Hepatic
Billary/Pancreatic
Immune
It puts the lotion on the SKIN!
Random!
100
A nurse is caring for a client following a paracentesis. Which of the following findings indicate the bowel was perforated during the procedure?
A. Client report of upper chest pain
B. Decreased urine output
C. Pallor
D. Temperature elevation
Answer: D
A. A report of sharp, constant abdominal pain is associated with bowel perforation.
B. Decreased urine output is associated with bladder perforation during a paracentesis.
C. Pallor may indicate hypovolemia related to fluid removal of ascites fluid during the procedure.
D. CORRECT: Fever is an indication of bowel perforation during a paracentesis.
100
The client has been admitted with a diagnosis of acute pancreatitis. The nurse would assess this client for pain that is:
A. Severe and unrelenting, located in the epigastric area and radiating to the back.
B. Severe and unrelenting, located in the left lower quadrant and radiating to the groin.
C. Burning and aching, located in the epigastric area and radiating to the umbilicus.
D. Burning and aching, located in the left lower quadrant and radiating to the hip.
Answer: A
The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back.
100
After several days of antibiotic therapy, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first?
a. Notify the health care provider.
b. Obtain a stool specimen for analysis.
c. Teach the patient about handwashing.
d. Place the patient on contact precautions.
Answer: D
Most likely C.Diff infection after antibiotic therapy.100
A male client comes to the physician’s office for treatment of severe sunburn. The nurse takes this opportunity to discuss the importance of protecting the skin from the sun’s damaging rays. Which instruction would best prevent skin damage?
A “Minimize sun exposure from 1 to 4 p.m. when the sun is strongest.”
B. “Use a sunscreen with a sun protection factor of 6 or higher.”
C. “Apply sunscreen even on overcast days.”
D. “When at the beach, sit in the shade to prevent sunburn.”
Answer: C
Sunscreen should be applied even on overcast days, because the sun’s rays are as damaging then as on sunny days. The sun is strongest from 10 a.m. to 2 p.m. (11 a.m. to 3 p.m. daylight saving time) — not from 1 to 4 p.m. Sun exposure should be minimized during these hours. The nurse should recommend sunscreen with a sun protection factor of at least 15. Sitting in the shade when at the beach doesn’t guarantee protection against sunburn because sand, concrete, and water can reflect more than half the sun’s rays onto the skin.
100
________________ is used to help control esophageal bleeding. (not medication)
What should ALWAYS be at the best side in case of dislodgement/displacement? Why?
Balloon tamponade used to stop/control bleeding varices .
ALWAYS keep scissors at the bedside in case of dislodgement/displacement. Cut the tube and pull out if this occurs.
200
What is the treatment for hepatic encephalopathy?
Removal/prevention of precipitating factors
reducing nitrogen and ammonia load --> lactulose, antibiotics
INcreased ammonia clearance --> Zn
200
A client with a history of pancreatitis is scheduled for surgery to excise a pseudocyt of the pancrease. The cleint ask, "what is a pseudocyst?" What information should the nurse include in a response to this question?
1. Malignant growth.
2. Pocket of undigested food particles.
3. Dilated space of necrotic tissue and blood
4. Sack filled with fluid and pancreatic enzymes.
Answer: 3
A pseudocyst of the pancreas is an abnormally dilated space that contains blood, necrotic tissue and enzymes, and is surrounded by connective tissue.
200
What is a left shift?
Answer:
An increase in neutrophil precursors (eg, band cells, metamyelocytes) with or without neutrophilia, usually from infection or inflammation
200
The nurse prepares to care for a male client with acute cellulites of the lower leg. The nurse anticipates that which of the following will be prescribed for the client?
A. Cold compress to the affected area
B. Warm compress to the affected area
C. Intermittent heat lamp treatments four times daily
D. Alternating hot and cold compresses continuously
Answer: B
Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.
200
A nurse is caring for a patient diagnosed with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when, abnormal, might identify a client who may benefit from neomycin enemas?
1. Ammonia level
2. Culture and sensitivity
3. White blood cell count
4. Alanine aminotransferase level.
Answer: 1
Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia forming bacteria in the intestines.
300
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which classic signs of hepatic coma should the nurse assess this client? SELECT ALL THAT APPLY!
1. Mental confusion
2. Increased cholesterol
3. Brown-colored stools
4. Flapping hand tremors
5. Hyperactive deep tendon reflexes
Answers: 1 and 4
2 is incoreected because not nesessarily present. 3 is incorrect because the stool would be clay colored due to lack of bile caused by a biliary obstruction. 5 is incorrect because encephalopathy advances to coma.
300
The nurse is reviewing the physician's orders written for a client admitted with acute pancreatitis. Which physician order would the nurse question if noted on the client's chart?
A. NPO status
B. Insert a nasogastric tube
C. An anticholinergic medication
D. Morphine for pain
Answer: D
Meperidine (Demerol) rather than morphine is the medication of choice because morphine can cause spasm in the sphincter of Oddi.
