NUR3410 MED SURGE II FINAL EXAM RATED A

1. Crohn’s disease. Diagnostic test. **If a client had irritable bowel syndrome, which of the following diagnostic tests would determine if the diagnosis is Crohn's disease or ulcerative colitis? Colonoscopy with biopsy A client had a colonoscopy and biopsy yesterday calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate? c. Remind the client that a small amount of bleeding is possible. 2. Review risk factor of acute renal failure – pre-renal **The nurse is assessing a client with a diagnosis of prerenal acute kidney injury (AKI). Which condition would the nurse expect to find in the patient’s recent history. b. Dehydration or myocardial infarction A nurse develops a dietary plan for a client with diabetes mellitus and new onset of microalbuminuria. Which component of the client’s diet would the nurse decrease? Proteins A client has a serum potassium level of 6.5 mEq/L (6.5 mmol/L), a serum creatinine level of 2 mg/dL (176 mcmol/L), and a urine output of 350 mL/day. What is the best action by the nurse? Place the client on a cardiac monitor immediately. A male client with gastric cancer is 1 week postoperative for a total gastrectomy and has normal hematologic parameters. Which supplement should the nurse explain to the client is indicated for lifetime to prevent complications? Vitamin B12, intramuscular y. What action(s) by the nurse is (are) appropriate to promote nutrition in a client who had a partial gastrectomy? (Select All That Apply) a. Administer vitamin B12 injections. b. Ask the primary health care provider about folic acid replacement. e. Provide iron supplements for the client 4. Acute Kidney Injury. Nursing education about requires diet **A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the client’s spouse about the renal-specific formulation for the enteral solution compared to standard formulas. What components would be discussed in the teaching plan? (Select all that apply.) a. Lower sodium c. Lower potassium. e. Higher calories 5. Hypoglycemia. Clinical manifestation. Nursing assessment A nurse is teaching a client with diabetes mellitus who asks, “Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?” How would the nurse respond? “Your brain needs a constant supply of glucose because it cannot store it.” The nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure. What actions will the nurse take at this time? (Select all that apply.) a. Administer glucagon 1 mg subcutaneously. b. Be sure the bed side rails are in the up position. c. Notify the primary health care provider immediately. d. Monitor the client’s blood glucose level. The nurse is caring for a client who has diabetes mellitus type 1 and is experiencing hypoglycemia. Which assessment findings will the nurse expect? (Select all that apply.) b. Nervousness f. Blurred vision **A client is admitted with a sudden decline in level of consciousness. What is the nursing action at this time? Assess the client for hypoglycemia and hypoxia. 6. Acute pyelonephritis. Clinical manifestation **A patient seen in the clinic for a bladder infection describes the following symptoms. Which information is most important for the nurse to report to the health care provider? Left-sided flank pain Which assessment finding for a patient who has just been admitted with acute pyelonephritis is most important for the nurse to report to the health care provider? Blood pressure 90/48 mm Hg The nurse is assessing a client with acute pyelonephritis. What assessment findings would the nurse expect? (Select all that apply.) a. Fever b. Chills c. Tachycardia d. Tachypnea e. Flank or back pain f. Fatigue 7. Review: Menorrhagia, Metrorrhagia, oligomenorrhea concepts. Menorrhagia= Heavy cyclical periods which interfere with quality of life and excessive, heavy bleeding in duration and in amount; usually periods last more than 7 days Metrorrhagia= bleeding between menstrual periods (irregular bleeding) Oligomenorrhea = heavy menstrual cycles for 2 consecutive cycles. **"I had a period once, but I don't have it anymore": b. Secondary Amenorrhea No menstrual cycle by age 17: a. Primary Amenorrhea **Cycles greater than 35 days c. Oligomenorrhea Cycles less than 21 days d. Polymenorrhea **hypermenorrhea (heavy bleeding) is also known as: e. Menorrhagia **NON cyclic bleeding (non-regular) is known as: f. Metrorrhagia 8 Diabetes insipidus. Clinical manifestation before and after Treatment. *A client is being treated for diabetes insipidus (DI) with synthetic vasopressin (desmopressin). What is the priority health teaching that the nurse provides regarding