ABC ‘S OF PASSING LOCAL BOARD EXAM

(ADDITIONAL BULLETS FOR MS)

 Laboratory Data : Decrease in Na and K, (+)
blood cultures usually for salmonella,
rotavirus and clostridium defficile
 Abdominal aortic aneurysm
 Main problem :Local distention / outpouching
 Nursing Diagnosis : Fluid and electrolyte
imbalance
of the artery wall usually in the thoracic or
abdominal area  Nursing Interventions :
Priority ; fluid replacement
 Initial manifestation :Initially asymptomatic; Remember : fluid loss is more critical in younger
pulsating abdominal mass is a common sign, patients because they have higher body fluid
backache and auscultation of bruit are common percentage.
manifestations ; abdominal or back pain Monitor the patient’s fluid status, weight is a critical
indicator of fluid loss, 1 gram of weight equals 1 ml
 Laboratory Data : Elevated BUN and creatinine
of body fluid.
levels MRI, CT scan and X-ray. UTZ is the best Initially offer oral rehydration solution such as
test to confirm AAA pedialyte then progress to non-carbonated drinks
 Nursing Diagnosis : Altered tissue perfusion ( Gatorade) limit apple juice since it can cause
diarrhea. BRAT diet
 Nursing Interventions : Avoid abdominal
palpation, prepare patient for surgery  Acquired Immune Deficiency Syndrome
Monitor for possible rupture preoperatively(signs of ( AIDS)
shock)
Monitor MIO and laboratory studies  Slow degeneration of the immune
Administer medications to decrease hypertension and system( defect in T- cell mediated immunity
control pain caused by the HIV) with the development of
Monitor peripheral pulses postoperatively opportunistic infections, malignancies and
frequent impairment of the central nervous
 Acne Vulgaris system
 Inflammatory disease of sebaceous follicles due  Initial Manifestation : Flu- like symptoms
to blockage of sebaceous glands occur 2-4
weeks after infection
 Initial manifestation : Closed comedones( “  Laboratory Data :
whiteheads “ ), open comedones ( “blackheads”) Diagnosis of AIDS is based on laboratory evidence of
 Nursing Diagnosis : Body image disturbance HIV infection coexisting with one or more indicator
diseases such as Pneumocyctis carinii Pneumonia ,
 Nursing Interventions : Instruct patient to wash Kaposis Sarcoma( most common malignancy),
face gently with mild soap 1-2 times daily. Cytomegalovirus , Candidal infection ,Herpes Simplex
Instruct patient to use benzoyl peroxide and Virus or AIDS dementia
never squeeze pimples HIV (+) on ELISA, confirmed by Western Blot
Use of Isotretinoin ( Accutane ) for treatment can cause HIV antibodies are detectable by routine tests, 3-6
birth defects. Instruct patient to use contraceptives months after infection so instruct the patient to have
during the entire duration of the therapy unitl a month an initial test 3-6 months after exposure. Patients
thereafter. Avoid exposure to sunlight and use sunblock who are initially negative should have a retest 12
when using these medications. weeks or less since a possible exposure
CD4 lymphocytes , 200 / cu .mm
 Acromegaly
 Priority Nursing Diagnosis : Risk for infection
 oversecretion of growth hormone(anterior  Nursing Interventions :
pituitary), long lasting stimulation affecting Instruct patient to practice safe sex, avoid needle
skeletal growth in adult by enlarging certain sharing.Maintain Satndard Precautions Monitor for
bones and tissues opportunistic infections.Monitor respiratory status
 Initial manifestation : coarse facial and laboratory values.Maintain diet/nutrition
Use 10 % household bleaching solution to cleanse
features, increased shoe size, increased
areas with blood stains from an HIV (+) patient
intracranial pressure due to tumor headache and
Assess the patient for signs and symptoms of
blindness
dementia like incoordination.
 Laboratory Data : elevated serum human growth
hormone and blood sugar levels  Addison’s Disease
 Priority Nursing Diagnosis : body image  Adrenal hypofunction usually due to
disturbance autoimmune disease
 Nursing Interventions :
provide emotional support
 Initial Manifestation :Hypotension; bronze
skin
prepare client for surgery and deligently monitor VS and
pigmentation is a common sign
Neurologic Status post-op
Monitor for signs and symptoms of diabetes  Laboratory Data : Hyponatremia,
octreotide ( Sandostatin) to decrease GH hyperkalemia,
hypoglycemia
 Acute gastroenteritis ( AGE ) / Diarrhea
 Increase in fluid , frequency and volume of stool
 Nursing Diagnosis : Fluid volume deficit
Nursing Interventions :
usually associated with rotavirus, clostridium
Monitor fluid and electrolyte balance
deficile, salmonella
Explain the need for lifelong medications of
 Initial manifestation : Frequent watery stool glucocorticoids and mineralocorticoids
Maintain high sodium, low potassium diet
Advice patient to avoid infection , trauma or stress, it Main Problem: Dramatic widespread acute
increases the risk for addisonian crisis( IV hydrocortisone atopic/allergic reaction which
and saline soln for addisonian crisis) causes vascular collapse
Initial Manifest: Sudden onset of rapidly
 Anemia , aplastic progressive urticaria respiratory
distress and hypotension which can
 Main Problem : Bone marrow hypoplasia or lead to shock
aplasia Diagnostic data: Skin testing to determine allergen
resulting in pancytopenia( decreased WBC, RBC Nursing Diagnosis: Risk for altered airway
and platelets) clearance related to
 Initial manifestation – abnormal bleeding bronchial edema
(purpura , petechiae, ecchymosis,epistaxis , Intervention: Observe for respiratory
melena and dyspnea) complications (laryngeal edema ),
watch out for signs and symptoms
 Laboratory data: decreased WBC , RBC and of shock.
Platelet Count Maintain airway patency – prepare
Nursing diagnosis: risk for infection; risk for injury suction and intubation set
Interventions: Early stages – no loss of
Prepare the patient for bone marrow transplant consciousness – epinephrine IM
Assess for signs and symptoms of bleeding with loss of consciousness –
epinephrine IV CPR for cardiac
 Anemia , folic acid deficiency arrest After emergency give
antihistamines
 Main Problem : Depletion of folate, which results
[diphenhydramine(Benadryl)] and
to progressive anemia
corticosteroids
 Initial manifestation: fatigue Prevent recurrence by avoiding
 Laboratory data: decreased folate levels exposure to known allergens
 Nursing diagnosis: activity intolerance 1) A major nursing responsibility prior to initial
 Interventions: teach patient to increase sources administration of antibiotics specifically penicillin
of folic acid in the diet like: green vegetables and sulfa drugs is :
( asparagus, broccoli and spinach), yeast , liver , a) Skin testing
organ meats and fresh fruits. b) Assessing for sensitivity to iodine
Avoid overcooking of vegetables c) Assessing for food allergies
Teach the patient regarding oral folic acid replacement d) Suction equipment at bedside

