EXAM 2: NCLEX (Renal, GI, Neuro)
Terms in this set (306)
A client admitted for acute pyelonephritis is about to start antibiotic therapy. Which symptom would be expected in this client?
2) Flank pain on the affected side
3) Pain that radiates toward the unaffected side
4) No tenderness with deep palpation over the
RATIONAL: 2) The client may complain of pain on the affected side because the kidney is enlarged and might have formed an abscess.
Hypertension is associated with chronic pyelonephritis. Pain may radiate down the ureters or to the epigastrium. The client would have tenderness with deep palpation over the CVA.
Discharge instructions for a client treated for acute pyelonephritis should include which statement?
- 1. Avoid taking any dairy products.
- 2. Return for follow-up urine cultures.
- 3. Stop taking the prescribed antibiotics when the symptoms subside.
- 4. Recurrence is unlikely because you've been treated with antibiotics.
RATIONALE: 2) The client needs to return for follow-up urine cultures because bacteriuria may be present but asymptomatic. Intake of dairy products won't contribute to pyelonephritis. Antibiotics need to be taken for the full course of therapy regardless of the symptoms. Pyelonephritis typically recurs as a relapse or new infection and frequently recurs within 2 weeks of completing therapy.
A client is complaining of severe flank and abdominal pain. A flat plate of the abdomen shows urolithiasis. Which intervention is important?
- 1. Strain all urine
- 2. Limit fluid intake
- 3. Enforce strict bed rest.
- 4. Encourage a high-calcium diet
RATIONALE: 1) Urine should be strained for calculi and sent to the laboratory for analysis. Fluid intake of 3 to 4 qt. 3 to 4 L/day is encouraged to flush the urinary tract and prevent further calculi formation. Ambulation is encouraged to help pass the calculi through gravity. A low-calcium formation of calcium calculi.
A client is diagnosed with cystitis. Client teaching aimed at preventing a recurrence should include which instruction?
- 1. Bathe in a tub.
- 2. Wear cotton underwear.
- 3. Use a feminine hygiene spray.
- 4. Limit your intake of cranberry juice.
RATIONALE: 2) Cotton underwear prevents infection because it allows for air to flow to the perineum. Women should shower instead of taking a tub bath to prevent infection. Feminine hygiene spray can act as an irritant. Cranberry juice helps prevent cystitis because it increases urine acidity; alkaline urine supports bacterial growth, so cranberry juice intake should be increased, not limited.
When performing a physical assessment, the nurse discovers a client's urinary drainage bag lying next to him. Based on this finding, the nurse identifies which priority nursing diagnosis?
- 1. Risk for infection
- 2. Reflex urinary incontinence
- 3. Impaired comfort
- 4. Risk for compromised human dignity
RATIONALE: 1) The drainage bag shouldn't be placed alongside the client or on the floor because of the increased risk of infection caused by microorganisms. It should hang on the bed in a dependent position. The other nursing diagnoses are not appropriate for this assessment finding.
Which method should be used to collect a specimen for urine culture?
- 1. Have the client void in a clean container.
- 2. Clean the foreskin of the penis of uncircumcised men before specimen collection.
- 3. Have the client void into a urinal, and then pour the urine into the specimen container.
- 4. Have the client begin the stream of urine in the toilet and catch the urine in a sterile container midstream.
RATIONALE: 4) Catching urine midstream reduces the amount of contamination by microorganisms at the meatus. Voiding in a clean container is done for a random specimen, not a clean-catch specimen for urine culture. When cleaning an uncircumcised male, the foreskin should be retracted and the glands penis should be cleaned to prevent specimen contamination. Voiding in a specimen because the urinal isn't sterile.
A client with renal insufficiency is admitted with a diagnosis of pneumonia. He's being treated with IV antibiotics, which can be nephrotoxic. Which laboratory value(s) should be monitored closely?
- 1. Blood Urea Nitrogen (BUN) and creatinine levels.
- 2. Arterial Blood Gas (ABG) levels
- 3. Platelet count
- 4. Potassium level
RATIONALE: 1) BUN and creatinine levels should be monitored closely to detect elevations due to nephrotoxicity. ABG determinations are inappropriate for this situation. Platelets and potassium levels should be monitored according to routine.
During a health history, which statement by a client indicates a risk of renal calculi?
- 1. "I've been drinking a lot of cola soft drinks lately."
- 2. "I've been jogging more than usual."
- 3. "I've had more stress since we adopted a child last year."
- 4. "I'm a vegetarian and eat cheese two or three times each day."
RATIONALE: 4) Renal calculi are commonly composed of calcium. Diets high in calcium may predispose a person to renal calculi. Milk and milk products are high in calcium. Cola soft drinks don't contain ingredients that would increase the risk of renal calculi. Jogging and increased stress aren't considered risk factors for renal calculi formation.
The nurse is assessing a client who reports painful urination during and after voiding. The nurse suspects the client may have a problem with which area of the client's urinary system?
- 1. Bladder
- 2. Kidneys
- 3. Ureters
- 4. Urethra
RATIONALE: 1) Pain during or after voiding indicates a bladder problems, usually infection. Kidney and ureter pain would be in the flank area, and problems or the urethra would cause pain at the external orifice that's commonly felt at the start of voiding.
A nurse is instructing a client with oxalate renal calculi. What foods should the nurse urge the client to eliminate from his diet?
1) Citrus fruits, molasses, and dried apricots
2) Milk, cheese, and ice cream
3) Sardines, liver and kidney
4) Spinach rhubarb and asparagus
RATIONALE: 4) To reduce the formation of oxalate calculi, urge the client to avoid foods high in oxalate, such as spinach, rhubarb, and asparagus. Other oxalate- rich foods to avoid include tomatoes, beets, chocolate, cocoa, celery, and parsley.
Citrus fruits, molasses, dried apricots, milk, cheese, ice cream, sardines and organ meats do NOT produce oxalate and do NOT need to be omitted from the client's diet.
A nurse is assessing a client diagnosed with acute pyelonephritis. Which of the following symptoms does the nurse expect to see?
1) Jaundice and flank pain
2) Costovertebral angle tenderness and chills
3) Burning sensation on urination
4) Polyuria and nocturia
RATIONALE: 2) Costovertebral angle tenderness and chills are symptoms of acute pyelonephritis (inflammation of the kidney and renal pelvis).
Jaundice indicates gallbladder or liver obstruction.
A burning sensation on urination is a sign of lower urinary tract infection (UTI).
Nocturia is associated with a lower UTI or benign prostatic hyperplasia.
Polyuria is seen with diabetes mellitus, diabetes insipidus, or the use of diuretics.
A nurse is caring for a client who has undergone surgery to create an ileal conduit. Which expected outcome statement is appropriate for this client?
1) The client uses sterile gloves when changing the appliance.
2) The client demonstrates the ability to irrigate the stoma correctly.
3) The client expresses understanding and acceptance of the fact that he can no longer engage in sexual relations.
4) The stoma remains pink and moist.
RATIONALE: 4) A healthy stoma is pink and moist.
Sterile gloves aren't necessary when changing the appliance.
The stoma isn't to be irrigated.
There's no physiologic reason why the client can't engage in sexual relations.
A client is admitted with dark urine, fever, and flank pain and is diagnosed with acute glomerulonephritis. What finding is the nurse most likely to find in the client's history?
1) Renal calculi
2) Renal trauma
3) Recent sore throat
4) Family history of acute glomerulonephritis
RATIONALE: 3) Recent sore throat. Typically, acute glomerulonephritis occurs 2 to 3 weeks after a strep throat infection. The Most Common form of acute glomerulonephritis is caused by group A beta-hemolytic streptococcal infection elsewhere in the body.
Renal calculi and renal trauma aren't known to cause acute glomerulonephritis.
A family history isn't associated with the development of acute glomerulonephritis.
A nurse is assessing a client who might have a UTI. What statement by the client suggests that a UTI is likely?
1) I urinate large amounts.
2) It burns when I urinate.
3) I go for hours without the urge to urinate.
4) My urine has a sweet smell.
RATIONALE: 2) Dysuria (painful urination) is a common symptom of a UTI.
Voiding large amounts of urine isn't associated with UTI's; clients with UTI's commonly report frequent voiding of small amounts of urine.
A client with a UTI is unlikely to be able to go for hours without urinating because UTI's increase feelings of urgency to void.
Urine with a sweet acetone odor is associated with diabetic ketoacidosis.
Foul-smelling urine may be a sign of infection.
While undergoing hemodialysis, a client complains of muscle cramps. What intervention is effective in relieving muscle cramps?
1) Encourage active ROM exercises.
2) Administer a 5% dextrose solution.
3) Infuse normal saline solution.
4) Increase the rate of dialysis.
RATIONALE: 3) Because muscle cramps can occur when sodium and water are removed too quickly during dialysis, treatment includes administering normal saline or hypertonic normal saline solution.
ROM exercises and an infusion of 5% dextrose solution wouldn't reduce muscle cramps.
Reducing, not increasing, the rate of dialysis may also alleviate muscle cramps.
A nurse is instructing a client how to obtain an accurate clean-catch urine specimen for a urine culture. She should include what instruction?
1) Clean the perineal area well.
2) Wash the inside of the container.
3) Void to fill the container.
4) Leave the container open to the air.
RATIONALE: 1) when obtaining a clean-catch urine specimen, the perineal area should be thoroughly cleaned.
The inside of the container is already sterile, so washing it would only contaminate it.
Only a small specimen of urine is needed, so it isn't necessary to completely fill the container.
The container should be closed as soon as the urine is collected to prevent contamination
Which client is at greatest risk for developing a UTI?
1) A 35 year old woman with an arm fracture.
2) An 18 year old woman asthma.
3) A 50 year old postmenopausal woman.
4) A 28 year old woman with angina.
RATIONALE: 3) Women are more prone to UTI's after menopause. Urinary stasis may develop due to a loss of pelvic muscle tone and prolapse of the bladder or uterus. Reduced estrogen levels lead to reduced levels of vaginal Lactobacilli bacteria, which protect against infection.
