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Using a soft toothbrush and electric razor generic propranolol 80 mg otc blood pressure high in the morning, avoiding enemas 40mg propranolol fast delivery arteria testicularis, and monitoring for bleeding (Option A) are thrombocytopenia precau tions purchase propranolol 40 mg line arteriogenesis. Putting on a mask discount propranolol 40mg mastercard blood pressure kiosk for sale, gown, and gloves when entering the patient’s room (Option B) is reverse isola tion. A neutropenic patient doesn’t need a clear liquid diet or sodium restrictions (Option C). Glucocorticoids (Option C) aren’t needed because the adrenal glands aren’t involved. In type 2 diabetes mellitus (Option C), the body produces insulin, but hyperglycemia results from insulin resistance or insufficiency. Correct answer: C During periods of infection or illness, an insulin-dependent patient may need even more insulin—not less insulin (Option B) or no change (Option A)—to compensate for increased blood glucose levels. Because the patient has insulin-dependent diabetes, oral antidiabetic agents (Option D) wouldn’t be indicated. Correct answer: C Repeating what the patient has said (or describing his feelings) encourages the patient to elaborate on his thoughts and feelings. Telling him not to worry (Option A) or saying that Hodgkin’s disease is very treatable (Option B) ignores his feelings and offers false reassurance. Telling a patient what to do, such as calling his minister (Option D), also ignores his feelings. People with the D anti gen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. A person with Rh-negative blood must receive Rh-negative blood, not Rh-positive blood (Options A, B, and D). If an Rh negative person receives Rh-positive blood, he develops anti-Rh agglutinins, and subsequent transfusions with Rh-positive blood may cause serious reactions, including clumping and hemolysis of red blood cells. Correct answer: C Fluid shifts to the site of the bowel obstruction, causing a fluid deficit—not excess fluid (Option D)—in the intravascular spaces. If the obstruction isn’t resolved immediately, the patient may experience Imbalanced nutrition: Less than body requirements (Option A); however, Deficient fluid volume takes priority. The patient also may experience pain (Option B), but that nursing diagnosis also takes lower priority. Correct answer: B the patient with irritable bowel syndrome needs to be on a diet high in fiber (at least 25 g/day) but that doesn’t contain fatty foods, which may precipitate symptoms. Correct answer: A Inflammation of the pancreas causes it to excrete pancreatic enzymes. Carbohy drate metabolism is impaired secondary to damage to pancreatic beta cells. As in many other disease processes, the serum calcium level decreases because of the saponification of calcium by fatty acids in the area of the inflamed pancreas. Correct answer: C Hepatitis A can result from contact with contaminated feces and may be trans mitted through infected water, milk, or food, especially shellfish from contaminated waters. Hepatitis C is usually caused by contact with infected blood, including blood transfusions (Option B). Correct answer: A Recognizing the rupture of esophageal varices, or hemorrhage, takes prior ity because the patient could succumb to this quickly. Although not as important, the nurse should also focus on controlling blood pressure (Option B) because doing so helps reduce the risk of variceal rupture. Lower priority measures include teaching the patient what foods he should avoid (such as spicy foods) (Option C) and explaining what varices are (Option D). Correct answer: C Clotting factors may not be produced normally when a patient has cirrhosis, indicating an increased potential for bleeding and resulting in a prolonged prothrombin time. There’s no associated change in carbon dioxide level (Option A) or pH (Option B) unless the patient is develop ing other comorbidities, such as metabolic alkalosis. Correct answer: C High bilirubin levels irritate peripheral nerves, causing an intense itching sensation. Itching isn’t a symptom of prolonged prothrombin time (Option A), decreased protein levels (Option B), or increased aspartate aminotransferase levels (Option D). Correct answer: D the patient should receive fluid and electrolyte replacement as well as antibi otics and blood replacement. Antacids (Option B) and H2-receptor antagonists (Option C) aren’t helpful in this situation. Small blood clots or pieces of tissue commonly are passed in the urine for up to 2 weeks postoperatively (Option B). Tub baths (Option C) are prohibited because they cause dilation of pelvic blood vessels. Sexual intercourse and driving are usually prohibited for about 3 weeks; exercising and returning to work are usually prohibited for about 6 weeks. Correct answer: B the patient needs to return for follow-up urine cultures because he may have asymptomatic bacteriuria. The patient must take the full course of antibiotics, regardless of his signs and symptoms (Option C). Pyelonephritis can recur as a relapse or new infection, frequently within 2 weeks of completing therapy (Option D). Correct answer: B A dusky or cyanotic stoma indicates insufficient blood supply, an emergency that needs prompt intervention. A urine output of less than 30 mL/hour or no urine output for more than 15 minutes should be reported; a urine output of more than 30 mL/hour is normal (Option C). Slight bleeding from the stoma when changing the appliance (Option D) may occur because the intestinal mucosa is fragile. Correct answer: C Urine retention is usually a temporary problem that requires insertion of a straight catheter. A coudé catheter (Option A) is used only when it’s difficult to insert a standard cathe ter, usually because of an enlarged prostate.