drug therapy? d. The need to weigh every day and report weight gain. **A client has received vasopressin for diabetes insipidus. Which assessment finding indicates a therapeutic response to this therapy? b. Urine output has decreased; specific gravity has increased. **The nurse is caring for a client who is diagnosed with diabetes insipidus (DI). For what common complication will the nurse monitor? Dehydration A client is admitted with a possible diagnosis of diabetes insipidus (DI). What assessment findings would the nurse expect. (Select all that apply.) a. Hypotension b. Increased urinary output e. Poor skin turgor **A nurse is caring for a patient recently diagnosed with diabetes insipidus. Which of the following medications would be appropriate for this disorder? Vasopressin 9. Somogyi phenomenon. Clinical manifestation. Treatment options *PROMOTE A PATIENT WITH SNACK BEFORE GO TO THE BED *MONITOR THE LEVEL OF INSULIN OR GLUCOSE DURING NIGHT Carol a 30 yr old type 2 diabetic, is on regular insulin and lente insulin in the morning and in the evening. She denied changes in her diet or any illness, but recently started attending aerobic classes in the afternoon. Because of the workouts, her blood sugar have dipped below 50mg/dl in the middle of the night. her fasting blood sugar before breakfast is now elevated and higher than normal. which of the following is best describe? Somogyi Phenomenon 10. Compartment syndrome. Clinical manifestation **A nurse caring for a client with a fracture of the femur, the nurse should be alert for compartment syndrome. What symptom is characteristic of this complication? Deep, throbbing, unrelenting pain which is not controlled with opioids. 11. Hyperthyroidism.Clinicalmanifestation.Complicationoftreatment ****Which is a major side effect of radioactive iodine treatment for hyperthyroidism? Hypothyroidism 12. Graves Disease. Clinical manifestation. Nursing action to alleviate the symptoms. ****A patient is admitted to the medical unit with possible Graves disease (hyperthyroidism). Which assessment finding supports this diagnosis? Exophthalmos(bulging of the eyes) 13. Graves’ disease. Complication. First line of Treatment The treatment protocol for a client with hyperthyroidism includes antithyroid medication and propranolol. The purpose of propranolol is to do which of the following? Decrease tachycardia and palpitations The nurse plans to administer propranolol (Inderal), to a patient hospitalized with Graves disease. Which data indicates the drug has been effective? Decrease in blood pressure and heart rate While assessing a client with Graves disease, the nurse notes that the client’s temperature has risen 1° F (1° C). What does the nurse do first? Turn the lights down and shut the patient’s door. A nurse is developing a plan of care for a client with a new diagnosed of graves disease which of the following interventions does the nurse include in the plan? providing a high calorie, high protein diet 14. Type 1 diabetes. Most common complication The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition? increase rate and depth respirations A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first? Examine the client’s feet for signs of injury. *A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? Administration of intravenous insulin A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) Deep and fast respirations (kusumal) Tachycardia Orthostatic hypotension 15. Review and recognize: Hydroceles, varicoceles and hematocele hydrocele inflammation that glows red on transillumination, (fulid) hematocele high accumulation of blood in tunica Phimosis is a foreskin that will not retract over the glans varicocele are dilated veins in the spermatic cord. When conducting an initial assessment on a 10-year-old male patient, the nurse assesses a mass in the left testicle that on transillumination glows red. The nurse notes the presence of: hydrocele. Due to malfunctioning valves in the spermatic venous system, blood pools and dilates the veins. What is the term for the condition in which a lengthening and enlargement of the venous system drains the testicle? Varicocele *A male patient is infertile after having mumps as a child. Which disorder should the nurse inform, the patient might occur related to the infertility? varicocele What is the most common cause of painless scrotal swelling? Hydrocele Collection of blood associated with trauma, surgery, neoplasms, or torsion? hematocele 16. Spironolactone (Aldactone) -related side effects y **Transgender client taking spironolactone is in the internal medicine