While chronic diseases, including diabetes mellitus and impaired immunity, increase the risk of UTI, angina, asthma, and fractures don't increase the risk of UTI.
A client is hospitalized and diagnosed with acute hydronephrosis. Which complaint does the nurse expect from this client?
1) Sudden onset of acute, colicky pain
2) Sharp left flank pain
3) Sharp, throbbing pain
4) Felling of pressure and distention
RATIONALE: 1) Sudden, acute colicky pain is a clinical sign of acute hydronephrosis. Hydronephrosis occurs when urine collects in the renal pelvis and calyces due to obstruction or atrophy of the urinary tract.
Flank pain most commonly indicates a kidney infection, although it may occur hydronephrosis.
Distention and pressure are commonly felt in the pelvis and bladder with lower urinary tract obstructions.
A nurse is instructing a client with renal calculi about recommended daily fluid consumption. The nurse would be most helpful by telling the client to drink approximately:
1) 4 cups per day
2) 8 cups per day
3) 12 cups per day
4) 16 cups per day
RATIONALE: 3) A client with renal calculi should drink 3L (12 cups) of fluid per day.
A nurse is caring for a client after a renal biopsy. The nurse observes the client for:
1) Increased activity
3) Changes in mental status
4) Increased blood pressure
RATIONALE: 2) A renal biopsy is obtained through needle insertion into the lower lobe of the kidney, which can need to hemorrhage, so the nurse needs to watch for signs and symptoms of bleeding.
After the procedure, the client should remain still for 4 to 12 hours.
Changes in mental status (unless the client is bleeding heavily) or blood pressure aren't related to renal biopsy.
A nurse is writing the teaching plan for a client with cystitis who's receiving phenazopyridine (Pyridium). What instruction should the nurse include?
1) Call the physician if urine turns orange-red
2) Take phenazopyridine just before urination to relieve pain
3) Discontinue prescribed antibiotics after painful urination is relieved
4) Stop taking phenazopyridine after painful urination is relieved.
RATIONALE: 4) Phenazopyridine is taken to relieve dysuria because it provides an analgesic and anesthetic effect on the urinary tract mucosa. The client can stop taking it after the dysuria is relieved.
Warn the client that the dye in the drug (azo dye) may temporarily turn the urine red or orange but that isn't cause for calling the physician.
Phenazopyridine is usually taken three times per day for 2 days. It isn't taken just before voiding.
Antibiotics must be taken for the full course of therapy, even if the burning on urination is relieved.
A nurse is teaching a female client how to prevent the recurrence of urinary tract infection. The nurse should teach her to do which action?
1) Wipe from back to front after urination or a bowel movement.
2) Urinate every 2 to 3 hours.
3) Drink at least 8 oz (236.6ml) of fluid each day.
4) Take daily bubble baths.
RATIONALE: 2) The nurse should instruct the client to void every 2 to 3 hours to flush bacteria from the urethra and prevent urinary stasis in the bladder.
Wiping from front to back (Not back to front) after a bowel movement or urination moves bacteria away from the urethral meatus.
Drink 2 to 3 quarts (2 to 3L) of fluid per day helps flush bacteria out of the urinary tract.
The nurse should tell the client to avoid bubble baths because they can irritate the urethra, increasing the risk of inflammation and infection.
A nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse should be alert for which of the following? SELECT ALL THAT APPLY.
1) Trousseau's sign
2) Cardiac arrhythmia
4) Decreased clotting time
5) Drowsiness and lethargy
RATIONALE: 1, 2, 6.
Hypocalcemia is a calcium deficit that causes irritability and repetitive muscle spasms.
S/S of hypocalcemia include Trousseau's sign, cardiac arrhythmias, diarrhea, increased clotting times, anxiety, and irritability.
The calcium-phosphorus imbalance leads to brittle bones and pathologic fractures.
A nurse is teaching a male client how to collect a clean-catch midstream urine specimen. What cleaning technique should the nurse include in her teaching?
1) Clean in a circular motion, starting at the urethral meatus and moving several inches down the shaft of the penis.
2) Clean in circular patterns, starting several inches down the penis and moving up toward the tip of the penis.
3) Scrub back and forth across the urethral meatus and down the shaft of the penis.
4) Wipe in rows starting at the urethral meatus and moving down the shaft of the penis.
RATIONALE: 1) before collecting a clean-catch urine specimen, a male client should clean around the urethral meatus in a circular motion and move several inches down the shaft of the penis.
When the penis is cleaned from down the shaft to up toward the urethral meatus, organisms from the skin of the penis are dragged toward the meatus.
Scrubbing back and forth repeatedly moves organisms across the urethral meatus, not away from it.
Some areas of the skin around the tip of the penis may be missed when cleaning is done in rows.
A client is receiving peritoneal dialysis. What should the nurse do when the return fluid is slow to drain?
1) Check for kinks in the outflow tubing
2) Raise the drainage bag above the level of the abdomen
3) Place the client in a reverse Trendelenburg position
4) Ask the client to cough
RATIONALE: 1) Tubing problems are common cause of outflow difficulties. When the return fluid is slow to drain, check the tubing for kinks and ensure all clamps are open.
Other measures that may improve drainage include having the client change positions (moving side to side or sitting up in bed), applying gentle pressure over the abdomen, or having a bowel movement.
Placing the drainage bag lower (not higher) than the abdomen may also improve drainage.
Placing the client in reverse Trendelenburg position wouldn't help drainage and could impair respirations.
Coughing doesn't affect drainage time.
After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an I.V. of D5W infusing at 40ml/hr and a triple lumen urinary catheter with normal saline solution infusing at 200,l/hr. A nurse empties the urinary catheter drainage bag 3 times during an 8 hr period, for a total of 2780ml. How many milliliters does the nurse calculate as urine? Round to the nearest whole number. ________ ml
RATIONALE: During 8 hrs, 1600ml of bladder irrigation has been infused (200ml x 8hrs = 1600ml/8hrs).
The nurse then subtracts this amount of infused bladder irrigation from the total volume in the drainage bag (2780ml - 1600ml = 1180ml) to determine urine output.
A nurse is caring for a client in the immediate postoperative period after a prostatectomy.
What complication requires priority assessment?
3) Urine retention
4) Deep vein thrombosis
RATIONALE: 2) Immediately after a prostatectomy, , hemorrhage is a potential complication.
Pneumonia may occur if the client doesn't turn, cough, and breathe deeply after surgery.
Urine retention isn't a problem immediately after surgery because a catheter is in place.
Thrombosis may occur later if the client doesn't ambulate.
A client is scheduled to undergo a transurethral prostatectomy (TURP) under spinal anesthesia. During the preoperative teaching, the nurse explains to the client that as a result of spinal anesthesia he'll:
1) Be unable to move his arms immediately after surgery
2) Require analgesics to relieve pain in his back
3) Be unable to move his legs immediately after surgery
4) Require a special machine to help him breathe after surgery
RATIONALE: 3) a client who had anesthesia can't move extremities below the level of the anesthesia. This client wouldn't be able to move his legs but could move his arms.
Back pain isn't necessarily caused by spinal anesthesia.
He wouldn't have difficulty breathing.
While undergoing hemodialysis, a client becomes restless and tells a nurse that he has a headache and feels nauseous. Which complication does the nurse suspect?
2) Disequilibrium syndrome
3) Air embolus
4) Acute hemolysis
RATIONALE: 2) Disequilibrium syndrome is caused by a rapid reduction in urea, sodium, and other solutes from the blood. This may lead to cerebral edema and increased intracranial pressure (IICP).
S/S of ICCP include HA, nausea, and restlessness as well as vomiting, confusion, twitching, and seizures.
Fever and elevated WBC may indicate infection.
Popping or ringing in the ears, chest pain, dizziness, or coughing suggests an air embolus.
Chest pain, dyspnea, burning at the access site and cramping suggests acute hemolysis.
A nurse is caring for a client with end stage renal disease. Which nursing diagnosis has priority?
1) Activity intolerance
2) Excess fluid volume
3) Deficient knowledge
4) Chronic pain
RATIONALE: 2) Excess Fluid Volume is a top priority nursing diagnosis for a client with end stage renal disease because the kidney can no longer remove fluid and wastes. The other diagnoses may also apply, but they don't take priority.
A nurse is caring for a client with renal calculi. Which drug does the nurse expect the physician to order?
1) Opioids analgesics
2) Nonsteroidal anti-inflammatory drugs
3) Muscle relaxants
RATIONALE: 1) Opioid analgesics are usually needed to relieve the severe pain of renal calculi.
NSAIDs and Salicylates are used for their anti-inflammatory and antipyretic properties and to treat less severe pain.
Muscle relaxants are typically used to treat skeletal muscle spasms.
A client admitted with renal failure is in the oliguric phase. A nurse expects the client's 24-hr urine output to be less than what amount?
RATIONALE: Oliguria is defined as a diminished urine output of less than 400ml/24hrs
A client in acute renal failure becomes severely anemic and the physician prescribes 2 units of packed red blood cells. A nurse should plan to administer each unit:
1) As quickly as the client can tolerate the infusion
2) Over 30minutes to an hour
3) Between 1 and 3 hours
4) Up to 6 hours, but no longer
RATIONALE: Infusing a unit of RBCs over 1 to 3 hours is standard practice.
A nurse is teaching a client how to collect a clean catch midstream urine specimen for culture and sensitivity testing. What instructions should a nurse include?
1) Collect the first 30ml of urine voided on rising in the morning
2) Discard the first void urine; collect for the next 24hrs
3) Collect a specimen after discarding the first 30ml of urine
4) Collect all urine voided until the bladder is empty
RATIONALE: 3) To collect a clean catch midstream urine specimen; tell the client to void 30ml, stop, and then begin collecting the urine in a sterile urine container. After the sterile container is removed, the client should then finish voiding rest of the urine in the bladder.
Discarding the first 30ml of urine flushes away microorganisms that may be around the urinary meatus and distal portions of the urethra.
Collecting the first 30ml of urine voided on rising in the morning results in a contaminated specimen.
Urine isn't collected for 24hrs for a clean-catch specimen.
