Adult Medical Surgical B () Questions And Answers

Adult Medical Surgical B (2022/2023) Questions And Answers A nurse is receiving report on a client who is postoperative following an open repair of Zenker's Diverticulum. The nurse should anticipate the surgical incision to be in which of the following locations? Correct Ans:- Throat A nurse is caring for a client who has a potassium level of 3 mEq/L. Which of the following assessment findings should the nurse expect? Correct Ans:- Hypoactive bowel sounds A nurse is providing discharge instructions to a client who has a partial thickness burn of the hand. Which of the following instructions should the nurse include? Correct Ans:- Wrap fingers with individual dressings A nurse is assessing a client following the administration of magnesium sulfate 1g IV bolus. For which of the following adverse effects should the nurse monitor? Correct Ans:- Respiratory Paralysis A nurse is assessing a client's hydration status. Which of the following findings indicate fluid volume overload? Correct Ans:- Distended neck veins A nurse is assessing a client following the administration of IV penicillin G. Which of the following findings should indicate to the nurse that the client is experiencing an anaphylactic reaction? Correct Ans:- Flushing A nurse is providing teaching to a client who has a severe form of stage II Lyme disease. Which of the following statements made by the client reflects an understanding of the teaching? Correct Ans:- My joints ache because I have Lyme Disease A nurse is caring for a client who has portal hypertension. The client is vomiting blood mixed with food after a meal. Which of the following actions should the nurse take first? Correct Ans:- Obtain vital signs A nurse is assessing a client following IV urography. Which of the following findings is the priority? Correct Ans:- swollen lips A nurse is providing teaching to a client who has hypertension and a new prescription for verapamil. Which of the following statements by the client indicates an understanding of the teaching? Correct Ans:- I will count my heart beats before taking this medication. A nurse is providing teaching to a client who is receiving chemotherapy and has a new prescription for epoetin alfa. Which of the following client statements indicates an understanding of the teaching? Correct Ans:- I will monitor my blood pressure while taking this medication. A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following should the nurse plan to administer? Correct Ans:- Regular insulin 20 units IV bolus A nurse is reviewing the laboratory findings of a client who developed chest pain 6 hr ago. The nurse should identify which of the following findings as an indication of a myocardial infarction(MI)? Correct Ans:- Troponin 8 ng/mL A nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take? Correct Ans:- Remain with the client for the first 15 minutes of the infusion. A nurse is assessing a client who had extracorporeal shock wave lithotripsy(ESWL) 6 hr ago. Which of the following findings should the nurse expect? Correct Ans:- Stone fragments in the urine A nurse is teaching a group of newly licensed nurses about pain management for older adult clients. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? Correct Ans:- Ibuprofen can cause gastrointestinal bleeding in older adult clients. A nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Correct Ans:- Loosen restrictive clothing A nurse is assessing a client who has Cushing's disease. Which of the following findings should the nurse expect? Correct Ans:- Muscle atrophy A nurse is planning to irrigate and dress a clean, granulating wound for a client who has a pressure ulcer. Which of the following actions should the nurse take? Correct Ans:- Use a 30 mL syringe A nurse is reviewing the laboratory results of a client who had a recent exposure to hepatitis C virus. Which of the following tests should the nurse identify as indicating the presence of hepatitis C antibodies? Correct Ans:- Enzyme immunoassay (EIA) A nurse in an emergency department is assessing a client who has a detached retina. Which of the following should the nurse expect the client to report? Correct Ans:- It's like a curtain closed over my eye. A nurse is assessing heart sounds of a client who reports substernal precordial pain. Identify which of the following sounds the nurse should document in the client's medical record by listening to audio clip. Correct Ans:- Pericardial friction rub A nurse is caring for a client who has active bleeding from peptic ulcer disease. Which of the following findings is an indication that the client is experiencing compensatory shock? Correct Ans:- Increased heart rate A nurse is conducting an admission history for a client who is to undergo a CT scan with an IV contrast agent. The nurse should identify that which of the following findings requires further screening? Correct Ans:- Shellfish allergy A nurse is providing teaching to a client who has a recent diagnosis of constipation-predominant irritable bowel syndrome. Which of the following instructions should the nurse include in the teaching? Correct Ans:- Consume at least 30 g of fiber daily A nurse is caring for a client who has type 1 diabetes mellitus and has had acute bronchitis for the past 3 days. Which of the following statements should the nurse include when instructing the client? Correct Ans:- Take insulin even if you are unable to eat your regular diet. A nurse is reviewing the laboratory report of a client who is receiving nonsurgical treatment for Cushing's disease. Which of the following laboratory findings should the nurse identify as a positive outcome of the treatment? Correct Ans:- Decreased sodium A nurse is reviewing the laboratory results of a client who has AIDS and is taking amphotericin B for a fungal infection. The nurse should identify that which of the following values is an indication of an adverse effect of the medication? Correct Ans:- BUN 34 mg/dL An older adult client is brought to an emergency department by a