Nursing Interventions and Patient Assessment

Nursing Interventions during Emergencies and Pathophysiological Principles

Burn Injuries

• Crucial Nursing Intervention in Emergent Phase of Burn Injury
  • Most crucial intervention: Calculating and administering fluid replacement.
  • Other options considered:
  • Administering high dose antibiotics.
  • Applying topical steroids to the burn.
  • Providing nutritional support.

Pressure Injuries

• Common Factor Associated with Development of Pressure Injuries
  • Most commonly associated factor: Immobility.
  • Other options considered:
  • Increased mobility.
  • High protein diet.
  • Frequent movement.

Fluid Replacement for Severe Burns

• Appropriate Nursing Action for Calculating Fluid Replacement Requirements
  • Correct method: Calculating using the patient’s body surface area and weight.
  • Other options considered:
  • Administer fluids based on patient’s subjective report of thirst.
  • Estimating fluid needs.
  • Use a standard fluid replacement protocol for all patients.

Sinus Bradycardia

• Nursing Intervention for Client with Symptomatic Sinus Bradycardia
  • Appropriate intervention: Administer IV atropine as prescribed to increase heart rate.
  • Other options considered:
  • Encourage the client to stop all medications immediately.
  • Advise the client to perform high intensity exercise.
  • Instruct the client to change positions quickly to avoid dizziness.

Cardiomyopathy and Heart Failure (HF) Identification

• Symptoms Indicative of Potential HF in Patients with Cardiomyopathy

  • Most indicative symptom: Fatigue during physical activity.
  • Other symptoms considered:
  • Headaches.
  • Chest pain.
  • Blurred vision.

• Relevant Questions for Assessing a Patient with Suspected Cardiomyopathy

  • Most relevant question: What is your dose of medication and have you been adhering to daily dosing?
  • Other questions considered:
  • Do you have more palpitations during the day or night?
  • What makes you most anxious about pregnancy?
  • Have you been around any sick individuals recently?

Diagnostic Tests and Clinical Presentations

• Laboratory Test for Diagnosing Pericarditis

  • Most commonly used test: Erythrocyte Sedimentation Rate (ESR).
  • Other tests considered:
  • Complete Blood Count (CBC).
  • Liver Function Tests (LFTs).
  • Thyroid Function Test.

• Clinical Presentation Indicative of DVTs

  • Most indicative presentation: Unilateral leg swelling.
  • Other presentations considered:
  • Bilateral leg swelling.
  • Generalized itching.
  • Decreased sensation in both legs.

• Laboratory Findings in Iron Deficiency Anemia

  • Expected Decreased Finding: Hemoglobin (HGB).
  • Other options considered:
  • White Blood Cells (WBC).
  • Platelet count.
  • Serum calcium.

Pathophysiology of Multiple Myeloma

• Description of Pathophysiology
  • Accurate description: Originates from abnormal plasma cells in the bone marrow.
  • Other options considered:
  • Caused by a viral infection that attacks lymphocytes directly.
  • Affects RBCs leading to anemia and fatigue.
  • Primary symptoms include swollen lymph nodes in the neck and groin.

Peripheral Artery Disease (PAD) and Wound Healing

• Priority Intervention for Client with PAD and Impaired Skin Integrity
  • Priority intervention: Encourage smoking cessation to promote wound healing.
  • Other options considered:
  • Limit intake of fluid.
  • Encourage high impact exercise.
  • Ensure the client wears compression stockings.

Diagnostic Tests for Pericarditis

• Effective Diagnostic Tests for Determining Fluid Accumulation
  • Most effective test: Echocardiogram.
  • Other tests considered:
  • Electrocardiogram (ECG).
  • Chest X-ray.
  • Cardiac biomarkers.

Pain in Sickle Cell Anemia

• Primary Reason for Severe Pain in Patients with Sickle Cell Anemia
  • Primary reason: The sickle-shaped red blood cells block normal blood flow to the vessels.
  • Other options considered:
  • The rapid breakdown of RBCs increases acidity in blood.
  • The presence of sticky hemoglobin causes the blood to thicken.
  • Low levels of oxygen in the blood lead to muscle cramps.

Chronic Myeloid Leukemia (CML) and Common Manifestations

• Common Manifestations Associated with CML
  • Most commonly associated manifestation: Fatigue.
  • Other manifestations considered:
  • Joint swelling.
  • Nausea and vomiting.
  • Severe headaches.

Risk Factors for Chronic Venous Disease

• Common Risk Factor for Developing Chronic Venous Disease
  • Common risk factor: History of DVT.
  • Other factors considered:
  • Age under 30.
  • Low body mass.
  • Regular physical activity.

Atrial Fibrillation (A-Fib) Management

• Primary Goal in Patient with Atrial Fibrillation

  • Primary goal: Improve cardiac perfusion by converting to Normal Sinus Rhythm (NSR).
  • Other options considered:
  • Maintaining a slow ventricular rate during exercise.
  • Increasing heart rate for better cardiac output.
  • Avoiding the use of anticoagulants during treatment.

• Clinical Manifestations Associated with A-Fib in Older Adults

  • Common manifestation: Palpitations.
  • Other options considered:
  • Skin rash.
  • Nausea and vomiting.
  • Severe headaches.

ECG Interpretation

• Components of ECG Strip for Analyzing Ventricular Depolarization and Repolarization
  • Component to examine: QT Interval.
  • Other components:
  • PR Interval.
  • ST Segment.
  • QRS Complex.

HIV Patient Management

• Conditions to Monitor in Client with HIV and Low CD4 T-cell Count
  • Conditions to monitor: Tuberculosis (TB).
  • Other options considered:
  • Hepatitis.
  • Gonorrhea.
  • Chlamydia.

Kidney Cancer in Older Adults

• Anticipated Experiences for Older Adult with Kidney Cancer
  • Anticipation: The client might experience spinal cord compression.
  • Other anticipations considered:
  • The client might experience hypercalcemia.
  • The client might receive multiple chemotherapeutic agents.
  • The client’s cancer treatments might need to be adjusted.

Risk of Opportunistic Infections

• Clients at Highest Risk for Developing Opportunistic Infections
  • Highest risk client: A client with HIV.
  • Other clients considered:
  • A client with severe anaphylaxis.
  • A client with a rheumatoid arthritis flare-up.
  • A client who has advanced osteoarthritis.

Prostate Cancer Screening in High-Risk Populations

• Consideration for Prostate Screening
  • Important consideration: Prostate cancer mortality rate is more than double for black American males than for men in any other race.
  • Other considerations:
  • Dietary factors can increase the risk of prostate cancer.
  • The best way to determine prostate cancer is not a CT scan.
  • Occupational toxin exposure among factory workers may increase the risk of prostate cancer by 30%.