300
Select all the possible opportunistic infections that adversely affect HIV/AIDS infected patients:
A. Visual losses
B. Kaposi's sarcoma
C. Wilms' sarcoma
D. Tuberculosis
E. Peripheral neuropathy
F. Toxoplasma gondii
Answer: B, D and F
Kaposi's sarcoma, tuberculosis, toxoplasma gondii, mycobacterium avium, herpes simplex, histoplasmosis and salmonella infections are HIV/AIDS associated opportunistic infections.
*Although many affected patients can experience blindness and peripheral neuropathy, these disorders result from impaired nervous system damage rather than an infection.
*Lastly, Wilms' tumor (sarcoma) is a pediatric form of kidney cancer and it is neither an infection nor something that typically affects the patient with HIV/AIDS
300
The clinic nurse is assessing the skin of a white client who is diagnosed with psoriasis. Which of the following characteristic is associated with this skin disorder?
A. Clear, thin nail beds
B. Red-purplish scaly lesions
C. Oily skin and no episodes of pruritus
D. Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions
BONUS: What are the most affected areas?
Answer: D
Psoriatic patches are covered with silvery-white scales. Affected areas include the scalp, elbows, knees, shins, trunk, and sacral area.
300
What is Lupus and what is the treatment?
Answer: is a chronic inflammatory disease that affects multiple body systems. A butterfly rash on the cheeks and on the bridge of the nose is a classic sign of SLE.
Treatment:Avoid prolonged sun exposure•Well-balanced diet•Antimalarial medications
400
Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? Select all that apply:*
A. Thrombocytopenia
B. Vision changes
C. Increased PT/INR
D. Leukopenia
Answer: A,C and D
The answers are A, C, and D. A patient with an enlarged spleen (splenomegaly) due to cirrhosis can experience thrombocytopenia (low platelet count), increased PT/INR (means it takes the patient a long time to stop bleeding), and leukopenia (low white blood cells). The spleen stores platelets and WBCs. An enlarged spleen can develop due to portal hypertension, which causes the platelets and WBCs to become stuck inside the spleen due to the increased pressure in the hepatic vein (hence lowering the count and the body’s access to these important cells for survival).
400
When caring for a patient with a biliary obstruction, the nurse will anticipate administering which vitamin supplements (select all that apply)?
A. Vitamin A
B. Vitamin D
C. Vitamin E
D. Vitamin K
E. Vitamin B
Answer: A,B ,C, D
Biliary obstruction prevents bile from entering the small intestine and thus prevents the absorption of fat-soluble vitamins. Vitamins A, D, E, and K are all fat-soluble and thus would need to be supplemented in a patient with biliary obstruction.
400
Which of the following is a true statement about antibiotic resistant bacterial illnesses:
a. They usually occur in the hospital setting but may be acquired in the community
b. Immunosuppressed patients are at the greatest risk of acquiring them.
c. Not completing a full prescription of antibiotics may cause bacteria to adapt and become resistanct.
d. All of the above
Answer: D
400
A nurse is caring for patients with a variety of wounds. Which would will most likely heal by primary intention?
1. Cut in the skin from a kitchen knife
2. Excoriated perineal area
3. Abrasion of the skin
4. Pressure ulcer
Answer: 1
1. Cut in the skin from a kitchen knife; A cut in the skin by a sharp instrument with minimal tissue loss can heal by primary intention when the wound edges are lightly pulled together (approximated).
Excoriations, abrasions, and pressure ulcers heal by secondary, not primary. Secondary intention healing occurs when wound edges are not approximated because of full-thickness tissue loss; the wound is left open until it fills with new tissue. Abrasions and excoriations are injuries to the surface of the skin.
400
A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following?
1. Development of a cataract.
2. Possible retinal degeneration.
3. Part of the disease process.
4. A coincidental occurrence.
Answer:2
Difficulty seeing out of one eye, when evaluated in conjunction with the client's medication therapy regimen, leads to the suspicion of possible retinal degeneration. The possibility of an irreversible retinal degeneration caused by deposits of hydroxychloroquine (Plaquenil) in the layers of the retina requires an ophthalmologic examination before therapy is begun and at 6-month intervals. Although cataracts may develop in young adults, they are less likely, and damage from the hydroxychloroquine is the most obvious at-risk factor. Eyesight is not affected by the disease process of rheumatoid arthritis.
500
Mr. Hasakusa is in end-stage liver failure. Which interventions should the nurse implement when addressing hepatic encephalopathy? (Select all that apply.)