Answer: a - antibiotic therapy is done after negative

skin test results to prevent occurrence of
hypersensitivity reactions
Anemia , iron deficiency
Main Problem: Decreased oxygen carrying capacity of  Aphasia
the Main Problem: An acquired disorder of
blood. communication resulting from
The condition is usually associated with brain damage. Speech difficulty
nutritional deficiency of iron. /change usually caused by right
Initial Manifest: Easy fatigability; poor sucking (infants) sided hemiplegia (left brain
chubby but pale babies (milk babies) involvement)
Laboratory data: Decreased Hgb and Hct, microcytic, Initial Manifest: Expressive Aphasia – difficulty
hypocromic RBC’s expressing self in understandable
Nursing Diagnosis: Activity intolerance speech
Interventions: Instruct patient to have frequent rest Receptive Aphasia – does not
periods comprehend spoken or written
Increase iron in the diet (organ meat, word
egg yolk) milk is a poor source of iron Global Aphasia – combination of
Administer oral iron supplements as both
ordered Nursing Diagnosis: Impaired Verbal
Communication
 Anemia , Pernicious Interventions: Give the patient enough time to
Main Problem: Reduced vitamin B 12 Absorption due speak and respond and speak
to the absence of the intrinsic factor clearly and slowly while facing
usually related to gastrectomy and patient
atrophy of the gastric mucosa Provide visual cues like pictures
Initial Manifest: Fatigue; beefy red tongue or glossitis a and gestures when talking to the
common sign patient (verbal and non-verbal)
Laboratory Data: Schillings test reveals low value urinary Approach on the visually
excretion of ingested vitamin B12 < unaffected side
10% in 24 hours
Nursing Diagnosis: Activity Intolerance  Arrythmias
Interventions: Teach patient monthly IM Vit B12 Main Problem: Abnormal electrical conduction or
injections for life. automaticity changes in the heart
Inform patient to report tingling rate or rhythm which affects
sensation in the lower extremities cardiac output and blood pressure
indicating complication – peripheral Initial Manifest: Hypotension and deteriorating
neuropathy level of consciousness
Diagnostic Data: ECG tracing reveals the following:
 ANAPHYLAXIS Atrial Fibrillation- irregular atrial
rhythm > 400 beats / min.
 indiscernible PR interval and no P MAIN PROBLEM: Inflammation of the appendix due
waves to obstruction of the intestinal
Ventricular Tachycardia- ECG shows lumen
rate of 140 – 220 bpm, wide and bizarre Initial Manifest: Right lower quadrant abdominal
QRS complex and no P waves pain with
Ventricular fibrillation - ECG shows rebound tenderness. Lessenign of
rapid and chaotic ventricular rhythm, pain indicates rupture of the
wide and irregular QRS complexes and appendix
no visible P waves. Laboratory Data: Elevated WBC and urinalysis
Premature Ventricular Contractions- negative for UTI (ruled out)
irregular intervals between QRS Nursing Diagnosis: Pain and Potential for injury
complexes Interventions: Place patient in any position of
Asystole – no atrial or ventricular rate comfort if appendix has not yet
Nursing Diagnosis: Ineffective tissue perfusion: ruptured , if it is ruptured place
cardiopulmonary patient in high fowler’s position to
Decreased cardiac output prevent upward spread of infection.
Interventions: Watch out for hypotension and Administer antibiotics as ordered.
decreased urine output Avoid applying hot compress on
Assist with measures to treat the RLQ.
underlying cause (electrolyte No analgesics, antispasmodics and
replacement , oxygen therapy and enema during observation phase.
pulmonary care) Prepare patient for appendectomy
Hook on cardiac monitor and assess and teach post op
Level of consciousness, RR, PR , BP and interventions/responsibilities.
fluid and electrolyte balance
Perform ACLS measures Early  Arthritis , gouty
defibrillation for VT and VF Main Problem: Metabolic disorder of uric acid
Cardioversion for atrial dysrhythmias formation and excretion
Administer antiarrythmics Initial Manifest: Initially asymptomatic.
(Lidocaine,Inderal,Cordarone) A common sign is dusky red hot
for arrythmias and PVC’s – hypotension swollen joint(inflamed painful),
common side effect usually the big toe. Pathognomonic
Perform CPR and intubation prn prepare : Formation of Tophi
patient for possible pacemaker Laboratory Data: Elevated urate crystals in synovial
insertion fluids and elevated serum uric acid
Nursing Diagnosis: Pain
1) In a patient on antidysrhythmic drug therapy , the Interventions: Teach patient to Maintain purine
following intervention is necessary to monitor for the restricted diet (avoid organ meats ,
common side effect of the drug: alcohol , legumes, sardines).
a) Use of infusion pump for continous Increase oral fluid intake
administration Avoid aspirin and diuretics as these
b) Ensure IV remains patent and check insertion interfere with uric acid excretion.
site Alkalanize urine – fruit, vegetables
c) Check BP regularly and milk.
d) Administer slowly and at a prescribed rate Use bed cradle to prevent linen
Answer : c – major side effect of anti arrthmics is from coming in contact with the
hypotension inflamed joint which aggravates
the pain
 Angina Pectoris Common Complication : Uric Acid
Main Problem: Insufficient coronary blood flow results Kidney stone formation
to inadequate oxygen supply causing Encourage compliance to anti gout
intermittent chest pain medications:
Initial Manifest: Squeezing , burning , pressing , Allopurinol blocks formation of
chocking , aching or bursting left uric acid,
sternal chest pain lasting not more than Colchicine analgesic and anti-
20 minutes. The patient often says , “It inflammatory,
feels like gas or heartburn or Probenecid reduces uric acid
indigestion“ Sulfinpyrazone reduces uric acid
Laboratory Data: ECG reveals ST segment depression in the blood
Nursing Diagnosis: Pain
Administer nitroglycerine sublingually  Arthritis , osteo
to relieve the pain. Main Problem: Degeneration of the articular
Teach the patient that a burning cartilage in the joints
sensation under the tongue after Initial Manifest: Pain and swelling in a weight
nitroglyvcerine indicates that the drug bearing joint, usually aggravated
is potent. The drug may also cause by activity
facial flushing or headache Laboratory Data: X – ray
Prepare patient for PTCA (percutaneous Nursing Diagnosis: Pain
Transluminal Coronary Angioplasty) by Interventions : Priority : Minimize Discomfort –
informing the patient that a balloon Implement:
tipped catheter will be introduced W- eight control
through a guide wire into a coronary H- ot compress or ice packs
vessel . A – spirin use
T – runk assistive devices – cane
 Appendicitis
 Arthritis , Rheumatoid
Main Problem: Systemic recurrent inflammation of the Interventions: Force fluids
synovial lining of the joints, usually Pre-op – assess understanding of
upper extremities.More common in procedure and anticipated
women postoperative course. Explain TURP
Initial Manifest: Morning stiffness relieved by warm bath (Transurethral Resection
or soaks Prostatectomy) will not involve any
Laboratory Data: Elevated ESR and (+) rheumatoid factor incision. Post – op assess for pain ,
Nursing Diagnosis: Pain related to joint discomfort and complications
inflammation ( bleeding and infections )
Interventions: Teach patient to take aspirin regularly Monitor continous bladder
as ordered even in the absence of irrigations
symptoms.
Instruct the patient that tinnitus is a
side effect of aspirin.
Apply moist heat for 15 – 30 minutes to
 Bleeding Esophageal Varices
reduce muscle spasm. Main Problem: Bleeding of dilated veins in the
Use ice packs during acute phase to lower esophagus
decrease pain Initial Manifest: Hematemesis
Nursing Diagnosis: Fluid Volume Deficit
Interventions: Monitor the pateint’s airway
 Asthma Assist with the insertion of
Main Problem: Abnormal Bronchial hyperactivity to Sengstaken – Blakemore Tube
certain substances and conditions ( keep a pair of scissors at the
Initial Manifest: Dyspnea and wheezing(asymptomatic bedside, this is used to cut the port
between attacks) of the tube leading the balloon, to
Laboratory Data: PFT’s during attacks show decreased deflate it, in case aspiration occurs)
forced expiratory volumes , elevated
immunoglobulin E , ABG reveals  Bronchiectasis
respiratory Acidosis, peak flow levels Main Problem: Chronic abnormal dilation of
below normal bronchi and destruction of
Nursing diagnosis: Ineffective Breathing Pattern bronchial walls leading to multiple
related to respiratory complications
bronchospasm Initial Manifest: Chronic cough that produces
Interventions: Assess precipitating factor and copious, foul smelling,
eradicate these sources mucopurulent secretions, possibly
Instruct patient to avoid 3 E’s ( exercise totaling several cupfuls daily
specially in cold weather, Laboratory Data: Bronchoscopy helps identify source
environmental factors like dust , chest x-ray shows peribronchial
emotional factors ) thickening,
Position patient in orthopneic position areas of atelectasis and scattered
and encourage patient to do pursed lip cystic changes
breathing Pulmonary Function tests detect
Administer medications – decreased volumes
Bronchodilators and corticosteroids Nursing Diagnosis: Ineffective airway
usually via nebulization clearance related to secretions
Impaired gas exchange related to
 Autonomic dysreflexia alveolar exudate
Main Problem: Exaggerated autonomic responses to Interventions: Assess respiratory status and level
local stimuli below the level of the of consciousness to detect early
spinal cord injury. Occurs in clients with signs of hypoxia and
lesions above T6 after spinal shock has decompensation
