RENAL FAILUIRE--------- RISK FOR EXCESS FLUID VOLUME.

due to decrease kidney function The causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with an ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume.

Causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respirations
or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigations, is at risk for excess fluid volume.

OB Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.

Mild anemia is considered when hemoglobin is between 9.5 - 13.0 g/dLModerate anemia is considered when hemoglobin is between 8.0 - 9.5 g/dL Severe anemia is considered for hemoglobin concentrations below 8.0 g/dL ABRUPTIO PLACENTA Uterine tenderness accompanies placental abruption, especially with a central abruption and trappedblood behind the placenta. The abdomen will feel hard and board-like on palpation

Several factors are associated with preterm labor. These include a history of medical conditions, present and past obstetric problems, social and environmental factors, and demographic factors such as race and age. Other risk factors include a multifetal pregnancy, which contributes to overdistention of the uterus, anemia, which decreases oxygen supply to the uterus, and age younger 18 years or first pregnancy older than the age of 40.

Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft, relaxed, nontender uterus, and the fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, in abruptio placentae, the abdomen will feel hard and board-like on palpation as the blood penetrates the myometrium and causes uterine irritability.

Lochia, the discharge present after birth, is red for the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor or an odor similar to menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. The other options are normal findings for a 1-day postpartum client. The priority nursing diagnosis for a client who delivered 2 hours ago and who has a midline episiotomy and hemorrhoids is acute pain. Most clients have some degree of discomfort during the immediate postpartum period. There is no data in the question that indicate the presence of Disturbed body image, Impaired urinary elimination, Risk for imbalanced fluid volume.

Features of newborn infants diagnosed with fetal alcohol syndrome include craniofacial abnormalities, intrauterine growth retardation, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal assessment findings in the full-term newborn infant.

The neonate born to a diabetic mother is at risk for hypoglycemia so risk for injury related to low blood glucose levels would be a priority nursing diagnosis. The infant would also be at risk for hyperbilirubinemia, respiratory distress, hypocalcemia, and congenital anomalies. Hyperthermia, risk for delayed development, and risk for aspiration are not expected problems.

Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden drop in fetal heart rate and maternal heart rate and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L. Proteinuria of 3+ is likely to be noted in a client with preeclampsia.

Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

In the law and order orientation of Kohlbergs theory, the child has more concern with society as a whole and emphasis is on obeying laws to maintain social order. The child wants to be considered good by persons whose opinions matter to them. Option 1 is the only option that reflects these criteria. Options 2, 3, and 4 are unrelated to the law and order orientation.

Children should remain in a booster seat until they are 8 to 12 years old and at least 4 feet, 9 inches tall. An infant should ride in a car in a semireclined, rear-facing position in an infant-only seat or a convertible seat until they weigh at least 20 lb and are at least 1 year of age. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg (20 lb) and 1 year of age. Convertible car safety seats are used until the child weighs at least 40 lb

By age 2 years, the child can use a cup and spoon correctly but with some spilling. By age 3 to 4, the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and begin to use a knife for cutting.Bowel control usually is achieved before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness. The physical ability to control the anal and urethral sphincters is achieved some time after the child is walking, probably between the age of 18 and 24 months.

Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as mama occurs between 9 and 12 months of age. Linking syllables together when communicating occurs between 6 and 9 months of age. Cooing begins at birth and continues until 2 months of age. 146 Hot liquids should never be left unattended

Changes in mental status and confusion are commonly associated with infections in the older adult. Assessments of the pulmonary and renal systems would be the priority. The older adult is at risk for pneumonia. The lungs should be auscultated for decreased breath sounds and other adventitious sounds. Urinary tract infections are also common in older adults, especially women. Flank pain with frequency and urgency are symptoms. The urine should be monitored for cloudiness, odor, and other changes indicating hematuria. Based on the data in the question, the body systems identified

The older client is at risk for medication toxicity because of decreased lean body mass and an ageassociated decreased glomerular filtration rate. Although options 1, 2, and 3 identify age-related changes that occur in the older client, they are not associated specifically with this risk.

Many nonpharmacologic sleep aids can be used to influence sleep. The client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The client should exercise regularly, because exercise promotes sleep by burning off tension that accumulates during the day. A 20- to 30-minute walk, swim, or bicycle ride three times a week is helpful. The client should sleep on a bed with a firm mattress. Smoking and alcohol should be avoided.

The client should avoid large meals, peanuts, beans, fruit and raw vegetables that produce gas, and snacks high in fat that are difficult to digest.

156 Short-term memory may decline with age, but long-term memory usually is maintainedThe vomiting that occurs in Reyes syndrome is caused by cerebral edema and is a symptom of increased intracranial pressure. Small frequent meals will not affect the amount of vomiting but, if vomiting occurs, the parents should contact the health care provider. Decreasing stimuli and providing rest decrease stress on the brain tissue. Checking for jaundice will assist in identifying the presence of liver dysfunction that occurs in Reyes syndrome.

Autistic disorder is a complex childhood disorder that involves abnormalities in behavior, social interactions, and communication. Autistic children are unable to relate to persons or to respond to social and emotional cues.

Characteristically, these children engage in repetitive behaviors, including head banging, twirling in circles, biting themselves, and flapping their hands or arms. Abnormal communication patterns include verbal and nonverbal communication. A child with autism needs decreased stimulation, with

limited visual and auditory distractions. A private room would be the best environment, allowing for control of visual and auditory distractions. The semiprivate and four-bed ward rooms would be too stimulating for the child with autism. Autism is not a disorder that requires contact isolation. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the nature of the injury, there is a high risk of secondary infection and the probability of the catheter entering the brain through the fracture. Fluid balance is monitored closely by daily weight, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on an NPO status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications if necessary.

Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing cerebrospinal fluid obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure, turbid or cloudy cerebrospinal fluid, and elevated leukocyte, elevated protein, and decreased glucose levels.

The most likely assessment findings in sexual abuse include difficulty walking or sitting; torn, stained, or bloody underclothing; pain, swelling, or itching of the genitals; and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may indicate physical neglect. Bald spots on the scalp and fear of the parents most likely are associated with physical abuse. Absence seizures ( PETI-MAL SEIZURE) are brief episodes of altered awareness. No muscle activity occurs except eyelid fluttering or twitching. The child has a blank facial expression. These seizures last only 5 to 10 seconds, but they may occur one after another several times a day. Myoclonic seizures are brief random contractions of a muscle group that can occur on one or both sides of the body. Simple partial seizures consist of twitching of an extremity, face, or neck, or the sensation of twitching or numbness in an extremity or face or neck. Newborn infants with spina bifida (myelomeningocele type) are at risk for hydrocephalus; herefore, the head circumference should be measured to obtain a baseline. Options 1, 2, and 3 are incorrect because pulse rate will not be affected with this disorder, the specific gravity can indicate hydration status but it is not priority at this time, and abdominal masses do not occur with this disorder. Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Conjunctivitis is an inflammation of the conjunctiva. A diagnosis of chlamydial conjunctivitis in a child who is not sexually active should signal the health care provider to assess the child for possible sexual abuse. Allergy, infection, and trauma can cause conjunctivitis, but the causative organism is not likely to be chlamydia.

A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. Parents need to be instructed that the child should not blow his or her nose for 7 to 10 days. Bath and lake water are potential sources of bacterial contamination. Diving and swimming in deep water are prohibited. The childs ears need to be kept dry. Options 1, 2, and 3 are appropriate instructions

Because the tonsillar area is so vascular, postoperative bleeding is a concern. The prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding. The creatinine level, sedimentation rate, and blood urea nitrogen would not determine the potential for bleeding.

After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction because of the risk of trauma to the oropharynx. Monitoring for bleeding is an important nursing intervention following any type of surgery. Milk and milk products are avoided initially because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. Clear, cool liquids are encouraged.

myringotomy Antibiotics are not tapered but are administered for the full course of therapy. Weight is the most reliable method of measurement of body fluid loss or gain. A weight change of 1 kg represents 1 L of fluid loss or gain. Although options 2, 3, and 4 identify components of the assessment for dehydration, these are not the most reliable determinants, because they require more subjective interpretation than weight, which is more objectively determined.

Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and a sore throat. Option 4 is an incorrect position. Options 1 and 3 are incorrect because epiglottitis causes a high fever and tachycardia. In a sweat test, sweating is stimulated on the childs forearm with pilocarpine, the sample is collected on absorbent material, and the amounts of sodium and chloride are measured. A sample of at least 50 mg of sweat is required for accurate results. A chloride level higher than 60 mEq/L is considered to be a positive test result. A chloride level of 40 mEq/L suggests cystic fibrosis and requires a repeat test. A chloride level of less than 40 mEq/L indicates no cystic fibrosis.

Croup often begins at night and may be preceded by several days of upper respiratory infection symptoms. Croup is characterized by a sudden onset of a harsh, brassy cough, sore throat, and inspiratory stridor. Symptoms usually worsen at night and are better in the day. Croup usually is accompanied by a low-grade fever, but occasionally the temperature may be as high as 104 F.

The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods of time. Pallor may be noted but is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to rheumatic fever. Anti-inflammatory agents, including aspirin, may be prescribed for the child with rheumatic fever. Aspirin should not be given to a child who has chickenpox or other viral infections, such as the flu. Options 1 and 2 are clinical manifestations of rheumatic fever. Facial edema may be associated with the development of a cardiac complication.

A diagnosis of rheumatic fever is confirmed by the presence of two major manifestations or one major and two minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive antistreptolysin O titer, Streptozyme assay, or an anti-DNase B assay. Options 1, 2, and 3 will not help to confirm the diagnosis of rheumatic fever.

In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. In addition, the parents should be instructed that if a dose is missed and is not identified until 4 hours later, the dose should not be administered. Immune globulin is administered intravenously to the child with Kawasaki disease to decrease the incidence of coronary artery lesions and aneurysms and to decrease fever and inflammation. Options 1, 3, and 4 are not components of the treatment plan for this disease.

The early signs of congestive heart failure (CHF) include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in CHF as a result of mucosal swelling and irritation but is not an early sign. Pallor may be noted in the infant with CHF but is also not an early sign.

Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures. Options 1, 2, and 3 are not likely to produce crying in the infant.

Any child who exhibits the 3 Cscoughing and choking with feedings and unexplained cyanosisshould be suspected of tracheoesophageal fistula.

Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration, including a decrease in urine output.

Intussusception is a telescoping of one portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. The child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly like stools.

Renal function is monitored closely during the administration of chelation therapy because the medications are excreted via the kidneys. Although it is important to monitor the red blood cell count for the presence of anemia in a child with lead poisoning, this laboratory result is not specific to chelation therapy. Options 1 and 4 are unrelated to the administration of chelation therapy.

The mother is taught the ESSR method of feeding the child with a cleft palate: enlarge the nipple, stimulate the sucking reflex, swallow, and rest to allow the infant to finish swallowing what has been placed in the mouth. Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall to the right of the umbilical cord. There is no membrane covering the exposed bowel. Surgical repair will be done as soon as possible because of the risk of infection in the unprotected bowel. Therefore, the highest risk immediately after delivery would be infection. Risk for impaired parenting and riskfor disorganized infant behavior are possible later nursing problems, but they would not have priority. Risk for impaired urinary elimination is unlikely because the gastrointestinal tract is affected, not the genitourinary system.

In the preoperative period, enemas or laxatives should not be administered. Additionally, heat is not applied to the abdomen. Any of these interventions can cause rupture of the appendix and resultant peritonitis. IV fluids would be started, and the child would be NPO while awaiting surgery. Usually, antibiotics are administered because of the risk of perforation. Prescribed preoperative medications most likely would be administered on call to the operating room. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hr, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for the child with dehydration, these assessments are not related specifically to the intravenous (IV) administration of potassium chloride.

Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath and a decreasing level of consciousness. Hunger can be a sign of hypoglycemia or hyperglycemia, but hypertension is not a sign of diabetic ketoacidosis. Instead, hypotension occurs because of a decrease in blood volume related to the dehydrated state that occurs during diabetic ketoacidosis. Cold, clammy skin, irritability, sweating, and tremors are all signs of hypoglycemia.

Phenylketonuria is characterized by blood phenylalanine levels higher than 8 mg/dL. A normal level is lower than 2 mg/dL. A result of 1 mg/dL is a negative test result. To help decrease variations in absorption from day to day, the adolescent should use one major site for injections for 2 to 3 weeks before changing major sites. The injections are rotated to different locations within that major site. Options 1, 2, and 3 are incorrect. Rehydration is the initial step in resolving diabetic ketoacidosis. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level reaches an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment. Hemolytic-uremic syndrome (HUS) is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute renal failure in children. Clinical features of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria will be on fluid restriction. Pain is not associated with hemolytic-uremic syndrome and potassium would be restricted, not encouraged, if the child was anuric. Peritoneal dialysis does not require an AV shunt (only hemodialysis). Orchiopexy All vigorous activities should be restricted for 2 weeks following surgery to promote healing and prevent injury. This will prevent dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; therefore, allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parent should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output. In bladder exstrophy, the bladder is exposed and external to the body. The highest priority is impaired tissue integrity related to the exposed bladder mucosa. Although the infant needs to be monitored for elimination patterns and kidney function, option 3 is not a concern for this condition. Parental knowledge deficit related to the diagnosis and treatment of the condition will need to be addressed but again is not the priority. Although infection related to the anatomical location of the defect is an appropriate nursing diagnosis, it is a potential problem and not an actual one. In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate

tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed. Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A beta-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, the child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The assessment data in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis.

Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or red-brown urine, is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.

Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight.Sensorium is an accurate guide to determine the adequacy of fluid resuscitation. The burn injury itself does not affect the sensorium, so the child should be alert and oriented. Any alteration in sensorium should be evaluated further. A neurological assessment would determine the level of sensorium in the child. Options 1, 3, and 4 would not provide an accurate assessment of the adequacy of fluid resuscitation.

Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and firmly attach to the hair shaft near the scalp. The occiput is an area in which nits can be seen. White flaky particles are indicative of dandruff. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis.

Eczema is a superficial inflammatory process involving primarily the epidermis. The major goals of management are to relieve pruritus, lubricate the skin, reduce inflammation, and prevent and control secondary infection. Secondary infection can occur when areas affected by eczema are scratched as a result of the itching because open skin is a portal of entry for pathogens. The lesions are not viral and they do not present as thick white crusty plaques. They appear as red and scaly lesions that can weep, ooze, and crust. They commonly occur in the antecubital and popliteal areas. Throat edema and mouth ulcers are not characteristics of this disorder. Scabies appears as burrows or fine, grayish-red, thread-like lines. They may be difficult to see if they are obscured by excoriation and inflammation. Purple-colored lesions may indicate various disorders, including systemic conditions. Thick, honey-colored crusts are characteristic of impetigo or secondary infection in eczema. Clusters of fluid-filled vesicles are seen in herpesvirus infection. Lindane is contraindicated for children younger than 2 years. These children have more permeable skin and high systemic absorption may occur, placing the child at risk for central nervous system toxicity and seizures. Lindane also is used with caution in children between the ages of 2 and 10 years. Siblings and other household members also should be treated at the same time. Options 2 and 4 are unrelated to the use of lindane.

Lindane is not recommended for use by a breast-feeding woman because the medication is secreted into breast milk.

Impetigo is most common during hot, humid summer months. Impetigo may begin in an area of broken skin, such as an insect bite or atopic dermatitis. Infection may be caused by Staphylococcus aureus, group A beta-hemolytic streptococci, or a combination of these bacteria. Impetigo is extremely contagious. Lesions usually are located around the mouth and nose but may be present on the hands and extremities. Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome. Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as those to relieve pain, may be prescribed depending on the source of bleeding from the disorder. A child with hemophilia A will be at risk for joint bleeding after a fall. Factor VIII will be prescribed intravenously to replace the missing clotting factor and minimize the bleeding. Desmopressin (DDAVP) is used to stimulate production of factor VIII, but it is not given intravenously. Factor X and cryoprecipitate are not used for clients with hemophilia A.

Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Therefore, abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time. The platelet count, hemoglobin level, and hematocrit level are normal in hemophilia. -Thalassemia is an autosomal recessive disorder characterized by the reduced production of one of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with thalassemia major). The major complication of chronic transfusion therapy is hemosiderosis. To prevent organ damage from too much iron in the blood, chelation drug therapy with deferoxamine (Desferal) is used. Deferoxamine is classified as an antidote for acute iron toxicity. Dalteparin is an anticoagulant used as prophylaxis for postoperative deep vein thrombosis. Meropenem is an antibiotic. Metoprolol is a blocker used to treat hypertension.

Sickle cell anemia is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape and the cells become rigid and clumped together, obstructing capillary blood flow. Therefore, oral and intravenous fluids are an important part of treatment.

10

Meperidine (Demerol) is not recommended for the child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would thus question the order for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain in painful joints, oxygen, and a high-calorie, highprotein diet are also important parts of the treatment plan.

von Willebrand disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor (vWF). The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding. An elevated creatinine level is not associated with this disorder. Clinical manifestations specifically associated with Hodgkins disease include painless, firm, and movable adenopathy in the cervical and supraclavicular areas. Hepatosplenomegaly also is noted. Although fever, malaise, anorexia, and weight loss are associated with Hodgkins disease, these manifestations are seen in many disorders. Vital signs and neurological status are assessed frequently. Special attention is given to the childs temperature, which may be elevated because of hypothalamic or brainstem involvement during surgery. A cooling blanket should be in place on the bed or readily available if the child becomes hyperthermic. Options 1 and 3 are related to functional deficits following surgery. Orthostatic hypotension is not a commoclinical manifestation following brain surgery. An elevated blood pressure and widened pulse pressure may be associated with increased intracranial pressure, which is a complication following brain surgery.

The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies. The CD4+ cell count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection, such as pneumonia.

IPV (intravenous polio vaccine) contains neomycin. A history of an anaphylactic reaction to neomycin is considered a contraindication to IPV. The presence of a minor illness such as the common cold is not a contraindication. In addition, a history of frequent respiratory infections is not a contraindication to receiving a vaccine. A local reaction to an immunization is not a contraindication to receiving a vaccine. The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal stage. Options 1, 2, and 4 are accurate descriptions of rubeola. The small bluewhite spots found in this communicable disease are called Kopliks spots. Option 3, the incorrect option, describes the incubation period for rubella, not rubeola. The general contraindications for vaccines include a previous anaphylactic reaction to a vaccine or a component of a vaccine or the presence of a severe illness. The other items listed are not contraindications to receiving a vaccine.

Pastias sign describes a rash seen in scarlet fever that will blanch with pressure except in areas of deep creases and the folds of joints. The tongue initially is coated with a white furry covering, with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off, leaving a red swollen tongue (strawberry tongue). The pharynx is edematous and beefy red.

11

Kopliks spots are associated with rubeola (measles). These are small red spots with a bluish white center and a red base located on the buccal mucosa. Petechial red, pinpoint spots occurring on the soft palate are characteristic of rubella (German measles).

Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces. Warm compresses may be used to decrease the discomfort, erythema, and edema. After tissue and blood cultures are obtained, antibiotics will be initiated. The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia. Heat lamps can cause more disruption to already inflamed tissue. Cold compresses and alternating cold and hot compresses are not the best measures.

Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation will control the bleeding, but occasionally an artery is damaged and may require ligation. Formation of granulation tissue is not the intent of an escharotomy. Escharotomy will not affect the formation of edema

Fluid management during the first 24 hours following a burn injury generally includes the infusion of a balanced salt solution, usually lactated Ringers solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30 mL/hr. The clients urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, the physician would prescribe an increase in the amount of IV lactated Ringers solution administered per hour. Administering a diuretic would not correct the problem because it would not replace needed fluid. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Dextrose in water is an isotonic solution and an isotonic solution maintains fluid balance. This type of solution may be administered after the first 24 hours following the burn injury, depending on the clients physiological needs. Blood replacement is not consistent with fluid therapy for burn injuries.

The emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys, and renal perfusion and glomerular filtration are decreased, resulting in low urine output. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts.

Carbon monoxide levels between 11% to 20% result in flushing, headache, decreased visual activity, decreased cerebral functioning, and slight breathlessness; levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, tachycardia; levels of 41% to 60% result in seizure and coma; and levels higher than 61% result in death.

12

If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Options 1, 2, and 3 are incorrect.

Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. The most reliable indicator for determining adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL.

Acyclovir is a topical antiviral agent that inhibits DNA replication in the virus. Acyclovir has activity against herpes simplex virus types 1 and 2, varicella-zoster virus, Epstein-Barr virus, and cytomegalovirus. Gentamicin sulfate is an antibacterial and would not be effective in treating herpesvirus. Mupirocin calcium is a topical antibacterial active against Staphylococcus aureus, betahemolytic streptococci, or Streptococcus pyogenes. Salicylic acid is a keratolytic.

Coal tar is used to treat psoriasis and other chronic disorders of the skin. Coal tar suppresses DNA synthesis, mitotic activity, and cell proliferation. Coal tar has an unpleasant odor, frequently stains the skin and hair, and can cause phototoxicity. Systemic toxicity does not occur.

Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication should be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn inuury.

Sodium hypochlorite is a solution used for irrigating and cleaning necrotic or purulent wounds. It cannot be used to pack purulent wounds because the solution is inactivated by copious pus. The solution should not come into contact with healing or normal tissue and should be rinsed off immediately following irrigation. The solution loses its potency during storage, so fresh solution should be prepared frequently.

Dextranomer is a cleansing rather than a dbriding agent that is effective for wet wounds only. Dextranomer is not packed tightly into the wound because maceration of surrounding tissue may result.

Fibrinolysin and desoxyribonuclease (Elase) is used to dbride wounds, including burns, pressure ulcers, and inflamed or infected lesions. Dextranomer (Debrisan) is not a dbriding agent but is a cleansing agent that actually absorbs peptides and proteins. Nitrofurazone (Furacin) and silver sulfadiazine (Silvadene) are antibacterials and are not used for wound debridement

13

Risk factors for cervical cancer include human papillomavirus (HPV) infection, active and passive cigarette smoking, certain high-risk sexual activities (first intercourse before 17 years of age, multiple sex partners, or male partners with multiple sex partners). Screening via regular gynecological exams and Papanicolaou smear (Pap test) with treatment of precancerous abnormalities decrease the incidence and mortality of cervical cancer.

Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma. Hodgkins disease is a disorder of young adults. Options 1, 3, and 4 are characteristics of this disease.

Alopecia is not an assessment finding in testicular cancer. Alopecia may occur, however, as a result of radiation or chemotherapy. Options 2, 3, and 4 are assessment findings in testicular cancer. Back pain may indicate metastasis to the retroperitoneal lymph nodes. Hodgkins disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease.

Clinical manifestations of ovarian cancer include abdominal distention, urinary frequency and urgency, pleural effusion, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, constipation, ascites with dyspnea, and ultimately general severe pain. Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.

Conization procedure involves removal of a cone-shaped area of the cervix. Complications of the procedure include hemorrhage, infection, and cervical stenosis. Ovarian perforation is not a complication

Hypercalcemia is a serum calcium level higher than 10 mg/dL, most often occurs in clients who have bone metastasis, and is a late manifestation of extensive malignancy. The presence of cancer in the bone causes the bone to release calcium into the bloodstream.

Arm edema on the operative side (lymphedema) is a complication following mastectomy and can occur immediately postoperatively or may occur months or even years after surgery. Options 1, 3, and 4 are expected occurrences following mastectomy and do not indicate a complication. Pg.315 Saunders The most common risk factor associated with laryngeal cancer is cigarette smoking. Heavy alcohol use and the combined use of tobacco increase the risk. Another risk factor is exposure to environmental pollutants.

14

A vesicovaginal fistula is a genital fistula that occurs between the bladder and vagina. The fistula is an abnormal opening between these two body parts and, if this occurs, the client may experience drainage of urine through the vagina. The clients complaint is not associated with options 1, 3, and 4.

A high-fat diet plays a role in the development of cancer of the pancreas not in the gastric cancer smoking belongs to Gastric CA. Options 1, 3, and 4 are risk factors related to gastric cancer.

Colorectal cancer risk factors include age older than 50 years, a family history of the disease, colorectal polyps, and chronic inflammatory bowel disease.

Vague abdominal discomfort or crampy, colicky abdominal pain is a characteristic symptom of a right colon tumor. Options 1, 2, and 4 are symptoms associated with left colon tumors. To reduce the risk of contamination at the time of surgery, the bowel is emptied and cleansed. Laxatives and enemas are given to empty the bowel. Intestinal anti-infectives such as neomycin or kanamycin (Kantrex) are administered to decrease the bacteria in the bowel.

Air conditioners need to be avoided to protect from excessive coldness. A humidifier in the home should be used if excessive dryness is a problem. Options 1, 2, and 4 are appropriate interventions regarding stoma care following radical neck dissection and creation of a tracheotomy.

The incidence of bladder cancer is greater in men than in women and affects the white population twice as often as blacks. The most common symptom in clients with cancer of the bladder is hematuria. The client also may experience irritative voiding symptoms such as frequency, urgency, and dysuria, and these symptoms often are associated with carcinoma in situ. Superior vena cava syndrome -PEriorbital edema is an early sign occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client complaints of tightness of a shirt or blouse collar. As the compression worsens the client experiences edema of the hands and arms. Mental status changes and cyanosis are late signs.

Cancer is a common cause of syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a mechanism of action that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal. Bleeding precautions need to be initiated when the platelet count decreases. The normal platelet count is 150,000 to 450,000/mm3. When the platelets are lower than 50,000 /mm3, any small trauma can lead to episodes of prolonged bleeding. The normal white blood cell count is 5,000 to 10,000/mm3. When the

15

white blood cell count drops, neutropenic precautions need to be implemented. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 15 to 45 mcg/dL.

Hyperuricemia is especially common following treatment for leukemias and lymphomas because chemotherapy results in
massive cell kill. Although options 1, 2, and 4 also may be noted, an increased uric acid level is related specifically to cell destruction.

Cardiotoxicity noted by abnormal electrocardiographic findings or cardiomyopathy manifested as congestive heart failure is a toxic effect of daunorubicin. Bone marrow depression is also a toxic effect. Nausea and vomiting is a frequent side effect associated with the medication that begins a few hours after administration and lasts 24 to 48 hours. Fever is a frequent side effect and diarrhea can occur occasionally. Options 1, 2, and 3, however, are not toxic effects.

To ensure that the client receives optimal doses of chemotherapy, dosing is usually based on the total body surface area (BSA), which requires a current accurate height and weight for BSA calculation (before each medication administration). Asking the client about his or her height and weight may lead to inaccuracies in determining a true BSA and dosage. Calculating body mass index and measuring abdominal girth will not provide the data needed.

Bleomycin (Blenoxane) is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. Pulmonary function studies along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and crackles, which indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Cisplatin (Platinol) is an alkylating type of medication and vincristine (Oncovin, Vincasar PFS) is a vinca (plant) alkaloid. Alkylating medications are cell cycle phase-nonspecific. Vinca alkaloids are cell cycle phase-specific and act on the M phase. Combinations of medications are used to enhance tumoricidal effects and increase the therapeutic response. High concentrations of methotrexate harm and damage normal cells. To save normal cells, leucovorin is given, which is known as leucovorin rescue. Leucovorin bypasses the metabolic block caused by methotrexate, thereby permitting normal cells to synthesize. Note that leucovorin rescue is potentially hazardous. Failure to administer leucovorin in the right dose at the right time can be fatal. A side effect specific to vincristine is peripheral neuropathy, which occurs in almost every client. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation rather than diarrhea is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication

Tamoxifen (Nolvadex) is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen is used to treat metastatic breast carcinoma in women and men. Tamoxifen is also effective in delaying the recurrence of cancer following mastectomy. Tamoxifen reduces DNA synthesis and estrogen response.

16

Tamoxifen (Nolvadex) may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium levels should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, deep bone, and flank pain. Megestrol acetate (Megace) suppresses the release of luteinizing hormone from the anterior pituitary by inhibiting pituitary function and regressing tumor size. Megestrol is used with caution if the client has a history of thrombophlebitis. Options 1, 2, and 4 are not contraindications for this medication. Shakiness is a sign of hypoglycemia and would indicate the need for food or glucose. A fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL, the infusion rate is reduced and 5% dextrose is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. NPH insulin is not used to treat DKA. Fifty percent dextrose is used to treat hypoglycemia. Phenytoin (Dilantin) is not a usual treatment measure for DKA.

Levothyroxine (Synthroid) is a synthetic thyroid hormone that increases cellular metabolism. Levothyroxine should be given in the morning in a single dose to prevent insomnia and should be given at the same time each day to maintain an adequate drug level. Hyperglycemic hyperosmolar nonketotic syndrome occurs in clients with type 2 diabetes mellitus. The onset of symptoms may be gradual. The symptoms may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. Options 1, 2, and 3 are incorrect interpretations of the clients symptoms. CAPILLARY GLUCOSE LEVEL - FOR DM TYPE 1 & 2

Hypercalcemia is the hallmark of hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria.

DM type 1 hypoglycemia- Tremors / Hyperclycemia-Hot dry skin

Pheochromocytoma is a catecholamine-producing tumor. Hypertension is the major symptom associated with pheochromocytoma. Taking the clients blood pressure would assess the blood pressure status. Glycosuria, weight loss, and diaphoresis are also clinical manifestations of pheochromocytoma, yet hypertension is the major symptom. Assays of catecholamines are performed on single-voided urine specimens, 2- to 4-hour specimens, and 24-hour urine specimens. The normal range of urinary catecholamines is up to 14 mcg/100 mL of urine, with higher levels occurring in pheochromocytoma. The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, renal failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the presence of a dysrhythmia. A urinary output of 50 mL/hr is an adequate output. A blood urea nitrogen level of 20 mg/dL is a normal finding. A coagulation time of 5 minutes is normal.

17

An elevated temperature may indicate infection. Infection is a leading cause of hyperglycemic hyperosmolar nonketotic syndrome or diabetic ketoacidosis. The other findings noted in the question are within normal limits.

Clients with type 2 diabetes mellitus have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to these clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of the insulin by digestion. Options 1, 2, and 3 are incorrect. A diet low in carbohydrates and sodium but ample in protein and potassium is encouraged for a client with Cushings syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue. Prednisone causes hyperglycemia./ Aspirin, anti-histamine & OTC meds is contraindicated. Glucocorticoids can elevate blood glucose levels. Clients with diabetes mellitus may need their dosages of insulin or oral hypoglycemic medications increased during glucocorticoid therapy Water intoxication (overhydration) or hyponatremia is an adverse reaction to desmopressin. Early signs include drowsiness, listlessness, and headache. Because of its powerful vasoconstrictor actions, vasopressin can cause adverse cardiovascular effects. By constricting arteries of the heart, vasopressin can cause angina pectoris and even myocardial infarction, especially if administered to clients with coronary artery disease. In addition, vasopressin may cause vascular problems by decreasing blood flow in the periphery.

Propylthiouracil (PTU) inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves disease. Myxedema indicates hypothyroidism. Cushings syndrome and Addisons disease are disorders related to adrenal function. An adverse effect of somatropin (Humatrope) is hypothyroidism. Thyroid function is monitored throughout therapy. Options 1 and 2 would evaluate pancreatic function, and option 3 evaluates renal function.

