Med surge Final Exam review – Flashcards
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The Client underwent cataract removal with an intraocular lens implant. The nurse is giving discharge instructions. Which instructions should the nurse include? a. Avoid straining during bowel movement or bending at the waist. b.Avoid lifting objects that weigh more than 5 lbs. c. Lie on your abdomen in bed d. Keep rooms brightly lit.
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(A)
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A client is being discharged after successful same day cataract surgery. The nurse instructs client about permitted activities and activities to avoid. What activity is permitted? a. Vacuuming b. Cooking c. Washing hair in the shower d. Driving
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(B) Cooking will not cause increased intraocular pressure.
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A nurse is caring for a client with Glaucoma who has gradually lost his eye sight.. Where should the nurse position herself to help the client walk? a. slightly in front of the client, offering an elbow for the client to hold b. Next to the client offering an elbow for the client to hold c. slightly in front of the client grasping the clients elbow?
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(A)
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A nurse is performing dressing change on a client with a red, granulating foot ulcer. Which action is part of this procedure? a. Fully cleaning the ulcer vigorously b. Cleaning the wound with normal saline solution c. Performing wet-to-dry dressing change d. Applying a dry gauze dressing change
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(B) A well granulating foot ulcer is healing well and should be cleaned with a normal saline solution.
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A nurse is performing an admission assessment. What finding on a patient indicates an increased risk for skin cancer? a. Dark mole on the back b. white, irregular patches on the arm c. A deep sunburn d. an irregular scar on the abdomen
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(C) A deep sunburn is a risk factor for skin cancer
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A nurse is teaching a client with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates the teaching has been effective. a. "I'll eat plenty of fruits and vegetables" b. "my foot should feel cold" c. "I'll make sure that my bandage is wrapped tightly" d. "I'll limit my intake of protein"
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(A) For effective tissue healing, adequate intake of protein, vitamins A, B, complex C,D,E, and K are needed.
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To promote healing by secondary intention, a nurse packs a clients wound with medicated dressings. When evaluating the wound, which finding indicates that the healing is taking place? a. The wound drainage is serous b. the surrounding tissue is red in color c. The granulation tissue is at the wound edges d. The skin around the wound is edematous
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(C) Connective tissue develops and fills in the wound edges from granulation tissue. Thus, evidence of granulation tissue indicates wound healing.
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When changing the dressing on a pressure ulcer, a nurse notes that the wound has necrotic tissue on the edges. Which action should the nurse anticipate the physician to order? a. Incision and Drainage b. Irrigation c. Debridement d. Culture
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(C) Because Necrotic tissue wont allow the wound to heal, it must be removed. This is accomplished by debridement.
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A client has conductive hearing loss caused by otosclerosis and has repeatedly refused surgery. To facilitate communication with the client, the nurse should: a. Say the clients name loudly before starting to talk b. Use exaggerated lip and mouth movements when talking c. Stand in front of a light or window when speaking d. Sit or stand in front of the client when speaking
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(D) Standing directly in front of a hearing impaired client allows him to lip read and see facial expressions that offer cues to whats being said.
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A client on prolonged bed rest has developed a pressure ulcer.The wound shows no sign of healing even though the client has received skin care and has been turned every two hours. Which intervention should the nurse use in the care plan for her client? a. Give protein shakes in between meals b. massage the area hourly c. Increase vitamin d intake d. Give calcium carbonate with meals
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(A) Protein loss is accelerated in an inflammatory state, therefor protein intake must increase for wound healing
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A nurse is giving home care instructions on a client who just had cataracts removed and an intraocular lens implanted. What should the nurse tell the client? a. Wear the eye shield continuously for 2 weeks. b. Don't sleep on the operated side c. Straining during bowel movements is allowed d. Aspirin may be taken for mild pain
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(B) avoid sleeping on the operated side as well as lifting heavy objects or straining, all of which could cause bleeding in the eye. Because of its anti coagulant properties, aspirin should be avoided for the same reason.
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A client has a history of Asthma, Epilepsy, Glaucoma, and Hypothyroidism. Which of these disorders contradict the use of antichloinergics ? a. Asthma b. Epilepsy c. Glaucoma d. Hypothyroidism
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(C) Antichloinergics are contradicted in patients with Glaucoma and hyperthyroidism. These drugs are sometimes used to treat chronic asthma, epilepsy and hypothyroidism.
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A nurse is providing care for a client who has sacral pressure ulcer with a wet-to-dry saline dressing. Which guideline is appropriate use for a wet-to-dry dressing? a. The wet-to-dry dressing should be tightly packed into the wound b. The dressing should be allowed to be dried out before removal. c. A plastic sheet-type dressing should cover the wet dressing d. The wound should remain moist from the dressing
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(B) A wet-to-dry saline dressing should be allowed to dry out before removal to help mechanically debride the wound. If the dressing remains moist, this would not occur. Tight package, or dry package can cause tissue damage or pain. A dry guaze should cover the wet dressing.
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A clients blood glucose is 45mg/dl. The patient is alert and oriented. The nurse should next: a. Give the client 4 to 6 oz of orange juice b. Recheck the clients blood glucose in 15 min. c. Give the client cheese and crackers d. Administer Dextrose 50% IV
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(A)
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A nurse is developing a teaching plan for a client diagnosed with Diabetes Insipidus. The nurse should include information about which hormone, commonly lacking in patients with Diabetes Insipidus? a. Luteinizing Hormone (LH) b. Follicle-stimulating Hormones (FSH) c. Thyroid-stimulating Hormones (TSH) d. Antidiueretic hormone (ADH)
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(D) ADH is the hormone lacking in diabetes insipidus.
