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Medical Surgical Exam Part 1

Medical Surgical Exam Part 1

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Published by: api-3822508 on Oct 18, 2008
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MEDICAL-SURGICAL NURSING
Part 11. After a cerebrovascular accident, a 75 yr oldclient is admitted to the health care facility. Theclient has left-sided weakness and an absentgag reflex. He’s incontinent and has a tarrystool. His blood pressure is 90/50 mm Hg, andhis hemoglobin is 10 g/dl. Which of the followingis a priority for this client?a. checking stools for occult bloodb. performing range-of-motion exercises to theleft sidec. keeping skin clean and dryd. elevating the head of the bed to 30 degreesANS: DBecause the client’s gag reflex is absent,elevating the head of the bed to 30 degreeshelps minimize the client’s risk of aspiration.Checking the stools, performing ROM exercises,and keeping the skin clean and dry areimportant, but preventing aspiration throughpositioning is the priority.2. The nurse is caring for a client with acolostomy. The client tells the nurse that hemakes small pin holes in the drainage bag tohelp relieve gas. The nurse should teach himthat this action:a. destroys the odor-proof sealb. wont affect the colostomy systemc. is appropriate for relieving the gas in acolostomy systemd. destroys the moisture barrier sealANS: AAny hole, no matter how small, will destroy theodor-proof seal of a drainage bag. Removing thebag or unclamping it is the only appropriatemethod for relieving gas.3. When assessing the client with celiacdisease, the nurse can expect to find which of the following?a. steatorrheab. jaundiced scleraec. clay-colored stoolsd. widened pulse pressureANS: Abecause celiac disease destroys the absorbingsurface of the intestine, fat isn’t absorbed but ispassed in the stool. Steatorrhea is bulky, fattystools that have a foul odor. Jaundiced scleraeresult from elevated bilirubin levels. Clay-coloredstools are seen with biliary disease when bileflow is blocked. Celiac disease doesn’t cause awidened pulse pressure.4. A client is hospitalized with a diagnosis of chronic glomerulonephritis. The client mentionsthat she likes salty foods. The nurse shouldwarn her to avoid foods containing sodiumbecause:a. reducing sodium promotes urea nitrogenexcretionb. reducing sodium improves her glomerular filtration ratec. reducing sodium increases potassiumabsorptiond. reducing sodium decreases edemaANS: DReducing sodium intake reduces fluid retention.Fluid retention increases blood volume, whichchanges blood vessel permeability and allowsplasma to move into interstitial tissue, causingedema. Urea nitrogen excretion can beincreased only by improved renal function.Sodium intake doesn’t affect the glomerular filtration rate. Potassium absorption is improvedonly by increasing the glomerular filtration rate; itisn’t affected by sodium intake.5. The nurse is caring for a client with a cerebralinjury that impaired his speech and hearing.Most likely, the client has experienced damageto the:a. frontal lobeb. parietal lobec. occipital lobed. temporal lobeAN:S DThe portion of the cerebrum that controls speechand hearing is the temporal lobe. Injury to thefrontal lobe causes personality changes,difficulty speaking, and disturbance in memory,reasoning, and concentration. Injury to theparietal lobe causes sensory alterations andproblems with spatial relationships. Damage tothe occipital lobe causes vision disturbances.6. The nurse is assessing a postcraniotomyclient and finds the urine output from a catheter is 1500 ml for the 1st hour and the same for the2nd hour. The nurse should suspect:a. Cushing’s syndromeb. Diabetes mellitusc. Adrenal crisisd. Diabetes insipidusANS: DDiabetes insipidus is an abrupt onset of extremepolyuria that commonly occurs in clients after brain surgery. Cushing’s syndrome is excessiveglucocorticoid secretion resulting in sodium andwater retention. Diabetes mellitus is ahyperglycemic state marked by polyuria,polydipsia, and polyphagia. Adrenal crisis isundersecretion of glucocorticoids resulting inprofound hypoglycemia, hypovolemia, andhypotension.7. The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy.In this procedure, an ultrasonic probe insertedthrough a nephrostomy tube into the renal pelvisgenerates ultra-high-frequency sound waves toshatter renal calculi. The nurse should instructthe client to:
 
