BSN Hesi 266 Medical surg

The correct answer is: d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring.

Explanation:

The client who has recently undergone cardiac stent placement and now presents with chest pressure and shortness of breath is showing signs that could indicate a cardiac event, such as a myocardial infarction (MI) or stent thrombosis. These are serious complications that require immediate assessment and intervention.

d. Obtain a 12-lead electrocardiogram (ECG) and begin continuous cardiac monitoring: The first priority is to obtain a 12-lead ECG to assess for changes in heart rhythm or ischemia. Chest pressure and shortness of breath are highly suggestive of a cardiac event, and an ECG is a crucial tool to assess for acute changes in the heart's electrical activity, such as signs of ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), or arrhythmias. Additionally, continuous cardiac monitoring will allow for real-time observation of any life-threatening arrhythmias or other complications.

Why the other options are incorrect:

a. Listen for extra heart sounds, murmurs, and rhythm with the bell of the stethoscope: While auscultation is important in assessing for heart sounds, murmurs, and rhythm, it is not the priority in this situation. The client’s symptoms are more urgent, and immediate ECG and cardiac monitoring are needed to assess for potential cardiac emergencies like stent thrombosis or myocardial infarction.

b. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema: Although evaluating perfusion and pitting edema can be helpful in certain contexts (like assessing for heart failure or peripheral vascular issues), this action does not directly address the immediate concern of acute chest pain and shortness of breath that may be indicative of a cardiac emergency. The priority should be to assess the heart's function and rhythm via ECG and monitoring.

c. Verify troponin level assessments are scheduled every 3-6 hours for a series of three: While troponin levels are important in diagnosing myocardial infarction (MI) and stent complications, the first action should be to obtain an ECG and begin cardiac monitoring. Troponin testing is usually ordered after the immediate assessment of the electrical activity of the heart and is used to confirm the presence of myocardial injury. However, ECG and continuous monitoring are the immediate priorities to identify any life-threatening complications.

Summary:

The client’s chest pressure and shortness of breath are indicative of a cardiac emergency. The most urgent action is to obtain a 12-lead ECG and initiate continuous cardiac monitoring to assess for potential myocardial infarction or stent thrombosis. Monitoring for cardiac markers like troponin and assessing perfusion are important but should be done after the initial ECG and cardiac monitoring.

The correct answer is: D. Restrict salt and fluid intake.

Explanation:

Cirrhosis can lead to complications such as pedal edema (swelling in the lower legs) and ascites (fluid buildup in the abdomen), both of which are related to fluid retention. The liver's reduced ability to produce proteins like albumin, which helps maintain the body's fluid balance, along with increased pressure in the veins that supply the liver (portal hypertension), contribute to the development of these conditions. In managing fluid retention in cirrhosis:

Restricting salt intake: Sodium contributes to fluid retention, which exacerbates edema and ascites. By reducing salt intake, the body is less likely to retain excess fluid.

Fluid restriction: Fluid retention also occurs because of low albumin levels and increased aldosterone production, which increases water retention. Fluid restriction helps prevent further accumulation of fluids in the body.

Why the other options are incorrect:

A. Avoid high carbohydrate foods: There is no need to restrict carbohydrates in cirrhosis unless the client has issues like insulin resistance or diabetes. Carbohydrates are an important energy source for these clients.

B. Decrease intake of fat-soluble vitamins: Fat-soluble vitamins (A, D, E, and K) can be depleted in cirrhosis due to malabsorption, and these vitamins are important for overall health. Restricting fat-soluble vitamins is not indicated unless there is a specific deficiency.

C. Decrease caloric intake: The goal for clients with cirrhosis is to maintain proper nutrition, including adequate caloric intake, to prevent malnutrition and muscle wasting, which are common in liver disease. Decreasing caloric intake may worsen nutritional status.

Summary:

In clients with cirrhosis who develop pedal edema and ascites, it is most important to restrict salt and fluid intake to help manage fluid retention and prevent further complications.

The correct answer is: B. blood pressure, both standing and sitting.

