HESI-Med Surg I final study guide
Impaired neural functioning
Paralytic ileus occurs when neurologic impulses are diminished as a result of
anesthesia, infection, or surgery. Interference in blood supply will result in
necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis.
Obstruction of the bowel initially will cause increased peristalsis and bowel
sounds.
Four days after abdominal surgery a client has not passed flatus and there are no bowel
sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely
cause of the ileus?
Ammonia level
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. Culture and sensitivity testing is unnecessary; cirrhosis is an
inflammatory, not infectious, process. Increased white blood cell count may
indicate infection; however, this will have no relationship to the need for
neomycin enemas. ALT, also called serum glutamic-pyruvic transaminase
(SGPT), assesses for liver disease but has no relationship to the need for
neomycin enemas.
A nurse is caring for a client 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?
Arthritis
Chronic fatigue
R: Systemic infectious disease caused by Spirochete Borrelia Burgdorferi.
Name the characteristics that support chronic persistent stage of Lyme disease
Fatigue
Mild chest pain
dry cough
R:The manifestations include low-grade fever; fatigue; mild chest pain; and a dry,
harsh cough. Inhalation anthrax is a two-stage illness, prodromal and fulminant.
The prodromal stage is the early stage and is difficult to distinguish from
influenza or pneumonia. A special feature of inhalation anthrax is that it is not
accompanied by upper respiratory manifestations of sore throat or rhinitis.
symptoms of Prodomal stage w/inhalation of anthrax.
Sarcoidosis and poison ivy
In type IV hypersensitivity, the inflammation is caused by a reaction of sensitized
T cells with the antigen and the resultant activation of macrophages due to
lymphokine release. Myasthenia gravis is an example of a type II or cytotoxic
, hypersensitivity reaction. Rheumatoid arthritis and systemic lupus
erythematosus are examples of type III immune complex-mediated reactions.
Which are examples of a type IV hypersensitivity reaction?
Replace the Pt's fluid and electrolytes
R:Fluid and electrolyte replacement is a life-saving strategy; it must be done
before surgery is performed. Helping the client regain former body weight is not
the priority at this time. The client is neither physically nor cognitively ready to
learn the psychomotor skill of how to manage an ileostomy. The client is not
demonstrating a readiness for contact with other persons with ileostomies at this
time
A client was diagnosed with ulcerative colitis. Two months after the diagnosis, the client
is readmitted for an exacerbation of the illness. The client is weak, thin, and irritable.
The client states, "I am now ready for surgery to create an ileostomy." Which nursing
intervention will best meet the client's priority need?
Human herpes virus-8
The client in the image has Kaposi's sarcoma (KS). The risk for KS appears to be
related to co-infection with human herpes virus-8. KS is the most common
acquired immune deficiency syndrome-related malignancy. Cytomegalovirus may
lead to retinitis, encephalitis, pneumonitis, adrenalitis, hepatitis, and
disseminated infection. Varicella-zoster virus causes chicken pox and shingles.
Human papilloma virus causes multiple types of malignancies such as cervical
and anal cancer.
A nurse discovers the condition depicted in the image upon assessment of a client.
Which organism may lead to this condition?
Cabbage
R:Cabbage is a gas-producing food that can cause a client with a colostomy
problems with odor control and ballooning of the ostomy bag, which may break
the device seal and allow leakage. Milk, cheese, and coffee should not cause
excessive gas problems in moderation. The client with a new colostomy should
slowly introduce new foods into the diet to test toleration.
The nurse instructs a client with a new colostomy to avoid foods and drinks that produce
a large amount of gas, specifically to avoid the intake of what?
Obtain the Pt's vitals
Rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis;
vital signs provide supporting data. Ambulation is indicated if pain was the result
of flatulence; however, rigidity is associated with bleeding or peritonitis, and
additional data are needed. An analgesic may mask the symptoms, thereby
delaying diagnosis. Encouraging use of the incentive spirometer is unrelated to
the symptoms presented.
On the third postoperative day after a subtotal gastrectomy, a client reports having
severe abdominal pain. The nurse palpates the client's abdomen and determines
rigidity. What should be the nurse's first action?