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A nurse is caring for a patient with type 1 diabetes mellitus who exhibits confusion, lightheadedness, and aberrant behavior. The client is still conscience. The nurse should at first administer: a. I.M or subcutaneous glucagen b. 15 to 29 grams of fast acting carbohydrates c. 10 units of fast acting insulin d. An IV bolus of Dextrose 50%
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(B) The client is experiencing a hypoglycemic episode. Because the client is conscience, the nurse should first administer a fast acting carb. such as orange juice, hard candy, or honey. If the client has lost consciousness, then the nurse should administer I.M or subcutaneous glucagen or an IV bolus of dextrose 50 % . You should not administer insulin to a patient experiencing a hypoglycemic episode.
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A client tells a nurse that she has been working hard for the past three months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the clients efforts, the nurse should check: a. Glycosylated hemoglobin level b. Urine glucose level c. Fasting blood glucose level d. Serum fructosamine
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(A) Glycosylated hemoglobin level provide information about blood glucose levels for the past three months.
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The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply. a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Decreased oxygen saturation with mild exercise d. A widened diaphragm noted on the chest x-ray e. Pulmonary function tests that demonstrate increased vital capacity
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(b,c) Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.
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The nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to promote which outcome? a. Promote oxygen intake b. Strengthen the diaphragm c. Strengthen the intercostal muscles d. Promote carbon dioxide elimination
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(D) Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.
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The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? a. 1 minute b. 5 seconds c.10 seconds d.30 seconds
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(C) Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
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The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate
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(D) The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body.
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A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? a. Hot, flushed feeling b.Sudden chills and fever c. Chest pain that occurs suddenly d. Dyspnea when deep breaths are taken
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(C) The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis
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A client who is human immunodeficiency virus (HIV)-positive has had a tuberculin skin test (TST). The nurse notes a 7-mm area of induration at the site of the skin test and interprets the result as which finding? a. Positive b. Negative c. Inconclusive d. Need for repeat testing
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(A) The client with human immunodeficiency virus (HIV) infection is considered to have positive results on tuberculin skin testing with an area of induration larger than 5 mm. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor.
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An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? a. Face tent b. Venturi mask c. Aerosol mask d. Tracheostomy collar
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(B) The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration.
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The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? a. Sitting up in bed b. Side-lying in bed c.Sitting in a recliner chair d.Sitting on the side of the bed and leaning on an overbed table
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(D) Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.
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A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? a. Regular insulin b. Glipizide (Glucotrol) c. Repaglinide (Prandin) d.Metformin (Glucophage)
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(D) Metformin (Glucophage) needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization.
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A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often at rest in the absence of precipitating factors. How would the nurse best describe this type of anginal pain? a. Stable angina b. Variant angina c. Unstable angina d. Nonanginal pain
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(B) Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. Stable angina is induced by exercise and relieved by rest or nitroglycerin tablets. Unstable angina occurs at lower levels of activity or at rest, is less predictable, and is often a precursor of myocardial infarction.
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A client is admitted to the emergency department following a motor vehicle accident. The client was wearing a lap seat belt when the accident occurred and now the client has hematuria and lower abdominal pain. To assess further whether the pain is caused by bladder trauma, the nurse should ask the client if the pain is referred to which area? a. Hip b. Shoulder c. Umbilicus d. Costovertebral angle
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(B) Bladder trauma or injury is characterized by lower abdominal pain that may radiate to one of the shoulders due to phrenic nerve irritation.
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The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? a. Avoid overuse of the eyes. b. Decrease the amount of salt in the diet. c. Eye medications will need to be administered for life. d. Decrease fluid intake to control the intraocular pressure
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(C) The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life
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The nurse is performing an assessment on a client with a suspected diagnosis of cataract. What is the chief clinical manifestation that the nurse expects to note in the early stages of cataract formation? a. Diplopia b. Eye pain c. Floating spots d. Blurred vision
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(D) A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perception.
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The nurse is preparing a teaching plan for a client who is undergoing cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? Select all that apply: a. Avoid activities that require bending over. b. Contact the surgeon if eye scratchiness occurs. c. Place an eye shield on the surgical eye at bedtime. d. Episodes of sudden severe pain in the eye are expected. e. Contact the surgeon if a decrease in visual acuity occurs. f. Take acetaminophen (Tylenol) for minor eye discomfort.
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(a,c,e,f) Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure, such as bending over.
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The nurse notes that the health care provider has documented a diagnosis of presbycusis on a client's chart. The nurse understands that which describes this condition? a. Tinnitus that occurs with aging b. Nystagmus that occurs with aging c. A conductive hearing loss that occurs with aging d. A sensorineural hearing loss that occurs with aging
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(D) Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.
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A client with Ménière's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? a. Increase sodium in the diet. b. Avoid sudden head movements. c. Lie still and watch the television. d. Increase fluid intake to 3000 mL a day.
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(B) The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and watching television will not control vertigo
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A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which should the nurse specifically observe in the postoperative period? a. Hemorrhage b. Edema of the residual limb c. Slight redness of the incision d. Separation of the wound edges
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(D) Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative edema of the residual limb and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation.
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The client with acquired immunodeficiency syndrome is diagnosed with cutaneous Kaposi's sarcoma. Based on this diagnosis, the nurse understands that this has been confirmed by which finding? a. Swelling in the genital area. b. Swelling in the lower extremities c. Positive punch biopsy of the cutaneous lesions. d. Appearance of reddish-blue lesions noted on the skin
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(C) Kaposi's sarcoma lesions begin as red, dark blue, or purple macules on the lower legs that change into plaques. These large plaques ulcerate or open and drain. Diagnosis is made by punch biopsy of cutaneous lesions and biopsy of pulmonary and gastrointestinal lesions.
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The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? a. "I will handle the area gently." b. "I will wear loose-fitting clothing." c. "I will avoid the use of deodorants." d. "I will limit sun exposure to 1 hour daily."
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(D) The client needs to be instructed to avoid exposure to the sun. Because of the risk of altered skin integrity, options 1, 2, and 3 are accurate measures in the care of a client receiving external radiation therapy.
