Upgrade to remove ads
Complex Exam 2
Terms in this set (58)
Cholecystitis assessment finding
Cirrhosis assessment finding
Acute Pancreatitis assessment finding
Gastrointestinal Reflux Disorder assessment finding
Vitamin B12 Deficiency assessment finding
smooth, beefy, red tongue
Ulcerative Colitis assessment finding
Crohn's Disease assessment finding
large intestine function
water and electrolyte absorption
food storage, mixes food with gastric secretions, and empties into small boluses
liver and gallbladder function
emulsification of fats and absorption of fatty acids and fat soluble vitamins // removes toxins and bacteria from blood
salivary gland functions
secretes amylase, aids in lubricating food
has exocrine and endocrine functions, release of enzymes, insulin, amylin, glucagon, somatostatin secretion
small intestine functions
digestion and uptake of nutrients from the gut lumen to the bloodstream
0 or negative measures urinary excretion of conjugated bilirubin
Prothrombin time (PT)
11-12.5 sec determination of prothrombin activity
0.1-2.2 ng/mL ; essential cofactor for many clotting factors
200 mg/dL ; varying with age, synthesized and excreted by the liver // high in bilirubin obstruction and low in cirrhosis and malnutrition
Alkaline phosphatase (ALP)
30-120 U/L; originates from bone and liver, serum levels rise when excretion is impaired because of obstruction in biliary tract
albumin 3.5-5 g/dL
globulin 2.3-3 measures serum proteins made by liver
total protein 6.4-8.3g/dL
conversion of ammonia to urea normally occurs in liver // increase can result in hepatic encephalopathy secondary to liver cirrhosis
Aspartate aminotransferase (AST)
0-35 U/L; high in liver damage and inflammation
A patient is admitted to the hospital with a diagnosis of diarrhea with dehydration. The nurse recognizes that increased peristalsis resulting in diarrhea can be related to
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?
Notify the health care provider (HCP).
On the basis of the signs and symptoms presented in the question, the nurse should suspect peritonitis and notify the HCP
The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence?
Ask the client to extend the arms
Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing.
The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the health care provider?
Purple discoloration of the stoma
Ischemia of the stoma would be associated with a dusky or bluish or purple color
A client with hiatal hernia chronically experiences heartburn following meals. The nurse should plan to teach the client to avoid which action because it is contraindicated with a hiatal hernia?
Lying recumbent following meals
Hiatal hernia is caused by a protrusion of a portion of the stomach above the diaphragm where the esophagus usually is positioned. The client usually experiences pain from reflux caused by ingestion of irritating foods, lying flat following meals or at night, and eating large or fatty meals. Relief is obtained with the intake of small, frequent, and bland meals; use of H2-receptor antagonists and antacids; and elevation of the thorax following meals and during sleep.
The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client?
- Maintain NPO (nothing by mouth) status.
- Encourage coughing and deep breathing
- Give hydromorphone intravenously as prescribed for pain
The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?
"I'm glad I don't have to lie still for this procedure."
The client does have to lie still for ERCP, which takes about 1 hour to perform. The client also has to sign a consent form. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.
Which gland regulates circadian rhythms?
A patient has a serum calcium (total) level of 13.4 mg/dL (3.34 mmol/L). Which disorder would the nurse suspect?
A normal serum calcium (total) is 8.6 to 10.2 mg/dL (2.15 to 2.55 mmol/L). The patient with a serum calcium level of 13.4 mg/dL has hypercalcemia. Serum calcium levels are increased in hyperparathyroidism.
A patient with thyroid nodules is to undergo a thyroid scan with oral radioactive isotopes. Which instructions, if given by the nurse, are appropriate?
"It is important to drink at least 2 to 3 liters of liquids for the next 1 to 2 days."
Patients should drink increased amount of fluids for 24 to 48 hours unless this is contraindicated. No special precautions are needed. The radionuclide will be eliminated in 6 to 24 hours. Reaction to iodine in allergic patients is rare because the amount of iodine in preparation is minimal. Sedation is not necessary for this procedure.
A patient has signs of hypothyroidism. Which diagnostic test will the nurse expect to be done first?
Thyroid-stimulating hormone (TSH)
The most sensitive and accurate laboratory test is measurement of TSH, and it is often recommended as a first diagnostic test for evaluation of thyroid function. If the TSH is abnormal, the other laboratory tests may be ordered.
