MedSurg2 Exam 1

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MedSurg2 Exam 1
2011-10-22 23:29:05
MedSurg2 Exam

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  1. the movement of fluid through a cell or blood vessel membrane b/c of hydrostatic pressure differences on both sides of the membrane; occurs b.c of differences in watervolume pressing against the confining walls of the space
  2. is when water molecules in a confined space constantly press outward against the confining walls; "water-pushing" pressure
    hydrostatic pressure
  3. the free movement of particles (solute) across a permeable membrane from an area of higher concentration to lower concentration
  4. Hyponatremia
    serum sodium level lower than 136 mEq/L
  5. s/s of pts with hyponatremia
    cerebral changes are the most obvious, behavioral changes, sudden onset of acute or increased confusion often seen in older pts; muscle weakness, diminshed deep tendon reflexes; increased motility causing nausea, diarrhea, and abdominal cramping, hyperactive bowel sounds; rapid, weak, thready pulses, BP decreased and peripheal pulses are difficult to palpate
  6. in pt's w/ hyponatremia, if they have muscle weakness, what should the nurse do?
    immediately check respiratory effectiveness b/c ventilation depends on adequate strength of respiratory muscles
  7. hypernatremia
    serum sodium levels higher than 145 mEg/L
  8. s/s of a pt w/ hypernatremia
    nervous system: short attention span and agitated or confsed about recent events, manic episodes or seizures, lethargic, drowsy or even comatose; skeletal muscle: muscle twitching and weakening, deept tendon reflexes are reduced or absent; cardiovascular: decreased contactility
  9. s/s of a pt exhibiting fluid deficit
    heart rate increases, peripheral pulses are weak, BP decreases, neck and hand veins are flat, increased rate of respirations, hypoxia, skin turgor is poor, oral mucous membranes are not moist, deep furrows on surface of tongue, confusion (mental status changes are especially common in older adults) and decreased urine volume and composition (urine becomes more concentrated)
  10. s/s of pt's with fluid overload
    increased pulse rate, bounding and full pulses, elevated BP, distended neck and hand veins, increased rate of respirations, pitting edema and pale cool skin, altered LOC, headache, and increased motility
  11. hypokalemia
    serum potassium level bwlow 3.5 mEq/L
  12. Why can hypokalemia be life threatening?
    B/c it affects every body system
  13. what should be the first thing assessed in any pt who might have hypokalemia
    respiratory status
  14. s/s of a pt w/ hypokalemia
    muscle weakness, thready and weak pulse, orthostatic hypotension, short-term irritability and anxiety followed by lethargy and acute confusion, decreased peristalsis, hypoactive BS, nausea, vomiting, constipation and abdominal girth
  15. severe hypokalemia causes the absences of what
  16. hyperkalemia
    serum potassium level is higher than 5.0 mEq
  17. changes to what system are the most severe problems from hyperkalemia and the most common cause of death
    cardiovascular system
  18. s/s of a pt w/ hyperkalemia
    bradycardia, hypotensions, ectopic beats, msucles tingle and burn w/ numbness, weakness, increased motility, hyperactive bowel sounds,
  19. hypocalcemia
    serum calcium levels are below 9 mg/dL
  20. s/s of a pt w/ hypocalcemia
    frequent painful muscle spasms (charley horses) in calves or foot, paresthesias tingling and numbness, slower or faster HR?, weak/thready pulse, increased peristalsis, abdominal cramping, diarrhea, loss of bone density (osteoprosis)
  21. hypercalcemia
    serum calcium level above 10.5 mg/dL
  22. s/s of a pt w/ hypercalcemia
    increased HR and BP, impaired blood flow, severe muscle weakness, decreased deep tendon reflexes, constipation, anorexia, nausea, vomiting, and abdominal pain, hypoactive or absent bowel sounds, increased abdominal sixe
  23. hypophosphatemia
    serum phosphorous level below 3.0 mEq/L
  24. s/s of a pt w/ hypophosphatemia
    decreased stroke volume and cardiac output, slow peripheral pulses, cardiac depression, weak skeletal muslces, acute muscle breakdown (rhabdomyolysis), decreased bone density, irritability
  25. hyperphosphatemia
    serum phosphorous level above 4.5 mEq/L
  26. s/s of hyperphosphatemia
    renal insufficiency, hypoparathyroidism
  27. hypomagnesemia
    serum magnesium level below 1.3 mEq/L
  28. s/s of a pt w/ hypomagnesemia
    hyperactive deep tendon reflexes, numbness and tingling, and painful msucle contractions, muscle weakness, psychological depression, psychosis, confusion, reduced motility in intestinal tract, anorexia, nausea, constipation and abdominal distention
  29. hypermagnesemia
    serum magnesium level above 2.1 mEq/L
  30. s/s of a pt w/ hypermagnesemia
    bradycardia, peripheral vasodilation and hypotension, drowsy or lethargic, decreased nerve impuls transmission to skeletal muscles, reduced or absent deep tendon reflexes
  31. Patients w/ what are in grave danger of cardiac arrest
    severe hypermagnesemia
  32. needed fr activating vitamins and enzymes, forming ATP for energy supplies and assisting in cell growth and metabolism
  33. is critical for skeletal muscle contraction, carbohydrate metabolism, ATP formation, vitamin activation and cell growth
  34. this electrolyte is important in the formation of hydrochloric acid in the stomach
  35. 2 most important areas to monitor during rehydration
    pulse rate and quality and urine output
  36. what is the best indicator of lfuid retention and overload
    rapid weight gain
  37. the priority for nursing care ofthe pt w/ hyponatremia is what?
    monitoring the pt's response to therapy to prevent hypernatremia and fluid overload