The first and last voided urine are discarded in a clean catch specimen.
A client with chronic renal failure is undergoing peritoneal dialysis. A nurse knows that the proper infusion time for the dialysate is:
1) 15 min
RATIONALE: 1) Dialysate should be infused quickly. When performing dialysis, the dialysate should be infused over 15 minutes or less. The fluid then dwells in the peritoneum, whre the exchange of fluid and waste products takes place over a period ranging from 30min to several hours.
A client with hiatal hernia reports to the nurse that he has trouble sleeping because of abdominal pain. The nurse should instruct the client to sleep:
1) With his upper body elevated
2) In a prone position
3) Flat or in a side lying position
4) With his lower body slightly elevated
RATIONALE: 1) Upper body elevation can reduce the gastric reflux associated with hiatal hernia.
Sleeping in a prone or side lying position, or with his lower body slightly elevated, won't help the client.
A nurse is caring for a client with hepatic encephalopathy. The nurse expects which of the following lab values to be abnormal?
RATIONALE: 1) Hepatic encephalopathy is a degenerative disease of the brain caused by advanced liver disease. It develops because of increasing blood ammonia levels. Ammonia levels increase because of proper shunting of blood, causing ammonia to enter the systemic circulation, with carries it to the brain. Excess protein intake, sepsis, excessive accumulation of nitrogenous body wastes (from constipation or GI hemorrhage), and bacterial action on protein and urea also lead to increases in ammonia levels.
Amylase levels increase with panceatitis, and inflammation of the pancreas.
Hepatic encephalopathy doesn't result from increasing levels of potassium or calcium.
A client is admitted to the med-surg. Floor with a diagnosis of acute pancreatitis. His BP 136/76, P 96 bpm, R 22 breaths/min, and T 101F/38.3C. His PMHx reveals hyperlipidemia and alcohol abuse. The physician prescribes an NG tube for the client. The nurse knows the NG tube will:
1) Empty the stomach of fluids and gas
2) Prevent spasms at the spincter of Oddi
3) Prevent air from forming in the small and large intestines
4) Remove bile from the gallbladder
RATIONALE: 1) an NG tube is inserted into the client's stomach to drain fluids and gas.
An NG tube doesn't prevent spasms at the sphincter of Oddi or prevent air from forming in the small and large intestine.
A T tube collects bile drainage from the common bile duct.
While preparing a client for an upper GI endoscopy, which interventions should the nurse implement?
SELECT ALL THAT APPLY!
1) Administer a preparation, such as polyethylene glycol (GoLYTELY), to clean the GI tract
2) Tell the client not to eat or drink 6-12 hrs prior to procedure
3) Tell the client to consume only clear liquids for 24 hrs prior to procedure
4) Inform the client that he'll receive a sedative before the procedure
5) Inform the client that he may eat and drink immediately after the procedure.
RATIONALE: 2) and 4) The client shouldn't eat or drink for 6-12 hrs before the procedure to ensure that his upper GI tract is clear for viewing.
The client will receive a sedative before the endoscope is inserted that will help him relax while allowing him to remain conscious.
GI tract cleansing and liquid diet are interventions before a lower GI tract procedure such as colonoscopy. Food and fluids must be withheld until the gag reflex returns.
A client returns from the operating room after extensive abdominal surgery. He has 1,000ml of lactated Ringer's solution infusing via central line. The physician orders the I.V. fluid to be infused at 125ml/hr plus the total output of the previous hour. The drip factor of the tubing is 15gtt/min. The client's output for the previous hour was 75m. via Foley catheter, 50ml via NG tube, and 10ml via Jackson-Pratt tube. How many drops per minute should the nurse set the I.V. flow rate at to deliver the correct amount of fluid? Record as a whole number. ______ ggt/minute.
RATIONALE: 65ggt/min. First calculate the volume to be infused in milliliters: 75ml + 50ml + 10ml = 135ml total output for the previous hour; 135ml + 125ml ordered as a constant flow = 260ml to be infused over the next hour.
Next, used the formula: Volume to be infused/ Total minutes to be infused x Drip Factor = Drops per min.
In this case, 260ml divided by 60min x 15 ggt/min = 65 ggt/min
A nurse is teaching the family of a client with liver failure. The nurse instructs them to limit which foods in the client diet?
1) Meats and beans
2) Butter and gravies
3) Potatoes and pasta
4) Cakes and pastries
RATIONALE: 1) Meats and beans are high in protein foods. In liver failure, the liver can't metabolize protein adequately, causing protein by-products to build up in the body rather than be excreted. This causes such problems as hepatic encephalophathy (a neurologic syndrome that develops as a result of rising blood ammonia levels).
One intervention in liver failure is to limit the client's intake of protein. Although other nutrients, such as fat and carbohydrates, may be regulated, it's mostly important to limit protein.
A nurse is conducting discharge teaching for a client with Hepatitis B. Which statement by the client indicates that he understands the teaching?
1) Now I can never get Hepatitis again
2) I can safely give blood after 3 months
3) I'll never have a problem with my liver again, even if I drink alcohol
4) My family knows that if I get tired and start vomiting, I may be getting sick again.
RATIONALE: 4) Hep.B is characterized by reappearing S/S, including fatigue, nausea, vomiting, bleeding and bruising.
Hep.B can recur.
Clients who have had Hepatitis are permanently barred from donating blood. Alcohol is metabolized by the liver and should be avoided by the client with Hep.B
A client is experiencing an acute episode of ulcerative colitis. What should be the nurse's highest priority?
1) Replace loss of fluid and sodium
2) Monitor for increased serum glucose level from steroid therapy
3) Restrict the dietary intake of foods high in potassium
4) Note any change in color and consistency of stool
RATIONALE: 1) Diarrhea caused by an acute episode of ulcerative colitis leads to fluid and electrolyte losses; therefore; fluid and sodium replacement is necessary.
There is no need to restrict foods high in potassium; potassium may need to be replaced.
If the client is taking steroid medications, the nurse should monitor his glucose levels, but this isn't the highest priority.
Noting changes in stool consistency is important, but fluid replacement takes priority.
A client is receiving pancrelipase (Viokase) for the treatment of chronic pancreatitis. Which observation by the nurse best indicates the treatment is effective?
1) Aspirate for gastric secretions with a syringe
2) Begin feeding slowly to prevent cramping
3) Get an X-ray of the tip of the tube within 24 hrs.
4) Clamp off the tube until the feedings begin.
RATIONALE: 1) before starting a feeding, it's essential to ensure that the tube is in the proper location. Aspiration for stomach contents confirms correct placement.
Giving the feeding without confirming proper placement puts the client at risk for aspiration.
If an x-ray is ordered, it should be done immediately, not in 24 hrs.
Clamping the tube provides no information about tube placement.
A client, with cirrhosis of the liver, develops asciteis. The nurse should expect the physician to write which of the following orders.
1) Restrict fluid to 1,000ml per day
2) Ambulate 100ft, TID
3) High Sodium diet
4) Maalox 30 mg PO BID
RATIONALE: Restrict fluids decreases in the amount fluid present in the body, thus decreasing the amount of fluid, accumulation in the peritoneal space.
Other temp. treatments include a restriction of physical activity, a low-sodium diet. And the use of diuretics.
A client is receiving pancrelipase (Viokase) for the treatment of chronic pancreatitis. Which observation by the nurse best indicates the treatment.
1) The client has no skin breakdown.
2) The client's appetite improves
3) The client loses more than 10lbs/4.5kg
4) The client's stool have increased in frequent by and are less fatty in appearance.
RATIONALE: 4) Pancrelipase provides a exocrine and pancreatic enzyme necessary for proper protein, fat and carbohydrate digestion.
With increased fat digestion and absorption, stools become less frequent and are normal in appearance.
Lack of skin breakdown, an improved appetite, and weight loss aren't effects of pancrelipase.
A nurse is caring for a client diagnosed with diverticulous. Which should be the nurse expect to institute?
1) Low Fiber diet and fluid restriction
2) Total parenteral nutrition and bed rest.
3) High fiber diet and administration of psyllium
4) Administer of analgesics and antacids
RATIONALE: 3) Diverticulosis is characterized by an out-pouching of the colon. The client needs a high fiber diet and psyllim (bulk laxative) administration to promote normal soft stools.
A low fiber diet, decreased fluid intake, bed rest, analgesics, and some antacids can lead to constipation.
A nurse is caring for a client who requires a NG tube for feeding. What should the nurse do immediately after inserting an NG tube for enteral feedings.
1) Aspirate for gastric secretions with a syringe
2) Begin feeding slowly to prevent cramping
3) Get an xray of the tip of the tube within 24 hrs
4) Clamp off tube until feedings begin.
RATIONALE: 1) Before starting a feeding, it's essential to ensure that the tube is in the proper location. Aspirating for stomach contents confirms correct placement.
Giving the feeding without proper placement puts the client at risk for aspiration.
If an X-ray is ordered, it should be done immediately, not in the next 24 hrs. Clamp tube provided no informal about the tube placement.
A client with a history of long term anti inflammatory use has dark, tarry stools. The nurse knows that this indicates bleeding in the:
1) Upper colon
2) Lower colon
3) Upper GI tract
4) Small intestine
3) Melena is the passage of dark, tarry stools that contain a large amount of digested blood. It occurs with bleeding from the upper GI tract.
Passage of red blood from the rectum indicates lower GI (colon, small intestine, and rectum) bleeding.
Bleeding in the lower colon would cause bright red blood in the stool.
After an abdominal resection for colon cancer, the client returns to his room with a Jackson-Pratt drain in place. The client's spouse asks the nurse about the purpose of the drain. The best response would be for the nurse to say:
1) It irrigates the incision with a saline solution
2) It helps prevent bacterial infection of the incision
3) It measures the amount of fluid lost after surgery
4) It helps prevent the accumulation of drainage in the wound.
4) The accumulation of fluid in a surgical wound interferes with the healing process. A Jackson-Pratt drain promotes wound healing by allowing fluid to escape from the wound. The drain may be placed in the client's incision, or it may be placed in the wound and brought out to the skin surface through a stab wound near the incision.
