontinued 24 hours after beginning antibiotic therapy. Viral meningitis and other types of bacterial meningitis usually do not require droplet precautions.

An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered LOC. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia. -assessing client's breath sounds every 2 hours -placing client in the side-lying position in bed -titrating client's oxygen to maintain saturation greater than 93% -turning and repositioning the client every 2 hours

-placing client in the side-lying position in bed --Clients with decreased LOC may not be alert enough to protect their own airways; therefore, a side lying or lateral position is used to decrease the risk for developing aspiration pneumonia. If vomiting were to occur, this position promotes drainage of emesis out of the mouth instead of down the pharynx where it can be aspiration into the lungs. Maintaining an upright position during and after meals will allow remaining food particles to clear from the pharynx. --assessing breath sounds can help identify the presence of pneumonia but does not prevent the client from aspirating. Turning and repositioning every 2 hours helps to prevent stasis of secretions in the lungs but does not prevent the client from aspirating.

The nurse is caring for a client with severe chronic obstructive pulmonary disease COPD). The nurse anticipates which laboratory results for this client? -anemia -neutropenia -polycythemia -thrombocytopenia

-polycythemia --The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces more red blood cells to carry needed oxygen to the cells.

The nurse is caring for a client who has undergone a colonscopy. Which client assessment finding should most concern the nurse? -abdominal cramping -frequent, watery stools -positive rebound tenderness -recurring flatus

-positive rebound tenderness --A risk of a colonscopy is perforation. Signs of perforation include abdominal pain (with shoulder tip pain), positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or board-like abdomen. Another potential complication is rectal bleeding.

The nurse is caring for a client with a hx of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a HA. The nurse documents the confusion and HA as which phrase of the client's seizure activity? -aural phase -ictal phase -postictal phase -prodromal phase

-postictal phase --During this phase, the client may experience confusion while recovering from the seizure. The client may also experience a HA. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.

The nurse is caring for a client with end-stage liver failure from hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with IV albumin, IV furosemide, and oral spironolactone. The following day the nurse checks the client's labs. Which of the following lab findings is most important for the nurse to communicate to the HCP? -albumin 2.5 g/dL -INR 1.4 -potassium 3.0 mEq/L -sodium 131 mEq/L

-potassium 3.0 mEq/L --The client with cirrhosis is at risk of hepatic encephalopathy. Hypokalemia, high protein intake, GI bleeding, constipation, hypovolemia, and infection can precipitate hepatic encephalopathy. Use of furosemide can cause hypokalemia, which must be corrected immediately to prevent the precipitation of hepatic encephalopathy and dangerous arrhythmias --a low albumin level of 2.5 g/dL is common in liver failure due to decrease protein synthesis. The lower limit for serum albumin is 3.5 g/dL and there is no treatment to correct it. --elevated prothrombin time and INR are common with liver disease or cirrhosis.

Which prescription should the nurse question when caring for a hospitalized client diagnosed with acute diverticulitis? -metronidazole 500 mg IV every 8 hours -nasogastric tube to suction -NPO -prepare for barium enema in AM

-prepare for barium enema in AM --Diverticular disease of the colon occurs when saclike protrusions form in the large intestine. When diverticula become infected and inflamed, the client has diverticulitis. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve.This includes IV antibiotic therapy, NPO status, NG suction, IV fluids, and bed rest.

Key measures of skincare that clients receiving teletherapy should take includes:

-protecting skin from infection (no rubbing, scratching, or scrubbing) -cleanse skin daily with lukewarm water and mild soap -use creams or lotions approved by HCP only -shield the skin from effects of sun during/after treatment -avoid extremes in skin temperature (no heating/ice packs)

A graduate nurse is caring for a client with acute appendicitis who is awaiting surgery. Which action by the graduate nurse would require the precepting nurse to intervene? -administers morphine IV PRN for pain -initiates continuous normal saline IV -provides a heating pad for abdominal discomfort -teaches client about prescribed strict NPO status

-provides a heating pad for abdominal discomfort --Appendicitis is inflammation of the appendix often resulting from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which many lead to peritonitis and sepsis. Appendicitis is often treated surgically via removal of the appendix. Nurses caring for clients with appendicitis should avoid interventions that increase intestinal blood circulation, gut motility, or appendiceal intraluminal pressure. The application of heat to the abdomen increases intestinal circulation and the risk for appendiceal perforation.