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A client is diagnosed with glaucoma. Which nursing assessment data identifies a risk factor associated with this eye disorder? a. Cardiovascular disease b. Frequent urinary tract infections c. A history of migraine headaches d. Frequent upper respiratory infection
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(A) Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma.
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The nurse is providing instructions to the client receiving external radiation therapy. Which statement, if made by the client, indicates the need for further instruction? a. "I will dry affected areas with patting motions." b. "I will wear soft clothing over the affected site." c. "I will use a washcloth to wash the affected area." d. "I need to make sure I carry my purse on the unaffected side."
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(C) External radiation therapy requires markings to be placed on the skin so that therapy can be aimed at the affected areas. The hand rather than a washcloth should be used to wash the area to avoid irritation. The nurse should instruct the client undergoing external radiation therapy to dry affected areas with a patting (rather than rubbing) motion so as not to disrupt the markings on the skin. Soft clothing should be worn so that the affected area is not irritated. The client should be sure to carry her purse on the unaffected side.
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A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL. Which intervention should the nurse anticipate to be initially prescribed for the client? a. Glucagon via the subcutaneous route b. Glyburide (DiaBeta) via the oral route c. Humulin N insulin via the subcutaneous route d. Humulin R insulin via the intravenous (IV) route
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(D) The client is most likely in diabetic ketoacidosis (DKA). Humulin R insulin via the IV route is the preferred treatment for DKA. Humulin R insulin is a short-acting insulin and can be given intravenously; it is titrated to the client's high blood glucose levels. Glucagon is used to treat hypoglycemia, and glyburide is an oral hypoglycemia agent used to treat diabetes mellitus type 2. Humulin N insulin is an intermediate-acting insulin and is not appropriate for the emergency treatment of DKA.
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The nurse in the health care clinic is providing instructions to a client regarding the use of a hearing aid. Which statement is most appropriate for the nurse to include? a. "The hearing aid should not be worn if an ear infection is present." b. "The ear mold for the hearing aid should be washed with mild soap and water once a month." c. "The hearing aid should be removed from the ear at the end of the day and then turned off after removal." d. "The hearing aid contains a lifelong battery, so you will not need to be concerned about changing batteries."
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(A) The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should wash the ear mold frequently with mild soap and water and use a pipe cleaner to clean the cannula of the hearing aid. The client should be instructed to turn the hearing aid off before removing it from the ear to prevent any squealing feedback. The hearing aid should be turned off when not in use, and the client should keep extra batteries on hand at all times.
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The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? a. Bananas b. Broccoli c. Antacids d. Cantaloupe
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(C) The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.
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rosiglitazone (Avandia)
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Thiazolidinediones: "Insulin sensitizers" (Taken orally) ...most effective for people who have insulin resistance. Because thiazolidinediones do not increase insulin production, Avandia does not cause hypoglycemia when used alone. These drugs are rarely used today because of their adverse drug effects Black Box Warning: May cause or exacerbate congestive heart failure.
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nicardipine (Cardene)
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Anti-hypertensive drug/Calcium Channel Blocker : Used for hypertensive crisis in hospitalized patients. When administered IV, asses patients blood pressure and pulse every 2-3 minuets during initial administration of the drug. Monitor the ECG for heart dysrhythmias and signs of ischemia or MI . Use extreme caution in patients with CAD or cerebrovascular disease. Measure urine output hourly. CHANGE PERIPHERAL IV INFUSION SITE EVERY 12 HOURS TEACH PATIENT: Change position slowly (may cause orthostatic hypotension). Avoid alcohol, grapefruit juice, limit caffeine. Avoid tasks requiring motor skills, alertness until response to drug is stable.
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ramipril (Altace)
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ACE inhibitor: used for treating high blood pressure, heart failure and for preventing kidney failure due to high blood pressure and diabetes. The effects of ACE inhibitors are particularly beneficial to people with congestive heart failure. PATIENT TEACHING:Do not use with salt substitute . Change position slowly (may cause orthostatic hypotension, Can cause dry hacking cough).
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The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? a. Listening to lung sounds b. Monitoring for organomegaly c. Assessing for jugular vein distention d. Assessing for peripheral and sacral edema
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(A) The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function
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The nurse is reviewing the electrocardiogram (ECG) rhythm strip obtained on a client with a diagnosis of myocardial infarction. The nurse notes that the PR interval is 0.20 second. The nurse should make which interpretation about this finding? a. A normal finding b. Indicative of atrial flutter c. Indicative of atrial fibrillation d. Indicative of impending reinfarction
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(A) The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. Options 2, 3, and 4 are incorrect.
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A client reports to the health care clinic for an eye examination, and a diagnosis of macular degeneration is made. Which nursing assessment question will most specifically elicit information regarding the clinical manifestations associated with this disorder? a. "Do bright lights bother you?" b. "Do you have any pain in your eye?" c. "Have you had any blurred vision?" d. "Are you having difficulty seeing things out of the sides of your eyes?"
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(C) Blurred central vision occurs with macular degeneration. Glare from bright lights is a common complaint in the client with a cataract. Pain in the eye is not specifically associated with macular degeneration. Changes in peripheral visual acuity most often occur with glaucoma.
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A clinic nurse is reviewing the record of a client with a diagnosis of a cataract. Which clinical manifestation is associated with this disorder? a. Eye pain b. Opacity of the lens c. Loss of central vision d. Inability to identify the color red on an eye examination
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(B) A cataract is an opacity of the lens of the eye. The classic symptom of a cataract is painless, progressive loss of peripheral vision in one or both eyes. Many affected persons complain of glare from bright lights. Color blindness is not an associated symptom.