Explanation:

Steroid therapy, particularly long-term use of glucocorticoids like prednisone, can have various systemic effects. One of the key side effects of long-term steroid use is its impact on the cardiovascular system, including causing fluid retention, hypertension, and an increased risk of orthostatic hypotension (a significant drop in blood pressure when standing up). Monitoring the client's blood pressure in both sitting and standing positions helps detect orthostatic hypotension, which is a critical condition to manage in clients who have been on long-term steroid therapy. This ensures the client is not experiencing dangerous drops in blood pressure upon standing, which could lead to dizziness, fainting, or falls.

Why the other options are wrong:

A. Pulse rate, both apically and radially. While it is important to monitor the pulse, there are no direct indications in this scenario that pulse rate would be the most critical aspect to assess in a client on long-term steroids. Blood pressure monitoring is more relevant for detecting complications from steroid use like hypertension or orthostatic hypotension.

C. Temperature Temperature assessment is generally important for detecting fever, which could indicate an infection. However, temperature changes are not typically associated with the side effects of long-term steroid use. Therefore, it is not the priority assessment in this case.

D. Skin color and turgor Skin changes, such as thinning of the skin and poor skin turgor, can occur with long-term steroid use due to their effects on collagen. However, monitoring blood pressure is of greater importance because hypertension and orthostatic hypotension are more immediately life-threatening and require more urgent management in this context.

Summary:

In a client who has been on long-term steroid therapy for COPD, monitoring blood pressure in both sitting and standing positions is the most critical nursing function. Steroid use can cause fluid retention and increase the risk of orthostatic hypotension, so it is important to assess blood pressure changes to prevent potential complications like dizziness or falls. Other assessments, such as pulse, temperature, and skin changes, are important but not as immediately urgent in this situation.

Correct answer: C. Carotid bruit

Explanation:

A carotid bruit is an important assessment finding that indicates turbulent blood flow in the carotid artery, often due to the presence of plaque or narrowing of the artery. This condition significantly increases the risk of a brain attack (stroke) because the plaque can cause ischemic damage by obstructing blood flow to the brain. A carotid bruit is a clear warning sign of potential stroke risk, as it suggests that the blood vessels supplying the brain may be compromised.

Why the other options are wrong:

A. Nuchal rigidity:

Nuchal rigidity refers to stiffness in the neck and is a common sign of meningeal irritation, such as in cases of meningitis or subarachnoid hemorrhage. It is not directly related to stroke or a brain attack.

B. Jugular vein distention:

Jugular vein distention (JVD) is typically a sign of heart failure, fluid overload, or increased central venous pressure. It is not associated with stroke risk. While it indicates circulatory issues, it does not directly relate to the carotid arteries or brain ischemia.

D. Palpable cervical lymph node:

A palpable cervical lymph node may indicate infection or inflammation in the head or neck, but it is not a typical sign of stroke. Lymph node enlargement is unrelated to the vascular conditions that cause stroke.

Summary:

The most significant risk factor for a brain attack (stroke) in the context provided is the carotid bruit, as it indicates potential vascular obstruction in the arteries supplying the brain, leading to an increased likelihood of stroke. The other findings, such as nuchal rigidity, jugular vein distention, and palpable cervical lymph nodes, are not associated with stroke risk.

The correct answer is C. Provide back and skin care while maintaining the traction.

Explanation:

The nursing diagnosis "Potential for impairment of skin integrity related to immobility from traction" suggests that the client is at risk for skin breakdown due to prolonged immobility and pressure from the traction. The nurse should implement interventions to maintain skin integrity and prevent breakdown, especially in areas vulnerable to pressure, such as the back, heels, and other bony prominences.

C. Provide back and skin care while maintaining the traction: This option is correct because it focuses on providing necessary skin care (such as repositioning and preventing pressure sores) while maintaining the integrity of the traction. Repositioning the client and providing regular skin care is essential to prevent impairment of skin integrity, and it should be done while the traction is in place to avoid disrupting the healing process.

Why the Other Options Are Incorrect:

A. Release the traction q4h to provide skin care: Releasing the traction for skin care purposes can compromise the therapeutic goals of the traction, such as maintaining proper alignment and immobilizing the injured area. This would not be the correct action, as it could interfere with the healing process.

B. Turn the client for back care while suspending traction: This is partially correct in that back care should be provided, but it is not advisable to suspend the traction during this process, as it could disrupt the alignment and intended immobilization of the knee. Traction should not be suspended unless specifically ordered by the healthcare provider.

