Miscellaneous Flashcards

Question

how might one experience metabolic acidosis?

Answer 1

Choice A is correct. Diarrheal stools are high in bicarbonate. The loss of this bicarbonate, which is a base, from diarrhea stools results in metabolic acidosis. Choice C is correct. End-stage renal disease causes metabolic acidosis due to the inability of the kidneys to produce sufficient bicarbonate. Because bicarbonate is a base, and the kidneys cannot produce enough bicarbonate, acidosis occurs. Choice D is correct. Diabetic ketoacidosis (DKA) is an acute metabolic complication of diabetes characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. This occurs when a client with type I diabetes mellitus has so little insulin, that the cells have no glucose reserves for energy and subsequently resort to breaking down fat to use for energy. A byproduct of this fat breakdown is ketones, which are acids, and cause acidosis.

Answer 2

direct Coombs test measures maternal antibodies, specifically IgG, that are present on the infant’s red blood cells (Choice A). The presence of these antibodies is what causes erythroblastosis fetalis; therefore, the direct Coombs test indicates erythroblastosis fetalis ✓ Assessment findings in the newborn may include rapid onset jaundice, anemia, and swelling ✓ A newborn experiencing erythroblastosis fetalis may require a blood exchange transfusion

Answer 3

Atrial fibrillation is an irregularly irregular arrhythmia that produces an irregular pulse. This pulse irregularity is often a clinical indicator that a client requires a cardiac evaluation. Atrial fibrillation is associated with atrial fibrosis and loss of muscle mass. These structural changes are common in heart diseases such as hypertension, heart failure, and coronary artery disease. Characteristically, atrial fibrillation is irregularly, irregular with no P-waves identified. The biggest complication associated with atrial fibrillation is stroke because of blood pooling in the atrium. Treatment options for atrial fibrillation include digoxin (not as commonly used), amiodarone, diltiazem, verapamil, or atenolol. The client may be prescribed an oral anticoagulant such as apixaban to prevent thrombosis. If medication is not desired, synchronized cardioversion may be prescribed.

Answer 4

Heparin-induced thrombocytopenia (HIT) may be a life-threatening complication of exposure to heparinoids. The treatment for HIT Is to discontinue exposure to the heparin product immediately and to continue the anticoagulation with a non-heparin product. Agents that may be safely used include apixaban, dabigatran, or rivaroxaban. HIT is an adverse response to heparinoids. This autoantibody reaction causes venous (deeper vein thrombosis, pulmonary embolism) and arterial thrombosis (thrombotic strokes, myocardial infarction, arterial thromboembolism) The priority of HIT is to recognize it and stop the heparin product. The classic presentation of HIT is a reduction in the platelets by up to 50%, which is likely to occur between days four and five of heparin therapy. The nurse must report this type of platelet reduction immediately to the primary healthcare physician (PHCP). HIT treatment includes using an alternative anticoagulation agent such as fondaparinux, warfarin, rivaroxaban, dabigatran, and argatroban, inhibiting thrombin. Note that anticoagulation must be pursued in HIT despite thrombocytopenia.

Answer 5

Risk factors for testicular cancer include cryptorchidism, human immunodeficiency virus (HIV), and family history. Cryptorchidism (Choice A) refers to undescended testicle where the testicle fails to descend to its normal position in the scrotum. Undescended testicles are associated with decreased fertility, testicular torsion, inguinal hernias, and an increased risk of testicular germ cell tumors. HIV-positive ( Choice B) men are more likely to develop testicular cancer. Family history (Choice D) of testicular cancer is another risk factor, with 8-10 times increased risk if the man has a sibling with testicular cancer. Testicular cancer, if caught early, has a high cure rate. This cancer most likely occurs between ages 15-34. Risk factors for testicular cancer include Caucasian males, ages 15-34, HIV infection, cryptorchidism, and family history. Testicular cancer may manifest as a dull ache in the scrotum or abdomen, a solid mass on a testicle, scrotal swelling, or heaviness. A scrotal ultrasound is preferred if a primary healthcare provider suspects testicular cancer.

Answer 6

- imitate speech, sounds, non-speech sounds, actions, and gestures - recognizes own name - shifts gaze to objects being spoken aout -strings together sullabyls I series (ma-ma-ma; da-da-da)

Answer 7

✓ Influenza is a highly contagious respiratory infection primarily spread by infected respiratory droplets ✓ Appropriate infection control includes isolating the client using droplet precautions. This includes staff and visitors wearing a surgical mask within three feet of the client. Meticulous hand hygiene should be reinforced, including alcohol-based hand sanitizers before and after client care. ✓ Medical management aims to provide symptomatic care by using prescribed antipyretics and encouraging PO (by mouth) fluids. Antivirals may be used to shorten the duration of the illness; the guideline is to initiate oseltamivir 48 hours within influenza symptom onset.

Answer 8

Sodium bicarbonate is an alkaline agent used to correct severe acidosis. This medication is given in ampules via intravenous push or a continuous infusion. Epinephrine is the drug of choice for anaphylaxis as it relieves upper airway obstruction and treats hypotension. The intramuscular (IM) route is preferred over IV. Glucagon is an effective treatment for hypoglycemia as well as beta-blockers and calcium channel blocker toxicity. This medication is given intravenously (IV) or intramuscular (IM) along with other treatments such as epinephrine and calcium gluconate. Magnesium sulfate is indicated in the treatment of severe asthma attacks, eclamptic seizures, and torsades de pointes which is a ventricular dysrhythmia that may be fatal if not treated.

Answer 9

Critical thinking is a combination of reasoned thought, openness to alternatives, the ability to reflect, and a desire to seek the truth. There are many definitions of critical thinking. It is a complex concept and people think about it in different ways. Any situation that requires critical thinking is likely to have more than one “right” answer. You do not need critical thinking to add 2 + 2 and come up with the solution. However, you do need critical thinking to problem-solve essential decisions. A crucial aspect of critical thinking is the process of identifying and checking your assumption. This is also a necessary part of the research process. Critical thinking is a combination of reasoned thought, openness to alternatives, the ability to reflect, and a desire to seek the truth.

Answer 10

Hypokalemia is when the potassium level is less than 3.5 mEq/l. Conditions such as metabolic alkalosis, potassium wasting diuretics, Cushing’s syndrome, and alcoholism may all contribute to hypokalemia. The normal potassium level is 3.5-5.0 mEq/l. Conditions causing hypokalemia include metabolic alkalosis, which causes an intracellular shift of potassium. Cushing’s syndrome or disease causes hypokalemia because of this increase in aldosterone (potassium elimination and sodium retention). Symptoms of hypokalemia include muscle weakness, cramping, and lethargy. Cardiac rhythm changes include flattened T-waves and the presence of U waves.

Answer 11

Pneumonia Streptococcus, group A Adenovirus pneumonia Mumps (infectious parotitis) Rubella Pandemic influenza Epiglottitis, due to Haemophilus influenzae type b Mycoplasma pneumonia Pharyngeal diphtheria Rheumatic fever, infectious mononucleosis, and cryptococcosis meningitis require just standard precautions Clostridium difficile, rotavirus, and scabies require contact precautions Varicella zoster requires contact and airborne precautions until the lesions crust over

Answer 12

Bupropion is contraindicated in the treatment of bulimia because of its weight negative effects. Weight loss is not a treatment goal for a client with bulimia nervosa, and thus, this medication should not be utilized.Fluoxetine is an SSRI and is approved to treat bulimia nervosa. This medication is effective when treating this eating disorder, especially when coupled with psychotherapy. Major side effects of fluoxetine include weight gain, sexual dysfunction, insomnia, and agitation.

Answer 13

Have a pulse oximetry device readily available. Avoiding any open flame or heat. This includes an oven, stovetop, candles, matches, and cigarettes. Flammable products such as alcohol and oil should be avoided. Have working smoke detectors in the home as well as fire extinguishers. Use a water-soluble jelly to lubricate the nasal passages and mouth to prevent drying.

Answer 14

The Pavlik harness is a treatment method for developmental dysplasia of the hip (DDH) ✓ Treatment before 2 months often achieves the highest rate of success ✓ Treatment involves the application of a harness, casting, or surgery ✓ For the newborn to 6 months, the Pavlik harness may be applied ✓ This harness is applied, adjusted, and removed by the PHCP - not the parents ✓ The goal of the harness is to prevent hip extension and adduction ✓ Skin care is important while a client is wearing the harness ✓ Skin should be checked frequently for any reddened areas or overt skin breakdown ✓ Lotions and powders should not be used because of the potential for fungal dermatitis ✓ The diaper should be placed under the straps ✓ The infant should be dressed in loose, stretchy clothing ✓ If the straps get soiled, gentle soap and water via a washcloth may be used ✓ Provide sponge baths to the infant while leaving the harness in place ✓ Frequent follow-up appointments are necessary because the infant is growing

Answer 15

Urinary retention occurs when urine is produced normally but is not entirely emptied from the bladder. Retention can occur because of mechanical obstruction of the bladder outlet (enlarged prostate in a man or vaginal prolapse in a woman). Antihistaminic medications (such as diphenhydramine) tend to have anticholinergic side effects. Urinary retention can occur from the use of drugs with anticholinergic side effects. The bladder muscle's (detrusor smooth muscle) primary function is to "contract" and fully empty the bladder. Detrusor smooth muscle has muscarinic (cholinergic) receptors that facilitate this contraction. Anticholinergic agents impair this function and predispose to urinary retention. Excessive urinary retention eventually results in "overflow" incontinence.

Answer 16

The patient should be instructed to eat small portions of dry foods to aid digestion. A low carbohydrate, moderate fat, and moderate protein content will promote tissue healing and help to meet the body’s increased energy demands.

Answer 17

increase fluid oral intake

Answer 18

Lightheadedness/dizziness may be a sign that the patient’s rhythm has changed. The nurse should assess the patient and the rhythm as well as report any changes to the physician.

Answer 19

✓ Aspirin (ASA) overdose is highly concerning because it causes many serious effects ✓ The Poison Control Center should always be consulted with ASA overdoses for guidance on the client's care ✓ Manifestations of ASA overdose include Tinnitus Nausea and vomiting Tachypnea Metabolic acidosis Respiratory alkalosis (they may be in a mixed state of both) Tachycardia Hypovolemia Life-threatening pulmonary edema ✓ Treatment includes correcting the acid-based imbalance with sodium bicarbonate infusion(s), activated charcoal may be given if the ingestion was within two hours of presentation, cardiac monitoring, parenteral fluid replacement to correct hypotension, and glucose replacement

Answer 20

A patient with a recent lower lobe lung removal will have a chest tube drainage system to collect the blood and drainage and to prevent it from accumulating in the chest.`

Answer 21

Abdominal paracentesis is performed for clients with gross ascitic fluid due to liver cirrhosis. Nursing care for an abdominal paracentesis includes - ➢ Witnessing informed consent that the primary healthcare provider obtains ➢ Assisting the client to void before the procedure ➢ Obtaining baseline vital signs ➢ Measure the abdominal girth ➢ Gather appropriate supplies (suction, tubing, paracentesis kit) ➢ Position the client per the physician's prescription. The positioning is likely upright to allow the fluid to settle in the lower abdominal quadrants. ➢ Monitor the client and the drainage ➢ Send the initial ascitic fluid to the lab for culture and sensitivity, as prescribed Reposition the client, as needed to facilitate better drainage ➢ Monitor the client's vital signs throughout and after the procedure ➢ Administer an infusion of albumin, as prescribed for large volume (> 5 liters) paracentesis

Answer 22

Hypothermia is defined as a core body temperature of less than 95° F ( 35°C). Hypothermia is staged into Mild, moderate, severe, and profound hypothermia ( stages I to IV). Staging helps guide the treatment recommendations.

Answer 23

A core body temperature between 90 to 95° F (32.2°C to 35°C) is considered mild hypothermia

Answer 24

a temperature between 82° F to 90° F (27.8°C to 32.2°C) is considered moderate hypothermia Manifestations of moderate hypothermia include decreased level of consciousness (LOC), hypoventilation, bradycardia, atrial fibrillation, hypovolemia, cessation of shivering, and possible hyperglycemia.

Answer 25

A core temperature less than 82° F (27.8°C) is severe. However, measuring the core body temperature accurately is challenging. Therefore, a model based on the vital signs and clinical symptoms called the "swiss staging model" is used to stage hypothermic patients.

Answer 26

The Client Bill of Rights To courtesy, respect, dignity, and timely, responsive attention to his or her needs. To receive information from their physicians and to have opportunity to discuss the benefits, risks, and costs of appropriate treatment alternatives, including the risks, benefits and costs of forgoing treatment. Patients should be able to expect that their physicians will provide guidance about what they consider the optimal course of action for the patient based on the physician’s objective professional judgment. Ask questions about their health status or recommended treatment when they do not fully understand what has been described and have their questions answered. To make decisions about the care the physician recommends and to have those decisions respected. A patient who has decision-making capacity may accept or refuse any recommended medical intervention. To have the physician and other staff respect the patient’s privacy and confidentiality. To obtain copies or summaries of their medical records. To obtain a second opinion. To be advised of any conflicts of interest their physician may have in respect to their care. To continuity of care. Patients should be able to expect that their physician will cooperate in coordinating medically indicated care with other health care professionals and that the physician will not discontinue treating them when further treatment is medically indicated without giving them sufficient notice and reasonable assistance in making alternative arrangements for care.

Answer 27

The nurse must first determine if the client is of sound mind and legally competent to make decisions regarding his care before letting him sign an 'Against Medical Advice' form. If he is deemed incompetent, the facility must keep the client involuntarily to prevent further harm or injury to himself.

Answer 28

Myocardial infarction (MI) may present with symptoms of shortness of breath and muscle weakness. Silent MI is something that may not occur with pain. Other symptoms of myocardial infarction include: Chest discomfort. Most heart attacks involve pain in the center of the chest that lasts more than a few minutes – or it may go away and then return. It can feel like uncomfortable pressure, squeezing, fullness, or pain. Discomfort in other areas of the upper body. Symptoms can include pain or discomfort in one or both arms, back, neck, jaw, or stomach. Shortness of breath can occur with or without chest discomfort. Other signs include breaking out in a cold sweat, nausea, or lightheadedness. Since hyperlipidemia has no symptoms, it can cause damage before an individual realizes a problem. It can cause atherosclerosis and limit blood flow, increasing the risk of heart attack or stroke. Factors that can increase your risk of bad cholesterol include a poor diet. These foods are high in saturated fat (found in animal products), and trans fats (found in some commercially baked products) can contribute to an elevated cholesterol level. Additionally, obesity, lack of exercise, age, and history of diabetes can increase the chances of experiencing hyperlipidemia.

Answer 29

The most common area injured during lifting is the lumbar spine. This is because it supports the lower back.

Answer 30

Effective Measures to Prevent Back Injury Include Have the necessary assistance to move the object. Planning the move and communicating with the other individual who will assist you. Using the shoulder, upper arms, hips, and thighs as the predominant muscles to help with the move. Keep objects close to your body when lifting or carrying objects. Avoid twisting by using your feet to turn your body. Use a mechanical lift when necessary.

Answer 31

This client is exhibiting signs and symptoms of an adrenal crisis because of the abrupt cessation of prednisone. Findings supporting the crisis include the client’s lethargy, altered mental status, hypotension, tachycardia, and peaked T waves on the electrocardiogram. The client’s hypotension and tachycardia are explained by the significant dehydration associated with an adrenal crisis. This is further supported by their dry skin and tenting. The peaked T waves on the ECG are evidence of hyperkalemia, a feature of an adrenal crisis. An adrenal crisis may be triggered by a sudden cessation of a corticosteroid (especially if it is a considerable dose and the duration is greater than two weeks). An adrenal crisis is a medical emergency manifested by hypovolemia which causes hypotension and tachycardia. Hypoglycemia is also a clinical feature along with hyponatremia. The client will have elevated potassium levels that may cause cardiac dysrhythmias. The priority treatment for a client with an adrenal crisis is prompt administration of intravenous hydrocortisone! Additional treatment includes intravenous fluids, glucose, and regular insulin to lower the potassium.

Answer 32

Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. It is a medical emergency with a high mortality rate. Fortunately, it is now a rare presentation of hypothyroidism, likely due to earlier diagnosis as a result of the widespread availability of thyroid-stimulating hormone (TSH) assays. Early recognition and therapy of myxedema coma are essential. Treatment should be initiated on the basis of clinical suspicion without waiting for laboratory results. Important clues to the possible presence of myxedema coma in a poorly responsive patient are the presence of a thyroidectomy scar or a history of radioiodine therapy or hypothyroidism. A history obtained from family members often reveals antecedent symptoms of thyroid dysfunction followed by progressive lethargy, stupor, and coma.

Answer 33

Immediately following a surgical procedure (such as total hip arthroplasty), immediate assessments should include: Vital signs Lung sounds Cardiac rhythm Incision status Pain Nausea and vomiting Older adults are more at risk for complications, including suboptimal thermoregulation, urinary retention, wound disruption, and delirium.

Answer 34

Factitious disorder is characterized by an individual feigning their symptoms. The individual falsifies medical or psychiatric symptoms. This disorder may be imposed on themselves or others (by proxy). Nursing care for a client with this disorder includes – Develop a therapeutic rapport with the patient. Avoid confrontation or power struggles. Focus on the patient’s disorder – not symptoms. Investigate any new physical symptoms appropriately without them dominating the conversation.

Answer 35

You should immediately stop the urokinase and call the physician. Urokinase is a thrombolytic medication used in the treatment of blood clots. It is given over 12 hours through an intravenous site. One of the severe side effects of urokinase is bleeding. The bleeding can be from any location, including internal bleeding in the abdomen that can result in bloody stools. Although the team will closely monitor the patient, the nurse should immediately stop the urokinase and call the physician for further orders.

Answer 36

"Impaired urinary elimination related to an alkaline urinary pH" is the most appropriate nursing diagnosis for an immobilized client on complete bed rest. A urinary pH of 9.9 is abnormal, as this is outside the normal urinary pH value range of 4.5 to 8.0. A urinary pH of less than 4.5 is considered acidic, while urinary pH values greater than 8.0 are considered alkaline. Abnormal alkalinity, a known complication of immobility, places the client at risk for the formation of renal calculi and urinary impairments.

Answer 37

Dietary factors often affect urine pH. Alkaline urine is observed in clients who consume large quantities of citrus fruit and vegetables. Acidic urine is observed in clients with high meat intake. Elevated urine pH levels may be due to urinary tract infections, vomiting, kidney failure, metabolic alkalosis, respiratory alkalosis, etc. Decreased urine pH levels may be due to diarrhea, diabetes mellitus, diabetic ketoacidosis, metabolic acidosis, starvation, etc.

Answer 38

Bronchoscopy should only be performed by a pulmonologist or trained surgeon in an operating room or intensive care unit. Patients should remain nothing by mouth for a minimum of six hours before a bronchoscopy and have IV access, intermittent blood pressure monitoring, continuous pulse oximetry, cardiac monitoring, and supplemental oxygen for the procedure. Patients usually receive conscious sedation with short-acting benzodiazepines, opioids, or both before the procedure to decrease anxiety, discomfort, and cough. General anesthesia is also commonly used. The pharynx and vocal cords are anesthetized with nebulized or aerosolized lidocaine.

Answer 39

According to Skinner's theory, changes in behavior result from an individual's response(s) to the specific events, or stimuli, which occur in their respective environment. According to Skinner's research, everything we do and are shaped by our experience of punishment and reward. More specifically, when a stimulus-response pattern is rewarded, the individual is conditioned to respond similarly in the future. The key to Skinner's theory is reinforcement, or, more specifically, anything that strengthens the desired response. The central tenet of Skinner's work is that positively reinforced behavior will reoccur. When an individual is rewarded for a specific behavior, that individual is more likely to repeat the behavior due to positive reinforcement. Conversely, under Skinner's theory, negative reinforcement involves removing an undesirable stimulus to increase a behavior (not to be confused with a "negative punishment," where one would remove a pleasant stimulus to decrease a behavior). Despite Skinner's operant conditioning findings dating back to publications from the 1960s, many of these scientific theories continue to be implemented today. While Skinner's research and findings greatly influence countless fields, education is one of the most notable. Education appears to have been affected by Skinner's theories at all educational levels, having been integrated into all aspects of classroom management by instructors, instructional designers, administrators, etc., continuing to this day. Skinner's theories relating to behavior management techniques and procedures continue to be cited and implemented today.

Answer 40

A: The nurse irrigating a nasogastric tube connected to suction should draw up 30 mL of saline (or the amount indicated on the order) into the syringe. C: The nurse should place the tip of the syringe in the tube to gently insert the saline solution. E and F: After instilling the irrigant, the nurse should hold the end of the NG tube over an irrigation tray or emesis basin and observe for return flow of NG drainage into an available container.

Answer 41

Some of the contraindications for warfarin include: ✓ Active bleeding: Warfarin can increase the risk of bleeding and should not be used in people who are actively bleeding. ✓ Hemorrhagic stroke: People who have had a hemorrhagic stroke (a stroke caused by bleeding in the brain) should not use warfarin, as it can increase the risk of bleeding and worsen the stroke. ✓ Pregnancy: Warfarin is contraindicated in pregnancy, as it can cross the placenta and cause birth defects or bleeding in the fetus. ✓ Severe liver or kidney disease: Warfarin is metabolized in the liver and excreted by the kidneys, so people with severe liver or kidney disease may not be able to properly metabolize or excrete the drug. Hypersensitivity to warfarin: People who have had an allergic reaction to warfarin in the past should not use the medication.

Answer 42

Risk factors for type two diabetes include family history, gestational diabetes, overweight, and being over the age of 45. Metabolic syndrome is the common driver of diabetes (abdominal obesity, hypertension, hyperlipidemia, hyperglycemia). Diabetes mellitus has a much higher prevalence in non-Hispanic whites as it impacts Native Americans and Alaskan Indians more than any other population group.

Answer 43

laster casts are not commonly used and have been widely replaced by fiberglass material. However, it is important for all types of casts that the client is taught: ➢ Plaster cast should be exposed to air until it is dry. ➢ Plaster cast should be handled with the palms instead of the fingers to avoid indentation. ➢ All casts should be kept dry and out of the shower. ➢ The affected extremity that is casted should be elevated for the first 24 hours (above the heart). ➢ Manifestations of compartment syndrome (paresthesias, unrelieved pain) should be taught to the client. ➢ Objects should not be inserted into the cast. If the skin itches, a hair dryer on the cool setting may be used.

Answer 44

Essential labs to monitor while a client takes lithium include the lithium level, thyroid panel (lithium may cause hypothyroidism), creatinine (risk of nephrotoxicity), and sodium (hyponatremia may precipitate lithium toxicity). Lithium levels should be maintained between 0.6 – 1.2 mEq/L. The client should be educated on the following points – Lithium requires the client to maintain adequate fluid and salt. Failing for the client to do so may result in lithium toxicity. Lab findings expected with lithium include leukocytosis and hypothyroidism (long-term use). The client should avoid medications such as diuretics, NSAIDs, and ACE inhibitors, as these medications may cause lithium toxicity. Lithium levels should be drawn twelve hours following the client’s last dose. If not, this may falsely elevate the lithium level. Lithium toxicity signs and symptoms include nausea, vomiting, lethargy, confusion, delirium, coma, seizures, and hypotension. Lithium inhibits both iodine uptake & thyroxine release -> Hypothyroidism (monitor TSH; T4) * Lithium increases PTH & also, causes parathyroid hyperplasia -> Hyperparathyroidism (monitor calcium)

Answer 45

Alprazolam (Xanax) is a type of benzodiazepine. The patient is presenting with classic benzodiazepine drug withdrawal symptoms: anxiety, coarse hand/tongue/eyelid tremors, irritability, increased autonomic activity (tachycardia and sweating), orthostatic hypotension, and insomnia.

Answer 46

This finding requires follow-up because flank pain when a client has a nephrostomy tube would suggest pyelonephritis, a serious infection. Common findings associated with pyelonephritis include cloudy urine, nausea, fever, and malaise. This infection must be treated promptly because it can lead to urosepsis. ✓ Nursing care for pyelonephritis is like that of cystitis, which includes the administration of prescribed antibiotics, educating the client to stay hydrated, and measures to prevent a recurrence. ✓ A nephrostomy tube increases the client's risk for pyelonephritis because the catheter is directly threaded into the renal pelvis. ✓ A complication of pyelonephritis is sepsis. Thus, signs of sepsis, such as tachycardia and hypotension, should be reported to the primary healthcare provider.

Answer 47

Standards are the levels of performance accepted and expected by the nursing staff or other healthcare team members. They are established by authority, custom, or consent. The Committee on Quality Health Care in America of the Institute of Medicine, in its report Crossing the Quality Chasm, highlights six aims to be met by health care systems about quality care: Safe: Avoiding injury Useful: Avoiding overuse and underuse Patient-centered: Responding to patient preferences, needs, and values Timely: Reducing waits and delays Efficient: Avoiding waste Equitable: Providing care that does not vary in quality to all recipients

Answer 48

NSAIDs (naproxen, ibuprofen), ACE inhibitors (lisinopril, enalapril), and diuretics (furosemide, hydrochlorothiazide) should be avoided while a client is taking lithium. ACE inhibitors promote sodium wasting, and low levels of sodium precipitate lithium toxicity. NSAIDs reduce renal blood flow, cause lithium retention and raise its serum level to a potentially toxic range. The client with aches and pains should be recommended acetaminophen.

Answer 49

The client's digitalis level of 2.5 ng/mL indicates toxicity. Digoxin has a narrow therapeutic index, which can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Normal corrective serum digoxin levels range from 0.5–2 ng/mL. A level higher than 2 ng/mL is considered toxic. The nurse is correct in withholding the scheduled dose and assessing the client's heart rate and rhythm, as the client is likely to be experiencing bradycardia. The normal therapeutic range for digitalis is 0.5-2 ng/dL. Hypokalemia is a significant cause of digitalis toxicity and may be induced by certain diuretics. The earliest manifestation of digoxin toxicity is lack of appetite, nausea, and vomiting.

Answer 50

A client with stage I dysphagia has severe difficulty swallowing. These clients must be fed puréed foods. Stage I dysphagia clients are fed diets consisting of primarily puréed foods, including puréed fruits, vegetables, and meats. Additional foods include gravies, puddings, egg yolks, and baby foods.

Answer 51

Oxaprozin is a non-steroidal anti-inflammatory drug (NSAID). This drug is effective in osteoarthritis because this disease causes significant pain, especially when the affected joint is used. Long-term NSAID use may cause renal insufficiency and increase the risk of a gastrointestinal ulcer.

Answer 52

Beta-blockers decrease blood pressure by causing vasodilation of the vessels. They block catecholamines from the beta receptor sites found in the heart and lungs. Beta-blockers decrease the heart's workload through vasodilation and lowering the heart rate. This relaxation of the vasculature and reduction in heart rate will reduce the myocardial oxygen demand. This is why beta blockers (low doses) may be prescribed during an acute myocardial infarction and afterward.

Answer 53

✓ Beta-adrenergic blockers, more commonly referred to as beta blockers ✓ Beta-blockers block catecholamines from binding to the receptors found in the heart and lungs ✓ These medications block the beta receptors, the rate at which the pacemaker (sinoatrial [SA] node) fires decreases, and the time it takes for the node to recover increases ✓ Some beta-blockers are more cardioselective (metoprolol and atenolol) compared to nonselective beta-blockers (propranolol) ✓ Underlying restrictive and obstructive respiratory illness may worsen when beta-blockers are given because the medication causes bronchoconstriction ✓ The nurse needs to assess the client's pulse (P) and blood pressure (BP) before administration ✓ These medications may raise the client's risk for falls because they may cause orthostatic hypotension ✓ Beta-blockers should not be administered if the client is experiencing any atrioventricular (AV) block or bradyarrhythmia ✓ Examples of beta-blockers include propranolol, metoprolol, and carvedilol

Answer 54

Patients with ascites present with tightly stretched skin over a rounded, distended abdomen due to accumulation of fluid in the peritoneal cavity typically related to liver disease, portal hypertension, tuberculosis, or nephritic syndrome. Upon percussion of the abdomen, the nurse would expect to note tympany over the top of the abdomen where the intestines float, and dullness over the sides where fluid settles (fluid shifts when the patient is turned to the side).

Answer 55

A CVS is a test utilized to determine the presence of chromosomal abnormalities and involves the aspiration of small samples of the placenta for prenatal genetic diagnosis. Maternal blood and urine specimens are not necessary for this test. Chorionic villus sampling is a test that may be performed as early as ten gestational weeks to determine if the fetus has any chromosomal abnormalities. Chorionic villus sampling has drawbacks that preclude its use, including possible spontaneous abortion of the fetus and fetomaternal hemorrhage.

Answer 56

Documentation is a written record of (1) the interactions between and among health care professionals, patients, and their families (2) tests, procedures, treatments, and patient education (3) test results or patient’s responses to treatment interventions. Several methods are used for documentation. These include narrative charting, source-oriented charting, problem-oriented charting, PIE charting, focus charting, charting by exception (CBE), computerized documentation, and critical pathway documentation. Case management refers to the process of organizing the patient care throughout an episode of illness so that certain clinical and financial outcomes are achieved within an assigned time frame. Case management uses a critical pathway documentation system as a form of patient care delivery and documentation. Critical pathways are time-oriented multidisciplinary plans of care that are established and approved by the interdisciplinary team. Variances are deviations from the expected course that are documented within the critical pathway system.

Answer 57

Diltiazem is a rate lowering calcium channel blocker used in the management of atrial fibrillation. This medication assists in maintaining rate control. While not always indicated, an anticoagulant such as warfarin or rivaroxaban is used in the management of atrial fibrillation as this arrhythmia puts the patient at high risk for a stroke. ✓ The primary goal for a client with atrial fibrillation is to maintain rate control (60-100) and to prevent stroke ✓ Medications such as diltiazem, digoxin, amiodarone, and dronedarone may be used to control heart rate ✓ Anticoagulants are also indicated as ischemic strokes are commonly associated with atrial fibrillation ✓ Anticoagulants commonly used include rivaroxaban, apixaban, and warfarin

Answer 58

Fentanyl via a transdermal patch is an effective way to provide around-the-clock pain control. The medication establishes efficacy within 24 hours, and the patch should be kept on the client for 72 hours.

Answer 59

Pregabalin is a medication used to manage neuropathic pain (neuropathy, phantom limb pain). This medication may cause an individual to experience drowsiness.

Answer 60

Ketorolac is an anti-inflammatory medication that may be used short-term for individuals with mild to moderate pain. The client should have their doses limited as this medication may cause nephrotoxicity.

Answer 61

A health care proxy is an individual named in a written legal document designated to make medical decisions for the client when the client is no longer able to make decisions for themself.

Answer 62

A power of attorney (POA) primarily authorizes the person you designate to make financial decisions for you. It cannot be used to make health care decisions. You must complete a health care proxy to enable someone else to make healthcare decisions for you when you can no longer do so.

Answer 63

Onychomycosis is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque/yellow, and crumbling. Since Onychomycosis is the most common cause of nail dystrophy presenting to the outpatient department, a nurse plays a crucial role in the diagnosis, management, and education of the clients. Dermatophytes (Trichophyton) cause 90% of these toenail infections. The remaining 10% are caused by non-dermatophytes (Saprophytes) and yeast (Candida). The prevalence of onychomycosis in patients between 20 to 60 years of age is 20%, whereas prevalence in older adults > 70 years of age is about 50%. The nurse should be aware of the risk factors and educate at-risk clients regarding foot care. Some common risk factors for onychomycosis include immunosuppression, diabetes mellitus, age greater than 70, persistently wet feet, repetitive nail trauma, tight-fitting footwear, HIV infection, prolonged steroid use, peripheral vascular disease, and genetics. Often, patients are asymptomatic. But the quality of life can be substantially decreased because of onychomycosis. Clients may have low self-esteem and feel embarrassed about having thick, discolored nails. Also, they may report mild pain and discomfort. Diagnosis is based on history and clinical exam. Diagnosis can be confirmed by demonstrating dermatophytes in KOH preparation of nail scrapings. The condition is often challenging to treat. Recurrence and failures may be in the range of 20 to 50% (i.e., the cure rate is approximately 50%). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails. Most antifungal treatments may have liver toxicity; therefore, liver function tests may have to be monitored. Terbinafine is contraindicated in clients with baseline liver disease.

Answer 64

Onychomadesis is the falling off and the separation of the nails from the nail bed. It is not the appearance of the affected nail in the exhibit. The cause of onychomadesis is often idiopathic (unknown). However, in children, it may occur as a rare complication 4 to 6 weeks following Hand, Foot, and Mouth disease.

Answer 65

Onychomadesis is the falling off and the separation of the nails from the nail bed. It is not the appearance of the affected nail in the exhibit. The cause of onychomadesis is often idiopathic (unknown). However, in children, it may occur as a rare complication 4 to 6 weeks following Hand, Foot, and Mouth disease.

Answer 66

Onychorrhexis is the formation of vertical ridges on the nails or brittle nails that tend to break easily. The pins are not thick and discolored, as shown in the exhibit. Onychorrhexis occurs due to disordered keratinization in the nail matrix. Causes include the normal aging process, recurrent nail trauma, anemia, hypothyroidism, and eating disorders.

Answer 67

Onychia is an inflammation of the nail folds. It does not appear in the exhibit provided. Onychia is not the infection of the nail itself, but rather a disease of the surrounding tissue of the nail plate.

Answer 68

The therapeutic VPA level is 50-125 mcg/mL. A 40 mcg/mL VPA level is considered sub-therapeutic and requires follow-up as the client is at risk of seizure. A cause of this level being subtherapeutic may be caused by non-adherence to the medication.

Answer 69

✓ VPA is indicated in preventing seizures, treatment for bipolar disorder, and migraine headache prevention ✓ The most common adverse effects of VPA include nausea, vomiting, blood dyscrasias, hair loss, and metabolic syndrome ✓ The liver enzymes should be monitored while a client takes VPA, as hepatic injury may occur ✓ The therapeutic level of VPA is 50-125 mcg/mL

Answer 70

An IV urography (pyelogram) is a diagnostic test used to gather urinary tract imaging that views the collecting ducts and renal pelvis and outlines the ureters, bladder, and urethra. The client must perform a bowel cleansing the night before to ensure adequate visualization of the urinary tract. During this procedure, the client will empty their bladder, and then an intravenous injection of contrast medium is given, and a series of x-ray films and fluoroscopy is used to observe the passage of urine from the renal pelvis to the bladder. The use of this test has decreased because of computed tomography scans of the urinary tract. ✓ This procedure requires female clients to undergo a pregnancy test before the procedure because of the adverse effect radiation may have on the fetus ✓ The purpose of this test is to diagnose neoplasms of the urinary tract, urolithiasis, scars, and urinary strictures ✓ Laxatives may be prescribed the night before to cleanse the bowel effectively ✓ Anesthesia is not used for this procedure ✓ Contrast dye is used in this procedure, but the relationship between IV contrast dye and allergies to shellfish has been discredited

Answer 71

Inflammation from thrombophlebitis increases the size of the affected extremity and can be assessed by measuring circumference regularly. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the diameter of the involved extremity. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if the patient experiences any chest pain or dyspnea. The patient should be instructed not to massage the legs.

Answer 72

It is most appropriate to request an interpreter from the hospital's interpreter service. A certified medical interpreter has the proper training to quickly and accurately translate the conversation as well as protect client confidentiality. This is the appropriate action by the nurse.

Answer 73

The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. Conditions that should be triaged as emergent include: active hemorrhage, unstable vital signs, significant trauma, chest pain, and manifestations of a stroke.

Answer 74

The urgent triage category indicates that the client should be treated quickly but that an immediate threat to life does not exist at the moment. Conditions that typically fall into the urgent category are those with a new onset of pneumonia (as long as respiratory failure does not appear imminent), renal colic, abdominal pain, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature higher than 101°F (38.3°C).

Answer 75

Those triaged as non-urgent can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration. Conditions within this classification include clients with sprains and strains, simple fractures, general skin rashes, and uncomplicated urinary tract infections.

Answer 76

Angioedema is a life-threatening adverse effect that is seen with ACE inhibitors such as enalapril. Angioedema may cause swelling anywhere in the body but swelling in the face, lips, and eyes can be life-threatening. ACE inhibitors are central in the treatment of heart failure and hypertension. These medications inhibit the deleterious effects associated with Angiotensin II. Medications in this class include lisinopril, enalapril, and captopril. The most serious adverse effect is angioedema. A nagging, dry cough is a common side-effect associated with this medication, and if this should occur, a prescriber may switch the client to an ARB such as valsartan. Finally, these drugs may raise potassium and creatinine.

Answer 77

✓ Magnesium is an essential mineral that plays a vital role in various physiological functions, including muscle and nerve function, blood pressure regulation, and protein synthesis. ✓ The following are some dietary sources of magnesium recommended by the American Dietetic Association (ADA): Green leafy vegetables Nuts and seeds Legumes Whole grains Seafood Dairy products ✓ It is essential to note that the magnesium content of foods can vary depending on the soil in which they are grown and the processing methods used. Therefore, it is recommended to consume a variety of magnesium-rich foods to meet daily magnesium requirements. ✓ The ADA recommends a daily intake of 310-320 mg of magnesium for adult women and 400-420 mg for adult men.

Answer 78

When a client experiences a myxedema coma, it is because of severe hypothyroidism. These dangerously low levels of thyroid hormone produce symptoms such as altered level of consciousness, hyponatremia, hypothermia, hypoventilation, and hypoglycemia. Treatment is essential and is geared towards the prompt administration of intravenous levothyroxine and liothyronine. Glucocorticoids are usually added to the treatment to help mitigate the hypotension and potential overlook of adrenal dysfunction. Myxedema coma is a rare but extremely serious complication associated with severe hypothyroidism. ✓ Manifestations of a myxedema coma include hyponatremia, hypothermia, hypoventilation, and hypoglycemia. ✓ The nurse must initiate medical and symptomatic treatment, such as intravenous levothyroxine and hydrocortisone. ✓ The nurse may also treat the client's symptoms with passive rewarming.

Answer 79

Pheochromocytoma is a condition caused by a tumor that sits on the adrenal medulla. This causes a surge in catecholamine discharge resulting in headaches, palpitations, marked hypertension, and hyperglycemia. Treatment includes antihypertensives and removal of the tumor. The client should be educated to avoid sources of caffeine, smoking, and stressful situations, as this would further increase blood pressure.

Answer 80

A patient with increased intracranial pressure should have the head of the bed elevated at 30 or 40 degrees. Nurses should also be sure to avoid Trendelenburg and prevent the patient’s neck from flexing. A standard ICP is about 5 to 15 mmHg.

Answer 81

➢ PCAs can be used for individuals as early as seven years old. ➢ The settings on the PCA include on-demand dosing, basal, or both. ➢ The PHCP will prescribe the opioid (morphine, fentanyl, or hydromorphone) along with the amount, lockout period, and maximum dose. ➢ When initiating a PCA device, it is essential to have a second nurse verify the settings before the infusion. ➢ It is recommended that continuous pulse oximetry be applied to the client to detect early signs of opioid toxicity. ➢ If on-demand dosing is prescribed, the client must be cognitively aware of operating the device. ➢ When the basal setting is used, the client is at an increased risk of adverse events because this setting delivers continuous pain medication regardless of the client pushing the button.

Answer 82

Macewen’s sign is a sign used to detect hydrocephalus. The examiner percusses on the skull at the junction of the frontal, temporal, and parietal bones and can auscultate a “cracked pot”, or hyper-resonant sound if hydrocephalus is present. Macewen's sign is unrelated to congestive heart failure or chronic hypoxia.

Answer 83

Sitagliptin is a DPP-4 Inhibitor used in managing diabetes mellitus type II. This medication reduces blood glucose levels by delaying gastric emptying and slowing the rate of nutrient absorption into the blood. The most common adverse effect associated with this medication is pancreatitis. Pancreatitis is manifested by abdominal pain, nausea, and persistent vomiting.Sitagliptin is a treatment that may be prescribed for type II diabetes mellitus ✓ Persistent abdominal pain should be reported because pancreatitis is the major adverse effect of this medication. ✓ Other medications in this class include linagliptin, saxagliptin, and alogliptin.

Answer 84

Primary, secondary, and tertiary prevention are three levels of healthcare strategies used to prevent or manage diseases and injuries: ✓ Primary prevention: Primary prevention aims to prevent the onset of a disease or injury before it occurs. ✓ Secondary prevention aims to identify and treat a disease or injury in its early stages to prevent it from progressing or causing complications. ✓ Tertiary prevention: Tertiary prevention aims to prevent or reduce the long-term effects of a disease or injury that has already occurred.

Answer 85

✓ Serotonin syndrome (serotonin toxicity) is a serious condition that ranges from mild (most cases go unnoticed) to life-threatening. ✓ Most cases are caused by a client being on a serotonergic agent (such as an SSRI [citalopram, paroxetine, fluoxetine]) and then a newly prescribed (or over over-the-counter) medication taken by the client which causes a tremendous elevation in serotonin giving the client abdominal cramping, myoclonus, diarrhea, diaphoresis, agitation, fever, and tachycardia ✓ Treatment is withdrawing the serotonergic drug and administering prescribed aggressive dosing of benzodiazepines, intravenous fluids, seizure precautions, and cyproheptadine (a serotonin antagonist)

Answer 86

A PET scan is primarily indicated to detect cancers and their response to treatment. Before a PET scan, the client is instructed to be nothing by mouth (NPO) four to six hours before the exam and have a glucose level below 150 mg/dL. The reasoning is that this exam primarily looks at cancerous tissue, which uses a substantial amount of glucose. If the radioisotope is metabolized in the body, similar to glucose, it will accumulate in the most active areas. Glucose greater than 150 mg/dL or less than 60 mg/dL will alter the results. PET imaging is primarily used to detect cancers, assess the treatment response, and evaluate the extent of metastasis. F-18 fluorodeoxyglucose (FDG) is used during this exam and emits positrons, and the technique often produces images with higher contrast and spatial resolution. Malignant tissue uses a substantial amount of glucose, and if the radioisotope is metabolized in the body, similar to glucose, it will accumulate in the most active areas. The client is instructed to be NPO 4-6 hours before this exam. The client should be instructed to refrain from vigorous exercise 24- hours before the exam. After the injection of FDG, the client must lie in a quiet room for 60 minutes before the scan.

Answer 87

Cutaneous or superficial somatic pain arises in the skin or subcutaneous tissue. Such pain is described as sharp, aching, gnawing, or cramping. It is often localized. The client is experiencing "sharp" pain, which goes more in favor of cutaneous pain. Physical pain is either nociceptive or neuropathic. These two types of pain differ in the way they affect the patient as well as in how they are treated. Nociceptive pain is the most common type of pain experienced. It occurs when pain receptors, which are called nociceptors, respond to stimuli that are potentially damaging, for example, as a result of noxious thermal, chemical, or mechanical stimuli. Nociceptive pain may occur as a result of trauma, surgery, or inflammation. Two types of nociceptive pain are visceral pain (i.e. pain originating from internal organs) and somatic pain (i.e. pain originating from the skin, muscles, bones, or connective tissue).

Answer 88

Very Low-Calorie Diets (VLCDs) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis. Deficient calorie diets, generally providing fewer than 800 kcal per day, became widely available for outpatient use in the treatment of adult obesity in the 1980s. These diets, sometimes called protein-sparing modified fasts, were associated with significant medical risks (electrolyte abnormalities, arrhythmias, and sudden death) but became widely marketed as part of many commercial weight loss programs. Despite their overall success in supporting rapid weight loss, most patients experienced subsequent weight regain once the deficient calorie diet was discontinued. These extremely hypocaloric diets have been used on a limited basis in the pediatric population, generally in an inpatient setting, with close medical supervision. Given the deficient daily caloric intake associated with the VLCD, this diet requires almost a full liquid approach. Patients are often on 3–5 shakes daily, with multivitamin and mineral supplementation. Side effects include fatigue, hair loss, dizziness, constipation, and the risk for cholelithiasis secondary to rapid weight loss. The VLCD usually results in >20% weight loss within the first 3–4 months. Although rapid weight loss is seen, it is not regularly well maintained with many patients gaining up to 50% of that weight back within the subsequent 12 months and gaining all of the weight back in less than five years. Low-calorie diets (LCDs) are not as extreme and with almost twice as many calories allowed (1200–1500 kcal/day), the weight loss is modest.

Answer 89

Delirium Tremens (DTs) is a medical emergency that may result in seizure activity. The nurse should always put the client's safety at the forefront and provide seizure precautions. This includes padding the side rails, ensuring that intravenous access has been established, oxygen is at the bedside, and suction is available. ✓ Delirium Tremens (DTs) are a medical emergency and may cause autonomic hyperactivity, resulting in tachycardia, diaphoresis, fever, anxiety, insomnia, and hypertension. ✓ Delusions and visual and tactile hallucinations are common in alcohol withdrawal delirium. ✓ This may occur within 72 hours following the last alcoholic beverage consumed. ✓ Withdrawal seizures may occur within 12 to 24 hours after alcohol cessation. ✓ These seizures are generalized and tonic-clonic. Additional seizures may occur within hours of the first seizure. ✓ Diazepam is given intravenously as a common treatment for withdrawal seizures. Nursing care for DTs includes - Rapid assessment of the client's vital signs Initiate seizure precautions and establish patent intravenous access Obtain a prescription for benzodiazepines, such as lorazepam or diazepam Administer intravenous fluids and electrolytes to replete the lost fluids Assess the client using the CiWa-Ar scale to trend the severity of the symptoms

Answer 90

Agnosia is a clinical feature associated with dementia. Agnosia is the inability to identify familiar objects or people, even a spouse.

Answer 91

✓ Alzheimer's disease (AD) is the most common type of dementia. ✓ The progressive deterioration of cognitive functioning commonly characterizes AD. ✓ Initial deterioration may be so subtle and insidious that others may not notice it. ✓ In the early stages of the disease, the affected person may be able to compensate for and hide cognitive deficits. ✓ Manifestations of AD include impairment of recent memory which progresses to remote memory. ✓ As the disease progresses, the client may have impairment in executive functioning, including planning, organizing, and problem-solving. ✓ Additional clinical features of AD include the triple-A (agraphia, agnosia, and apraxia). ✓ Nursing care is aimed at maximizing function and promoting safety. The nurse should also provide caregiver/family support because of the emotional toll of this disorder.

Answer 92

deviated tongue

Answer 93

✓ Osteoporosis is a condition characterized by a decrease in bone mass ✓ Risk factors are postmenopausal women, Asian or White race, excessive use of alcohol, tobacco use, sedentary lifestyle, prolonged exposure to corticosteroids, hormone insufficiency (testosterone/estrogen) ✓ The biggest complication of osteoporosis is fracture ✓ Prevention is the best treatment by encouraging weight-bearing exercises to increase bone mass, adequate calcium and vitamin D intake, and smoking, and alcohol cessation ✓ Diagnosis is established by a bone density (DEXA) scan ✓ Nursing care is focused on mitigating risk factors, preventing falls, and encouraging the client to remain active to help with restoring bone mass

Answer 94

Reducing medical errors is a continuous process,, and several proven factors may mitigate errors. These factors include: Having nurse-to-nurse bedside handoff reporting. Not only does this process increase client satisfaction by having the client participate, but it allows for errors to be noted by two individuals instead of one. For example, if an infusion pump is malfunctioning or administering the wrong dose. Bedside handoff reporting also mitigates distractions from being in the hallway or at the desk where it may be loud. A standardized handoff reporting (ISBAR) is helpful because it keeps communication concise to pertinent information. This standardized tool is useful because it keeps the communication process structured,, minimizing the risk of omission. Fatigue is a common source of errors. One way to minimize fatigue is to ensure all staff is taking uninterrupted breaks. Poor lighting and distractions continually contribute to errors, and increasing lighting around critical pieces of equipment, such as mediation dispensaries, may be helpful to reduce errors regarding reading product labels and drawing up accurate medication dosages.

Answer 95

A halo vest immobilizer is used to stabilize cervical spinal cord injuries. The goal is to stabilize the spinal cord using external fixation. Pin care should be completed every shift using sterile gauze and the prescribed solution. If the client should have the wrench taped to the front of the vest or at the head of the bed in case the device needs to be taken down for emergent cardiopulmonary resuscitation. Loosening of the pins is the most common complication and should be addressed immediately. The client should use a straw for drinking as moving the neck to swallow liquids is not permitted. When caring for a client with a halo vest immobilizer, the nurse should instruct the client about pin care, signs of infections at the pin site, not driving while in the vest, and keeping the wrench affixed to the front of the vest. To perform CPR, the wrench may be necessary to let down the metal posts. Before discharge, a client with this type of device will need to meet with an occupational and speech therapist to learn how to perform ADLs safely.

Answer 96

Standard precautions are utilized in the management of inhalation anthrax. Inhalation anthrax is not transmitted from person to person, and its vector is contaminated materials, such as wool, hides, or hair. ✓ Anthrax is a bioterrorism agent and must be taken seriously because it has a high mortality rate. ✓ Anthrax may be cutaneous or inhaled and is caused by exposure to the gram-positive bacterium. ✓ Standard precautions are used for a client with inhalation anthrax. ✓ Nursing care is aimed at stabilizing the client's breathing and promptly initiating treatment: antibiotics (levofloxacin) and/or antitoxins such as raxibacumab.

Answer 97

In Benchmarking, the nurse-manager compares best practices from top hospitals with her unit and adapts the unit’s methods to improve unit performance.

Answer 98

✓ Metabolic alkalosis is a medical condition characterized by an elevation in blood pH above the normal range of 7.35-7.45, resulting from an accumulation of bicarbonate ions (HCO3-) in the body. ✓ Causes: The most common causes of metabolic alkalosis include excessive vomiting or gastric suction, diuretic use, hyperaldosteronism, and excess bicarbonate administration. ✓ Symptoms: The symptoms of metabolic alkalosis include confusion, twitching, muscle cramps, and tingling in the fingers and toes. Severe cases can lead to seizures, respiratory depression, and cardiac arrest. Diagnosis: Diagnosis of metabolic alkalosis involves measuring arterial blood gases, serum electrolytes, and urine pH. ✓ Treatment: Treatment depends on the underlying cause of metabolic alkalosis. It may involve fluid and electrolyte replacement, correction of acid-base imbalance, and addressing the underlying condition.

Answer 99

Conditions requiring droplet precautions include: Rubella Influenza Pertussis Bacterial meningitis Pneumonic plague Diphtheria (Pharyngeal) Mumps Rhinovirus

Answer 100

Bradycardia is not a typical symptom of decreased cardiac output in neonates. Instead, a decreased cardiac output generally results in tachycardia as the heart pumps faster to compensate. Typical signs of decreased cardiac output in an infant include oliguria, difficulty feeding, hypotension, irritability, restlessness, pallor, and decreased distal pulses.

Answer 101

Tolvaptan is a vasopressin antagonist and is indicated in treating the syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, the client retains water which causes fluid retention without edema. Classic manifestations of SIADH include polydipsia, hemodilution, and oliguria. This medication promotes free water excretion, normalizing sodium levels and increasing urine output. This urine-specific gravity is normal (1.005 - 1.025) and indicates that the medication is having its therapeutic effect because a client with SIADH would have a high USG from the limited water spilled into the urine. ✓ SIADH may be caused by pulmonary tuberculosis and certain lung malignancies. ✓ Clinical features of SIADH include hyponatremia because of excessive water. Other features include increased urine-specific gravity, oliguria, and hemodilution. ✓ Treatment includes prescribed fluid restrictions and tolvaptan. ✓ Tolvaptan causes the excretion of free water, which raises sodium levels. ✓ The client's sodium needs to be monitored carefully while administering this medication because it may cause hypernatremia. ✓ This medication is very hepatotoxic, and the liver function tests should be monitored closely.

Answer 102

The client may have broccoli, lettuce, and apples. Lettuce and apples are low in calcium and oxalate. Broccoli is high in calcium. However, it is low in oxalate and high in potassium. Being high in potassium, broccoli reduces calcium excretion in urine and reduces the formation of kidney stones. Therefore, this is the reason that it need not be held back in renal calculi. Kidney stones in the urinary tract are formed in several ways. Calcium can combine with chemicals, such as oxalate or phosphorous, in the urine. This can happen if these substances become so concentrated that they solidify. Kidney stones can also be caused by a buildup of uric acid related to the metabolism of protein. Most urinary tract calculi, especially calcium oxalate stones, can be prevented by following dietary recommendations. Generally, clients should avoid high calcium and high oxalate-containing foods. Clients should also be instructed to avoid stone-forming, high oxalate foods such as beets, chocolate, spinach, rhubarb, and tea. Most nuts are rich in oxalate and colas are rich in phosphate, both of which can contribute to kidney stones. Fluids, especially water, help to dilute the chemicals that form stones. Patients should be encouraged to drink at least eight glasses of water every day. ✓Increasing fluid intake: Drinking plenty of water and other fluids can help dilute the urine and reduce the risk of stone formation. ✓Reducing sodium intake: Consuming too much salt can increase the amount of calcium in the urine, contributing to kidney stones' formation. ✓Eating a balanced diet: Eating a diet that is high in fruits, vegetables, and whole grains and low in animal protein and refined sugars can help reduce the risk of kidney stones. ✓Avoiding certain foods: Some foods, such as those high in oxalates or purines, may increase the risk of kidney stones and should be avoided or limited.

Answer 103

Meloxicam is a COX-2 inhibitor and is indicated in treating chronic musculoskeletal conditions causing pain, such as osteoarthritis or rheumatoid arthritis. COX-2 inhibitors are purported to provide pain control while decreasing the risk of gastrointestinal bleeding when compared to an NSAID such as naproxen. The client's vital signs are not concerning. The client has a temperature of 99° F (37° C), is commonly found with rheumatoid arthritis, and is not concerning. The client's pain does not require follow-up because the nurse has a prescription for pain control, meloxicam. Pain with RA is expected. An allergy to doxycycline is not a contraindication to the administration of meloxicam. NSAIDs, COX-2 inhibitors, and aspirin should be avoided in individuals with congestive heart failure because of their ability to worsen the condition. The nurse must clarify this point with the physician before administering the medication. NSAIDs and COX-2 inhibitors are nephrotoxic and may cause an acute kidney injury. The client's renal function tests are elevated and would prohibit the dosing of this medication. ✓ Pain control for an individual with rheumatoid arthritis (RA) is an essential aspect of the treatment plan ✓ Medications such as topical creams and alternating with ice and heat are plausible options ✓ Antiinflammatory medications such as naproxen or ketorolac may be used ✓ COX-2 inhibitors may be used in lieu of an NSAID because of their decreased risk of causing gastrointestinal bleeding ✓ COX-2 inhibitors include meloxicam and celecoxib ✓ Contraindications with COX-2 inhibitors include renal insufficiency, congestive heart failure, and stroke

Answer 104

Signs and symptoms of cervical cancer include back and leg pain, spotting between menstrual periods and after intercourse, vaginal discharge, and lengthening of a menstrual period. A pap smear is needed to assess cellular changes (i.e. check for cancerous and precancerous conditions).

Answer 105

Hyperglycemic-hyperosmolar state (HHS) is likely to develop in individuals with type II diabetes mellitus. The patient secretes just enough insulin to prevent ketosis in HHS but not enough to prevent hyperglycemia. Severe hyperglycemia causes an individual to experience significant diuresis, causing severe dehydration. Correcting fluid and electrolyte imbalances is essential for an individual with HHS. The clinical guideline is to infuse one liter of saline in one hour and reassess the client’s volume status thereafter. HHS development is related to residual insulin secretion. The client secretes just enough insulin to prevent ketosis in HHS but not enough to prevent hyperglycemia. The hyperglycemia of HHS is more severe than that of DKA, greatly increasing blood osmolarity, leading to extreme diuresis with severe dehydration and electrolyte loss. HHS is a common complication associated with type II diabetes mellitus. Treatment for HHS emphasizes fluid replacement. Neurological functional needs to be monitored closely as cerebral edema may consequently occur from rapid fluid replacement. Any alteration in mental status needs to be reported. Treatment goals aim to restore circulatory volume at a steady pace.

Answer 106

A client with gram-negative sepsis faces an array of complications, including DIC. The release of the endotoxin by the bacteria may cause excessive activation of the clotting cascade, leading to exhaustion by the clotting factors. Clients with sepsis need to be monitored for DIC as this condition is life-threatening. The risk for DIC caused by gram-negative sepsis is even higher for those with hypothermia and acidosis because the coagulation factors' enzymatic functions are pH and temperature-dependent. ✓ DIC is a medical emergency and can be caused by an array of conditions, including eclampsia, gram-negative sepsis, and cancer ✓ Extensive, abnormal clotting occurs throughout the blood vessels of individuals with DIC. This widespread clotting depletes circulating clotting factors and platelets. As this happens, extensive bleeding occurs. ✓ Bleeding from many sites is the most common problem, ranging from oozing to fatal hemorrhage. ✓ Clots block blood vessels and decrease blood flow to major body organs, resulting in pain, ischemia, strokelike symptoms, dyspnea, tachycardia, reduced kidney function, and bowel necrosis. ✓ Treatment includes packed red blood cells and fresh frozen plasma transfusions. Heparin may be prescribed for any thrombi.

Answer 107

DI can be divided into either neurogenic (central) or nephrogenic. The water deprivation test is used to help differentiate whether the DI is neurogenic or nephrogenic. In this test, the client is deprived of water for up to eight hours (they may still eat dry foods). Serial labs, including plasma and urine osmolality measurements, are obtained during that time. Additionally, the client's urine volume and weight are meticulously measured hourly. If the client's body weight should decrease, this supports the diagnosis of DI. At the end of the eight hours, a dose of desmopressin is administered. If there is an increase in urine osmolarity and a decrease in urine volume, it is considered central/neurogenic DI (because the problem responded to the DDAVP). If no response is observed after the DDAVP is administered, nephrogenic DI is likely. ✓ DI is a condition that may be central or nephrogenic ✓ The client is at risk for fluid volume deficit because the client may experience polyuria ✓ This may manifest as tachycardia, hypotension, and a thread pulse ✓ Common laboratory findings for an individual with DI include hypernatremia, decreased urine specific gravity (it is dilute), and increased hematocrit (hemoconcentration) ✓ Treatment for central diabetes insipidus is by administering desmopressin (intranasal or tablet) ✓ Nephrogenic diabetes insipidus is treated by withdrawing the offending agent (such as lithium) and administration of thiazide diuretics or NSAIDs

Answer 108

This client demonstrates signs of acute respiratory distress syndrome (ARDS), a complication of pneumonia (hypoxemia). The client's inability to oxygen is highly concerning and is a classic manifestation of ARDS. An RRT should be immediately called to assist with appropriate interventions, including intubation by a qualified provider. Inflammation from pneumonia may cause a client to develop ARDS. A classic manifestation of ARDS is hypoxemia (PaO2 less than 80 mm Hg). Adventitious lung sounds are not normally auscultated initially with ARDS and are not a reliable assessment. Treatment for ARDS is correcting the underlying cause and maintaining adequate oxygenation and ventilation via invasive and non-invasive means. The normal PaO2 is 80-100 mm Hg, and the normal SpO2 is greater than 95%.

Answer 109

Tannins are polyphenolic compounds found in plants, wood, leaves, fruits, and tea. The tannin that is present in tea decreases the absorption of iron. But adding lemon juice, which is high in vitamin C, seems to cancel the inhibitory effect of tannins on iron absorption.

Answer 110

Zidovudine (ZDV) is an antiretroviral medication that may be administered intrapartum to further reduce vertical transmission of HIV. This medication is commonly indicated for women who have a scheduled cesarean delivery or, in the rare instance of a vaginal delivery. This medication is preferred because it may be administered intravenously and can provide pre-exposure prophylaxis to the fetus. Whether this medication is prescribed and administered intrapartum depends on the mother's viral load. The lower the viral load, the less likely of transmission to the fetus. ✓ Women should continue taking their antiretroviral therapy (ART) regimen as much as possible during labor and delivery or scheduled cesarean delivery ✓ Zidovudine is an intravenous antiretroviral that is administered intrapartum to reduce vertical transmission further ✓ To further reduce HIV transmission during labor and delivery, avoid fetal scalp electrode monitoring when possible ✓ To identify HIV infection in infants and young children (less than 18 months), HIV viral load (VL) testing must be performed using assays that detect HIV deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) ✓ Antibody tests are not accurate because the infant acquires maternal antibodies, which may cause a false positive ✓ Cord blood should not be used for testing because of the possibility of contamination of the sample with maternal blood

Answer 111

x The Patient-Generated Subjective Global Assessment is a client-reported screening tool to assess nutritional status. The Patient-Generated Subjective Global Assessment, often referred to as the PG-SGA or the PG-SGA nutritional assessment, is well recognized in clinical research as the reference method for determining the nutrition status of clients with cancer.

Answer 112

Neuropathic pain describes constant inflammation or irritation of nerve cells that causes pain sensation due to oversensitive nerve cells and a decrease in opioid receptors. Examples of neuropathic pain sources include CNS lesions, stroke, tumor, multiple sclerosis, sciatica, shingles, and phantom limb pain.

Answer 113

Valacyclovir is an antiviral and is effective in the management (and prevention) of outbreaks associated with herpes simplex virus (HSV). It is highly recommended that the client start valacyclovir at the earliest sign of an outbreak which is the prodromal symptoms of headache, fever, malaise, itching, and burning in the affected area. A client will either take this during an outbreak or daily to prevent an outbreak (suppressive therapy).

Answer 114

Shoulder pain may occur following a cesarean section due to gas or referred pain from the surgery. The nurse should assess the patient’s pain to determine the cause before administering medications or other interventions.

Answer 115

cyanosis A tracheoesophageal fistula is an abnormal passage or connection between the esophagus (typically the lower) and the trachea. Cyanotic spells, also known as blue spells, dying spells, or apparent life-threatening events, refer to a bluish tone visible in the mucosal membranes and skin caused by an oxygen decrease in the peripheral circulation. Esophageal atresia and tracheoesophageal fistula often occur together. The two conditions are also frequently seen in children with other birth defects of the spine, heart, kidney, genitals, ears, and limbs and retardation of mental development, physical development, or both.