Meperidine (Demerol) rather than morphine sulfate is the medication of choice to treat pain because morphine sulfate can cause spasms in the sphincter of Oddi. Options 1, 2, and 4 are appropriate interventions for the client with acute pancreatitis. COLONOSCOPY The client should not drive for several hours after discharge because the client would have received sedative medications during the procedure. Important decisions also should be delayed for at least 24 hours for the same reason. The client should resume intake slowly and progress as tolerated. The client may experience gas, bloating, or abdominal tenderness for a short while after the procedure, and this is normal.

Chronic gastritis causes deterioration and atrophy of the lining of the stomach, leading to the loss of the function of the parietal cells. The source of the intrinsic factor is lost, which results in the inability to absorb vitamin B12. This leads to the development of pernicious anemia. The client is not at risk for vitamin A, C, or E deficiency. Indomethacin (Indocin) CONTAINDICATED WITH ACUTE GASTRITIS. INDOMETHACIN is a nonsteroidal anti-inflammatory drug and can cause ulceration of the esophagus, stomach, or small intestine. Indomethacin is contraindicated in a client with gastrointestinal disorders. Furosemide (Lasix)

18

is a loop diuretic. Digoxin is a cardiac medication. Propranolol (Inderal) is a -adrenergic blocker. Furosemide, digoxin, and propranolol are not contraindicated in clients with gastric disorders.

Perforation of an ulcer is a surgical emergency and is characterized by sudden, sharp, intolerable severe pain beginning in the midepigastric area and spreading over the abdomen, which becomes rigid and board-like. Nausea and vomiting may occur. Tachycardia may occur as hypovolemic shock develops. Numbness in the legs is not an associated finding.

In a Billroth II (gastrojejunostomy) procedure, the proximal remnant of the stomach is anastomosed to the proximal jejunum. Patency of the nasogastric tube is critical for preventing the retention of gastric secretions. The nurse should never irrigate or reposition the gastric tube after gastric surgery, unless specifically ordered by the physician. In this situation, the nurse should clarify the order. Options 1, 2, and 4 are appropriate postoperative interventions.

Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down. ULCERATIVE COLITIS Rebound tenderness may indicate peritonitis. Bloody diarrhea is expected to occur in ulcerative colitis. Because of the blood loss, the client may be hypotensive and the hemoglobin level may be lower than normal. Signs of peritonitis must be reported to the physician. CROHNS DISEASE- DIARRHEA Crohns disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Options 2, 3, and 4 are not characteristics of Crohns disease. Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein and this results in the formation of ammonia. If the client has hepatic encephalopathy, a low-protein diet would be prescribed. AMMONIA BY PRODUCT OF PROTEIN/ MORE PROTEIN, MORE AMMONIA o DIET FOR CIRRHOSIS- LOW PROTIEN late stage/ early stage- HIGH CHO, CALORIES The client is expected to have a body image disturbance after colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest deal of acceptance when the client participates in the actual colostomy care. Each incorrect option represents an interest in colostomy care but is a passive activity. The correct option shows the client participating in self-care. A prolapsed stoma is one in which the bowel protrudes through the stoma. A stoma retraction is characterized by sinking of the stoma. Ischemia of the stoma would be associated with a dusky or bluish color. A stoma with a narrowed opening at the level of the skin or fascia is said to be stenosed. As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase the output of watery stool by increasing

19

propulsion through the bowel. Ileostomy output is liquid. Addition or elimination of various foods can help to thicken or loosen this liquid drainage. A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period. KOCK POUCH USES CATHETER IN DRAINING THE POUCH REGULARLY A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours and then decreases the draining to about three times a day, or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool only from the rectum if an ileal-anal pouch or anastomosis were created. This type of operation is a two-stage procedure. The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. Chronic pancreatitis is aggravated by continued alcohol intake. The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sauces and gravies, fatty meats, fried foods, products made with cream, and heavy desserts. The correct option is baked fish, which is low in fat. During an acute episode of cholecystitis, the client may complain of severe right upper quadrant pain that radiates to the right scapula and shoulder. This is determined by the pattern of dermatomes in the body. The other options are incorrect. Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts. Jaundice occurs in the skin and mucous membranes. In light-skinned persons, jaundice first is seen in the sclera of the eyes and later in the skin. In dark-skinned persons, jaundice is observed in the inner canthus of the eyes and hard palate of the mouth. Pallor is detected in the nail beds, and flushing associated with increased body temperature is best noted on the flexor surfaces of the extremities. The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication such as meperidine will be prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and also may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions. Cholestyramine (Questran) is a bile acid sequestrant used to lower the cholesterol level and client compliance is a problem because of its taste and palatability. The use of flavored products or fruit juices can improve the taste. Some side effects of bile acid sequestrants include constipation and decreased vitamin absorption. The principle manifestations of Crohns disease are diarrhea and abdominal pain. Infliximab (Remicade) is an immunomodulator that reduces the degree of inflammation in the colon, thereby reducing the diarrhea. Docusate sodium is a stool softener that promotes absorption of water into the stool, producing a softer consistency of stool. The intended effect is relief or prevention of constipation. The medication does not decrease the amount of fat in the stools, stop gastrointestinal bleeding, or relieve abdominal pain. Cascara sagrada is a laxative that causes nausea and abdominal cramps as the most frequent side effects.

20

Trimethobenzamide (Tigan) is an antiemetic agent used to treat nausea and vomiting. Pancrelipase (Pancrease) is a pancreatic enzyme used in clients with pancreatitis as a digestive aid. The medication should reduce the amount of fatty stools (steatorrhea). Another intended effect could be improved nutritional status. It is not used to treat abdominal pain or heartburn. Its use could result in weight gain but should not result in weight loss if it is aiding in digestion. Calcium carbonate can be used as an antacid for the relief of heartburn and indigestion. Calcium carbonate also can be used as a calcium supplement (option 3) or to bind phosphorus in the gastrointestinal tract with renal failure (option 4). Option 2 is incorrect, although adequate calcium levels are needed for proper neurological function. The client who chronically uses nonsteroidal anti-inflammatory drugs (NSAIDs) is prone to gastric mucosal injury. Misoprostol is a gastric protectant and is given specifically to prevent this occurrence. Diarrhea can be a side effect of the medication but is not an intended effect. Omeprazole is a proton pump inhibitor classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often called heartburn by clients Triple therapy for Helicobacter pylori infection usually includes two antibacterial drugs and a proton pump inhibitor. Metronidazole and clarithromycin are antibacterials. Omeprazole is a proton pump inhibitor. These medications will kill the bacteria and decrease acid production. This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury. Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity. THEOPHYLLINE should be administered with food such as milk and crackers to prevent gastrointestinal irritation. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system. In respiratory acidosis, the pH will be lower than normal and the PCO2 will be elevated. The normal pH is 7.35 to 7.45. The normal PCO2 is 35 to 45 mm Hg. Isoniazid and rifampin are contraindicated in clients with acute liver disease or a history of hepatic injury. Option 1 is the only option that addresses hepatic dysfunction. If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to this procedure.

21

The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain. The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include tachycardia, fever, diaphoresis, cough, anxiety, and possibly syncope. The most important item to ask about is the clients pregnancy status because pregnant women should not be exposed to radiation .(CLIENT-CENTERED) Clients also are asked to remove any chains or metal objects that could interfere with obtaining an adequate film. A chest radiograph most often is obtained at full inspiration, which gives optimal lung expansion. If a lateral view of the chest is ordered, the client is asked to raise the arms above the head. Most films are done in a posterioranterior view. Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest. The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. The normal pulmonary capillary wedge pressure (PCWP) is 8 to 13 mm Hg, and the client is considered to have high readings if they exceed 18 to 20 mm Hg. The client with acute respiratory distress syndrome has a normal PCWP, which is an expected finding because the edema is in the interstitium of the lung and is noncardiac. The client with tuberculosis usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever. The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client generally is considered not to be contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of three sputum cultures are negative. Carbon dioxide narcosis is a condition that results from extreme hypercapnia, with carbon dioxide levels in excess of 70 mm Hg. The client experiences symptoms such as confusion and tremors, which may progress to convulsions and possibly coma. The client with human immunodeficiency virus (HIV) infection is considered to have positive results on Mantoux skin testing with an area larger than 5 mm of induration. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.

22

In uncomplicated or simple silicosis, the client would be asymptomatic, although evidence of fibrosis on an x-ray would be present. Malaise, anorexia, weight loss, and severe dyspnea on exertion would occur in a client with chronic complicated silicosis. The client with simple silicosis may be asymptomatic or have mild ventilatory restriction and has evidence of fibrosis on chest x-ray. Pulmonary function studies reveal some decreases in vital capacity and total lung volume. Massive fibrosis is not evident at this stage. This disease is restricted to the respiratory system only.

With a rapid drop in carbon dioxide levels, the kidneys are unable to excrete bicarbonate ions at the same rate. The client can experience rebound metabolic alkalosis, with resulting seizure activity. The nurse evaluates the clients status carefully during this period. Options 1, 2, and 3 are not adverse effects. Pulmonary sarcoidosis can lead to cor pulmonale (or failure of the right side of the heart), characterized by distended neck veins, elevated central venous pressure, full bounding pulse, weight gain, engorged liver, and peripheral edema. Bilateral lung crackles would indicate failure of the left side of the heart. Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure Benzonatate is a locally acting antitussive and its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough without eliminating the cough reflex Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza and clients are usually contagious for up to 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate change in activities, especially when driving or operating machinery if dizziness occurs. Guaifenesin (Humibid) is an expectorant and should be taken with a full glass of water to decrease the viscosity of secretions. Sustained-release preparations should not be broken open, crushed, or chewed. The medication occasionally may cause dizziness, headache, or drowsiness as side effects. The client should contact the physician if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache. The client is taught about side effects that could occur with the use of codeine sulfate. The most common side effects include drowsiness, confusion, hypotension, nausea and vomiting, and constipation. Others include bradycardia, respiratory depression, and urinary retention.

Cromolyn sodium (Intal) is an inhaled nonsteroidal antiallergy agent and a mast cell stabilizer. The most common undesired side effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia. Terbutaline (Brethine) is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, or hyperthyroidism, and a history of seizures. The medication may increase blood glucose levels.

Zafirlukast (Accolate) is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication.

23

Isoniazid (INH) is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B6) intake. E FOR THE EYES Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadin). Chest pain is assessed by using the standard pain assessment parameters (e.g., characteristics, location, intensity, duration, precipitating and alleviating factors, and associated symptoms). Options 1, 2, and 4 may or may not help discriminate the origin of pain. Pain of pleuropulmonary origin usually worsens on inspiration. Cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a rapid pulse that becomes weaker, decreased urine output, and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissecting aortic aneurysms usually are accompanied by back pain. Metformin (Glucophage) needs to be withheld 48 hours before and after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system, the client would be at increased risk for lactic acidosis Heart failure is precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Pagets disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, and hypervolemia. Digoxin exerts a positive inotropic effect on the heart while slowing the overall rate through a variety of mechanisms. Digoxin is the medication of choice to treat heart failure. Diltiazem and verapamil (calcium channel blockers) and propranolol (-adrenergic blocker) have a negative inotropic effect and would worsen the failing heart. Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles. Rhonchi and diminished breath sounds are not associated with pulmonary edema. Stridor is a crowing sound associated with laryngospasm or edema of the upper airway. Strategy- Recalling that fluid produces sounds that are called crackles Pulmonary edema causes the client to be extremely agitated and anxious. The client may complain of a sense of drowning, suffocation, or smothering. The serum potassium level is measured in the client receiving digoxin and furosemide. Heightened digoxin effect leading to digoxin toxicity can occur in the client with hypokalemia. Hypokalemia also predisposes the client to ventricular dysrhythmias. Digoxin cause hypokalemia Classic signs of cardiogenic shock as they relate to this question include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium.

24

Sternotomy incision sites are assessed for signs and symptoms of infection, such as redness, swelling, induration, and drainage. Elevated temperature and white blood cell count after 3 to 4 days postoperatively usually indicate infection. CREATININE LEVEL The typical reference ranges are 0.5 to 1.0 mg/Dl The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal insult is signaled by decreased urine output and increased blood urea nitrogen and creatinine levels. The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, urinary tract infection, or glomerulonephritis. Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively. Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are higher than 100 beats/min. Motion artifact, or noise, can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference also can occur with electrode removal and cable disconnection.

V-Tach NO P WAVE
Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (longer than 0.12 second), and typically a rate between 140 and 180 impulses/min. The rhythm is regular. Ventricular tachycardia is a life-threatening dysrhythmia that results from an irritable ectopic focus that takes over as the pacemaker for the heart. The low cardiac output that results can lead quickly to cerebral and myocardial ischemia. Clients frequently experience a feeling of impending doom. Ventricular tachycardia is treated with antidysrhythmic medications, cardioversion (client awake), or defibrillation (loss of consciousness). Ventricular tachycardia can deteriorate into ventricular fibrillation at any time.

First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of antidysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate an already excitable ventricle and is contraindicated.

Ventricular fibrillation is characterized by irregular chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles. Premature ventricular contractions priority is blood pressure & oxygen saturation. PVC
can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beat leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpitations. Premature ventricular contractions can be caused by cardiac disorders, states of hypoxemia or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by intake of caffeine, nicotine, or alcohol.

25

Atrial fibrillation- bilis mag pump nang heart konting blood lang naman..result is
hypotension & dizziness The client with uncontrolled atrial fibrillation with a ventricular rate more than 100 beats/min is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Atrial fibrillation is characterized by a loss of P waves and fibrillatory waves before each QRS complex. The atria quiver, which can lead to thrombi formation. Until the defibrillator is attached and charged, the client is resuscitated by using cardiopulmonary resuscitation. Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections. A nitroglycerin patch, if present, is removed. The client does not have to be intubated to be defibrillated. Lidocaine may be given subsequently but is not required before defibrillation. The machine is not set to the synchronous mode because there is no underlying rhythm with which to synchronize.

After defibrillation, the client requires continuous monitoring of electrocardiographic rhythm, hemodynamic status, and neurological status. Respiratory and metabolic acidosis develops during ventricular fibrillation because of lack of respiration and cardiac output. These can cause cerebral and cardiopulmonary complications. Arousable status, adequate blood pressure, and a sinus rhythm indicate successful response to defibrillation. Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. HINDI PWEDE SA RELATED IN M.I. An automatic internal cardioverter-defibrillator (AICD) detects and delivers an electrical shock to terminate life-threatening episodes of ventricular tachycardia and ventricular fibrillation. These devices are implanted in clients who are considered high risk, including those who have survived sudden cardiac death unrelated to myocardial infarction, those who are refractive to medication therapy, and those who have syncopal episodes related to ventricular tachycardia. Pulmonary embolism is a life-threatening complication of deep vein thrombosis and

thrombophlebitis. Chest pain is the most common symptom, which is sudden in onset,
and may be aggravated by breathing. Other signs and symptoms include dyspnea, cough, diaphoresis, and apprehension. The mixture of arterial and venous manifestations (claudication and phlebitis,

respectively) in the young male client suggests thromboangiitis obliterans (Buergers disease). This disorder is characterized by inflammation and thrombosis of smaller arteries and veins. It typically is found in young adult males who smoke. The cause is not known precisely but is suspected to have an autoimmune component. Raynauds disease responds favorably to eliminating caffeine from the diet and cessation of smoking. Medications may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is important. However, moving to a warmer climate may not necessarily be beneficial

26

because the symptoms still could occur with the use of air conditioning and during periods of cooler weather. After inferior vena cava filter insertion, the nurse inspects the surgical site for bleeding and signs and symptoms of infection. Otherwise, care is the same as for any other postoperative client. MYOCARDIAL INFARCTION An electrocardiogram taken during a chest pain episode captures ischemic changes, which include ST segment elevation or depression. Tall, peaked T waves may indicate hyperkalemia. A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates delay in intraventricular conduction, such as a bundle branch block. An expected outcome of surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. Therefore, options 2, 3, and 4 are incorrect interpretations. PERICARDIOCENTESIS Following pericardiocentesis, a rise in blood pressure and a fall in

central venous pressure are expected. The client usually expresses immediate relief.
Heart sounds are no longer muffled or distant. Not all clients with abdominal aortic aneurysm exhibit symptoms. Those who do may describe a feeling of the heart beating in the abdomen when supine or being able to feel the mass throbbing. A pulsatile mass may be palpated in the middle and upper abdomen. A systolic bruit may be auscultated over the mass. Hyperactive bowel sounds are not related specifically to an abdominal aortic aneurysm. Common laboratory ranges for activated partial thromboplastin time are 20 to 36 seconds. Because the activated partial thromboplastin time should be 1.5 to 2.5 times the normal value, the clients activated partial thromboplastin time would be considered therapeutic if it were 60 seconds. -Blockers such as metoprolol slow conduction of impulses through the AV node and decrease the heart rate. In rapid atrial fibrillation, the goal first is to slow the ventricular rate and improve the cardiac output and then attempt to restore normal sinus rhythm. RISK FOR HYPERKALEMIA-------- Spironolactone is a potassium-sparing diuretic and competes with aldosterone at receptor sites in the distal tubule, resulting in excretion of sodium, chloride, and water and retention of potassium and phosphate.

Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. -blockers
may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored. BETA BLOCKER IS A BIG NO-NO TO COPD / ASTHMA The client receiving dopamine therapy should be assessed for ineffective tissue perfusion related to peripheral vasoconstriction. Thiazide diuretics such as hydrochlorothiazide are sulfa-based medications, and a client with a sulfa allergy is at risk for an allergic reaction. Also, clients are at risk for hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, and hyperuricemia. Nicotinic acid, even an over-the-counter form, should be avoided because it may lead to liver abnormalities. All lipid-lowering medications also can cause liver abnormalities, so a combination of nicotinic acid and cholestyramine resin is to be avoided. Constipation and bloating are the

27

two most common side effects. Walking and the reduction of fats in the diet are therapeutic measures to reduce cholesterol and triglyceride levels Flushing is a side effect of Nicotinic acid. Aspirin or a nonsteroidal antiinflammatory drug can be taken 30 minutes prior to taking the medication to decrease flushing. Alcohol consumption needs to be avoided because it will enhance this side effect. The medication should be taken with meals but this will decrease gastrointestinal upset; taking the medication with meals has no effect on the flushing. Clay-colored stools are a sign of hepatic dysfunction and should be immediately reported to the physician. Bumetanide (Bumex) is a diuretic. The paroxysmal nocturnal dyspnea may be due to increased venous return when the client is lying in bed, and the client needs diuresis. Propranolol is a blocker, lidocaine is an antiarrhythmic, and streptokinase is a thrombolytic. Double vision, loss of appetite, and nausea are early signs of digoxin toxicity. Additional signs of digoxin toxicity include bradycardia, difficulty reading, visual alterations such as green and yellow vision or seeing spots or halos, confusion, vomiting, diarrhea, decreased libido, and impotence. Clients on potassium-wasting diuretics are at high risk for hypokalemia. Clinical manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias, and dysrhythmias.

The reference range for prothrombin time is usually around 1215 seconds; the normal range for the INR is 0.81.2. PT measures factors I, II, V, VII, and X. (control value) The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the clients control value, the therapeutic range for this individual would be 16.5 to 22 seconds. Therefore the result is within the therapeutic range.
Nesiritide is a recombinant version of human B-type natriuretic peptide, which vasodilates arteries and veins. It is used for the treatment of decompensated heart failure, increases renal glomerular filtration, and increases urine output The client on hemodialysis should monitor fluid status between hemodialysis treatments by recording intake and output and measuring weight daily. Ideally, the hemodialysis client should not gain more than 0.5 kg of weight/day. Bladder trauma or injury is characterized by lower abdominal pain that may radiate to one of the shoulders. Bladder injury pain does not radiate to the umbilicus, costovertebral angle, or hip The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicate patency of the fistula. Although the presence of a radial pulse in the left wrist and capillary refill shorter than 3 seconds in the nail beds of the fingers on the left hand are normal findings, they do not assess fistula patency.

The client with prostatitis has a swollen and tender prostate gland that is also warm to the touch, firm, and indurated. Systemic symptoms include fever with chills, perineal and low back pain, and signs of urinary tract infection, which often accompany the disorder.

28

Disequilibrium syndrome-Headache and deteriorating level of consciousness mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity. Disequilibrium syndrome is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. The syndrome most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates. Following dialysis, the clients vital signs are monitored to determine whether the client is remaining hemodynamically stable. Weight is measured and compared with the clients predialysis weight to determine effectiveness of fluid extraction. Laboratory studies are done as per protocol but are not necessarily done after the hemodialysis treatment has ended. If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit level, and gross or microscopic hematuria also would indicate bleeding. Signs of infection would not appear immediately following a biopsy. The biopsy site would be the flank area and not the lower abdomen. No data are given to support the presence of renal colic.

Polyuria occurs early in chronic renal failure and, if untreated, can cause severe dehydration. Polyuria progresses to anuria, and the client loses all normal kidney functions. Oliguria and anuria are not early signs, and polydipsia is unrelated to chronic renal failure.

In an older client, the only symptom of a urinary tract infection may be something as vague as increasing mental confusion. Frequency and urgency may commonly occur in an older client. Therefore, these symptoms are not specific to urinary tract infection in the older client. Fever can be associated with a variety of conditions.

To increase urinary output, diuretics and osmotic agents are administered. The client should be monitored closely because fluid overload can cause hypertension, congestive heart failure, and pulmonary edema. Fluid intake would not be encouraged or restricted. Irrigation of the Foley catheter will not assist in alleviating this oliguria.

Acute rejection
most often occurs in the first 2 weeks after transplantation. Clinical manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, and manifestations of deteriorating renal function. Chronic rejection occurs gradually over a period of months to years. Although kidney infection or obstruction can occur, the symptoms presented in the question do not relate specifically to these disorders. Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such

29

as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.

Blood Pressure: 120-160mmHg Pulse: 60-100 Beats/min.

BENIGN PROSTAIC HYPERPLASIA Frank bleeding (arterial or venous) may occur during the first day after surgery. Some hematuria is usual for several days after surgery. A urinary output of 200 mL more than intake is adequate. Bladder spasms are expected to occur following surgery. A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The physician should be notified.

Individuals with polycystic kidney disease seem to waste rather than retain sodium. Thus, they need increased sodium and water intake. Aggressive control of hypertension is essential. Genetic counseling is advisable because of the hereditary nature of the disease.

Potential complications after renal angiography include allergic reaction to the dye, renal damage from the dye, and vascular complications, which include hemorrhage, thrombosis, or embolism. The nurse detects these complications by noting signs and symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the insertion site, and/or signs of decreased circulation to the affected leg.

The client with polycystic kidney disease should report any signs and symptoms of urinary tract infection so that treatment may begin promptly. Lowered blood pressure is not a complication of polycystic kidney disease, and it is an expected effect of antihypertensive therapy. The client would be concerned about increases in blood pressure because control of hypertension is essential. The client may experience heart failure as a result of hypertension, and thus any symptoms of heart failure, such as shortness of breath, are also a concern

Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The nurse also teaches the client to rest, increase fluid intake, and use sitz baths for comfort. Antimicrobial therapy is always continued until the prescription is finished.

In the client with benign prostatic hyperplasia, episodes of urinary retention can be triggered by certain medications, such as

30

decongestants,

anticholinergics, and antidepressants. The client should be questioned about the use of these medications if the client has urinary retention. Retention also can be precipitated by other factors, such as alcoholic beverages, infection, bed rest, and becoming chilled.

Nalidixic acid can intensify the effects of oral anticoagulants by displacing these agents from binding sites on plasma protein. When an oral anticoagulant is combined with nalidixic acid, a decrease in the anticoagulant dosage may be needed.

FOR URINARY RETENTION Bethanechol chloride (Urecholine) can be hazardous to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these URINARY STRICTURES. Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously.

Propantheline bromide (Pro-Banthine) is contraindicated in clients with narrow-angle glaucoma, obstructive uropathy, gastrointestinal disease, or ulcerative colitis. The medication decreases bladder

muscle spasms.

CYCLOSPORINE(IMMUNOSUPPRESSANT) PREVENT KIDNEY REJECTION

IS

FOR

KIDNEY

TRANSPLANTATION

TO

Nephrotoxicity can occur from the use of cyclosporine (Sandimmune). Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. Cyclosporine does not depress the bone marrow.
Amphotericin B deoxycholate, erythromycin, and ketoconazole can elevate cyclosporine levels. When any of these medications is combined with cyclosporine, the dosage of cyclosporine must be reduced to prevent accumulation to toxic levels. The most common adverse effects of cyclosporine are nephrotoxicity, infection, hypertension, tremors, and hirsutism. Of these, nephrotoxicity and infection are the most serious HEMATOCRIT Epoetin alfa is used to reverse anemia associated with chronic renal failure. Therapeutic effect is seen when the hematocrit is between 30% and 33%

Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of

31

tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the clients thinking process and attention span. The most appropriate nursing diagnosis for the client scheduled for cataract surgery is Sensory perception, disturbed (visual) related to lens extraction and replacement A mydriatic medication produces mydriasis or dilation of the pupil. Mydriatic medications are used preoperatively in the cataract client. These medications act by dilating the pupils. They also constrict blood vessels. An osmotic diuretic may be used to decrease intraocular pressure. A miotic medication constricts the pupil. A thiazide diuretic is not likely to be prescribed for a client with a cataract. The client is instructed to wear a metal or plastic shield to protect the eye from accidental injury and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen (Tylenol) as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 lb.

In the Weber tuning fork test, the nurse places the vibrating tuning fork in the middle of the clients head, at the midline of the forehead, or above the upper lip over the teeth. Normally, the sound is heard equally in both ears by bone conduction. If the client has a sensorineural hearing loss in one ear, the sound is heard in the other ear. If the client has a conductive hearing loss in one ear, the sound is heard in that ear.

Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which then is removed using ear forceps. When the foreign object is vegetable matter, irrigation is not used, because this material expands with hydration and the impaction becomes worse. OTOSCLEROSIS- is an abnormal growth of bone near the middle ear. It can result in hearing loss. TX- FENESTRATION. Following ear surgery, the client needs to avoid straining when having a bowel movement. The client needs to be instructed to avoid drinking with a straw for 2 to 3 weeks, air travel, and coughing excessively. The client needs to avoid getting his or her head wet, washing hair, showering for 1 week, and rapidly moving the head, bouncing, and bending over for 3 weeks.

Treatment for acoustic neuroma is surgical removal via a craniotomy. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve. Acoustic neuromas rarely recur following surgical removal.

Bloody or clear watery drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture. This warrants immediate attention
PILOCARPINE HYDROCHLORIDE, PILOCARPINE, CARBACHOL are miotic agents used to treat glaucoma. ATROPINE SULFATE is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate

32

the pupil and can cause an increase in intraocular pressure in the eye. CATARACT- MYDRIATIC GLAUCOMA- MIOTIC Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, syncope, cardiac dysrhythmias, and seizures. Atropine sulfate must be available in the event of systemic toxicity. Pindolol is a blocker. Naloxone hydrochloride is an opioid antagonist used to reverse narcotic-induced respiratory depression. Protamine sulfate is the antidote for heparin. Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia The client can lie down or sit with the head tilted back. The lower lid should be pulled downward with the thumb or fingers. The client holds the bottle like a pencil, with the tip downward, and squeezes the bottle gently, allowing one drop to fall into the sac. The client gently closes the eye A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise. Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalvas maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising. The client with spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of T7. Autonomic dysreflexia is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a lifethreatening syndrome triggered by a noxious stimulus below the level of the injury. Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinskis reflex. Recall that spinal shock is characterized by the loss of movement of skeletal muscles, bowel or bladder wall, and depressed reflex action. Return of any of these indicates that spinal shock is beginning to resolve. Note that options 1, 2, and 3 are comparative or alike, indicating the presence of reflexes.

Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan

33

the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available. Placing an eye patch over one eye in the client with diplopia removes the second image and restores more normal vision. The patch is alternated each day to maintain the strength of the extraocular muscles of the eyes. Myasthenia gravis often can be diagnosed based on clinical signs and symptoms. The diagnosis can be confirmed by injecting the client with a dose of edrophonium (Tensilon). This medication inhibits the breakdown of an enzyme in the neuromuscular junction, so more acetylcholine binds onto receptors. If the muscle is strengthened for 3 to 5 minutes after this injection, it confirms a diagnosis of myasthenia gravis. Another medication, neostigmine (Prostigmin) also may be used because the effect lasts for 1 to 2 hours, giving a better analysis. For either medication, atropine sulfate should be available as the antidote. Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine (Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis

The client with Parkinsons disease should exercise in the morning when energy levels are highest. The client should avoid sitting in soft deep chairs because they are difficult to get up from. The client can rock back and forth to initiate movement. The client should buy clothes with Velcro fasteners and slide-locking buckles to support the ability to dress self. Trigeminal neuralgia (TN), tic douloureux[1] (also known as prosopalgia) is a neuropathic disorder characterized by episodes of intense pain in the face. Originating in one of the three trigeminal nerves. This pain may be felt in any or all of the following: the ear, eye, lips, nose, scalp, forehead, cheeks teeth, or jaw and alongside of the face, some patients also experience pain in their left index finger;[2] it is not easily controlled or cured. Contusions are localized, while concussions are widespread. Contusions are macroscopic, while concussions are microscopic. The changes in neurological signs from an epidural hematoma begin with loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebrospinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood cause the intracranial pressure to rise rapidly, and the clients neurological status deteriorates quickly. The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should use powder or lotions sparingly, or not at all. The wool liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client may not drive because the device impairs the range of vision. The client with a spinal cord injury is at risk for autonomic dysreflexia(hyperreflexia) with an injury above the level of T7. Autonomic dysreflexia is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

34

An edrophonium injection makes the client in cholinergic crisis temporarily worse. This is known as a negative Tensilon test. The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL. The therapeutic phenytoin level is 10 to 20 mcg/mL. At a level higher than 20 mcg/mL, involuntary movements of the eyeballs (nystagmus) appears. At a level higher than 30 mcg/mL, ataxia and slurred speech occur. Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbances, thrombophlebitis, dysrhythmias, and dermatological effects. Side effects of meperidine (Demerol) include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention. After arthroscopy, the client usually can walk carefully on the leg once sensation has returned. The client is instructed to avoid strenuous exercise for at least a few days. The client may resume the usual diet. Signs and symptoms of infection should be reported to the physician. A clear chest radiograph is a good indicator that a fat embolus is resolving. When fat embolism occurs, the chest radiograph has a snowstorm appearance. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be higher than 95%. The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by narcotics, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. The nursing assessment conducted after spinal surgery is similar to that done after other surgical procedures. For this specific type of surgery, the nurse assesses the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after insertion of hardware, but a temperature of 101.6 F should be reported. Normal Uric acid levels are 2.4-6.0 mg/dL (female) and 3.4-7.0 mg/dL (male) In addition to the presence of clinical manifestations, gout is diagnosed by the presence of persistent hyperuricemia, with a uric acid level higher than 8 mg/dL; a normal value is 4.0 to 8.5 mg/dL. Options 1, 3, and 4 indicate normal laboratory values. Additionally, the presence of uric acid in an aspirated sample of synovial fluid confirms the diagnosis. What To Eat for GOUT Because purines are so prevalent in our food, it can be difficult to find acceptable alternatives when trying to cut them out of the diet. Some good choices include low-fat dairy products such as milk, cheese and yogurt. Whole grain breads and pasta are also a good choice. For people who are suffering from gout, drinking plenty of fluids, preferably water, is also important because it can help flush the uric acid from the body more quickly. The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify with activity. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Morning stiffness lasting longer than 30 minutes occurs in rheumatoid arthritis. Elevated white blood cell counts, platelet counts, and antinuclear antibody levels occur in rheumatoid arthritis.