subsided Administer antibiotics as necessary
Initial Manifest: Pounding headache or severe Teach and perform Respiratory
hypertension Physiotherapy - deep breathing and
NursingDiagnosis: Urinary retention related to coughing, postural drainage and
effects of spinal cord injury chest percussion(done early
Interventions: Catheterize the patient to prevent morning and before bedtime)
bladder distention. Teach importance of quitting
Relieve fecal impaction and pressure on smoking and avoidance of milk
skin which can precipitate attacks. products.
Place patient in sitting position to help 1) Priority nursing diagnosis for patient with
lower blood pressure. bronchiectasis is:
Administer antihypertensives a) Altered breathing pattern
b) Potential for infection
 Benign prostatic hypertrophy c) Knowledge deficit
Main Problem: Enlargement of the prostate gland d) Ineffective airway clearance
Resulting to narrowing of urethral  Answer: d - copious, foul smelling,
opening mucopurulent secretions, possibly
Initial Manifest: Decreased force and amount of urine totaling several cupfuls daily
Laboratory Data: Elevated Ph of prostatic fluid
rectal examination shows enlarged  Buergers disease ( thromboangitis
prostate Cystoscopy shows enlarged Obliterans )
prostate gland, obstructed urine flow Main Problem: Vasculitis of the small and medium
and urinary stasis sized veins and arteries usually in
Nursing Diagnosis: Altered bladder elimination the lower extremities. It is more
related to enlarged prostate common in men and in smokers
Initial Manifest:Pain is an outstanding symptom, Inform the patient that
intermittent claudication is a common Mammography will involve placing
problem the breasts between two X-ray
Laboratory Data: Leg arteriography reveals inflammatory plates.
lesions Avoid use of deodorant ,lotions or
Nursing Diagnosis: Altered peripheral Tissue powderIn post mastectomy patient
Perfussion elevate affected arm to prevent
Interventions: Instruct patient to stop smoking and lympedema and to avoid activities
administer calcium channel blockers that increase infection like
and peripheral vasodilators as ordered. gardening and sewing. No BP
taking , venipuncture and
 Burns constrictive clothing on the
Main Problem: Traumatic injury caused by thermal affected arm
,electrical ,chemical or radioactive
agents
Initial Manifestations:
 Cancer , Cervix
Main Problem: Presence of malignant cells in the
1st Degree – pinkish skin with pain
cervix associated with multiple
2nd degree – reddish with painful blisters
sexual partners and history of
3rd degree – eschar , charred , painless
sexually transmitted disease
Laboratory Data: Hyperglycemia , anemia
Initial Manifest: Initially asymptomatic , postcoital
Nursing Diagnosis: Decrerased cardiac output
bleeding is common manifestation
related to fluid shifts
Laboratory data: Pap smear reveals presence of
Interventions: On strict MIO .
malignant
Administer fluids as ordered during
cells
acute phase by fluid replacement
Nursing Diagnosis: Knowledge deficit of
calculations using body weight
cervical cancer and
multiplied by BSA burned based on rule
chemotherapy
of nines. ½ of the total volume to be
Interventions: Instruct patient to avoid douching
infused on the first 8 hours then the
and sexual intercourse 24 hours
remaining ½ infused in the next 16
before Paps’ SmearStress the
hours.
importance of lifelong follow
Maintain a high calorie , high protein
up visits to detect response to
diet
treatment.
Treat pain with IV narcotics, provide
Prepare patient for chemotherapy ,
tetanus prophylaxis and topical
radiation
antimicrobial therapy. Institute reverse
and surgery
isolation in severe cases. Administer
pain medications prior to ROM
,ambulation and whirlpool therapy  Cancer , Esophagus
Main Problem: Malignant tumor in the
esophagus
 Cancer , Bladder
related to alcoholism and
Main Problem: Presence of malignant cells in the
smoking
bladder
Initial manifestation: Dysphagia – presenting
Initial Manifest: Painless hematuria
symptom
Laboratory data: Elevated Acid Phosphatase
Laboratory Data: Barium Swallow with
Nursing Diagnosis: Altered urinary Elimination
fluoroscopy reveals large
Interventions: Prepare patient for surgery and
masses. CT scans may
chemotherapy
be employed to evaluate
Encourage patient to verbalize fears
extent of tumor
Nursing Diagnosis: Altered Nutrition
 Cancer Breast Interventions: Prepare patient for surgery ,
Main Problem: Presence of malignant tumors usually in radiation therapy and
the upper outer quadrant of the left chemotherapy. Administer
breast. It is associated with nulliparity antacids and analgesics as
or having the first child after age 35 ordered
Initial Manifest: Skin dimpling and edema(peau d’ Prepare patient for tube or
orange .Painless mass most common gastroctomy feedings and short
sign course hyperalimentation
Laboratory Data: Mammography reveals the presence of Post operatively instruct
non – palpable lesion. Baseline patient to avoid overeating raw
mammography should be made fruits and vegetables
between age 35 – 40 . Q2 years 40 – 50
years old if w/o predisposition ;yearly
 Cancer ,Larynx
for high risk women;yearly after age 50.
Main Problem: Presence of malignant cells in
Nursing Diagnosis: Knowledge deficit of breast
the larynx associated with
cancer and
smoking and alcoholism
mastectomy
Initial Manifestations: Hoarseness or voice change,
Interventions: Prepare patient for chemotherapy ,
tickling sensation in the throat
radiation and surgery. Teach patient
Laboratory data: Laryngoscopy and Biopsy
how to perform Self Breast
reveals malignant cells
examinations. Done monthly , a week
Nursing Diagnosis: Knowledge deficit of laryngeal
after menstruation since the breast are
cancer
less tender at this time. The best
Interventions: Prepare patient for radiation ,
position is lying down with pillow under
chemotherapy and surgery .
shoulder of breast being examined.
teach patient to avoid cold air
 Instruct patient that swimming is
not
 Development of a neoplasm in the
recommended post –laryngectomy. respiratory tract(squamous cell-slow
Institute alternative modes of growing; large and small oat cell – fast
communication growing).Presence of malignant tumor in the
epithelium of the respiratory tract usually
related to smoking or exposure to
 Cancer , Ovary
asbestosis
Main Problem: Gynecologic cancer associated with
high fat diet and nulliparity  Chronic,nagging cough ( smokers cough)
 Initial Manifestation : Initial asymptomatic ,  Sputum cytology positive for cancer cells
vague abdominal discomfort like indigestion is a CXR shows a lesion or mass
common symptom Bronchoscopy confirms a positive biopsy
 Laboratory data : laparoscopy and Ultrasound  Impaired gas exchange
reveals the presence of mass Impaired breathing pattern
 Nursing Diagnosis : Pain
 Interventions : Prepare patient for surgery and
 Monitor respiratory status and pulse
oximetry
chemotherapy
Check for cyanosis suggesting respiratory failure and
Assist the patient to cope with
increase in sputum production indicates infection
change in body image
Provide adequate pain control
Institute effective
Increase oral fluid intake and IVF as ordered
pharmacologic and non pharmacologic pain management
Provide increased CHON, high caloric diet( TPN or
enteral,prn)
 Cancer , Prostate Perform and teach Respiratory Physiotherapy
 Main Problem : Malignant tumor in the prostate Provide rest periods and mouth care
gland Prepare patient for surgery and chemotherapy
 Initial Manifestation : Decreased size and force Elevate head of bed to prevent fluid collection in the
of urinary stream upper body
 Laboratory data : Elevated Prostate Specific 1) All the following except one are diagnostic
Antigen ( PSA ) , elevated acid phosphatase procedures done to confirm bronchogenic
cancer:
 Nursing Diagnosis : Pain related to tumor
a) Sputum cytology
metastases to bone
b) Chest X- ray
 Interventions : Support patient undergoing
c) Bronchoscopy
radiation therapy
d) Pulmonary angiography
Inform the patient that radical
 Answer : d - pulmonary angiography
prostatectomy, which involves the removal of the entire
is the rapid injection of radiopaque
prostate gland, may cause impotence
dye into the pulmonary circulation
useful in determining the site of
 Cancer , colon( colorectal Ca)
pulmonary embolism, sputum
 Primary or metastatic malignant tumor of the cytology, CXRay and bronchoscopy
colon or rectum which infiltrate causing are tests done to confirm lung
obstruction, ulceration and hemorrhage. cancer.
 Change in bowel habits, character of  Cancer, Skin
stools, diarrhea and constipation- fecal oozing  Malignant primary tumor of the skin mainly
( melena or hematochezia) caused by prolonged exposure to the sun or
other carcinogenic agents
 Barium enema locates mass, sigmoidoscopy /
colonoscopy identifies and locates mass, positive  Squamous cell carcinoma- small red nodular
for fecal occult blood and positive biopsy for lesion that begins as an erythematous
Ca cells macule or plaque
 Altered bowel elimination  Skin biopsy shows positive cytology
 Assess GI status, fluid and electrolyte studies,  Impaired skin integrity
monitor for bleeding , infection and electrolyte  Assess lesion and monitor skin punch test
imbalance site for bleeding
Provide post-chemotherapeutic and post radiation Pre and post chemotherapy or radiation therapy
therapy nursing care nursing care
Provide adequate nutrition and administer antiemetics Teach patient to avoid contact with chemical
and anti - diarrheals irritants.
Prepare for surgery and Teach ostomy self care Use sunblock and layered clothing when outdoors
Administer TPN as ordered