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery. During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm. What action should the nurse take? -anticipate the scheduling of a biopsy -apply ice to the node -reassure the client that it is an expected finding -request an antibiotic

-reassure the client that it is an expected finding --A lymph node that is superficial, palpable, small (<1 cm), mobile, firm, and nontender is a normal finding. Hard and fixed nodes are most concerning as they are likely due to malignancy. Tender nodes usually indicate inflammation/infection

drug class and function of palifermin (Kepivance)

-recombinant human keratinocyte growth factor --prevents oral mucositis in clients diagnosed with hematologic malignancies

Interventions for amyotrophic lateral sclerosis involves?

-respiratory support with noninvasive positive pressure (BiPAP) or mechanical ventilation -feeding tube for enteral nutrition -medications to decrease symptoms -mobility assistive devices (walker and wheelchair) -communication assistive devices (alphabet boards, specialized computers)

The nurse is caring for a client who has homonymous hemianopsia following an acute stroke. Which nursing diagnosis is the most appropriate for this client? -risk for ineffective airway maintenance -risk for knowledge deficit -risk for poor fluid intake -risk for self-neglect

-risk for self-neglect --Cerebral vascular accidents can cause visual and perceptual deficits depending on which part of the brain is affected. Clients with changes in visual field or perception of their body in space can be at risk for safety-related injuries. Homonymous hemianopsia is a loss in half of the visual field on the same side. For example, the client may lose the left side of the visual field in both eyes. A client unable to see the left side of the body is at a higher risk for neglecting that side or being unable to eat food placed on the left side of a plate. These clients are at higher risk for injury because they are unable to incorporate full visual field input. They are taught to turn the head and scan to the side with the visual field deficit to reduce the risk for injury and self-neglect.

The nurse assesses a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicles. Which burn stage does the nurse document? -first degree -second degree -third degree -fourth degree

-second degree --second degree burns appear as moist or weeping wounds with blisters and shiny, fluid-filled vesicles. Pain is moderate or severe.

What are the major complications associated with toxic epidermal necrolysis?

-sepsis -fluid and electrolyte imablance -hypothermia -ophthalmic issues

The nurse cares for a client admitted with severe burns who is now on fluid resuscitation therapy. Which assessment findings would best indicate that fluid resuscitation has been successful? -heart rate 89/min, blood pressure 99/52 mm Hg -potassium decrease from 5.7 mEq/L to 5.0 mEq/L -urine output 31 mL/hr, respirations 20/min -weight gain of 2.2 lbs in last 8 hours and palpable pulses

-urine output 31 mL/hr, respirations 20/min --After a burn injury, increased capillary permeability leads to third spacing, allowing proteins, plasma, and electrolytes to leave the vascular space and occupy other spaces and tissues. This creates a state of hypovolemic shock, which poses the highest risk of mortality in the initial phase of the burn process. Therefore, aggressive fluid resuscitation to correct hypovolemia is a priority. Adequate urine output depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion.

The hospitalized client with anorexia nervosa is started on nutrition via enteral and parenteral routes. Which client assessment is the most important for the nurse to check during the first 24-48 hours of administration? -serum albumin level and body weight -serum potassium and phosphate -symptoms of dumping syndrome -white blood cell count and neutrophils

-serum potassium and phosphate --Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients. The client's lack of oral intake results in the pancreas making less insulin. After the client receives food or IV fluids with glucose, insulin secretion is increased, leading to phosphorous, potassium, and magnesium shifting intracellularly. Phosphorus is the primary deficient electrolyte as it is required for energy. Hypophosphatemia causes muscle weakness and respiratory failure. Deficiencies in potassium and magnesium potentiate cardiac arrythmias. Therefore, aggressive initiation of nutrition without adequate electrolyte repletion can quickly precipitate cardiopulmonary failure. --Daily weights and periodic serum albumin level are indicated to evaluate the efficacy of nutritional replenishment, but is not the most important --dumping syndrome is seen after surgery for stomach cancer or bariatric surgery, which results in decreased storage area in the stomach. It is not seen with anorexia