A patient with type 1 diabetes calls the clinic reporting nausea, vomiting, and diarrhea. It is most important that the nurse advise the patient to
Check the blood glucose level every 2 to 4 hours.
If a person with type 1 diabetes is ill, they should test blood glucose levels at least at 2- to 4-hour intervals to determine the effects of this stressor on the blood glucose level.
The nurse plans a class for patients who have newly diagnosed type 2 diabetes. Which goal is most appropriate?
Enable the patients to become active participants in the management of their disease.
A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmoL/L).
Which statement by the nurse is best?
"You are at increased risk for developing diabetes."
Impaired fasting glucose (fasting blood glucose level between 100 and 125 mg/dL) and impaired glucose tolerance (2-hour plasma glucose level between 140 and 199 mg/dL) represent an intermediate stage between normal glucose homeostasis and diabetes. This stage is called prediabetes, and patients are at increased risk for the development of type 2 diabetes.
The nurse is caring for a patient who just returned to the surgical unit following a thyroidectomy. The nurse is most concerned if which is observed?
The patient makes harsh, vibratory sounds when breathing.
After thyroid surgery, the patient may experience an airway obstruction related to excess swelling, hemorrhage, hematoma formation, or laryngeal stridor (harsh, vibratory sound). Emergency equipment should be at the bedside, including oxygen, suction equipment, and a tracheostomy tray.
The nurse gives corticosteroids to a patient with acute adrenal insufficiency.
The nurse determines that treatment is effective if what is observed?
The patient is alert and oriented.
The patient in acute adrenal insufficiency will have the following clinical manifestations: hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion. Collaborative care will include administration of corticosteroids. An outcome that would indicate patient improvement would be improved level of consciousness (i.e., alert and oriented).
An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy.
Which explanation, if given by the nurse, is most appropriate?
"This medicine is given to help your body respond to stress after removal of the adrenal glands."
Hydrocortisone is administered IV during and after a bilateral adrenalectomy to ensure adequate responses to the stress of the procedure
The client is prescribed a loading dose of phenytoin of 15 mg/kg IV for seizure activity, then 100 mg IV tid. The client weighs 198 lb. How many milligrams should the nurse administer for the loading dose?
The client hospitalized with a vertebral fracture has a halo external fixation device in place.
Which intervention should the nurse plan?
Cleanse sites where the pins enter the skull
A halo external fixation device is a static device that consists of a "halo" that is screwed into the skull by four pins. It is attached to a vest that the client wears. The device provides immobilization and stability to the spinal cord while healing occurs with or without surgical intervention. Care includes inspection and cleansing of the pin sites.
The nurse is caring for the client with a C6 SCI. Which findings support the nurse's conclusion that the client may be experiencing autonomic dysreflexia?
Select all that apply.
a. Blurred vision results from the hypertension occurring with autonomic dysreflexia.
b. Hypertension is a symptom of autonomic dysreflexia from overstimulation of the sympathetic nervous system (SNS).
c. Bradycardia (not tachycardia) results from autonomic dysreflexia; the parasympathetic nervous system attempts to maintain homeostasis by slowing down the HR.
d. Headache results from the hypertension occurring with autonomic dysreflexia.
e. Sweating results from the sympathetic stimulation above the level of injury.
The nurse is assessing the motor and sensory function of an unconscious client. The nurse should use which technique to test the client's peripheral response to pain?
Nail bed pressure
The client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy?
The client had a serious head injury 4 weeks ago
Contraindications to thrombolytic therapy for the client with an ischemic stroke include a serious head injury within the previous 3 months. This would put the client at risk of developing serious bleeding problems, specifically cerebral hemorrhage.
The client who has expressive aphasia is having difficulty communicating with the nurse. Which action by the nurse would be most helpful?
Ask the client to point to needed objects
The client has right homonymous hemianopia following an ischemic stroke. The nurse asks the Nursing Assistant to help the client with meals knowing that this problem may result in which client response?
Eating food on only half of the plate
Homonymous hemianopia (hemianopsia) is a visual field abnormality that results in blindness in half of the visual field in the same side of both eyes. It results from damage to the optic tract or occipital lobe.
The nurse is caring for the client with a leaking cerebral aneurysm. Which early sign should prompt the nurse to notify the HCP of an increasing ICP?
Change in the level of consciousness
The experienced nurse is instructing the new nurse on subarachnoid hemorrhage. The nurse evaluates that the new nurse understands the information when the new nurse makes which statements?
Select all that apply.
"Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm."
"The client experiencing a subarachnoid hemorrhage may describe having a severe headache."
"A subarachnoid hemorrhage often results in the cerebrospinal fluid appearing bloody."
The nurse is caring for the older adult client with normal pressure hydrocephalus (NPH). Which treatment measure should the nurse anticipate?
NPH is treated with the placement of a permanent shunt in a lateral ventricle of the brain to the peritoneal cavity. The excess CSF drains into the peritoneal cavity.
A client is placed in reverse isolation after a stem cell transplant. How does the nurse best explain reverse isolation precautions to the client?
"The precautions will protect you from outside infections from others."
Immunosuppressed clients need to be protected from infections from others following a stem cell transplant. Although it is standard protocol, the best response by the nurse is to provide education with the answer.
A nurse explains the preparation for a bone marrow transplant to the client. Which information is important for the nurse to provide? Select all that apply,
- A course of chemotherapy will be administered.
- Total body radiation will be administered.
- A suitable donor must be identified prior to the transplant.
Which symptom may indicate acute rejection of a transplanted kidney?
Pain at the graft site
Signs and symptoms of acute rejection of a transplanted kidney include pain at the graft site. Other s/s would include decreased urine output, hypertension, elevated WBC count, fever, and elevated creatinine level.
The client with leukemia received an allogeneic bone marrow transplant 3 weeks ago. The client's current lab values are: hemoglobin of 12 g/dL, white blood cell count of 2200/mm3 with neutrophils of 50, and platelet count of 100,000/mm3. Which information should the nurse teach the client?
Avoid individuals who are potentially infectious.
The client's low WBC count and neutrophil count make the client at risk for infection because the client lacks mature WBC's to fight infection. The client's hemoglobin and platelet count are within normal limits and would not require rest, bleeding precautions, or supplements.
The client diagnosed with septicemia is admitted to the emergency department. Which intervention should the nurse implement first?
Administer the intravenous (IV) antibiotic.
Which assessment data indicates the client diagnosed with septic shock is responding to the medical treatment?
A urinary output of 200 mL in the last 4 hours.
The client must have a urinary output of at least 30 mL an hour. An output of 200 mL in 4 hours shows the client's kidneys are functioning normally, which indicates the client is responding to treatment
What characteristics are seen with acute transplant rejection? Select all that apply.
- Usually is reversible with additional or increased immunosuppressant medication.
- Recipient's T-cytotoxic lymphocytes attack the foreign organ.
- Long-term use of immunosuppressant medication is necessary to prevent rejection.
Acute transplant rejection occurs when the recipient's T cytotoxic lymphocytes attack the foreign organ. Long-term immunosuppressant help combat it, and it is usually reversible with additional immunosuppressants. Acute rejection can occur with any type of organ transplant. Hyperacute rejection occurs when the recipient has antibodies against the donor's human leukocyte antigen (HLA), is most common with kidney transplants, and results in the organ having to be removed.
What is the most important method to identify the presence of infection in the post-transplant client with neutropenia?
Frequent temperature monitoring.
A client who had a kidney transplant 6 months ago is admitted to the hospital with an episode of acute rejection. Anti-thymocyte globulin (ATG) is ordered: 1.5 mg/kg of body weight administered IV daily for 7 days. The client weighs 180 lbs. What dose of ATG will the client receive with each IV infusion? Round to the nearest whole number.
Change the client's weight from lb to kg (divide 180 by 2.2).
Then multiply the client's weight in kg (81.818) x the dose of 1.5 mg to get answer of 122.72,
and round to nearest whole number = 123
What are the classes of immunosuppressive therapy that clients take to prevent transplant rejection? Select all that apply
Cytotoxic (antiproliferative) drugs
The classes of immunosuppressive therapy that clients take to prevent transplant rejection include calcineurin inhibitors, corticosteroids, cytotoxic (antiproliferative) drugs. and antibodies (more common for treating rejection).
The immunosuppressant drugs are listed in the Lewis textbook, Chapter 13, Table 13.17 Drug Therapy, Immunosuppressive Therapy.
This set is often in folders with...
HESI Case Studies- Benign Prostatic Hyperplasia
HESI Case Studies - Peptic Ulcer Disease
Unit 1 adult health study questions
Other sets by this creator
Complex Exam 1
NUR4467 Exam 1
MH Exam 3
Other Quizlet sets
52. Mare Breeding Management
Ch 4. Study Guide
push period 3