a. limit oral fluid intake for 1 to 2 weeksb. report the presence of fine, sandlike particlesthrough the nephrostomy tube.c. Notify the physician about cloudy or foul-smelling urined. Report bright pink urine within 24 hours after the procedureANS: CThe client should report the presence of foul-smelling or cloudy urine. Unless contraindicated,the client should be instructed to drink largequantities of fluid each day to flush the kidneys.Sand-like debris is normal because of residualstone products. Hematuria is common after lithotripsy.8. A client with a serum glucose level of 618mg/dl is admitted to the facility. He’s awake andoriented, has hot dry skin, and has the followingvital signs: temperature of 100.6º F (38.1º C),heart rate of 116 beats/minute, and bloodpressure of 108/70 mm Hg. Based on theseassessment findings, which nursing diagnosistakes the highest priority?a. deficient fluid volume related to osmoticdiuresisb. decreased cardiac output related to elevatedheart ratec. imbalanced nutrition: Less than bodyrequirements related to insulin deficiencyd. ineffective thermoregulation related todehydrationANS: AA serum glucose level of 618 mg/dl indicateshyperglycemia, which causes polyuria anddeficient fluid volume. In this client, tachycardiais more likely to result from deficient fluid volumethan from decreased cardiac output because hisblood pressure is normal. Although the client’sserum glucose is elevated, food isn’t a prioritybecause fluids and insulin should beadministered to lower the serum glucose level.Therefore, a diagnosis of Imbalanced Nutrition:Less then body requirements isn’t appropriate. Atemperature of 100.6º F isn’t life threatening,eliminating ineffective thermoregulation as thetop priority.9. Capillary glucose monitoring is beingperformed every 4 hours for a client diagnosedwith diabetic ketoacidosis. Insulin isadministered using a scale of regular insulinaccording to glucose results. At 2 p.m., the clienthas a capillary glucose level of 250 mg/dl for which he receives 8 U of regular insulin. Thenurse should expect the dose’s:a. onset to be at 2 p.m. and its peak at 3 p.m.b. onset to be at 2:15 p.m. and its peak at 3 p.m.c. onset to be at 2:30 p.m. and its peak at 4 p.m.d. onset to be at 4 p.m. and its peak at 6 p.m.ANS: CRegular 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 insulinat 2 p.m., the expected onset would be from2:15 to 2:30 p.m. and the peak from 4 p.m. to 6p.m.10. A client with a head injury is being monitoredfor increased intracranial pressure (ICP). Hisblood pressure is 90/60 mmHG and the ICP is18 mmHg; therefore his cerebral perfusionpressure (CPP) is:a. 52 mm Hgb. 88 mm Hgc. 48 mm Hgd. 68 mm HgANS: ACPP is derived by subtracting the ICP from themean arterial pressure (MAP). For adequatecerebral perfusion to take place, the minimumgoal is 70 mmHg. The MAP is derived using thefollowing formula:MAP = ((diastolic blood pressure x 2) + systolicblood pressure) / 3MAP = ((60 x2) + 90) / 3MAP = 70 mmHgTo find the CPP, subtract the client’s ICP fromthe MAP; in this case , 70 mmHg – 18 mmHg =52 mmHg.11. A 52 yr-old female tells the nurse that shehas found a painless lump in her right breastduring her monthly self-examination. Whichassessment finding would strongly suggest thatthis client’s lump is cancerous?a. eversion of the right nipple and a mobile massb. nonmobile mass with irregular edgesc. mobile mass that is oft and easily delineatedd. nonpalpable right axillary lymph nodesANS: BBreast cancer tumors are fixed, hard, and poorlydelineated with irregular edges. Nipple retraction—not eversion—may be a sign of cancer. Amobile mass that is soft and easily delineated ismost often a fluid-filled benigned cyst. Axillarylymph nodes may or may not be palpable oninitial detection of a cancerous mass.12. A Client is scheduled to have a descendingcolostomy. He’s very anxious and has manyquestions regarding the surgical procedure, careof stoma, and lifestyle changes. It would be mostappropriate for the nurse to make a referral towhich member of the health care team?a. Social worker b. registered dieticianc. occupational therapistd. enterostomal nurse therapistANS: DAn enterostomal nurse therapist is a registerednurse who has received advance education inan accredited program to care for clients withstomas. The enterostomal nurse therapist canassist with selection of an appropriate stomasite, teach about stoma care, and provideemotional support.13. Ottorrhea and rhinorrhea are mostcommonly seen with which type of skull
 