The nurse is providing care for a client with Alzheimer disease who often becomes angry and agitated 20 mintues or more after eating. The client accuses the nurse of not providing food, saying "I'm hungry. You didn't feed me". The nurse should take which action? -give the client gentle reminders that the client has already eaten -say that the client can have a snack in a couple of hours -serve the client half of the meal initially and off the other half later -take a picture of the client having a meal and show it when the client becomes upset.

-serve the client half of the meal initially and off the other half later --Most clients with Alzheimer disease experience eating and nutritional problems throughout the course of their disease. During the earlier stages, it is common for clients to forget that they have eaten recently. The best approach is for caregivers to give clients something to eat when they say they are hungry. Smaller meals throughout the day, along with low-calorie snacks, are effective strategies for clients who forget that they have eaten. --showing a picture of the client having a meal is confrontational and will have no meaning to the client.

manifestations of tumor lysis syndrome

-severe electrolyte abnormalities (increased potassium, phosphorus, and uric acid with decreased calcium) -AKI -cardiac arrhythmias

The nurse is reinforcing education to a client with irritable bowel syndrome who is experiencing diarrhea. Which of these meals selected by the client indicates an understanding of diet management? -beans, yogurt, and a fruit cup -beef, broccoli, and a glass of wine -eggs, a bagel, and black coffee -steak, tomato basil soup, and cornbread

-steak, tomato basil soup, and cornbread --IBS is a common, chronic bowel condition caused by altered intestinal motility. Peristaltic action is affected, causing diarrhea, constipation, or a combination of both. Management focuses on reducing diarrhea or constipation, abdominal pain, and stress. Clients can manage symptoms with diet, medications, exercise, and stress management. To manage IBS, clients should restrict gas-producing foods, caffeine, alcohol, and other GI irritants. Clients should gradually increase fiber intake as tolerated. Foods that are generally well tolerated include proteins, breads, and bland foods.

A client with a 10-year history of unipolar major depression has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb but weighed 150 lb 3 months prior to admission. Which foods would be best for this client? -crackers and cheddar cheese -hard-boiled egg with tomatoes -steamed fish and potatoes -tortilla chips with avocado dip

-steamed fish and potatoes --reduced appetite and significant, unintentional weight loss are included in the diagnostic criteria for unipolar major depression. A 35 lb weight loss within 3 months is a 23% change in this client's usual body weight and is considered severe weight loss. The client needs a diet high in calories and protein to promote adequate nutrition and weight gain. In addition, the client has a diagnosis of depression and may have a low energy level; providing foods that are easier to chew and swallow may be better choices for promoting intake.

The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)? -consume a low-fat, low-salt diet -do not smoke cigarettes -exercise and lose weight -take prescribed antihypertensive medications

-take prescribed antihypertensive medications --risk factors for stroke include diabetes, high cholesterol, hypertension, smoking, obesity, older age, and genetic susceptibility. The single most important modifiable risk factor is hypertension. Stroke risk can be reduced up to 50% with appropriate treatment of hypertension. Because clients often experience side effects from the antihypertensive medications and do not feel bad with untreated hypertension, they may not realize that it is essential to continue the medications. The nurse should therefore emphasize this point.

Preprocedure instructions for a barium enema includes

-taking a cathartic (magnesium citrate, polyethylene glycol) to empty the stool from the colon -follow a clear liquid diet the day before the procedure to aid in bowel preparation and to prevent dehydration; avoid red/purple liquids -do not eat or drink anything 8 hour before the test -expect to be placed in various positions during the procedure. Abdominal cramping and the urge to defecate may be experienced

A client comes to the clinic for a follow-up visit after a Billroth II surgery (gastrojejunostomy). The client reportsoccasional episodes of sweating, palpitations, and dizziness 30 minutes after eating. Which nursing action is most appropriate? -check serum blood glucose for hypoglycemia -ensure that the client consumes fluids with meals -take the client's blood pressure while lying and standing -teach the client to lie down after eating

-teach the client to lie down after eating --Billroth II surgery removes part of the stomach and shortens the upper GI tract. After a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, N/V, dizziness, generalized sweating, and tachycardia. To reduce to occurrence of symptoms, clients should avoid fluids with meals and lie down after eating to slow gastric emptying. An upright or sitting position increases the force of gravity, which increases the rate of gastric emptying.