This is a severe immune-mediated reaction that occurs when a previously sensitized patient is again exposed to propranolol 80mg without a prescription heart attack 21 year old female an allergen cheap 80mg propranolol amex blood pressure normal in pregnancy. Allergens may produce an allergic reaction by being ingested order 40 mg propranolol fast delivery blood pressure walmart, inhaled generic propranolol 40mg line blood pressure chart vaughns, injected, or absorbed through the skin/mucous membranes. Anaphylactic shock differs from less severe allergic reactions in that it is characterized by hypotension and obstructed airflow (upper and/or lower) that can be life-threatening. Subjective: Symptoms General malaise/weakness, lightheadedness, anxiety/feeling of impending doom diffuse itching/”scratchy” sensation in the back of the throat, chest tightness/difficulty breathing. Generalized itching with hives (pruritus and urticaria), and occasionally angioedema of the face (swelling of the eyelids, lips, cheeks) Capillary refill: Delayed in shock, longer than 3 seconds. Using Advanced Tools: Pulse oximetry Assessment: Differential Diagnosis Allergic reaction without hypotension and/or airway obstruction Vasovagal reaction after injection/immunization (common) Cardiogenic shock Angioedema Plan: Diagnostic Tests Essential: Clinical observation is the only diagnostic test. Close observation with frequent assessment/reassessment of mental status, vital signs, and pulse oximetry Recommended: Continuously monitor urinary output. If patient is intubated and ventilations are being supported, frequently reassess the pressures needed to ventilate. If due to an injected drug or venom, apply loose tourniquet proximal to injection/bite/sting site and place injection site in a dependant position to reduce venous/lymphatic circulation. Give epinephrine endotracheally if necessary to treat severe hypotension and bronchospasm. Diet: Avoidance of allergen if known Medications: Anaphylaxis kit (Epi-Pen autoinjector; Ana-Kit) for use in the event of recurrence. Albuterol (or other beta-agonist) inhaler if bronchospasm was a prominent symptom (be sure to properly teach patient how to use inhaler with spacer). Prevention and Hygiene: Avoid circumstances in which recurrent exposure is possible/likely No Improvement/Deterioration: Return immediately for any recurrence of symptoms after first self-adminis tering anaphylaxis kit. Tissue injury from trauma may worsen shock by causing microemboli that further activate the inflammatory and coagulation systems. Hemorrhage sufficient to cause shock usually happens in the torso, in the thigh(s) (femur fracture), or externally. Fractures of the femur, pelvis, and/or traumatic amputation are associated with substantial blood loss. From a clinical perspective, attempts to quantify blood loss in order to determine a shock category is of little value because even external blood loss is notoriously difficult to quantify and quite often trauma patients have significant internal as well as external hemorrhage. Subjective: Symptoms Constitutional: Diffuse weakness, anxiety/feelings of impending doom, difficulty concentrating, c/o being chilled to the bone; progressive thirst; shortness of breath. Consider thirst progressing in severity and breathing that becomes progressively deeper and more rapid to be evidence of worsening shock until proven otherwise. Pulse: Tachycardia except in some cases where an unexpected bradycardia is found (penetrating abdominal trauma, ruptured ectopic pregnancy or other pelvic bleeding); B/P: Progressive hypotension and orthostatic hypotension; narrowing pulse pressure (systolic diastolic pressure); Respirations: Tachypnea/hyperpnea; measurement of orthostatic vital signs may be helpful when significant postural hypotension is documented but this test is neither sensitive nor specific for shock. Most useful of all the vital signs in assessing hypovolemic/hemorrhagic shock is the pulse pressure (systolic diastolic pressure), which becomes progressively narrowed as shock proceeds. If a blood pressure cuff is not available, estimate the pulse pressure by the strength of the pulse. More important than the absolute value of any of the vital signs at a given point is their trend over time. Do not overlook falling blood pressure, a narrowing pulse pressure, and a rising heart rate these are signs of progressing shock. Continuously measuring the hourly urinary output is a readily obtainable, objective means of determining the adequacy of intravascular fluids. Auscultation: Clear lungs with deep, rapid respirations unless there is intrathoracic trauma Palpation: Cool, moist skin. In non-hypothermic