Acute Myocardial Infarction: Assessment

Acute Myocardial Infarction Assessment

• A nurse is assessing a client admitted for an acute myocardial infarction.
• The client's findings include blood pressure of 90/66, heart rate of 100, respiratory rate of 16, cool skin, is alert and oriented to person, place, and time but with mild anxiety, and minimal urine output of 40 mL/hr.
• These assessment findings are indicative of Class I hypovolemic shock.
• Hypovolemic shock is defined by a decrease in circulating blood volume, leading to inadequate perfusion of tissues and organs.
• These assessments are consistent with hypovolemic shock, including low blood pressure (90/66), increased heart rate (100), cool skin and reduced urine output (40 mL/h).
• Class I hypovolemic shock is the earliest stage of shock.
• The body attempts to compensate for low blood volume by increasing heart rate and vasoconstriction.
• The mild anxiety observed could be a response to decreased perfusion.
• Cardiogenic shock is typically associated with heart-related issues like a severe heart attack.
• Septic shock is related to a severe infection.
• Neurogenic shock is associated with a disruption of the sympathetic nervous system.
• Septic shock is associated with a severe infection leading to systemic inflammatory response syndrome (SIRS).
• The provided assessment findings do not indicate signs of infection, such as Fever, increased respiratory rate or specific signs of SIRS.
• Neurogenic shock is often associated with spinal cord injury or severe damage to the sympathetic nervous system.

Nasogastric Tube Monitoring for Pancreatitis

• Maintaining proper function of a nasogastric tube attached to suction is important when caring for a client with pancreatitis.
• The function of the nasogastric tube in this case is to protect the intestine from gastric secretions.
• An N/G tube removes acidic gastric contents to prevent them from entering and damaging the intestine because alkaline pancreatic secretions are not available to neutralize them.

Sengstaken-Blakemore Tube

• A Sengstaken-Blakemore tube is a 3-lumen tube.
• One lumen is for inflating a gastric balloon.
• A second lumen is for inflating an esophageal balloon.
• A third lumen to aspirate gastric contents.
• There is no esophageal suction port.
• It may cause saliva to pool in the esophagus, causing a risk of aspiration

Cerebral Perfusion Pressure

• Cerebral perfusion is a high-flow, low-pressure system with relatively preserved diastolic flow,
• Monitoring cerebral perfusion pressure requires measuring both the mean arterial pressure (MAP) and intracranial pressure (ICP).
• MAP can be measured directly through invasive hemodynamic means, often via cannulation of a peripheral artery.
• CPP = MAP - ICP
• Given a blood pressure of 90/60 and ICP of 18, the cerebral tissue perfusion pressure is calculated as follows:
• MAP = [SBP+2(DBP)]/3
• MAP = [90+2(60)]/3 = 210/3 = 70 mmhg
• CPP = MAP - ICP = 70-18 = 52 mmhg

Thoracentesis Procedure

• A patient is admitted with pleural effusion, and the attending doctor orders a thoracentesis.
• Include explaining the procedure to the patient in the care plan.
• A thoracentesis is performed at the bedside without the need for the patient to be NPO
• Explaining the procedure is a crucial nursing action to reduce the patient's anxiety and promote their understanding and cooperation.

Rescuing an Unresponsive Adult:

• While attempting to give an unresponsive adult a rescue breath, you notice the chest does not appear to rise.
• Repeat the head tilt/chin lift maneuver and attempt the breath again.
• Look for effective chest wall movement when giving rescue breaths.
• Reposition the airway by repeating the head tilt/chin lift maneuver.

