Major Goals of Treatment for Patients with Chronic, Progressive Neurologic Diseases, Exams of Nursing

Download Major Goals of Treatment for Patients with Chronic, Progressive Neurologic Diseases and more Exams Nursing in PDF only on Docsity! CCI Final Exam Flashcards Questions and Answers 2024 20. A 38-year-old woman has newly diagnosed multiple sclerosis (MS) and asks the nurse what is going to happen to her. What is the best response by the nurse? a. "You will have either periods of attacks and remissions or progression of nerve damage over time." b. "You need to plan for a continuous loss of movement, sensory functions, and mental capabilities." c. "You will most likely have a steady course of chronic progressive nerve damage that will change your personality." d. "It is common for people with MS to have an acute attack of weakness and then not to have any other symptoms for years." - 20. a. Most patients with multiple sclerosis (MS) have remissions and exacerbations of neurologic dysfunction or a relapsing-remitting initial course followed by progression with or without occasional relapses, minor remissions, and plateaus that progressively cause loss of motor, sensory, and cerebellar functions. Intellectual function generally remains intact but patients may experience anger, depression, or euphoria. A few people have chronic progressive deterioration and some may experience only occasional and mild symptoms for several years after onset. 21. During assessment of a patient admitted to the hospital with an acute exacerbation of MS, what should the nurse expect to find? a. Tremors, dysphasia, and ptosis b. Bowel and bladder incontinence and loss of memory c. Motor impairment, visual disturbances, and paresthesias d. Excessive involuntary movements, hearing loss, and ataxia - 21. c. Specific neurologic dysfunction of MS is caused by destruction of myelin and replacement with glial scar tissue at specific areas in the nervous system. Motor, sensory, cerebellar, and emotional dysfunctions, including paresthesias as well as patchy blindness, blurred vision, pain radiating along the dermatome of the nerve, ataxia, and severe fatigue, are the most common manifestations of MS. Constipation and bladder dysfunctions, short-term memory loss, sexual dysfunction, anger, and depression or euphoria may also occur. Excessive involuntary movements and tremors are not seen in MS. 22. The nurse explains to a patient newly diagnosed with MS that the diagnosis is made primarily by a. spinal x-ray findings. b. T-cell analysis of the blood. c. analysis of cerebrospinal fluid. d. history and clinical manifestations. - d. There is no specific diagnostic test for MS. A diagnosis is made primarily by history and clinical manifestations. Certain diagnostic tests may be used to help establish a diagnosis of MS. Positive findings on MRI include evidence of at least two inflammatory demyelinating lesions in at least two different locations within the central nervous system (CNS). Cerebrospinal fluid (CSF) may have increased immunoglobulin G and the presence of oligoclonal banding. Evoked potential responses are often delayed in persons with MS. 23. Mitoxantrone (Novantrone) is being considered as treatment for a patient with progressive-relapsing MS. The nurse explains that a disadvantage of this drug compared with other drugs used for MS is what? a. It must be given subcutaneously every day. b. It has a lifetime dose limit because of cardiac toxicity. c. It is an anticholinergic agent that causes urinary incontinence. d. It is an immunosuppressant agent that increases the risk for infection. - 23. b. Mitoxantrone (Novantrone) cannot be used for more than 2 to 3 years because it is an antineoplastic drug that causes cardiac toxicity, leukemia, and infertility. It is a monoclonal antibody given IV monthly when patients have inadequate responses to other drugs. It increases the risk of progressive multifocal leukoencephalopathy. Priority Decision: A patient with MS has a nursing diagnosis of self-care deficit related to muscle spasticity and neuromuscular deficits. In providing care for the patient, what is most important for the nurse to do? a. Teach the family members how to care adequately for the patient's needs. b. Encourage the patient to maintain social interactions to prevent social isolation. c. Promote the use of assistive devices so the patient can participate in self-care activities. d. Perform all activities of daily living (ADLs) for the patient to conserve the patient's energy. - 24. c. The main goal in care of the patient with MS is to keep the patient active and maximally functional and promote self-care as much as possible to maintain independence. Assistive devices encourage independence while preserving the patient's energy. No care activity that the patient can do for himself or herself should be performed by others. Involvement of the family in the patient's care and maintenance of social interactions are also important but are not the priority in care. 25. A patient with newly diagnosed MS has been hospitalized for evaluation and initial treatment of the disease. Following discharge teaching, the nurse realizes that additional instruction is needed when the patient says what? a. "It is important for me to avoid exposure to people with upper respiratory infections." b. Barbiturates, sodium valproate and phenytoin are liver enzyme inhibitors c. It is important that the person strictly adheres to the dosage d. Antiepileptic drugs are ideally administered parenterally - b. Barbiturates, sodium valproate and phenytoin are liver enzyme inhibitors. These drugs are liver enzyme inducers and thus they may be implicated in drug interactions. Adverse effects of antiepileptic drugs commonly include: a. hyperactivity and aggression b. CNS depression c. cardiovascular and respiratory stimulation d. hepatotoxicity. - b. CNS depression Antiepileptics are by their mechanism of action CNS depressants. How do generalized seizures differ from focal seizures? a. Focal seizures are confined to one side of the brain and remain focal in nature. b. Generalized seizures result in loss of consciousness whereas focal seizures do not. c. Generalized seizures result in temporary residual deficits during the postictal phase. d. Generalized seizures have bilateral synchronous epileptic discharges affecting the whole brain at onset of the seizure - d. Generalized seizures have bilateral synchronous epileptic discharge affecting the entire brain at onset of the seizure. Loss of consciousness is also characteristic but many focal seizures also include an altered consciousness. Focal seizures begin in one side of the brain but may spread to involve the entire brain. Focal seizures that start with a local focus and spread to the entire brain, causing a secondary generalized seizure, are associated with a transient residual neurologic deficit postictally known as Todd's paralysis. Which type of seizure occurs in children, is also known as a petit mal seizure, and consists of a staring spell that lasts for a few seconds? a. Atonic b. Simple focal c. Typical absence d. Atypical absence - c. The typical absence seizure is also known as petit mal and the child has staring spells that last for a few seconds. Atonic seizures occur when the patient falls from loss of muscle tone accompanied by brief unconsciousness. Simple focal seizures have focal motor, sensory, or autonomic symptoms related to the area of the brain involved without loss of consciousness. Staring spells in atypical absence seizures last longer than those in typical absence seizures and are accompanied by peculiar behavior during the seizure or confusion after the seizure. The patient is diagnosed with complex focal seizures. Which characteristics are related to complex focal seizures (select all that apply)? a. Formerly known as grand mal seizure b. Often accompanied by incontinence or tongue or cheek biting c. Psychomotor seizures with repetitive behaviors and lip smacking d. Altered memory, sexual sensations, and distortions of visual or auditory sensations e. Loss of consciousness and stiffening of the body with subsequent jerking of extremities f. Often involves behavioral, emotional, and cognitive functions with altered consciousness - c, d, f. Complex focal seizures are psychomotor seizures with automatisms such as lip smacking. They cause altered consciousness or loss of consciousness producing a dreamlike state and may involve behavioral, emotional, or cognitive experiences without memory of what was done during the seizure. In generalized tonic-clonic seizures (previously known as grand mal seizures) there is loss of consciousness and stiffening of the body with subsequent jerking of extremities. Incontinence or tongue or cheek biting may also occur. Chapter 59: Nursing Management: Chronic Neurologic Problems Chapter 59: Nursing Management: Chronic Neurologic Problems Test Bank MULTIPLE CHOICE 1. The nurse determines that teaching about management of migraine headaches has been effective when the patient says which of the following? a. "I can take the (Topamax) as soon as a headache starts." b. "A glass of wine might help me relax and prevent a headache." c. "I will lie down someplace dark and quiet when the headaches begin." d. "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time." - ANS: C It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches. DIF: Cognitive Level: Apply (application) REF: 1416 | 1419 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 2. The nurse will assess a 67-year-old patient who is experiencing a cluster headache for a. nuchal rigidity. b. unilateral ptosis. c. projectile vomiting. d. throbbing, bilateral facial pain. - ANS: B Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches. DIF: Cognitive Level: Understand (comprehension) REF: 1414 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 3. While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Time and observe and record the details of the seizure and postictal state. d. Avoid touching the patient to prevent further nervous system stimulation. - ANS: C Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure. DIF: Cognitive Level: Apply (application) REF: 1422 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 4. A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best? a. "You might benefit from some psychologic counseling." b. "Epilepsy usually can be well controlled with medications." c. "You will want to contact the Epilepsy Foundation for assistance." d. "The Department of Vocational Rehabilitation can help with work retraining." - ANS: B The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented. DIF: Cognitive Level: Apply (application) REF: 1422 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 5. A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication? a. Inspect the oral mucosa. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light. - ANS: A a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward. - ANS: B Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait. DIF: Cognitive Level: Apply (application) REF: 1437 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? a. The patient has a chronic dry cough. b. The patient has four loose stools in a day. c. The patient develops a deep vein thrombosis. d. The patient's blood pressure is 92/52 mm Hg. - ANS: D Hypotension is an adverse effect of bromocriptine, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with bromocriptine use. DIF: Cognitive Level: Apply (application) REF: 1435 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 14. The nurse advises a patient with myasthenia gravis (MG) to a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception. - ANS: A Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used. DIF: Cognitive Level: Apply (application) REF: 1437 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 15. Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Multivitamin (Stresstabs) b. Acetaminophen (Tylenol) c. Ibuprofen (Motrin, Advil) d. Diphenhydramine (Benadryl) - ANS: D Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome. DIF: Cognitive Level: Apply (application) REF: 1427 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 16. A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion (ROM). b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures. - ANS: A ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations. DIF: Cognitive Level: Apply (application) REF: 1439 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 17. A 40-year-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. prophylactic antibiotics to decrease the risk for aspiration pneumonia. c. option of genetic testing for the patient's children to determine their own HD risks. d. lifestyle changes of improved nutrition and exercise that delay disease progression. - ANS: C Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD. DIF: Cognitive Level: Apply (application) REF: 1440 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 18. When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing. - ANS: B The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it. DIF: Cognitive Level: Apply (application) REF: 1434 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 19. A 22-year-old patient seen at the health clinic with a severe migraine headache tells the nurse about having other similar headaches recently. Which initial action should the nurse take? a. Teach about the use of triptan drugs. b. Refer the patient for stress counseling. c. Ask the patient to keep a headache diary. d. Suggest the use of muscle-relaxation techniques. - ANS: C The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first. DIF: Cognitive Level: Apply (application) REF: 1419 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 20. A hospitalized patient complains of a bilateral headache, 4/10 on the pain scale, that radiates from the base of the skull. Which prescribed PRN medications should the nurse administerinitially? a. Lorazepam (Ativan) b. Acetaminophen (Tylenol) c. Morphine sulfate (Roxanol) d. Butalbital and aspirin (Fiorinal) - ANS: B The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic. DIF: Cognitive Level: Apply (application) REF: 1414 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 21. A 46-year-old patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches. Which action will the nurse plan to take first? a. Discuss the need to stop taking the acetaminophen. The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient. DIF: Cognitive Level: Apply (application) REF: 1436 OBJ: Special Questions: Prioritization TOP: Nursing Process: Analysis MSC: NCLEX: Physiological Integrity 28. Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness - ANS: C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical. DIF: Cognitive Level: Apply (application) REF: 1438-1439 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 29. Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone). - ANS: B The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis. DIF: Cognitive Level: Apply (application) REF: 1438-1439 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 30. A hospitalized 31-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? a. Start the ordered PRN oxygen at 6 L/min. b. Put a moist hot pack on the patient's neck. c. Give the ordered PRN acetaminophen (Tylenol). d. Notify the patient's health care provider immediately. - ANS: A Acute treatment for cluster headache is administration of 100% oxygen at 6 to 8 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache. DIF: Cognitive Level: Apply (application) REF: 1417 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 31. Which intervention will the nurse include in the plan of care for a patient with primary restless legs syndrome (RLS) who is having difficulty sleeping? a. Teach about the use of antihistamines to improve sleep. b. Suggest that the patient exercise regularly during the day. c. Make a referral to a massage therapist for deep massage of the legs. d. Assure the patient that the problem is transient and likely to resolve. - ANS: B Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms and RLS is likely to progress in most patients. DIF: Cognitive Level: Apply (application) REF: 1427 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 32. Which information about a 72-year-old patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication? a. Patient has generalized tonic-clonic seizures. b. Patient experiences an aura before seizures. c. Patient's most recent blood pressure is 156/92 mm Hg. d. Patient has minor elevations in the liver function tests. - ANS: D Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy. DIF: Cognitive Level: Apply (application) REF: 1424 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 33. After change-of-shift report, which patient should the nurse assess first? a. Patient with myasthenia gravis who is reporting increased muscle weakness b. Patient with a bilateral headache described as "like a band around my head" c. Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin) d. Patient with Parkinson's disease who has developed cogwheel rigidity of the arms - ANS: A Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should also be assessed, but do not appear to need immediate nursing assessments or actions to prevent life- threatening complications. DIF: Cognitive Level: Analyze (analysis) REF: 1438-1439 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment MULTIPLE RESPONSE 1. A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube - ANS: A, C, D The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention. DIF: Cognitive Level: Apply (application) REF: 1426 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 2. A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms. - ANS: A, B, D Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations. DIF: Cognitive Level: Apply (application) REF: 1436-1437 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity SHORT ANSWER c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy." - A. During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS. Which action will the nurse plan to take for a 40-year-old patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder? a. Decrease the patient's evening fluid intake. b. Teach the patient how to use the Credé method. c. Suggest the use of adult incontinence briefs for nighttime only. d. Assist the patient to the commode every 2 hours during the day. - B. The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying. A 73-year-old patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which action will the nurse include in the plan of care? a. Instruct the patient in activities that can be done while lying or sitting. b. Suggest that the patient rock from side to side to initiate leg movement. c. Have the patient take small steps in a straight line directly in front of the feet. d. Teach the patient to keep the feet in contact with the floor and slide them forward. - B. Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait. The nurse advises a patient with myasthenia gravis (MG) to a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception. - A. Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled, but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG, and muscle atrophy does not occur because although there is muscle weakness, they are still used. A 64-year-old patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care? a. Assist with active range of motion (ROM). b. Observe for agitation and paranoia. c. Give muscle relaxants as needed to reduce spasms. d. Use simple words and phrases to explain procedures. - A. ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations. A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement - D. Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease. When a 74-year-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor, the nurse will anticipate teaching the patient about a. oral corticosteroids. b. antiparkinsonian drugs. c. magnetic resonance imaging (MRI). d. electroencephalogram (EEG) testing. - B. The diagnosis of Parkinson's is made when two of the three characteristic manifestations of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia. The next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it. Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements - D. The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient. Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness - C. Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical. Following a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone). - B. The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis. A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. Priority Decision: A patient with MS has a nursing diagnosis of self-care deficit related to muscle spasticity and neuromuscular deficits. In providing care for the patient, what is most important for the nurse to do? a. Teach the family members how to care adequately for the patient's needs. b. Encourage the patient to maintain social interactions to prevent social isolation. c. Promote the use of assistive devices so the patient can participate in self-care activities. d. Perform all activities of daily living (ADLs) for the patient to conserve the patient's energy. - 24. c. The main goal in care of the patient with MS is to keep the patient active and maximally functional and promote self-care as much as possible to maintain independence. Assistive devices encourage independence while preserving the patient's energy. No care activity that the patient can do for himself or herself should be performed by others. Involvement of the family in the patient's care and maintenance of social interactions are also important but are not the priority in care. 25. A patient with newly diagnosed MS has been hospitalized for evaluation and initial treatment of the disease. Following discharge teaching, the nurse realizes that additional instruction is needed when the patient says what? a. "It is important for me to avoid exposure to people with upper respiratory infections." b. "When I begin to feel better, I should stop taking the prednisone to prevent side effects." c. "I plan to use vitamin supplements and a high-protein diet to help manage my condition." d. "I must plan with my family how we are going to manage my care if I become more incapacitated." - 25. b. Corticosteroids used in treating acute exacerbations of MS should not be abruptly stopped by the patient because adrenal insufficiency may result and prescribed tapering doses should be followed. Infections may exacerbate symptoms and should be avoided and high-protein diets with vitamin supplements are advocated. Long-term planning for increasing disability is also important. 26. The classic triad of manifestations associated with Parkinson's disease is tremor, rigidity, and bradykinesia. What is a consequence related to rigidity? a. Shuffling gait b. Impaired handwriting c. Lack of postural stability d. Muscle soreness and pain - 26. d. The degeneration of dopamine-producing neurons in the substantia nigra of midbrain and basal ganglia lead to this triad of signs. Muscle soreness, pain, and slowness of movement are patient function consequences related to rigidity. Shuffling gait, lack of postural stability, absent arm swing while walking, absent blinking, masked facial expression, and difficulty initiating movement are all related to bradykinesia. Impaired handwriting and hand activities are related to the tremor of Parkinson's disease (PD). 27. A patient with a tremor is being evaluated for Parkinson's disease. The nurse explains to the patient that Parkinson's disease can be confirmed by a. CT and MRI scans. b. relief of symptoms with administration of dopaminergic agents. c. the presence of tremors that increase during voluntary movement. d. cerebral angiogram that reveals the presence of cerebral atherosclerosis. - 27. b. Although clinical manifestations are characteristic in PD, no laboratory or diagnostic tests are specific for the condition. A diagnosis is made when at least two of the three signs of the classic triad are present and it is confirmed with a positive response to antiparkinsonian medication. Research regarding the role of genetic testing and MRI to diagnose PD is ongoing. Essential tremors increase during voluntary movement whereas the tremors of PD are more prominent at rest. 28. Which observation of the patient made by the nurse is most indicative of Parkinson's disease? a. Large, embellished handwriting b. Weakness of one leg resulting in a limping walk c. Difficulty rising from a chair and beginning to walk d. Onset of muscle spasms occurring with voluntary movement - 28. c. The bradykinesia of PD prevents automatic movements and activities such as beginning to walk, rising from a chair, or even swallowing saliva cannot be executed unless they are consciously willed. Handwriting is affected by the tremor and results in the writing trailing off at the end of words. Specific limb weakness and muscle spasms are not characteristic of PD. 29. A patient with Parkinson's disease is started on levodopa. What should the nurse explain about this drug? a. It stimulates dopamine receptors in the basal ganglia. b. It promotes the release of dopamine from brain neurons. c. It is a precursor of dopamine that is converted to dopamine in the brain. d. It prevents the excessive breakdown of dopamine in the peripheral tissues. - 29. c. Peripheral dopamine does not cross the blood-brain barrier but its precursor, levodopa, is able to enter the brain, where it is converted to dopamine, increasing the supply that is deficient in PD. Other drugs used to treat PD include bromocriptine, which stimulates dopamine receptors in the basal ganglia, and amantadine, which blocks the reuptake of dopamine into presynaptic neurons. Carbidopa is an agent that is usually administered with levodopa to prevent the levodopa from being metabolized in peripheral tissues before it can reach the brain. 30. To reduce the risk for falls in the patient with Parkinson's disease, what should the nurse teach the patient to do? a. Use an elevated toilet seat. b. Use a walker or cane for support. c. Consciously lift the toes when stepping. d. Rock side to side to initiate leg movements. - c. The shuffling gait of PD causes the patient to be off balance and at risk for falling. Teaching the patient to use a wide stance with the feet apart, to lift the toes when walking, and to look ahead helps to promote a more balanced gait. Use of an elevated toilet seat and rocking from side to side will enable a patient to initiate movement. Canes and walkers are difficult for patients with PD to maneuver and may make the patient more prone to injury. 31. A patient with myasthenia gravis is admitted to the hospital with respiratory insufficiency and severe weakness. When is a diagnosis of cholinergic crisis made? a. The patient's respiration is impaired because of muscle weakness. b. Administration of edrophonium (Tensilon) increases muscle weakness. c. Administration of edrophonium (Tensilon) results in improved muscle contractility. d. EMG reveals decreased response to repeated stimulation of muscles. - 31. b. The reduction of the acetylcholine (ACh) effect in myasthenia gravis (MG) is treated with anticholinesterase drugs, which prolong the action of ACh at the neuromuscular synapse, but too much of these drugs will cause a cholinergic crisis with symptoms very similar to those of MG. To determine whether the patient's manifestations are due to a deficiency of ACh or to too much anticholinesterase drug, the anticholinesterase drug edrophonium chloride (Tensilon) is administered. If the patient is in cholinergic crisis, the patient's symptoms will worsen; if the patient is in a myasthenic crisis, the patient will improve. Priority Decision: During care of a patient in myasthenic crisis, maintenance of what is the nurse's first priority for the patient? a. Mobility b. Nutrition c. Respiratory function d. Verbal communication - 32. c. The patient in myasthenic crisis has severe weakness and fatigability of all skeletal muscles, affecting the patient's ability to breathe, swallow, talk, and move. However, the priority of nursing care is monitoring and maintaining adequate ventilation. 