The incision doesn't need to be irrigated.
Fluid from the drain is absorbed into the dressings and can't be measured accurately.
A Jackson-Pratt drain doesn't prevent infection.
A nurse is doing preoperative teaching with a client expected to undergo a herniorrhaphy (surgical repair of a hernia). The nurse should instruct the client to:
1) Avoid the use of pain medication
2) Cough and deep breathe every 2 hrs
3) Splint the incision if he can't avoid sneezing or coughing
4) Apply heat to scrotal swelling.
3) After herniorrhaphy, teach the client to avoid activities that increase intra-abdominal pressure, such as coughing, sneezing, or straining with bowel movement. If the client must cough or sneeze, splinting the incision with a pillow is helpful. Encourage the use of analgesics for pain or discomfort. The client should be instructed not to cough, but deep-breathing exercises should be still be preformed q2hrs. Ice may be used to reduce scrotal edema and pain after herniorrhaphy.
Daily abdominal girth measurements are prescribed for a client with liver dysfunction and ascites. To increase accuracy, the nurse should use which landmark?
1) Xiphoid process
3) Illiac crest
4) Symphysis pubis
2) The proper technique for measuring abdominal girth involves using the umbilicus as a landmark while encircling the abdomen with a tape measure.
Using the xiphoid process, the iliac crest, or the symphysis pubis as a landmark would yield inaccurate measurements.
Following abdominal surgery, a client has developed a gaping incision due to delayed wound healing. The nurse is preparing to irrigate the incision using a piston syringe and sterile normal saline solution. Which method should the nurse use as a part of the irrigation process.
1) Rapidly instill a stream of irrigating solution into the wound
2) Apply a wet-to-dry dressing to the wound after the irrigation
3) Moisten the area around the wound with normal saline solution after the irrigation
4) Irrigate continuously until the solution becomes clear or until all of the solution is used.
4) To wash away tissue debris and drainage effectively, irrigate the wound until the solution becomes clear or until all of the solution is used.
After the irrigation, dry the area around the wound; moistening it promotes microorganism growth and skin irritation.
When the area is dry, apply sterile dressing rather than a wet-to-dry dressing.
Always instill the irrigating solution gently; rapid or forceful instillation can damage tissues.
A nurse is caring for a client who requires total parenteral nutrition (TPN). The client asks the nurse why he's getting TPN. The nurse best response is:
1) It adds necessary fluids and electrolytes to the body
2) It gives you complete nutrition by the I.V. route until you can eat again.
3) These tube feedings provide nutritional supplementation.
4) It contains liquid protein to supplement your diet between meals.
2) TPN is given I.V. to provide all the nutrients the client needs; it provides more than just fluids and electrolytes.
TPN solutions typically provide glucose, amino acids, trace elements and vitamins, and fats.
TPN is neither a tube feeding nor a liquid dietary supplement.
The nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following should the nurse include?
1) Administering a lactulose enema as ordered.
2) Encouraging a protein rich diet
3) Adminis.tering sedatives as needed.
4) Encouraging ambulation at least 4 times a day.
1) Hepatic encephalopathy is a degenerative disease of the brain that is a complication of cirrhosis. For the client with hepatic encephalopathy, the nurse may administer the laxative lactulose to reduce ammonia levels in the colon.
Protein intake is usually restricted to reduce serum ammonia levels until the client's mental status begins to improve.
Sedatives are avoided because they can cause respiratory or circulatory failure.
Bed rest is encouraged because physical activity increases metabolism, leading to an increased production of ammonia.
A client is admitted with inflammatory bowel syndrome (Crohn's disease). Which treatment measures should the nurse expect to be part of the care plan?
SELECT ALL THAT APPLY!
1) Laculose therapy
2) High fiber diet
3) High protein milkshakes
4) Corticosteroid therapy
5) Antidiarrheal medications
4) and 5) Corticosteroids, such as prednisone, reduce the S/S of diarrhea, pain, and bleeding by decreasing inflammation. Antidiarrheals, such as diphenoxylate (Lomotil), combat diarrhea by decreasing peristalsis.
Lactulose is used to treat chronic constipation and would aggravate the symptoms.
A high fiber diet, milk, and milk products are contraindicated in clients with Crohn's disease because they may promote diarrhea.
A client who recently had abdominal surgery tells the nurse he felt a popping sensation in his incision during a coughing spell, following by severe pain. The nurse anticipates an evisceration.
Which supplies should she bring to the client's room?
1) A suture kit
2) Sterile water and a suture kit
3) Sterile water and sterile dressings
4) Sterile saline solution and sterile dressings
4) Saline solution is isotonic, or close to body fluids in content, and is used along with sterile dressings to cover an eviscerated wound (a wound that opened, allowing the intestines to protrude outside the body) and keep it moist.
Sterile water and a suture kit aren't used. The physician will contacted, and the client will most likely return to the operating room for closure.
A client is admitted with upper GI bleeding. The nurse promotes hemodynamic stability by:
1) Encouraging oral fluid intake
2) Monitoring central venous pressure (CVP)
3) Monitoring laboratory test results and vital signs
4) Giving blood, electrolyte, and fluid replacement.
4) to stabilize a client with acute bleeding, normal saline solution or lactated Ringer's solution is given until blood pressure rises and urine output returns to 30ml/hr.
A CVP line is inserted to monitor circulatory volume.
When shock is severe, plasma expanders are given until typed and crossmatched blood is available. Oral fluid intake is contraindicated with upper GI bleeding.
Monitoring vital signs and laboratory values enables the nurse to evaluate the results of treatment, but these measures don't facilitate hemodynamic stabilization.
A client has undergone a colostomy for a ruptured diverticulum. The nurse is assessing the client's colostomy stoma 2 days after surgery. Which assessment finding should the nurse report to the physician?
1) Blanched stoma
2) Edematous stoma
3) Reddish pink stoma
4) Brownish black stoma
4) A brownish black stoma color indicates a lack of blood flow to the stoma, and necrosis is likely.
A blanched or pale stoma indicates possible decreased blood flow and should be assessed regularly.
2 days postoperatively, the stoma should be edematous and reddish pink.
A nurse is caring for a client with liver cirrhosis who has developed ascites and requires paracentesis. Relief of which symptom indicates that the paracentesis was effective?
4) Peripheral neuropathy
2) Ascites (fluid buildup in the abdomen) puts pressure on the diaphragm. Paracentesis (surgical puncture of the abdominal cavity to aspirate fluid) is done to remove fluid from the abdominal cavity and thus reduce pressure on the diaphragm.
The goal is to improve the client's breathing.
Pruritus, jaundice, and peripheral neuropathy are signs of cirrhosis that aren't relieved or treated by paracentesis.
A client admitted with peritonitis is under a NPO order. The client is complaining of thrist. Which action is the most appropriate for the nurse to take?
1) Increase the I.V. infusion rate
2) Use diversion activities
3) Provide frequent mouth care
4) Give ice chips every 15 minutes
3) frequent mouth care helps relieve dry mouth. Increasing the I.V. infusion rate does not alleviate the feeling of thirst. Diversion activities aren't specific. Ice chips are a form of liquid and shouldn't be given as long as the client is under an NPO order.
A nurse is preparing to teach a client who has been newly diagnosed with stomach cancer.
Which statement should the nurse include in her teaching?
1) Stomach pain is typically a late symptom of stomach cancer.
2) Surgery is commonly a successful treatment for stomach cancer.
3) Chemotherapy and radiation are usually successful treatments for stomach cancer.
4) You may be on TPN for an extended time.
1) Stomach pain is typically a late sign of stomach cancer; outcomes are particularly poor when the cancer reaches that point.
Surgery, chemotherapy, and radiation have minimal positive effects on stomach cancer.
TPN may increase the growth of cancer cells.
A client is admitted with acute pancreatitis. Which laboratory result should the nurse expect?
1) Creatinine of 4.3 mg/dl
2) ALT of 124 international units/L
3) Amylase of 306 units/L
4) Troponin level of 3.5 mcg/L
3)Pancreatitis involves activation of pancreatic enzymes, such as amylase and lipase. Therefore, serum amylase and lipase levels are elevated in a client with acute pancreatitis.
Serum creatinine levels are elevated with kidney disfunction.
Injury or disease of the liver elevated ALT levels.
Troponin levels are elevated with heart damage such as myocardial infarction.
A client is admitted with possible bowel obstruction. Which intervention is most important for the nurse to perform?
1) Obtain daily weights.
2) Measure abdominal girth.
3) Keep strict intake and output.
4) Encourage the client to increase fluids.
2) With a bowel obstruction, abdominal distention occurs. Measuring abdominal girth provides quantitative information about increases or decreases in the amount of distention.
Monitoring daily weights provides information about fluid status. An increase In daily weight usually indicates fluid retention.
Measuring intake and output provides no information about abdominal distention or obstruction. A client with an obstruction would receive a NPO order.
A nurse is advising a client with a colostomy who reports problems with flatus. Which food should the nurse recommend?
4)High fiber food stimulate peristalsis and thus, flatulence.
Tell the client to include yogurt in his diet to reduce gas formation. Other helpful foods include crackers and toast.
Peas, cabbage, and broccoli are all gas forming foods.
caused by rush of IV fluid administered; med races to blood-rich heart and brain and floods them w/toxic levels of med
s/s of speed shock
dizziness, facial flushing, HA, chest tightness, hypotension, irregular pulse, progression of shock
What does RN do if hematoma develops
- cool compress if blood is new
- warm compress if blood is old
how often should IV site be checked by RN
q 1-2 hrs
What is empiric treatment?
treatment that is started before C & S comes back with definitive cause of infection.
3 types of phlebitis:
1) mechanical (cannula causes issue)
2) chemical (solution is irritating)
3) bacterial (microorganism introduced to vein)
s/s of phlebitis:
palpable cord, pain, redness
s/s of infection:
redness, fever, pain, increased WBC
s/s fluid overload:
rapid/bounding pulse, distended neck veins, HTN, cough, SOB, crackles, HA, restlessness
s/s of IV infection:
local- redness, pain, drainage @ site
systemic - fever, chills, elevated WBC, shock
medication that neutralizes acid that's already been made
What classification of meds decreases bowel motility?