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A client comes to the hospital emergency department complaining of redness and pain on the lower eyelid. A diagnosis of hordeolum is made. The nurse provides instructions to the client regarding measures to treat the disorder. Which statement made by the client would best indicate an understanding of these home care treatment measures? a. "Antibiotic ointments will not help this condition." b. "I should apply cool compresses to the eye three times a day." c. "I should apply warm compresses to the eye for 15 minutes four times a day." d. "When the hordeolum comes to a head, I should try to press it to make it open and drain."
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(B) Hordeolum is commonly known as a stye, and therapeutic management includes the application of warm compresses for 15 minutes four times a day and the instillation of an ophthalmic antibiotic ointment to combat the causative infectious organism and prevent the spread of infection to surrounding lid glands. Warm compresses promote comfort and aid in bringing purulent contents to a head, causing rupture with drainage. The client should not press or squeeze the stye to produce rupture because this pressure could force infectious material into the venous system, potentially transmitting infection to the brain.
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The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding should the nurse expect to note in this client? a. Dry skin b. Thin, silky hair c. Bulging eyeballs d. Fine muscle tremors
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(A) Myxedema is a deficiency of thyroid hormone. The client will present with a puffy, edematous face, especially around the eyes (periorbital edema), along with coarse facial features, dry skin, and dry, coarse hair and eyebrows. Options 2, 3, and 4 are noted in the client with hyperthyroidism.
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The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should the nurse expect to note in this client? a. "I will check my blood glucose level every day at 5:00 pm." b. "I will check my blood glucose level 1 hour after each meal." c. "I will check my blood glucose level 2 hours after each meal." d. "I will check my blood glucose level before each meal and at bedtime."
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(B) Hyperthyroidism is clinically manifested by goiter (increase in the size of the thyroid gland) and exophthalmos (bulging eyeballs). Other clinical manifestations include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. Additional signs found in this disorder include tachycardia; shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair and thin skin; infrequent blinking; and a staring appearance.
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The nurse has provided instructions for measuring blood glucose levels to a client newly diagnosed with diabetes mellitus who will be taking insulin. The client demonstrates understanding of the instructions by identifying which method as the best method for monitoring blood glucose levels? a. "I will check my blood glucose level every day at 5:00 pm." b. "I will check my blood glucose level 1 hour after each meal." c. "I will check my blood glucose level 2 hours after each meal." d. "I will check my blood glucose level before each meal and at bedtime."
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(D) The most effective and accurate measure for testing blood glucose is to test the level before each meal and at bedtime. If possible and feasible, testing should be done during the nighttime hours. Checking the level after the meal will provide an inaccurate assessment of diabetes control. Checking the level once daily will not provide enough data related to control the diabetes mellitus.
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The nurse is providing dietary instructions to help with diabetes control for a client newly diagnosed with diabetes mellitus who will be taking insulin. The nurse should provide the client with which best instruction? a. Eat meals at approximately the same time each day. b. Adjust meal times depending on blood glucose levels. c. Vary meal times if insulin is not administered at the same time every day. d. Avoid being concerned about the time of meals so long as snacks are taken on time.
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(A) Meal times must be approximately the same each day to maintain a stable blood glucose level. The client should not be instructed that meal times can be varied depending on blood glucose levels, insulin administration, or consumption of snacks.
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The nurse is reviewing the health care provider (HCP) prescriptions for a client with a diagnosis of diabetes mellitus who has been hospitalized for treatment of an infected foot ulcer. The nurse expects to note which finding in the HCP prescriptions? a. A decreased-calorie diet b. An increased-calorie diet c. A decreased amount of NPH daily insulin d. An increased amount of NPH daily insulin
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(D) Infection is a physiological stressor that can cause an increase in the level of epinephrine in the body. An increase in epinephrine causes an increase in blood glucose levels. When the client is under stress, such as when an infection is present, an increase in the dose of insulin will be required to facilitate the transport of excess glucose into the cells. The client will not necessarily need an adjustment in the daily diet.
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The nurse is monitoring a client with diabetes mellitus for signs of hypoglycemia. Which manifestations are associated with this complication? a. Slow pulse; lethargy; warm, dry skin b. Elevated pulse; lethargy; warm, dry skin c. Elevated pulse; shakiness; cool, clammy skin d. Slow pulse, confusion, increased urine output
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(C) Signs and symptoms of mild hypoglycemia include tachycardia, shakiness, and cool, clammy skin. Options 1, 2, and 4 do not specify the manifestations of hypoglycemia.
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The nurse is caring for a client who has been hospitalized with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L/min. The client asks why the oxygen is necessary. The nurse should provide which information to the client? a. Oxygen has a calming effect. b. Oxygen will prevent the development of any thrombus. c. Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle. d. The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells.
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(D) The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client.
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Cortisol (plasma) Blood test
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Levels of plasma cortisol are higher in the morning and lower in the afternoon. Test between 8 am-10 am (There is no food or fluid restriction). TEACH THE CLIENT: That he/she should be on bed rest 2 hours prior to test. Physical activity affects the cortisol level.It is recommended oral contraceptives are stopped two months prior to test because they can alter the results. Decreased levels: Assess for signs of Addison's disease. Increased levels: Assess for signs of Cushing's syndrome.
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Which assessment is of highest priority for the nurse to complete before administration of morphine? a. Pain rating b. Blood pressure c. Respiratory rate d. Level of consciousness
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(C) A decreased respiratory rate below 12/min is a sign of opioid toxicity. Using the ABC approach in prioritization of care, a patent airway is always the first priority and is important to assess as a baseline before and during the administration of morphine.