clinic reporting heart palpitations. What action by the nurse takes priorit? Obtain a STAT electrocardiogram (ECG). **a Patient is taking spironolactone a drug that blocks the action of aldosterone on the kidney for hypertension the nurse will monitor for?? Elevated serum potassium 17. Hypothyroidism. Clinical manifestation. Complications of treatment ****The nurse is planning health teaching for a client starting on levothyroxine. What health teaching about this drug would the nurse include? The need to report chest pain and dyspnea when starting the drug **A nurse cares for a client who has hypothyroidism as a result of Hashimotothyroiditis. The client asks, “How long will I need to take this thyroid medication?” How would the nurse respond? c. “You’ll need thyroid pills for life because your thyroid won’t start working again.” *a patient with hypothyroidism begins PO levothyroxine(syntroid) the nurse assesses the patient at the beginning of the shift and notes a heart rate of 60 beats per minute and a temperature of 97.2. The patient is lethargic and difficult to arouse. The nurse will contact the provider to request an order for which drug? intravenous levothyroxine When caring for an older client who has hypothyroidism, what assessment findings will the nurse expect? (Select all that apply.) a. Lethargy c. Low body temperature e. Slowed speech f. Weight gain A nurse assesses a client on the medical-surgical unit. Which statement made by the client alerts the nurse to assess the patient for hypothyroidism? d. “I am always tired, even with 12 hours of sleep.” *A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? b. Levothyroxine ? A nurse plans care for a client with hypothyroidism. Which priority problem does the nurse address first for this client? st a. Depression and withdrawal 18. Diabetes mellitus. Clinical manifestation ***A velvety skin discoloration/thickening of the neck/armpits/groin, often indicating insulin resistance and predisposition to Type 2 Diabetes. acanthosis nigricans A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take fir ? Examine the client’s feet for signs of injury. 19. Review and recognize the different neurologic body posturing: Decorticate, Decerebrate A nurse assesses a client and notes the client's position as indicated in the illustration below: document this finding? b. Decorticate posturing 20. Acute pancreatitis. Clinical manifestation A client is admitted with acute pancreatitis. What priority problem would the nurse expect y the client to report? Severe boring abdominal pain The nurse documents the vital signs of a client diagnosed with acute pancreatitis: Apical pulse = 116 beats/min Respirations = 28 breaths/min Blood pressure = 92/50 What complication of acute pancreatitis would the nurse suspect that the client might have? c. Internal bleeding 21. Acute pancreatitis: Clinical manifestations The nurse is caring for a client who has possible acute pancreatitis. What serum laboratory findings would the nurse expect for this client? (Select all that apply.) a. Elevated amylase b. Elevated lipase c. Elevated glucose d. Decreased calcium e. Elevated bilirubin f. Elevated leukocyte count ****A nurse is assessing a client who has acute pancreatitis and is at risk for an acid–base imbalance. For which manifestation of this acid–base imbalance would the nurse assess? Kussmaul respirations After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for further teaching? “If I develop an infection, I should stop taking my corticosteroid.” 22 Peritoneal dialysis. Complication. Nursing action **A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the prioritaction by the Nurse? Obtain a sample of the effluent and send to the laboratory. 23 Review: orchitis, Phimosis and Peyronie Disease. clinical manifestation Orchitis= an inflammation of one or both testicles. due to a Bacterial or viral infections Phimosis = congenital condition in which the opening of the foreskin is to small to allow the foreskin to pull back over the glans penis Peyronie disease= curve penis Disorder of the penis. It is a fibrotic disorder of the tunica albuginea resulting in various degrees of penile curvature and sexual dysfunction **A patient informs the nurse that during an erection, his penis curves downward causing pain. What condition does the nurse suspect that this patient has? peyronie disease The nurse is providing care to a patient who reports a tightened penile foreskin. When assessing this patient, the nurse is unable to pull the foreskin forward from the retracted position. Based on these data, which diagnosis does the