35

RA is characterized by chronic joint pain of variable intensity, which is more severe on rising in the morning. The pain subsides once the client moves around. The nurse would note that joint involvement is symmetrical and the joints are swollen, shiny, reddened, and painful. Rheumatoid nodules, which are painless subcutaneous movable skin nodules near bony prominences, may occur anywhere on the body. Infection and pancytopenia are side effects of etanercept (Enbrel). Laboratory studies are performed prior to and during drug treatment. The appearance of abnormal white blood cell counts and abnormal platelet counts can alert the nurse to a potentially life-threatening infection. Injection site itching and edema are common occurrences following administration. A metallic taste and loss of appetite are not common signs of side effects of this medication. Colchicine is contraindicated in clients with severe gastrointestinal, renal, hepatic, or cardiac disorders and in clients with blood dyscrasias. Clients with impaired renal function may exhibit myopathy and neuropathy manifested as generalized weakness. This medication should be used with caution in clients with impaired hepatic function, the older client, and the debilitated client. Baclofen is a skeletal muscle relaxant and frequently causes drowsiness, dizziness, weakness, and fatigue. Baclofen also can cause nausea, constipation, and urinary retention. Clients should be warned about the possible reactions Coal tar is used to treat psoriasis and other chronic disorders of the skin. It suppresses DNA synthesis, mitotic activity, and cell proliferation. It has an unpleasant odor, frequently can stain the skin and hair, and can cause phototoxicity. It does not cause diarrhea. Dose-related liver damage is the most serious adverse effect of dantrolene. To reduce the risk of liver damage, tests of liver function should be performed before treatment and throughout the treatment interval. Dantrolene is administered in the lowest effective dosage for the shortest time necessary.

Clients with seizure disorders may have a lowered seizure threshold when baclofen is administered. Concurrent therapy may require an increase in the anticonvulsive medication.
The disorders in options 2, 3, and 4 are not contraindications or cautions for the use of this medication.

Because cyclobenzaprine (Flexeril) has anticholinergic effects, it should be used with caution in clients with a history of urinary retention, glaucoma, and increased intraocular pressure. Cyclobenzaprine should be used only for a short term (2 to 3 weeks). Treatment of systemic lupus erythematosus is based on the systems involved and symptoms. Treatment normally consists of anti-inflammatory drugs, corticosteroids, and immunosuppressants Foscarnet (Foscavir) is toxic to the kidneys. The serum creatinine level is monitored before therapy, two or three times per week during induction therapy, and at least weekly during maintenance therapy. Foscarnet also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels also are measured with the same frequency. Stavudine (d4t, Zerit) is an antiretroviral used to manage human immunodeficiency virus infection in clients who do not respond to or who cannot tolerate conventional therapy. The medication can cause peripheral neuropathy, and the nurse should monitor the clients gait closely and ask the client about paresthesia. o Monitor CBC

36

ZIDOVUDINE (AZT)- Common side effects of this medication therapy are leukopenia and anemia. The nurse monitors the complete blood count results for these changes. o

PSYCHE

transference refers to redirection of a patient's feelings for a significant person to the therapist. Countertransference[6] is defined as redirection of a therapist's feelings toward a patient In the termination phase, the relationship comes to a close. Ending treatment sometimes may be traumatic for clients who have come to value the relationship and the help. Because loss is an issue, any unresolved feelings related to loss may resurface during this phase.

Denial is refusal to admit to a painful reality, which is treated as if it does not exist. In projection, a person unconsciously rejects emotionally unacceptable features and attributes them to other persons, objects, or situations. In regression, the client returns to an earlier, more comforting, although less mature, way of behaving. Rationalization is justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener. Ego defense mechanisms are operations outside of a persons awareness that the ego calls into play to protect against anxiety. Displacement is the discharging of pent-up feelings on persons less threatening than those who initially aroused the emotion. Denial is the blocking out of painful or anxiety-inducing events or feelings. Repression is unconsciously keeping unacceptable feelings out of awareness. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Generally, the client seeks voluntary admission. A voluntary admission permits a client to make a written application for admission. If the client seeks voluntary admission, the most likely expectation is that the client will participate in the treatment program Involuntary admission is made without the clients consent. Involuntary admission is necessary when a person is a danger to self or others or is in need of psychiatric treatment Clients who are admitted involuntarily do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The informed consent needs to be obtained from the client. False imprisonment is an act with the intent to confine a person to a specific area. A nurse can be charged with false imprisonment if the nurse prohibits a client from leaving the hospital if the client has been admitted voluntarily and if no agency or legal policies exist for detaining the client. However, if the client has been admitted involuntarily or had agreed to an evaluation before discharge, the nurses actions are reasonable. The sponsor of a self-help group is an experienced member of the group. A nurse or psychiatrist may be asked by the group to serve as a resource but would not be the leader of the group Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. Mania is a period when the mood is predominantly elevated, expansive, or irritable. All options reflect a clients possible symptomatology. Option 2, however, clearly presents a problem that compromises physiological integrity and needs to be addressed immediately. o DEMENTIA- SUNDOWN SYNDROME

37

The clinical picture of dementia varies from the development of mild cognitive defects to severe, life-threatening alterations in neurological functioning. For the client to use confabulation or the fabrication of events or experiences to fill in memory gaps is not unusual. Often, lack of inhibitions on the part of the client may constitute the first indication of anything being wrong to the clients significant others (the client may undress in front of others or demonstrate slovenly table manners but was formerly well mannered). As the dementia progresses, the client will have episodes of wandering or sundowning. The risk for impulsive and aggressive behavior may increase if a client is receiving command hallucinations to harm self or others. The nurse should ask the client whether he or she has intentions to hurt himself or herself or others. Talking about auditory hallucinations can interfere with subvocal muscular activity associated with a hallucination. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment if an attack occurs. Avoidance of such situations usually results in reduction of social and professional interactions. Social phobia focuses more on specific situations, such as the fear of speaking, performing, or eating in public. Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health. A conversion disorder is the alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. A conversion disorder is thought to be an expression of a psychological need or conflict. In this situation, the client witnessed an accident that was so psychologically painful that the client became blind. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Psychosis is a state in which a persons mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the persons ability to deal with lifes demands. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

Major depression, recurrent, with psychotic features, alerts the nurse that in addition to the criteria that designates the diagnosis of major depression, one also must deal with the clients psychosis. Psychosis is defined as a state in which a persons mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the persons ability to deal with the demands of life. Disturbed thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all the nursing diagnoses may be appropriate because the client is experiencing psychosis, option 4 is the correct option.

Excessive exercise is a characteristic of anorexia nervosa, not a characteristic of clients with bulimia. Frequent vomiting, in addition to laxative and diuretic abuse, may lead to dehydration and electrolyte imbalance. Assessing for dehydration and electrolyte imbalance are important nursing actions. Option 3 is the only option that is not a characteristic of bulimia. Some of the symptoms associated with withdrawal delirium typically are anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes in level of consciousness, agitation, fever, and delusions Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety.

38

A situational crisis arises from external rather than internal sources. External situations that could precipitate a crisis include loss of or change of a job, the death of a loved one, abortion, change in financial status, divorce, addition of new family members, pregnancy, and severe illness. Options 1, 3, and 4 identify adventitious crises. An adventitious crisis is not a part of everyday life; it is unplanned or accidental. A depressed suicidal client often gives away that which is of value as a way of saying good-bye and wanting to be remembered Hanging is a serious suicide attempt. The plan of care must reflect action that will ensure the client safety. Constant observation status (one to one) with a staff member who is never less than an arms length away is the best selection. Seclusion should not be the initial intervention, and the least restrictive measure should be used. Placing the client in a hospital gown and requesting that a peer remain with the client will not ensure a safe environment. A suicidal client may have numerous diagnoses that encompass inadequate coping skills, anxiety, and strained interpersonal relationships. The question, however, directly and clearly designates that the problems that need to be dealt with are the Risk for self-directed violence and the clients suicidal ideations with a plan. The expected outcome is that the client no longer has suicidal ideations and has identified options to deal with stress. A client who is moderately depressed and has only been in the hospital 2 days is unlikely to have such a dramatic cure. When a depression suddenly lifts, it is likely that the client may have made the decision to harm himself or herself. Suicide precautions are necessary to keep the client safe. The most common side effects related to this medication include central nervous system and gastrointestinal system dysfunction. Fluoxetine (Prozac) affects the gastrointestinal system by causing nausea and vomiting, cramping, and diarrhea Buspirone (BuSpar) is not recommended for the treatment of drug or alcohol withdrawal, thought disorders, or schizophrenia. Buspirone hydrochloride most often is indicated for the treatment of anxiety. Clomipramine (Anafranil) is a tricyclic antidepressant used to treat obsessive-compulsive disorder. Weight gain and tachycardia are side effects of this medication. Sedation sometimes occurs and insomnia is a seldom side effect. Amitriptyline hydrochloride is a tricyclic antidepressant. Depressed individuals sleep for extended periods, have a change in appetite, are unable to go to work, and have difficulty concentrating. They also may experience increased fatigue, feelings of guilt or worthlessness, loss of interest in activities, and possible suicidal tendencies. Once they have had some therapeutic effect from their medication, they will report resolution of many of these complaints and demonstrate an improvement in their appearance. Haloperidol (Haldol) is an antipsychotic used to manage psychotic disorder. Hallucinations, delusions, and altered thought processes are characteristics of a psychotic disorder and should decrease with effective treatment. Fixed stare (option 1) and dry mouth (option 4) are side effects of therapy. The nurse monitors for signs of toxicity. Seizure activity is common in bupropion(Wellbutrin dosages higher than 450 mg daily. This medication does not cause significant orthostatic blood pressure

39

changes. Weight gain is an occasional side effect, constipation is a common side effect of this medication.

whereas

The client taking clozapine (Clozaril) may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count drops below 3000/mm3. Agranulocytosis could be fatal if undetected and untreated. Benztropine (Cogentin) is an anticholinergic medication used to treat druginduced extrapyramidal reactions, except tardive dyskinesia. Tardive dyskinesia is an adverse reaction that can occur from antipsychotic medication. It is characterized by uncontrollable involuntary movements of the body and extremities, particularly the tongue. Torticollis refers to an extrapyramidal side effect involving the upper body. Hypertensive crisis can occur from the use of monoamine oxidase inhibitors and is characterized by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, and vomiting. Neuroleptic malignant syndrome is a potentially fatal syndrome that may occur at any time during therapy with neuroleptic (antipsychotic) medications. It is characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, and skeletal muscle rigidity. TREATMENT FOR IODINE(LUGOLS) TOXICITY Gasrtic lavage & Sodium Thiosulfate

In option 1, there is an implication of periorbital and facial edema, which could be indicative of gestational hypertension. Because the question identifies an adolescent who has not sought early prenatal care, she is at higher risk for the development of gestational hypertension. Treatment for gonorrhea consists of antibiotic ceftriaxone, plus oral doxycycline, for 7 days; For Mastectomy The client demonstrates the best adaptation by participating in her own care. This would include care of surgical drains that would be in place for a short time after discharge. Asking for pain medication is also an action-oriented option, but it does not relate to acceptance of the loss of the breast. Reading the postoperative care booklet is useful, but is not the best of the options presented here. Refusing to look at the wound indicates no adaptation to the loss. When epiglottitis is suspected, the priorities are to maintain patent airway and obtain a chest x-ray to confirm the diagnosis. a therapy with

If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate surgical airway.
Epinephrine is not used in the treatment of epiglottitis. For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the placenta.

40

The client who has had vein ligation and stripping should avoid standing or sitting for prolonged periods. The client should remain lying down unless performing a specific activity for the first few days following the procedure. Prolonged standing and sitting increase the risk of edema in the legs by decreasing blood return to the heart. The client should avoid crossing the legs at any level for the same reason. Levothyroxine (Synthroid) accelerates the degradation of vitamin Kdependent clotting factors. As a result, the effects of warfarin (Coumadin) are enhanced. Therefore, if thyroid hormone replacement therapy is instituted in a client who has been taking warfarin, the dosage of warfarin should be reduced. The pain of pancreatitis is aggravated by lying supine or by walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior peritoneal wall with these positions or movements. The fetal position

(with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) will also alleviate some of the pain associated with pancreatitis.

The client should avoid positions or activities that place strain on the lower back. The client should not sleep on the abdomen (prone) or on the side if the hips and knees are straight. The client should not lean forward without bending the knees, stand in one position for lengthy amounts of time, or lift anything above elbow level. It may be helpful for the client to stand with a foot elevated on a stool, or to sit using a form of lumbar support. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and the Pco2 is elevated. To prevent acute adrenal insufficiency, glucocorticoids should not be abruptly discontinued. These medications can cause sodium and water retention and the loss of potassium, and clients should be instructed to limit sodium intake and consume potassium-rich foods. Additionally, adequate dietary intake is important. These medications can increase the risk of infection and the client should avoid contact with persons who are ill. It is important to emphasize to the client and family that they are not eating a diabetic diet but rather a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods. NPH is an intermediate-acting insulin. The onset of action is 3 to 4 hours, it peaks in 4 to 12 hours, and its duration of action is 16 to 20 hours. Hypoglycemic reactions most likely occur during peak time. The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum period. HIV transmission can occur during breast-feeding. Therefore, HIV-positive clients should be encouraged to bottlefeed their neonates. Frequent hand washing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infants home care, the impact of the diagnosis of HIV infection, and available financial resources. It is

41

recommended that newborn infants of HIV-positive clients receive antiviral medications for their first 6 weeks of life. If the child wears contact lenses, he or she should be instructed to discontinue wearing them until the infection has cleared completely. Securing new contact lenses will eliminate the chance of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration. Factors that increase the risk of otitis media include exposure to illness in other children in day care centers, household smoking, bottle-feeding, and congenital conditions such as Down syndrome and cleft palate. The use of a pacifier beyond age 6 months has also been identified as a risk factor. Allergies are also thought to precipitate otitis media. Common manifestations of Addisons disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and irritability. Neuroblastoma is a solid tumor found only in children. It arises from neural crest cells that develop into the sympathetic nervous system and the adrenal medulla. Typically, the tumor compresses adjacent normal tissue and organs. Neuroblastoma cells may excrete catecholamines and their metabolites. Urine samples will indicate elevated vanillylmandelic acid (VMA) levels. The presence of blast cells in the bone marrow occurs in leukemia. Projectile vomiting occurring most often in the morning and a positive Babinskis sign are clinical manifestations of a brain tumor. With viral pneumonia, treatment is supportive. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids. Antibiotics are not given. Bacterial pneumonia however, is treated with antibiotic therapy. Cystic fibrosis (CF) is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. Jaundice, if present, is best assessed in the sclera, nail beds, and mucous membranes. Generalized jaundice will appear in the skin throughout the body. Membrane in the ear canal is not an appropriate area to assess for the presence of jaundice. Stress causes increased heart workload and the client should be instructed to avoid stress. To avoid infections, individuals with active infections should not be allowed to visit the client. Otherwise, restrictions are not required. Too much weight gain can place further demands on the heart. Resting should be on the left side to promote blood return. Initial treatment of salicylate overdose includes the administration of an emetic or gastric lavage . Activated charcoal may be administered to decrease absorption. Fluids and sodium bicarbonate may be administered intravenously to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin sodium (Coumadin) overdose. o

OB- review this part quite tricky...