family member. Which of the following assessment findings should cause the nurse to suspect that the client has hypertonic dehydration? Correct Ans:- Urine specific gravity is 1.045 A nurse is caring for a client who has had a cerebrovascular accident. Which of the following findings indicates that the client has homonymous hemianopsia? Correct Ans:- The client has to turn her head to see the entire visual field. A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus and is planning a trip. Which of the following instructions should the nurse include in the teaching? Correct Ans:- Take additional pairs of shoes A nurse is providing teaching to a client who has end-stage kidney disease and is waiting for a kidney transplant. Which of the following information should the nurse provide? Correct Ans:- Hemodialysis is sometimes needed after surgery. A nurse is reviewing the health record of a client who is scheduled for allergy skin testing. The nurse should postpone the testing and report to the provider which of the following findings? Correct Ans:- Current medications A nurse is assessing a client who is receiving morphine via a PCA pump. Which of the following findings indicates an adverse effect of the medication? Correct Ans:- Urinary retention A nurse in an ICU is assessing a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a component of Cushing's triad? Correct Ans:- Bradycardia A nurse is providing teaching for a female client who has recurrent urinary tract infections. Which of the following information should the nurse include in the teaching? Correct Ans:- Void before and after intercourse A nurse is providing education to a client who has tuberculosis (TB) and his family. Which of the following information should the nurse include in the teaching? Correct Ans:- Family members in the household should undergo TB testing A nurse is caring for a client 1 hr following a cardiac catheterization. The nurse notes the formation of a hematoma at the insertion site and a decreased pulse rate in the affected extremity. Which of the following interventions is the nurse's priority? Correct Ans:- Apply firm pressure to the insertion site A nurse is caring for a client who has cirrhosis of the liver with esophageal varices. Which of the following activities should the nurse instruct the client to avoid? Correct Ans:- Straining to have bowel movements A nurse is providing dietary teaching to a client who has celiac disease. Which of the following food choices should the nurse identify as an indication that the client understands the teaching? Correct Ans:- Grilled chicken breast A nurse is providing discharge instructions to a client following an upper gastrointestinal series with barium contrast. Which of the following information should the nurse provide? Correct Ans:- Increased fluid intake A nurse in an emergency department is caring for a client who reports chest pain of 8 on a pain scale of 0 to 10. Which of the following actions should the nurse take first? Correct Ans:- Administer morphine A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? Correct Ans:- Low urine specific gravity A nurse is caring for a client who has a pneumothorax and a closed-chest drainage system. Which of the following findings is an indication of lung re-expansion? Correct Ans:- Bubbling in the water-seal chamber has ceased. A nurse is caring for a client who has HIV. Which of the following findings indicates a positive response to the prescribed HIB treatment? Correct Ans:- Decreased viral load A nurse is caring for a client who is 4 hr postoperative following an open reduction internal fixation of the right ankle. Which of the following assessment findings should the nurse report to the provider? Correct Ans:- Extremity cool upon palpation A home health nurse is assigned to a client who was recently discharged from a rehabilitation center after experiencing a right-hemispheric cerebrovascular accident(CVA). Which of the following neurologic deficits should the nurse expect to find when assessing the client? Correct Ans:- Visual spatial deficits Left hemianopsia One-sided neglect A nurse in an ICU is planning care for a client who is in cariogenic shock. The nurse should prepare to administer which of the following medications to increase cardiac output? Correct Ans:- Dopamine A nurse is caring for a client who has viral pneumonia. The client's pulse oximeter readings have fluctuated between 79% and 88% for the last 30 min. Which of the following oxygen delivery systems should the nurse initiate to provide the highest concentration of oxygen? Correct Ans:- Non-rebreather mask A client who has emphysema is receiving mechanical ventilation. The client appears anxious and restless, and the high-pressure alarm is sounding. Which of the following actions should the nurse take first? Correct Ans:- Instruct the client to allow the machine to breathe for him. A nurse is assessing a client who has a diagnosis of rheumatoid arthritis. Which of the following non pharmacological interventions should the nurse suggest to the client to reduce pain? Correct Ans:- Alternate application of heat and cold to the affected joints A nurse is assessing a client who is taking carvedilol for heart failure. which of the following findings is the priority for the nurse to report to the provider? Correct Ans:- Weight gain A client who has a diagnosis of Clostridium difficile is placed on contact precautions. Which of the following actions should the nurse take? Correct Ans:- Leave a stethoscope in the room for blood pressure monitoring. A nurse is teaching a client who has a cardiac dysrhythmia about the purpose of undergoing continuous telemetry monitoring. Which of the following statements by the client reflects an understanding of the teaching? Correct Ans:- This identifies if the pacemaker cells of my heart are working properly. A nurse is caring for a client who has pancreatitis. The nurse should expect which of the following laboratory results to be below the expected reference range? Correct Ans:- Calcium A nurse