True or False an anti-diarrheal is contraindicated w/a bowel obstruction:
True - colitis, N/V, and diarrhea should not be suppressed if underlying cause is not known
What is acid reflux?
when stomach acid splashes up into esophagus
Maalox & Mylanta commonly interfere w/absorption of other meds. T or F
true - especially when kidneys have failed
What classification is Pepcid and what does it treat?
H2 antagonist (blocks histamine receptor)
Treats dyspepsia, GERD, PUD, esohagitits
When teaching a patient about taking Pepcid what should you include:
Take 1 hr before meals (causes acid-producing parietal cells of stomach to be less responsive to stimulation-blocks 90% of acid secretion)
rhythmic contraction and alternate relaxation of a limb that is caused by suddenly stretched position
loss of movement
weakness or incomplete loss of muscle function
Monoparesis or Monoplegia:
affecting one limb
Hemiparesis or hemiplegia:
affecting both limbs on one side
Diparesis, diplegia, paraparesis, or paraplegia:
affecting both upper OR both lower limbs
Quadriparesis or quadriplegia:
affecting all four limbs
Physical Assessment of Renal System-
Skin, Mouth, Face & extremities, Abdomen, Weight, General State of Health
Renal System- INSPECTION:
SKIN: pallor, yellow-gray cast, excoriations, changes in turgor, bruises, texture (e.g., rough, dry skin)
MOUTH: stomatitis, ammonia breath odor
FACE & EXTREMITIES: generalized edema, peripheral edema, bladder distention, masses, enlarged kidneys
ABDOMEN: striae, abdominal contour for midline mass in lower abdomen (may indicate urinary retention) or unilateral mass (occasionally seen in adult, indicating enlargement of one or both kidneys from large tumor or polycystic kidney)
WEIGHT: weight gain secondary to edema; weight loss and muscle wasting in renal failure
GENERAL STATE OF HEALTH: fatigue, lethargy, and diminished alertness
Physical Assessment of Renal System-
Renal System- PALPATION:
A landmark useful in locating the kidneys is the costovertebral angle formed by the rib cage and the vertebral column.
The normal-size kidney is usually not palpable.
If the kidney is palpable, its size, contour, and tenderness should be noted. Kidney enlargement is suggestive of neoplasm or other serious renal pathologic condition.
The urinary bladder is normally not palpable unless it is distended with urine.
Physical Assessment of Renal System-
Renal System- PERCUSSION:
Tenderness in the flank area may be detected by fist percussion (kidney punch).
Normally a firm blow in the flank area should not elicit pain.
Normally a bladder is not percussible until it contains 150 ml of urine. If the bladder is full, dullness is heard above the symphysis pubis. A distended bladder may be percussed as high as the umbilicus.
Physical Assessment of Renal System-
With a stethoscope the abdominal aorta and renal arteries are auscultated for a bruit (an abnormal murmur), which indicates impaired blood flow to the kidneys.
Physical Assessment of Renal System-
Because almost all creatinine in the blood is normally excreted by the kidneys, creatinine clearance is the most accurate indicator of renal function. The result of a creatinine clearance test closely approximates that of the GFR.
Physical Assessment of Renal System-
URODYNAMIC TESTS: study the storage of urine within the bladder and the flow of urine through the urinary tract to the outside of the body.
BELL'S PALSY :
Facial nerve inflammation;
Peripheral facial paralysis due to CN VII motor dysruption; affects one side of face.
Inflammation, edema, ischemia, demyelination of nerve, causing sensory and motor loss.
Outbreak of herpes vesicles in or around ear; Caused by a reactivation of herpes simplex virus, although other infections (e.g., syphilis or Lyme disease) are sometimes implicated
BELL'S PALSY :
Unilateral weakness of facial muscles
Pain around ear
Unilateral inability to close eye
Drooping of mouth
Inability to smile, frown, whistle
paralysis that distorts smiling, eye closure, salivation, and tear formation on the affected side.
Distinguishing it from the facial paralysis associated with some strokes, which affect the muscles of the mouth more than those of the eye or forehead.
Complication: Corneal abrasion or ulceration
Residual facial weakness
ICP: Intracranial Pressure
INTRACRANIAL TUMORS :
CNS Abresses, tumors of brain and spinal cord due to:
Extradural brain abscesses are related with osteomyelitis- following mastoidititis, sinusitis or even sinusitis surgery
INTRACRANIAL TUMORS :
s/s: Depends on location: visual, motor, neurologic, GI
HEADACHE AND SEIZURE
cognitive dysfunction, muscle weakness, sensory losses, aphasia, increased ICP, cerebral edema, obstruction of CSF pathways.
Crisis prevention: Prevent Intracranial Pressure, remove tumor if possible.
ALS: AMYOTROPHIC LATERAL SCLEROSIS :
Degeneration of motor neurons in brain stem and spinal cord: brain's messages don't reach the muscles
ALS: AMYOTROPHIC LATERAL SCLEROSIS :
s/s: Weakness, dysarthria, dysphagia
No loss of cognitive function
Complications/Crisis: respiratory failure.
Assess Respiratory function: ABC's, clear lungs.
Swallowing: proper food choices & eventual NG tube. Mobility. Skin. Suctioning: difficult chewing, swallowing, drooling, choking. Communication.
GUILLIAN-BARRE' SYNDROME :
Polyneuritis: peripheral nerve disease; autoimmune inflammatory response to prior infection.
Acute immune-mediated polyneuropathy d/t damage to myelin sheath of Peripheral Nerves.
GUILLIAN-BARRE' SYNDROME :
Begins in extremities: weakness, paralysis, respiratory failure
Progressive ascending muscle weakness of the limbs with: symmetric flaccid paralysis; paresthesias or numbness; loss of tendon reflexes.
Autonomic nervous system involvement causes postural hypotension, dysrrhythmias, facial flushing, diaphoresis, and urinary retention.
Pain occurring with the slightest of movements is a common feature.
Crisis: will progress to medical emergency, likely respiratory failure.
TRIGEMINAL NEURALGIA :
Trigeminal Nerve- degeneration/ pressure.
Chronic disease of trigeminal nerve (cranial nerve V) causing severe facial pain
The maxillary and mandibular divisions of nerve are effected
TRIGEMINAL NEURALGIA :
s/s: facial pain.
Severe facial pain occurring for brief seconds to mins hundreds of x/day, several x/yryear
Usually occurs unilaterally in area of mouth and rises toward ear &eye
Triggers: areas on the face may initiate the pain- eating, swallowing, talking
Often there is spontaneous remission after years, and then condition recurs with dull ache in between pain episodes.
Assess/monitor pts trigger factors, complications of pain, nutrition, hygiene, oral care, anxiety.
Acute infection of the meninges.
Bacterial meningitis is an infection of the ventricular system and the CSF.
s/s: Severe HA, fever, delirium,
Nuchal Rigidity: stiff neck
Kernig's Sign: from bent leg/knee to strait is painful
Brudzinski's Sign: pain; resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine
Edema and inflammation of the optic nerve
Purpuric rash on the skin and mucous membranes
Assess for IICP: LOC, VS, Eyes, Motor function
Crisis: COMA- Acute complication from IICP
SEIZURES- Acute cerebral edema/ IICP
MG: MYASTHENIA GRAVIS :
Chronic neuromuscular disorder characterized by fatigue and severe weakness of skeletal muscles
Occurs with remissions and exacerbations.
Causes decrease in muscle's ability to contract, despite sufficient acetylcholine.
MG: MYASTHENIA GRAVIS :
s/s: Risk complications: Swallowing/Arrest
Weakness, dysarthria, dysphagia, difficulty sitting up,
Eye and periorbital muscles most affected- manifested by diplopia, ptosis, ocular palsies
Sx least evident in the AM and most evident w/effort as the day proceeds
Crisis: Sudden exacerbation of motor weakness putting client at risk for respiratory failure and aspiration:
MYASTHENIC CRISIS: Respiratory, and swallowing muscles too weak. Risk complications: Swallowing/Arrest
THYMOMA-A rare neoplasm, usually found in the anterior mediastinum and originating in the epithelial cells of the thymus.
Assess an maintain respiratory, swallowing, atelectasis.
Flaccid paralysis, respiratory failure, GI symptoms, severe muscle weakness, vertigo. Tx: Atropine
MS: MULTIPLE SCLEROSIS :
Autoimmune dz, progressive degeneration of CNS; the body attacks its own tissues, destroying nerve fibers of the brain and spinal cord (disseminated demyelination)
MS: MULTIPLE SCLEROSIS :
Difficulty chewing, speaking, walking. Shakiness, muscle weakness, tinnitus, visual problems, incontinent,
Ataxia, Nystagmus, Spasticity, tremors, dysphagia, speech impaired, fatigue
Help pts identify triggers: illness, stress
PD: PARKINSON'S DISEASE :
slow, progressive disorder of the nervous system that affects movement.
Characterized by tremor at rest, muscle rigidity and akinesia due to lack of dopamine.
PD: PARKINSON'S DISEASE :
Classic s/s: tremor at rest, muscle rigidity, bradykinesia.
Complications: risk for fall, aspiration, urinary retention/UTI, dysphagia, oculogyric crisis: fixed lateral and upward gaze.
Paroxysmal, uncontrolled electrical discharge of neurons in the brain that interrupts normal function.
Tonic Phase: Loss of consciousness; muscles contract 10-20 sec
Clonic Phase: rhythmic contraction <2min
Aura: warning sx
HAVE SUCTION, AIRWAY, O2 AT BEDSIDE!
Protect pt: lower to floor, pad siderails, pillow under head, don't restrain, allow post-ictal rest.
Prevent Aspiration: turn side, loosen neck clothing, suction.
Ongoing: Monitor VS, LOC, O2 saturation, Glasgow coma scale, reassure & orient pt after seizure
CVA: CEREBROVASCULAR ACCIDENT :
Ischemia of brain tissue: Hemorrhage, thrombus, embolus.
