1. ADMINISTER IV NORMAL SALINE
This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher).
Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion.
(Option 2) Testing for the presence of blood in the urine is important in determining if kidney damage has occurred, but circulation stability is a priority.
(Option 3) A neurological assessment is essential, but circulation stability is a priority ("C before D" [disability]).
(Option 4) Bladder and stool impaction are etiologies for autonomic dysreflexia and generally occur in a client with a high-level fracture at T6 or above with a stimulation below the fracture. Autonomic dysreflexia is a medical emergency that presents with severe headache, hypertension, piloerection, and diaphoresis. It is seen weeks to years after the injury.
Neurogenic shock/distributive shock can occur from vasodilation soon after spinal injury. Classic symptoms are hypotension, bradycardia, and pink and dry skin. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion.
4. WHEN I SIT DOWN TO REST AND ELEVATE MY LEGS, THE PAIN INCREASES
Peripheral artery disease (PAD [previously called peripheral vascular disease]) refers to arteries that have thickened, have lost elasticity due to calcification of the artery walls, and are narrowed by atherosclerotic plaques (made up of fat and fibrin). Pain due to decreased blood flow is the most common symptom of PAD. Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with rest. However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legs and improved when the legs are dependent. Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen). Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. Clients should be advised that a progressive walking program will aid the development of collateral circulation.
(Options 1, 2, and 3) Chronic venous insufficiency refers to inadequate venous blood return to the heart. Too much venous blood remains in the lower legs, and venous pressure increases. This increased venous pressure inhibits arterial blood flow to the area, resulting in inadequate supply of oxygen and nutrients to area cells and the development of stasis ulcers, which are typically found around the medial side of the ankle. By the end of the day or after prolonged standing, the legs become edematous with dull pain due to venous engorgement. The skin of the lower leg becomes thick with a brown pigmentation.
The pain of peripheral artery disease is arterial in nature and results from decreased blood flow to the legs. It is made worse with leg elevation. Arterial ulcers are formed at the most distal end of the body. Venous ulcers form over the medial malleolus, and compression bandaging is needed to reduce the pressure.
1, 3, & 4
Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet. This is due to the chronic complication of peripheral neuropathy, which results from nerve damage in the extremities.
Instructions for diabetic foot care include:
Wash feet daily with warm water and mild soap; test water temperature with thermometer beforehand. Gently pat feet dry, particularly between the toes (Option 2). Use lanolin to prevent dry and cracked skin, but do not apply between the toes.
Inspect for abrasions, cuts, or sores. Have others inspect the feet if eyesight is poor.
To prevent injury, use cotton or lamb's wool to separate overlapping toes. Cut toenails straight across and use a nail file to file along the curves of the toes. Avoid going barefoot and wear sturdy leather shoes. Use mild foot powder to absorb perspiration and wear clean, absorbent socks with seams aligned (Options 1, 3, and 4).
Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions (Option 5).
To improve circulation, do not sit with legs crossed or for extended periods, avoid tight-fitting garments, and perform daily exercise.
Report other types of problems such as infections or athlete's foot immediately.
Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Clients should keep feet clean, dry, and free from irritation.
1. ADMINISTER AS NEEDED DOSE OF HYDROCORTISONE iv
Addison's disease is adrenocortical insufficiency or hypofunction of the adrenal cortex. Addisonian crisis or acute adrenocortical insufficiency is a potentially life-threatening complication. Clients report nausea, vomiting, and abdominal pain. Signs of addisonian crisis include hypotension, tachycardia, dehydration, hyperkalemia, hyponatremia, hypoglycemia, fever, weakness, and confusion. Priority emergency management of addisonian crisis includes shock management, with fluid resuscitation using 0.9% normal saline and 5% dextrose; and administration of high-dose hydrocortisone replacement IV push.
(Options 2, 3, and 4) Assessment and documentation are important components of the nursing process, but emergency treatment of an addisonian crisis is the priority action.
Addisonian crisis is a potentially life-threatening complication of Addison's disease and commonly presents with abdominal pain, hypotension, and hypoglycemia. Emergency management includes shock management with fluid resuscitation using 0.9% normal saline and 5% dextrose, and administration of high-dose hydrocortisone replacement IV push.
2. ELEVATE THE AFFECTED ARM ON A PILLOW
After a mastectomy, an important goal is restoring function in the client's affected arm. Measures to promote function are initiated immediately after surgery. Elevating the affected arm to heart level (eg, on a pillow) is crucial to reduce fluid retention and prevent lymphedema in the affected arm (Option 2). Hand and arm exercises are implemented gradually, beginning with finger flexion and extension. These activities maintain muscle tone, prevent contractures, and improve lymph and blood circulation, which promote function and also prevent lymphedema. The return of full range of motion in the affected arm is desired within 4-6 weeks.
Additional nursing care for clients after a mastectomy includes keeping the client in semi-Fowler position and placing a sign over the bed that specifies, "No blood pressure, venipuncture, or injections on left arm," as these actions could cause lymphedema.
(Option 1) Ice reduces inflammation, swelling, and pain. Although this reduces discomfort, it does not directly contribute to restoring arm function and is not the priority.
(Option 3) Frequent ambulation is not the priority in the initial postoperative period as it does not facilitate lymph drainage or help restore arm function.
(Option 4) Pneumatic compression devices may be used to facilitate lymph drainage when lymphedema is present. Elevating and exercising the arm help prevent lymphedema from developing and are priority in this client.
A priority goal for a client following a mastectomy is restoring function in the affected arm. Elevation of the arm and institution of arm exercises begin immediately following surgery to prevent lymphedema.