is caring for a client who has a stage III pressure ulcer. Which of the following findings contributes to delayed wound healing? Correct Ans:- Urine output 25 mL/hr A nurse is administering packed RBCs to a client. Which of the following assessment findings indicates a hemolytic transfusion reaction? Correct Ans:- Low back pain and apprehension A nurse is caring for a client who has a cervical spinal cord injury sustained 1 month ago. Which of the following manifestations indicates that the client is experiencing autonomic dysreflexia (AD)? Correct Ans:- Heart rate 52/min A nurse is reviewing the laboratory results of a client who has cirrhosis. Which of the following laboratory plus should the nurse expect? Correct Ans:- Elevated bilirubin level A nurse is assessing a client who is at risk for development of pernicious anemia resulting from peptic ulcer disease. Which of the following images depicts a condition caused by pernicious anemia? A.) depicts oral candidiasis/thrush B.) depicts dry oral mucous membrane C.) depicts glossitis D.) depicts a healthy tongue dull in color Correct Ans:- Glossitis A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following findings as a manifestation of cardiogenic shock? Correct Ans:- Hypotension A nurse is assessing a client who is postoperative following a transurethral resection of the prostate (TURP) and note clots in the client's indwelling urinary catheter and a decrease in urinary output. Which of the following actions should the nurse take? Correct Ans:- Irrigate the indwelling urinary catheter A nurse is obtaining the health history of a client who has an abdominal aortic aneurysm. Which of the following findings should the nurse expect? Correct Ans:- Bruit heard over the middle upper abdomen A nurse is administering meperidine IM in the right deltoid of a client. The nurse aspirates the pulse back blood in the syringe. Which of the following actions should the nurse take? Correct Ans:- Dispose of the medication A nurse is caring for a client who is undergoing renal dialysis to treat end-stage kidney disease (ESKD). The client reports muscle cramps and a tingling sensation in his hands. Which of the following medications should the nurse plan to administer? Correct Ans:- Calcium carbonate A nurse is caring for a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect? Correct Ans:- BUN 32 mg/dL A nurse is caring for a client who is receiving a blood transfusion. The client becomes restless, dyspneic, and has crackles noted to the lung bases. Which of the following actions should the nurse anticipate taking? Correct Ans:- Slow the infusion rate A nurse is planning care for a client who has community-acquired pneumonia. Which of the following interventions should the nurse include in the plan of care? Correct Ans:- Monitor the client for confusion A nurse is caring for a client who has amyotrophic lateral sclerosis (ALS) and is being admitted to the hospital with pneumonia. Which of the following assessment findings is the nurse's priority? Correct Ans:- Increased respiratory secretions A nurse is providing teaching to a client who is at risk for developing type 1 diabetes mellitus. The nurse should inform the client that which of the following manifestations indicate diabetes? Correct Ans:- Polyuria Polydipsia Neuropathy A nurse is providing teaching to a client who has hypothyroidism and is receiving levothryoxine. The nurse should instruct the client that which of the following supplements can interfere with the effectiveness of the medication? Correct Ans:- Calcium A nurse is caring for a client who is receiving total parenteral nutrition (TPN) and is NPO. When reviewing the chart, the nurse notes the following prescription: capillary blood glucose AC and HS. Which of the following actions should the nurse take? Correct Ans:- Contact the primary care provider to clarify the prescription. A nurse is caring for a client who has increased intracranial pressure (ICP) and is receiving mannitol via continuous IV infusion. The nurse should report which of the following adverse effects of this medication to the provider? Correct Ans:- Crackles heard on auscultation A nurse is assessing an older adult client who has heart failure and takes digoxin. Which of the following findings should the nurse recognize as an indication of digoxin toxicity? Correct Ans:- Bradycardia A nurse is providing teaching to a client who has esophageal cancer and is to undergo radiation therapy. Which of the following statements should the nurse identify as an indication that the client understands the teaching? Correct Ans:- I will use my hands rather than a washcloth to clean the radiation area A nurse is providing teaching to a client who takes ginkgo biloba as an herbal supplement. Which of the following statements should the nurse make? Correct Ans:- Ginkgo biloba can cause an increased risk for bleeding A nurse in a provider's office is assessing a client who has hypertension and takes propranolol. Which of the following findings should indicate to the nurse that the client is experiencing an adverse reaction to this medication? Correct Ans:- Report of a night cough A nurse is providing teaching to a client who has angina and a new prescription for sublingual nitroglycerin. Which of the following instructions should the nurse include? Correct Ans:- Store the medication in its original container A nurse is caring for a newly admitted client who has a gastric hemorrhage and is going into shock. Identify the sequence of actions the nurse should take. Correct Ans:- Administer oxygen via a nonrebreather mask Initiate IV therapy with a large bore catheter Insert NG tube Administer Ranitidine A nurse is planning care for a client who has a sealed radiation implant for cervical cancer. Which of the following interventions should the nurse include in the plan of care? Correct Ans:- Keep a lead-lined container in the client's room A nurse is caring for a client who has hepatic encephalopathy that is being treated with lactulose. The client experiencing excessive