nurse anticipate? paraphimosis What are most cases of orchitis associated with? Viral mumps infection 24. Esophageal varices. Complication. Clinical manifestation A patient is admitted with a gastrointestinal hemorrhage due to esophagogastric varices. The nurse knows that varices are caused by which pathophysiologic mechanism? Portal hypertension resulting in diversion of blood from a high-pressure area to a low-pressure area stools that are black and tarry occur with slow bleeding_From the stomach 25. Review Cranial Nerve The nurse is assessing a client diagnosed with trigeminal neuralgia affecting cranial nerve V. What assessment findings will the nurse expect for this client? Severe facial pain The nurse is performing an assessment of cranial nerve III. Which testing is appropriate? Pupil constriction 26 Review Which STD must be reported to the public health department? What type of transmitted infections must be reported to local health department? HIV, AIDS, gonorrhea, syphilis, chlamydia, chancroid, and viral hepatitis A female client returned to the clinic with a yellow vaginal discharge after being treated for Chlamydiainfection 3 weeks ago. Which statement by the client alerts the nurse that there may be a recurrence of the infection I never told my boyfriend about the infection A 24 year-old female has been diagnosed with genital warts. Which action by the nurse is best? Encourage the client to complete STI screening. A college student seeks information from the school’s nurse about how to avoid sexually transmitted infections (STIs) without abstinence as a choice. Which statement by the nurse is best? b. “A vaccine can prevent genital warts caused by some strains of the human papilloma virus (HPV).” 27. Colonoscopy. Positioning for procedure *to promote comfort and the passage of flatus after a colonoscopy in what position does the nurse place the client? Left lateral 28. Review types of urinary incontinent. Recognize each one *A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their description? (Select all that apply.) a. Stress incontinence—urine loss with physical exertion. coughing or lifting heavy things b. Urge incontinence—loss of urine upon feeling the need to void involuntary loss of urine d. Overflow incontinence—constant dribbling of urine bladder doesn’t empty completely 29. Paracentesis procedure. Complication. Nursing assessment ***A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? Assist the client to void before the procedure. A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? Urine output via indwelling urinary catheter is 20 mL/hr What are complications of a paracentesis? Hypovolemia Bladder perforation Peritonitis 30. Graves’ disease. Diet recommendation ***What is the recommended diet in a patient with hyperthyroidism? or graves’ disease ? High calorie, high protein diet 31. Bacterial vaginosis. Clinical manifestations What is the most common cause of abnormal vaginal discharge in a woman of reproductive age? Bacterial vaginosis (BV). A middle-aged woman is recently diagnosed with Bacterial vaginosis. What is the most likely aetiological cause? Gardnerella vaginalis A 30-year-old woman presents with a white, malodorous vaginal discharge. There is no associated itch or dyspareunia. A diagnosis of bacterial vaginosis is suspected. Overgrowth of which one of the following organisms is most likely to cause this presentation? Gardnerella vaginalis A 20-year-old woman presents to the sexual health clinic with a grey-white offensive homogeneous vaginal discharge. Microscopy of the discharge revealed clue cells with a positive whiff test. What is the most likely cause of this infection? Bacterial vaginosis (BV) A 20-year-old female presented with vaginal discharge which is non irritating and malodorous. Saline wet preparation reveals clue cells. Clue cells are used to detect which type of vaginitis? Bacterial vaginosis 32. Duodenal ulcers. Diagnostic test How is H. Pylori diagnosed? ( he had asked which would be best for a non invasive procedure) through blood, stool, urea breath test, gastric biopsy. During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect? c. Melena 33. 24-hour urine collection for creatinine clearance test. Nursing education A nurse collaborates with assistive personnel (AP) to provide care for a client who is prescribed 24 hour urine specimen collection. Which statement would the nurse include when teaching the AP about the activity? Note the time of the patient’s first void and collect urine for 24 hours. No restriction **The nurse will teach the patient who is scheduled to complete a 24 hrs collection for 17 ketosteroids and you are supposed to tell the patient to? keep specimen refrigerated or in ice 34. Diabetes insipidus. Clinical manifestation. **What manifestation does the nurse expect to find in a client diagnosed with diabetes insipidus (DI)? D. Increased Urinary Frequency In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition? increased thirst. 