D. Give back care after the client is released from traction: This approach would delay necessary skin care and could lead to skin breakdown. Skin care should be provided regularly and while the traction is still in place to ensure the patient remains comfortable and safe.

Summary:

The best intervention for a client in skeletal traction at risk for skin impairment is to provide back and skin care while maintaining the traction. This ensures the skin remains healthy and intact while also preventing any disruption in the healing process due to the traction.

The correct answers are:

b. Monitor the client's white blood cell count.

c. Send wound drainage for culture and sensitivity.

e. Institute contact precautions for staff and visitors.

Explanation:

When a client is suspected of having Methicillin-Resistant Staphylococcus Aureus (MRSA) with draining skin lesions, specific nursing interventions are crucial to manage the infection, monitor the patient's condition, and prevent transmission to others.

Monitor the client's white blood cell count:

The white blood cell count (WBC) is a critical parameter to monitor in clients with suspected infections. An elevated WBC count can indicate an active infection or inflammatory response, which is common in bacterial infections like MRSA. Monitoring this helps assess the severity of the infection and the body’s response to it.

Send wound drainage for culture and sensitivity:

For any suspected bacterial infection, including MRSA, sending a sample of the wound drainage for culture and sensitivity is essential. This helps identify the specific bacteria causing the infection and determine the most appropriate antibiotic treatment. MRSA, being resistant to certain antibiotics, may require alternative therapies, and culture results guide this decision.

Institute contact precautions for staff and visitors:

MRSA is primarily transmitted through direct contact with infected skin or contaminated surfaces. To prevent transmission, it is crucial to institute contact precautions, which include using personal protective equipment (PPE) such as gloves and gowns when entering the room, and ensuring that staff and visitors adhere to these precautions. This helps protect both the patient and others from potential infection spread.

Why the other options are incorrect:

a. Explain the purpose of a low bacteria diet:

A low-bacteria diet is generally recommended for immunocompromised patients, such as those with neutropenia, to reduce the risk of infection from contaminated food. However, it is not specifically necessary for a patient with MRSA unless they have a weakened immune system. The focus for MRSA is on infection control, antibiotics, and wound care, rather than dietary restrictions related to bacteria.

d. Use standard precautions and wear a mask:

Standard precautions, including hand hygiene, gloves, and gown use, are always important, but MRSA requires more specific precautions, such as contact precautions, to prevent the spread of the infection through direct contact. Wearing a mask is not necessary unless the patient is suspected of having a respiratory infection, which is not the primary concern for a skin lesion from MRSA.

Summary

The appropriate nursing interventions for a client with suspected MRSA include monitoring the white blood cell count to assess the infection's severity, sending wound drainage for culture and sensitivity to guide antibiotic treatment, and instituting contact precautions to prevent transmission to others. A low-bacteria diet and wearing a mask are not directly relevant to the management of MRSA skin lesions.

The correct answer is A. Eating patterns of dietary intake.

Explanation:

Chronic pancreatitis is characterized by ongoing inflammation of the pancreas, which can affect its ability to secrete digestive enzymes. This leads to difficulty in digesting food, causing persistent abdominal pain, particularly after eating. The nurse should assess the client's eating patterns to understand how food consumption is impacting the pain. Certain foods or eating behaviors may exacerbate symptoms, and understanding this relationship will allow for better pain management and dietary modifications. In chronic pancreatitis, individuals are often advised to avoid fatty or heavy meals as they can trigger the pain.

Why the other options are wrong:

B. Color and consistency of feces

While assessing the color and consistency of feces can be relevant in managing gastrointestinal issues, it is not as directly related to pain management in chronic pancreatitis. Though steatorrhea (fatty stools) can occur in chronic pancreatitis due to malabsorption, the primary focus for managing abdominal pain is understanding the impact of eating patterns on the pain rather than stool characteristics.

C. Activity level of bowel sounds

Bowel sounds may provide some indication of gastrointestinal function but are not as important in understanding or managing the pain associated with chronic pancreatitis. The presence or absence of bowel sounds can indicate issues like bowel obstruction or ileus, but they do not provide specific insight into how food intake is affecting pain, which is the key concern in this scenario.