Initial Management of DKA

• An RN receives a 22-year-old male client to the emergency department with complaints of fever, elevated blood glucose level and confusion over the past three hours.
• The client has a pulse rate of 140/min
• respirations of 30/min
• blood pressure of 80/50 mmHg
• dry mucous membranes
• delayed capillary refill
• serum potassium level of 3.2 mEq/L
• serum glucose level of 580 mg/dL
• arterial blood gas (ABG) analysis shows a pH of 7.0.
• Infusion of 0.9% normal saline is the most appropriate initial management due to the glucose level of 580 mg/dl, pulse rate of 140 b/min, dry mucous membranes, delayed capillary refill, and acidosis (pH = 7) on ABG analysis.
• These symptoms are of diabetic ketoacidosis.
• Initial therapy should focus on resuscitation of dehydration and hyperglycemia associated with diabetic ketoacidosis.

Assessing Patient Vital Signs

• When assessing vital signs for a newly admitted patient, the nurse should position the patient sitting upright, assuming there are no contraindications.
• Sitting upright allows easy access to the anterior and posterior chest for auscultating heart and breath sounds.

Blood Pressure Measurement

• Actions appropriate when preparing to take a client's blood pressure:
• Select a cuff with a bladder that is 80% of the arm circumference.
• Wrap the cuff so the lower border is 2 cm above the antecubital space, centering the bladder over the brachial artery.
• Inflate the cuff to 30 mm Hg above the reading where the brachial pulse disappears.
• Release the bulb valve slowly so the pressure drops about 2 to 3 mm Hg per second.

HIV Opportunistic Infection

• Cough is the sign the nurse must assess in an infant of an HIV-positive mother for opportunistic infection.
• Pneumonia caused by Pneumocystis jiroveci is the most common opportunistic infection of children with HIV.

Nutritional Intake of Toddlers

• For children between 2 and 3 years old, the daily total fat intake should be no more than 30%.
• 30% is acceptable for nutrition and digestive needs.

Allergic Bronchospasm

• In a patient with allergic bronchospasm, pulmonary function results will show a decreased FEV1/FVC (Forced Expiratory Volume in one second/Forced Vital Capacity).
• Bronchospasm increases the resistance to airflow, making it more difficult to expel gas rapidly from the lung during expiration.
• Therefore, although both FEV1 and vital capacity decrease, the FEV1/FVC ratio also decreases dramatically.
• Obstructive disease also produces air trapping, which increases the residual volume, functional residual capacity (FRC), and total lung capacity.

Parenteral Nutrition Complications

• A patient receiving parenteral nutrition (PN) complains of a headache, and the nurse notes a bounding pulse, jugular distension, and weight gain greater than desired,
  • These signs and symptoms are consistent with hypervolemia.
• Management:
  • Place the client in a semi-Fowler's or high-Fowler's position.
• Administer diuretics such as Furosemide (Lasix) as indicated to promote the excretion of fluid.

Post Cardiac Catheterization Care

• When a client returns from undergoing a cardiac catheterization, it is most essential for the nurse to check peripheral pulses
• The complications most likely to occur are hemorrhage and obstruction of the vessel, which are assessed via peripheral pulses.
• Cold may be applied to the insertion site to vasoconstrict, while heat vasodilates and is contraindicated.
• The extremity used for the insertion site must remain still.

Thermal Injury or Burns

• Regarding thermal injury or burns, it is true that prophylactic intravenous antibiotics should be given for deep partial-thickness and full-thickness burns, because infection of burns normally is secondary to Staphylococcus aureus or Pseudomonas aeruginosa
• Superficial partial-thickness: include blisters and open and weeping surfaces, and are very painful.
• Deep partial-thickness: Reveal skin that is mottled, waxy, and white in appearance with ruptured blisters. Pain sensation is absent, but pressure sensation is intact.
• Full-thickness involves all layers of the epidermis and dermis (including nerve endings) and are classically painless.

Endotracheal Suction

• When performing endotracheal suction, the nurse must insert the thumb pressure control suction catheter into an ETT until meeting resistance.
• Pull back the suction catheter 1-2 cm above the carina.
• Prevents complications like tracheo-mucosal injury
• Applying negative suction pressure at the point of the carina will stimulate the vagal response and can lead to bradycardia.