Impaired neural functioning
Paralytic ileus occurs when neurologic impulses are diminished as a result of
anesthesia, infection, or surgery. Interference in blood supply will result in
necrosis of the bowel. Perforation of the bowel will result in pain and peritonitis.
Obstruction of the bowel initially will cause increased peristalsis and bowel
sounds.
Four days after abdominal surgery a client has not passed flatus and there are no bowel
sounds. Paralytic ileus is suspected. What does the nurse conclude is the most likely
cause of the ileus?
Ammonia level
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. Culture and sensitivity testing is unnecessary; cirrhosis is an
inflammatory, not infectious, process. Increased white blood cell count may
indicate infection; however, this will have no relationship to the need for
neomycin enemas. ALT, also called serum glutamic-pyruvic transaminase
(SGPT), assesses for liver disease but has no relationship to the need for
neomycin enemas.
A nurse is caring for a client 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?
Arthritis
Chronic fatigue
R: Systemic infectious disease caused by Spirochete Borrelia Burgdorferi.
Name the characteristics that support chronic persistent stage of Lyme disease
Fatigue
Mild chest pain
dry cough
R:The manifestations include low-grade fever; fatigue; mild chest pain; and a dry,
harsh cough. Inhalation anthrax is a two-stage illness, prodromal and fulminant.
The prodromal stage is the early stage and is difficult to distinguish from
influenza or pneumonia. A special feature of inhalation anthrax is that it is not
accompanied by upper respiratory manifestations of sore throat or rhinitis.
symptoms of Prodomal stage w/inhalation of anthrax.
Sarcoidosis and poison ivy
In type IV hypersensitivity, the inflammation is caused by a reaction of sensitized
T cells with the antigen and the resultant activation of macrophages due to
lymphokine release. Myasthenia gravis is an example of a type II or cytotoxic
, hypersensitivity reaction. Rheumatoid arthritis and systemic lupus
erythematosus are examples of type III immune complex-mediated reactions.
Which are examples of a type IV hypersensitivity reaction?
Replace the Pt's fluid and electrolytes
R:Fluid and electrolyte replacement is a life-saving strategy; it must be done
before surgery is performed. Helping the client regain former body weight is not
the priority at this time. The client is neither physically nor cognitively ready to
learn the psychomotor skill of how to manage an ileostomy. The client is not
demonstrating a readiness for contact with other persons with ileostomies at this
time
A client was diagnosed with ulcerative colitis. Two months after the diagnosis, the client
is readmitted for an exacerbation of the illness. The client is weak, thin, and irritable.
The client states, "I am now ready for surgery to create an ileostomy." Which nursing
intervention will best meet the client's priority need?
Human herpes virus-8
The client in the image has Kaposi's sarcoma (KS). The risk for KS appears to be
related to co-infection with human herpes virus-8. KS is the most common
acquired immune deficiency syndrome-related malignancy. Cytomegalovirus may
lead to retinitis, encephalitis, pneumonitis, adrenalitis, hepatitis, and
disseminated infection. Varicella-zoster virus causes chicken pox and shingles.
Human papilloma virus causes multiple types of malignancies such as cervical
and anal cancer.
A nurse discovers the condition depicted in the image upon assessment of a client.
Which organism may lead to this condition?
Cabbage
R:Cabbage is a gas-producing food that can cause a client with a colostomy
problems with odor control and ballooning of the ostomy bag, which may break
the device seal and allow leakage. Milk, cheese, and coffee should not cause
excessive gas problems in moderation. The client with a new colostomy should
slowly introduce new foods into the diet to test toleration.
The nurse instructs a client with a new colostomy to avoid foods and drinks that produce
a large amount of gas, specifically to avoid the intake of what?
Obtain the Pt's vitals
Rigidity and pain are hallmarks of bleeding from the suture line or of peritonitis;
vital signs provide supporting data. Ambulation is indicated if pain was the result
of flatulence; however, rigidity is associated with bleeding or peritonitis, and
additional data are needed. An analgesic may mask the symptoms, thereby
delaying diagnosis. Encouraging use of the incentive spirometer is unrelated to
the symptoms presented.
On the third postoperative day after a subtotal gastrectomy, a client reports having
severe abdominal pain. The nurse palpates the client's abdomen and determines
rigidity. What should be the nurse's first action?