33. When providing care for a patient with ALS, the nurse recognizes what as one of the most distressing problems experienced by the patient? a. Painful spasticity of the face and extremities b. Retention of cognitive function with total degeneration of motor function weakness are important nursing interventions for patients with ALS but are unrelated to causes of death for these patients. When establishing a diagnosis of MS, the nurse should teach the patient about what diagnostic studies (select all that apply)? A. EEG B. CT scan C. Carotid duplex scan D. Evoked response testing E. Cerebrospinal fluid analysis - B, D, E There is no definitive diagnostic test for MS. CT scan, evoked response testing, cerebrospinal fluid analysis, and MRI along with history and physical examination are used to establish a diagnosis for MS. EEG and carotid duplex scan are not used for diagnosing MS. The nurse is caring for a group of patients on a medical unit. After receiving report, which patient should the nurse see first? A. A 42-year-old patient with multiple sclerosis who was admitted with sepsis B. A 72-year-old patient with Parkinson's disease who has aspiration pneumonia C. A 38-year-old patient with myasthenia gravis who declined prescribed medications D. A 45-year-old patient with amyotrophic lateral sclerosis who refuses enteral feedings - C. Patients with myasthenia gravis who discontinue pyridostigmine (Mestinon) will develop a myasthenic crisis. Myasthenia crisis results in severe muscle weakness and can lead to a respiratory arrest. The nurse observes a 74-year-old man with Parkinson's disease rocking side to side while sitting in the chair. Which action by the nurse is most appropriate? A. Provide the patient with diversional activities. B. Document the activity in the patient's health record. C. Take the patient's blood pressure sitting and standing. D. Ask if the patient is feeling either anxious or depressed. - B. Patients with Parkinson's disease are instructed to rock from side to side to stimulate balance mechanisms and decrease akinesia. A 65-year-old woman was just diagnosed with Parkinson's disease. The priority nursing intervention is a. searching the Internet for educational videos. b. evaluating the home for environmental safety. c. promoting physical exercise and a well-balanced diet. d. designing an exercise program to strengthen and stretch specific muscles. - c Rationale: Promotion of physical exercise and a well-balanced diet are major concerns of nursing care for patients with Parkinson's disease. Social effects of a chronic neurologic disease include (select all that apply) a. divorce. b. job loss. c. depression. d. role changes. e. loss of self-esteem. - a, b, c, d, e Rationale: Social problems related to chronic neurologic disease may include changes in roles and relationships (e.g., divorce, job loss, role changes); other psychologic problems (e.g., depression, loss of self-esteem) also may have social effects. The nurse is reinforcing teaching with a newly diagnosed patient with amyotrophic lateral sclerosis. Which statement would be appropriate to include in the teaching? a. "ALS results from an excess chemical in the brain, and the symptoms can be controlled with medication." b. "Even though the symptoms you are experiencing are severe, most people recover with treatment." c. "You need to consider advance directives now, since you will lose cognitive function as the disease progresses." d. "This is a progressing disease that eventually results in permanent paralysis, though you will not lose any cognitive function." - d Rationale: The disease results in destruction of the motor neurons in the brainstem and spinal cord, causing gradual paralysis. Cognitive function is maintained. Because there is no cure for amyotrophic lateral sclerosis (ALS), collaborative care is palliative and based on symptom relief. Death usually occurs within 3-6 years after diagnosis. 7. When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido. - ANS: B Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS. DIF: Cognitive Level: Apply (application) REF: 1429 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 8. A 31-year-old woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy." - ANS: A During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS. DIF: Cognitive Level: Understand (comprehension) REF: 1429 TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching? a. Recommendation to drink at least 4 L of fluid daily b. Need to avoid driving or operating heavy machinery c. How to draw up and administer injections of the medication d. Use of contraceptive methods other than oral contraceptives - ANS: C Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer. DIF: Cognitive Level: Apply (application) REF: 1430 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations. DIF: Cognitive Level: Apply (application) REF: 1439 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? a. Shuffling gait b. Tremor at rest c. Cogwheel rigidity of limbs d. Uncontrolled head movement - ANS: D Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease. DIF: Cognitive Level: Apply (application) REF: 1435 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity hich nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements - ANS: D The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient. DIF: Cognitive Level: Apply (application) REF: 1436 OBJ: Special Questions: Prioritization TOP: Nursing Process: Analysis MSC: NCLEX: Physiological Integrity Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness - ANS: C Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical. DIF: Cognitive Level: Apply (application) REF: 1438-1439 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity ollowing a thymectomy, a 62-year-old male patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of nausea and severe abdominal cramps. Which action should the nurse take first? a. Auscultate the patient's bowel sounds. b. Notify the patient's health care provider. c. Administer the prescribed PRN antiemetic drug. d. Give the scheduled dose of prednisone (Deltasone). - ANS: B The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis. DIF: Cognitive Level: Apply (application) REF: 1438-1439 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which nursing interventions will be included in the plan of care (select all that apply)? a. Use an elevated toilet seat. b. Cut patient's food into small pieces. c. Provide high-protein foods at each meal. d. Place an armchair at the patient's bedside. e. Observe for sudden exacerbation of symptoms. - ANS: A, B, D Because the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations. DIF: Cognitive Level: Apply (application) REF: 1436-1437 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity A renal stone in the pelvis of the kidney will alter the function of the kidney by interfering with the a. structural support of the kidney. b. regulation of the concentration of urine. c. entry and exit of blood vessels at the kidney. d. collection and drainage of urine from the kidney. - d. collection and drainage of urine from the kidney. A patient with kidney disease has oliguria and a creatinine clearance of 40 mL/min. These findings most directly reflect abnormal function of a. tubular secretion. b. glomerular filtration. c. capillary permeability. d. concentration of filtrate. - b. glomerular filtration. The nurse identifies a risk for urinary calculi in a patient who relates a past health history that includes a. hyperaldosteronism. b. serotonin deficiency. c. adrenal insufficiency. d. hyperparathyroidism. - d. hyperparathyroidism. Diminished ability to concentrate urine, associated with aging of the urinary system, is attributed to a. a decrease in bladder sensory receptors. b. a decrease in the number of functioning nephrons. c. decreased function of the loop of Henle and tubules. d. thickening of the basement membrane of Bowman's capsule. - a. aspirin use. b. tobacco use. c. chronic alcohol abuse. d. use of artificial sweeteners. - b. tobacco use. In planning nursing interventions to increase bladder control in the patient with urinary incontinence, the nurse includes a. teaching the patient to use Kegel exercises. b. clamping and releasing a catheter to increase bladder tone. c. teaching the patient biofeedback mechanisms to suppress the urge to void. d. counseling the patient concerning choice of incontinence containment device. - a. teaching the patient to use Kegel exercises. A patient with a ureterolithotomy returns from surgery with a nephrostomy tube in place. Postoperative nursing care of the patient includes a. encouraging the patient to drink fruit juices and milk. b. encouraging fluids of at least 2 to 3 L/day after nausea has subsided. c. irrigating the nephrostomy tube with 10 mL of normal saline solution as needed. d. notifying the physician if nephrostomy tube drainage is more than 30 mL/hr. - b. encouraging fluids of at least 2 to 3 L/day after nausea has subsided. A patient has had a cystectomy and ileal conduit diversion performed. Four days postoperatively, mucous shreds are seen in the drainage bag. The nurse should a. notify the physician. b. notify the charge nurse. c. irrigate the drainage tube. d. document it as a normal observation. - d. document it as a normal observation. Which descriptions characterize acute kidney injury (select all that apply)? a. Primary cause of death is infection. b. It almost always affects older people. c. Disease course is potentially reversible. d. Most common cause is diabetic nephropathy. e. Cardiovascular disease is most common cause of death. - a. Primary cause of death is infection. c. Disease course is potentially reversible. RIFLE defines three stages of AKI based on changes in a. blood pressure and urine osmolality. b. fractional excretion of urinary sodium. c. estimation of GFR with the MDRD equation. d. serum creatinine or urine output from baseline. - d. serum creatinine or urine output from baseline. During the oliguric phase of AKI, the nurse monitors the patient for (select all that apply) a. hypotension. b. ECG changes. c. hypernatremia. d. pulmonary edema. e. urine with high specific gravity. - b. ECG changes. d. pulmonary edema. If a patient is in the diuretic phase of AKI, the nurse must monitor for which serum electrolyte imbalances? a. Hyperkalemia and hyponatremia b. Hyperkalemia and hypernatremia c. Hypokalemia and hyponatremia d. Hypokalemia and hypernatremia - c. Hypokalemia and hyponatremia A patient is admitted to the hospital with chronic kidney disease. The nurse understands that this condition is characterized by a. progressive irreversible destruction of the kidneys. b. a rapid decrease in urine output with an elevated BUN. c. an increasing creatinine clearance with a decrease in urine output. d. prostration, somnolence, and confusion with coma and imminent death. - a. progressive irreversible destruction of the kidneys. Nurses must teach patients at risk for developing chronic kidney disease. Individuals considered to be at increased risk include (select all that apply) a. older African Americans. b. patients more than 60 years old. c. those with a history of pancreatitis. d. those with a history of hypertension. e. those with a history of type 2 diabetes. - a. older African Americans. b. patients more than 60 years old. d. those with a history of hypertension. e. those with a history of type 2 diabetes. Patients with chronic kidney disease experience an increased incidence of cardiovascular disease related to (select all that apply) a. hypertension. b. vascular calcifications. c. a genetic predisposition. d. hyperinsulinemia causing dyslipidemia. e. increased high-density lipoprotein levels. - a. hypertension. b. vascular calcifications. d. hyperinsulinemia causing dyslipidemia. Nutritional support and management are essential across the entire continuum of chronic kidney disease. Which statements would be considered true related to nutritional therapy (select all that apply)? a. Fluid is not usually restricted for patients receiving peritoneal dialysis. b. Sodium and potassium may be restricted in someone with advanced CKD. c. Decreased fluid intake and a low-potassium diet are hallmarks of the diet for a patient receiving hemodialysis. d. Decreased fluid intake and a low-potassium diet are hallmarks of the diet for a patient receiving peritoneal dialysis. e. Decreased fluid intake and a diet with phosphate-rich foods are hallmarks of a diet for a patient receiving hemodialysis. - a. Fluid is not usually restricted for patients receiving peritoneal dialysis. b. Sodium and potassium may be restricted in someone with advanced CKD. c. Decreased fluid intake and a low-potassium diet are hallmarks of the diet for a patient receiving hemodialysis. An ESRD patient receiving hemodialysis is considering asking a relative to donate a kidney for transplantation. In assisting the patient to make a decision about treatment, the nurse informs the patient that a. successful transplantation usually provides better quality of life than that offered by dialysis. b. if rejection of the transplanted kidney occurs, no further treatment for the renal failure is available. c. hemodialysis replaces the normal functions of the kidneys, and patients do not have to live with the continual fear of rejection. d. the immunosuppressive therapy following transplantation makes the person ineligible to receive other forms of treatment if the kidney fails. - a. successful transplantation usually provides better quality of life than that offered by dialysis. To assess the patency of a newly placed arteriovenous graft for dialysis, the nurse should (select all that apply) a. monitor the BP in the affected arm. b. irrigate the graft daily with low-dose heparin. c. palpate the area of the graft to feel a normal thrill. d. listen with a stethoscope over the graft to detect a bruit. e. frequently monitor the pulses and neurovascular status distal to the graft. - c. palpate the area of the graft to feel a normal thrill. d. listen with a stethoscope over the graft to detect a bruit. e. frequently monitor the pulses and neurovascular status distal to the graft. A major advantage of peritoneal dialysis is a. the diet is less restricted and dialysis can be performed at home. b. the dialysate is biocompatible and causes no long-term consequences. d. Urine for culture and sensitivity - d. A urine specimen specifically obtained for culture and sensitivity is required to diagnose pyelonephritis because it will indicate the bacteria causing the infection and provide information on what drug the bacteria is sensitive to for treatment. The renal biopsy is used to diagnose chronic pyelonephritis or cancer. Blood cultures would be done if bacteremia is suspected. Intravenous pyelogram (IVP) would increase renal irritation, but CT urograms may be used to assess for signs of infection in the kidney