Enteral Feeding Tube for High Aspiration Risk

• A jejunostomy tube should be used in a ventilated patient at high risk of aspiration.
• The tube is surgically placed in the jejunum of the small intestine.
• Patients at risk of regurgitation (gastric atony, gastroparesis, pancreatitis, feeding beyond the ampulla) should be considered for a jejunostomy tube to reduce aspiration risk.

Indwelling Urinary Catheter Insertion

• The nurse should advance the urinary catheter till the bifurcation point and then inflate the balloon once the tip of the catheter is in the urethra and urine begins to flow.
• Ensure the balloon of the catheter is in the bladder before inflating it to avoid trauma.
• Pull the catheter back until slight resistance is felt and then secure it to the thigh.

Correct Assistance for Client Transfer

• The nursing assistant should have the feet apart and knees bent when lifting or moving clients:
• The nursing assistant must not tug on the client's arms:
• The nursing assistant should not ask the client to grab the arm of the staff member; feet close together and knees straight for injury.
• Lowering the head of the bed is appropriate to maintain body machanics.

Medication Administration Without Armband

• The nurse should ask the adults at the bedside what the child's name is and administer the medication if the adults verify the name of the child.
• The nurse should verify this with the adults at the bedside because a 4-year-old child is not old enough to be responsible for verifying his name prior to medication administration.

Speech Defect

• A six-year-old child who presents with difficulty pronouncing certain sounds.
• They often substitute one sound for another will likely be diagnosed with a phonological disorder.
• Phonological disorder is a speech disorder that primarily affects the development and organization of speech sounds and phonological patterns, typically during early speech development.

Oral Slander

• Slander is the oral defamation of character using false statements.
• Defamation is the destruction of a person's reputation by making false statements about them in writing or orally.

Arterial Blood Gases

• An infant with pyloric stenosis who has been vomiting often experiences metabolic alkalosis.
• An ABG will show increased pH and increased bicarbonate.

Lipoprotein Lipase Deficiency

• In a patient with lipoprotein lipase deficiency, Chylomicrons are increased following a fatty meal, because the enzyme is needed.
• LDL and HDL are low.

Descriptions of DNA

• DNA is double-stranded, where the “D” refers to “deoxy-“.
• DNA molecules in eukaryotes interact with histones to form strands of nucleosomes.
• RNA is single-stranded, but the strands loop back on themselves and the bases pair: Guanine with cytosine and Adenine with uracil.
• Deoxyribose is in DNA, whereas RNA contains ribose.

Anuria Definition

• Anuria in clinical practice is defined as passage of less than 100 mL of urine in a day.
• A urine output of 400 mL is defined as oliguria a day.

Pulmonary Artery Catheter Insertion Preparation

• Insertion of a pulmonary artery catheter requires continuous electrocardiographic (ECG) monitoring for dysrhythmias.
• The patient doesn't need placement in High Fowler's or to be NPO.
• An Allen test isn't required to check arterial competence

Thrombophlebitis Complications

• In an unconscious patient who develops thrombophlebitis, the most serious complication is acute chest pain, dyspnea, coughing and frothy sputum.
• A thrombus may break loose and travel to a pulmonary artery, causing a pulmonary embolism.

Anterior Cruciate Ligament Injury

• The most sensitive finding in physical examination for an anterior cruciate ligament (ACL) injury is a positive Lachman test, in which the tibia is pulled anteriorly with the other hand
• Excessive valgus laxity is associated with a medial cruciate ligament injury.

Diagnosing Septic Arthritis vs. Gout

• The most definitive study to differentiate between joint problems is synovial fluid aspiration.
• Urate crystals are seen in gout, synovial fluid aspirate demonstrates bacteria and white blood cells with high neutrophils on differential count in septic arthritis

Most Common Wound Infection

• In a wound abscess, Staphylococcus aureus is the commonest bacterium found.