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The nurse should teach a patient to avoid which medication while taking ibuprofen? a. Aspirin b. Furosemide (Lasix) c. Nitroglycerin (Nitro-Bid) d. Morphine sulfate (generic)
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(A) The patient should not take aspirin while taking ibuprofen because the combination could increase the risk of GI bleeding
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Superficial Somatic Pain
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Pain arising from skin, mucous membranes, subcutaneous tissue or has the potential to do so if prolonged. Tends to be well localized EX: Sunburn, Skin Contusions
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Deep Somatic Pain
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Pain arising from muscles, fasciae, bones, tendons. It can be localized or diffused and radiating EX: Arthritis, tendonitis, mayofasical pain
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Neuropathic Pain
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Abnormal processing of sensory input by peripheral or central nervous system. Central Pain: post stroke, multiple sclerosis Peripheral Neuropathies (caused by damage to nerve): diabetic neuropathy, alcohol-nutritional neuropathy, trigeminal neuralgia, postherpetic neuralgia Deafferentation Pain: Phantom limb pain, post mastectomy pain, spinal cord injury pain
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Normal ABG Values
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pH: 7.35-7.45 PCO2: 35-45mm Hg PO2: 80 to 100 mm Hg HCO3: 21-28 mEq/L
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A male client is receiving chemotherapy for lung cancer. He asks the nurse how the drug will work. Which of the following is the correct response of the nurse? a. "Chemotherapy affects all rapidly dividing cells." b. "Structure of the DNA is altered." c. "Chemotherapy encourages cancer cells to divide." d. "Cancer cells have susceptible drug toxins."
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(A) There are many mechanisms of action for chemotherapeutic agents, but most affect the rapidly dividing cells-both cancerous and noncancerous. Cancer cells are characterized by rapid cell division. Chemotherapy slows cell division
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The nurse is writing the teaching plan for a client undergoing a radioactive iodine uptake test to study thyroid function. Which of the following instructions should the nurse include? a. "You need to stay at least 4 feet (1.2 m) away from other people after the test because you'll be radioactive." b. "You need to lie very still on a stretcher that is placed in a long tube for the scan" c. "Don't take any iodine or thyroid medication before the test." d. "Schedule the bone scans before your radioactive iodine uptake test."
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(C) Medications such as iodine, contrast media, and antithyroid and thyroid drugs can affect the test results and should be withheld by the client for a week or longer, as directed by the physician. During a radioactive iodine uptake test, the client receives radioactive iodine by mouth or I.V. in small doses and doesn't require isolation. During magnetic resonance imaging--not radioactive iodine uptake testing--a client needs to lie still inside a long tube. Any test, such as a bone scan, that requires iodine contrast media should be scheduled after the radioactive iodine uptake test because the iodinated contrast medium can decrease uptake.
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When teaching a patient infected with HIV regarding transmission of the virus to others, which statement made by the patient would indicate a need for further teaching? a. "I will need to isolate any tissues I use so as not to infect my family." b. "I will notify all of my sexual partners so they can get tested for HIV." c. "Unprotected sexual contact is the most common mode of transmission." d. "I do not need to worry about spreading this virus to others by sweating at the gym."
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(A) HIV is not spread casually. The virus cannot be transmitted through hugging, dry kissing, shaking hands, sharing eating utensils, using toilet seats, or attending school with an HIV-infected person. It is not transmitted through tears, saliva, urine, emesis, sputum, feces, or sweat
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The nurse is providing care for a patient who has been living with HIV for several years. Which assessment finding most clearly indicates an acute exacerbation of the disease? a. A new onset of polycythemia b. Presence of mononucleosis-like symptoms c. A sharp decrease in the patient's CD4+ count d. A sudden increase in the patient's WBC count
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(C) A decrease in CD4+ count signals an exacerbation of the severity of HIV. Polycythemia is not characteristic of the course of HIV. A patient's WBC count is very unlikely to suddenly increase, with decreases being typical. Mononucleosis-like symptoms such as malaise, headache, and fatigue are typical of early HIV infection and seroconversion.
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A pregnant woman who was tested and diagnosed with HIV infection is very upset. What should the nurse teach this patient about her baby's risk of being born with HIV infection? a. "The baby will probably be infected with HIV." b. "Only an abortion will keep your baby from having HIV." c. "Treatment with antiretroviral therapy will decrease the baby's chance of HIV infection." d. "The duration and frequency of contact with the organism will determine if the baby gets HIV infection."
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(C) On average, 25% of infants born to women with untreated HIV will be born with HIV. The risk of transmission is reduced to less than 2% if the infected pregnant woman is treated with antiretroviral therapy. Duration and frequency of contact with the HIV organism is one variable that influences whether transmission of HIV occurs. Volume, virulence, and concentration of the organism as well as host immune status are variables related to transmission via blood, semen, vaginal secretions, or breast milk.
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A 25-year-old male patient has been diagnosed with HIV. The patient does not want to take more than one antiretroviral drug. What reasons can the nurse tell the patient about for taking more than one drug? a. Together they will cure HIV. b. Viral replication will be inhibited. c. They will decrease CD4+ T cell counts. d. It will prevent interaction with other drugs.
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(B) The major advantage of using several classes of antiretroviral drugs is that viral replication can be inhibited in several ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance that is a major problem with monotherapy. Combination therapy also delays disease progression and decreases HIV symptoms and opportunistic diseases. HIV cannot be cured. CD4+ T cell counts increase with therapy. There are dangerous interactions with many antiretroviral drugs and other commonly used drugs.
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The nurse was accidently stuck with a needle used on an HIV-positive patient. After reporting this, what care should this nurse first receive? a. Personal protective equipment b. Combination antiretroviral therapy c. Counseling to report blood exposures d. A negative evaluation by the manager
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(B) Postexposure prophylaxis with combination antiretroviral therapy can significantly decrease the risk of infection. Personal protective equipment should be available although it may not have stopped this needle stick. The needle stick has been reported. The negative evaluation may or may not be needed but would not occur first.