and complications of pyelonephritis. A patient with suprapubic pain and symptoms of urinary frequency and urgency has two negative urine cultures. What is one assessment finding that would indicate interstitial cystitis (IC)? a. Residual urine greater than 200 mL b. A large, atonic bladder on urodynamic testing c. A voiding pattern that indicates psychogenic urinary retention d. Pain with bladder filling that is transiently relieved by urination - d. The symptoms of interstitial cystitis (IC) imitate those of an infection of the bladder, but the urine is free of infectious agents. Unlike a bladder infection, the pain with IC increases as urine collects in the bladder and is temporarily relieved by urination. Acidic urine is very irritating to the bladder in IC and the bladder is small, but urinary retention is not common. When caring for the patient with IC, what can the nurse teach the patient to do? a. Avoid foods that make the urine more alkaline. b. Use high-potency vitamin therapy to decrease the autoimmune effects of the disorder. c. Always keep a voiding diary to document pain, voiding frequency, and patterns of nocturia. d. Use the dietary supplement calcium glycerophosphate (Prelief) to decrease bladder irritation. - d. Calcium glycerophosphate (Prelief) is an over-the- counter dietary supplement that alkalinizes the urine and can help to relieve the irritation from acidic foods. A diet low in acidic foods is recommended; if a multivitamin is used, high-potency vitamins should be avoided because these products may irritate the bladder. A voiding diary is useful in diagnosis but does not have to be kept indefinitely. Glomerulonephritis is characterized by glomerular damage caused by a. growth of microorganisms in the glomeruli. b. release of bacterial substances toxic to the glomeruli. c. accumulation of immune complexes in the glomeruli. d. hemolysis of red blood cells circulating in the glomeruli. - c. Glomerulonephritis is not an infection but rather an antibody-antigen-induced injury of the glomerulus, and complement activation causes inflammation. Prior infection by bacteria or viruses may stimulate the antibody production but is not present or active at the time of glomerular damage. What manifestation in the patient will indicate the need for restriction of dietary protein in management of acute poststreptococcal glomerulonephritis (APSGN)? a. Hematuria b. Proteinuria c. Hypertension d. Elevated blood urea nitrogen (BUN) - d. An elevated blood urea nitrogen (BUN) indicates that the kidneys are not clearing nitrogenous wastes from the blood and protein may be restricted related to the degree of proteinuria until the kidney recovers. Proteinuria indicates loss of protein from the blood and possibly a need for increased protein intake. Hypertension is treated with sodium and fluid restriction, diuretics, and antihypertensive drugs. The hematuria is not specifically treated. The nurse plans care for the patient with APSGN based on what knowledge? a. Most patients with APSGN recover completely or rapidly improve with conservative management. b. Chronic glomerulonephritis leading to renal failure is a common sequela to acute glomerulonephritis. c. Pulmonary hemorrhage may occur as a result of antibodies also attacking the alveolar basement membrane. d. A large percentage of patients with APSGN develop rapidly progressive glomerulonephritis, resulting in kidney failure. - a. Most patients recover completely from acute poststreptococcal glomerulonephritis (APSGN) with supportive treatment. Chronic glomerulonephritis that progresses insidiously over years and rapidly progressive glomerulonephritis that results in renal failure within weeks or months occur in only a few patients with APSGN. In Goodpasture syndrome, antibodies are present against both the GBM and the alveolar basement membrane of the lungs, and dysfunction of kidneys and lungs are present. What results in the edema associated with nephrotic syndrome? a. Hypercoagulability b. Hyperalbuminemia c. Decreased plasma oncotic pressure d. Decreased glomerular filtration rate - c. The massive proteinuria that results from increased glomerular membrane permeability in nephrotic syndrome leaves the blood without adequate proteins (hypoalbuminemia) to create an oncotic colloidal pressure to hold fluid in the vessels. Without oncotic pressure, fluid moves into the interstitium, causing severe edema. Hypercoagulability occurs in nephrotic syndrome but is not a factor in edema formation, and glomerular filtration rate (GFR) is not necessarily affected in nephrotic syndrome. Which infection is asymptomatic in the male patient at first and then progresses to cystitis, frequent urination, burning on voiding, and epididymitis? a. Urosepsis b. Urethral diverticula c. Goodpasture syndrome d. Genitourinary tuberculosis - d. The manifestations of genitourinary tuberculosis are described. Urosepsis is when the UTI has spread systemically. Urethral diverticula are localized outpouching of the urethra and occur more often in women. Goodpasture syndrome manifests with flu-like symptoms with pulmonary symptoms that include cough, shortness of breath, and pulmonary insufficiency and renal manifestations that include hematuria, weakness, pallor, anemia, and renal failure What can patients at risk for nephrolithiasis do to prevent the stones in many cases? a. Lead an active lifestyle b. Limit protein and acidic foods in the diet c. Drink enough fluids to produce dilute urine d. Take prophylactic antibiotics to control UTIs - c. Because crystallization of stone constituents can precipitate and unite to form a stone when in supersaturated concentrations, one of the best ways to prevent stones of any type is by drinking adequate fluids to keep the urine dilute and flowing (e.g., an output of about 2 L of urine a day). Sedentary lifestyle is a risk factor for renal stones, but exercise also causes fluid loss and a need for additional fluids. Protein foods high in purine should be restricted only for the small percentage of patients with uric acid stones. Although UTIs contribute to stone formation, prophylactic antibiotics are not indicated. Which type of urinary tract calculi are the most common and frequently obstruct the ureter? a. Cystine b. Uric acid c. Calcium oxalate d. Calcium phosphate - c. Calcium oxalate calculi are most common (35% to 40%) and small enough to get trapped in the ureter. Cystine calculi incidence is 1% to 2%; uric acid incidence is 5% to 8%; calcium phosphate incidence is 8% to 10%. A female patient with a UTI also has renal calculi. The nurse knows that these are most likely which type of stone? a. Cystine b. Struvite c. Uric acid d. Calcium phosphate - b. Struvite calculi are most common in women and always occur with UTIs. They are also usually large staghorn type. The male patient is Jewish, has a history of gout, and has been diagnosed with renal calculi. Which treatment will be used with this patient (select all that apply)? a. Reduce dietary oxalate b. Administer allopurinol c. Administer α-penicillamine Which disease causes connective tissue changes that cause glomerulonephritis? a. Gout b. Amyloidosis c. Diabetes mellitus d. Systemic lupus erythematosus - d. Systemic lupus erythematosus causes connective tissue damage that affects the glomerulus. Gout deposits uric acid crystals in the kidney. Amyloidosis deposits hyaline bodies in the kidney. Diabetes mellitus causes microvascular damage affecting the kidney. When obtaining a nursing history from a patient with cancer of the urinary system, what does the nurse recognize as a risk factor associated with both kidney cancer and bladder cancer? a. Smoking b. Family history of cancer c. Chronic use of phenacetin d. Chronic, recurrent nephrolithiasis - a. Both cancer of the kidney and cancer of the bladder are associated with smoking. A family history of renal cancer is a risk factor for kidney cancer. Cancer of the bladder has been associated with long-term indwelling catheters, recurrent renal calculi (often bladder), and chronic lower UTIs. Thirty percent of patients with kidney cancer have metastasis at the time of diagnosis. Why does this occur? a. The only treatment modalities for the disease are palliative. b. Diagnostic tests are not available to detect tumors before they metastasize. c. Classic symptoms of hematuria and palpable mass do not occur until the disease is advanced. d. Early metastasis to the brain impairs the patient's ability to recognize the seriousness of symptoms. - c. There are no early characteristic symptoms of cancer of the kidney, and gross hematuria, flank pain, and a palpable mass do not occur until the disease is advanced. The treatment of choice is a partial or radical nephrectomy, which can be successful in early disease. Radiation is palliative. Many kidney cancers are diagnosed as incidental imaging findings. The most common sites of metastases are the lungs, liver, and long bones. Which characteristics are associated with urge incontinence (select all that apply)? a. Treated with Kegel exercises b. Found following prostatectomy c. Common in postmenopausal women d. Involuntary urination preceded by urgency e. Caused by overactivity of the detrusor muscle f. Bladder contracts by reflex, overriding central inhibition - d, e, f. Urge incontinence is involuntary urination preceded by urgency caused by overactivity of the detrusor muscle when the bladder contracts by reflex, which overrides central inhibition. Treatment includes treating the underlying cause and retraining the bladder with urge suppression, anticholinergic drugs, or containment devices. The other options are characteristic of stress incontinence. Patients may have a combination of urge and stress incontinence. The patient has a thoracic spinal cord lesion and incontinence that occurs equally during the day and night. What type of incontinence is this patient experiencing? a. Reflex incontinence b. Overflow incontinence c. Functional incontinence d. Incontinence after trauma - a. Reflex incontinence occurs with no warning, equally during the day and night, and with spinal cord lesions above S2. Overflow incontinence is when the pressure of urine in the overfull bladder overcomes sphincter control and is caused by bladder or urethral outlet obstruction. Functional incontinence is loss of urine resulting from cognitive, functional, or environmental factors. Incontinence after trauma or surgery occurs when fistulas have occurred or after a prostatectomy. Which drugs are used to treat overflow incontinence (select all that apply)? a. Baclofen (Lioresal) b. Anticholinergic drugs c. α-Adrenergic blockers d. 5α-reductase inhibitors e. Bethanechol (Urecholine) - c, d, e. α-Adrenergic blockers block the stimulation of the smooth muscle of the bladder, 5α-reductase inhibitors decrease outlet resistance, and bethanechol enhances bladder contractions. Baclofen or diazepam is used to relax the external sphincter for reflex incontinence. Anticholinergics are used to relax bladder tone and increase sphincter tone with urge incontinence. To assist the patient with stress incontinence, what should the nurse teach the patient to do? a. Void every 2 hours to prevent leakage. b. Use absorptive perineal pads to contain urine. c. Perform pelvic floor muscle exercises 40 to 50 times per day. d. Increase intraabdominal pressure during voiding to empty the bladder completely. - c. Pelvic floor exercises (Kegel exercises) increase the tone of the urethral sphincters and should be done in sets of 10 or more contractions four to five times a day (total of 40 to 50 per day). Frequent bladder emptying is recommended for patients with urge incontinence and an increase in pressure on the bladder is recommended for patients with overflow incontinence. Absorptive perineal pads should be only a temporary measure because long-term use discourages continence and can lead to skin problems. What is included in nursing care that applies to the management of all urinary catheters in hospitalized patients? a. Measuring urine output every 1 to 2 hours to ensure patency b. Turning the patient frequently from side to side to promote drainage c. Using strict sterile technique during irrigation and obtaining culture specimens d. Daily cleaning of the catheter insertion site with soap and water and application of lotion - c. All urinary catheters in hospitalized patients pose a very high risk for infection, especially antibiotic-resistant, health care-associated infections, and scrupulous aseptic technique is essential in the insertion and maintenance of all catheters. Routine irrigations are not performed. Turning the patient to promote drainage is recommended only for suprapubic catheters. Cleaning the insertion site with soap and water should be performed for urethral and suprapubic catheters, but lotion or powder should be avoided. Site care for other catheters may require special interventions. A patient has a right ureteral catheter placed following a lithotripsy for a stone in the ureter. In caring for the patient immediately after the procedure, what is the most appropriate nursing action? a. Milk or strip the catheter every 2 hours. b. Measure ureteral urinary drainage every 1 to 2 hours. c. Irrigate the catheter with 30-mL sterile saline every 4 hours. d. Encourage ambulation to promote urinary peristaltic action. - b. Output from ureteral catheters must be monitored every 1 to 2 hours because an obstruction will cause overdistention of the renal pelvis and renal damage. The renal pelvis has a capacity of only 3 to 5 mL, and if irrigation is ordered, no more than 5 mL of sterile saline is used. The patient with a ureteral catheter is usually kept on bed rest until specific orders for ambulation are given. Suprapubic tubes may be milked to prevent obstruction of the catheter by sediment and clots. During assessment of the patient who had an open nephrectomy, what should the nurse expect to find? a. Shallow, slow respirations b. Clear breath sounds in all lung fields c. Decreased breath sounds in the lower left lobe d. Decreased breath sounds in the right and left lower lobes - b. A nephrectomy incision is usually in the flank, just below the diaphragm or in the abdominal area. Although the patient is reluctant to breathe deeply because of incisional pain, the lungs should be clear. Decreased sounds and shallow respirations are abnormal and would require intervention. Which