Assessment for a Patient Receiving Oxygen via Nasal Cannula

• The nurse should reassess the nares, cheeks and ears for signs of pressure injury every 2 hours.
• Compression form the nasal prongs can cause tissue irritation.

Patient With Pleural Effusion Care

• You are assigned to provide care to a patient admitted with pleural effusion, which includes eplaining the procedure to the patient in order to reduce the patient’s anxiety level and to gain co-operation

Gastric Lavage

• While preparing for the gastric lavage for a child admitted into the emergency department with a history of poison, the nurse will place the patient in left lateral with 15° to 30° head down.

Ascites and Albumin

• Nurse expect to have a slow IV rate and fluid restriction on a patient with ascites who is receiving albumin.

Postoperative Respiratory Complications of Atelectasis/Aspiration:

• Hypoxemia is associated with atelectasis and aspiration as well as pulmonary edema, pulmonary embolism and bronchospasm.

Laryngeal Assessment

• A nurse is assessing a client for possible laryngeal nerve injury implement on anhourly basis which means ask the client to speak

Hypothermia Treatment

• The PACU nurse can treat a postoperative patient who is Shivering and has a body temperature of 96.0°F (35.6°C) with applying Oxygen in order to treat the increased demand for oxygen.

Client with A mechanical Ventilator

• The nurse should know that the order for restraints is valid up to 24 hrs

Data Collection

• A nurse is caring for a male patient complaining of right-sided flank pain, nausea & vomiting and restlessness and will collect dark, scanty urine output as subjective data.

Injections in the vastus lateralis

• Inject the medication in the deltoid muscle when described by the patient

Hyperventilation

• During cerebral hypoxia, hyperventilation causes vasodilation and reduced volume.

Tracheostomy Care

• Tracheostomy care for a three year old child, the nurse apply new tracheostomy ties prior to removing the soiled ones

High-Pressure Alarm

• A right pneumothorax of a patient with chest injury and on ventilator will signal a high-pressure alarm on the ventilator.

Emergency Contraception

• Levonorgestrel 1.5 mg within 72 hours can be used for emergency contraception.

Primary Intentional Wound

• Primary intention is where the edges are sutured or stapled and the wound heals quickly with minimal tissue loss.

Hyperglycemia TPN

• A patient strictly monitor the patient for the sign of TPN associated Hyperglycemias. Which of the following sign, means report Thirst, blurred vision and diuresis

Patients with immunodeficiency

• Patients who are immunocompromised at an increased at increased risk of infection (kaposi's sarcoma, candidiasis, and herpes simplex 1,).

Emergency Assessment (The "E" Step)

• Remove the patient's clothing and assess

Complication from Chest Tube

• The nurse is most concerned if assessing 400 ml of blood in collection chamber.

National Iron Initiative

• Includes children 6-59 months, etc.

Child CPR

• compress at the lower half of the sternum.

Duchenne Muscular Dystrophy

• Mode of inheritance of recessive

Atrial Septal Defect Findings

• Second heart soundwide and fixed ,surgery usually done before 3 year ,soft delayed diastolic rumble

Posthumous Child

• birth after Death is said to be if at the biological father

Frame Shift Mutation

• it occurs duw insertion

Wilsons disesse

• May present with acute hepatic

What is the ranal value?

• 180mgdl

Frameshift Mutation

• Insersion

Objective Resolution

• Was introduced bu the Nehru

Main Character of the scientific Research

• experemental research

Blood Relation

• blood related to arty as pipe

Smaletsr computer

• killybytes

Hc of twou

• two numbers are 7, if these two numbers are in the ratio of 13:9. Find the numbers.
• correct. 91, 63

Number which Multiply

• cubit that 5*

Framework Value

• Critical Thinking

Indicator systems?

• machinty

59 seconds and 70 seconds.

• 4800

In relationship

• is correct that all the follows

Harps city?

• Gujarat

4800

• in a relationship all the follows

Number of what will follow?

• all follows