1) Among the following diagnostic results ,which is more

suggestive of colorectal cancer? 1) Nursing interventions for patients undergoing
a) Painless hematuria radiation therapy include all of the following
b) Presence of occult blood in stool except:
c) Increased level of acid phosphatase a) Monitoring the punch test site for bleeding
d) Indigestion b) Teach patient to avoid contact with
chemical irritants
c) Using sunblock when outdoors
 Answer: b – lab test suggestive of
d) Using layered clothing when sun exposure
colorectal cancer includes fecal occult
is possible
blood and positive biopsy for Ca cells
Answer : a - skin punch test / skin biopsy is a
 Cancer , lung ( Bronchogenic Ca ) diagnostic procedure to confirm the presence of skin
cancer
 Institute regular bowel and bladder training
 Cancer , Testicular Establish means of communication
 Main Problem : Malignancy in the testes usually
associated with cryptorchidism  Chest injury (Flail Chest )
 Initial manifestations Painless swelling and  Main Problem : Loss of stability of chest wall
enlargement of the testes , accompanied by with subsequent respiratory impairment
sensation of heaviness in the scrotum  Initial manifestation : Dyspnea , Paradoxical
 Laboratory data : Elevated HCG and alpha feto Chest Movement may occur ( detached part
protein of the chest will be pulled in on inspiration
 Nursing Diagnosis : Knowledge deficit and blown out on expiration )
 Interventions : Prepare patient for surgery and  Laboratory data : X ray reveals rib fractures
chemotherapy  Nursing Diagnosis : Ineffective breathing
Teach patient about testicular self examination pattern
.It should be done once a month while having warm bath  Interventions : Stabilize the flail portion of
or standing in front of mirror. Suspect cancer when the chest with hands or cover with
spongy upon palpation impermeable dressing with three sides
taped
 Cardiogenic shock Turn patient on affected side to provide space for the
 Main Problem : Extensive damage of the left unaffected lung to reexpand
ventricle due to Myocardial Infarction Place 10 pound sandbag at the site of flail
 Initial manifestation : decreased systolic
pressure  Cholecystitis / Cholelithiasis
 Laboratory Data : Elevated BUN , creatinine and
liver enzymes  Infection of the biliary tract associated with
 Nursing diagnosis : Altered cardiac Output the presence of gallstones (Cholelithiasis) .
( decreased related to impaired contractility of Predisposing factors includes Fat, Female,
the heart Age Forty and above, and Fair skinned.
 Interventions : Monitor BP , MIO and weight .  Intolerance to fatty foods and severe pain
Evaluate serum electrolytes for hyponatremia located on the RUQ of abdomen radiating to
and hypokalemia R scapula with nausea and vomiting.
Indigestion, flatulence, belching, jaundice
 Cataract and clay colored stools
 Main Problem : Opacity of the lens usually  Hepatobiliary tract UTZ
associated with aging , prolonged intake of  Altered nutrition ; less than body
steroids and chromosomal aberrations requirements
 Initial manifestation : painless blurring of vision  Position in semi-fowlers,provide rest and
 Laboratory data : Slit lamp test reveals milky limit activity
white color of the pupils Small frequent meals low fat, low calorie, high
carbohydrate and fiber , no gas forming foods.
 Nursing diagnosis : potential for injury related to
NPO on acute phase. Administer IV fluids / TPN as
visual loss
ordered
 Interventions : Prepare patient for surgery
Prepare client for Extracorporeal Shock Wave
Postoperatively instruct patient to avoid activities that
Lithotripsy or cholecystectomy- T – tube for biliary
requires bending, report sudden eye pain, this indicates
drainage placed
hemorrhage and increased IOP.
Teach post-op procedures and care(incentive
Avoid lifting and rapid head movements
spirometry and deep breathing)
Position in fowlers position or instruct patient to lie down
Give medications as ordered:
on the unaffected side
Analgesics-Demerol ( morphine
contraindicated)
Antibiotics-Ceftazidine, Clindamycin ,
 Cerebrovascular Accident (CVA) Gentamycin
 Sudden loss of brain function resulting from a Anticholinergics- Probanthine
disruption of blood supply to a part of the brain Anti-emetic- Compazine
causing temporary or permanent dysfunction. Anti-pruritic- Benadryl
(TIA warning sign of CVA – no neurovascular NGT to low suction to decompress stomach
deficits / complete resolution of manifestation
within 24 hours)
 Initial Manifestation : depends on the site of 1) Management for patient post cholecystectomy
brain involvement includes:
Middle cerebral artery : hemiparesis a) Adequate fat diet
Internal Carotid artery : hemiplegia b) Maintain NPO for 3 days
Right hemispheric lesion : spatial disorientation c) Place patient in supine position
Left Hemispheric lesion : language disturbances
d) Instruct and encourage use of incentive
Common manifestations: spirometry
Hemiplegia and homonymous hemianopsia  Answer : d – management for clients
Emotional and personality disturbances post cholocystectomy includes
Aphasia maintaining high fowlers position,
Dysphagia deep breathing and coughing, pain
management, NPO until peristalsis
 Laboratory : Elevated Cholesterol Levels returns, administer IVF and T – tube
 Nursing Diagnosis : Ineffective Breathing Pattern monitoring and care.
Unilateral Neglect
 Interventions : Maintain adequate airway  Cardiac Tamponade
  Main Problem : Fluid Accumulation in the A common sign of pacemaker failure is hiccups
pericardial sac Atropine Sulfate is given as a vagolytic
 Initial Manifestation : hypotension muffled heart
sounds is a common sign  Congestive Heart failure
 Laboratory data : ECG reveals ST and T wave  Main Problem : failure of the heart to pump
abnormalities blood to meet oxygen requirements.
 Nursing Diagnosis : Altered cardiac Output  Initial manifestations : Right sided edema ,
hepatomegaly
 Interventions : prepare the patient for Left sided : dyspnea , rales
pericardiocentesis. Tjis involves aspirating the  Laboratory data : Elevated CVP above 12
fluid or air from the pericardial sac. Assess for mmHG for right sided failure. Elevated PAP
complications and PCWP for left sided failure
 Nursing diagnosis : altered cardiac output
 Cor pulmonale related to impaired contractility
 A chronic heart condition, is the hypertrophy of  Interventions : Maintain patient in semi –
the heart, right ventricle and associated fowlers position
structure that results from diseases affecting the Administer digitalis and diuretics as ordered
function and the structure of the lungs Maintain low sodium and low cholesterol diet
 Chronic productive cough , dyspnea on exertion, Monitor potassium levels
edema and fatigue
 Crohn’s Disease ( Regional Enteritis)
 ABG- decreased Pa O2 < 70 mmHg  Main Problem : Chronic Inflammatory
CXR and UTZ – suggests R ventricular hypertrophy Disease of the small intestines
ECG- shows arrhythmia during severe hypoxia
 Initial manifestation : Crampy abdominal
 Altered Tissue perfusion related to pain in the right lower quadrant of the
cardiopulmonary changes abdomen
 Measure ABG levels and administer O2 by mask  Laboratory data : Barium Swallow reveals
or cannula as ordered. Monitor serum K if on “string sign”
diuretics
 Nursing Diagnosis : Pain and alteration in
Low salt , fluid restricted , small frequent feedings
bowel elimination ;diarrhea
Monitor digoxin level and check radial pulse prior to
cardiac glycoside administration to avoid complications  Interventions : Maintain high protein , high
Reposition and provide meticulous respiratory care carbohydrate , low fat diet
Administer steroids as ordered
1) Then following are diagnostic tests Provide small frequent feeding
done to assess the presence of cor Monitor input and output
pulmonale except:
a. CXR  Cushing ‘s Syndrome
b. ECG  Main Problem : Hypersecretrion of the
c. UTZ glucocorticoids by the adrenal glands
d. Venogram  Initial Manifestation : Central type or truncal
obesity with thin extremities, moon face ,
 Answer : d – buffalo hump and hirsutism
insertion of a dye  Laboratory data : Elevated serum cortisol
into a vein for the levels, hypernatremia , hypokalemia ,
purpose of outlining hypertension , hyperglycemia
an obstruction or  Nursing Diagnosis : Altered skin integrity
lesion. related to impaired healing
 Interventions : Maintain patient on high
 Chronic Bronchitis ( Blue Bloater ) potassium and low sodium diet
 Main problem : excessive mucus secretion with Instruct patient that treatment will involve lifelong
the airways and recurrent cough usually related administration of glucocorticoid synthesis inhibitors
to smoking , pollution and infection. ( Mitotane )
 Initial Manifestation : Cough with copious Inform patient about slow wound healing
sputum
 Laboratory data : ABG reveals respiratory  Cystitis
acidosis  Main problem : inflammation of the urinary
 Nursing Diagnosis : Impaired breathing pattern bladder
 Interventions : Increase Humidity  Initial Manifestation : Frequency and
Provide postural drainage before meals Urgency
Relieve bronchospasm  Laboratory data : Culture and sensitivity
Teach the patient about breathing techniques like : tests reveal the presence of bacteria usually
blowing bubbles , blowing a trumpet , blowing a feather in E coli
the air  Nursing diagnosis ; Altered Urinary
Elimination
 Complete Heart Block  Interventions : Increase Oral Fluid Intake
 Main Problem : altered transmission of wave Instruct the patient to avoid bubble baths ,
impulses from the SA node to the AV node silk underwear. Cotton underwear is
 Initial Manifestation : Bradycardia preferred. Maintain acid ash diet ; (cheese ,
 Laboratory data : ECG reveals prolonged PR cranberry , prunes , plums , poultry , eggs)
interval
 Nursing Diagnosis : Altered tissue perfusion  Diabetes Mellitus
 Interventions : Monitor patients’ ECG  Main Problem : Chronic disorder of
Prepare patient for pacemaker insertion cardohydrate , protein and fat metabolism
 characterized by an imbalance between insulin  Acute reversible disturbance of
supply and demand. Type 1 – IDDM ( no consciousness accompanied by a change in
insulin ) ; Type 2 – NIDDM ( little insulin or cognition not attributed to pre-existing
insensitivity of cells to insulin) dementia lasting several hours or days
 Initial manifestation : Polyuria , Polyphagia ,  Altered psychomotor activity such as
Polydipsia and weight loss apathy, withdrawal and agitation with
 Laboratory data ; elevated FBS level above 120 disorientation
mg / dl  Result of a physiologic condition, metabolic
 Nursing Diagnosis : Alteration in nutrition imbalance, intoxication, substance
 Interventions : withdrawal, toxic exposure, prescribed
D-IET : 50-60%cho , 20-30% FATS , 10-20% CHON medicines or combination . No specific
I – NSULIN – TYPE 1 laboratory test. Multiple tests to rule out or
A – NTIDIABETIC AGENTS –TYPE 2 confirm underlying factors
B – LOOD SUGAR MONITORING  Altered cerebral perfusion and high risk for
E - XERCISE injury
T – RANSPLANT OF PANCREAS  Assess and correct underlying physiologic
E – NSURE ADEQUATE FOOD INTAKE problem
S – CRUPULOUS FOOT CARE  Create a structured safe environment