35. Addison Disease. Pathophysiology. Abnormal Labs glucose normal rate = 70-106 *A nurse is reviewing serum laboratory results for a client who has Addison's disease. Which of the following findings are typical for a client who has this condition? (select all that apply.) A. Sodium 130 mEq/L B. Potassium 6.1 mEq/L C. Calcium 11.6 mg/dL E. Glucose 65 mg/dL Which conditions can lead to hyperkalemia? Addison disease A nurse notes that a client’s serum potassium level is 5.8 mEq/L. The nurse interprets this as an expected finding in the clients with Addison disease When a patient is hospitalized with acute adrenal insufficiency and adrenal shock, which assessment finding by the nurse indicates that the prescribed replacement therapies are effective? Reducing heart rate _36. Acute glomerulonephritis. Clinical manifestations of A nurse evaluates a client with acute glomerulonephritis (GN). Which assessment finding would the nurse recognize it as a positive response to the prescribed treatment? The client lost 11 lb (5 kg) in the past 10 day What manifestation in the patient will indicate the need for restriction of dietary protein in management of acute poststreptococcal glomerulonephritis (APSGN)? Elevated blood urea nitrogen (BUN) The nurse is caring for a child suspected of having acute glomerulonephritis. When reviewing the data collected, the nurse is most likely to note what in the health history? Recent upper respiratory infection ****The nurse is caring for a patient diagnosed with glomerulonephritis. The nurse notes that the patient is feeling confined with reports of feeling "bored and caged." During the interaction, the patient asks when he can resume his normal activities. The nurse clarifies that bed rest is enforced until: hypertension and hematuria are gone. The nurse is reviewing the results of a client’s urinalysis. The client has a diagnosis of acute glomerulonephritis. Which urine findings would the nurse expect? (Selectallthatapply.) Presence of protein Presence of white blood cells Acidic urine In assessing a client recently diagnosed with acute glomerulonephritis, the nurse asks which question to determine potential contributing factor Have you had a cold or sore throat within the last 2 weeks? A client with glomerulonephritis has a glomelar filtration rate of 40ml/min (normal values 90- 120ml/min) as measured by a 24 hrs. creatinine clearance. Which is the nurse’s interpretation of the finding? elevated creatinine in blood, client at risk for fluid overload 37. Cauda equina syndrome. Common cause of syndrome what causes cauda equina syndrome? damage to cauda equina (LUMBAR & SACRAL nerve roots 38. Hemorrhagic stroke. Nursing education to prevent compilation *The nurse is caring for a client admitted for hemorrhagic stroke 12 hours ago. The nurse should make sure the bed is in which position? HOB elevated 30 degrees The nurse is caring for a client who had a hemorrhagic stroke. Which assessment finding is the earliest sign of increasing intracranial pressure (ICP) for this client? Decreased level of consciousness ***A nurse is caring for a client who has a hemorrhagic stroke. The nurse knows that which of the following is the most concerning? Hypertension Based on the known risk factors for stroke, which health promotion practices would the nurse teach a client to promote heart health and prevent strokes? (Select all that apply.) a. Blood pressure control b. Aspirin use c. Smoking cessation e. Cholesterol management The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. e. Avoid clustering care nursing activities and procedures. 