CVA: CEREBROVASCULAR ACCIDENT :
Motor changes: opposite side, balance, coordination, gait, proprioception
Sensory Changes: Aphasia, Agnosia, Apraxia, Visual problems, hemianopsia
Cognitive Changes: impaired memory, disoriented
Paralysis, difficulty swallowing, talking, memory, pain.
Assessment includes: glasgow coma scale/LOC
Bowel obstruction :
Blockage in small intestine or colon that prevents food and fluid from passing through. Tissue death & perforation of intestine can lead to severe infection and shock.
Can be life-threatening.
Used to remove antibodies. Often done when respiratory involvement has occurred, or before planned surgery.
Slowed or delayed movement that affects chewing, speaking, eating
The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain?
◦ A. Sternal rub
◦ B. Nail bed pressure
◦ C. Pressure on the orbital rim
◦ D. Squeezing of the sternocleidomastoid muscle
B- Nail bed pressure
Rationale: Motor testing in the unconscious client can be done only by testing response painful stimuli. Nail bed pressure tests a basic peripheral pressure on the orbital rim, or squeezing the clavical or sternoleidomastoid muscle.
The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which of the following measures would the nurse avoid in planning for the client's safety?
◦ A. Padding the side rails of the bed
◦ B. Putting a padded tongue blade at the head of the bed
◦ C. Placing an airway, oxygen, and suction equipment at the bedside
◦ D. Having intravenous equipment ready for insertion of an intravenous catheter
B- Putting a padded tongue blade at the head of the bed
Rationale: seizure precautions may vary from agency to agency but the generally have some common features. Usually an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth.
The nurse is caring for the client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?
◦ A. Loosening restrictive clothing
◦ B. Restraining the client's limbs
◦ C. Removing the pillow and raising padded side rails
◦ D. Positioning the client to the side, if possible, with the head flexed forward
B- Restraining the Client's Limbs
Rationale: Nursing Actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising the side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible protects the head from injury, and moves furniture that may injure the client. Other aspects of care are as described for the client who is in bed.
pain with resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine
1) related to Light
2) related to Sound
Edema and inflammation of the optic nerve at its point of entrance into the retina.
drooping of eyelids
Mnemonic for Cholinergic Crisis Symptoms:
L- LACRIMATION (tearing)
G- GASTRIC UPSET
The nurse is assigned to care for a client with complete right-sided hemiparesis, the nurse plans care knowing that in this condition:
◦ A. The client has complete bilateral paralysis of the arms and legs
◦ B. The client has weakness on the right side of the body, including the face and tongue
◦ C. The client has lost the ability to move the right arm but is able to walk independently
◦ D. The client has lost the ability to feed and bathe self without assistance.
B- The client has weakness on the right side of the body, including the face and tongue
Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. Complete hemiparesis is weakness of the face and tongue, arm and leg on one side. Complete bilateral paralysis does not occur in the condition. The client with right- sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing and ambulating.
The client with a stroke has residual dysphagia. When the diet order is initiated, the nurse avoids doing which of the following?
◦ A. Giving the client thin liquids
◦ B. Thickening liquids to the consistency of oatmeal
◦ C. Placing food on the unaffected side of the mouth
◦ D. Allowing plenty of time for chewing and swallowing
A- Giving the client thin liquids
Rationale: before the client with dyshagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.
The nurse has instructed the family of a client with a stroke who has homonymous hemianopsia about measures to help the client overcome the deficit. The nurse determines that the family understands the measures to use if the state that they will:
◦ A. Place objects in the client's impaired field of vision
◦ B. Discourage the client from wearing eyeglasses.
◦ C. Approach the client from the impaired field of vision
◦ D. Remind the client to turn the head to scan the lost visual field.
D- Remind the client to turn the head to scan the lost visual field
Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with Homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision: The nurse encourages the use of personal eye glasses, if they are available.
The nurse is assessing the adaptation of the client to changes in the functional status after a stroke. The nurse assesses that the client is adapting most successfully if the client:
◦ A. Gets angry with family if they interrupt a task
◦ B. Experiences bouts of depression and irritability
◦ C. Has difficulty with using modified feeding utensils
◦ D. Consistently uses adaptive equipment in dressing self
D- Consistently uses adaptive equipment in dressing self
Rationale: Client's are evaluated as coping successfully with lifestyle changes after a brain attack (stroke) if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions.
A nursing student is caring for a client with a stroke who is experiencing unilateral neglect. The nurse would intervene if the student plans to use which of the following strategies to help the client adapt to this deficit?
◦ A. Tells the client to scan the environment
◦ B. Approaches the client from the unaffected side
◦ C. Places the bedside articles on the affected side
◦ D. Moves the commode and chair to the affected side
B- Approaches the client from the unaffected side.
Rationale: The nurse teaches the client to scan the environment to become aware of that half of the body and approaches the client form the affected side to increase awareness further.
The nurse is trying to communicate with a client with a stroke and aphasia. Which of the following actions by the nurse would be least helpful to the client?
◦ A. Speaking to the client a slower rate
◦ B. Allowing plenty of time for the client to respond
◦ C. Completing the sentences that the client cannot finish
◦ D. Looking directly at the client during attempts at speech
C- Completing the sentences that the client cannot finish.
Rationale: Note that the question asks which is least helpful. These words indicate a negative event query and ask you to select an option that is and incorrect action.
The client has experienced an episode of Myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:
◦ A. Getting too little exercise
◦ B. Taking excess medication
◦ C. Omitting doses of medication
◦ D. Increasing intake of fatty foods
C- Omitting doses of medication
The nurse is teaching the client with myasthenia gravis, about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:
◦ A. Eating large, well-balanced meals
◦ B. Doing muscle-strengthening exercises
◦ C. Doing all chores early in the day while less fatigued
◦ D. Taking medications on time to maintain therapeutic blood levels
D- Taking medications on time to maintain therapeutic blood levels
The client with Parkinson's disease has a nursing diagnosis of falls, Risk for related to an abnormal gait documented in the nursing care plan. The nurse assesses the client, expecting to observe which type of gait?
◦ A. Unsteady and staggering
◦ B. Shuffling and propulsive
◦ C. Broad-based and waddling
◦ D. Accelerating with walking on the toes
B- Shuffling and propulsive
The nurse has given instructions to the client with Parkinson's disease about maintaining mobility. The nurse determines that the client understands the directions if the client sates that he or she will:
◦ A. Sit in soft, deep chairs
◦ B. Exercise in the evening to combat fatigue
◦ C. Rock back and forth to start movement with bradykinesia
◦ D. Buy clothes with many buttons to maintain finger dexterity
C- Rock back and forth to start movement with bradykinesia
The nurse has given suggestions to the client with trigeminal neuralgia about strategies to minimize episodes of pain. The nurse determines that the client needs reinforcement of information if the client makes which of the following statements?
◦ A. "I will wash my face with cotton pads."
◦ B. "I'll have to start chewing on the unaffected side."
◦ C. "I'll try to eat my food either very warm or very cold."
◦ D. "I should rinse my mouth sometimes if toothbrushing is painful."
C- I'll try to eat my food either very warm or very cold
The nurse is planning to test the function of the trigeminal nerve (cranial nerve V). The nurse would gather which of the following items to perform the test?
◦ A. Tuning fork and audiometer
◦ B. Snellen chart, ophthalmoscope
◦ C. Flashlight, pupil size chart or millimeter ruler
◦ D. Safety pin, hot and cold water in test tubes, cotton wisp
D- Safety pin, hot and cold water in test tubes, cotton wisp
The nurse has given the client with Bell's Palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will:
◦ A. Expose the face to cold and drafts
◦ B. Massage the face with a gently upward motion
◦ C. Perform facial exercises
◦ D. Wrinkle the forehead, blow out the cheeks, and whistle.
A- Expose the face to cold and drafts
The client is admitted to the hospital with a diagnosis of Guillian-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of:
◦ A. Seizures or trauma to the brain
◦ B. Meningitis during the last 5 years
◦ C. Back injury or trauma to the spinal cord
◦ D. Respiratory or gastrointestinal infection during the previous month
D- Respiratory or gastrointestinal infection during the previous month
The client with Guillian-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?
◦ A. Giving client full control over care decisions and restricting visitors
◦ B. Providing positive feedback and encouraging active range of motion
◦ C. Providing information, giving positive feedback, and encouraging relaxation
◦ D. Providing intravenously administered sedatives, reducing distractions, and limiting visitors
C- Providing information, giving positive feedback, and encouraging relaxation.
The nurse is admitting a client with Guillian- Barre syndrome to the nursing unit. The client has an ascending paralysis to the level of the waist. Knowing the complication of the disorder, the nurse brings which of the following items into the client's room?
◦ A. Nebulizer and pulse oximeter
◦ B. Blood pressure and flashlight
◦ C. Flashlight and incentive spirometer
◦ D. Electrocardiographic monitoring electrodes and intubation tray
D- Electrocardiographic monitoring electrodes and intubation tray
The nurse is evaluation the respiratory outcomes for the client with Guillain-Barre syndrome. The nurse determines that which of the following is the least optimal outcome for the client?
◦ A. Spontaneous breathing
◦ B. Oxygen saturation of 98%
◦ C. Adventitious breath sounds
◦ D. Vital capacity within normal range
C- Adventitious breath sounds
The nurse is evaluating the status of the client who had a craniotomy 3 days ago. The nurse would suspect that the client is developing meningitis as a complication of surgery if the client exhibits:
◦ A. A negative Kernig's sign
◦ B. Absence of nuchal rigidity
◦ C. A positive Brudzinski's sign
◦ D. A Glasgow Coma Scale score of 15
C- A positive Brudzinski's sign
A nurse is preparing to administer an I.M. injection in a client with a spinal cord injury. Which muscle is best to use in this case?
