Sign of pulmonary embolsim
Stabbing chest pain, dyspnea
The client reports sudden shortness of breath, stabbing chest pain, and feelings of doom.
... [Show More] what is this patient experiencing?
pulmonary embolsim
they might also exhibit, tachycardia, chest petechiae and decreased SaO2
Who is at increase risk for breast cancer?
-AGE OVER 5O YEARS
-Increase breast density,
-BMI of 32,
-1-2 alcoholic beverages per week.
peripheral arterial disease
hair loss
dependent rubor
painful ulcerations to the toes
pain when resting
A nurse is caring for a patient who is receiving radiation therapy for breast cancer and reports a metallic taste in the mouth. which recommendation would you give?
Offer mints which can overcome the metallic taste
-ADD coffee to sweet beverages or milk
-SHOULD consume citrus/tart flavors
nurse is reviewing laboratory values for an adult client who has sickle cell anemia and a history of of receiving blood transfusions. which of the following complications should the nurse monitor for?
Iron toxicity: a client who is received several blood transfusions is at risk of hemosiderosis, which is the excess storage of iron in the body
Autonomic Dysreflexia due to a C5 spinal cord injury
(potentially life threatening emergency!) HOB elevate 90 degrees, (HIGH FOWLERS) loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)
Health fair a pt blood pressure is 150/90 which action should the nurse take?
Give the client a written record of his BP to bring to the provider within 2 MONTHS
Lupus, what should the nurse expect to be increased?
erythrocyte sedimentation rate --> indicated inflammation
what can cause Lupus exacerbation?
Pregnancy
Sunlight
Infection
NOT: exercise
which medications would the nurse administer for lupus?
Corticosteroids such as prednisone
Pancreatitis what lab is elevated?
AMYLASE begins to increase in 3-6 hours
Amylase typically shows elevation within 12-24 hours and remain elevated for 2-3 days
**LIPASE is also elevated
Hypocalcemia & hypo magnesium is expected
Meniere's disease
condition of the inner ear in which excess fluid distorts the inner ear canal system
It affects the COCHLEA
AVOID sudden movements
an adolescent has recurrent external otitis, what instructions should the nurse give?
instill a diluted alcohol solution into the ear after swimming to decrease bacteria and dry the external ear canal
DKA Expected findings
Kussmaul respirations
urine positive for ketones
Hypotension becasue of dehydration
Cervical Cancer manifestation
Vaginal Bleeding
Unplanned weight loss
Dysuria
Pelvic pain and chest pain
Gastric surgery and an NG tube was inserted, which finding should be reported to the provider?
200 mL of bright red drainage
what is the purpose of the NG type?
Prevents excessive pressure on the suture lines. it drains the air
-pt will began with taking clear liquids by mouth and progress accordingly
diabetes insipidus
Polyuria, polydipsia
Low specific gravity, Na will be high, serum osmo is high
Post total knee arthroplasty
wear elastic stockings on both of my legs
Risk factor for osteoporosis
Anorexia nervosa because inadequate protein intake --> decreased bone density
Risk factors for bone loss
small body frame
low vitamin D intake
smoking
Treatment for osteoporosis medication = alendronate. what teaching is needed for this medication?
I will sit upright for 30 min after taking the medication to prevent esophageal irritation and ulceration
-TAKE IN MORNING
-Calcium supplement at a DIFFERENT time of day
-TAKE 3O MIN BEFORE FOOD
what to recommend a patient with osteoporosis
perform weight bearing exercises
such as walking
what food will the nurse recommend to promote calcium absorption?
fortified milk
Strategies for preventing bone loss
begin a program of brisk walking
Leg amputation.
"I will lie on my stomach for 20-30 min a few times a day to help reduce risk of developing hip flexion contractures
Rewrap the residual limb with a bandage 3 times per days
AIDS.
-Seperate plastic bag to dispose of soiled tissues
-Implement handwashing to prevent spread of infection
-Wash soiled clothes in hot water along with 1 cup of bleach
- CLEAN BLOOD UP WITH BLEACH SOLUTION AND GLOVES
AIDS precautions
Discard food after 24 hour
thaw frozen food in the refrigerator
-USE A SEPARATE CUTTING BOARD FOR RAW POULTRY
-store cold foot at 4.4 celcius or less
Primary open-angle glaucoma (POAG). Include in teaching:
-Driving can be dangerous due to the loss of peripheral vision
-Laser surgery can help reestablish the flow of aqueous humor
Hep A: understanding teaching
Hep A: transmitted via the fecal oral route through consumption of contaminated fruits, vegetables, water, milk or uncooked shellfish.