stools. Which of the following findings is an adverse effect of this medication? Correct Ans:- Hypokalemia A nurse is assessing a client who has a comminuted fracture of the femur. Which of the following findings should the nurse identify as an early manifestation of a fat embolism. Correct Ans:- Dyspnea A home health nurse is providing teaching to a client who has a stage I pressure ulcer on the greater trochanter of his left hip. Which of the following instructions should the nurse include in the teaching? Correct Ans:- Change position every hour A nurse on a medical-surgical unit is reviewing the medical record of an older adult client who is receiving IV fluid therapy. Which of the following client information should indicate to the nurse that the client requires a revision of his IV therapy prescription? Correct Ans:- BUN A nurse is caring for a client who has a peripherally inserted central catheter (PICC). Which of the following actions should the nurse take to manage the PICC? Correct Ans:- Flush the PICC line with 10 mL NS before and after medication administration. A nurse is preparing a client who has supra ventricular tachycardia for elective cardioversion. Which of the following prescribed medications should the nurse instruct the client to withhold for 48 hr prior to cardioversion? Correct Ans:- Digoxin A nurse is reviewing the medical record of a client who is taking warfarin for chronic atrial fibrillation. Which of the following values should the nurse identify as a desired outcome for this therapy? Correct Ans:- INR 2.5 A nurse admits a client who has anorexia, low-grade fever, night sweats, and productive cough. Which of the following actions should the nurse take first? Correct Ans:- Initiate airborne precautions Hypoxia Correct Ans:- All body organs are affected by shock, and either work harder to adapt and compensate for reduced oxygenation or fail to function because of ? Shock Correct Ans:- is widespread abnormal cellular metabolism that occurs when the body's need for oxygenation and tissue PERFUSION is not met adequately. Hypovolemic Shock Correct Ans:- Overall Cause = Total body fluid decreased (in all fluid compartments). Specific Cause or Risk Factors • Hemorrhage • Trauma • GI ulcer • Surgery • Inadequate CLOTTING • Hemophilia • Liver disease • Cancer therapy • Anticoagulation therapy • Dehydration • Vomiting • Diarrhea • Heavy diaphoresis • Diuretic therapy • Nasogastric suction • Diabetes insipidus Cardiogenic Shock Correct Ans:- Overall Cause = Direct pump failure (fluid volume not affected). Specific Cause or Risk Factors • Myocardial infarction • Cardiac arrest • Ventricular dysrhythmias • Cardiac amyloidosis • Cardiomyopathies • Myocardial degeneration A nurse is caring for a client who is experiencing an acute myocardial infarction. The nurse should identify which of the following findings as a manifestation of cardiogenic shock? hypotension bradypnea warm, dry skin increased urinary output Correct Ans:- Hypotension Obstructive Shock Correct Ans:- Overall Cause = Cardiac function decreased by noncardiac factor (indirect pump failure). Total body fluid is not affected, although central volume is decreased. Specific Cause or Risk Factors • Cardiac tamponade • Arterial stenosis • Pulmonary embolus • Pulmonary hypertension • Constrictive pericarditis • Thoracic tumors • Tension pneumothorax Distributive Shock Correct Ans:- Overall Cause = Fluid shifted from central vascular space (total body fluid volume normal or increased). Specific Cause or Risk Factors • Neural-induced • Pain • Anesthesia • Stress • Spinal cord injury • Head trauma • Chemical-induced • Anaphylaxis • Sepsis • Capillary leak • Burns • Extensive trauma • Liver impairment • Hypoproteinemia Key Features of Shock Correct Ans:- Cardiovascular Symptoms = • Decreased cardiac output • Increased pulse rate • Thready pulse • Decreased blood pressure • Narrowed pulse pressure • Postural hypotension • Low central venous pressure • Flat neck and hand veins in dependent positions • Slow capillary refill in nail beds • Diminished peripheral pulses Respiratory Symptoms = • Increased respiratory rate • Shallow depth of respirations • Increased PaCO2 • Decreased PaO2 • Cyanosis, especially around lips and nail beds Gastrointestinal Symptoms = • Decreased motility • Diminished or absent bowel sounds • Nausea and vomiting • Constipation Neuromuscular Symptoms = *Early • Anxiety • Restlessness • Increased thirst *Late • Decreased central nervous system activity (lethargy to coma) • Generalized muscle weakness • Diminished or absent deep tendon reflexes • Sluggish pupillary response to light Kidney Symptoms = • Decreased urine output • Increased specific gravity • Sugar and acetone present in urine Integumentary Symptoms = • Cool to cold • Pale to mottled to cyanotic • Moist, clammy • Mouth dry; pastelike coating present PaCO2, Partial pressure of arterial carbon dioxide; PaO2, partial pressure of arterial oxygen. What problems most often lead to shock Correct Ans:- Cardiovascular Highest risk of shock occurs where Correct Ans:- Acute care setting Shock is most commonly classified by what?. Correct Ans:- the functional impairment it causes or by the origin of the problem. Many manifestations of shock Correct Ans:- including the effects of hypotension and anaerobic cellular metabolism, are similar regardless of what starts the process or which tissues are affected first. The common manifestations of shock result from what Correct Ans:- result from physiologic adjustments, known as adaptive or compensatory mechanisms, made by the sympathetic nervous system, the endocrine system, and the cardiovascular system that attempt to ensure continued oxygenation of vital organs. Cardiogenic shock Correct Ans:- occurs when the actual heart muscle is unhealthy and pumping is directly impaired. Myocardial infarction Correct Ans:- is the most common cause of direct pump failure. Obstructive shock Correct Ans:- is caused by the inability of the heart to pump normally. The most common cause is cardiac tamponade. Distributive