urinary diversion is a continent diversion created by formation of an ileal pouch with a stoma for catheterization? a. Kock pouch b. Ileal conduit c. Orthotopic neobladder d. Cutaneous ureterostomy - A dehydrated patient is in the Injury stage of the RIFLE staging of AKI. What would the nurse first anticipate in the treatment of this patient? a. Assessment of daily weight b. IV administration of fluid and furosemide (Lasix) c. IV administration of insulin and sodium bicarbonate d. Urinalysis to check for sediment, osmolality, sodium, and specific gravity - b. Injury is the stage of RIFLE classification in which urine output is less than 0.5 mL/kg/hr for 12 hours, the serum creatinine is increased times two, or the glomerular filtration rate (GFR) is decreased by 50%. This stage may be reversible by treating the cause or, in this patient, the dehydration by administering IV fluid and a low dose of a loop diuretic, furosemide (Lasix). Assessing the daily weight will be done to monitor fluid changes, but it is not the first treatment the nurse should anticipate. IV administration of insulin and sodium bicarbonate would be used for hyperkalemia. Checking the urinalysis will help to determine if the AKI has a prerenal, intrarenal, or postrenal cause by what is seen in the urine. With this patient's dehydration, it is thought to be prerenal to begin treatment. What indicates to the nurse that a patient with oliguria has prerenal oliguria? a. Urine testing reveals a low specific gravity. b. Causative factor is malignant hypertension. c. Urine testing reveals a high sodium concentration. d. Reversal of oliguria occurs with fluid replacement. - d. In prerenal oliguria, the oliguria is caused by a decrease in circulating blood volume and there is no damage yet to the renal tissue. It can be reversed by correcting the precipitating factor, such as fluid replacement for hypovolemia. Prerenal oliguria is characterized by urine with a high specific gravity and a low sodium concentration, whereas oliguria of intrarenal failure is characterized by urine with a low specific gravity and a high sodium concentration. Malignant hypertension causes damage to renal tissue and intrarenal oliguria. In a patient with AKI, which laboratory urinalysis result indicates tubular damage? a. Hematuria b. Specific gravity fixed at 1.010 c. Urine sodium of 12 mEq/L (12 mmol/L) d. Osmolality of 1000 mOsm/kg (1000 mmol/kg) - b. A urine specific gravity that is consistently 1.010 and a urine osmolality of about 300 mOsm/kg is the same specific gravity and osmolality as plasma. This indicates that tubules are damaged and unable to concentrate urine. Hematuria is more common with postrenal damage. Tubular damage is associated with a high sodium concentration (greater than 40 mEq/L). Metabolic acidosis occurs in the oliguric phase of AKI as a result of impairment of a. excretion of sodium. b. excretion of bicarbonate. c. conservation of potassium. d. excretion of hydrogen ions. - d. Metabolic acidosis occurs in AKI because the kidneys cannot synthesize ammonia or excrete hydrogen (H+) ions or the acid products of metabolism, resulting in an increased acid load. Sodium is lost in urine because the kidneys cannot conserve sodium. Bicarbonate is normally generated and reabsorbed by the functioning kidney to maintain acid-base balance. Impaired excretion of potassium results in hyperkalemia. What indicates to the nurse that a patient with AKI is in the recovery phase? a. A return to normal weight b. A urine output of 3700 mL/day c. Decreasing sodium and potassium levels d. Decreasing blood urea nitrogen (BUN) and creatinine levels - d. The blood urea nitrogen (BUN) and creatinine levels remain high during the oliguric and diuretic phases of AKI. The recovery phase begins when the glomerular filtration returns to a rate at which BUN and creatinine stabilize and then decrease. Urinary output of 3 to 5 L/ day, decreasing sodium and potassium levels, and fluid weight loss are characteristic of the diuretic phase of AKI. While caring for the patient in the oliguric phase of AKI, the nurse monitors the patient for associated collaborative problems. When should the nurse notify the HCP? a. Urine output is 300 mL/day. b. Edema occurs in the feet, legs, and sacral area. c. Cardiac monitor reveals a depressed T wave and elevated ST segment. d. The patient experiences increasing muscle weakness and abdominal cramping. - d. Hyperkalemia is a potentially life-threatening complication of AKI in the oliguric phase. Muscle weakness and abdominal cramping are signs of the neuromuscular impairment that occurs with hyperkalemia. In addition, hyperkalemia can cause the cardiac conduction abnormalities of peaked T wave, prolonged PR interval, prolonged QRS interval, and depressed ST segment. Urine output of 300 mL/day is expected during the oliguric phase, as is the development of peripheral edema. In caring for the patient with AKI, of what should the nurse be aware? a. The most common cause of death in AKI is irreversible metabolic acidosis. b. During the oliguric phase of AKI, daily fluid intake is limited to 1000 mL plus the prior day's measured fluid loss. c. Dietary sodium and potassium during the oliguric phase of AKI are managed according to the patient's urinary output. d. One of the most important nursing measures in managing fluid balance in the patient with AKI is taking accurate daily weights. - d. Measuring daily weights with the same scale at the same time each day allows for the evaluation and detection of excessive body fluid gains or losses. Infection is the leading cause of death in AKI, so meticulous aseptic technique is critical. The fluid limitation in the oliguric phase is 600 mL plus the prior day's measured fluid loss. Dietary sodium and potassium intake are managed according to the plasma levels. A 68-yr-old man with a history of heart failure resulting from hypertension has AKI as a result of the effects of nephrotoxic diuretics. Currently his serum potassium is 6.2 mEq/L (6.2 mmol/L) with cardiac changes, his BUN is 108 mg/dL (38.6 mmol/L), his serum creatinine is 4.1 mg/dL (362 mmol/L), and his serum HCO3− is 14 mEq/L (14 mmol/L). He is somnolent and disoriented. Which treatment should the nurse expect to be used for him? a. Loop diuretics b. Renal replacement therapy c. Insulin and sodium bicarbonate d. Sodium polystyrene sulfonate (Kayexalate) - b. This patient has at least three of the six common indications for renal replacement therapy (RRT), including (1) high potassium level, (2) metabolic acidosis, and (3) changed mental status. The other indications are (4) volume overload, resulting in compromised cardiac status (this patient has a history of hypertension), (5) BUN greater than 120 mg/dL, and (6) pericarditis, pericardial effusion, or cardiac tamponade. Although the other treatments may be used, they will not be as effective as RRT for this older patient. Loop diuretics and increased fluid are used if the patient is dehydrated. Insulin and sodium bicarbonate can be used to temporarily drive the potassium into the cells. Sodium polystyrene sulfonate (Kayexalate) is used to actually decrease the amount of potassium in the body. Prevention of AKI is important because of the high mortality rate. Which patients are at increased risk for AKI (select all that apply)? a. An 86-yr-old woman scheduled for a cardiac catheterization b. A 48-yr-old man with multiple injuries from a motor vehicle accident c. A 32-yr-old woman following a C-section delivery for abruptio placentae d. A 64-yr-old woman with chronic heart failure admitted with bloody stools e. A 58-yr-old man with prostate cancer undergoing preoperative workup for prostatectomy - a, b, c, d, e. High-risk patients include those exposed to nephrotoxic agents and advanced age (a), massive trauma (b), prolonged hypovolemia or hypotension (possibly b, c, and d), obstetric complications (c), cardiac failure (d), preexisting chronic kidney disease (CKD), extensive burns, or sepsis. Patients with prostate cancer may have obstruction of the outflow tract, which increases risk of postrenal AKI (e). A patient on a medical unit has a potassium level of 6.8 mEq/L. What is the priority action that the nurse should take? a. Place the patient on a cardiac monitor. b. Check the patient's blood pressure (BP). c. Instruct the patient to avoid high-potassium foods. d. Call the lab and request a redraw of the lab to verify results. - a. Dysrhythmias may occur with an elevated potassium level and are potentially lethal. Monitor the rhythm while contacting the health care provider or calling the rapid response team. Vital signs should be checked. Depending on the patient's history and cause of increased potassium, instruct the patient about dietary sources of potassium; d. A patient with CKD may have sugars and starches (unless the patient is diabetic); hard candy is an appropriate snack and may help to relieve the metallic and urine taste that is common in the mouth. Raisins are a high-potassium food. Ice cream contains protein and phosphate and counts as fluid. Pickled foods have high sodium content. Which complication of chronic kidney disease is treated with erythropoietin? a. Anemia b. Hypertension c. Hyperkalemia d. Mineral and bone disorder - a. Erythropoietin is used to treat anemia, as it stimulates the bone marrow to produce red blood cells. The patient with CKD asks why she is receiving nifedipine (Procardia) and furosemide (Lasix). The nurse understands that these drugs are being used to treat the patient's a. anemia. b. hypertension. c. hyperkalemia. d. mineral and bone disorder. - b. Both are used to treat hypertension. Nifedipine (Procardia) is a calcium channel blocker, and furosemide (Lasix) is a loop diuretic that can help decrease potassium. Which drugs will be used to treat the patient with CKD for mineral and bone disorder (select all that apply)? a. Cinacalcet (Sensipar) b. IV glucose and insulin c. Calcium acetate (Eliphos) d. IV 10% calcium gluconate e. Sevelamer carbonate (Renvela) - a, c, e. Cinacalcet (Sensipar), a calcimimetic agent to control secondary hyperparathyroidism; calcium acetate, a calcium-based phosphate binder, and sevelamer carbonate (Renvela), a non-calcium-based phosphate binder, are used to treat mineral and bone disorder in CKD. IV glucose and insulin and IV 10% calcium gluconate along with sodium polystyrene sulfonate (Kayexalate) are used to treat the hyperkalemia of CKD. Which description accurately describes the care of the patient with CKD? a. Iron is a nutrient that is commonly supplemented for the patient on dialysis because it is dialyzable. b. The syndrome that includes all of the signs and symptoms seen in the various body systems in CKD is azotemia. c. The use of morphine is contraindicated in the patient with CKD because accumulation of its metabolites may cause seizures. d. The use of calcium-based phosphate binders in the patient with CKD is contraindicated when serum calcium levels are increased - d. In the patient with CKD, when serum calcium levels are increased, calcium-based phosphate binders are not used. The dialyzable nutrient supplemented for patients on dialysis is folic acid, although IV iron sucrose injections may be prescribed for anemia if the patient receives erythropoietin. The various body system manifestations occur with uremia, which includes azotemia. Meperidine is contraindicated in patients with CKD related to possible seizures. During the nursing assessment of the patient with renal insufficiency, the nurse asks the patient specifically about a history of a. angina. b. asthma. c. hypertension. d. rheumatoid arthritis. - c. The most common causes of CKD in the United States are diabetes mellitus and hypertension. The nurse should obtain information on long-term health problems that are related to kidney disease. The other disorders are not closely associated with renal disease. The patient with chronic kidney disease is considering whether to use peritoneal dialysis (PD) or hemodialysis (HD). What are advantages of PD when compared to HD (select all that apply)? a. Less protein loss b. Rapid fluid removal c. Less cardiovascular stress d. Decreased hyperlipidemia e. Requires fewer dietary restrictions - c, e. Peritoneal dialysis (PD) is less stressful for the cardiovascular system and requires fewer dietary restrictions. PD actually contributes to more protein loss and increased hyperlipidemia. The fluid and creatinine removal are slower with PD than hemodialysis (HD). What does the dialysate for PD routinely contain? a. Calcium in a lower concentration than in the blood b. Sodium in a higher concentration than in the blood c. Dextrose in a higher concentration than in the blood d. Electrolytes in an equal concentration to that of the blood - c. Dextrose or icodextrin or amino acid is added to dialysate fluid to create an osmotic gradient across the membrane to remove excess fluid from the blood. Dialysate usually contains higher calcium to promote its movement into the blood. Dialysate sodium is usually less than or equal to that of blood to prevent sodium and fluid retention. The dialysate fluid has no potassium so that potassium will diffuse into the dialysate from the blood. Number the following in the order of the phases of exchange in PD. Begin with 1 and end with 3. a. Drain b. Dwell c. Inflow - a.3; b.2; c.1 In which type of dialysis does the patient dialyze during sleep and leave the fluid in the abdomen during the day? a. Long nocturnal HD b. Automated peritoneal dialysis (APD) c. Continuous venovenous hemofiltration (CVVH) d. Continuous ambulatory peritoneal dialysis (CAPD) - b. Automated peritoneal dialysis (APD) is the type of dialysis in which the patient dialyzes during sleep and leaves the fluid in the abdomen during the day. Long nocturnal HD occurs while the patient is sleeping and is done up to six times per week. Continuous venovenous hemofiltration (CVVH) is a type of continuous RRT used to treat AKI. Continuous ambulatory peritoneal dialysis (CAPD) is dialysis that is done with exchanges of 2 to 3 L of dialysate at least four times daily. To prevent the most common serious complication of PD, what is important for the nurse to do? a. Infuse the dialysate slowly. b. Use strict aseptic technique in the dialysis procedures. c. Have the patient empty the bowel before the inflow phase. d. Reposition the patient frequently and promote deep breathing. - b. Exit