patients an ascending palpation of the skin from feet to chest to note the point at which the skin becomes warm is a useful, rapid, method for estimating the degree of shock. Assessment: Differential Diagnosis Vaso-vagal faint transient hypotension due to bradycardia caused by parasympathetic stimulation Hemorrhagic shock intravascular volume depletion through blood loss. Septic shock loss of vascular tone due to release of infectious toxins in the circulatory system. Neurogenic shock loss of vascular tone due to impaired neural or spinal function. Distributive shock distribution of blood flow is impaired (pulmonary embolus blocks blood from entering into lungs, cardiac tamponade mechanical impairment of the pumping action of the heart and tension pneumothorax loss of blood return to the thorax and heart due to pressures building in the chest cavity). Once hemorrhage is controlled, initiate blood administration as soon as it can safely be accomplished. Further efforts at hemorrhage control should be performed en route and should not delay evacuation. Measure urine output and all blood and fluid loss to insure replacement and use guidelines such as those used to direct fluid resuscitation of burned patients to estimate volume losses. Attempting to maintain urinary output (and systolic pressure) of patients with on-going, uncontrollable, blood loss may temporarily maintain their urinary output at the expense of increasing the rate of red blood cell loss. External heating (active rewarming) before volume has been restored may produce undesired vasodilation, worsening hypotension. Place all badly wounded patients in a position with their feet elevated about 12 inches with the head and heart low. Utilize the head-down position unless it causes obvious distress, labored respiration or cyanosis, even in patients with chest wounds and with head wounds as long as their systolic blood pressure remains below 80 mm Hg.

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Pain Specific attention to cheap propranolol 80 mg online pulse pressure 60 how a patients’ pain interferes with their ability to 80mg propranolol free shipping blood pressure medication used for acne perform usual activities has been shown to propranolol 40 mg on-line blood pressure normal zone be useful in predicting chronicity for low back and other musculoskeletal problems buy propranolol 80mg online arteria records, particularly in injured worker populations. A fast and simple approach to track the Interference 29-31 impact of the patient’s pain on their function could be a simple anchored 0-10 scale such as: In the last month, how much has your shoulder pain/problem interfered with your daily activities? Tests, based on presence or Weakness location of subscapular pain, do not appear to correlate well. It is more sensitive for partial subscapular ruptures compared to the Lift-Off test. Palpation of the tendon insertion is not possible; creation of tenderness is the objective. May indicate distal clavicle osteolysis in individuals with continued extreme loading. Contractile Resisted contraction assessments of shoulder movements are often used for the purpose of localizing where pain occurs when specific contractile tissues are recruited. Studies of these tests have generally not correlated with surgical or imaging studies and are considered provocation 13 unreliable for localization or diagnosis. Positional General shoulder pain/restriction: provocation  Painful Arc test (painful active midrange abduction at 70°-100° with decreased pain above 100°) has good intra/inter rater reliability. When a pain occurs in this range on active movement, but not on passive movement, contractile tissue is likely involved. When a painful arc is found on both active & passive movement, any number of soft tissues may be involved (contractile, bursa, 1, 24 etc. However, experienced examiners may be able to differentiate between normal palpatory joint end feel and pathological palpatory joint end feel of passive shoulder end range. Examiners’ findings of pathological end feel moderately correlates with patient report of pain. Cyriax “capsular,” “tendinous,” etc 13, 36 end feel) may not reflect restrictions coming from the named structures. Rotator cuff tendonosis: 37  Drop Arm Test Inability to control lowering outstretched arm from abducted position suggests rotator cuff involvement. Labrum tear:  Sharp, reproducible pain at a discrete point on active moment (that can be avoided with alternative movement) suggests internal 1 Glenohumeral derangement such as labrum tear. Dislocation:  Post traumatic avoidance of most-all movement generally suggests fracture or dislocation. Miscellaneous