fracture?a. basilar b. temporalc. occipitald. parietalANS: AOttorrhea and rhinorrhea are classic signs of basilar skull fracture. Injury to the duracommonly occurs with this fracture, resulting incerebrospinal fluid (CSF) leaking through theears and nose. Any fluid suspected of beingCSF should be checked for glucose or have ahalo test done.14. A male client should be taught abouttesticular examinations:a. when sexual activity startsb. after age 60c. after age 40d. before age 20ANS: DTesticular cancer commonly occurs in menbetween ages 20 and 30. A male client shouldbe taught how to perform testicular self-examination before age 20, preferably when heenters his teens.15. Before weaning a client from a ventilator,which assessment parameter is most importantfor the nurse to review?A. fluid intake for the last 24 hoursB. baseline arterial blood gas (ABG) levelsC. prior outcomes of weaningD. electrocardiogram (ECG) resultsANS: BBefore weaning a client from mechanicalventilation, it’s most important to have a baselineABG levels. During the weaning process, ABGlevels will be checked to assess how the client istolerating the procedure. Other assessmentparameters are less critical. Measuring fluidvolume intake and output is always importantwhen a client is being mechanically ventilated.Prior attempts at weaning and ECG results aredocumented on the client’s record, and thenurse can refer to them before the weaningprocess begins.16. The nurse is speaking to a group of womenabout early detection of breast cancer. Theaverage age of the women in the group is 47.Following the American Cancer Society (ACS)guidelines, the nurse should recommend thatthe women:A. perform breast self-examination annuallyB. have a mammogram annuallyC. have a hormonal receptor assay annuallyD. have a physician conduct a clinical evaluationevery 2 yearsANS: BAccording to the ACS guidelines, “Women older than age 40 should perform breast self-examination monthly (not annually).” Thehormonal receptor assay is done on a knownbreast tumor to determine whether the tumor isestrogen- or progesterone-dependent.17. When caring for a client with esophagealvarices, the nurse knows that bleeding in thisdisorder usually stems from:A. esophageal perforationB. pulmonary hypertensionC. portal hypertensionD. peptic ulcersANS: CIncreased pressure within the portal veinscauses them to bulge, leading to rupture andbleeding into the lower esophagus. Bleedingassociated with esophageal varices doesn’tstem from esophageal perforation, pulmonaryhypertension, or peptic ulcers.18. A 49-yer-old client was admitted for surgicalrepair of a Colles’ fracture. An external fixator was placed during surgery. The surgeonexplains that this method of repair:A. has very low complication rateB. maintains reduction and overall hand functionC. is less bothersome than a castD. is best for older peopleANS: BComplex intra-articular fractures are repairedwith external fixators because they have a better long-term outcome than those treated withcasting. This is especially true in a young client.The incidence of complications, such as pin tractinfections and neuritis, is 20% to 60%. Clientsmust be taught how to do pin care and assessfor development of neurovascular complications.19. A client is hospitalized with a diagnosis of chronic renal failure. An arteriovenous fistulawas created in his left arm for hemodialysis.When preparing the client for discharge, thenurse should reinforce which dietary instruction?A. “Be sure to eat meat at every meal.”B. “Monitor your fruit intake and eat plenty of bananas.”C. “Restrict your salt intake.”D. “Drink plenty of fluids.”ANS: CIn a client with chronic renal failure, unrestrictedintake of sodium, protein, potassium, and fluidsmay lead to a dangerous accumulation of electrolytes and protein metabolic products,such as amino acids and ammonia. Therefore,the client must limit his intake of sodium, meat(high in Protein), bananas (high in potassium),and fluid because the kidneys can’t secreteadequate urine.20. The nurse is caring for a client who has justhad a modified radical mastectomy withimmediate reconstruction. She’s in her 30s andhas tow children. Although she’s worried abouther future, she seems to be adjusting well to her diagnosis. What should the nurse do to supporther coping?A. Tell the client’s spouse or partner to be

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