site infection and peritonitis are common complications of peritoneal dialysis (PD) and may require catheter removal and termination of dialysis. Infection occurs from contamination of the dialysate or tubing or from progression of exit-site or tunnel infections, and strict sterile technique must be used by health care professionals as well as the patient to prevent contamination. Too-rapid infusion may cause shoulder pain, and pain may be caused if the catheter tip touches the bowel. Difficulty breathing, atelectasis, and pneumonia may occur from pressure of the fluid on the diaphragm, which may be prevented by elevating the head of the bed and promoting repositioning and deep breathing. A patient on HD develops a thrombus of a subcutaneous arteriovenous graft (AVG), requiring its removal. While waiting for a replacement graft or fistula, the patient is most likely to have what done for treatment? a. Peritoneal dialysis b. Peripheral vascular access using radial artery c. Long-term cuffed catheter tunneled subcutaneously to the jugular vein d. Peripherally inserted central catheter (PICC) line inserted into subclavian vein - c. A more permanent, soft, flexible double-lumen catheter is used for long-term access when other forms of vascular access have failed. These catheters are tunneled subcutaneously and have Dacron cuffs that prevent infection from tracking along the 32-48 mmHg What is the laboratory value for HCO3? - 22-26 mEq/L When does an increase, decrease, or absence of fremitus mean? - increased fremitus = lung are filled with fluid or denser decreased fremitus = pleural effusion or the lung is hyperinflated (barrel chest) absent fremitus = pneumothorax or atelectasis What is fremitus? - the vibrations of the chest wall produced by vocalization How is fremitus performed? - place the palmer surface of the hands w/hyperextended fingers against the patient's chest. Ask the patient to repeat a phrase such as "99" in a deeper, louder than normal voice. Move your hands from side to side at the same time from top to bottom on the patient's chest What does a positive TB skin test indicate? - the patient has been exposed to the antigen After doing percussion and vibration, what should the patient experiece next? - coughing, the patient may have to sit to cough effectively and it may take as long as 30 minutes Is the flu vaccine safe for patients with asthma? - Yes, regardless of the severity of their asthma Does the patient who has had a positive TB skin test have active TB? - no, just means the patient has been exposed to the TB antigen What is the first thing that should be done when your patient has a false-positive reaction? - you should be certain the the injection is intradermal and not subcutaneous How should you read the TB skin test? - with good light, read the test. If there is an induration mark with a marking pen to indicate the periphery on all four sides for measurement.Measure in millimeters. Do you measure reddened, flat areas on the TB skin test? - no, only induration are measured After a bronchoscopy procedure what is the priority nursing intervention? - Keep patient NPO, until gag relex returns What is a pulmonary function tests? - used to evaluate lung function. Involves use of spirometer to assess air movement as patient performs perscribed respiratory maneuvers. What are the nursing responsibility for pulmonary function tests? - avoid scheduling immediately after mealtime. Avoid administration of inhaled bronchodilator 6 hr before procedure. Explain procedure to patient. Assess for respiratory distress before procedure and report. Provide rest after the procedure. What is a thoracentesis? - Used to obtain specimen of pleural fluid for diagnosis, to remove pleural fluid, or to instill medication. Chesk x-ray is always obtained after procedure to check for pneumothorax. What are the nursing responsibility for a thoracentesis? - Explain procedure to patient and obtain signed permit before procedure. Position patient upright with elbow on an overbed table and feet supported. Instruct patient not to talk or cough, and assist during procedure. Observe for signs of hypoxia and pneumothorax and verify breath sounds in all fields after procedure. Encourage deep breaths to expand lungs. Send labeled specimens to laboratory What interpreting response to a TB skin test if you have have a result of ≥5-mm induration? - HIV-infected persons; recent contact of a person w/TBdisease; Persons w/fibrotic lesions on chest x-ray consistent w/prior TB; patients w/organ transplants; persons who are immunosuppress What interpreting response to a TB skin test if you have have a result of ≥10-mm induration? - Recent immigrants (<5yr) from high-prevalence contries; injecting drug users, Residents and employees of high-risk congregate settings; mycovacteriology laboratory personnel; persons w/clinical conditions What interpreting response to a TB skin test if you have have a result of ≥15-mm induration? - all other persons who are at low risk How is TB spread? - via airborne droplets How is TB spread via airborne droplets when a person is infected? - Coughs Speaks Sneezes Sings What is latent TB infection? - TB infection in a person who does not have the active TB disease Can a person w/LTBI spread the disease? - No, not until the disease becomes active Who is at the hightest risk for the TB disease? - Immunosuppresed and diabetic patients How do you classify TB? - 0 = No TB exposure 1 = Exposure, no infection 2 = Latent TB, infection, no disease 3 = TB, clinically active 4 = TB , but not clinically active 5 = TB suspect What are the clinical manifestations of TB? - Fatigue Malaise Anorexia Weight loss Low‐grade fevers Night sweats (#1 sign of TB) persistent cough What will a persistent cough look like with a patient with TB? - white, frothy, mucoid or mucopurulent sputum What is another name for the tuberculin skin test (TST) - mantoux test isoniazid (INH) side effects and considerations - Hepatitis, asymptomatic elevation of aminotransferases monitor liver function tests monthly rifampin (Rifadin) side effects and considerations - Hepatitis, thrombocytopenia, orange discoloration of bodily fluids pyrazinamide (PZA) side effects and considerations - Hepatitis, arthralgias, hyperuricemia ethambutol (Myambutol) side effects and considerations - Ocular toxicity (decreased red-green color discrimination) Amount of air that can be quickly and forcefully exhaled after maximum inspiration - over 80% of predicted Forced expiratory volume in first second of expiration (FEV1) - amount of air exhaled in first second of FVC; grades severity of airway obstruction - over 80% predicted FEV1/FVC ratio - dividing of value for FEV1 by value for FVC; useful in differentiation obstructive and restrictive pulmonary dysfunction Peak expiratory flow rate (PEFR) - maximun airflow rate during forced expiration; aids in monitoring bronchoconstriction in asthma; can be measured w/peak flow meter - up to 600 L/min What exercise testing can be used to diagnosis, determine exercise capacity, and identify disability evaluation? - a 6-minute walk test can be used to measure functional capacity and response to medical interventions in patients w/moderate to severe heart or lung disease What is pneumonia? - an acute inflammation of the lung parenchyma that is most frequently caused by a microorganism Which age groups are the most affected by pneumonia? - 1-4 yrs old and over 65 year of age What is Hospital-Acquired pneumonia? (HAP) - occurs 48 hours or longer after hospital admission and not incubating at the time of hospitalization What is Ventilator-associated pneumonia? (VAP) - occurs more than 48 hours after endotracheal intubation What is Health care-associated pneumonia? (HCAP) - a new-onset pneumonia in a patient who (1) was hospitalized in an acute care hospital for 2 days or longer w/in 90 days of the infection (2) resided in a long-term care facility (3) received recent intravenous antibiotic therapy, chemotherapy, or wound care w/in the past 30 days of the current infection (4) attended a hospital or hemodialysis clinic How do you treat pneumonia once diagnosed? - empiric treatment in initiated based on risk factors What is a major problem in treating HCAP? - multi-drug resistant (MDR) organisms -- antibiotic susceptibility test can identify MDR organisms. What are the stages of pneumonia? - 1. congestion 2. red hepatization 3. gray hepatization 4. resolution A patient has rusty-colored mucus, what stage is this? - red hepatization What is gray hepatization? - when leukocytes and fibrin consolidate in the affected part of the lung ( looks like a white mass on the x-ray) What are the manifestations of pneumonia? - fever, shaking chills, shortness of breath, cough productive of purulent sputum, and sometimes pleuritic chest pain What are the S&S of Chronic Bronchitis? - color dusky to cyanotic; recurrent cough & increase sputum production; hypoxia; hypercapnia; respiratory acidosis; increase Hbg; increase respiratory rate, exertional dyspnea, incidence in heavy cigarette smokers; digital clubbing; cardiac enlargement; use of accessory muscles to breathe; leads to right-sided failure What are the S&S of Emphysema? - decrease CO2 retention (pink); minimal cyanosis; purse lip breathing, dyspnea; minimum cough; hyperresonance on chest percussion; orthopneic; barrel chest; exertional dyspnea; prolonged expiratory time; speaks in short jerky sentences; anxious; use of accessory muscles to breathe; thin appearance What are the S&S of COPD? - Easily fatigued; frequent respiratory infections; use of accessory muscles to breathe; orthopneic, cor pulmonale (late in disease), thin in appearance; wheezing; pursed-lip breathing; chronic cough; barrel chest; dyspnea; prolonged expiratory time; digital clubbing Pleurisy - inflammation of the pleura pleural effustion - transudate fluid in the pleural space atelectasis - collapsed, airless alveoli bacteremia - bacterial infection in the blood priority nursing diagnosis for pneumonia - Impaired gas exchange What is TB? - an infectious disease caused by Mycobacterium tuberculosis Is Asthma reversible? - Yes, if caught early enough What is Asthma? - a chronic inflammatory disorder of the airways What are the manifestations of Asthma? - recurrent episodes of whezzing; breathlessness, chest tightness, and cough, particularly at night or in the early morning Classification of Asthma severity : Intermittent - symptoms: <2 days/wk nighttime awakenings: <2 x/mo SABA use for symptoms: <2 days/wk Interference w/normal activity: none lung function: normal FEV1 btwn exacerbations; FEV1 > 80%; FEV1/FVC normal Classification of Asthma severity : Mild - symptoms: <2 days/wk, not daily nighttime awakenings: 3-4 x/mo SABA use for symptoms: >2 days/wk Interference w/normal activity: minor limitation lung function: FEV1 > 80%; FEV1/FVC normal Classification of Asthma severity : Moderate - symptoms: daily nighttime awakenings: >1x wk, not nightly SABA use for symptoms: daily Interference w/normal activity: some limitation lung function: FEV1 60-80%; FEV1/FVC reduced by 5% Classification of Asthma severity : Severe - symptoms: continyous nighttime awakenings: often, 7x/wk SABA use for symptoms: several times per day Interference w/normal activity: extremely limited lung function: FEV1 <60 predicted; FEV1/FVC reduced by 5% a. decreased EF and increased PAWP b. decreased PAWP and increased EF. c. decreased pulmonary hypertension associated with normal EF d. decreased afterload and decreased left ventricular end-diastolic pressure - a. decreased EF and increased PAWP Rationale: Systolic heart failure results in systolic failure in the left ventricle (LV). The LV loses its ability to generate enough pressure to eject blood forward through the aorta. This results in increased pulmonary artery wedge pressure (PAWP). The hallmark of systolic failure is a decrease in the left ventricular ejection fraction (EF). A 54-year-old male patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? A Perform a bladder scan to assess for urinary retention. B Restrict the patient's oral fluid intake to 500 mL per day. C Assist the patient to a sitting position with arms on the overbed table. D Instruct the patient to use pursed-lip breathing until the dyspnea subsides. - C Assist the patient to a sitting position with arms on the overbed table. The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. This position helps decrease venous return because of the pooling of blood in the extremities. This position also increases the thoracic capacity, allowing for improved ventilation. Pursed-lip breathing helps with obstructive air trapping but not with acute pulmonary edema. Restricting fluids takes considerable time to have an effect. The home care nurse visits a patient with chronic heart failure. Which clinical manifestations, assessed by the nurse, would indicate acute decompensated heart failure (pulmonary edema)? Fatigue, orthopnea, and dependent edema Severe dyspnea and blood-streaked, frothy sputum Temperature is 100.4oF and pulse is 102 beats/min Respirations 26 breaths/min despite oxygen by nasal cannula - Severe dyspnea and blood-streaked, frothy sputum Clinical manifestations of pulmonary edema include anxiety, pallor, cyanosis, clammy and cold skin, severe dyspnea, use of accessory muscles of respiration, a respiratory rate greater than 30 breaths/min, orthopnea, wheezing, and coughing with the production of frothy, blood-tinged sputum. Auscultation of the lungs may reveal crackles, wheezes, and rhonchi throughout the lungs. The heart rate is rapid, and blood pressure may be elevated or decreased. A compensatory mechanism involved in HF that leads to inappropriate fluid retention and additional workload of the heart is: a. ventricular dilation b. ventricular hypertrophy c. neurohormonal response d. sympathetic nervous system activation - c. neurohormonal response Rationale: The following mechanisms in heart failure lead to inappropriate fluid retention and additional workload of the heart: activation of the renin-angiotensin-aldosterone system (RAAS) cascade and release of antidiuretic hormone from the posterior pituitary gland in response to low cerebral perfusion pressure that results from low cardiac output. A70-year-old woman with chronic heart failure and atrial fibrillation asks the nurse why warfarin (Coumadin) has been prescribed for her to continue at home. Which response by the nurse is accurate? A "The medication prevents blood clots from forming in your heart." B "The medication dissolves clots that develop in your coronary arteries." C "The medication reduces clotting by decreasing serum potassium levels." D "The medication increases your heart rate so that clots do not form in your heart." - A "The medication prevents blood clots from forming in your heart." Chronic heart failure causes enlargement of the chambers of the heart and an altered electrical pathway, especially in the atria. When numerous sites in the atria fire spontaneously and rapidly, atrial fibrillation occurs. Atrial fibrillation promotes thrombus formation within the atria with an increased risk of stroke and requires treatment with cardioversion, antidysrhythmics, and/or anticoagulants. Warfarin is an anticoagulant that interferes with hepatic synthesis of vitamin K-dependent clotting factors. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is a. weight loss of 2 pounds overnight. b. hourly urine output greater than 60 mL. c. reduction in patient complaints of chest pain. d. decreased dyspnea with the head of bed at 30 degrees. - D Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis or improvement in cardiac output has occurred but are not as specific to evaluating this patient's response. The nurse is preparing to administer a nitroglycerin patch to a patient. When providing instructions regarding the use of the patch, what should the nurse include in the teaching? Avoid high-potassium foods Avoid drugs to treat erectile dysfunction Avoid over-the-counter H2-receptor blockers Avoid nonsteroidal antiinflammatory drugs (NSAIDS) - Avoid drugs to treat erectile dysfunction The use of erectile drugs concurrent with nitrates creates a risk of severe hypotension and possibly death. High-potassium foods, NSAIDs, and H2-receptor blockers do not pose a risk in combination with nitrates. A 54-year-old male patient who had bladder surgery 2 days ago develops acute decompensated heart failure (ADHF) with severe dyspnea. Which action by the nurse would be indicated first? - C Assist the patient to a sitting position with arms on the overbed table. The nurse should place the patient with ADHF in a high Fowler's position with the feet horizontal in the bed or dangling at the bedside. Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 38%? a. Need to participate in an aerobic exercise program several times weekly b. Use of salt substitutes to replace table salt when cooking and at the table c. Importance of making a yearly appointment with the primary care provider d. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors - D The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure. Aerobic exercise may not be appropriate for a patient with this level of heart failure, salt substitutes are not usually recommended because of the risk of hyperkalemia, and the patient will need to see the primary care provider more frequently than annually. You are caring for a patient with ADHF who is receiving IV dobutamine (Dobutrex). You know that this drug is ordered because it (select all that apply): a. incerases SVR b. infection c. rejection d. vasculopathy e. sudden cardiac death - b, c, & e Rationale: A variety of complications can occur after heart transplantation. In the first year after transplantation, the major causes of death are acute rejection and infection. Heart transplant recipients also are at risk for sudden cardiac death. Later, malignancy (especially lymphoma) and cardiac vasculopathy (accelerated CAD) are major causes of death. A patient who has chronic heart failure tells the nurse, "I felt fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment information as a. pulsus alternans. b. two-pillow orthopnea. c. acute bilateral pleural effusion. d. paroxysmal nocturnal dyspnea. - D Paroxysmal nocturnal dyspnea is caused by the reabsorption of fluid from dependent body areas when the patient is sleeping and is characterized by waking up suddenly with the feeling of suffocation. Pulsus alternans is the alternation of strong and weak peripheral pulses during palpation. Orthopnea indicates that the patient is unable to lie flat because of dyspnea. Pleural effusions develop over a longer time period. A patient with a recent diagnosis of heart failure has been prescribed furosemide. What outcome does the nurse anticipate will occur that demonstrates medication effectiveness? Promote vasodilation. Reduction of preload. Decrease in afterload. Increase in contractility. - Reduction of preload. Diuretics such as furosemide are used in the treatment of heart failure to mobilize edematous fluid, reduce pulmonary venous pressure, and reduce preload. They do not directly influence afterload, contractility, or vessel tone. The nurse is administering a dose of digoxin (Lanoxin) to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom(s)? - D. Anorexia, nausea Also vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity. After having a myocardial infarction (MI), the nurse notes the patient has jugular venous distention, gained weight, developed peripheral edema, and has a heart rate of 108 beats/min. What should the nurse suspect is happening? ADHF Chronic HF Left-sided HF Right-sided HF - Right-sided HF An MI is a primary cause of heart failure. The jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided heart failure. During a visit to a 72-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain, and complains of "feeling too tired to do anything." Based on these data, the best nursing diagnosis for the patient is a. activity intolerance related to fatigue. b. disturbed body image related to leg swelling. c. impaired skin integrity related to peripheral edema. d. impaired gas exchange related to chronic heart failure. - A The patient's statement supports the diagnosis of activity intolerance. There are no data to support the other diagnoses, although the nurse will need to assess for other patient problems. The nurse is preparing to administer digoxin to a patient with heart failure. In preparation, laboratory results are reviewed with the following findings: sodium 139 mEq/L, potassium 5.6 mEq/L, chloride 103 mEq/L, and glucose 106 mg/dL. What should the nurse do next? A Withhold the daily dose until the following day. B Withhold the dose and report the potassium level. C Give the digoxin with a salty snack, such as crackers. D Give the digoxin with extra fluids to dilute the sodium level. - B Withhold the dose and report the potassium level The normal potassium level is 3.5 to 5.0 mEq/L. The patient is hyperkalemic, which makes the patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The physician may order the digoxin to be given once the potassium level has been treated and decreases to within normal range. The nurse is preparing to administer a nitroglycerin patch to a patient. When providing instructions regarding the use of the patch, what should the nurse include in the teaching? Avoid high-potassium foods Avoid drugs to treat erectile dysfunction Avoid over-the-counter H2-receptor blockers Avoid nonsteroidal antiinflammatory drugs (NSAIDS) - Avoid drugs to treat erectile dysfunction What is the priority assessment by the nurse caring for a patient receiving IV nesiritide (Natrecor) to treat heart failure? A Urine output B Lung sounds C Blood pressure D Respiratory rate - C Blood pressure Although all identified assessments are appropriate for a patient receiving IV nesiritide, the priority assessment would be monitoring for hypotension, the main adverse effect of nesiritide. The nurse working in the heart failure clinic will know that teaching for a 74-year-old patient with newly diagnosed heart failure has been effective when the patient a. uses an additional pillow to sleep when feeling short of breath at night. b. tells the home care nurse that furosemide (Lasix) is taken daily at bedtime. c. calls the clinic when the weight increases from 124 to 130 pounds in a week. d. says that the nitroglycerin patch will be used for any chest pain that develops. - C Teaching for a patient with heart failure includes information about the need to weigh daily and notify the health care provider about an increase of 3 pounds in 2 days or 5 pounds in a week. Nitroglycerin patches are used primarily to reduce preload (not to prevent chest pain) in patients with heart failure and should be used daily, not on an "as necessary" basis. Diuretics should be taken earlier in the day to avoid nocturia and sleep disturbance. The patient should call the clinic if increased orthopnea develops, rather than just compensating by elevating the head of the bed further. What should the nurse recognize as an indication for the use of dopamine (Intropin) in the care of a patient with heart failure? A Acute anxiety B Hypotension and tachycardia C Peripheral edema and weight gain D Paroxysmal nocturnal dyspnea (PND) - B Hypotension and tachycardia Dopamine is a β-adrenergic agonist whose inotropic action is used for treatment of severe heart failure accompanied by hemodynamic instability. Such a state may be indicated by tachycardia accompanied by hypotension. PND, anxiety, edema, and weight gain are common signs and symptoms of heart failure, but these do not necessarily warrant the use of dopamine. While admitting an 80-year-old with heart failure to the hospital, the nurse learns that the patient lives alone and sometimes confuses the "water pill" with the "heart pill." When planning for the patient's discharge the nurse will facilitate a. transfer to a dementia care service. b. referral to a home health care agency. c. placement in a long-term care facility. d. arrangements for around-the-clock care. - B The data about the patient suggest that assistance in developing a system for taking medications correctly at home is needed. A home health nurse will assess the patient's home situation and help the patient develop a method for taking the two medications as directed. There is no evidence that the patient requires services such as dementia care, long-term care, or around-the-clock home care. Following an acute myocardial infarction, a previously healthy 67-year-old develops clinical manifestations of heart failure. The nurse anticipates discharge teaching will include information about a. angiotensin-converting enzyme (ACE) inhibitors. b. digitalis preparations. c. -adrenergic agonists. d. calcium channel blockers. - A ACE inhibitor therapy is currently recommended to prevent the development of heart failure in patients who have had a myocardial infarction and as a first-line therapy for patients with chronic heart failure. Digoxin therapy for heart failure is no longer considered a first-line measure, and digoxin is added to the treatment protocol when therapy with other medications such as ACE-inhibitors, diuretics, and -adrenergic blockers is insufficient. Calcium channel blockers are not generally used in the treatment of heart failure. The -adrenergic agonists such as dobutamine are administered through the IV route and are not used as initial therapy for heart failure. A 55-year-old with Stage D heart failure and type 2 diabetes asks the nurse whether heart transplant is a possible therapy. Which response by the nurse is appropriate? a. "Since you are diabetic, you would not be a candidate for a heart transplant." b. "The choice of a patient for a heart transplant depends on many different factors." c. "Your heart failure has not reached the stage in which heart transplants are considered." d. "People who have heart transplants are at risk for multiple complications after surgery." - B Indications for a heart transplant include end-stage heart failure, but other factors such as coping skills, family support, and patient motivation to follow the rigorous posttransplant regimen are also considered. Diabetic patients who have well-controlled blood glucose levels may be candidates for heart transplant. Although heart transplants can be associated with many complications, this response does not address the patient's question. Which diagnostic test will be most useful to the nurse in determining whether a patient admitted with acute shortness of breath has heart failure? a. Serum creatine kinase (CK) b. Arterial blood gases (ABGs) c. B-type natriuretic peptide (BNP) d. 12-lead electrocardiogram (ECG) - C BNP is secreted when ventricular pressures increase, as with heart failure, and elevated BNP indicates a probable or very probable diagnosis of heart failure. 