Rotator cuff tendonosis: provocation and  Combining Painful Arc, Drop Arm, and infraspinatus strength tests appear to have a higher positive predictive value for 37 correlating with surgical finding of rotator cuff tear than individual tests. Impingement syndrome:  Subacromial impingement can be evaluated by combining Hawkins-Kennedy, Painful Arc & infraspinatus strength tests. They 10 37 appear to have higher positive predictive value for finding impingement syndromes in surgery than individual tests. Pain felt with the apprehension sign relieved by the relocation sign is an indication of posterior-superior impingement of the posterior capsule and labrum. Labrum tear:  Individual clinical provocation tests do not have good general predictability for findings of labrum tear on advanced imaging or during surgery. However, when combined tests are positive (specifically Crank, Apprehension, and Load & Shift tests), and 39-41 there is a consistent presentation & history. Instability:  Relocation & Anterior Release tests are reported to have good predictability for obvious instability but are of questionable value for subtle lesions. Other orthopedic tests (including Apprehension, Clunk, Release, Load & Shift tests, and the Sulcus sign) are not 40 useful for determining glenohumeral instability. Despite the extensive availability of clinical examination methods and “conventional wisdom” regarding Shoulder differential diagnosis of shoulder problems, reliability and validity of various clinical assessments for shoulder conditions have been shown Conditions to be of limited value. Six diagnostic criteria recommended by the Dutch College of General Practitioners included: Capsular Syndrome capsulitis, arthritis; Acute bursitis; Acromioclavicular syndrome joint and superior muscle lesions including spine and scapula; Subacromial syndrome tendinosis, chronic bursitis; Rest Group non-mechanical, unexplained; Mixed clinical picture -multiple 11 45, contributing structures). Diagnostic grouping was especially difficult for patients with high pain severity, chronic, and bilateral conditions. A key issue when considering imaging is to anticipate how the result of an imaging study would modify a conservative care trial. For most pain and restriction conditions associated with a workplace exposure, imaging should only be considered if the condition does not respond to 4 weeks of conservative treatment. Circumstances where imaging 2 should be considered include:  Acute, severe trauma (blunt force, suspicion of fracture, abnormal shape/suspicion of dislocation). Plain film radiography is useful for assessing:  Impingement – using Outlet view and Zanca (15 degree cephalad view) for subacromial impingement due to a hooked acromion or osteophytic impingement. These should typically be reserved for cases where conservative care has failed to resolve the problem. Shoulder pain/restriction attributed to “subacromial girdle” (acromioclavicular and glenohumeral joint) lesion (pain & restriction with specific localized findings)  A-C joint disorders – Radiographs not initially indicated of non-traumatic origin. Adhesive capsulitis  Radiographs are not routinely indicated, but may be used to exclude complicating factors. Dislocation  Glenohumeral dislocation – Typically results from significant soft tissue injury. Conventional x rays can usually establish the presence of dislocation, however, not instability. In Washington State, occupational conditions that may be a result of cumulative workplace exposure across multiple employers may have claim and experience Work costs apportioned to both former and current employers. Worker and employer appeals rights can factor into adjudication decisions and 62, 63 Relatedness contribute to delays that are associated with worse outcomes. Exposure: Workplace activities that contribute to or cause shoulder conditions, and 2.

Theyunderstandwhatisbeing saidandthegram m aticalconstructionof theirspeech isnorm al propranolol 80mg mastercard blood pressure medication infertility. W henlanguageareasinthedom inanthem ispherearedam aged order propranolol 40mg overnight delivery blood pressure when to go to er,thereisdisturbanceof understanding and/orex pressionof words 40 mg propranolol visa blood pressure stroke range. D isturbedarticulationm ayresultfrom locallesionsof thetongue cheap 80 mg propranolol amex blood pressure up after exercise,lipsorm outh,ill-fitting denturesorfrom anydisruptionof theneurom uscular pathways. Thisis characteriz edbyasm all,spastic tongueanddifficultypronouncing consonantsandisoftenaccom paniedbyapositivejaw jerkandem otional lability. Bulbarpalsyistheresultof lowerm