2) Dorsal gluteal
3) Vastus lateralis
4) Ventral gluteal
RATIONALE: 1) IM injections should be give in the deltoid muscle in clients with spinal cord injuries. These clients exhibit reduced use of - and consequently reduced blood flow to - muscles in the buttocks (dorsal gluteal and ventral gluteal) and legs (vastus lateralis). Decreased blood flow results in decreased drug absorption.
Describe extrapyramidal signs and symptoms:
Restlessness or desire to keep moving, rigidity, tremors, pill rolling, mask-like face, shuffling gait, muscle spasms, twisting motions, difficulty speaking or swallowing, loss of balance control
T or F Antacids promote premature dissolving of enteric-coated meds
T - separate administration of other meds by 1-2 hours
Medications used to treat H pylori:
prilosec and prevacid - acid reducers and proton pump inhibitors -
Teaching for prilosec and prevacid should include:
1) take 30-60 mins before meals
2) highly protein bound. Stronger than Pepsid (H2 antagonist)
T or F Nauseas & vomitting should not be treated until pt acutally vomits.
F- n/v should be treated aggressively; preventing comfort,safety, and compliance w/tx regimen
Compazine is a(an)______ and results in _______
An antiemetic and is calming and sedating (putting pt at risk for aspiration)
This drug is an antiemetic that should never be given IV and when given IM MUST be Z-tracked
Vistaril (hydroxyzine) - is also antihistamine and antidepressant that is often used for post-op pts
Reglan (metoclopramide) is a (an) _______ that is most effective when given prophylactically (at least 30 min prior to chemo/radiation)
an antiemetic that blocks CTZ(no response to vomitus stimulus) and stimulates gastric emptying (downward into GI)
antiemetic; antiserotonergic (blocks serotonin receptor in GI tract and CTZ)
Ginger is a herbal remedy thought to be effective in treating _______
nausea and vomiting (n/v) particularly w/ chemo & radiation tx and hyperemesis in pregnancy
Ipecac should not be used if____
ingested substance is sedating (may become too lethargic to prevent aspiration) or caustic (cause more oral and esophageal damage).
What allergy would you assess for in pts being given Pancrelipase?
Pork - used as enzyme supplement to aid in break down of food so that it can be utilized for energy, cell growth and repair
Lomotil inhibits what?
GI motility - it is a non-analgesic opiod that stops diarrhea in its tracks and is contraindicated w/ infectious diarrhea
What category is simethicone (Gas-X, Mylicon) and how does it work?
anti-flatulent that reduces surface tension of air bubbles which helps alleviate the pain associated with gas
RN implications before GI meds can be given:
-Upper and lower GI assessment
-Assess fluid/electrolyte status
A pt that presents w/UTI s/s may be experiencing what:
frequency, urgency, suprapubic pain, dysuria, hematuria, fever, confusion in older adult
S/s of pyleonephritis are the same as UTI except for ____
flank pain and/or pain at the costovertebral angle
TMP-SMZ(Bactrim) may be prescribed for a pt with what?
a pt who is being prescribed TMP-SMZ should be assessed for what allergy?
allergy to sulfas
Pts taking Pyridium should be taught what?
that a reddish orange discoloration of urine may occur.
Bacterium most commonly causing UTI's?
If pt is scheduled for an IVP what allergy should you assess for?
allergy to iodine or seafood
What is glomerulonephritis?
-loss of kidney function
-acute lasts 5-21 days
-chronic after acute phase or slowly over time
s/s of pyleonephritis:
HA, increased BP, facial/periorbital edema, lethargic, low grade temp, wt gain (edema), and protein-, hema-, olgi-, dys- uria
alkaline-ash diet consists of:
what is the antidote for a cholenergic medication?
What is Steven-Johnson's Syndrome?
severe allergic reaction to meds flu-like symptoms, followed by a painful red or purplish rash leads to top layer of skin necrosising if pt develops lesions in the lungs, death may result.
who are the most susceptible pts for UTI?
pregnant and/or sexually active women
what symptom is different for older pts suffering from UTI?
they are more likely to present with confusion and not abd pain.
if UTI is suspected how many mls of fluid should the RN encourage daily?
3000 ml unless contraindicated ie CHF pt
interventions for UTI may include
heating pad for discomfort and Pyridium for spasms
Macrobid may be used for tx of UTI, why?
it acts as a disinfectant in the urinary tract but is not effective outside of the UT
T or F Macrobid should be given with milk?
If Macrobid causes pulmonary side effects such as SOB, cough, etc when will they subside?
2-3 days after stopping
While taking Cipro or Levaquin if you experience dizziness, light sensitivity or light-headedness what might this indicate:
While taking Bactrim what side effect would be a concern:
Most important assessment if pyleonephritis is suspected?
Common test for renal caliculi?
If alkaline-ash diet is ordered to increase pH of urine what will it include:
Milk, veggies, beef, halibut, trout, salmon
No prunes or plums
if pt is on acid-ash diet to decrease pH of urine what will it include:
bread, cereal, whole grains, cranberries, legumes, tomatoes,oysters, fish, poultry, pastries
types of urinary tract caliculi
calcium oxalate (30-45%)
calcium phosphate (8-10%)
oxalate rich foods include:
dark roughage, spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, runner beans, chocolate, instant coffee, Ovaltine, tea, worcestershire sauce
calcium rich foods include:
dairy products, lentils, fish w/ fine bones, dried fruits, nuts, chocolate, cocoa, Ovaltine
If pt is undergoing shockwave therapy as tx for stones what is an important teaching?
push fluids - stones will be broken up into sandlike particles
T or F calcium stones are alkaline:
True - this pt would need acid ash diet
Uric acid stone (excess purine) would require what kind of diet?
Post surgery for stone removal hematuria is expected T or F
True bright red blood would be cause for concern
If pt has renal insufficiency what would you assess for?
this is end-stage kidney disease, kidneys aren't functioning; assess for psychosocial changes - depression, anxiety, ability to cope, suicide, withdraw from loved ones
if pt needs a blood transfusion what must be obtained?
When hospitalized every pt is considered a _________
What are the four phases of the Nurse/client relationship
In what phase of the RN/Client relationship is the RN meeting the client and establishing his/her role?
In what phase is the RN maintaining the contract, gathering further data, promoting self-sufficiency and continuing the nursing process?
in what phase would the symptoms of the client be relieved/managed and the contract fulfilled?
Post EGD procedure pt would need to remain NPO until ___________ :
gag reflex returns (pt is at risk for aspiration until it has returned)
EGD pt what must be checked every 15 to 30 mins for 1-2 hrs and why
temp must be checked a spike could mean possible perforation
if you are teaching a GI pt to push fluids and that his stool may be white for up to 72 hrs after test, what test has this pt just undergone?
barium swallow - detects structural abnormalities
If you want to view a pts gallbladder and ducts what would be ordered?
an ERCP - gag is paralyzed so NPO until returns
If serum amylase and lipase are high what might this indicate?
Hematocrit (HCT) and Hemaglobin(Hgb) can be ordered to detect what in a GI pt?
GI bleed results would indicate anemia
T or F cardiac enzymes are ordered for GI pts?
T - they will rule out if s/s are due to cardiac issue rather than GI issue
T or F while caring for pt w/suspected appendicitis you would give enema or laxatives in prep for sx?
False - peristalsis can cause appendix to ruputure
Pt has severe pain in periumbilical area that gets increasing worse and then goes away, what may have just happened?
rebound tenderness, muscular rigidity, laying still w/fast shallow breaths, distended abd, ascites, fever
inflamed matter trapped in the diverticula (out pouches)
out pouching in intestinal wall
What would you teach a pt that has diverticulitis?
increase fiber, decrease fat and red meat, increase activity to increase peristalsis, avoid tight restrictive clothing
If auscultating bowel sounds in pt w/obstruction what would you expect to hear?
high pitch above obstruction and absent below obstruction
In diagnosing bowel obstruction what must you do before barium enema?
must see xray - may not be administered if peritonitis is present
The name of the scale used globally to assess a person's consciousness
Glasgow Coma Scale
The Glasgow Coma scale is a 15 point scale that is used to measure neurological status, what does it measure responses to?
Eyes Open, Verbal Response, Motor Response
What is the high and low score of a Glasgow Coma Scale indicate?
Above 15 = Non-neurological impaired
8 or less = Coma
3 or less is = likely brain death
The Glasgow Coma Scale
System for assessing the degree of consciousness, or impairment in the critically ill and for predicting the duration + outcome of coma.
Plasmapheresis (plasma exchange)
Removal of patients plasma and plasma components Produces a temporary reduction in the antibodies Does not treat the underlying abnormality
Too much medication
N&V, diarrhea, cramps hypotension
Tensilon to distinguish from Myasthenia Crisis Atropine to reverse
Respiratory support may be needed
Parkinson's disease Complications
Respiratory tract infections.
Urinary tract infections.
Adverse affects of medications.
Amyotrophic Lateral Sclerosis (ALS) Supportive care
Treat symptoms. NG tubes. Mechanical ventilation.
Cranial Nerve Disorders
Bell's palsy (CN VII), unilateral paralysis of the facial muscles. Trigeminal neuralgia (CN V), chronic disease severe facial pain.
Etiology Pathophysiology Cranial Nerve Disorders
Inflammation, Infection, Viral
Clinical Manifestations Bell's palsy
One-sided facial paralysis, Loss of corneal reflex, Loss or impairment of taste, Increased tearing from lachrymal gland
5 S/S of ICP:
1. Visual changes and headaches.
2. Change in LOC and blown pupil.
3. widened pulse pressure, increased BP, bradycardia, and hyperflexia.
5. papilledema (choked eye disc)
NSG Interventions for ICP:
elevate HOB 30-45 degrees to promote venous return, place neck in neutral position, avoid flexion of hip as well as head, restrict fluids, avoid val salves maneuver, insert foley, admin O2 via mask or cannula, and increase body temp.
Tonic Clonic (Grand-Mal) Seizure:
loss of consciousness and falling to floor.
Signs: aura, cries, loss of consciousness, fall, tonic clonic movements, incontinence, cyanosis, excessive salvation, tongue or cheek biting. Posticatal period: need 1-2hr for sleep after.