STRICT MONITORING FOR COMPLICATIONS( DKA for  Decresase sensory stimulation and
IDDM and HHNKS for NIDDM) administer medications as ordered:
 Tranquilizer
 Benzodiazepines
 Diabetes Insipidus  Cholinesterase inhibitors
 Main Problem : Hyposecretion of antidiuretic  Antipsychotics
hormone
 Risperidone(risperdal)
 Initial manifestation : Polyuria , polydipsia
 Laboratory data : fluid deprivation test confirms
the disorder
 Nursing Diagnosis : Fluid Volume Deficit 1) Clinical manifestations not typical of delirium :
 Interventions : Maintain Adequate fluid intake a) Slowed thought processes , confusion and
Monitor urine specific gravity disorientation
Administer Desmopressin acetate or Vasopressin b) Misperception of stimuli and incoherent
intranasally as ordered speech
c) “ sundowner’s syndrome” and dream like
 Dementia , Alzheimers state
 Irreversible progressive impairment in the d) memory impairment , aphasia and apraxia
patients cognitive functioning, memory and
personality  answer : d - memory
impairment , aphasia and
 Confusion, easy forgetfulness and memory
apraxia more associated with
loss( cannot retain or recall recent information)
dementia
( confabulates to cover up memory loss)
 Cognitive assessment- deterioration of cognitive
 Compartment Syndrome
ability
Mental status exam – reveals disorientation and recall  Pressure within a muscle and its
difficulty. Functional Dementia Scale shows some degree surrounding structures increases causing
of dementia circulation impairment or interruption
Cortical atrophy seen on MRI / CT scan caused by application of dressing, tight
casting, burns, closed fractures and
 Altered thought processes
crushing injuries
 Group therapy and increase social interaction -
 Pain increased with stretching and
reminiscence therapy to increase self esteem )
unrelieved by narcotic analgesics
Provide for a safe , highly structured environment.
Paresthesias, pallor, pulseless and paralysis
Maintain consistency and provide constant orientation
When agitated – redirect focus
Simplify communications , tasks and routines  No specific diagnostic test
Diet adequate in folic acid and provide adequate fluids  Risk for peripheral neurovascular
and nutrition dysfunction
Palliative medical management with:  Position the affected extremity lower than
Anticholinesterase – Tacrine(Cognex), Donepezil the heart to increase circulation to the area
(Aricept) Bivalving or removal of dressings and constrictive
Antipsychotics, Benzodiazepines,Antidepressants and coverings from area
Vitamin E supplements Monitor affected extremity and perform
neurovascular checks.
1. Clinical manifestations more typical of dementia 1) In patient with complaining of intense pain on the
include all of the following except: casted extremity unrelieved by analgesics the
a. wandering:becoming lost nurse would :
b. impairment of cognitive functioning a) Ask the patient to wiggle the fingers or toes
c. memory impairment of the extremity
d. no personality changes b) The nurse would refer to patient to the AP
for increase in narcotics
 answer : d - in dementia c) check for distal pulses and elevate the
there is personality changes extremity
that interfere with ADL. d) prepare the client for possible bivalving
 Delirium
  answer d : in compartment
 Endocarditis
syndrome emergency bivalving is
the most appropriate intervention  Main Problem : Infection of the inner lining
done of the heart caused by direct invasion of
bacteria leading to deformity of the valve
leaflets
 Initial Manifestation : Fever
 Disseminated Intravascular Coagulation ( DIC )  Laboratory data : elevated ESR
 Main Problem : Wide spread coagulation all over  Nursing Diagnosis : Altered Cardiac Output
the body resulting to subsequent depletion of  Interventions : Record daily weight
clotting factors Evaluate jugular vein distention, as this signifies the
 Initial Manifestation : petechiae and ecchymosis development of CHF
on the skin , mucous membrane , heart lungs Instruct the patient to take antibiotics before dental
and other organs procedures that can cause bleeding
 Laboratory Data : Prolonged PT and PTT Avoid sharing of needles
Teach the women in child bearing years the risks of
 Nursing Diagnosis : Risk for Injury
using IUD’s or other birth control ( source of infection
 Interventions : Monitor for signs of bleeding )
( tarry stool , hemoptysis , nosebleeding )
 Epileptic Seizure
Administer heparin as ordered.heparin inhibits thrombin
thus preventing further clot formation and allowing  Main Problem : Abnormal sudden excessive
coagulation factors to accumulate. discharge of electrical activity within the
Administer Blood transfusion as ordered brain
Instruct patient to avoid aspirin and aspirin containing  Initial Manifestation : Impaired
compounds Consciousness
 Laboratory Data : EEG ( abnormal brain
waves ) , CT scan reveals brain lesions
 Nurisng Diagnosis : Altered tissue Perfusion
 Interventions: (On seizure precautions)
 Diverticulitis Maintain Patent Airway
 Main Problem _ Inflammation of a pouch or Protect from injury
saccular dilation in the colon ( diverticula) Do not restrain
 Initial Manifestation : Left lower Quadrant Pain Administer valium,drug of choice as prescribed ; &
 Laboratory data : Sigmoidoscopy confirms the other anticonvulsants
diagnosis Oxygen equipment and suction at bedside
 Nursing Diagnosis : Pain
 Fractures
 Interventions : Provide Low Fiber Diet ( avoid
vegetables) in diverticulitis, high fiber in  Break in the continuity of the bone due to
Diverticulosis trauma, bone tumors and osteoporosis
Administer Metamucil as ordered  Acute pain, cyanosis, loss of function,
Administer meperidine for relief of pain swelling , deformity and crepitus
 Antero posterior lateral X-ray of the area
 Acute pain and impaired physical activity
 Dumping Syndrome  Rest
 Main Problem : Rapid emptying of the stomach Immobilize
contents into the small intestine usually a Cold compress and control bleeding
complication of gastric surgery Elevate
 Initial manifestations : 3 D’s ( Diarrhea ,
Diaphoresis , Drowsiness) Alleviate pain by giving adequate
 Laboratory data : non – specific analgesics/narcotics except in presence of head
 Nursing Diagnosis : Altered Elimination injury
 Interventions : Maintain patient on supine Prepare patient for reduction and alignment
position after ( Splinting , casting, application of traction and
Meals and withold fluids during meals surgical fixation (CRIF/ORIF)
Maintain high fat , high protein , dry diet, low in simple Provide adequate care for clients with traction
sugars ( fat delays emptying of the stomach
T-rapeze bar overhead
R – equires free – hanging weights
 Emphysema (Pink Puffer) A – nalgesics is given to relieve pain
 Main problem : destruction of the alveoli , C – heck circulation (pulse)
narrowing of small airways and trapping of air T – emperature monitoring
resulting in loss of lung elasticity I – nfection prevention
O – utput and intake monitoring
 Initial manifestation : shortness of breath ; N – utrition( appropriate diet)
barrel chest ( increase in anteroposterior S – kin must be checked frequently
diameter of the chest ) is a late sign
 Laboratory data : ABG reveals Respiratory 1) In management for fractures by closed reduction
Acidosis the bones are:
 Nursing Diagnosis : Ineffective breathing Pattern a) Realigned through surgical means
 Interventions : Keep the patient in orthopneic b) May involve removal of damaged bone
position / sitting c) Bone replacement with prosthesis
Administer low flow oxygen d) Bones realigned without surgery and cast
Encourage patient to do pursed lip breathing applied to hold bones in alignment
Instruct patient to avoid powerful odors , extremes of
temperature, pets , fireplace and feather pillows
  Answer : d – closed reduction – common in males. Von Willebrands disease
bone realignment without surgery is transmitted to both male and female
offsprings of a carrier
 Glaucoma  Initial Manifestation: Hemarthrosis
 Main problem: increased intraocular pressure ( bleeding joints)
due to accumulation of aqueous humor  Laboratory Data : prolonged Bleeding Time
 Initial manifestation : Tunnel Vision , Gun Barrel  Nursing Diagnosis: Altered tissue perfusion
Vision  Interventions : Avoid Aspirin
Closed angle – with pain Control by : Rest
Immoblize
 Laboratory Data : Tonometer reading of 25 mm
Cold Compress
Hg and above Elevate
 Nursing Diagnosis : Potential for Injury related to
visual impairment  Hepatic encephalopathy / coma
 Interventions : Explain to the patient that
glaucoma cannot be cured but it can be  Main Problem : Decreasing level of
controlled consciousness
Administer Miotics ( pilocarpine ) related to accumulation of ammonia
Mydriatics contraindicated(ATSO4)
Instruct patient to avoid activities that can contribute to
 Initial manifestation : personality changes ;
flapping
increased IOP
tremors (asterexis) common sign
Teach patient about trabeculoplasty – creation of an
opening in the trabecular meshwork to increase the  Laboratory Data : Elevated serum ammonia
outflow of aqueous humor.  Nursing Diagnosis : Altered Thought Process
 Interventions : Monitor LOC
 Gastritis Maintain low CHON diet
 Acute and chronic inflammation of gastric
mucosa causing edema, hemorrhage and  Hiatal Hernia
erosion  Main Problem :A portion of the stomach
 Abdominal cramping, epigastric discomfort, is herniated through the esophageal
hematemesis and indigestion hiatus of the diaphragm
 Occult blood in stool and vomitus, decreased  Initial Manifestation: initially
Hgb and Hct asymptomatic , heartburn is a common
Upper GI endoscopy confirms diagnosis when performed complaint
within 24 hours of bleeding  Laboratory Data: Endoscopy reveals
 Acute and chronic pain herniation of a part of the stomach
Risk for fluid volume defict  Nursing Diagnosis : Altered Nutrition
Altered nutrition less than body requirements  Interventions : Maintain the patient in
 Give IVF and antiemetics. Monitor MIO an upright position after meals
Provide bland diet in smaller frequent meals Instruct patient to avoid bending
Administer antacids(between meals) and H2 blockers to Provide small frequent meals
promote healing, anticholinergics and Vit B12 Avoid anticholinergic drugs and coughing
Angiography with vasopressin infused in NSS during
bleeding  Hip Fracture
Teach importance of smoking cessation , avoid spicy  Main Problem : Break in the continuity of the
foods and caffeine, taking steroids with milk, foods or hip bone
antacids and to avoid aspirin containing compounds  Initial manifestation: Shortening and
external rotation of the affected leg
1) Complications of gastritis include  Laboratory : Hip X – ray
a) gastric carcinoma and pernicious anemia  Nursing Diagnosis : Impaired Physical
b) bleeding and dehydration Mobility
c) a and b  Interventions : Prepare the patient for
d) b only surgery
Postoperatively maintain the legs in abduction by
 answer : b - gastric carcinoma , pernicious placing a wedge pillow between legs
anemia, Monitor for signs and symptoms of complications
bleeding and dehydration are complications of gastritis ( petechiae over chest indicates fat embolism)