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The HIV-infected patient is taught health promotion activities including good nutrition; avoiding alcohol, tobacco, drug use, and exposure to infectious agents; keeping up to date with vaccines; getting adequate rest; and stress management. What is the rationale behind these interventions that the nurse knows? a. Delaying disease progression b. Preventing disease transmission c. Helping to cure the HIV infection d. Enabling an increase in self-care activities
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(A) These health promotion activities along with mental health counseling, support groups, and a therapeutic relationship with health care providers will promote a healthy immune system, which may delay disease progression. These measures will not cure HIV infection, prevent disease transmission, or increase self-care activities.
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A 52-year-old female patient was exposed to human immunodeficiency virus (HIV) 2 weeks ago through sharing needles with other substance users. What symptoms will the nurse teach the patient to report that would indicate the patient has developed an acute HIV infection? a. Cough, diarrhea, headaches, blurred vision, muscle fatigue b. Night sweats, fatigue, fever, and persistent generalized lymphadenopathy c. Oropharyngeal candidiasis or thrush, vaginal candidal infection, or oral or genital herpes d. Flu-like symptoms such as fever, sore throat, swollen lymph glands, nausea, or diarrhea
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(D) Clinical manifestations of an acute infection with HIV include flu-like symptoms between 2 to 4 weeks after exposure. Early chronic HIV infection clinical manifestations are either asymptomatic or include fatigue, headache, low-grade fever, night sweats, and persistent generalized lympadenopathy. Intermediate chronic HIV infection clinical manifestations include candidal infections, shingles, oral or genital herpes, bacterial infections, Kaposi sarcoma, or oral hairy leukoplakia. Late chronic HIV infection or acquired immunodeficiency syndrome (AIDS) includes opportunistic diseases (infections and cancer)
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A 62-year-old patient has acquired immunodeficiency syndrome (AIDS), and the viral load is reported as undetectable. What patient teaching should be provided by the nurse related to this laboratory study result? a. The patient has the virus present and can transmit the infection to others. b. The patient is not able to transmit the virus to others through sexual contact. c. The patient will be prescribed lower doses of antiretroviral medications for 2 months d. The syndrome has been cured, and the patient will be able to discontinue all medications.
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(A) In human immunodeficiency virus (HIV) infections, viral loads are reported as real numbers of copies/μL or as undetectable. "Undetectable" indicates that the viral load is lower than the test is able to report. "Undetectable" does not mean that the virus has been eliminated from the body or that the individual can no longer transmit HIV to others.
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You are caring for a patient admitted with a diagnosis of chronic obstructive pulmonary disease (COPD) who has the following arterial blood gas results: pH 7.33, PaO2 47 mm Hg, PaCO2 60 mm Hg, HCO3 32 mEq/L, and O2 saturation of 92%. What is the correct interpretation of these results? a. Fully compensated respiratory alkalosis b. Partially compensated respiratory acidosis c. Normal acid-base balance with hypoxemia d. Normal acid-base balance with hypercapnia
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(B) A low pH (normal 7.35-7.45) indicates acidosis. In the patient with respiratory disease such as COPD, the patient retains carbon dioxide (normal 35-45 mm Hg), which acts as an acid in the body. For this reason, the patient has respiratory acidosis. The elevated HCO3 indicates a partial compensation for the elevated CO2.
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You are caring for a patient admitted with heart failure. The morning laboratory results reveal a serum potassium level of 2.9 mEq/L. Which classification of medications should you withhold until consulting with the physician? a. Antibiotics b. Loop diuretics Correct c. Bronchodilators d. Antihypertensives
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(B) Loop diuretics are contraindicated during episodes of hypokalemia because these medications cause the kidneys to excrete sodium and potassium. Thus administration of this type of medication at this time would worsen the hypokalemia, putting the patient at risk for dysrhythmias. The prescribing physician should be consulted for potassium replacement therapy, and the drug should be withheld until the potassium has returned to normal range.
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While caring for a patient with metastatic bone cancer, which clinical manifestations would alert the nurse to the possibility of hypercalcemia in this patient? a. Weakness b. Paresthesia c. Facial spasms d. Muscle tremors
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(A) Signs of hypercalcemia are lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting. Paresthesia, facial spasms, and muscle tremors are symptoms of hypocalcemia.
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While performing patient teaching regarding hypercalcemia, which statements are appropriate (select all that apply)? a. Have patient restrict fluid intake to less than 2000 mL/day. b. Renal calculi may occur as a complication of hypercalcemia. c. Weight-bearing exercises can help keep calcium in the bones. d. The patient should increase daily fluid intake to 3000 to 4000 mL. e. Treatment of heartburn can best be managed with Tums as needed.
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(B,C,D) A daily fluid intake of 3000 to 4000 mL is necessary to enhance calcium excretion and prevent the formation of renal calculi, a potential complication of hypercalcemia. Tums are a calcium-based antacid that should not be used in patients with hypercalcemia. Weight-bearing exercise does enhance bone mineralization.
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When assessing the patient with a multi-lumen central line, the nurse notices that the cap is off one of the lines. On assessment, the patient is in respiratory distress, and the vital signs show hypotension and tachycardia. What is the nurse's priority action? a. Administer oxygen. b. Notify the physician. c. Rapidly administer more IV fluid. d. Reposition the patient to the right side.
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(A) The cap off the central line could allow entry of air into the circulation. For an air emboli, oxygen is administered; the catheter is clamped; the patient is positioned on the left side with the head down. Then the physician is notified.
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You are admitting a patient with complaints of abdominal pain, nausea, and vomiting. A bowel obstruction is suspected. You assess this patient for which anticipated primary acid-base imbalance if the obstruction is high in the intestine? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
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(C)Because gastric secretions are rich in hydrochloric acid, the patient who is vomiting will lose a significant amount of gastric acid and be at an increased risk for metabolic alkalosis.