39. Type 1 diabetes mellitus (DM). Nursing education if patient requires to go surgery teach patient how to use sliding scale **The nurse is providing preoperative instructions to a patient with diabetes. What instructions should the nurse include? Sulfonylureas should be discontinued one day before surgery. The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero (0) units; 151 to 200, three (3) units; 201 to 250, six (6) units; >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client? Three (3) units. **The client diagnosed with HHNS was admitted yesterday with a blood glucose level of 780 mg/dL. The client's blood glucose level is now 300 mg/dL. Which intervention should the nurse implement? Notify the HCP to obtain an order to decrease insulin A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client’s teaching to decrease the client’s insulin needs “Walk at a moderate pace for 1 mile daily.” The insulin dose that is given based on blood sugar level is known as: Sliding Scale Insulin 40. Renal calculi. Nursing diagnosis After teaching a client with a history of renal calculi, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching? a. “I should drink at least 3 L of fluid every day.” A nurse assesses a client who is recovering from extracorporeal shock-wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the client’s right lower back. What action would the nurse take? Apply an ice pack to the site. A client has renal colic due to renal lithiasis. What is the nurse's priority in managing care for this client? Administer an opioid analgesic as prescribed. *A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6 ° F (38.1 ° C). Which of the following would be a priority outcome for this client? Alleviation of pain. **in addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for signs of: Referred pain 41. Kidney transplant rejection. Clinical manifestation A nurse reviews the laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L (135 mmol/L) Potassium 5 mEq/L (5 mmol/L) Blood urea nitrogen (BUN) 44 mg/dL (15.7 mmol/L) Serum creatinine 2.5 mg/dL (221 mcmol/L) What initial intervention would the nurse anticipate? Increase the dose of immunosuppression. The patient in the acute rejection phase typically presents with what type of s/s? Oliguria, anuria Elevated temp and BP Lethargy flank tenderness 42. Review each region of the brain Function To evaluate a client's cerebellar function, a nurse should ask: "Do you have any problems with balance? A client is diagnosed with a brain tumor. The nurse's assessment reveals that the client has difficulty interpreting visual stimuli. Based on these findings, the nurse suspects injury to which lobe of the brain? occipital Which cerebral lobe contains the auditory receptive areas? temporal Which cerebral lobes is the largest and controls abstract thought? frontal lobe ****regulates expressive speech (Frontal lobe) Broca's area function 43. Hiatal Hernia. Clinical manifestation. Treatment What is a laparoscopic Nissen fundoplication done for? to correct a hiatal hernia. A client has an open traditional hiatal hernia repair this morning. What is the nurse’s priority for client care at this time? Preventing respiratory complications A laparoscopic Nissen fundoplication mainly involves what part of the stomach? Fundus 44. Colostomy. Normal versus abnormal finding., Nursing action **The nurse evaluates the client's stoma during the initial post-op period of a colostomy. Which of the following observations should be reported immediately to the physician? Select one: The stoma is dark red to purple **A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. The nurse should document stoma assessment findings. A nurse cares for a client who had a colostomy placed in the ascending colon 2 weeks ago. The client states, “The stool in my pouch is still liquid.” How would the nurse respond? “The stool will always be liquid with this type of colostomy.” A nurse cares for a client who has a new colostomy. Which action would the nurse take? Empty the pouch frequently to remove excess gas collection. 45.Myasthenia gravis. Diagnosis test **The client w/ MG is admitted to the emergency room with a sudden exacerbation of motor weakness. Which assessment data indicate the client is experiencing cholinergic crisis? The tensilon test does not show improvement in the client's muscle strength **Toy with a tentative diagnosis of myasthenia gravis is admitted for diagnostic make up. Myasthenia gravis can confirm by: A positive edrophonium (Tensilon) test A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? MG is an autoimmune problem in which nerves do not cause muscles to contract. **the nurse is preparing a client for tensilon test what action by the nurse is important obtain atropine sulfate 46. Peptic ulcer. Complication. Clinical manifestation **The nurse is caring for a client who has been diagnosed with peptic ulcer disease. For which complication would the nurse monitor? Upper gastrointestinal (GI) bleeding During an interview, the client tells the nurse that the client has a duodenal ulcer. Which assessment finding would the nurse expect? Melena A client with peptic ulcer disease is in the emergency department and reports gastric pain that has gotten much worse over the last 24 hours. The client’s blood pressure when lying down is 112/68 mm Hg and when standing is 98/52 mm Hg. What action by the nurse is most appropriate? c. Start a large-bore IV with normal saline. 