 Guillain – Barre Syndrome

 Main Problem : acquired acute inflammatory
disease of the peripheral nerves
 Initial Manifestation : ascending paralysis ,
weakness at first
 Hyperparathyroidism
 Laboratory Data :CSF exam reveals elevated
 Main Problem : hypersecretion of the
total protein
parathyroid hormone
 Nursing Diagnosis: Ineffective Breathing Pattern
 Initial manifestation : bone pain
 Interventions : Maintain a patent airway  Laboratory Data : elevated serum calcium
Monitor for respiratory involvement levels
Instruct patient to avoid crowded areas  Nursing Diagnosis : Risk for Injury
Keep tracheostomy and suction equipment at bedside  Interventions : Prepare the patient for
 Hemophilia Surgery
 Main Problem : Deficiency of clotting factors. Sex Increase oral fluid intake
Provide low calcium diet
–linked recessive trait ( type A and B ) more
Strain all urine
Complication : renal calculi  Laboratory Data : Decreased serum calcium
levels
 Hypertension  Nursing Diagnosis : Potential ; altered
 Main Problem : Persistent BP above 140 / systolic cardiac output
and 90 / diastolic  Interventions : Assess for increased signs of
 Initial manifestation : Asymptomatic , occipital neuromuscular irritability ( Chvosteks’ and
headache is a common complaint Trousseau’s Sign)
 Laboratory data : elevated BP Provide a quiet room , no stimulus
 Nursing Diagnosis : Altered Tissue Perfusion Provide high calcium , low phosphorus diet
 Interventions: Avoid Stimulants
Low salt , low fat diet
Stress reduction techniques  Hypothyroidism
Lifestyle , dietary and behavioral modification  Main Problem : Hyposecretion of thyroid
Compliance to HPN pharmacotherapy hormone
Specially maintenance meds  Initial Manifestation : Fatigue , facial edema
is a common sign
 Hyperthyroidism  Laboratory Data : Decreased T3 and T4
 Main Problem : Hypersecretion of thyroid levels
hormones  Nursing Diagnosis : Activity Intolerance
 Initial manifestation : Fine hand tremors ,  Interventions : Maintain low calorie , low
intolerance to heat is a common symptom cholesterol and low saturated fat diet
 Laboratory Data : Elevated T3 and T4 Provide warm environment and avoid sedatives
 Nursing Diagnosis : Risk for Injury Provide frequent rest periods
 Interventions : Maintain a high calorie , High Instruct patient that administration of synthroid is
CHON Diet lifelong
Provide adequate rest
Provide acool environment  Hypovolemic shock
Elevate head of bed  Main Problem : Loss of effective circulating
Propylthiouracil medication is lifetime blood volume leading to circulatory collapse
Prepare patient for thyroidectomy resulting to inadequate tissue perfusion
Post thyroidectomy – assess for hemorrhage by slipping  Initial manifestation : narrowing pulse
the hand behind the neck pressure
 Diagnostic data ; Decreased BP and
 Hyperlipidemia Decreased CVP
 Nursing Diagnosis : altered Tissue Perfusion
 Increased serum levels of two plasma lipids;
cholesterol and triglycerides above 200 mg/ dl.  Interventions : Maintain patent airway
Factor causation of atherosclerosis and Keep patient in modified trendelenburg position
conductive to arteriosclerosis Start fluid replacement immediately
Administer vasopressors as ordered
 Initially asymptomatic
 Hemorrhoids
 Lipid Profile Test – elevated
 Varicosities or outpouching of the veins of
 Non compliance to therapeutic regimen
the hemorrhoids plexus
 Instruct patient to eat salmon and tuna at least
 Internal- painless bleeding in defecation
several times a week and increase intake of high
External – intense rectal itching with bleeding and
fiber foods
pain upon defecation
Administer antilipidemic drugs with meals –
Clofibrate ( Atromid-S)  Rectal examination
and Cholestyramine ( Cuemid)  Pain related to irritation, pressure,
sensitivity in recto-anal area
1) Management for patients with
hyperlipidemia:  Conservative treatment:
a) Diet low in cholesterol and Application of hot and cold compress
saturated fats Analgesic ointment(nupercaine)
b) Carbohydrate restricted diet Hot sitz bath
c) A and b Prepare patient for treatment by ligation, injection of
d) A only sclerosing agent or preop and post –op care for
hemorroidectomy
 Answer : c – low Position prone post hemorroidectomy,
saturated fat and low Watch out for hemorrhage 24 hours to 10 days post-
cholesterol diet can op when sutures are sloughing off.
maintain serum Administer laxative, full diet until few hours before
cholesterol below 140 anesthetic is given. Stool softeners and bulk
mg/dl. Carbohydrate formers(Metamucil)
restriction can lower Increase bulk and fluids
serum triglyceride
levels by reducing 1) Post hemorrhoidectomy nursing care monitoring
lipoprotein derived for potential complication includes observation
from carbohydrate for:
a) Bleeding and urinary retention
 Hypoparathyroidism b) Bleeding and atelectasis
c) Respiratory complications and urinary
 Main Problem : Hyposecretion of parathyroid
retention
hormone
d) None of the above
 Initial manifestations : Tingling sensation around
the lips and upper extremities
  Answer : a – bleeding and urinary retention are  Laboratory Data : CT scan reveals
possible complications of hemorrhoidectomy hyperplasia of the thymus gland. Tensilon
test ; increased muscle strength 30 seconds
after administration of Endrophonium
 Increased intracranial pressure  Nursing Diagnosis : Ineffective Breathing
 Main problem : increase in amount of CNS tissue Pattern
or CSF fluid leading to an ICP greater than 15  Interventions : Maintain Patent Airway
mmHg Instruct the patient to avoid quinidine , morphine and
 Initial Manifestation : Widening pulse pressure , antibiotics since these may trigger muscle weakness.
decreasing LOC Instruct the patient to avoid prolonged talking over
 Laboratory Data : elevated Blood pressure the phone especially before meals since this will
( systolic) weaken the facial muscles which are also used for
 Nursing diagnosis : Potential for ineffective eating.
breathing pattern
 Interventions : Keep the patient in high – fowler’s  Intestinal obstruction
position  Blockage of intestinal lumen causing gas,
Administer dexamethasone and mannitol as ordered to fluid and digested material substance to
decrease cerebral edema accumulate near the obstruction and
Monitor level of consciousness increase peristalsis.H2O and electrolytes are
 Liver Cirrhosis then secreted into the blocked bowel
causing inflammation and inhibiting
 Main Problem : Normal liver tissues are replaced absorption
with scar tissues  Abdominal distention, cramping pain,
 Initial manifestation : edema decreased or absent bowel sounds
 Laboratory data : elevated SGOT / SGPT ; AST /  Abdominal X-ray – increased amount of gas
ALT in the bowel
 Nursing Diagnosis: Altered Fluid Volume
 Interventions : Maintain A low protein diet
 Acute pain related to abdominal distention
Constipation related to inability of stool to pass
Assess the patient for bleeding
through obstructed area
Prepare the patient for paracentesis
Weigh the patient daily  Place patient on NPO and fluid and
Asterixis indicates hepatic encephalopathy electrolyte replacement through IVF infusion
Assess bowel sounds,mio,vs and labs- stoll exams
and measure abdominal girth to assess for distention
 Meniere’s Disease
Semi-fowlers for comfort , bedrest and quiet envt.
 Main Problem: Dilation of the endolymphatic
Administer analgesics( Demerol)and
system causing degeneration of the vestibular
antibiotics(Gentamycin)
and cochlear hair cells in the inner ear . It affects
Teach and monitor pre-op and post –op care for
cranial nerve VIII
bowel resection with or without anastomosis
 Initial Manifestations : Vertigo usually described Avoid constipating food
by patients as “ I feel like I’m spinning “ , I feel GI decompression using NGT, Miller abbott or cantor
as if the room is revolving “ tubes maintained position and low intermittent
 Laboratory Data : Caloric Stimulation test suction
reveals moderate nystagmus
 Nursing Diagnosis : Risk for Injury
1) The priority nursing diagnosis for patients with
 Interventions : Priority Safety Keep the patient in bowel obstruction are Constipation related to
supine position during the attack inability of stool to pass through obstructed area
Maintain low sodium diet and:
Encourage the patient ot stop smoking a) Fluid volume deficit, potential for
Keep the room dark when photophobia is present b) Pain
c) High risk for infection
d) Potential for non – compliance
 Multiple Sclerosis
 Main Problem : Chronic Progressive disease of  Answer : b : pain is an immediate problem
the CNS characterized by small patches of the other choices are potential problems.
demyelination in the brain and spinal cord
 Initial Manifestations : Intentional Tremors and  Myocardial Infarction
Diplopia  Main Problem : Destruction of the cardiac
 Laboratory Data : MRI reveals small plaques tissue due to reduced coronary blood flow
scattered throughout the CNS  Initial Manifestation : lower sternal pain not
 Nursing Diagnosis : Impaired Physical Mobility relieved by rest and nitroglycerine ,
related to nuscle weakness ; Risk for injury characterized as crushing or excruciating
 Interventions : Promote safety of the client  Laboratory Data : Elevated CPK and
Teach the patient certain stress management techniques Troponin , ECG reveals ST segment
Encourage daily exercise elevation or depression and T wave
inversion
 Myasthenia Gravis  Nursing Diagnosis : Pain related to
 Main Problem ; Faulty Neuromuscular decreased tissue oxygenation
transmission of the voluntary muscles of the Interventions: Morphine / Demerol to relieve pain
body due to a deficiency in acetylcholine Oxygen Administration
receptor sites in the myoneural junction Nitroglycerine
 Initial Manifestation : Descending muscle Aspirin
weakness initially manifested by ptosis
Position in semi-fowler’s
Maintain low fat , low cholesterol and low sodium diet
 a) infuse Potassium chloride
 Osteoporosis b) Use of antacids and bicarbonate of soda
 Main Problem : Loss of bone matrix leading to c) IVF with bicarbonates and lactate
bone weakness predisposing it to fractures. d) All of the above
Usually associated with smoking , menopause ,
immobility and hyperparathyroidism  Answer : a - Infusion of acidifying agents are
 Initial manifestation : asymptomatic beneficial to counteract metabolic alkalosis
 Laboratory Data : X- ray reveals decrease in
bone density  Respiratory alkalosis
 Nursing Diagnosis : Potential for Injury  Deficiency of CO2 in the blood as indicated
 Interventions ; Increase Vit D and Calcium in the by decreased PaCO2 caused by alveolar
diet hyperventilation which elevates blood Ph.
Estrogen replacement therapy for post menopausal  Deep rapid breathing > 40 bpm( cardinal)
women Circumoral or peripheral paresthesias
Encourage patient to perform active weight bearing Carpopedal spasms and lightheadedness
exercises like brisk walking , jumping rope , hiking ,  ABG – Pa CO2 < 35 mHg
tennis and bal;lroom dancing.
 Impaired gas exchange
Swimming does not meet criteria for resistance needed
Ineffective breathing pattern
for prevention of osteoporosis
 Eradicate underlying condition by treatment
of CNS disease, fever, sepsis or removal of
ingested toxins
 Metabolic acidosis
Teach effective deep breathing into a paper bag
 state of excess acid accumulation and deficient Watch out for twitching and cardiac
base bicarbonate arrythmias
 drowsiness and Kussmauls respiration, CNS Monitor ABG’S and serum electrolyte levels
depression, lethargy and stupor
 ABG reveals pH < 7.35 and HCO3 level < 24 1) Common management for respiratory alkalosis
mEq / L includes:
 Impaired gas exchange a) Oxygenation by nasal cannula
 Assess and correct underlying cause b) Oxygen delivery by face mask at 10 LPM
Watch out for increased serum potassium,frequent c) Teach deep breathing in a paper bag
monitoring of vital signs , labs and level of consciousness d) Encourage patient to breathe deeply in a
Keep sodium bicarbonate ready and institute seizure pursed lip manner
precautions.
Teach urine and blood tests for sugar or acetone.  Respiratory Acidosis
Encourage strict adherence to OHA or insulin therapy  Acid – base disturbance characterized by
excess CO2 in the blood( hypercapnia) >45
1) Hyperglycemia in patients with IDDM can cause what mmHg resulting from reduced alveolar
metabolic imbalance: ventilation
a) Metabolic acidosis  Restlessness and confusion
b) Metabolic alkalosis  ABG – Ph below normal < 7.35 ; pCO2 >
c) All of the above 45
d) None of the above
 Impaired gas exchange
Ineffective breathing pattern
 Answer : a – excess production of metabolic
 Monitor pulmonary function tests
acids such as hyrglycemia in patients with IDDM
warrants use of fats which liberates ketone  Prepare patient for intubation and /or
bodies which is a metabolic acid precipitates mechanical ventilation if with hypoxemia,
metabolic acidosis. decreased level of consciousness and
respiratory distress.
Administer antibiotics, sodium bicarbonate and
bronchodilators as needed
 Metabolic Alkalosis
Chest physiotherapy, suctioning and O2 with
 Clinical state marked by decreased amounts of humidification
acid and increased amounts of base bicarbonate Eradicate underlyingt cause by intubation and Mech.
 Confusion, hypoventilation, irritability, picking at Ventilation, removal of foreign body and dialysis to
bedlinens and twitching remove toxic drugs.
 ABG pH . 7.45 and Bicarbonate level > 28 mEq /
L 1) Respiratory acid – base imbalance caused by
retention of CO2 which combines with H2O to
 High risk for injury related to metabolic alkalosis form carbonic acid H2CO3 includes the following
Alteration in tissue perfusion and Impaired gas exchange disorders except:
 Assess and Treat underlying cause
 Measure I and O and watch out for tachycardia
a) COPD and Asthma
b) hyperventilation
and hypotension indicating hypokalemia
c) CNS depression
Avoid the use of alkaline agents such as antacids,
d) Pulmonary edema and respiratory paralysis
bicarbonate of soda and no administration of IVF with
increased concentration of bicarbonate or lactate
 Answer : b – hyperventilation causes
Acidifying agent- ammonium Chloride IV and potassium
alkalosis
Chloride – supplements IV ( not given to clients with
hepatic and renal diseases and given on slow infusions to
prevent hemolysis)