D. Level and amount of physical activity

Physical activity can affect overall health, but it is not as directly tied to the management of chronic pancreatitis pain as dietary habits are. While staying active can help with overall wellness and digestive health, assessing physical activity level is not the most relevant step when dealing with a client's pain from chronic pancreatitis. The focus should be on managing triggers related to eating.

Summary:

For a client with chronic pancreatitis, the most important assessment to help manage their pain is understanding their eating patterns of dietary intake. This approach allows the nurse to identify potential triggers related to food consumption and adjust the client's diet accordingly to reduce pain. The other options, while relevant to general health management, do not directly address the pain associated with the condition in the same way that evaluating eating habits does.

The correct answer is C. Assess pulses with a vascular doppler.

Explanation:

In this situation, the client has had an abdominal aortic aneurysm repair four days ago and is exhibiting edema of both lower extremities, along with nonpalpable pedal pulses. The priority action is to assess the pulses using a vascular Doppler to confirm whether the nonpalpable pulses are due to poor circulation or another factor, such as post-operative changes in circulation or vessel occlusion. This assessment will give important information about the status of the client's circulation and whether there might be a compromise that needs immediate attention.

Why the other options are wrong:

A. Wrap the feet with warmed blankets

While keeping the feet warm can be helpful in improving circulation, it is not the first priority in this scenario. The primary concern should be ensuring that the client has adequate blood flow to the lower extremities. Using a Doppler to assess pulses is more immediate and essential to understand the cause of the nonpalpable pulses. Wrapping the feet with blankets may be done later if no significant vascular issues are identified.

B. Evaluate edema for pitting

While evaluating the degree of edema is important for understanding the client's condition, it does not directly address the immediate concern of nonpalpable pulses. The presence of edema can be secondary to venous stasis or fluid retention, but the key issue right now is assessing circulation and whether there are any indications of impaired blood flow following surgery. This should come after pulse assessment.

D. Elevate extremities on pillows

Elevating the extremities can help reduce swelling and promote venous return, but it is not the first action in this case. The immediate concern is assessing the client's circulation status using a Doppler before deciding on interventions like elevation. Elevating the legs without knowing the cause of the nonpalpable pulses might not be appropriate if there is an underlying circulatory issue, such as a clot or reduced perfusion.

Summary:

The most important first step is to assess the pedal pulses using a vascular Doppler to evaluate the adequacy of circulation in the lower extremities. This will help determine if there are any post-operative complications such as reduced perfusion, which could be critical. Once circulation is assessed, the nurse can proceed with further interventions, such as elevating the extremities or addressing the edema, depending on the findings.

Correct Answer: A. Prevention of deformities.

Explanation

In clients with rheumatoid arthritis (RA), splints are commonly prescribed for nighttime use to help in the prevention of deformities. RA is a chronic inflammatory condition that affects the joints, leading to joint instability, deformities, and loss of function over time. Nighttime splints are designed to maintain joints in a functional position, preventing the joints from becoming misaligned or developing contractures during sleep. This can help prevent long-term damage and deformities associated with RA, such as ulnar deviation or boutonnière deformity.

Why the Other Options Are Incorrect:

B. Avoidance of joint trauma.

Splints are not primarily designed to prevent joint trauma but rather to maintain joint alignment and prevent deformities. Trauma usually refers to acute injury or impact to the joint, which is not the main concern during sleep in RA patients.

C. Relief of joint inflammation.

Splints are not intended to reduce the inflammation that is a hallmark of rheumatoid arthritis. While splints can help protect joints and limit movement, they do not directly address the inflammatory process. Management of joint inflammation in RA typically involves medications such as NSAIDs, corticosteroids, or disease-modifying antirheumatic drugs (DMARDs).

D. Improvement in joint strength.

Splints do not improve joint strength. They are designed to protect the joint and maintain proper alignment but do not enhance the muscles or ligaments around the joint. Strengthening exercises and physical therapy are more appropriate for improving joint strength.

Summary:

The primary purpose of nighttime splints for rheumatoid arthritis is to prevent deformities by ensuring proper joint positioning during sleep. Splints help in maintaining functional joint alignment, thus preventing further joint damage and deformities. They are not primarily used for relieving inflammation, improving joint strength, or avoiding trauma.