shock Correct Ans:- occurs when blood volume is not lost from the body but is distributed to the interstitial tissues, where it cannot perfuse organs. can be caused by a loss of sympathetic tone, blood vessel dilation, pooling of blood in venous and capillary beds, and increased blood vessel permeability. Chemical-induced distributive shock has three common origins: Correct Ans:- anaphylaxis, sepsis, and capillary leak syndrome. It occurs when certain body chemicals or foreign substances in the blood and vessels start widespread changes in blood vessel walls. Anaphylaxis Correct Ans:- is one result of Type I allergic reactions, beginning within seconds to minutes after exposure to a specific allergen in a susceptible person. • The result is widespread loss of blood vessel tone and decreased cardiac output. • Assess all patients at risk for shock for a change in affect, reduced cognition, altered level of consciousness, and increased anxiety. • Stay with the patient in shock. Reassure patients who are in shock that the appropriate interventions are being instituted. • Immediately assess vital signs of patients who have a change in level of consciousness, increased thirst, or anxiety. • Assess for changes in pulse rate and quality rather than blood pressure as an indicator of shock. • Give oxygen to any patient in shock. Sepsis Correct Ans:- SIRS resulting from an infection Severe Sepsis Correct Ans:- sepsis with acute associated organ failure Septic shock Correct Ans:- persistently low mean arterial blood pressure as a result of overwhelming infection despite adequate fluid resuscitation Refractory septic shock Correct Ans:- persistently low MAP despite vasopressor therapy and adequate fluid resuscitation Sepsis meds Correct Ans:- •Antibiotic: most common cause of sepsis is gram-negative bacteria •NPSG's: give antibiotics effective against gram-negative bacteria within 1 hour of diagnosis (Vano) Goals for treating sepsis Correct Ans:- •Resuscitation •Correct hypoxia, hypotension, and impaired tissue oxygenation (hypoperfusion) •Fluid resuscitation, vasopressors (dopamine, dobutamine, norepinephrine (levophed), epinephrine, etc...) •Identify the source of infection •Antibiotics, surgery •Maintain adequate organ system function, guided by cardiovascular monitoring, and stop the progression to multiple organ dysfunction syndrome (MODS) •Surviving Sepsis Campaign: Bundles urosepsis Correct Ans:- More frequent in older adults, Increased use of catheters in long-term care facilities, Late detection of urinary tract infection, Decreased sensation of burning, urgency, etc... What are the s/s of urosepsis in an older adult? Correct Ans:- Confusion, suprapubic pain, fever, irritable, hematuria, decreased output At risk for systemic infections Correct Ans:- •Those at risk for systemic infections, potential sepsis and organ failure •Environmental, chronic illness, hypersensitivities, immune function, autoimmune diseases, HIV •Wounds, burns, trauma •Secondary opportunistic infections can rapidly progress to sepsis in very young; premies, and elderly •Those with immune issues •Underlying infection, addictions, smoking, malnutrition, anemia, hepatic diseases, etc.... SIRS Correct Ans:- • Uncontrolled inflammation in multiple organs that are far from the area of insult • Overwhelming self-defense mechanism • Re-increased activation of the inflammatory cell, such as neutrophils macrophages lymphocytes and damage to the vascular epithelium, deterioration in distribution of nutrient to the organs, ends with MOF SIRS causes Correct Ans:- Some causes: • Infection, pancreatitis, ischemia, trauma, hemorrhagic shock, aspiration of gastric contents, massive transfusions, host defense deficiencies • An insult occurs to the body • Inflammatory Immune Response occurs • Systemic Inflammatory Response Syndrome • Neuroendocrine responses • SNS response (cortisol, catecholamine's released: increase glucose production and activation of platelets • Renal responses • Decreased kidney perfusion with hypotension; renin angiotensin response • May lead to Multiple Organ Dysfunction Syndrome MODS ARDS Correct Ans:- •Non-cardiac pulmonary edema •Increased permeability of alveolar capillary membrane Etiology •Aspiration, near drowning, smoke/toxic chemical inhalation, radiation, drug toxicity, chest trauma, sepsis, pneumonia, cardiopulmonary bypass, embolism , pancreatitis, SIRS, DIC, shock Disseminated Intravascular Coagulation (DIC) Correct Ans:- •Characterized by systemic activation of blood coagulation - overstimulation of clotting cascade •Results in generation and deposition of fibrin •Leads to microvascular thrombi in various organs Contribute to multiple organ dysfunction syndrome MODS. •Consumption and subsequent exhaustion of coagulation proteins and platelets •Causes severe bleeding •Excessive clotting depletes clotting factors faster than the liver and bone marrow can replace them. •The blood clots cause hypoperfusion of tissues and organs leading to ischemia, while the anticoagulants released to dissolve the clots trigger hemorrhages in other locations. •The sudden hemorrhages to the tissues beneath the skin and mucous membranes produce bruises. S+S of DIC Correct Ans:- •A patient with DIC can present with a simultaneous: excessive clotting and hemorrhage S+S = bleeding from eyes, IV sites bleeding, NO MORE NEEDLES! Give them heparin give them platelets and fresh frozen plasma DIC complications Correct Ans:- •Microvascular clots impairs circulation •i.e., clots in kidneys - kidney failure, in lungs: ARDS •Cells die, release of mediators that activate the inflammatory process •Hypoxia, acidosis and shock occur •Systems affected by DIC: •Skin, lungs, kidneys, CNS and GI systems •Severe bleeding, stroke, lack of blood flow to arms, legs or organs Acute Coronary Syndrome Correct Ans:- is used to describe patients who have either unstable angina or an acute myocardial infarction -it is believed that the atherosclerotic plaque in the coronary artery ruptures, resulting in platelet aggregation, thrombus