***AVOID SHELLFISH if you have HEP A. *ENCOURAGE HER TO EAT FOODS HIGH IN CARBS
HIV Instructions to help with infection prevention
-Avoid large gatherings of people
-Clean the toothbrush by running through the dishwasher or beach followed by hot water
-Avoid digging in the garden --> increase risk of infection
HIV --> AIDS manifestation
You can expect a persistent fever and swollen glands
How is HIV transmitted ?
anyone who has had contact with infected blood
Variant (Prinzmetal's) Angina
-due to a coronary artery spasm, often occurring during periods of rest.
-results in less oxygen supplying the myocardium --> changes to the EKG
Expected finding with chemotherapy
Pancytopenia (deficiency of WBC'S, RBC's, and platelet count
Perforation of a peptic ulcer expected finding
BOARDLIKE ABDOMEN and severe pain in the abdomen or back that radiates to the RIGHT SHOULDER
malignant melanoma expected findings
-Commonly starts on exposed areas of body and then metastasizes to other areas
-CHANGE IN COLOR, SIZE, SHAPE OF A SKIN LESION WITH IRREGULAR BORDERS, in hues of BLUE, WHITE OR RED TONES.
liver cirrhosis with abdominal distention
Take serial measurements of the abdomen with a tape measure, obtain PT & INR, administer lactulose, administer daily multivitamin
Mesastasizing malignant neoplasm in the colon
I have cancer of the colon that has begun to spread
Post op frontal craniotomy
Semi fowlers
Bowel obstruction--> indication possible bowel perforation =
rigid abdomen tenderness
hypotension
TPN was stopped for physical therapy, the nurse is monitoring for which finding?
diaphoresis because of sudden withdrawal of TPN --> hypoglycemia
hypoglycemia
diaphoresis, irritability, mental confusion, double vision, hunger, tachy, palpitations, SLURRED SPEECH
TPN through a CENTRAL LINE, which action should the nurse perform?
Daily weights b/c pt is at risk for FLUID & ELECTROLYTE IMBALANCES
-Change tubing q24 hours
-Check glucose Q4 HOURS
- CHANGE DRESSING Q24-72 HOURS
Papules
small, solid, elevated lesion with distinct borders. It is usually smaller than 10mm in diameter. papules are common lesions of warts and elevated moles
Macule
change in the COLOR of the skin that is flat, cariably shaped, discolored, and small. freckles and the rash associated with rubella are type of macules
Wheals aka HIVES
are transient, elevated, irregularly shaped lesions caused by localized edema. common manifestation of an allergic reaction
Vesicles (chickenpox)
A circumscribed, elevated lesion or blister containing serous fluid. Vesicles typically arise in herpes simplex, poison ivy, and chicken pox
Herpes zoster or shingles --> viral infection --> what medication ?
ACYCLOVIR inhibits the replication of the virus
What are manifestations for herpes zoster or shingles exacerbation?
ACUTE, UNILATERAL INFLAMMATION OF THE DORSAL ROOT GANGLION
Dumping syndrome
increase fat and protein,
small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink
myocardial infarction. which complication should the nurse monitor in the first 24 hours
Ventricular dysrththmias
MI patient, what clinical manifestations would the nurse see?
nausea***
**Substernal chest pain (most common)
pain in jaw, shoulder or abdomen
acute confusion
Multiple Sclerosis
Acute episodes are usually followed by remissions, which can vary in duration.
Priority for full thickness burn w/ smoke inhalation
MONITOR RESP STATUS
Raynaud's disease
a peripheral arterial occlusive disease in which intermittent attacks are triggered by cold or stress
-SMOKING cessation can PREVENT the onset of the manifestations of raynauds disease
-increase exposure to sunlight
-alcohol does not relate to raynauds
Gout
reduce/limit foods high in purine such as organ meats
The nurse should identify that what places the client at risk for gout?
Diuretic use
pt has gout and urolithiasis. what suggestions should the nurse provide?
take allopurinol
Exercise several times a week
limit intake of foods high in purine
medication for gout? & what can interact with it?
Probenecid
aspirin
Thyroidectomy for the presence of hypoparathyroidism --> expected findings
INVOLUNTARY MUSCLE SPASMS because parathyroid glands are damaged or removed during a thyroidectomy.
-Muscle twitching and paresthesias can result due to decreased parathyroid hormone levels and calcium deficiency
**TACHY & HYPERTENSION
**LARYNGEAL STRIDOR & HOARSENESS
**POSITIVE TROUSSEAUS sign
Alzheimer's disease.
Use gestures when speaking to the client
Secondary Prevention actions for colorectal cancer
Importance of colonoscopy screening starting at 50 years old [Show Less]