otorneuronelesionsaffecting thesam egroup of cranialnerves. Thenatureof thespeech disturbanceis determ inedbywhich nervesandm usclesareinvolved. D ysphasias A natom y Thelanguageareasarelocatedinthedom inantcerebralhem isphere,which istheleftinthevastm ajorityof right-handedandm ostleft-handed people. Thereispoorcom prehensionandalthough speech m aybefluentit m aybem eaninglessandcontainparaphasiasandneologism s. C onductiondysphasiaisduetodam agetothearcuatefasciculusand,whilecom prehensionandunderstanding m aybeintact,thepatientis unabletorepeatwordsorphrasesspokenbytheex am iner. D om inantparietallobelesionsaffecting thesupram arginalgyrusandrelatedareasm aycausedifficultycom prehending writtenlanguage (dyslexia),problem swith sim pleadditionandsubtraction(dyscalculia)andim pairm entof writing (dysgraph ia). Stiffnessorrestrictedm ovem entof theneckorlum barregionm ayresultfrom variouscausesdescribedinex am inationof thespineinChapter10. Inflam m ationorirritationof them eningescanleadtoincreasedresistancetopassiveflex ionof theneckandtheex tendedleg. If neckstiffnessispresentitisnotpossibletopassivelyflex theneckfullyandyou m ayfeelspasm intheneckm uscles. E x am inetheoptic fundiforpapilloedem a(alatesignof raisedintracranialpressure,andabsenceof papilloedem adoesnotex cluderaisedintracranialpressure). E x am ineforfocalneurologicalsigns(cerebralh aemorrh age,haem orrhageintointracranialtumour). Bipolarcellsintheolfactorybulb form olfactoryfilam entswith sm allreceptorsprojecting through the cribriform platehigh inthenasalcavity. Thesecellssynapsewith secondorderneuroneswhich projectcentrallyviatheolfactorytracttothem edial tem porallobeandipsilateralam ygdaloidbody. Providedthatthepatientdoesnothavenasalcongestionordisease,lossof thesenseof sm ell (anosmia)m ayresultfrom shearing dam agetotheolfactoryfilam entsaftersevereheadinjury,localcom pressionorinvasionbycancer. Itisuncom m onbutm ayoccurafterhead traum a,sinusinfectionorasaside-effectof drugs. Photoreceptorssynapsewith theverticallyorientatedbipolarcellsof theretinawhich inturnsynapsewith theganglioncellsof theoptic nerve (F ig. Initiallyunm yelinated,the nervefibresof theoptic nervem yelinateonleaving theeyethrough theoptic disc. Passing through theorbit,theoptic nerveisliabletocom pression from enlargedocularm uscles. Theoptic tractsterm inatebysynapsing with thelateralgeniculatebodiesof thethalam us. A few fibresleavethetractbeforethelateralgeniculatenucleusas partof theafferentlim b of thepupillaryreflex. Theoptic radiationspassthrough theposteriorinternalcapsule toenterthecerebralhem isphereviatheparietalandtem porallobestotheoccipitalcortex (F ig. Theparasym pathetic fibresfrom theE dinger-W estphalnucleusform partof theoculom otornerveandareinvolvedintheefferentsupplyof thepupillaryreflex es(F ig. Although each nervecontrols discreteactionstheyareex am inedtogetherbecauseof theirclosefunctionalinterrelationships. Itpassesjustbelow thefreeedgeof thetentorium inrelationtotheposteriorcom m unicating arteryandentersthedurasurrounding thecavernoussinus. Through theparasym pathetic fibresarising from theE dinger-W estphalnerves,thenervealsoindirectlysupplies thesphincterm usclesof theiriscausing constrictionof thepupil,andtheciliarym usclewhich isresponsibleforfocusing thelensfornearvision (accom m odation). F orex ample,apatientwhose diplopiaismax imum onlooking downandtotherighthaseitheraweakrightinferiorrectusoraweakleftsuperioroblique. Theautonom ic nervoussystem andintegrityof theiris determ inetheresting siz eof thepupil. Theefferentlim b involvestheinferiordivisionof thethirdnerve,passing through theciliary ganglionintheorbittoterm inateintheconstrictorm uscleof theiris. W ith parasym pathetic stim ulation(thefibresof which travelwith thethirdnerve)theoppositeoccurs. Sensationfrom thecornea,conjunctivaandintraocularstructuresareconveyedbytheophthalm ic branch (V1)of thetrigem inalnerve. Jerk nystagm us ischaracterisedbyoscillationswhich haveaslow initiating phaseandafastcorrectivephase. Centrallesionsinthebrainstem orcerebellum producebidirectionalnystagm us(thedirectionof nystagm uschangeswith thedirectionof gaz e) which isunaffectedbyvisualfix ation. L esionsof them ediallongitudinalfasciculusintheponsproducenystagm usinthecontralateralabducting eyealong with im pairedadductionof theipsilateraleye. Inspection L ookat: headposition positionof eyelidswhenlooking straightaheadandoneyem ovem ent proptosis periorbitalappearance lacrim alapparatus eyelidm argin conjunctiva sclera cornea resting appearanceof pupils. C om m onabnorm alities Congenitalandlongstanding paralytic squintsoftenresultinabnormalh ead postureswith theheadturnedortiltedtom inim iz ethediplopia.