1) Most appropriate nursing intervention to correct  Pancreatitis

metabolic alkalosis is to:
  Laboratory Data : Allen’s test reveals
 Main Problem : Autodigestion of the pancreas
circulatory problems
 Initial Manifestation : Periumbilical Pain
 Nursing Diagnosis : Altered Tissue Perfusion
 Laboratory Data : Elevated Serum Amylase
 Interventions : Avoid cold weather
 Nursing Diagnosis : Pain
 Wear leather gloves when getting anything
 Interventions : Administer Demerol to relieve from the refrigerator
pain. Morphine contraindicated as it causes
 Stop smoking
spasm of the spincter of oddi
Maintain low fat diet , patient on NPO during acute phase  Administer vasodilators as ordered
Instruct patient to avoid coffee and alcohol
 Renal Colic ( Urolithiasis)
 Main Problem : Presence of renal stone in
the urinary system
 Parkinson ‘ s Disease  Initial manifestation : Sudden severe pain
 Main Problem : Progressive Neurologic Disorder that leads to shock, unrelieved by
affecting the brain centers responsible for analgesics
control and regulation of movement due to  Laboratory Data : IVP reveals the presence
depletion of dopamine of stone
 Initial manifestation : Bradykinesia  Nursing diagnosis : Pain
 Laboratory data : No Specific  Interventions : Strain all patients urine , to
 Nursing Diagnosis : Risk for Injury assess if the patient is passing out stones
 Interventions ; Maintain Exercise program Increase Oral Fluid Intake
Maintain a low protein diet at daytime and high protein at Prepare Patient for Extracorporeal Shock Wave
night because absorption of levodopa which is usually Lithotripsy- area submerged in water and electrically
taken at daytime is slowed down by intake of high protein generated shock wave directed to the location of the
foods and vitamin B6 stone. Pain medications given to minimize pain
Maintain patient on low sodium , low protein diet
Institute safety measures ( rubber soled shoes , low heels
and grab bars )
Prepare patient for stereotaxic thalamotomy , surgery  Renal Failure , Acute
done to decrease tremors  Main Problem : Abrupt reversible cessation
of renal function as a result of trauma ,
allergy and kidney stones
 Initial Manifestation : Oliguria ( U.O. , 400 ml
/ 24 hours )
 Peptic Ulcer Disease , Duodenal  Laboratory data : elevated BUN and
 Main Problem : Increased in HCL acid levels in creatinine
the stomach  Nursing Diagnosis : Alteration in Urinary
 Initial manifestation : Right Epigastric Pain which Elimination
occurs 2-3 hours after meals usually at night and Fluid and electrolyte imbalance
is relieved by eating
 Laboratory Data : Gastric Analysis reveals  Interventions : Monitor Intake and output
elevated HCL Maintain a low protein , high carbohydrate , low
 Nursing diagnosis : Potential for fluid volume sodium diet and fluid restricted during the oliguric
deficit phase and high protein , high calorie and fluid
 Interventions : Maintain high fat , high replacement during diuretic phase
carbohydrate and low protein diet. Instruct
patient to avoid spicy and caffeine containing
foods , alcohol and smoking  Renal Failure , Chronic
 Main Problem : Irreversible slow or
 Peptic Ulcer Disease , Gastric progressive failure of the kidneys to function
 Main Problem : Weak Gastric Mucosa that results in death unless treatment is
 Initial Manifestation : Left epigastric pain which instituted
occurs 30 minutes – 1 hour after meals usually  Initial manifestation : GI manifestations like
at day time and is relieved by vomiting anorexia , nausea and vomiting
 Laboratory Data : Endoscopy reveals ulcer
usually in the lesser curvature of the stomach
 Laboratory Data : Elevated serum creatinine
level and low urine creatinine clearance
 Nursing Diagnosis : Potential for fluid volume
deficit  Nursing Diagnosis : Alteration in urinary
 Interventions ; Maintain High fat , high elimination
carbohydrate and low protein diet Fluid Volume Excess
Instruct the patient to avoid spicy , caffeine containing  Interventions : Maintain low protein , low
foods , alcohol and smoking sodium , low potassium diet
Administer antacids separately from other drugs that the Prepare patient for hemodialysis / peritoneal dialysis
patient is taking , as ordered. and monitor for complications
Prepare patient for surgery ( Billroth 1 , 2 or gastrectomy Monitor for signs and symptoms of anemia
or vagotomy) Administer Epogen , diuretics and antihypertensives
as ordered
 Raynauds disease
 Main Problem : VAsospastic condition of arteries  Pulmonary Embolism
of the hands tha occurs with exposure to cold or  Obstruction of blood flow to pulmonary
stress vessels by an undissolved substance( air,
 Initial Manifestation : Intermittent arteriolar fat, emboli,thrombus) resulting in
vasoconstriction pulmonary hypertension and possible
iinfarction
  Sudden onset of dyspnea, tachypnea, crackles  Hydrothorax – water
and chest pain  Pyothorax – pus and exudates
 ABG – hypoxemia; pulmonary angiography
shows location of embolism and filing defect
 Acute symptoms of dyspnea and
CXR – shows pneumoconstriction pulmonary arterial paradoxical chest movement( absent or
dilation restricted movement on the affected side
Lung scan shows VQ mismatch with decreased or absent breath sounds ,
may lead to mediastinal shift)
 Impaired gas exchange
Ineffective tissue perfusion; cardiopulmonary  Lung scan shows VQ ratio mismatches
 Monitor ABG and watch out for respiratory  CXR showing decreased perfusion
distress and assess cardiovascular status and ABG showing hypoxemia
CVP  Impaired gas exchange
Irregular pulse – arrhythmia caused by hypoxemia  Monitor PFT’s and prepare patient for
Hyperthermia – pulmonary embolism caused by thoracentesis and observe for complications
thrombophlebitis of chest tube placements ( constant
Monitor lab studies – maintain PTT at 1 ½ to 2 times bubbling in the water seal chamber–
control in patient with heparin – PT at 1 ½ to 2 times indicates leak; 3 days post insertion can
control or INR at 2 -3 in patient receiving coumadin indicate lung re-expansion)
Place patient in fowlers position, suction and administer Place patient in high fowlers position and place on O2
IVF, analgesics, anticoagulants, diuretics and fibrinolytics therapy as indicated.
as ordered Instruct patient to do valsalva maneuver during chest
tube removal.
1) The nursing diagnosis with least significance for
patients with pulmonary embolism is: 1) The following are measures to promote adequate
a) Altered pattern of breathing related to dyspnea respirations and maintain proper function of the
b) Impaired gas exchange related to decreased drainage bottle system:
diffusion a) Prevent movement to prevent displacement
c) Pain related to pleural irritation of the tube
d) Anxiety related to hypoxia b) Keep drainage bottles below chest level and
position patient flat on bed
 Answer : d – physiological needs first c) Constant clamping of the tubes
d) Milking not routinely done