formation, and vasoconstriction. Three categories according to the presence or absence of ST-segment elevation on the ECG and positive serum troponin markers: Correct Ans:- -ST-elevation MI (STEMI) (traditional manifestation) -Non-ST-elevation MI (NSTEMI) (common in women) -Unstable angina pectoris Unstable angina pectoris Correct Ans:- is chest pain or discomfort that occurs at rest or with exertion and causes severe activity limitation, increase in the number of attacks and in the intensity of the pressure indicated unstable angina; the pressure may last more than 15 minutes or may be poorly relieved by rest or nitroglycerin. New onset angina Correct Ans:- describes the patient who has his/her first angina symptoms, usually after exertion or other increased demands on the heart. Variant (Prinzmetal's) Angina Correct Ans:- is chest pain or discomfort resulting from coronary artery spasm and typically occurs after rest Pre-infarction angina Correct Ans:- refers to chest pain that occurs in the days or weeks before an MI Modifiable risk factors Correct Ans:- -are lifestyle choices that can be controlled by the patient -elevated serum lipid levels -smoking/tobacco use -limited physical activity -hypertension -diabetes mellitus -obesity -excessive alcohol -excessive stress/decreased coping skills Non-modifiable risk factors Correct Ans:- -age -gender -family -history -ethnic background MI Correct Ans:- the most serious acute coronary syndrome, undiagnosed or untreated angina can lead to MI. -occurs when myocardial tissue is abruptly and severely deprived of oxygen Labs to check for MI Correct Ans:- troponin and creatine kinase-MB A client had an embolic stroke and is having an echocardiogram. When the client asks why the provider ordered "a test on my heart," how should the nurse respond? a. "Most of these types of blood clots come from the heart." b. "Some of the blood clots may have gone to your heart too." c. "We need to see if your heart is strong enough for therapy." d. "Your heart may have been damaged in the stroke too." Correct Ans:- ANS: A An embolic stroke is caused when blood clots travel from one area of the body to the brain. The most common source of the clots is the heart. The other statements are inaccurate. A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best? a. Have the student ask the client if it is desired or not. b. Inform the student that the docusate should be given. c. Tell the student to document the rationale. d. Tell the student to give it unless the client refuses. Correct Ans:- ANS: B Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea. A nurse is providing community screening for risk factors associated with stroke. Which client would the nurse identify as being at highest risk for a stroke? a. A 27-year-old heavy cocaine user b. A 30-year-old who drinks a beer a day c. A 40-year-old who uses seasonal antihistamines d. A 65-year-old who is active and on no medications Correct Ans:- ANS: A Heavy drug use, particularly cocaine, is a risk factor for stroke. Heavy alcohol use is also a risk factor, but one beer a day is not considered heavy drinking. Antihistamines may contain phenylpropanolamine, which also increases the risk for stroke, but this client uses them seasonally and there is no information that they are abused or used heavily. The 65-year-old has only age as a risk factor. The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.) a. Alcohol intake b. Diabetes c. High-fat diet d. Obesity e. Smoking Correct Ans:- ANS: A, C, D, E Alcohol intake, a high-fat diet, obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention. A nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assess neurologic status with the Glasgow Coma Scale. b. Check and document oxygen saturation every 1 to 2 hours. c. Cluster client care to allow periods of uninterrupted rest. d. Elevate the head of the bed to 45 degrees to prevent aspiration. e. Position the client supine with the head in a neutral midline position. Correct Ans:- ANS: B, E The UAP can take and document vital signs, including oxygen saturation, and keep the client's head in a neutral, midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees. Ischemia Correct Ans:- occurs when insufficient oxygen is supplied to meet the requirements of the myocardium. Infarction Correct Ans:- (necrosis, or cell death) occurs when severe ischemia is prolonged and decreased PERFUSION causes irreversible damage to tissue. Which cholesterol contributes to arteriosclerosis? Correct Ans:- LDL-C, need to increase HDL to treat What effect does this process have on the cell lumen size? Correct Ans:- Bad cholesterol gets in the artery wall and imbedded in cell wall as fatty streaks - then becomes plaque- plaque expands to maintain artery opening - expansion of plaque and angina may start now and calcium deposits to reduce flexibility - increased pressure then may cause blood clot that blocks artery How does this process cause an embolism? Correct Ans:- - Increased pressure then may cause blood clot that blocks artery due to calcium binding to plaque or blood goes to site to repair if it breaks off Dx for Coronary Artery Disease CAD Correct Ans:- • Electrocardiogram, Holter monitor, Chest X-ray • Cardiac enlargement, calcifications, of aorta, pulmonary vascular congestion, non cardiac issues • Laboratory tests = Troponin, CK MB • Electrocardiogram (ECG) stress test • Pharmacological stress test - Adenoscene stress test • Stress echocardiogram Metabolic Syndrome Correct Ans:- Also called syndrome X, has been recognized as a risk factor for cardiovascular (CV) disease and is being researched aggressively. Higher in Mexican Americans, American Indians, and Alaska Native people living in the southwestern United States. A combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes. Metabolic Syndrome Causes Correct Ans:- • Central obesity • Increased triglycerides • Low HDL cholesterol • Hypertension • Elevated fasting glucose • 3 or the five risk factors - considered to have Met-syndrome More modifiable Risk Factors • Previous health status • Stress and coping • Dietary factors • Alcohol intake • Elevated homocysteine levels Non-modifiable risk factors = Age, Heredity, Gender, Chronic renal disease Silent Ischemia Correct Ans:- • Ischemic episodes without knowing it. No pain is felt • An MI may occur with no prior warning. • People with angina also may have undiagnosed episodes of silent ischemia. • At RISK: DIABETES due to neuropathies Assessment with clinical manifestations of angina • Pain (discomfort) assessment • Descriptions: o Dull, achy, tight, squeezing, pressure, "someone's sitting on my chest." o Pain or pressure unrelated to movement or respirations o May radiate to jaw, neck, shoulder, left arm, elbow, between shoulder blades, or epigastrium. Or may simply be in the arm, elbow, jaw or back (referred pain). o Mild to severe • Accompanying symptoms: nausea, moist/diaphoresis, short of breath, dizzy, weak • Anxious "I just don't feel right" • c/o indigestion, epigastric discomfort • Precipitated by: o Activity, emotional stress, cold weather, large meals Silent ischemia; ischemia with no detectable pain (SILENT MI) is often mistaken as Correct Ans:- Mistaken for indigestion, nausea, muscle pain or a bad case of the flu. Elevated BNP Correct Ans:- There is increased hormone/diuretic = Cardiac problem TIA - transient ischemic attack Correct Ans:- • Temporary neurologic dysfunction resulting from a brief interruption in cerebral blood flow • Usually resolves in 30 - 60 minutes; up to 24 hours • Indicate a high stroke risk • Multiple TIA's may damage brain tissue TIA assessment Correct Ans:- •Temporary neurological dysfunction average: may last only a few minutes, 30 - 60 minutes; but less than 24 hours () •Visual deficits: blurred vision, diplopia, blindness in one eye, tunnel vision •Mobility deficits: weakness (facial droop, arm or leg drift, hand grasp), ataxia •Sensory perception deficits: numbness to face, hand arm or leg; vertigo •Speech deficits: aphasia, dysarthria CVA Correct Ans:- •Interruption of perfusion to parts of the brain resulting in death of cerebra tissue (infarction) •Blood flow is affected causing damage to other parts of the brain, increased ICP Types of strokes: •Ischemic (embolic and thrombotic) Occlusive strokes •Hemorrhagic (bleed) Hemorrhagic stroke Correct Ans:- MASSIVE HEADACHE Hemorrhagic stroke - Intracerebral hemorrhage (ICH) Correct Ans:- •Bleed into brain tissue •Causes: severe or sustained hypertension, cocaine use •Brain damage: bleeding which causes edema, irritation and displacement Hemorrhagic stroke - Subarachnoid hemorrhage (SAH) Correct Ans:- •More common •Ruptured aneurysm or arteriovenous malformation •Angled collection of malformed, thin-walled dilated vessels without a capillary network Impaired communication due to stroke Correct Ans:- •Aphasia •Expressive aphasia (Broca's aphasia) •Unable to express thoughts •Receptive aphasia (Wernicke's aphasia) •Comprehension problem •Global aphasia •Both expressive and receptive aphasia Stroke Interventions Correct Ans:- •ABC's, Accucheck (Is it really a stroke, or hypoglycemia?) •Stat CT scan (within 25 minutes of arrival) •Start 2 IV lines •Ischemic? Assess history and if no contraindications, start thrombolytics (Alteplase/Activase) •Time begins when patient was last seen "normal" •Endovascular interventions (intra-arterial thrombolysis, mechanical embolectomy, carotid stent placement •Bleed •Hydrocephalus: shunt •Aneurysm: clip •Large hematoma: surgically remove •Arteriovenous malformation (AVM) STROKE PT care per deficit Correct Ans:- ... Homonymous hemianopsia (or homonymous hemianopia) Correct Ans:- is hemianopic visual field loss on the same side of both eyes. Homonymous hemianopsia pt education Correct Ans:- Nursing Intervention: Position the patient in proper body alignment; use a splint to keep the hand in a functional position. *provide frequent passive range-of-motion exercises *reposition patient every 2 hours Nursing Intervention: Approach the patient from the unaffected side; remind the patient to turn the head to compensate for visual deficits Deficit: Dysartheria (muscles of speech impaired) Correct Ans:- Nursing Intervention: Provide for an alternative method of communication Deficit: Dysphagia (muscles of swallowing impaired) Correct Ans:- Nursing Intervention: Test palatal and pharyngeal reflexes before offering nourishment *keep NPO until swallow screen completed and oral intake approved by Dr *Elevate and turn the head to the unaffected side *If able to manage oral intake, place food on the unaffected side of the patient's mouth Deficit: Double vision (diplopia) Correct Ans:- Nursing Intervention: Apply an eye patch on the affected eye Deficit: Absent or diminished response to superficial sensation (touch, pain, pressure, heat, cold) Correct Ans:- Nursing Intervention: Increase the amount of touch administrating patient care. *Protect the involved areas from injury *Protect the involved areas from burns *Examine the involved areas for signs of skin irritation and injury *Provide patient with an opportunity to handle various objects of different weight, texture, and size *If the pain is present, assess its location and type as well as the duration of the pain Deficit: Body scheme disturbance (denial of paralyzed extremities; unilataeral neglect syndrome) Correct Ans:- Nursing Intervention: Protect the involved area *Accept patient's self-perception *Position patient to face involved area Deficit: Disorientation (to time, place, and person) Correct Ans:- Nursing Intervention: Control amount of changes in patient's schedule *reorient as necessary *talk to patient *provide a calendar, clock, pictures of family, and so forth Deficit: Non-fluent aphasia (difficulty in transforming sound into patterns of understandable speech)= can speak using single word responses Correct Ans:- Nursing Intervention: Ask patient to repeat individual sounds of the alphabet as a start to retrain Deficit: Agnosia (inability to identify the environment by means of senses) Correct Ans:- Nursing Intervention: Correct misconceptions Deficit: Defects in localizing objects in space estimating their size, and judging distance Correct Ans:- Nursing Intervention: Reduce any stimuli that distracts the patient Deficit: Fear, hostility, frustration or anger Correct Ans:- Nursing Intervention: Accept the behavior, be supportive Deficit: Bladder Incontinence Correct Ans:- Nursing Intervetion: Do NOT suggest insertion of indwelling catheter immediately after the stroke; intermittent cathererization is better than an indwelling foley Deficit: The unilateral lesion from the stroke results in partial sensation and control of the bladder, so that patient experiences frequency, urgency, and incontinence Correct Ans:- Nursing Intervention: observe patient to identify characteristics of voiding pattern (e.g. frequency, amount, the forcefulness of stream, constant dribbling). Deficit: Constipation is most common problem, along with potential impaction Correct Ans:- Nursing Intervention: Institute a bowel program. Enemas are avoided in the presence of increased intracranial pressure Functions of the kidney Correct Ans:- Regulate blood volume and blood pressure - adjusts volume of water lost in urine, releasing erythropoietin and renin Regulates plasma concentrations of electrolytes sodium, potassium, chloride, and other ions reabsorption; controls calcium ion levels through the synthesis of calcitriol Calcitriol is produced in the cells of the proximal tubule of the nephron Helps stabilize blood pH - Controls loss of H+ and bicarbonate ions in urine Antidiuretic hormone (ADH) Correct Ans:- Regulates urine volume - increases water reabsorption Atrial natriuretic hormone (ANH) Correct Ans:- Secreted by muscle fibers in atria of heart; promotes sodium loss via urine Aldosterone Correct Ans:- Secreted by adrenal cortex; increases sodium absorption controls potassium secretion, leading to osmotic imbalances that causes reabsorption of water. Works with ADH Renin Correct Ans:- Enzyme secreted by kidney; regulates sodium and therefore BP and volume Renin-angiotensin system converts angiotensinogen to angiotensin 1 in liver Angiotensin 1 forms angiotensin II in lungs, which is a vasoconstrictor that stimulates adrenal cotes to produce aldosterone Erythropoietin Correct Ans:- Hormone; produced by kidney in response to low oxygen in arteries; travels to bone marrow and stimulate RBC production chronic renal disease Correct Ans:- is a progressive, irreversible disorder, and kidney function does not recover. It is defined as abnormalities in kidney structure or function that alter health and are present for longer than 3 months. When kidney function and waste ELIMINATION are too poor to sustain life, CKD becomes end-stage kidney disease (ESKD). Terms used with CKD include azotemia (buildup of nitrogen-based wastes in the blood), uremia (azotemia with symptoms), and uremic syndrome. Uremia Correct Ans:- • Metallic taste in the mouth • Anorexia • Nausea • Vomiting • Muscle cramps • Uremic "frost" on skin • Itching • Fatigue and lethargy • Hiccups • Edema • Dyspnea • Paresthesias AKI stages Correct Ans:- Prerenal (decreased blood flow to kidney) MAP <65 mm Hg 55% of renal failure; due to decreased blood flow to kidneys; reversible if caught early. Causes: Dehydration, diuretics, circulatory collapse, hypovolemia, shock Intrarenal (Damage to kidney tissue -glomeruli, nephrons, tubules) Caused by a disease process, inflammation, ischemia, toxic conditions such as acute glomerulonephritis, vascular disorders, toxic agents or severe infection Postrenal (obstruction of urine flow) Caused by any condition that obstructs urine flow such as BPH, renal or urinary tract calculi, or tumors Acute renal disease Correct Ans:- is a rapid reduction in kidney function resulting in a failure to maintain waste ELIMINATION, FLUID AND ELECTROLYTE BALANCE, and ACID-BASE BALANCE. AKI occurs over a few hours or days. The most current definition of AKI is an increase in serum creatinine by 0.3 mg/dL (26.2 mcmol/L) or more within 48 hours; or an increase in serum creatinine to 1.5 times or more from baseline, which is known or presumed to have occurred in the previous 7 days; or a urine volume of less than 0.5 mL/kg/hr for 6 hours Types of dialysis Correct Ans:- Hemodialysis From an AV fistula or graft A=arterial, V=venous. Fistula means an artery and vein are joined; graft means the artery and vein are joined by a synthetic tube or cadaver artery or vein From a central line Continuous Renal Replacement Therapy (CRRT) Therapeutic Plasma Exchange (TPE) TPE Peritoneal dialysis AV Fistula/Graft Assessment Correct Ans:- LISTEN to the bruit using a stethoscope to assess blood flow A continuous low-pitched bruit should be present. If it has disappeared or changed in tone, Notify physician. FEEL for the thrill. A thrill (purring or vibration) indicates blood flow through the AV fistula. A continuous thrill should be present, extending through both systole and diastole. It will diminish in strength as you move farther away from the anastomosis. FEEL for a pulse. The anastomosis should be easily compressible. Avoid forceful compression of the AV fistula with the examining finger. A strong pulse is not good and suggests a downstream obstruction. Management of hemodialysis Correct Ans:- Monitor for complications during dialysis. Dialysis circuit clotting, air bubbles in blood tubing, temperature of the dialysate (37.8° C [100° F]), regulation of the ultrafiltration. Hypotension, cramping, vomiting, bleeding at the access site, contamination of equipment. Monitor vital signs and coagulation studies during dialysis. Monitor for bleeding, such as oozing from the insertion site Administer anticoagulants as prescribed. Heparin is used to prevent clotting of the blood with foreign surfaces. Monitor the aPTT for risk of hemorrhage. Have protamine sulfate ready to reverse heparin if needed. Provide emotional support. Offer activities, such as books, magazines, music, cards, or television, to occupy the client. Peritonitis Correct Ans:- complication of dialysis