Describe the prodromal phase of a seizure

period with warning signs that precede the seizure. This phase occurs before the aural phase

The nurse is caring for a client with acute pancreatitis admitted 2 days ago. Which assessment finding is most concerning? -blood glucose levels for the past 24 hours are >250 mg/dL -client is lying with knees drawn up to the abdomen to alleviate pain -five large, liquid stools that are yellow and foul-smelling -temperature of 102.2 F with increasing abdominal pain

-temperature of 102.2 F with increasing abdominal pain --Clients with acute pancreatitis are at risk for pancreatic abscess development. This mainly results from secondary infection of pancreatic pseudocysts or pancreatic necrosis. High fever, leukocytosis, and increasing abdominal pain may indicate abscess formation. The abscess must be treated promptly to prevent sepsis. The HCP should be notified immediately as antibiotic therapy and immediate surgical management may be required. --Clients with acute pancreatitis are expected to have an elevated blood glucose. --Clients with acute pancreatitis often report severe, burning midepigastric abdominal pain that radiates to the back. Clients may seek relief from pain by positioning themselves in the knee-chest position, which decreases intra-abdominal pressure. --The client with pancreatitis may develop steatorrhea due to decrease in lipase production.

The ED nurse is triaging clients. Which neurologic presentation is most concerning for a serious etiology and should be given priority for definitive treatment? -history of Bell's palsy with unilateral facial droop and drooling -history of multiple sclerosis and reporting recent blurred vision -reports unilateral facial pain when consuming hot foods -temple region hit by ball, loss of consciousness, but GCS is now 14

-temple region hit by ball, loss of consciousness, but GCS is now 14 --Epidural hematoma is an accumulation of blood between the skull bone and dura mater. The majority of epidural hematomas are associated with fracture of the temporal bone and subsequent rupture or tear of the middle meningeal arterty. The bleed is arterial in origin, and so hematoma develops quickly. The clinical presentation of epidural hematoma is characteristic. The client may lose consciousness at the time of impact. The client then regains consciousness quickly and feels well for some time after the injury. This transient period of well-being is called a lucid interval. It is followed by a quick decline in mental function that can progress into coma and death.

The family practice clinic nurse is conducting client intake histories. Which client findings or histories indicate a need for heightened concern that the client may have cancer? SATA -the 60-year-old client was just diagnosed with benign prostatic hyperplasia -the client reports a mobile, golf ball-sized lesion under the skin over the right thigh that feels doughy -the client reports a nagging cough with hoarseness for the past 3 months -the female client who weight 150 lb has lost 15 b in 3 months without dieting -the male client reports a skin change on the breast that looks like an orange peel

-the client reports a nagging cough with hoarseness for the past 3 months -the female client who weight 150 lb has lost 15 b in 3 months without dieting -the male client reports a skin change on the breast that looks like an orange peel --Signs of potential cancer include unplanned weight loss, nagging cough/hoarseness, and dimpled skin on the breast. Hard, fixed masses, non-healing ulcers, and changing moles may also indicate malignancy and require further workup. Lymphomas are benign, fatty masses and rarely become malignant. They are subcutaneous, ave a soft doughy feel, and are mobile and asymptomatic.

The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale? -the nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain" -The nurse asks the client what day it is and the client says "banana". The nurse scores verbal response as "Confused" -the nurse speaks with client and then the client's eyes open. The nurse scores eye opening as "spontaneous" -the nurse walks in the room and the client states "Hi honey, how are you?" The nurse scores verbal response as "oriented"

-the nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain" --The GCS is used to determine LOC. The nurse follows a standardized assessment to determine the score of the client's eye opening response, verbal response, and ability to obey a command. If there is no response, the nurse next uses noxious stimuli and records the physical response. If the client tries to remove the painful stimulus, it is recorded as "localized" or moving toward the pain; whereas if the client retracts from the stimulus, it is recorded as "withdrawal".