 Pulmonary Edema  Answer : d – patient is positioned in

 A condition characterized by excessive amount semi- fowlers,drainage bottles
of fluid in the alveoli and pulmonary interstitial below chest level, milking not
tissues which tends to interfere with effective routinely done as it increases
diffusion of gases negative pressure, clamping of the
 Dyspnea, orthopnea, crackles paroxysmal tube done only when bottles are
nocturnal dyspnea and pink frothy sputum broken or must be raised above the
 Pulmonary function tests decreased VQ ratios, chest.
ABG’s indicate hypoxemia
 Impaired gas exchange related to right to left  Systemic Lupus Erythematosus
shunting and decreased V/Q ratios
Fluid volume excess related to left ventricular failure in  Chronic autoimmune multi-system disorder
cardiogenic pulmonary edema with periods of exacerbation and remission
Decreased cardiac output related to left ventricular and increased production of antibodies to
failure in cardiogenic pulmonary edema cellular DNA results in inflammatory process
 Monitor blood gases involving veins and arteries causing pain
If on ventilator , suction frequently. Maintain oxygenation swelling and tissue damage.
with ventilator( on PEEP) or nasal cannula
Restrict fluids and sodium for edema
 Pancytopenia and butterfly rash on the
face, palmar erythema, psychosis and
Administer inotropic drugs(Dopamine and dobutamine)
impaired cognitive function migratory pain
and diuretics in cardiogenic pulmonary edema
and swelling, hypertension & carditis
Prevent pulmonary infection with strict asepsis
Maintain nutrition with parenteral or enteral feedings  Positive rheumatoid factor and ANA test
positive
1) An example of a drug used in pulmonary edema to  ESR elevated and serum globulins elevated
decrease circulating fluid volume Urine chemistry – proteinuria and hematuria
 High risk for injury
a) Dopamine ( Intropin)
 Diet high in iron , CHON, vita.C
b) Dobutamine ( Dobutrex) Hemodialysis and kidney transplant if renal failure
occurs
c) Lasix( Furosemide)
Increase rest and sleep
d) Digoxin ( Digitoxin) Monitor musculo skeletal, renal and cardiopulmonary
 Answer : c – furosemide is a diuretic status
which decreases fluid volume by Administer antiemetics , and antidiarrheals
increasing renal water excretion Encourage expression of body image change
Avoid infections, injury, sunlight exposure, OTC
 Pneumothorax meds, oral contraceptives, hair spray and color
 A restrictive respiratory disease occurs when air Give medications as ordered – analgesics , anti-
enters the pleural space as a result of pulmonary emetics, anti-rheumatics, cytotoxic drugs, steroids
lesion, neoplasms, accidental or surgical opening and NSAIDS.
through the chest wall. Collapse of the lung due
to air in the pleural space.
 Hemothorax – blood
 1) Complications of SLE includes  Initial manifestation : Depends on the level
peripheral vascular disease which can of injury
be a cause of Cervical : Quadriplegia
a. Loss of limbs Thoracic : Paraplegia
b. COPD Lumbar : Paraplegia
c. Congestive heart failure
d. Stroke  Laboratory Data : X – Ray reveals the
location and extent of injury
 Answer : a – PVD as  Nursing Diagnosis : Ineffective
a complication of Breathing Pattern , Impaired Physical
SLE can lead to Mobility
peripjeral tisuue  Interventions : Avoid hyperflexion and
necrosis which hyperextension of the spine . log roll
warrants the patient
amputation Keep a catheter at the bedside to prevent bladder
distention which may stimulate autonomic
 Urinary Tract Infection dysreflexia
 Infection of the urinary tract as a result of
urethral ascend of bacteria usually caused by E.  Syndrome of Inappropriate antidiuretic
Coli. Hormone (SIADH)

Cystitis – inflammation of the urinary bladder  Main Problem : Inappropriate continued

release of antidiuretic hormone resulting in
Pyelonephritis water intoxication
 inflammation of the kidney and its pelvis  Initial Manifestation : Mental Confusion
 Laboratory Data : Hyponatremia – Na , 120
 Flank pain, with frequency,burning and mEq / L
urgency  Nursing Diagnosis : Fluid Volume Excess
Chills , muscle spasm, dysuria Fluid and electrolyte imbalance
 Urinalysis and urine C/ S confirms  Interventions : Fluid Restriction
causative agent Assess for signs and symptoms of hyponatremia
 Pain alteration in comfort  Ulcerative Colitis
 Stress the importance of medication  Main Problem : Ulceration of the mucosa of
compliance and bedrest during acute phase the lower colon and rectum
Relieve flank pain with analgesics , rest massage and  Initial manifestation : Bloody Mucoid
external heat application Diarrhea
Sulfonamides and broad spectrum antibiotics, urinary  Laboratory data : Barium enema reveals
antiseptics ( Bactrim , Septra) and lesions
urinary analgesics ( Pyridium)  Nursing Diagnosis : Pain
Increase oral fluid intake up to 4 liters per day and follow Altered Bowel Elimination ; diarrhea
up urinalysis every two weeks for a month then monthly  Interventions : Avoid dairy products
until urine is sterile. Maintain Low Residue and High protein Diet , avoid
cold fluids
1.)the following statement is true about pyelonephritis Teach patients about familial predisposition
except
a. may follow cystitis
b. clinical manifestation includes GOODLUCK AND GOD BLESS…JLO
costovertebral angle tenderness
c. most commonly caused by E coli
d. all of the above

 answer : d – all
statements are descriptive
of pyelonephritis

 Retinal Detachment
 Main Problem : Separation of the sensory retina
from the pigment epithelium of the retine
 Initial manifestation : Visual floaters described
by patients as cobwebs or curtain in eyes
 Nursing Diagnosis : Potential for Injury
 Interventions : Immediate Bedrest
Position patient with the affected side towards the bed ,
so gravity may help put the detached retina back into
place .
Avoid coughing ,sneezing and straining prepare the
patient for eye surgery.

 Spinal Cord Injury

 Main Problem : Partial or complete disruption of
nerve tracts and neurons resulting in paralysis
and sensory loss