1, 2, & 4
Case management involves assessing, planning, facilitating, and advocating for client health services to accomplish cost-effective quality client outcomes. This is done through communication and use of available resources. A professional nurse often serves in the case manager role. The case manager in the hospital setting assesses client needs, decreases fragmentation of care (Option 2), helps to coordinate care and communication between HCPs (Option 1), makes referrals, ensures quality standards are being met, and arranges for home health or placement after discharge (Option 4).
(Option 3) Case managers typically do not provide direct client care. Medication reconciliation should be done between the primary nurse directly caring for the client and the HCP.
(Option 5) Case managers often make daily rounds to the nursing department to review documentation in the client's chart but do not necessarily visit the client personally.
The nurse providing direct client care should be familiar with the nurse case manager role as part of the interdisciplinary team. The goal of the nurse case manager is to facilitate provision of quality care across a continuum, decrease fragmentation of care across various settings, and contain costs.
3. I SHOULD USE A COTTON SWAB TO GENTLY APPLY ALCOHOL TO THE CORD
The primary goal of cord care is to keep the cord stump clean and dry to facilitate healing and reduce infection risk. Additional teaching points regarding cord care include:
Keep the cord stump open to air when possible to allow for adequate drying.
Do not apply antiseptics (eg, alcohol, triple dye, chlorhexidine) to the cord stump, which can cause skin irritation (Option 3).
Report any signs of infection (eg, redness, purulent drainage, swelling) to the health care provider.
(Option 1) The umbilical cord is usually clamped and cut a few minutes after birth. The clamp is left in place until the cord begins to dry, usually around 24 hours after birth. The remaining cord stump begins to shrivel and turn black in 2-3 days.
(Option 2) The cord usually separates spontaneously from the umbilicus around 1-2 weeks after birth. Parents should be instructed to not pull on the cord stump or attempt to hasten cord separation, which could result in bleeding or other complications.
(Option 4) The diaper should be folded below the cord to keep the cord dry and prevent contamination with urine or feces.
The primary goal of cord care is to keep the cord stump clean and dry. Parents should keep the umbilical area dry, not apply antiseptics to the stump, and report any signs of infection.
2. INSERT NGT FOR UNCONTROLLED NAUSEA
Bariatric surgery for weight loss involves a surgical modification of the client's stomach and/or small intestine to restrict the client's intake. Postoperative nursing care focuses on managing pain and nausea and monitoring for complications (eg, infection, fluid and electrolyte imbalance, dumping syndrome, anastomotic leak). Nasogastric tubes are contraindicated after gastric surgery due to potential disruption of the surgical site, which can cause hemorrhage and anastomotic leak (Option 2). Postoperative nausea would be controlled using IV antiemetics.
(Option 1) Clients are placed on a clear liquid diet for the first 48-72 hours after bariatric surgery to promote healing. The diet is restricted to low-carbohydrate (eg, sugar-free) liquids to decrease the risk of dumping syndrome, rapid emptying into the small intestines that causes unpleasant vasomotor symptoms (eg, sweating, dizziness, cramping, diarrhea).
(Option 3) After bariatric surgery, low Fowler position is preferred during mealtimes as it slows gastric emptying, reducing the risk of dumping syndrome.
(Option 4) Morphine and patient-controlled analgesia pumps are commonly used to manage pain after bariatric surgery.
Nasogastric tube placement is contraindicated after gastric surgery due to the potential for disturbing the surgical site, which can result in hemorrhage and anastomotic leak.
1, 3, 4, & 5
A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP) (Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes (Option 5).
Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should:
Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors
Administer stool softeners to reduce strain during bowel movements (Option 1)
Reduce exertion, maintain strict bed rest, assist with activities of daily living
Maintain head in midline position to improve jugular venous return to the heart
(Option 2) Enoxaparin is an anticoagulant used to prevent venous thromboembolism (VTE). Anticoagulants are contraindicated in clients with hemorrhagic stroke; the nurse should question any prescriptions that increase risk for bleeding. A client with hemorrhagic stroke should instead receive nonpharmacologic interventions (eg, compression stockings) to prevent VTE.
A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding. The nurse should perform frequent neurological assessments, keep the client NPO, maintain seizure precautions and strict bed rest, and limit any activity that may increase bleeding (eg, anticoagulant administration) or intracranial pressure (eg, stimulation, straining during bowel movements).
1, 4, & 5
In pyloric stenosis, there is gradual hypertrophy of the pylorus until symptom onset at age 3-5 weeks. It is common in first-born boys and the etiology is unclear. Pyloric stenosis presents with postprandial projectile vomiting (ejected up to 3 feet) followed by hunger (eg, "hungry vomiter"). This is clearly distinguished from the "wet burps" infants have due to a weak lower esophageal sphincter. The emesis is nonbilious as the obstruction is proximal to the bile duct. Infants have poor weight gain and are often dehydrated (eg, sunken fontanelle, decreased skin turgor, delayed capillary refill).
The amount of milk consumed (particularly with bottle feedings) along with the mother's technique (mainly adequate burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology.
(Option 2) At times, formula intolerance or allergy is suspected initially when the infant first starts vomiting. However, celiac disease or gluten enteropathy is related to intolerance to gluten, a protein in barley, rye, oats, and wheat (BROW). Clients with celiac disease cannot eat these foods. A 3-week-old infant would only consume milk; this history would not be a factor at this time.
(Option 3) Physiological hyperbilirubinemia occurs due to the newborn's immature liver that is unable to metabolize hemoglobin byproducts. This is a "normal" finding that is unrelated to pyloric stenosis.
Pyloric stenosis is a hypertrophy of the pyloric sphincter that eventually causes complete obstruction. Classic signs include projectile nonbilious vomiting, an olive-shaped right upper quadrant mass, weight loss, dehydration, and/or electrolyte imbalance (metabolic alkalosis).