42

Contraction stress test results may be interpreted as negative (normal), positive (abnormal), or equivocal. A negative test result indicates that no late decelerations occurred in the fetal heart rate, although the fetus was stressed by three contractions of at least 40 seconds duration in a 10-minute period. Repetitive late decelerations render the test results positive.
A successful outcome for the nursing diagnosis of self-care deficit is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal, considering the clients condition. The nurse would determine that the outcome is unsuccessful if the client refuses care or allows others to do the care.

A psychosocial assessment of the client who is immobilized would most appropriately include the need for sensory stimulation. This assessment should also include such factors as body image, past and present coping skills, and coping methods used during the period of immobilization. Although transportation, home care support, and the ability to perform activities of daily living are components of an assessment, they are not as specifically related to psychosocial adjustment as is the need for sensory stimulation.

Vitamin K is associated with the production of prothrombin, which helps the blood properly clot. Vitamin A deficiency is associated with night blindness. Vitamin B2 (riboflavin) deficiency is associated with scaly skin. Vitamin D deficiency can cause skeletal pain.

Somatotropin (Humatrope) should not be administered during or after epiphyseal closure. Efficacy of therapy declines as the client grows older and is usually lost entirely by age 20 to 24 years.

Hyperglycemia can occur from the administration of growth hormone, particularly in a client with diabetes mellitus. Growth hormone therapy is associated with a decline in thyroid function. Hypercalciuria can occur, particularly during the first 2 to 3 months of therapy. Glucose and thyroid hormone levels should be monitored. An enlarged thyroid gland develops in the client with goiter because an excessive amount of thyroxine occurs in the thyroid gland, causing it to enlarge. Slow wound healing occurs with zinc deficiency. Chronic fatigue occurs with iron deficiency. Heart damage occurs with selenium deficiency. Additionally, heart damage would not likely be noted during the nursing assessment. Further diagnostic tests in addition to the assessment would be necessary to determine heart damage.
Diagnosis of HIV infection depends on serological studies to detect HIV antibodies. The most commonly used test is the enzyme-linked immunosorbent assay (ELISA). Options 1 and 4 are incorrect because HIV infection primarily occurs through the

43

exchange of body fluids. Option 3 is incorrect. A neonate born to an HIV-positive mother is at risk for developing the virus. o

Lindane- bawal sa bata/ 6 yr.oldCan cause Seizures- children are prone to Seizures

Lindane can penetrate the intact skin and can cause seizures if absorbed in sufficient quantities. Clients at highest risk for seizures are premature infants, children, and those with preexisting seizure disorders. Lindane should not be used on pediatric clients unless safer medications have failed to control infection.
The fluid of choice for a client with excess fluid volume is a hypertonic solution of 5% dextrose in 0.9% normal saline. This solution would pull fluid into the intravascular space; the kidneys could then excrete the excess fluid. The 0.45% normal saline solution is hypotonic. The lactated Ringers and 0.9% normal saline solutions are both isotonic solutions. Hypotonic solutions such as 0.45% normal saline are inappropriate for the client with cerebral edema because hypotonic solutions have the potential to cause cellular swelling and cerebral edema. The remaining choices of solutions would be appropriate because they are examples of isotonic solutions and thus are similar in composition to plasma. These fluids would remain in the intravascular space without potentiating the clients cerebral edema. Foul-smelling vaginal discharge is expected and will occur for some time following removal of a cervical radiation implant.

The most common side effect of metformin (Glucophage) is GI disturbances, including decreased appetite, nausea, and diarrhea. These generally subside over time. This medication does not cause weight gain; in fact, clients lose an average of 7 to 8 lb because the medication causes nausea and decreased appetite. Although hypoglycemia can occur, it is not the most common side effect. Sulfonylureas promote insulin secretion by the pancreas and may also increase tissue response to insulin. Biguanides decrease glucose production by the liver. -Glucosidase inhibitors inhibit carbohydrate digestion. Thiazolidinediones decrease insulin resistance. Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips or toes, muscle spasms, or twitching, the physician is notified immediately. Calcium gluconate should be kept at the bedside.
Certain factors create a risk for the development of thromboembolitic disorders. These include smoking, varicose veins, obesity, a history of thrombophlebitis, women older than 35 years or who have had more than three pregnancies, and women who have had a cesarean birth. From the options presented, a 26-year-old woman with a family history of thrombophlebitis is least likely to develop thromboembolitic disorders in the postpartum period. Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection. Clinical symptoms at birth in neonates exposed to cocaine in utero include tremors, tachycardia, marked irritability, muscular rigidity, hypertension, and exaggerated startle reflex. These infants are difficult to console

44

and exhibit an inability to respond to voices or environmental stimuli. They are often poor feeders and have episodes of diarrhea. Risk factors for breast cancer include family history of breast cancer, age older than 40 years, early menarche, late menopause, or both, previous cancer of the breast, uterus, or ovaries, nulliparity or first child born after age 30 years, and high-dose radiation exposure to chest. An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Option 1 is the description of the physical finding of liver enlargement. The liver is usually enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. Loss of sphincter control is not a sign of paralytic ileus. For the first 12 hours following a laparotomy, the nasogastric (NG) tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a greenish tinge. The physician should be notified if dark red drainage is noted 24 hours postoperatively. When the client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache, restlessness, mental status changes, such as drowsiness and confusion, visual disturbances, diaphoresis, cyanosis as the hypoxia becomes more acute, hyperkalemia, a rapid, irregular pulse, and dysrhythmias. o Check for the bowel sounds in all 4 quadrants before removing the ngt

Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, thus relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube prior to normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, tube placement, and pH of the gastric aspirate are important assessments for the client with a nasogastric tube in place, but would not assist in determining the readiness for removing the nasogastric tube. In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

Foscarnet (Foscavir) is very toxic to the kidneys. The serum creatinine level is monitored prior to therapy, two or three times weekly during induction therapy, and at least weekly during maintenance therapy. It also may cause decreased levels of calcium, magnesium, phosphorus, and potassium. Thus, these levels are also measured with the same frequency.

Signs of allergic reaction to the contrast dye include early signs such as localized itching and edema, which are then followed by more severe symptoms such as respiratory distress, stridor, and decreased blood pressure.

45

To prevent transmission of hepatitis, a condom is advised during sexual intercourse, as well as vaccination of the partner. Alcohol should be avoided for 1 year because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The clients activity is increased gradually.

Isoproterenol is an adrenergic bronchodilator. Side effects can include tachycardia, hypertension, chest pain, dysrhythmias, nervousness, restlessness, and headache. The nurse monitors for these effects during therapy.

Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma

Ang cardiovascular dse ay may kinalaman sa glaucoma The nurse places an eye patch over the clients affected eye to reduce eye movement. Some clients may need bilateral patching. Depending on the location and size of the retinal break, activity restrictions may be needed immediately. These restrictions are necessary to prevent further tearing or detachment and to promote drainage of any subretinal fluid. The nurse positions the client as prescribed by the physician.

Nalidixic acid (NegGram) is used for acute and chronic urinary tract infections, especially gram-negative bacterial infections. The medication is contraindicated in clients with a history of seizures. It is used with caution in clients with liver or renal disorders

When a nasogastric (NG) tube is attached to suction, it may be continuous or intermittent, with a pressure not exceeding 25 mm Hg. The specific pressure and intervals are prescribed by the physician.

Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the white blood cell (WBC) count (leukocytosis) to 10,000 to 18,000/mm3 with a shift to the left (an increased number of immature WBCs).

Common signs of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas, small, dilated blood vessels, are commonly seen in cirrhosis of the liver.

Ineffective coping may be evidenced by inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense

46

mechanisms, or impairment of usual patterns of communication. Disturbed thought processes are evidenced by altered attention span, distractibility, and disorientation to time, place, person, and events. A dysfunctional family process may exist when the family has difficulty adapting or responding to the changes or traumatic experience of the member in crisis. The client with severe flail chest will have significant paradoxical chest movement. This causes the mediastinal structures to swing back and forth with respiration. This movement can affect hemodynamics. Specifically, the clients central venous pressure (CVP) rises, the filling of the right side of the heart is impaired, and the arterial blood pressure falls. This is referred to as mediastinal flutter. Cough is the most frequent symptom of lung cancer, which begins as nonproductive and hacking, and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of cough usually occurs. Wheezing and bloodstreaked sputum (hemoptysis) are later signs. Pain is a very late sign, and is usually pleuritic in nature. Hoarseness indicates that the affected tissue is in the upper airway. o

Hypomagnesemia is somewhat similar with Hypocalcemia based on their manifestations.

Tetany, twitches, and a positive Trousseaus sign are seen in a client with hypomagnesemia.
The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours after the poisoning. If metabolic acidosis occurs, the client may exhibit hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity smelling breath because of improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia. Shortly after aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours postoverdose, however, the compensatory mechanism fails and the client reverts to metabolic acidosis.

The normal serum ammonia level is 35 to 65 mcg/dL. In the client with hepatic encephalopathy, the serum level is not likely to drop below normal, nor is it likely to drop into the low-normal range. The most optimal but realistic change would be to 40 mcg/dL, which falls into the high-normal range. A level of 80 mcg/dL represents insufficient effect of the medication.

The normal urine myoglobin level is negative. After extensive muscle destruction or damage, myoglobin is released into the bloodstream, where it is cleared from the body by the kidneys. When there is a large amount of myoglobin being cleared from the

47

body, there is a risk of the renal tubules being clogged with myoglobin, causing acute tubular necrosis. This is one form of acute renal failure. The normal hematocrit level for an adult male is 42% to 52%. The client who is in shock has an elevated level because of hemoconcentration. The clients level may be expected to drift back down to within the normal range once fluid volume has been adequately restored. The client with dumping syndrome should be placed on a high-protein, moderate-fat, and high-calorie diet. The client should lie down after eating and should avoid

drinking liquids with meals. Frequent small meals are encouraged and the client should avoid concentrated sweets.
Fruits and vegetables, except avocado, olives, and coconut, contain minimal amounts of fat. Normal hemoglobin levels indicate that iron and protein intake is sufficient. Elevated creatinine levels indicate kidney problems, which is not considered a nutritional disorder. Elevated albumin levels may falsely indicate dehydration. Normal red blood

cell levels indicate adequate vitamin B12 intake.

If the bladder irrigation is infusing at a sufficient rate, the urinary drainage through the Foley tubing should be pale pink. Bright red bleeding and clots could indicate a

complication, and if this is noted, it should be reported to the physician. A dark pink colored urine indicates that the rate of the irrigation solution should be increased. Teacolored urine is not seen after a TURP but may be noted in a client with other renal disorders such as renal failure.

A client with dehydration is likely to be lethargic or complaining of a headache. The client would also exhibit weight loss, sunken eyes, poor skin turgor, flat neck and peripheral veins, tachycardia, and a low blood pressure. The client who is dehydrated would not have bilateral crackles in the lungs because these are signs of fluid overload and is an unrelated finding of dehydration Vaginal discharge should be clear and watery after cryosurgery with laser therapy. The client should be told that the vaginal discharge may be odorous as a result of the sloughing of dead cell debris. This vaginal odor takes about 8 weeks to resolve. The client should be instructed to avoid any sitz baths or tub baths while the area is healing, which takes approximately 10 weeks. Narcotic analgesics would not be prescribed because pain is mild after this procedure. The client should understand that the medication prescribed is not likely to be a narcotic analgesic.

48

The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be avoided include sausage, gravies, fatty meats, fried foods, products made with cream, and desserts. Appropriate food choices include fruits and vegetables, fish, and poultry without skin.
Dicyclomine hydrochloride is an anticholinergic, antispasmodic agent often used to treat irritable bowel syndrome that is unresponsive to diet therapy. In order to be effective in decreasing bowel motility, antispasmodic medication should be administered 30 minutes before meals.

Dumping syndrome occurs after gastric surgery because food is not held as long in the stomach and is dumped into the intestine as a hypertonic mass. This causes fluid to shift into the intestine causing cardiovascular as well as GI symptoms. Symptoms can typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.

DIABETIC KETOACIDOSIS- SEVERE THIRST & POLYURIA OHA IS FOR DM TYPE 2 REGULAR INSULIN IS FOR DM TYPE 1 The client is most likely in diabetic ketoacidosis (DKA). Regular insulin via the IV route

is the preferred treatment for DKA. Regular insulin is a short-acting insulin and is the
only insulin that can be given intravenously; it is titrated to the clients high blood glucose levels. NPH insulin is an intermediate-acting insulin and is not appropriate for

the emergency treatment of DKA . Glucagon is used to treat hypoglycemia, and glyburide is an oral hypoglycemia agent used to treat diabetes mellitus type 2.

The client who is unconscious is at great risk for aspiration. The nursing assistant turns the clients head to the side and places an emesis basin underneath the mouth. A bite stick or a padded tongue blade is used to open the mouth, not a gloved finger, to prevent injury to the caregiver. Small volumes of fluids are used to rinse the mouth.

The client who is underhydrated will have a urine specific gravity of greater than 1.030. Normal values for urine specific gravity are 1.010 to 1.030. Pale yellow urine is a normal finding. A blood pressure of 120/80 mm Hg is within normal range. A temperature of 98.8 F is only 0.2 point above the normal temperature and would not be as specific an indicator of hydration status as would the urine specific gravity.

49

Lindane can penetrate intact skin and can cause convulsions if absorbed in sufficient quantities. A client with a preexisting seizure disorder is at high risk for convulsions. Other clients at high risk for convulsions include premature infants and children. Lindane should not be used on pediatric clients unless safer medications have failed to control the infection The therapeutic range for magnesium sulfate is 4 to 8 mg/dL. The signs of concealed bleeding include increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability.
Magnesium sulfate produces flushing and sweating due to decreased peripheral blood pressure. It decreases the central nervous system activity, acting as an anticonvulsant, and decreases the frequency and duration of uterine contractions. Magnesium sulfate decreases (not increases) acetylcholine, blocking neuromuscular transmission.

INEVITABLE ABORTION- WITH CERVICAL DILATION THREATENED ABORTION- WITHOUT CEVICAL DILATION INCOMPLETE ABORTION- WITH CERVICAL DILATION & PASSAGE OF LARGE CLOTS SPONTANEOUS ABORTION- SYPHILIS MATERNAL AGE OF 40 AND & DM RISK FACTOR FOR CONGENITAL MALFORMATIONS. Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. Weight and edema are priority interventions for the client with preeclampsia, and an elevated temperature is an indicator of infection

An abnormal pregnancy (ectopic) is suspected if -hCG is present but at lower levels than expected. The absence of -hCG would indicate no pregnancy, whereas normal limits could indicate a normal pregnancy. High levels could indicate a molar pregnancy. Known risk factors that increase the risk of developing gestational diabetes include obesity (over 198 pounds), chronic hypertension, family history of diabetes mellitus, previous birth of a large infant (over 4000 g), and gestational diabetes in a previous pregnancy.
Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy, can result in elevation of maternal blood glucose levels. This increases the mothers demand for insulin. This is referred to as the diabetogenic effect of pregnancy. Caloric intake is not affected by diabetes.

The most common signs and symptoms of gestational trophoblastic disease (hydatidiform mole) include elevated levels of hCG, vaginal bleeding, larger-thannormal uterus for gestational age, failure to detect fetal heart activity even with

50

sensitive instruments, excessive nausea and vomiting, and early development of gestational hypertension. Fetal activity would not be noted.

Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus will have difficulty contracting. An oral temperature of 99.0 F after delivery and the presence of afterpains are expected findings following delivery. Hemodialysis typically lowers the amounts of fluid, sodium, potassium, urea nitrogen, creatinine, uric acid, magnesium, and phosphate levels in the blood.