A. Assessing the client's neurologic status every 2 hours
B. Monitoring the client's hemoglobin and hematocrit levels
C. Evaluating the client's serum ammonia level
D. Monitoring the client's handwriting daily
E. Preparing to insert an esophageal tamponade tube
F. Making sure the client's fingernails are short
Answer: A, C, D
Hepatic encephalopathy results from an increased ammonia level due to the liver's inability to covert ammonia to urea, which leads to neurologic dysfunction and possible brain damage. The nurse should monitor the client's neurologic status, serum ammonia level, and handwriting. Monitoring the client's hemoglobin and hematocrit levels and insertion of an esophageal tamponade tube address esophageal bleeding. Keeping fingernails short address puritis associated with jaundice.
500
Which clinical manifestation would the nurse expect a client diagnosed with acute cholecystitis to exhibit?
A. Jaundice, dark urine, and steatorrhea
B. Acute right lower quadrant (RLQ) pain, diarrhea, and dehydration
C. Ecchymosis petechiae, and coffee-ground emesis
D. Nausea, vomiting, and anorexia
Answer: D. Nausea, vomiting, and anorexia
Acute cholecystitis is an acute inflammation of the gallbladder commonly manifested by the following: anorexia, nausea, and vomiting; biliary colic; tenderness and rigidity the right upper quadrant (RUQ) elicited on palpation (e.g., Murphy's sign); fever; fat intolerance; and signs and symptoms of jaundice. Ecchymosis, petechiae, and coffee-ground emesis are clinical manifestations of esophageal bleeding. The coffee-ground appearance indicates old bleeding. Jaundice, dark urine, and steatorrhea are clinical manifestations of the icteric phase of hepatitis.
500
The patient is an 82-year-old woman who has been a resident in an extended-care facility for the past year because of poor mobility and self-care problems. Today she is brought to the emergency department because she does not recognize her son and does not know where she is. She completed drug therapy for a urinary tract infection 1 week ago. Her skin is thin, and she has many bruises. In addition, she has a healing wound on her left shin, which her son tells you occurred 3 days ago when she scraped the area trying to get out of bed alone. The skin immediately surrounding the wound appears normal; however, about 3 inches to the right of the wound the skin is red, firm, and warm to the touch. These are her vital signs: T, 100.8 F (38.2 C); P, 112 beats/min; R, 24 breaths/min; BP, 118/80; SpO2, 92%. Oxygen at 3 L/min is applied until the neurologist can evaluate her, and an IV with normal saline is started at 100 mL/hr. Her son is concerned because she was given her oral antidiabetic drug this morning (5 hours ago) but has not eaten breakfast or lunch. When you check her blood glucose level, it is 131 mg/dL. When you assess her 15 minutes later, her oxygen saturation is 90%.
1. What risk factors does this patient have for sepsis?
2. What manifestations does she have that are consistent with sepsis and systemic inflammatory response syndrome (SIRS)?
3. What assessment should you perform immediately?
4. What would be the most likely source of infection?
5. Should you express concern about the possibility of sepsis and SIRS to the emergency department intensivist? Why or why not?
1. What risk factors does this patient have for sepsis?
Risk factors include older age, diabetes mellitus, poor mobility and self-care problems, a known urinary tract infection within the past 30 days, and an open skin area on a lower extremity.
2. What manifestations does she have that are consistent with sepsis and systemic inflammatory response syndrome (SIRS)?
Manifestations include elevated temperature, a heart rate of more than 90 beats/min, a respiratory rate greater than 20 breaths/min, a blood glucose level above 120 mg/dL, a recent known infection, decreasing oxygen saturation, and confusion.
3. What assessment should you perform immediately?
Assess the color of her skin and mucous membranes, capillary refill, and capnography. Obtain an order for a serum lactate level and a complete blood count with differential. Also obtain an order to insert a Foley catheter for accurate urine output assessment.
4. What would be the most likely source of infection?
The two most likely sources of infection are the leg wound (even though the red area is adjacent to the scrape, it is an indication of cellulitis) and the urinary tract.
5. Should you express concern about the possibility of sepsis and SIRS to the emergency department intensivist? Why or why not?
Absolutely; this patient meets multiple criteria for sepsis with SIRS and she is older. Her condition could worsen rapidly to severe sepsis and multiple organ dysfunction syndrome (MODS). She needs immediate intervention to save her life.
500
You are caring for an assigned client and notice a superficial ulcer on the client's buttock that appears as a shallow crater involving the epidermis and the dermis. Which of the following stages would you say best describes this break in skin integrity?
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
Answer: 2
Stage II; Stage I pressure ulcer involves a nonblanchable erythema of intact skin, while a stage II involves a partial-thickness skin loss involving epidermis, dermis, or both, with the ulcer being superficial and presenting as an abrasion, blister, or shallow crater.
500
The patient has vancomycin-resistant enterococci (VRE) infection in a surgical wound. What infection precautions should the nurse use to best prevent transmission of the infection to the nurse, other patients, staff, and those outside the hospital?
A. Droplet precautions
B. Contact precautions
C. Airborne precautions
D. Standard precautions
Answer: B