47. Infection control precaution TAKE PICTURE g An older client with diabetes is admitted with a heavily draining leg wound. The client’s white blood cell count is 38,000/mm3 (38 × 109/L) but the client is afebrile. Which nursing action is most appropriate at this time? c. Place the client on Contact Precautions. contact precaution = Body fluids, wound drain, mrsa airborne= tuberculosis varicella measles, rubella droppled = cough, influenza menigitis ], pneumonia 48. Review abdominal examination technique Inspection, Auscultation, Percussion, palpate Palpate the hurting area last. A nurse is assessing a client reporting right upper quadrant (RUQ) abdominal pain. What technique would the nurse use to assess this client’s abdomen? d. Lightly palpate the RUQ last. 49. UTI. Treatment. Nursing education Treatment Antibiotics Nitrofurantoin. Sulfonamides (sulfa drugs). Amoxicillin. paradian(phenazopyridine for pain *After teaching a client with bacterial cystitis who is prescribed phenazopyridine, the nurse assesses the client’s understanding. Which statement made by the client indicates acorrectunderstandin of the teaching? “An orange color in my urine should not alarm me 50. Type II diabetes. Hypoglycemia. Clinical manifestation. Nursing action A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes mellitus type 2. which A1c levels would the nurse expect? 7.4% * nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure. What actions will the nurse take at this time? (Select all that apply.) a. Administer glucagon 1 mg subcutaneously. b. Be sure the bed side rails are in the up position. c. Notify the primary health care provider immediately. d. Monitor the client’s blood glucose level 51. Primary amenorrhea. Risk factor. Clinical manifestation what are the 2 most common causes of primary amenorrhea? *Turner syndrome (ovaries replaced by streak gonads, or functionless tissue due to missing X chromosome) -Mullerian agenesis (uterus, cervix, and/or vagina absent) 52. Traumatic brain injury. Clinical manifestation. Complication. cerebellum edema, damage, increase ICP, fever spinal fluids A client is admitted to the emergency department with a probable traumatic brain injury. Which assessment finding would be the priority for the nurse to report to the primary health care provider? Decreasing level of consciousness ***When assessing a client who had a traumatic brain injury, the nurse notes that the client is drowsy but easily aroused. What level of consciousness will the nurse document to describe this client’s current level of consciousness? Lethargic A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The patient’s spouse is very frustrated, stating that the patient’s personality has changed and the situation is very difficult. What response by the nurse is most appropriate? Explain that personality changes are common following brain injuries. The nurse is caring for four clients with traumatic brain injuries. Which client would the nurse assess first? Client who has a temperature of 102° F (38.9° C) A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? Cardiac dysrhythmias A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? Mannitol a male client has a traumatic brain injury and its admitted with the Glasgow comma scale of 12, after thirty minutes the nurse reevaluates the client and determine the clients Glasgow scale of 7 Which changes from initial findings make the nurse suspect the client has increased intracranial pressure and developing a Cushing's trad? Select all that apply pulse pressure changes from 50 to 90 e systolic blood pressure changes from 120 to 160 heart rate changes from 92 to 60 53 Colonoscopy. Complication. Clinical manifestation A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is appropriate? c. Remind the client that a small amount of bleeding is possible. 54. Gastroscopy. Nursing action post procedure Professor: NPO status to prevent aspiration until gag reflex returns (cranial nerve IX and X) A client receiving continuous tube feeding to provide total enteral nutrition begins vomiting. What action by the nurse is most appropriate? c. Hold the feeding until the vomiting subsides. The nurse is caring for an older client receiving total enteral nutrition via a small-bore nasoduodenal tube. For what priority complication would the nurse assess? c. Aspiration pneumonia