The HCP prescribes a multivitamin regimen that includes thiamine for a client with a hx of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose? -to lower the blood alcohol level -to prevent gross tremors -to prevent Wernicke encephalopathy -to treat seizures related to acute alcohol withdrawal

-to prevent Wernicke encephalopathy --Clients with chronic alcohol abuse suffer from poor nutrition related to improper diet and altered nutrient absorption. Poor thiamine intake and/or absorption can lead to Wernicke encephalopathy, a serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Clients are prescribed thiamine to prevent this condition.

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? SATA -identify the number "8" traced on the palm -shrug the shoulders against resistance -swallow water -touch each finger of one hand to the hand's thumb -walk heel-to-toe

-touch each finger of one hand to the hand's thumb -walk heel-to-toe --The cerebellum is involved in 2 major functions: coordination of voluntary movements and maintenance of balance and posture. Maintenance of balance is assessed with gait testing and includes watching the client's normal gait first and then the gait on heel-to-toe, on toes, and on heels. Coordination testing involves the following: Finger tapping, rapid alternating movements, finger-to-nose testing, and heel-to-skin testing. --identifying a tracing on the palm is an example of testing sensory function, specifically fine touch. -shrugging the shoulders against resistant is an example of testing cranial nerve XI (spinal accessory). --swallowing water is an example of assessing CN IX (glossophrayngeal) and CN X (vagus)

Basic supportive care for toxic epidermal necrolysis

-wound care: sterile, moist dressings are applied to open areas of skin -infection prevention: strict sterile technique and reverse isolation decrease infection risk -fluids and nutrition: vital signs and urine output are monitored for signs of hypovolemia. oral feedings should be initiated early to promote wound healing; NG tube may be needed -hypothermia prevention: maintain room temperature 85 and higher -pain management: analgesics are administered around the clock and before painful procedures -eye care: sterile, cool compresses are applied to relieve discomfort. Lubricants may relieve dryness and prevent corneal abrasion

A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock? -jugular venous distension -mean arterial blood pressure 65 mm Hg -urine output <0.5 mL/kg/hr -warm, flushed skin

-urine output <0.5 mL/kg/hr --Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute or a relative fluid loss. Reduced intravascular volume results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism. Decreased urine output despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function.

The nurse is caring for a client with left-sided weakness from a stroke. When assisting the client to a chair, what should the nurse do? -bend at the waist -keep the feet close together -pivot on the foot proximal to the chair -use a transfer belt

-use a transfer belt --A transfer belt worn around the client's waist allows the nurse to assist the client while maintaining proper body mechanics and safety. --the nurse using proper body mechanics would pivot on the foot distal to the chair.

Which of the following diets would place aclient at the highest risk for macrocytic anemia? -lacto-ovo-vegetarian -lacto-vegetarian -macrobiotic -vegan

-vegan --megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 includes meat, fish, poultry, egg, and milk. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products from their diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective? -abdominal circumference reduced from admission recording -flapping tremor no longer visible with arm extension -shortness of breath no longer experienced in supine position -vital signs remain within the client's normal parameters

-vital signs remain within the client's normal parameters --Ascites is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis. Ascitic fluid increases abdominal pressure, resulting in weight gain, abdominal distension and discomfort, and shortness of breath. Paracentesis is often performed to reduce symptoms of ascites. However, clients undergoing paracentesis must be monitored closely for hypotension as changes in abdominal pressure often result in systemic vasodilation. Clients may receive IV albumin after paracentesis, which increases intravascular oncotic pressure resulting in increased intravascular fluid volume. Albumin administration prevents hypotension and tachycardia by irrigating hemodynamic changes associated with paracentesis. --Asterixis occurs due to elevated blood ammonia levels. Lactulose is commonly used to treat asterixis as it promotes ammonia excretion. Albumin does not affect ammonia excretion.