Absence (Petite-Mal) Seizure
usually occurs during childhood and decreases with age. Sudden LOC w/ little or no tonic clonic movement, occurs without warning, and appears a few hours after arising or when pt is quiet.
Signs: vacant facial expression w/ eyes focused straight ahead.
the inability to recognize familiar objects.
an acute exacerbation of disease caused by inadequate amount of meds, infection fatigue or stress.
Caused by overmedication with anticholinesterase.
Treatment: hold medication and give atropine if ordered.
Used to diagnose MG and to differentiate between myasthenic crisis and cholinergic crisis.
Bell's Palsy Nursing Interventions:
protect the eyes.
Eyes can be excessively dry or teary.
starts with weakness of lower extremities and gradually progresses to upper extremities and facial muscles.
Recovery is slow and can take years.
"ground to brain"
Major Nursing Concern for Guillian-Barre syndrome (polyneuritis)
the inability to extend legs
flexing of the hip and knee when neck is flexed
Diagnosis of meningitis
diagnosed by lumbar puncture where the CSF is analyzed for organisms.
the inability to recognize objects by sight
rapid shaking of the eyes
visual field cut; defective vision or blindness 1/2 visual field
visual field cut both eyes
impaired ability to coordinate movement
impairment of the ability to perform purposeful acts or to use objects properly
sensation of light or warmth that may precede the onset of a migraine or seizure.
abnormal slowness of voluntary movements and speech
difficult poorly articulated speech resulting from interference in the control over the muscles of speech
weak, soft and flabby muscles lacking normal tone
When feeding someone with a stroke or brain injury it may be better to have them ________________ while eating.
tuck their chin.
What neurological symptoms of hypokalemia would be observed in a patient?
In preparation for a cerebral angiography, what do you need to ask the patient before the test?
allergies to Iodine - contrast media (dye)
When is a lumbar puncture indicated?
to determine if there is an infection in the spine (CNS) such as meningitis.
When is a lumbar puncture not indicated?
When the patient has a possible brain tumor.
What do we do to check function of the optic nerve?
Field of vision, visual acuity and structures (external, internal, red reflex and optic disc.)
Reading a newspaper or magazine.
Holding up fingers
When doing a corneal reflex, we need to remember what key factor?
Age slows down the reflex. Contact lenses can affect the corneal reflex as well.
Cranial nerve 7 comes out of the temple and runs all the way down to the corner of the mouth. If there are problems with this nerve, what might we see?
Drooping of the corner of the mouth (Bell's Palsy)
Components of a neurological examination
LOC, pupillary evaluation, neuromuscular response, vital signs
Nursing care that can decrease ICP
positioning to prevent neck and hip flexion, limiting suctioning, space nursing care, preventing isometric muscle contraction, elevate HOB as ordered, and carefully regulate administration of IV fluids to prevent fluid volume excess.
What is decorticate posturing?
Hands pulled to chest and hyper-extended.
Internal rotation and adduction of the arms with flexion of the elbows, wrists & fingers.
"flexor - toward the cord"
What is decerebrate posturing?
Hands pushed to sides and body hyper-extended.
Arms are stiffly extended, adducted & hyperpronated. Hyperextension of the legs with plantar flexion of the feet. (May indicate more serious damage.)
"extensor = All E's"
What is the most common sign of Increased Intracranial Preasure?
#1 sign = Mental status changes indicate brain cells are deprived of O2.
Changes may be subtle:
- flat affect
- change in pts orientation (ie: pt is no longer A&Ox3)
- decreased level of attention
ICP: What are some expected changes in vital signs when a patient shows signs of increased ICP?
Cushing's triad (3 sx) = may present over time or present suddenly.
1. Widening pulse pressure= SPB increases, but DBP stays same.
Temperature will also increase if hypothalamus is impacted.
IICP: What are some expected changes that may be seen when assessing pts w/ compression of oculomotor nerves as a result of IICP?
Assess PERRLA, extraocular movements:
- dilation of pupil on the same side as the mass lesion,
- sluggish or no response to light
- inability to move the eye upward
- ptosis (drooping) of the eyelid
What are some expected changes that may be seen when assessing pts w/ Brain Herniation as a result of IICP?
IICP Brain Herniation:
- Unilateral dilated pupil.
- sluggish, equal pupil response.
What are some expected changes that may be seen when assessing pts w/ Opitic Nerve dysfunction (II, IV, VI) as a result of IICP?
IICP Optic Nerve Dysfunction:
- Blurred vision
- diplopia: double vision
- changes in extraocular eye movements
Signs of IICP:
1) changes in LOC
2) changes in Vital Signs
3) changes in Eyes
4) decreased motor function
Critical complication of IICP:
Acute complication of cerebral edema:
What rehab exercises differ for client with homonymous hemianopsia during Acute versus the Rehab phase?
Where would you place this pts plate of food?
Acute Phase: Put plate of food in pt's line of vision.
Rehab Phase: Help pt to retrain their eye. Put plate of food on table in front of them, but out of line of vision. Teach family to remind pt to turn head to scan the lost visual field.
What is the PPE transmission precaution for meningococcal meningitis?
Respiratory Isolation = Droplet precautions: Gloves, Gown, Mask within 3 ft of pt.
measures should an RN take when placing a client in seizure precautions?
Have suction, airway & oxygen at bedside.
status epilepticus -a state of continuous seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures.
A nurse is assessing a pt who has been identified as a seizure risk. When assessing the pt risk factors, the nurse assesses for status epilepticus. What is SE?
A state of continuous seizure activity, or a condition in which seizures recur in rapid succession, without return to consciousness between seizures.
- the inability to flex the head forward due to rigidity of the neck muscles.
If flexion of the neck is painful, but full range of motion is present, nuchal rigidity is absent
Positive Kernig's sign:
- positive when the leg is fully bent in the hip and knee, and subsequent extension in the knee is painful (leading to resistance)
What safety intervention should a nurse ensure for a pt identified as needing Seizure Precautions?
- padded side rails;
- all four up to prevent falling out of bed --> during a seizure
Elevate head of bed and sit up after eating.
Decrease high fat foods.
Drink fluids BETWEEN meals not with meals.
Avoid: milk at bedtime & late night snacking/meals, chocolate, peppermint, caffiene, tomato & orange juice.
NPO status after surgery until gag reflex returns
Cause: Inflammation of the appendix r/t obstruction of lumen by stool, tumors or foreign bodies.
S/S: N/V, fever, pain in RLQ, rebound tenderness, abd. muscle guarding
Critical: Perforation/rupture will likely lead to peritonitis
If pt presents w/ acute pain related to stones lodged in duct, what urine and feces characteristics are expected?
clay colored stools and dark amber urine
Lining (and deaper) of the digestive tract have PATCHES of inflammation/ulceration that occur anywhere in the digestive tract and often spreads deep into the layers of affected tissues.
S/S: Relapsing/Remitting- Severe diarrhea, abdominal pain, malnutrition, blood in stool, ulcers.
Chronic inflammation of the inner-most lining of large intestine (colon) and rectum
in CONTINUOUS STRETCHES of colon, only.
Can be debilitating or life-threatening.
NO CURE, w/ occasional remission.
Spillage of gastric or duodenal contents into peritoneal cavity.
S/S: Sudden, severe pain unrelated to intensity & location at admittance, Rigid, boardlike abdomen, shallow, grunting respirations
Inflammatory Bowel Dietary interventions
Low Residue/ NO Fiber diet - A high residue diet may irritate an inflamed mucosa. Avoid HOT, spicy foods & pepper (increase peristalsis). Increase Protein, Decrease Lactose. NO Alcohol, carbonated beverages, tea, coffee, broth.
Ulerative Bowel: Dietary modification
Expect pt to have physician orders for:
* w/ TPN
Bowel rest until ulcers have healed.
Irritable Bowel Syndrome and
High fiber: dietary consideration to prevent constipation/ diarrhea, to normalize bowel water content, and add bulk.
* to prevent obstruction to progress to bowel perforation.
TPN & Bowel rest until obstruction resolved.
Cause: Localized or generalized inflammatory process of the peritoneum
Primary - blood borne organisms enter peritoneal cavity
Secondary - abd. Organs perforate/rupture & release contents into peritoneal cavity (ex. Appendix rupture)
Can be fatal!
fat in feces with strong-foul smell, frothy urine and stool
Glomerulonephritis is commonly related to what infection?
Intervention- prevent and treat strep quickly!
Also: Immune dz such as Lupus. Vasculitis, Scarring from: HTN, Diabetic kidney dz.
Intervention- control blood sugars and hypertension.
Common interventions related to:
Empty bladder/bowel regularly & completely; Avoid stagnant urine in the bladder or urethra.
Drink water prior to intercourse to promote urination & empty bladder after intercourse.
Clean perineal area: front to back.
Drink large amt fluids daily.
Characteristic of Hematuria:
cola-colored urine from blood
Characteristic of Proteinuria:
foamy urine due to excess protein
What is the difference between and ischemic & hemorrhagic stroke?
ISCHEMIC STROKE- results from inadequate blood flow to the brain from partial or complete occlusion of an artery. They are further divided into thrombotic and embolic.
**Warning sign is usually a TIA and happens during or after sleep, slower progression, and recurrence is common.
HEMORRHAGIC STROKE- results from bleeding into the brain tissue itself (intracerebral or intraparenchymal hemorrhage) or into the subarchnoid space or ventricles (subarachnoid hemorrhage or intraventricular hemorrhage).
**Warning sign is usually a headache and happens during activity, sudden onset and fatality more likely with presence of coma.
A nurse is preparing to administer an I.M. injection in a client with a neuro/paralytic injury. Which muscle is best to use in this case?
2) Dorsal gluteal
3) Vastus lateralis
4) Ventral gluteal
RATIONALE: 1) IM injections should be give in the deltoid muscle in clients with neuropathic/ paralytic and spinal cord injuries.
These clients exhibit reduced use of - and consequently reduced blood flow to - muscles in the buttocks (dorsal gluteal and ventral gluteal) and legs (vastus lateralis).
Decreased blood flow results in decreased drug absorption.
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