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The nurse is caring for a 76-year-old woman admitted to the clinical unit with hypernatremia and dehydration after prolonged fever. Which beverage would be safest for the nurse to offer the patient? a. Malted milk b. Orange juice c. Tomato juice d. Hot chocolate
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(B) Orange juice has the least amount of sodium (approximately 2 mg in 8 ounces). Hot chocolate has approximately 75 mg sodium in 8 ounces. Tomato juice has approximately 650 mg sodium in 8 ounces. Malted milk has approximately 625 mg sodium in 8 ounces
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The nurse on a medical-surgical unit identifies that which patient has the highest risk for metabolic alkalosis? a. A patient with a traumatic brain injury b. A patient with type 1 diabetes mellitus c. A patient with acute respiratory failure d. A patient with nasogastric tube suction
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(D) Excessive nasogastric suctioning may cause metabolic alkalosis. Brain injury may cause hyperventilation and respiratory alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis.
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A 46-year-old woman with a subclavian triple-lumen catheter is transferred from a critical care unit after an extended stay for respiratory failure. Which action is important for the nurse to take? a. Change the injection cap after the administration of IV medications. b. Use a 5-mL syringe to flush the catheter between medications and after use. c. During removal of the catheter, have the patient perform the Valsalva maneuver. d. If resistance is met when flushing, use the push-pause technique to dislodge the clot.
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(C) The nurse should withdraw the catheter while the patient performs the Valsalva maneuver to prevent an air embolism. Injection caps should be changed at regular intervals but not routinely after medications. Flushing should be performed with at least a 10-mL syringe to avoid excess pressure on the catheter. If resistance is encountered during flushing, force should not be applied. The push-pause method is preferred for flushing catheters but not used if resistance is encountered during flushing.
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To promote airway clearance in a patient with pneumonia, what should the nurse instruct the patient to do (select all that apply)? a. Maintain adequate fluid intake. b. Splint the chest when coughing. c. Maintain a 30-degree elevation. d. Maintain a semi-Fowler's position. e. Instruct patient to cough at end of exhalation.
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(A,B,E) Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.
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What is the priority nursing intervention in helping a patient expectorate thick lung secretions? a. Humidify the oxygen as able. b. Administer cough suppressant q4hr. c. Teach patient to splint the affected area. d. Increase fluid intake to 3 L/day if tolerated
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(D) Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.
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After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime (Ceftin) to the patient? a. Orthostatic blood pressures b. Sputum culture and sensitivity c. Pulmonary function evaluation d. Serum laboratory studies ordered for AM
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(B) The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime as this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic BP, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics
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Which position is most appropriate for the nurse to place a patient experiencing an asthma exacerbation? a. Supine b. Lithotomy c. High Fowler's d. Reverse Trendelenburg
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(C) The patient experiencing an asthma attack should be placed in high Fowler's position and may need to lean forward to allow for optimal chest expansion and enlist the aid of gravity during inspiration. The supine, lithotomy, and reverse Trendelenburg positions will not facilitation ventilation.
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The nurse is assigned to care for a patient in the emergency department admitted with an exacerbation of asthma. The patient has received a β-adrenergic bronchodilator and supplemental oxygen. If the patient's condition does not improve, the nurse should anticipate what as the most likely next step in treatment? a. IV fluids b. Biofeedback therapy c. Systemic corticosteroids d. Pulmonary function testing
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(C) Systemic corticosteroids speed the resolution of asthma exacerbations and are indicated if the initial response to the β-adrenergic bronchodilator is insufficient. IV fluids may be used, but not to improve ventilation. Biofeedback therapy and pulmonary function testing may be used after recovery to assist the patient and monitor the asthma.
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A patient with an acute exacerbation of chronic obstructive pulmonary disease (COPD) needs to receive precise amounts of oxygen. Which equipment should the nurse prepare to use? a. Oxygen tent b. Venturi mask Correct c. Nasal cannula d. Oxygen-conserving cannula
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(B) The Venturi mask delivers precise concentrations of oxygen and should be selected whenever this is a priority concern. The other methods are less precise in terms of amount of oxygen delivered.
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The physician has prescribed salmeterol (Serevent) for a patient with asthma. In reviewing the use of dry powder inhalers (DPIs) with the patient, what instructions should the nurse provide? a. "Close lips tightly around the mouthpiece and breathe in deeply and quickly." b. "To administer a DPI, you must use a spacer that holds the medicine so that you can inhale it." c. "You will know you have correctly used the DPI when you taste or sense the medicine going into your lungs." d. "Hold the inhaler several inches in front of your mouth and breathe in slowly, holding the medicine as long as possible."
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(A) The patient should be instructed to tightly close the lips around the mouthpiece and breathe in deeply and quickly to ensure the medicine moves down deeply into the lungs. Dry powder inhalers do not require spacer devices. The patient may not taste or sense the medicine going into the lungs.
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The patient has an order for each of the following inhalers. Which one should the nurse offer to the patient at the onset of an asthma attack? a. Albuterol (Proventil) b. Salmeterol (Serevent) c. Beclomethasone (Qvar) d. Ipratropium bromide (Atrovent)
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(A) Albuterol is a short-acting bronchodilator that should be given initially when the patient experiences an asthma attack. Salmeterol (Serevent) is a long-acting β2-adrenergic agonist, which is not used for acute asthma attacks. Beclomethasone (Qvar) is a corticosteroid inhaler and not recommended for an acute asthma attack. Ipratropium bromide (Atrovent) is an anticholinergic agent that is less effective than β2-adrenergic agonists.
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The nurse is assisting a patient to learn self-administration of beclomethasone, two puffs inhaled every 6 hours. What should the nurse explain as the best way to prevent oral infection while taking this medication? a. Chew a hard candy before the first puff of medication. b. Rinse the mouth with water before each puff of medication. c. Ask for a breath mint following the second puff of medication. d. Rinse the mouth with water following the second puff of medication.