A parent calls the nursing triage line during the evening. The parent says that a 7-year-old was found playing in an area with poison ivy and asks what to do. Which is the most important instruction to give the parent? -apply cool, wet compresses for itching -apply topical cortisone ointment to the area -discourage the child from scratching the area -wash the skin where the contact occurred.

-wash the skin where the contact occurred. --Poison ivy can cause a contact dermatitis rash in those who are sensitive to the oily resin found on the leaves, stems, and roots of the plant. About 50% of people who come in contact with the plant develop a rash. It is often linear in appearance where the plant brushed against the skin. The rash develops 12-48 hours after exposure and can last for several weeks. The severity of the rash depends on the amount of resin on the skin. It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of the body.

Ways to prevent thrombus

-wearing graduated compression stockings -elevating legs when sitting -maintaining adequate hydration

An 80-year-old client has been hospitalized with pneumonia and malnutrition. Physical assessment findings include weakness and decreased muscle mass. Which finding best indicates that the client is responding to treatment? -client consuming 90% of each meal -serum albumin of 3.6 g/dL -weight gain of 2 lbs in 2 weeks -white blood cell count of 15,000/mm3

-weight gain of 2 lbs in 2 weeks --Malnutrition occurs due to inadequate intake of major nutrients or micronutrients. As malnutrition worsens and protein intake is reduce, muscles become fatigued and weak. Clinical manifestations depend on the severity of the malnutrition, ranging from mild to extreme. Weight gain is the best indicator that the client is responding to medical nutritional therapy. --consuming 90% of meals indicates that the client's appetite is good or improving, but does not provide conclusive evidence of an improved nutritional status. -although a serum albumin level of 3.6 g/dL is within the normal range of 3.5-5.0 g/dL, visceral protein stores are poor indicators of nutritional status in acute and chronic disease. During an inflammatory response (pneumonia), protein synthesis by the liver is decreased. Serum albumin has a long half-life, so laboratory levels may not reflect the change in nutritional status for over 2 weeks. Prealbumin has a half-life of only 2 days and is quicker and more reliable than serum albumin as an indicator of acute change in nutritional status -a while blood cell count of 15,000/mm3 is elevated, which indicates that the infection has not resolved.

Lifestyle and dietary measures that may prevent GERD and associated symptoms

-weight loss (excessive abdominal fat may increase gastric pressure) -small, frequent meals with sips of water or fluids (helps facilitate the passage of stomach contents into the small intestine and prevent reflux from becoming overly full during meals) - Avoiding GERD triggers (caffeine, alcohol, nicotine, high-fat foods, chocolate, spicy foods, peppermint, and carbonated beverages) -chewing gum (promotes salivation, which may help neutralize and clear acid from the esophagus) -sleeping with the head of the bed elevated -refraining from eating at bedtime and/or lying down immediately after eating

Oculomotor assessment

pupil constriction and extraocular movements

An adult client was severely burned in a warehouse accident. The client has sustained partial-thickness burns to the back and to the anterior and posterior surfaces of the right arm and leg. Using the rule of nines, what percentage of the client's body surface area is burned?

36%

CN X

Vagus

What is a classic sign of cyanide poisoning?

bitter almond smell on client's breath

Facial nerve assessment

facial movements (close eyes, smile)

Risk factors for skin cancer includes:

family or personal history of skin cancer -celtic ancestry traits (light skin, red/blonde hair, blue/green eyes, freckles) -aging -atypical or high number of moles -immunosuppression (lowers body's ability to defend against cancerous mutations) -ultraviolet light exposure

What type of fluid is 5% dextrose in water?

isotonic solution HOWEVER, it behaves as a hypotonic solution due to dextrose metabolizing in the body and water being released into the tissues.

Where is the most common area for diverticula to develop?

left (descending, sigmoid) colon

Describe a rash caused from poison ivy

linear in appearance

Describe the diet for a client with hepatitis

low fat, small, frequent meals (decreases nausea and promote intake with anorexia) --promote water consumption and diets adequate in carbs and calories

Define neutropenia

low white blood cell count

Rehabiliation phase of burn treatment is aimed at improving...

mobility and independence

Describe the aural phase of a seizure

period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure