PNLE IV for Care of Clients with Physiologic and Psychosocial Alterations (Part 2)

An electrocardiogram evaluates the complaints of chest pain, laboratory tests determines anemia, and the stool test for occult blood determines blood in the stool. Cardiac monitoring, oxygen, and creatine kinase and lactate dehydrogenase levels are appropriate for a cardiac primary problem. A basic metabolic panel and alkaline phosphatase and aspartate aminotransferase levels assess liver function. Prothrombin time, partial thromboplastin time, fibrinogen and fibrin split products are measured to verify bleeding dyscrasias, An electroencephalogram evaluates brain electrical activity.

When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.

Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.

The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4-3/8") long, 5 to 5.8 cm (2" to 2¼") wide, and 2.5 cm (1") thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae.

Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by uretheral distention and smooth muscle spasm; relief form pain is the priority.

Hydrocortisone, a glucocorticoid, should be administered according to a schedule that closely reflects the body's own secretion of this hormone; therefore, two-thirds of the dose of hydrocortisone should be taken in the morning and one-third in the late afternoon. This dosage schedule reduces adverse effects.

Lactulose is given to a patients with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experience diarrhea, it indicates over dosage and the nurse must reduce the amount of medication given to the patient. The stool will be mashy or soft. Lactulose is also very sweet and may cause cramping and bloating.

Regular insulin, which is a short-acting insulin, has an onset of 15 to 30 minutes and a peak of 2 to 4 hours. Because the nurse gave the insulin at 2 p.m., the expected onset would be from 2:15 p.m. to 2:30 p.m. and the peak from 4 p.m. to 6 p.m.

Serous fluid fills the space and eventually consolidates, preventing extensive mediastinal shift of the heart and remaining lung. Air can’t be left in the space. There’s no gel that can be placed in the pleural space. The tissue from the other lung can’t cross the mediastinum, although a temporary mediastinal shift exits until the space is filled.

Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determineshow much blood has been lost. The goal in this situation is to stop the bleeding. The nurse would call for help if it were warranted after the assessment of the situation. After determining the extent of the bleeding, vital signs assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.

Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly.

The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.

A corticotropin-secreting pituitary tumor would cause high corticotropin and high cortisol levels. A high corticotropin level with a low cortisol level and a low corticotropin level with a low cortisol level would be associated with hypocortisolism. Low corticotropin and high cortisol levels would be seen if there was a primary defect in the adrenal glands.

The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.

Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, helping to reduce the risk of another infraction by decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by decreasing the heart rate. Narcotics reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption bt decreasing left ventricular end diastolic pressure (preload) and systemic vascular resistance (afterload).

In stage 1, symptoms include a single enlarged lymph node (usually), unexplained fever, night sweats, malaise, and generalized pruritis. Although splenomegaly may be present in some clients, night sweats are generally more prevalent. Pericarditis isn’t associated with Hodgkin’s disease, nor is hypothermia. Moreover, splenomegaly and pericarditis aren’t symptoms. Persistent hypothermia is associated with Hodgkin’s but isn’t an early sign of the disease.

Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state from warfarin overload, and ASA decreases platelet aggregation.

In diabetes insipidus, excessive polyuria causes dilute urine, resulting in a below-normal urine osmolality level. At the same time, polyuria depletes the body of water, causing dehydration that leads to an above-normal serum osmolality level. For the same reasons, diabetes insipidus doesn't cause above-normal urine osmolality or below-normal serum osmolality levels.

An xenogeneic transplant is between is between human and another species. A syngeneic transplant is between identical twins, allogeneic transplant is between two humans, and autologous is a transplant from the same individual.

Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection.

HATT may occur after CABG surgery due to heparin use during surgery. Although DIC and ITP cause platelet aggregation and bleeding, neither is common in a client after revascularization surgery. Pancytopenia is a reduction in all blood cells.

The infracted area produces alveolar damage that can lead to the production of bloody sputum, sometimes in massive amounts. Clot formation usually occurs in the legs. There’s a loss of lung parenchyma and subsequent scar tissue formation.

A urine output of less than 40 ml/hour in a client with burns indicates a fluid volume deficit. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions also are normal. The client's rectal temperature isn't significantly elevated and probably results from the fluid volume deficit.

Because of the large amount of energy it takes to breathe, clients with emphysema are usually cachectic. They’re pink and usually breathe through pursed lips, hence the term “puffer.” Clients with ARDS are usually acutely short of breath. Clients with asthma don’t have any particular characteristics, and clients with chronic obstructive bronchitis are bloated and cyanotic in appearance.

The nurse should instruct the client to rotate injection sites within the same anatomic region. Rotating sites among different regions may cause excessive day-to-day variations in the blood glucose level; also, insulin absorption differs from one region to the next. Insulin should be injected only into healthy tissue lacking large blood vessels, nerves, or scar tissue or other deviations. Injecting insulin into areas of hypertrophy may delay absorption. The client shouldn't inject insulin into areas of lipodystrophy (such as hypertrophy or atrophy); to prevent lipodystrophy, the client should rotate injection sites systematically. Exercise speeds drug absorption, so the client shouldn't inject insulin into sites above muscles that will be exercised heavily.

This is the appropriate response. The nurse should help the mother how to cope with her own feelings regarding the child’s disease so as not to affect the child negatively. When the hair grows back, it is still of the same color and texture.

Epidermiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years.

A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through Pao2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased Paco2.

In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.

Back pain or paresthesia in the lower extremities may indicate impending spinal cord compression from a spinal tumor. This should be recognized and treated promptly as progression of the tumor may result in paraplegia. The other options, which reflect parts of the nervous system, aren’t usually affected by MM.

ET tube placement should be confirmed as soon as the client arrives in the emergency department. Once the airways is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make sure L.V. access is established. If the client experiences symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should try to find the cause of the client’s arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation and atrial flutter – not symptomatic bradycardia.

The emergency department nurse is no longer directly involved with the client’s care and thus has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call physician) has the right to information about his condition. Because the client requested that the nurse update his wife on his condition, doing so doesn’t breach confidentiality.

COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive.

Kayexalate,a potassium exchange resin, permits sodium to be exchanged for potassium in the intestine, reducing the serum potassium level.

Edema or swelling at the IV site is a sign that the needle has been dislodged and the IV solution is leaking into the tissues causing the edema. The patient feels pain as the nerves are irritated by pressure and the IV solution. The first action of the nurse would be to discontinue the infusion right away to prevent further edema and other complication.

This is the correct flow rate; multiply the amount to be infused (2000 ml) by the drop factor (10) and divide the result by the amount of time in minutes (12 hours x 60 minutes)

Since only a partial pneumonectomy is done, there is a need to promote expansion of this remaining Left lung by positioning the client on the opposite unoperated side.

Inadequate fluid intake during hyperglycemic episodes often leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. A client whose diabetes is controlled with oral antidiabetic agents usually doesn't need to monitor blood glucose levels. A highcarbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.

Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It’s important that a person with Rhnegative blood receives Rh-negative blood. If Rh-positive blood is administered to an Rh-negative person, the recipient develops anti-Rh agglutinins, and sub sequent transfusions with Rh-positive blood may cause serious reactions with clumping and hemolysis of red blood cells.

If abdominal distention is accompanied by nausea, the nurse must first auscultate bowel sounds. If bowel sounds are absent, the nurse should suspect gastric or small intestine dilation and these findings must be reported to the physician. Palpation should be avoided postoperatively with abdominal distention. If peristalsis is absent, changing positions and inserting a rectal tube won't relieve the client's discomfort.

A client with HHNS has an overall body deficit of potassium resulting from diuresis, which occurs secondary to the hyperosmolar, hyperglycemic state caused by the relative insulin deficiency. An elevated serum acetone level and serum ketone bodies are characteristic of diabetic ketoacidosis. Metabolic acidosis, not serum alkalosis, may occur in HHNS.

Tissue thromboplastin is released when damaged tissue comes in contact with clotting factors. Calcium is released to assist the conversion of factors X to Xa. Conversion of factors XII to XIIa and VIII to VIII a are part of the intrinsic pathway.

Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.

Because Paco2 is high at 80 mm Hg and the metabolic measure, HCO3- is normal, the client has respiratory acidosis. The pH is less than 7.35, academic, which eliminates metabolic and respiratory alkalosis as possibilities. If the HCO3- was below 22 mEq/L the client would have metabolic acidosis.

In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin degeneration products increase as fibrinolysis takes places.

Clients with chronic obstructive bronchitis appear bloated; they have large barrel chest and peripheral edema, cyanotic nail beds, and at times, circumoral cyanosis. Clients with ARDS are acutely short of breath and frequently need intubation for mechanical ventilation and large amount of oxygen. Clients with asthma don’t exhibit characteristics of chronic disease, and clients with emphysema appear pink and cachectic.

In osteoporosis, bones lose calcium and phosphate salts, becoming porous, brittle, and abnormally vulnerable to fracture. Sodium and potassium aren't involved in the development of osteoporosis.

Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician. Edema is an expected finding because aldosterone overproduction causes sodium and fluid retention. Dry mucous membranes and frequent urination signal dehydration, which isn't associated with Cushing's syndrome.

Persistent (more than 24 hours) vomiting, anorexia, and diarrhea are signs of toxicity and the patient should stop the medication and notify the health care provider. The other manifestations are expected side effects of chemotherapy.

This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated.

Long bone fractures are correlated with fat emboli, whichcause shortness of breath and hypoxia. It’s unlikely the client has developed asthma or bronchitis without a previous history. He could develop atelectasis but it typically doesn’t produce progressive hypoxia.

Kaposi's sarcoma is the most common cancer associated with AIDS. Squamous cell carcinoma, multiple myeloma, and leukemia may occur in anyone and aren't associated specifically with AIDS.

The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results of the answer are abnormally elevated, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls with the normal range of 60% to 75%.

Lugol’s solution provides iodine, which aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed.

Laboratory findings for clients with SLE usually show pancytopenia, elevated ANA titer, and decreased serum complement levels. Clients may have elevated BUN and creatinine levels from nephritis, but the increase does not indicate SLE.

Changes in behavior and level of consciousness are the first sins of hepatic encephalopathy. Hepatic encephalopathy is caused by liver failure and develops when the liver is unable to convert protein metabolic product ammonia to urea. This results in accumulation of ammonia and other toxic in the blood that damages the cells.

Hodgkin’s disease typically causes fever night sweats, weight loss, and lymph mode enlargement. Influenza doesn’t last for months. Clients with sickle cell anemia manifest signs and symptoms of chronic anemia with pallor of the mucous membrane, fatigue, and decreased tolerance for exercise; they don’t show fever, night sweats, weight loss or lymph node enlargement. Leukemia doesn’t cause lymph node enlargement.

(Look for no. 36 of text mode to view the computation.)

Narcotics may mask changes in the level of consciousness that indicate increased ICP and shouldn’t acetaminophen is strong enough ignores the mother’s question and therefore isn’t appropriate. Aspirin is contraindicated in conditions that may have bleeding, such as trauma, and for children or young adults with viral illnesses due to the danger of Reye’s syndrome. Stronger medications may not necessarily lead to vomiting but will sedate the client, thereby masking changes in his level of consciousness.

Severe hypoxia after smoke inhalation is typically related to ARDS. The other conditions listed aren’t typically associated with smoke inhalation and severe hypoxia.

Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia.

Then action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen, decrease infection, or decrease bone demineralization.

PTCA can alleviate the blockage and restore blood flow and oxygenation. An echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral sublingual medication. Cardiac catheterization is a diagnostic tool – not a treatment.

Severe lower back pain indicates an aneurysm rupture, secondary to pressure being applied within the abdominal cavity. When ruptured occurs, the pain is constant because it can’t be alleviated until the aneurysm is repaired. Blood pressure decreases due to the loss of blood. After the aneurysm ruptures, the vasculature is interrupted and blood volume is lost, so blood pressure wouldn’t increase. For the same reason, the RBC count is decreased – not increased. The WBC count increases as cell migrate to the site of injury.

Hepatic cell death causes release of liver enzymes alanine aminotransferase (ALT), aspartate aminotransferase (AST) and lactate dehydrogenase (LDH) into the circulation. Liver cirrhosis is a chronic and irreversible disease of the liver characterized by generalized inflammation and fibrosis of the liver tissues.

Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone (PTH). Clients also exhibit hypercaliuria-causing polyuria. While clients with diabetes mellitus and diabetes insipidus also have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than polyuria.

The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen.

3000 x 10 divided by 24 x 60.

Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation. There’s no information to suggest the postmyocardial infarction client has an arrhythmia or other complication. There’s no evidence to suggest hemorrhage or perforation for the remaining clients as a priority of care.

The kidneys respond to rise in blood pressure by excreting sodium and excess water. This response ultimately affects sysmolic blood pressure by regulating blood volume. Sodium or water retention would only further increase blood pressure. Sodium and water travel together across the membrane in the kidneys; one can’t travel without the other.

Essential thrombocytopenia is linked to immunologic disorders, such as SLE and human immunodeficiency vitus. The disorder known as von Willebrand’s disease is a type of hemophilia and isn’t linked to SLE. Moderate to severe anemia is associated with SLE, not polycythermia. Dressler’s syndrome is pericarditis that occurs after a myocardial infarction and isn’t linked to SLE.

The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at risk for ketosis. Urine specific gravity isn't indicated because although fluid balance can be compromised, it usually isn't dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of infection.

Furosemide is a loop diuretic that inhibits sodium and water reabsorption in the loop Henle, thereby causing a decrease in blood pressure. Vasodilators cause dilation of peripheral blood vessels, directly relaxing vascular smooth muscle and decreasing blood pressure. Adrenergic blockers decrease sympathetic cardioacceleration and decrease blood pressure. Angiotensin-converting enzyme inhibitors decrease blood pressure due to their action on angiotensin.

From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard.

Leukopenia, a reduction in WBCs, is a systemic effect of chemotherapy as a result of myelosuppression.

Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

Foods that bothered a person preoperatively will continue to do so after a colostomy.

Pneumonia, both viral and fungal, is a common cause of death in clients with neutropenia, so frequent assessment of respiratory rate and breath sounds is required. Although assessing blood pressure, bowel sounds, and heart sounds is important, it won’t help detect pneumonia.

.05 mg/ 1 ml = .12mg/ x ml, .05x = .12, x = 2.4 ml.

Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate.

Myxedema coma, severe hypothyroidism, is a life-threatening condition that may develop if thyroid replacement medication isn't taken. Exophthalmos, protrusion of the eyeballs, is seen with hyperthyroidism. Thyroid storm is life-threatening but is caused by severe hyperthyroidism. Tibial myxedema, peripheral mucinous edema involving the lower leg, is associated with hypothyroidism but isn't life-threatening.

A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from fat. The other modifications are appropriate for this client.

The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution. Proper positioning doesn't help prevent confusion, seizures, or cardiac arrhythmias.

The client was reacting to the drug with respiratory signs of impending anaphylaxis, which could lead to eventually respiratory failure. Although the signs are also related to an asthma attack or a pulmonary embolism, consider the new drug first. Rheumatoid arthritis doesn’t manifest these signs.

Promote venous return by applying external pressure on veins.

For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Placing the client on the right side with legs straight, prone with the torso elevated, or bent over with hands touching the floor wouldn't allow proper visualization of the large intestine.

Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.

A client about to go into respiratory arrest will have inefficient ventilation and will be retaining carbon dioxide. The value expected would be around 80 mm Hg. All other values are lower than expected.

An ileostomy stoma forms as the ileum is brought through the abdominal wall to the surface skin, creating an artificial opening for waste elimination. The stoma should appear cherry red, indicating adequate arterial perfusion. A dusky stoma suggests decreased perfusion, which may result from interruption of the stoma's blood supply and may lead to tissue damage or necrosis. A dusky stoma isn't a normal finding. Adjusting the ostomy bag wouldn't affect stoma color, which depends on blood supply to the area. An intestinal obstruction also wouldn't change stoma color.

A spontaneous pneumothorax occurs when the client’s lung collapses, causing an acute decreased in the amount of functional lung used in oxygenation. The sudden collapse was the cause of his chest pain and shortness of breath. An asthma attack would show wheezing breath sounds, and bronchitis would have rhonchi. Pneumonia would have bronchial breath sounds over the area of consolidation.

Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.

Jugular venous pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation with the head of the bed inclined between 15 to 30 degrees. Increased pressure can’t be seen when the client is supine or when the head of the bed is raised 10 degrees because the point that marks the pressure level is above the jaw (therefore, not visible). In high Fowler’s position, the veins would be barely discernible above the clavicle.

The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.

Bubbling in the water seal chamber of a chest drainage system stems from an air leak. In pneumothorax an air leak can occur as air is pulled from the pleural space. Bubbling doesn’t normally occur with either adequate or inadequate suction or any preexisting bubbling in the water seal chamber.

Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decreased the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.

Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.

A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis.

Cardiogenic shock is shock related to ineffective pumping of the heart. Anaphylactic shock results from an allergic reaction. Distributive shock results from changes in the intravascular volume distribution and is usually associated with increased cardiac output. MI isn’t a shock state, though a severe MI can lead to shock.

The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues. If pressure isn't relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation. During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn't prevent pressure ulcers. Adequate hydration is necessary to maintain healthy skin and ensure tissue repair. A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

Colles' fracture is a fracture of the distal radius, such as from a fall on an outstretched hand. It's most common in women. Colles' fracture doesn't refer to a fracture of the olecranon, humerus, or carpal scaphoid.

Observing standard precautions is the first priority when dealing with any blood fluid. Assessment of the groin site is the second priority. This establishes where the blood is coming from and determineshow much blood has been lost. The goal in this situation is to stop the bleeding. The nurse would call for help if it were warranted after the assessment of the situation. After determining the extent of the bleeding, vital signs assessment is important. The nurse should never move the client, in case a clot has formed. Moving can disturb the clot and cause rebleeding.

Dysplasia refers to an alteration in the size, shape, and organization of differentiated cells. The presence of completely undifferentiated tumor cells that don't resemble cells of the tissues of their origin is called anaplasia. An increase in the number of normal cells in a normal arrangement in a tissue or an organ is called hyperplasia. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn't found is called metaplasia.

In the TSH test, failure of the TSH level to rise after 30 minutes confirms hyperthyroidism. A decreased TSH level indicates a pituitary deficiency of this hormone. Below-normal levels of T3 and T4, as detected by radioimmunoassay, signal hypothyroidism. A below-normal T4 level also occurs in malnutrition and liver disease and may result from administration of phenytoin and certain other drugs.

Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.

A normal Paco2 value is 35 to 45 mm Hg CO2 has vasodilating properties; therefore, lowering Paco2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through Pao2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased Paco2.

Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.

ET tube placement should be confirmed as soon as the client arrives in the emergency department. Once the airways is secured, oxygenation and ventilation should be confirmed using an end-tidal carbon dioxide monitor and pulse oximetry. Next, the nurse should make sure L.V. access is established. If the client experiences symptomatic bradycardia, atropine is administered as ordered 0.5 to 1 mg every 3 to 5 minutes to a total of 3 mg. Then the nurse should try to find the cause of the client’s arrest by obtaining an ABG sample. Amiodarone is indicated for ventricular tachycardia, ventricular fibrillation and atrial flutter – not symptomatic bradycardia.

From the trauma the client experienced, it’s unlikely he has bronchitis, pneumonia, or TB; rhonchi with bronchitis, bronchial breath sounds with TB would be heard.

When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth. This application pattern reduces the risk of follicle irritation and skin inflammation.

The percentage designated for each burned part of the body using the rule of nines: Head and neck 9%; Right upper extremity 9%; Left upper extremity 9%; Anterior trunk 18%; Posterior trunk 18%; Right lower extremity 18%; Left lower extremity 18%; Perineum 1%.

Long bone fractures are correlated with fat emboli, whichcause shortness of breath and hypoxia. It’s unlikely the client has developed asthma or bronchitis without a previous history. He could develop atelectasis but it typically doesn’t produce progressive hypoxia.

HATT may occur after CABG surgery due to heparin use during surgery. Although DIC and ITP cause platelet aggregation and bleeding, neither is common in a client after revascularization surgery. Pancytopenia is a reduction in all blood cells.

Prior to bronchoscopy, the doctors sprays the back of the throat with anesthetic to minimize the gag reflex and thus facilitate the insertion of the bronchoscope. Giving the client food and drink after the procedure without checking on the return of the gag reflex can cause the client to aspirate. The gag reflex usually returns after two hours.

Sharp, severe pain (renal colic) radiating toward the genitalia and thigh is caused by uretheral distention and smooth muscle spasm; relief form pain is the priority.

Then action of colchicines is to decrease inflammation by reducing the migration of leukocytes to synovial fluid. Colchicine doesn’t replace estrogen, decrease infection, or decrease bone demineralization.

Osteoarthritis is the most common form of arthritis and can be extremely debilitating. It can afflict people of any age, although most are elderly.

A client with low serum HDL and high serum LDL levels should get less than 30% of daily calories from fat. The other modifications are appropriate for this client.

Inotropic agents are administered to increase the force of the heart’s contractions, thereby increasing ventricular contractility and ultimately increasing cardiac output. Beta-adrenergic blockers and calcium channel blockers decrease the heart rate and ultimately decreased the workload of the heart. Diuretics are administered to decrease the overall vascular volume, also decreasing the workload of the heart.

Cirrhosis of the liver results in decreased Vitamin K absorption and formation of clotting factors resulting in impaired clotting mechanism.

The client should be advised by the nurse to avoid contact sports. This will prevent trauma to the area of the pacemaker generator.

Hypertension, along with fever, and tenderness over the grafted kidney, reflects acute rejection.

Stomatitis can cause pain and this can be relieved by applying topical anesthetics such as lidocaine before mouth care. When the patient is already comfortable, the nurse can proceed with providing the patient with oral rinses of saline solution mixed with equal part of water or hydrogen peroxide mixed water in 1:3 concentrations to promote oral hygiene. Every 2-4 hours.

This height permits the solution to flow slowly with little force so that excessive peristalsis is not immediately precipitated.

COPD causes a chronic CO2 retention that renders the medulla insensitive to the CO2 stimulation for breathing. The hypoxic state of the client then becomes the stimulus for breathing. Giving the client oxygen in low concentrations will maintain the client’s hypoxic drive.

In DIC, platelets and clotting factors are consumed, resulting in microthrombi and excessive bleeding. As clots form, fibrinogen levels decrease and the prothrombin time increases. Fibrin degeneration products increase as fibrinolysis takes places.

Lactulose is given to a patients with hepatic encephalopathy to reduce absorption of ammonia in the intestines by binding with ammonia and promoting more frequent bowel movements. If the patient experience diarrhea, it indicates over dosage and the nurse must reduce the amount of medication given to the patient. The stool will be mashy or soft. Lactulose is also very sweet and may cause cramping and bloating.

The nurse should perform capillary glucose testing every 4 hours because excess cortisol may cause insulin resistance, placing the client at risk for hyperglycemia. Urine ketone testing isn't indicated because the client does secrete insulin and, therefore, isn't at risk for ketosis. Urine specific gravity isn't indicated because although fluid balance can be compromised, it usually isn't dangerously imbalanced. Temperature regulation may be affected by excess cortisol and isn't an accurate indicator of infection.

A client with massive pulmonary embolism will have a large region and blow off large amount of carbon dioxide, which crosses the unaffected alveolar-capillary membrane more readily than does oxygen and results in respiratory alkalosis.

The nurse needs to perform a thorough assessment that could indicate alterations in cerebral function, increased intracranial pressures, fractures and bleeding. Bleeding from the ears occurs only with basal skull fractures that can easily contribute to increased intracranial pressure and brain herniation.

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The client with liver disease has a decreased ability to metabolize carbohydrates because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen.

The emergency department nurse is no longer directly involved with the client’s care and thus has no legal right to information about his present condition. Anyone directly involved in his care (such as the telemetry nurse and the on-call physician) has the right to information about his condition. Because the client requested that the nurse update his wife on his condition, doing so doesn’t breach confidentiality.

Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat an excessive anticoagulate state from warfarin overload, and ASA decreases platelet aggregation.

An xenogeneic transplant is between is between human and another species. A syngeneic transplant is between identical twins, allogeneic transplant is between two humans, and autologous is a transplant from the same individual.

PTCA can alleviate the blockage and restore blood flow and oxygenation. An echocardiogram is a noninvasive diagnosis test. Nitroglycerin is an oral sublingual medication. Cardiac catheterization is a diagnostic tool – not a treatment.