Critical Care ATI CMS 2023/2024 GRADED A+

Sign of pulmonary embolsim Correct Answer: Stabbing chest pain, dyspnea The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom. what is this patient experiencing? Correct Answer: pulmonary embolsim they might also exhibit, tachycardia, chest petechiae and decreased SaO2 Who is at increase risk for breast cancer? Correct Answer: -AGE OVER 5O YEARS -Increase breast density, -BMI of 32, -1-2 alcoholic beverages per week. peripheral arterial disease Correct Answer: hair loss dependent rubor painful ulcerations to the toes pain when resting A nurse is caring for a patient who is receiving radiation therapy for breast cancer and reports a metallic taste in the mouth. which recommendation would you give? Correct Answer: Offer mints which can overcome the metallic taste -ADD coffee to sweet beverages or milk -SHOULD consume citrus/tart flavors nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of of receiving blood transfusions. which of the following complications should the nurse monitor for? Correct Answer: Iron toxicity: a client who is received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body Autonomic Dysreflexia due to a C5 spinal cord injury Correct Answer: (potentially life threatening emergency!) HOB elevate 90 degrees, (HIGH FOWLERS) loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) Health fair a pt blood pressure is 150/90 which action should the nurse take? Correct Answer: Give the client a written record of his BP to bring to the provider within 2 MONTHS Lupus, what should the nurse expect to be increased? Correct Answer: erythrocyte sedimentation rate -- indicated inflammation what can cause Lupus exacerbation? Correct Answer: Pregnancy Sunlight Infection NOT: exercise which medications would the nurse administer for lupus? Correct Answer: Corticosteroids such as prednisone Pancreatitis what lab is elevated? Correct Answer: AMYLASE begins to increase in 3-6 hours Amylase typically shows elevation within 12-24 hours and remain elevated for 2-3 days **LIPASE is also elevated Hypocalcemia & hypo magnesium is expected Meniere's disease Correct Answer: condition of the inner ear in which excess fluid distorts the inner ear canal system It affects the COCHLEA AVOID sudden movements an adolescent has recurrent external otitis, what instructions should the nurse give? Correct Answer: instill a diluted alcohol solution into the ear after swimming to decrease bacteria and dry the external ear canal DKA Expected findings Correct Answer: Kussmaul respirations urine positive for ketones Hypotension becasue of dehydration Cervical Cancer manifestation Correct Answer: Vaginal Bleeding Unplanned weight loss Dysuria Pelvic pain and chest pain Gastric surgery and an NG tube was inserted, which finding should be reported to the provider? Correct Answer: 200 mL of bright red drainage what is the purpose of the NG type? Correct Answer: Prevents excessive pressure on the suture lines. it drains the air -pt will began with taking clear liquids by mouth and progress accordingly diabetes insipidus Correct Answer: Polyuria, polydipsia Low specific gravity, Na will be high, serum osmo is high Post total knee arthroplasty Correct Answer: wear elastic stockings on both of my legs Risk factor for osteoporosis Correct Answer: Anorexia nervosa because inadequate protein intake -- decreased bone density Risk factors for bone loss Correct Answer: small body frame low vitamin D intake smoking Treatment for osteoporosis medication = alendronate. what teaching is needed for this medication? Correct Answer: I will sit upright for 30 min after taking the medication to prevent esophageal irritation and ulceration -TAKE IN MORNING -Calcium supplement at a DIFFERENT time of day -TAKE 3O MIN BEFORE FOOD what to recommend a patient with osteoporosis Correct Answer: perform weight bearing exercises such as walking what food will the nurse recommend to promote calcium absorption? Correct Answer: fortified milk Strategies for preventing bone loss Correct Answer: begin a program of brisk walking Leg amputation. Correct Answer: "I will lie on my stomach for 20-30 min a few times a day to help reduce risk of developing hip flexion contractures Rewrap the residual limb with a bandage 3 times per days AIDS. Correct Answer: -Seperate plastic bag to dispose of soiled tissues -Implement handwashing to prevent spread of infection -Wash soiled clothes in hot water along with 1 cup of bleach - CLEAN BLOOD UP WITH BLEACH SOLUTION AND GLOVES AIDS precautions Correct Answer: Discard food after 24 hour thaw frozen food in the refrigerator -USE A SEPARATE CUTTING BOARD FOR RAW POULTRY -store cold foot at 4.4 celcius or less Primary open-angle glaucoma (POAG). Include in teaching: Correct Answer: -Driving can be dangerous due to the loss of peripheral vision -Laser surgery can help reestablish the flow of aqueous humor Hep A: understanding teaching Correct Answer: Hep A: transmitted via the fecal oral route through consumption of contaminated fruits, vegetables, water, milk or uncooked shellfish. ****AVOID SHELLFISH if you have HEP A. **ENCOURAGE HER TO EAT FOODS HIGH IN CARBS HIV Instructions to help with infection prevention Correct Answer: -Avoid large gatherings of people -Clean the toothbrush by running through the dishwasher or beach followed by hot water -Avoid digging in the garden -- increase risk of infection HIV -- AIDS manifestation Correct Answer: You can expect a persistent fever and swollen glands How is HIV transmitted ? Correct Answer: anyone who has had contact with infected blood Variant (Prinzmetal's) Angina Correct Answer: -due to a coronary artery spasm, often occurring during periods of rest. -results in less oxygen supplying the myocardium -- changes to the EKG Expected finding with chemotherapy Correct Answer: Pancytopenia (deficiency of WBC'S, RBC's, and platelet count Perforation of a peptic ulcer expected finding Correct Answer: BOARDLIKE ABDOMEN and severe pain in the abdomen or back that radiates to the RIGHT SHOULDER malignant melanoma expected findings Correct Answer: -Commonly starts on exposed areas of body and then metastasizes to other areas -CHANGE IN COLOR, SIZE, SHAPE OF A SKIN LESION WITH IRREGULAR BORDERS, in hues of BLUE, WHITE OR RED TONES. liver cirrhosis with abdominal distention Correct Answer: Take serial measurements of the abdomen with a tape measure, obtain PT & INR, administer lactulose, administer daily multivitamin Mesastasizing malignant neoplasm in the colon Correct Answer: I have cancer of the colon that has begun to spread Post op frontal craniotomy Correct Answer: Semi fowlers Bowel obstruction-- indication possible bowel perforation = Correct Answer: rigid abdomen tenderness hypotension TPN was stopped for physical therapy, the nurse is monitoring for which finding? Correct Answer: diaphoresis because of sudden withdrawal of TPN -- hypoglycemia hypoglycemia Correct Answer: diaphoresis, irritability, mental confusion, double vision, hunger, tachy, palpitations, SLURRED SPEECH TPN through a CENTRAL LINE, which action should the nurse perform? Correct Answer: Daily weights b/c pt is at risk for FLUID & ELECTROLYTE IMBALANCES -Change tubing q24 hours -Check glucose Q4 HOURS - CHANGE DRESSING Q24-72 HOURS Papules Correct Answer: small, solid, elevated lesion with distinct borders. It is usually smaller than 10mm in diameter. papules are common lesions of warts and elevated moles Macule Correct Answer: change in the COLOR of the skin that is flat, cariably shaped, discolored, and small. freckles and the rash associated with rubella are type of macules Wheals aka HIVES Correct Answer: are transient, elevated, irregularly shaped lesions caused by localized edema. common manifestation of an allergic reaction Vesicles (chickenpox) Correct Answer: A circumscribed, elevated lesion or blister containing serous fluid. Vesicles typically arise in herpes simplex, poison ivy, and chicken pox Herpes zoster or shingles -- viral infection -- what medication ? Correct Answer: ACYCLOVIR inhibits the replication of the virus What are manifestations for herpes zoster or shingles exacerbation? Correct Answer: ACUTE, UNILATERAL INFLAMMATION OF THE DORSAL ROOT GANGLION Dumping syndrome Correct Answer: increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink myocardial infarction. which complication should the nurse monitor in the first 24 hours Correct Answer: Ventricular dysrththmias MI patient, what clinical manifestations would the nurse see? Correct Answer: nausea*** **Substernal chest pain (most common) pain in jaw, shoulder or abdomen acute confusion Multiple Sclerosis Correct Answer: Acute episodes are usually followed by remissions, which can vary in duration. Priority for full thickness burn w/ smoke inhalation Correct Answer: MONITOR RESP STATUS Raynaud's disease Correct Answer: a peripheral arterial occlusive disease in which intermittent attacks are triggered by cold or stress -SMOKING cessation can PREVENT the onset of the manifestations of raynauds disease -increase exposure to sunlight -alcohol does not relate to raynauds Gout Correct Answer: reduce/limit foods high in purine such as organ meats The nurse should identify that what places the client at risk for gout? Correct Answer: Diuretic use pt has gout and urolithiasis. what suggestions should the nurse provide? Correct Answer: take allopurinol Exercise several times a week limit intake of foods high in purine medication for gout? & what can interact with it? Correct Answer: Probenecid aspirin Thyroidectomy for the presence of hypoparathyroidism -- expected findings Correct Answer: INVOLUNTARY MUSCLE SPASMS because parathyroid glands are damaged or removed during a thyroidectomy. -Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and calcium deficiency **TACHY & HYPERTENSION **LARYNGEAL STRIDOR & HOARSENESS **POSITIVE TROUSSEAUS sign Alzheimer's disease. Correct Answer: Use gestures when speaking to the client Secondary Prevention actions for colorectal cancer Correct Answer: Importance of colonoscopy screening starting at 50 years old manifestation of colorectal cancer Correct Answer: Abdominal craps weight loss blood in stool Brainstem injury -- what to monitor Correct Answer: Respiratory effort, the MEDULLA controls the respiratory center What is the temporal lobe for? Correct Answer: Speech Frontal lobe Correct Answer: decision making and situational reactions What part of the brain controls temperature? Correct Answer: Hypothalamus Post op education for radical neck dissection for cancer of the larynx Correct Answer: -NPO status -Alternative methods of communication -Changes in body image - Swallowing exercises