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(D) Because beclamethosone is a corticosteroid, the patient should rinse the mouth with water following the second puff of medication to reduce the risk of fungal overgrowth and oral infection.
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The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? a. "I'll need to become a strict vegetarian." b. "I should use polyunsaturated oils in my diet." c. "I need to substitute eggs and whole milk for meat." d. "I should eliminate all cholesterol and fat from my diet."
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(B) The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.
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The nurse is caring for a client admitted to the hospital with uncontrolled type 1 diabetes mellitus. In the event that diabetic ketoacidosis (DKA) does occur, the nurse anticipates that which medication would most likely be prescribed? a. Glucagon b. Regular insulin c. Glyburide (DiaBeta) d. Neutral protamine Hagedorn (NPH) insulin
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(D) Giving regular insulin by the intravenous route is the treatment of choice for DKA. A short-acting insulin is the only insulin that can be given intravenously because it can be titrated to the client's blood glucose levels. Glucagon is used to treat hypoglycemia because it increases blood glucose levels, and glyburide is an oral hypoglycemic agent used to treat type 2 diabetes mellitus; both agents are inappropriate. NPH insulin is an intermediate-acting insulin and therefore is not appropriate for treatment of DKA.
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(TSH) Thyroid-Stimulating Hormone
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0.35-5.5 highlevels would be hypo low levels would be hyper PATIENT TEACHING: There is no food restriction. Shellfish should be avoided for several days prior to the test OBSERVE for signs of :myxedema (e.g., anorexia, fatigue, weight gain, dry and flaky skin, puffy hands face and feet, abdominal distention, bradycardia, infertility, and ataxia)
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When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? a. Restrict all caffeine. b. Restrict sodium intake c. Increase protein intake. d. Use calcium supplements.
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(B) The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Caffeine and protein intake do not affect hypertension. Calcium supplements are not recommended to lower BP.
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When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? a. Broiled fish b. Roasted duck c. Roasted turkey d. Baked chicken breast
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(B) Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall CVD risk. The other meats are lower in fat and are therefore acceptable in the diet
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The community health nurse is planning health promotion teaching targeted at preventing coronary artery disease (CAD). Which ethnic group would the nurse select as the highest priority for this intervention? a. White male b. Hispanic male c. African American male d. Native American female
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(A) The incidence of CAD and myocardial infarction (MI) is highest among white, middle-aged men. Hispanic individuals have lower rates of CAD than non-Hispanic whites or African Americans. African Americans have an earlier age of onset and more severe CAD than whites and more than twice the mortality rate of whites of the same age. Native Americans have increased mortality in less than 35-year-olds and have major modifiable risk factors such as diabetes.
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When providing nutritional counseling for patients at risk for CAD, which foods would the nurse encourage patients to include in their diet (select all that apply)? a. Tofu b. Walnuts c. Tuna fish d. Whole milk e. Orange juice
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(A,B,C) Tuna fish, tofu, and walnuts are all rich in omega-3 fatty acids, which have been shown to reduce the risks associated with CAD when consumed regularly.
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The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? a. Flushing b. Ashen skin c. Diaphoresis d. Nausea and vomiting e. S3 or S4 heart sounds
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(B,C,D,E) During the initial phase of an MI, catecholamines are released from the ischemic myocardial cells, causing increased sympathetic nervous system (SNS) stimulation. This results in the release of glycogen, diaphoresis, and vasoconstriction of peripheral blood vessels. The patient's skin may be ashen, cool, and clammy (not flushed) as a result of this response. Nausea and vomiting may result from reflex stimulation of the vomiting center by severe pain. Ventricular dysfunction resulting from the MI may lead to the presence of the abnormal S3 and S4 heart sounds.
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When evaluating a patient's knowledge regarding a low-sodium, low-fat cardiac diet, the nurse recognizes additional teaching is needed when the patient selects which food choice? a. Baked flounder b. Angel food cake c. Baked potato with margarine d. Canned chicken noodle soup
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(D) Canned soups are very high in sodium content. Patients need to be taught to read food labels for sodium and fat content.
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The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? a. Sinus tachycardia b. Pathologic Q wave c. Fibrillatory P waves d. Prolonged PR interval
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(B) The presence of a pathologic Q wave, as often accompanies STEMI, is indicative of complete coronary occlusion. Sinus tachycardia, fibrillatory P waves (e.g., atrial fibrillation), or a prolonged PR interval (first-degree heart block) are not direct indicators of extensive occlusion.
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Baseline BP
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Has to be taken twice at the same spot one min. apart. Use the highest reading. Take at level of heart.
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Hypertension follow up
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Patient should return for follow up and adjustment of medication at monthly intervals until goal bp has been reached. After goal is stable, they come back in 3-6 month intervals. Co-morbities would return more often (diabetes and heart failure)
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White coat blood pressure Pg 715
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Patient has high bp in clinical setting but normal bp out of clinical setting. Self monitor
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Chronic Stable Angina assessment
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Precipating factors Quality of pain Radiation of pain Severity of pain Timing
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Acute MI
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Cardiac test with elevated levels of Troponin, CK, and CKMB...is tested every 3 hours. (Troponin is the number on indicator)
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Lopressor
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Monitor pulse (decreases heart rate) and BP regularly Use with caution in patients with diaetes Contradicted in patients with Asthma and COPD 4 B' Bradycardia Bronchospasim decreased Blood pressure Blood sugar (low)
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Aldactone
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Monitor for hypokalemia. It is a potassium sparing diurretic. No excessive potassium intake . Normal level of potassium or 3.5-5.0. Reduces the effect of digoxin .
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Type two complications
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Over 600 Hyperosmolar Hyperlycemic complications as well as hypoglycemic. ADMINISTER IV NORMAL SALINE .9% or .45 % When glucose fall to 250 give them glucose (dextrose) so their level does not fall too low to prevent hypoglycemic . Have annual dialated eye exams.