12-lead ECGs, ABGs, and CK also may be used in determining the causes or effects of heart failure but are not as clearly diagnostic of heart failure as BNP. A stable patient with acute decompensated heart failure (ADHF) suddenly becomes dyspneic. Before positioning the patient on the bedside, what should the nurse assess first? A Urine output B Heart rhythm C Breath sounds D Blood pressure - D Blood pressure The nurse should evaluate the blood pressure before dangling the patient on the bedside because the blood pressure can decrease as blood pools in the periphery and preload decreases. If the patient's blood pressure is low or marginal, the nurse should put the patient in the semi-Fowler's position and use other measures to improve gas exchange. The patient has heart failure (HF) with an ejection fraction of less than 40%. What core measures should the nurse expect to include in the plan of care for this patient (select all that apply)? A Left ventricular function is documented. B Controlling dysrhythmias will eliminate HF. C Prescription for digoxin (Lanoxin) at discharge D Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge E Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen - A Left ventricular function is documented. D Prescription for angiotensin-converting enzyme (ACE) inhibitor at discharge E Education materials about activity, medications, weight monitoring, and what to do if symptoms worsen The Joint Commission has identified these three core measures for heart failure patients. Although controlling dysrhythmias will improve CO and workload, it will not eliminate HF. Prescribing digoxin for all HF patients is no longer done because there are newer effective drugs and digoxin toxicity occurs easily related to electrolyte levels and the therapeutic range must be maintained. Which action will the nurse include in the plan of care when caring for a patient admitted with acute decompensated heart failure (ADHF) who is receiving nesiritide (Natrecor)? a. Monitor blood pressure frequently. b. Encourage patient to ambulate in room. c. Titrate nesiritide rate slowly before discontinuing. d. Teach patient about safe home use of the medication. - A Nesiritide is a potent arterial and venous dilator, and the major adverse effect is hypotension. Since the patient is likely to have orthostatic hypotension, the patient should not be encouraged to ambulate. Nesiritide does not require titration and is used for ADHF but not in a home setting. A patient has been diagnosed with early left ventricular heart failure (HF). The nurse knows that the following changes occur as the disease progresses. In which order do the changes involved in the development of dyspnea associated with left ventricular HF occur? (Answer with a letter followed by a comma and a space (e.g. A, B, C, D).) A. Inadequate alveolar gas exchange B. Elevated pressure in the left atrium C. Ineffective ventricular contractility D. Fluid leaking into interstitial spaces - C, B, D, A D This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority. A patient with chronic heart failure who has prescriptions for a diuretic, an ACE-inhibitor, and a low-sodium diet tells the home health nurse about a 5-pound weight gain in the last 3 days. The nurse's first action will be to a. ask the patient to recall the dietary intake for the last 3 days. b. question the patient about the use of the prescribed medications. c. assess the patient for clinical manifestations of acute heart failure. d. teach the patient about the importance of dietary sodium restrictions. - C The 5-pound weight gain over 3 days indicates that the patient's chronic heart failure may be worsening. It is important that the patient be immediately assessed for other clinical manifestations of decompensation, such as lung crackles. A dietary recall to detect hidden sodium in the diet, reinforcement of sodium restrictions, and assessment of medication compliance may be appropriate interventions but are not the first nursing actions indicated. A patient in the intensive care unit with acute decompensated heart failure (ADHF) complains of severe dyspnea and is anxious, tachypneic, and tachycardic. All these medications have been ordered for the patient. The first action by the nurse will be to a. give IV diazepam (Valium) 2.5 mg. b. administer IV morphine sulfate 2 mg. c. increase nitroglycerin (Tridil) infusion by 5 mcg/min. d. increase dopamine (Intropin) infusion by 2 mcg/kg/min. - B Morphine improves alveolar gas exchange, improves cardiac output by reducing ventricular preload and afterload, decreases anxiety, and assists in reducing the subjective feeling of dyspnea. Diazepam may decrease patient anxiety, but it will not improve the cardiac output or gas exchange. Increasing the dopamine may improve cardiac output, but it also will increase the heart rate and myocardial oxygen consumption. Nitroglycerin will improve cardiac output and may be appropriate for this patient, but it will not directly reduce anxiety and will not act as quickly as morphine to decrease dyspnea. While assessing a 68-year-old with ascites, the nurse also notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates - c. increased right atrial pressure. jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects increased right atrial pressure. The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. Which clinical finding is the best indicator that the treatment has been effective? - d. Reduced dyspnea with the head of bed at 30 degrees Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees After receiving change-of-shift report, which of these patients admitted with heart failure should the nurse assess first? a. A patient who is receiving IV nesiritide (Natrecor) and has a blood pressure (BP) of 100/56 b. A patient who is cool and clammy, with new-onset confusion and restlessness c. A patient who had dizziness after receiving the first dose of captopril (Capoten) d. A patient who has crackles in both posterior lung bases and is receiving oxygen - B The patient who has "wet-cold" clinical manifestations of heart failure is perfusing inadequately and needs rapid assessment and changes in management. The other patients also should be assessed as quickly as possible, but do not have indications of severe decreases in tissue perfusion. Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 33%? - c. Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors The core measures for the treatment of heart failure established by The Joint Commission indicate that patients with an ejection fraction (EF) <40% receive an ACE inhibitor to decrease the progression of heart failure. Which assessment finding in a patient admitted with acute decompensated heart failure (ADHF) requires the most rapid action by the nurse? a. Oxygen saturation of 88% b. Weight gain of 1 kg (2.2 lb) c. Apical pulse rate of 106 beats/minute d. Urine output of 50 mL over 2 hours - A A decrease in oxygen saturation to less than 92% indicates hypoxemia. The nurse should administer supplemental oxygen immediately to the patient. An increase in apical pulse rate, 1-kg weight gain, and decreases in urine output also indicate worsening heart failure and require rapid nursing actions, but the low oxygen saturation rate requires the most immediate nursing action. IV sodium nitroprusside (Nipride) is ordered for a patient with acute pulmonary edema. During the first hours of administration, the nurse will need to titrate the nitroprusside rate if the patient develops - c. a systolic BP <90 mm Hg. Sodium nitroprusside is a potent vasodilator, and the major adverse effect is severe hypotension. A patient has recently started taking oral digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for control of heart failure. Which assessment finding by the home health nurse is most important to communicate to the health care provider? a. Presence of 1 to 2+ edema in the feet and ankles b. Liver is palpable 2 cm below the ribs on the right side. c. Serum potassium level is 3.0 mEq/L after 1 week of therapy d. Weight increase from 120 pounds to 122 pounds over 3 days - C Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which also can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level. An outpatient who has heart failure returns to the clinic after 2 weeks of therapy with carvedilol (Coreg). Which of these assessment findings is most important for the nurse to report to the health care provider? a. Pulse rate of 56 b. 2+ pedal edema c. BP of 88/42 mm Hg d. Complaints of fatigue - C The patient's BP indicates that the dose of carvedilol may need to be decreased because of hypotension. Bradycardia is a frequent adverse effect of -adrenergic blockade, but the rate of 56 is not unusual with -blocker therapy. -adrenergic blockade initially will worsen symptoms of heart failure in many patients, and patients should be taught that some increase in symptoms, such as fatigue and edema, is expected during the initiation of therapy with this class of drugs. During a visit to a 78-year-old with chronic heart failure, the home care nurse finds that the patient has ankle edema, a 2-kg weight gain over the past 2 days, and complains of "feeling too tired to get out of bed." Based on these data, the best nursing diagnosis for the patient is - a. activity intolerance related to fatigue. The patient's statement supports the diagnosis of activity intolerance. c. assist the patient in gently exercising the leg. d. keep the patient in bed in the supine position. - ANS: D The patient's history and clinical manifestations are consistent with acute arterial occlusion, and resting the leg will decrease the O2 demand of the tissues and minimize ischemic damage until circulation can be restored. Elevating the leg or applying an elastic wrap will further compromise blood flow to the leg. Exercise will increase oxygen demand for the tissues of the A patient at the clinic says, "I always walk after dinner, but lately my leg cramps and hurts after just a few minutes of starting. The pain goes away after I stop walking, though." The nurse should a. look for the presence of tortuous veins bilaterally on the legs. b. ask about any skin color changes that occur in response to cold. c. assess for unilateral swelling, redness, and tenderness of either leg. d. palpate for the presence of dorsalis pedis and posterior tibial pulses. - ANS: D The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness indicate venous thromboembolism. The nurse performing an assessment of a patient who has chronic peripheral artery disease (PAD) of the legs and an ulcer on the right second toe would expect to find a. dilated superficial veins. b. swollen, dry, scaly ankles. c. prolonged capillary refill in all the toes. d. serosanguineous drainage from the ulcer - ANS: C Capillary refill is prolonged in PAD because of the slower and decreased blood flow to the periphery. The other listed clinical manifestations are consistent with chronic venous disease When evaluating the discharge teaching for a patient with chronic peripheral artery disease (PAD), the nurse determines a need for further instruction when the patient says, "I will a. use a heating pad on my feet at night to increase the circulation." b. buy some loose clothes that do not bind across my legs or waist." c. walk to the point of pain, rest, and walk again for at least 30 minutes 3 times a week." d. change my position every hour and avoid long periods of sitting with my legs crossed." - ANS: A Because the patient has impaired circulation and sensation to the feet, the use of a heating pad could lead to burns. The other patient statements are correct and indicate that teaching has been successful. After teaching a patient with newly diagnosed Raynaud's phenomenon about how to manage the condition, which action by the patient best demonstrates that the teaching has been effective? a. The patient exercises indoors during the winter months. b. The patient immerses hands in hot water when they turn pale. c. The patient takes pseudoephedrine (Sudafed) for cold symptoms. d. The patient avoids taking nonsteroidal antiinflammatory drugs (NSAIDs). - ANS: A Patients should avoid temperature extremes by exercising indoors when it is cold. To avoid burn injuries, the patient should use warm rather than hot water to warm the hands. Pseudoephedrine is a vasoconstrictor and should be avoided. There is no reason to avoid taking NSAIDs with Raynaud's phenomenon The health care provider has prescribed bed rest with the feet elevated for a patient admitted to the hospital with venous thromboembolism. Which action by the nurse to elevate the patient's feet is best? a. The patient is placed in the Trendelenburg position. b. Two pillows are positioned under the affected leg. c. The bed is elevated at the knee and pillows are placed under the feet. d. One pillow is placed under the thighs and two pillows are placed under the lower legs. - ANS: D The purpose of elevating the feet is to enhance venous flow from the feet to the right atrium, which is best accomplished by placing two pillows under the feet and one under the thighs. Placing the patient in the Trendelenburg position will lower the head below heart level, which is not indicated for this patient. Placing pillows under the calf or elevating the bed at the knee may cause blood stasis at the calf level. The health care provider prescribes an infusion of heparin and daily partial thromboplastin time (PTT) testing for a patient with venous thromboembolism (VTE). The nurse will plan to a. decrease the infusion when the PTT value is 65 seconds. b. avoid giving IM medications to prevent localized bleeding. c. have vitamin K available in case reversal of the heparin is needed. d. monitor posterior tibial and dorsalis pedis pulses with the Doppler - ANS: B Intramuscular injections are avoided in patients receiving anticoagulation to prevent hematoma formation and bleeding from the site. A PTT of 65 seconds is within the therapeutic range. Vitamin K is used to reverse warfarin. Pulse quality is not affected by VTE. A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is most accurate? a. "Taking two blood thinners greatly reduces the risk for another clot to form." b. "Enoxaparin will work right away, but warfarin takes several days to begin preventing clots." c. "Enoxaparin will start to dissolve the clot, and warfarin will prevent any more clots from forming." d. "Because of the risk for a blood clot in the lungs, it is important for you to take more than one blood thinner." - ANS: B Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE. Anticoagulants do not thin the blood. The nurse has started discharge teaching for a patient who is to continue warfarin (Coumadin) after hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says which of the following? a. "I should get a Medic Alert device stating that I take warfarin." b. "I should reduce the amount of green, leafy vegetables that I eat." c. "I will need routine blood tests to monitor the effects of the warfarin." d. "I will check with my health care provider before I begin any new drugs." - ANS: B Patients taking warfarin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate. A 46-yr-old service-counter worker undergoes sclerotherapy for treatment of superficial varicose veins at an outpatient center. Which instructions should the nurse provide to the patient before discharge? a. Sitting at the work counter, rather than standing, is recommended. b. Exercise, such as walking or jogging, can cause recurrence of varicosities. c. Elastic compression stockings should be applied before getting out of bed. d. Taking an aspirin daily will help prevent clots from forming around venous valves. - ANS: C Elastic compression stockings are applied with the legs elevated to reduce pressure in the lower legs. Walking is recommended to prevent recurrent varicosities. Sitting and standing are both risk factors for varicose veins and venous insufficiency. An aspirin a day is not adequate to prevent venous thrombosis and would not be recommended for a patient who had just had sclerotherapy. Which topic should the nurse include in patient teaching for a patient with a venous stasis ulcer on the left lower leg? a. Need to increase carbohydrate intake b. Methods of keeping the wound area dry c. Purpose of prophylactic antibiotic therapy