Hemodialysis also worsens anemia, because RBCs are lost in dialysis from blood sampling and anticoagulation during the procedure, and from residual blood that is left in the dialyzer. Aluminum intoxication can occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. It may be treated with aluminum-chelating agents, which make aluminum available to be dialyzed from the body. It can be prevented by avoiding or limiting the use of phosphate-binding agents that contain aluminum. Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and presence of an indwelling urinary catheter or frequent catheterization. The normal ratio of BUN to creatinine is approximately 10:1 to 15:1. A value lower than 10:1 would indicate diminished urea concentration. A value greater than 15:1 would indicate inadequate renal function. An excretory urogram is an invasive test that uses contrast radiopaque dye to assess the ability of the kidneys to excrete dye in the urine. Bowel preparation is necessary to permit adequate visualization of the kidneys, ureters, and bladder Aluminum hydroxide binds with phosphate in the intestines for excretion in the feces, thus lowering phosphorus levels. It can cause constipation, and it does not promote the elimination of potassium. It may be used in the treatment of hyperacidity associated with gastric ulcers, but this is not the purpose of its use in the client with renal failure. For hemodialysis Dialysate is made from clear water and chemicals and is free from any metabolic waste products or medications. Bacteria and other microorganisms are too large to pass through the membrane; therefore, the dialysate does not need to be sterile. The dialysate is warmed to approximately 100 F to increase the efficiency of diffusion and

51

to prevent a decrease in the clients blood temperature. Heparin sodium inhibits the tendency of blood to clot when it comes in contact with foreign substances.

URINE SPECIFIC GRAVITY TELLS WHETHER OVERHYDRATION OR DEHYDRATION THEREFORE IT HAS THE BEST ABILITY TO REGULATE FLUID BALANCE IN THE KIDNEYS. Specific gravity evaluates the kidneys ability to regulate fluid balance and evaluates the hydration status of the body. The BUN and creatinine more specifically evaluate renal function. Although a small amount of protein in the urine may be normal, a high level of protein may be an indicator of renal pathology. Clinical manifestations associated with ARF occur as a result of metabolic acidosis. The nurse would expect to note Kussmauls respirations as a result of the metabolic acidosis because the bodily response is to exhale excess carbon dioxide.
Continuous ambulatory peritoneal dialysis (CAPD )closely approximates normal renal function, and the client will need to infuse and drain the dialysis solution several times a day. No machinery is used, and CAPD is a manual procedure. Candida infections, which are fungal infections, develop in persons who are on long-term antibiotic therapy because an alteration of normal flora occurs. These infections also are commonly seen in clients with blood dyscrasias, diabetes mellitus, cancer, or immunosuppression and in clients with a drug addiction. Gross, painless hematuria most frequently is the first manifestation of bladder cancer. As the disease progresses, the client may experience dysuria, frequency, and urgency.

Gross hematuria and proteinuria are the cardinal signs of glomerulonephritis. The urine may be small in volume, dark or smoky in color from the hematuria, and foamy from the proteinuria. Concurrent serum studies would reveal an elevated blood urea nitrogen, creatinine, C-reactive protein levels, and antistreptolysin O titer. With intrinsic renal failure, there is a fixed specific gravity and the urine tests definitely positive for proteinuria. In prerenal failure, the specific gravity is high, and there is very little or no proteinuria. In postrenal failure, there is a fixed specific gravity and little or no proteinuria. There is no disorder known as atypical renal failure. An AV fistula is the internal creation of an arterial-to-venous anastomosis. This causes engorgement of the vein, allowing both the artery and the vein to be easily cannulated for hemodialysis. Fistulas take 1 to 2 weeks to mature or develop before they can be used for dialysis, so the current method of access must remain in place to be used during that time period.

52

The priority nursing diagnosis for the client with anorexia nervosa is imbalanced nutrition. Although the nursing diagnoses identified in options 1, 2, and 3 may be considerations in the plan of care for the client with anorexia nervosa, imbalanced nutrition is the priority. Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory BP greater than 10 mm Hg). Bradycardia is not a sign of cardiac tamponade. The most common complication associated with TPN is infection. Monitoring the temperature would provide the assessment data that would indicate infection in the client. Weighing the client daily and monitoring I&O would provide information related to fluid volume overload. Monitoring the BUN level would not provide information related to infection and is most closely related to assessing renal function. The client with Cushings syndrome experiences hyperkalemia, hyperglycemia, an elevated

WBC count, and an elevated plasma cortisol and ACTH levels. These abnormalities are
due the effects of excess glucocorticoids and mineralocorticoids in the body. The laboratory values noted in options Risk factors associated with cervical cancer include early, frequent intercourse with multiple sexual partners, multiparity, chronic cervicitis, and a history of genital herpes or human papilloma. Cervical cancer also occurs with higher frequency in the black race. Regarding the options provided, the single white client is at lowest risk for the development of cervical cancer. Warfarin (Coumadin) is an anticoagulant, which is used as long-term prophylaxis of thrombosis. Clients must receive detailed instructions regarding the signs of bleeding. Hematuria is a sign of bleeding, which the client should report. Bruising is a common side effect associated with anticoagulant therapy and is almost unavoidable. The client,

however, should not stop the medication if bruising occurs. Option 2 is unrelated to
the use of warfarin, and option 3 is not completely accurate regarding prevention of a stroke. Nocturia, decreased force of urinary stream, and difficulty initiating urinary stream are all early signs of benign prostatic hypertrophy. Hematuria is not an early sign of BPH. Arterial ulcers have a pale, deep base and are surrounded by tissue that is cool with trophic changes such as dry, skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A venous stasis ulcer is one that has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion. A stage 1 ulcer indicates a reddened area with an intact skin surface.

53

Ngt suction

Gastric mucosa can be traumatized and pulled into the tube if the suction pressure is placed on high or if the suction is continuous. The suction should be set on low pressure and intermittent suction control.

Blurred central vision occurs with macular degeneration. Changes in peripheral visual acuity (option 3) most often occurs with glaucoma. Glare from bright lights (option 4) is a common complaint in the client with a cataract. Pain in the eye (option 2) is not specifically associated with macular degeneration.

The client should be instructed to maintain a diet high in fiber and to consume a high intake of liquids, unless contraindicated, to prevent constipation and straining at stool. Objects weighing 20 pounds or more should be moved by pushing the object along the floor using the feet, rather than by bending over. Activities such as bending over and straining at stool will increase intraocular pressure.

Myxedema is a deficiency of thyroid hormone. The client will present with a puffy edematous face, especially around the eyes (periorbital edema), along with coarse facial features, dry skin, and dry coarse hair and eyebrows. Thin silky hair, fine muscle

tremors & bulging fontanels are noted in the client with hyperthyroidism.

Hyperthyroidism is clinically manifested by goiter (increase in the size of the thyroid gland) and exophthalmos (bulging eyeballs). Other clinical manifestations include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. Additional signs found in this disorder include tachycardia, shortness of breath, excessive sweating, fine muscle tremors, thin silky hair and thin skin, infrequent blinking, and a staring appearance.

Cachexia accompanies chronic wasting diseases and conditions such as cancer, dehydration,

and starvation. Assessment findings in a client with cachexia include sunken eyes, hollow cheeks, and an exhausted, defeated expression
The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the clients jaws by pushing down on the chin; normally the jaws cannot be separated. Bringing a wisp of cotton in from the side of the eye and lightly touching

54

the cornea will assess the corneal reflex. Placing an object on the clients tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the clients chin assesses cranial nerve XI, the spinal accessory nerve Soft tissue injuries such as sprains are treated with (for sprained ankle) o RICE (rest, ice, compression, and elevation) for the first 24 to 48 hours after the injury, depending on physician prescription. Ice is applied intermittently for 20 to 30 minutes at a time. The client should rest and not walk around, and the foot should be elevated and not placed in a dependent position. Heat is not used for the first 24 hours because this could cause venous congestion, thereby increasing edema and pain. Blankets would produce heat to the affected area. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture that occurs through only a part of the cross section of the bone; one side of the bone is fractured and the other side is bent. A comminuted fracture is a complete fracture across the shaft of the bone with splintering of the bone fragments. A compound fracture, also called an open or a complex fracture, is one in which the skin or mucous membrane has been broken and the wound extends to the depth of the fractured bone. Edema in the extremity indicates impaired venous return. Signs of impaired arterial circulation in the limb include coolness and pallor of the skin and a diminished arterial pulse. Signs of infection under a cast area would include odor or purulent drainage from the cast and the presence of hot spots, which are areas of the cast that feel warmer to the touch than the rest of the cast. One of the earliest indicators of successful adaptation of the newborn to extrauterine life is the Apgar score. Scoring ranges from 0 to 10. A score of 8 to 10 indicates that the newborn is adjusting well to extrauterine life. A score of 5 to 7 often indicates that the newborn requires some resuscitative interventions. Scores of less than 5 indicate that the newborn is having difficulty adjusting to extrauterine life and requires vigorous resuscitation. Renal biopsy with microscopic examination is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound study

55

discriminates between a fluid-filled cyst and a solid mass. Renal arteriography outlines the renal vascular system. After nephrectomy, the client may be in considerable pain. This is due to the size of the incision and its location near the diaphragm, which makes coughing and deep breathing very uncomfortable. For this reason, opioids are used liberally and may be most effective when provided as patient-controlled analgesia or through epidural analgesia.

A complication of radiation therapy for bladder cancer is fistula formation. In women, this frequently is manifested as a vesicovaginal fistula, which is an opening between the bladder and the vagina. With this complication, the client senses that urine is flowing out of the vagina. In men, a colovesical fistula may develop, which is an opening between the bladder and the colon. This is manifested as voiding urine that contains fecal material.

After intravesical chemotherapy, the client treats the urine as a biohazard. This involves disinfecting the urine and the toilet with household bleach for 6 hours after the treatment. Scented disinfectants are of no particular use. The client does not need to have a separate bathroom for personal use. Using a bedpan for voiding is of no value in this situation.

Disturbed body image can be diagnosed when the client has either a verbal or a nonverbal response to a change in the structure or the function of a body part. Anxiety is a nonspecific feeling of unease. The diagnosis of fear can be used when the client has an identifiable concern; however, sterility is not mentioned as a concern by the client. Acute pain may apply but does not correlate with the information in the question.

When a hypothermia blanket is used, the skin is inspected frequently for pressure points, which over time could lead to skin breakdown.

Chlorpromazine is used to control shivering in hyperthermic states. It is a phenothiazine and has antiemetic and antipsychotic uses, especially when psychosis is accompanied by increased psychomotor activity. Prochlorperazine is a phenothiazine(Compazine) that is an antiemetic and antipsychotic. Fluphenazine is a phenothiazine that is used as an antipsychotic. Buspirone is an anxiolytic.

56

Normal ICP readings range from 5 to 15 mm Hg pressure. Pressures greater than 20 mm Hg are considered to represent increased ICP, which seriously impairs cerebral perfusion.

Hyperventilation with a PaCO2 of 25 to 30 mm Hg causes cerebral vasoconstriction, which decreases intracranial blood volume and ICP. The PaO2 is not allowed to fall below 80 mm Hg, to prevent cerebral vasodilation from hypoxemia.

A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and to call the physician or return the client to the emergency department for several signs and symptoms. These include confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. Minor headache is expected.

Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible, because it is one of the few areas of control that the client has left

Ptosis of the eyelid is due to pressure on and dysfunction of cranial nerve III. This condition, once it occurs, is ongoing; it does not relate to LOC. Early changes in LOC relate to alertness and verbal responsiveness. Less frequent speech, slight slurring of speech, and mild drowsiness are early signs of decreasing LOC.

Aminocaproic

acid is

an

antifibrinolytic

agent

that

prevents

clot breakdown or

dissolution. It is commonly ordered after subarachnoid hemorrhage if surgery is delayed or contraindicated, to prevent further hemorrhage. Heparin sodium and warfarin are anticoagulants, which interfere with propagation or growth of a clot. Alteplase is a fibrinolytic, which actively breaks down clots. Nimodipine is a calcium channelblocking agent that has an affinity for cerebral blood vessels. It is used to prevent or control vasospasm in cerebral blood vessels, thereby reducing the chance for rebleeding. It is typically ordered for 3 weeks duration. Streptokinase converts plasminogen in the blood to plasmin. Plasmin is an enzyme that digests or dissolves fibrin clots wherever they exist.

57

Diltiazem is a calcium channel blocker that inhibits calcium influx through the slow channels of the membrane of smooth muscle cells. These medications decrease myocardial oxygen demands and block calcium channels, thereby decreasing the force of contraction of the ventricular tissue.

Redness and heat are associated with musculoskeletal inflammation, infection, or a recent injury. Degenerative disease is accompanied by pain, but there is no redness. Swelling may or may not occur.

Before a fracture is reduced, the client is informed about the procedure, and an informed consent is obtained. An analgesic is given as prescribed, because the procedure is painful. Closed reductions may be done in the emergency department without anesthesia. If anesthesia is used, the procedure is done in the operating room.

The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smoothed as needed. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight bearing once it is dry, which takes from 24 to 72 hours depending on the nature and thickness of the cast.

Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and range of motion. The client may pull up using the trapeze, perform active range of motion with uninvolved joints, and do isometric muscle-setting exercises (such as quadriceps- and gluteal-setting exercises). The client also may flex and extend the feet.

A quad cane may be used by the client requiring greater support and stability than is provided by a straight leg cane. The quad cane provides a fourpoint base of support and is indicated for use by clients with partial or complete hemiplegia. Neither crutches nor a wheelchair is indicated for use with a client such as the one described in the question.

Typical signs and symptoms after femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may

58

report slight groin pain, or pain in the medial side of the knee. Moving the fractured extremity increases the pain significantly. These signs and symptoms are not associated with a fractured or dislocated knee or a fractured femur. Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knife-like, and localized in the affected area. Pressure on a spinal nerve root causes the symptoms of sciatica. Pressure on the spinal cord itself could result in a variety of manifestations, depending on the area involved. Clients who experience fractures of the femur, pelvis, thorax, and spine are at risk for hypovolemic shock. Bone fragments can damage blood vessels, leading to hemorrhage into the abdominal cavity and the thigh. This can occur with closed fractures as well as open fractures. Signs of hypovolemic shock include tachycardia and hypotension. A window may be cut in a dried cast to relieve pressure, assess pulses, relieve discomfort, or remove drains. Bivalving the cast involves splitting the cast along both sides to allow space for swelling or to facilitate taking radiographs, or to make a half-cast for use as an intermittent splint. Padding is not placed on top of a cast. The use of an air splint is not indicated. Laboratory dx for phenytoin- cbc The nurse monitors the CBC, because hematological side effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, and thrombocytopenia. Other test results that warrant monitoring include serum calcium levels and the results of urinalysis, hepatic, and thyroid function tests. Carbamazepine acts by depressing synaptic transmission in the central nervous system (CNS). Because of this, the client should avoid driving or doing other activities that require mental alertness until the effect of the medication on the client is known. The client should use protective clothing and sunscreen to avoid photosensitivity reactions. The medication may cause dry mouth, and the client should be instructed to provide good oral

59

hygiene and use sugarless candy or gum as needed. The medication should not be abruptly discontinued, because this could lead to return of seizures or status epilepticus. Fever and sore throat should be reported to the physician (leukopenia). Edrophonium commonly is given to test for myasthenic crisis. If the client is in myasthenic crisis, muscle strength improves after administration of the medication, and the improvement lasts for about 30 minutes.

Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension all are adverse effects of the medication

Bouchard's nodes are hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular (joint) cartilage. Bouchard's nodes are comparable in presentation to Heberden's nodes, similar osteoarthritic growths on the distal interphalangeal joints, but are significantly less common. Skin lesions or a rash on the face across the bridge of the nose and on the cheeks is a characteristic sign of SLE. Fever and fatigue may occur before and during exacerbation, but these signs and symptoms are vague. Anemia is most likely to occur in SLE. Several conditions present risks in the client scheduled for ECT. These include recent myocardial infarction, brain attack (stroke), and cerebrovascular malformation or an intracranial lesion. Paroxetine is an antidepressant used in the treatment of major depression. Amitriptyline is a tricyclic antidepressant (TCA) used to treat various forms of depression. Tranylcypromine is a monoamine oxidase (MAO) inhibitor used in the symptomatic treatment of severe depression in hospitalized or closely supervised clients, and thioridazine is an antipsychotic medication.

Complications from viral hepatitis include bleeding tendencies with increasing prothrombin time values as well as abnormalities on liver function tests. Clients also can develop encephalopathy. A characteristic sign of encephalopathy is asterixis. Serum transaminase levels such as the AST decrease and vitamin K becomes absorbed as liver cells heal and regenerate. Impaired gas exchange could occur after tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion due to immobility, or concurrent respiratory conditions. An oxygen saturation of 91% is less than optimal. A respiratory rate of 16 breaths/min is in the normal range. Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings from impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.

60

The client with pulmonary edema that developed after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A respiratory rate of 20 breaths/min is within normal limits. Pain with deep breathing is expected and is managed with analgesics. The client with pneumonectomy most likely will not have a chest tube.

Because tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is not necessary to discard any of these. It is important to perform proper hand washing after contact with body substances, tissues, or face masks. The client should cover the mouth with a tissue when laughing, coughing, or sneezing and dispose of tissues carefully. The client also may need to wear a mask as advised by the physician. Family members or others who have been in close contact with a client diagnosed with tuberculosis are placed on prophylactic therapy with isoniazid (INH) for 6 to 12 months. The client usually is not contagious after taking medication for 2 to 3 consecutive weeks. However, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection or drug-resistant tuberculosis. Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Hyperreflexia is an excessive reflex action. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. The least amount of invasiveness needed to produce a bowel movement is best. Fecal disimpaction is done only when the clients rectum has become impacted from constipation as a result of inattention or failure of other measures. Enemas may be needed on an every-other-day basis, but they are used cautiously (even if not contraindicated) because the Valsalva maneuver can increase intracranial pressure. Glycerin suppositories are the least invasive and usually stimulate bowel evacuation within a halfhour. Stool softeners may be prescribed on a regular schedule to avoid hard, dry stools. If the gastric residual is greater than 150 mL the client may be experiencing delayed gastric emptying. If this occurs, the feeding is stopped and the physician should be notified. The nurse should assess whether abdominal girth is enlarged and should auscultate bowel sounds to rule out intestinal obstruction. Some clients benefit from administration of metoclopramide (Reglan) to stimulate gastric emptying. The infusion rate cannot be too slow (option 1) if the client cannot tolerate the rate. Air in the stomach would be accompanied by abdominal distention and increased abdominal girth. Early peptic ulcer could be detected by Hematest-positive gastric aspirate. Some clients who have awakened from an unconscious state have reported they remember hearing specific voices and conversations. Family and staff should assume that the clients sense of hearing is still intact and act accordingly. Studies also have demonstrated that positive outcomes are associated with coma stimulationthat is, speaking to and touching the client. Ineffective breathing pattern is diagnosed when the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Impaired gas exchange occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Risk for aspiration and risk for injury are unrelated to the question. The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. Adaptive eating utensils may be beneficial when the client has partial paralysis of the hand. A raised toilet seat is useful when the client does not have the mobility or ability to flex the hips. A slider board is used in transferring a client from a bed to stretcher or wheelchair.

61

An ataxic gait is characterized by unsteadiness and staggering. A spastic gait is characterized by stiff, short steps with legs held together, hip and knees flexed, and with toes that catch and drag. A festinating gait is best described as walking on the toes with an accelerating pace. A dystrophic or broad-based gait is seen as waddling, with weight shifting from side to side, and with legs far apart. Corticosteroid therapy can result in glucose intolerance, leading to elevated blood glucose levels. The nurse monitors these levels to detect this side effect of therapy. With successful transplantation, the clients serum electrolyte levels should be better regulated, although corticosteroids also could cause sodium retention. The serum albumin will not be affected. With an inguinal hernia, inguinal swelling occurs when the infant cries or strains. Absence of this swelling would indicate resolution of this problem. Abdominal distention indicates a continuing gastrointestinal problem. A clean, dry incision refers to absence of wound infection after surgery. The flow of urine is not specific to an inguinal hernia. After hydrostatic reduction, the nurse observes for the passage of barium or water-soluble contrast material with stools The nurse provides instructions to the client regarding measures to promote sinus drainage, comfort, and resolution of the infection. The nurse instructs the client to apply heat in the form of wet packs over the affected sinuses to promote comfort and help resolve the infection. The client should be instructed to use a cool mist vaporizer to help liquify secretions and promote drainage. Consumption of large amounts of fluids is important to help liquify secretions. Sleeping with the head of the bed elevated to a 45-degree angle will assist in promoting drainage. To decrease the risk of laryngeal cancer, the client should be instructed to avoid cigarette smoking, alcohol consumption, exposure to airborne carcinogens, and vocal abuse. The client is instructed to schedule routine physical examinations. The client also should be instructed to seek medical care if difficulty in swallowing, persistent hoarseness, enlarged lymph nodes in the neck, or unexplained weight loss occurs. The client with a stoma should be instructed to wash the stoma daily with a wash cloth. Soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. A thin layer of petroleum applied to the skin around the stoma helps to prevent cracking. The client is instructed to protect the stoma from water. Pre-procedural instructions include informing the client that the procedure is painless. The procedure requires no dietary restrictions other than avoidance of cola, tea, and coffee on the morning of the test. These products have a stimulating effect and should be avoided. The hair should be washed the evening before the test and gels, hairsprays, and lotion should be avoided. The client is informed that the test will take 45 minutes to 2 hours and that medications usually are not withheld before the test.

After arthroscopy, the client is instructed to avoid excessive use of the joint for several days, to elevate the knee while sitting, to avoid twisting the knee, and to return for suture removal in about 7 days. Ice is applied to the affected joint for pain and swelling, and analgesics are administered as prescribed. Intermittent IV infusion of phenytoin is administered by injection into a large vein using normal saline solution. Dextrose solutions are avoided because the medication will precipitate in these solutions. A Tensilon test is performed to distinguish between myasthenic and cholinergic crisis. After administration of the Tensilon, if symptoms intensify, the crisis is cholinergic. Because the symptoms of cholinergic crisis will worsen with the administration of Tensilon, atropine sulfate should be available because it is the antidote.

62

Prazosin hydrochloride is antihypertensive medication used to treat high blood pressure. A decrease in blood pressure indicates a therapeutic effect from the medication. Clonidine is an antihypertensive medication that is applied to a hairless intact skin area of the upper arm or torso every 7 days. The most common symptom of appendicitis is a colicky, periumbilical, or lower abdominal pain located in the right quadrant. The classic signs and symptoms of intussusception are acute, colicky abdominal pain with currant jellylike stools. Clinical manifestations of Hirschsprungs disease include constipation, abdominal distention, and ribbon-like, foul-smelling stools. Peritonitis is a complication that can follow perforation or intestinal obstruction. The normal CSF pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range. The maximum amount of edema in a client with a burn injury is seen between 18 and 24 hours after the injury. With adequate fluid resuscitation, the transmembrane potential is restored to normal within 24 to 36 hours after the burn. A PASG (Pneumatic Anti-shock Garment) may be useful in the treatment of hypovolemic shock associated with traumatic injury to provide circulatory assistance. The device is used only as a temporary measure until definitive treatment is given because it can compromise blood flow to the lower half of the body. The critical nursing assessment includes monitoring the vascular status of the lower extremities. Although options 1, 3, and 4 may be components of the nursing assessment, these actions are not part of the critical assessment required with use of a PASG. The normal LAP is 1 to 10 mm Hg. Because the left atrium does not generate significant pressure during atrial contraction, the atrial pressure is recorded as an average (mean) pressure, rather than as a systolic or diastolic pressure. The client who receives circumferential burns to the extremities is at risk for altered peripheral circulation. The priority assessment would be to assess for peripheral pulses to ensure that adequate circulation is present. Although the respiratory rate and BP also would be assessed, the priority with a circumferential burn is the assessment for the presence of peripheral pulses. A fiberglass cast is made of water-activated polyurethane material that is dry to the touch within minutes and reaches full rigid strength in about 20 minutes. Accordingly, the client can bear weight on the cast within 20 to 30 minutes. A warm bath, avoidance of upright positioning, and other comfort measures to reduce crying are all simple measures to reduce a hernia. Coughing and crying increase the strain on the hernia. Likewise, physical activity and enemas of any type would increase the strain on the hernia. Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign but usually is mild, with temperatures less than 39 C. Epigastric pain radiating to the neck area is not a characteristic symptom.. o

LOW PRESSURE VOLUME ALARM- DISPLACEMENT/ HIGH PRESSURE VOLUME ALARM- KINK TUBE

The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts.

63

A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset amount. Causes of high-pressure alarm activation include excess secretions, mucous plugs, the clients biting on the endotracheal tube, kinks in the ventilator tubing, and the clients coughing, gagging, or attempting to talk.

Tidal volume is the amount of air delivered with each set breath on the mechanical ventilator. The respiratory rate is the number of breaths to be delivered by the ventilator. The fraction of inspired oxygen delivered to the client is indicated by the FIO2 indicator on the ventilator. A sigh is a breath that has a greater volume than the preset tidal volume. Sutures usually are removed 7 to 10 days after a skin biopsy, depending on physician preference. After a skin biopsy, the nurse instructs the client to keep the dressing dry and in place for a minimum of 8 hours. After the dressing is removed, the site is cleaned once a day with tap water or saline to remove any dry blood or crusts. The physician may prescribe an antibiotic ointment to minimize local bacterial colonization. The nurse instructs the client to report any redness or excessive drainage at the site.

CK is a cellular enzyme that can be fractionated into three isoenzymes. The MM band reflects CK from skeletal muscle. This band would be elevated in skeletal muscle disease. The MB band reflects CK from myocardial muscle. The BB band reflects CK from the brain. There is no MS band.

The normal serum creatinine level for an adult male is 0.6 to 1.3 mg/dL. The normal value for females is 0.5 to 1.0 mg/dL. The normal serum potassium level in the adult is 3.5 to 5.1 mEq/L A normal platelet count ranges from 150,000 to 400,000 cells/L. The normal range for the serum protein level in the adult client is 6.0 to 8.0 g/dL. The normal serum lipase level is 10 to 140 U/L. The normal hemoglobin level for an adult female is 12 to 15 g/D (Yung E-mail add ko) The normal hematocrit level for an adult male is 42% to 52%-( AGE NI MAMA) The primary lesion of herpes zoster is a vesicle. The classic presentation is grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the bodys midline. Warfarin is an anticoagulant. Bleeding is a concern while the client is taking this medication. Orangecolored urine indicates blood in the urine from an overdose of the medication. Bleeding also may be identified by urine that turns red, smoky, or black. The prothrombin time is determined to monitor the clotting mechanism. The half-life of the medication is 2 days, the peak effect is between 1 and 3 days, and the anticoagulation effect extends 4 to 5 days after discontinuation. Aspirin is an antiplatelet agent and would increase the risk of bleeding. Hyperglycemia results from decreased utilization and increased production of glucose. Increased utilization of glucose and overproduction of insulin would most likely cause hypoglycemia.

64

In extensive burn injuries (greater than 25% of total body surface area), the edema occurs in both burned and unburned areas as a result of the increase in capillary permeability and hypoproteinemia. Edema also may be caused as a result of the volume and oncotic pressure effects of the large fluid resuscitation volumes required. the normal adult value for magnesium is 1.5-2.5 mEq/L. Hypermagnesemia may be classified as mild (serum magnesia level of 3 to 5 mEq/L), moderate (6 to 7 mEq/L), severe (10 to 11 mEq/L), and emergency (12 to 15 mEq/L). A client with a mild degree of hypermagnesemia usually is asymptomatic. Neurological depression begins to occur at magnesium levels of 6 to 7 mEq/L and is manifested by drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia.

ELICIT- Symptom which is exclusively for that particular disease. Clinical manifestations of a Candida infection include vaginal pain, itching, and a thick, white vaginal discharge. Hematuria, edema, flank pain, and headache are clinical manifestations associated with urinary tract infections.

Assessment of a client with Hodgkins disease most often reveals enlarged, painless lymph nodes along with fever, malaise, and night sweats. Weight loss may be a feature in metastatic disease. Visual changes are not specifically associated with Hodgkins disease.

Eye movements are under the control of cranial nerves III, IV, and VI. Insight, judgment, and planning are part of the function of the frontal lobe in conjunction with association fibers that connect to other areas of the cerebrum. Level of consciousness (response to verbal stimuli) is controlled by the reticular activating system and both cerebral hemispheres. Feelings are part of the role of the limbic system and involve both hemispheres.

The client with uncontrolled atrial fibrillation with a ventricular rate higher than 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

Wheezing is not a reliable manifestation to determine the severity of an asthma attack. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on exhalation. As the asthma attack progresses, the client may wheeze during both inspiration and expiration. Diminished breath sounds may be an indication of severe obstruction and possibly respiratory failure.

The neurological system is primarily affected by carbon monoxide poisoning. With high levels of carbon monoxide, the neurological status progressively deteriorates. CARBON MONOXIDE POISONINGPRIORITYLEVEL OF CONSICIOUSNESS NOT

RESPIRATORY RATE. The client with heart failure may present with different symptoms depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.

65

THROMBOTIC BRAIN ATTACK (STROKE)- PARESTHESIA, HEADACHE IS RARE Cerebral thrombosis does not occur suddenly. In the few hours or days preceding a thrombotic stroke, the client may experience a transient loss of speech, hemiplegia, or paresthesias on one side of the body. Signs and symptoms of thrombotic stroke vary but may include dizziness, cognitive changes, or seizures. Headache is rare, but some clients with stroke experience signs and symptoms similar to those of cerebral embolism or intracranial hemorrhage.

Spironolactone is a potassium-sparing diuretic. Side effects include hyperkalemia, dehydration, hyponatremia, and lethargy. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means that the concern with this medication is hyperkalemia. Additional side effects include nausea, vomiting, cramping, diarrhea, headache, ataxia, drowsiness, confusion, and fever.

Somatization disorder is characterized by a long history of multiple physical problems with no satisfactory organic explanation. The clinical findings associated with schizophrenia, depression, and obsessive-compulsive disorder are unrelated to somatic complaints.

Grossly bloody urine with clots following cystoscopy is always an abnormal finding and should be reported to the physician immediately. The client may have clear or blood-tinged urine after cystoscopy. If a contrast agent such as methylene blue is used, the urine may have an unusual bluish or green tinge. A blood pressure of 130/82 mm Hg and a temperature of 99.4 F are not abnormal findings at this time.

Amantadine is an antiparkinson agent that potentiates the action of dopamine in the central nervous system. The expected effect of therapy is a decrease in akinesia and rigidity. Leukopenia, urinary retention, and hypotension all are adverse effects of the medication.

Because of the location of the incision in the neck area, many clients are afraid of thyroid surgery for fear of having a visible large scar postoperatively. Having all or part of the thyroid gland removed will not cause the client to experience gynecomastia or hirsutism. Sexual dysfunction and infertility could possibly occur if the entire thyroid was removed and the client was not placed on thyroid replacement medications.

Hypertension is the major symptom associated with pheochromocytoma. Glycosuria, weight loss, and diaphoresis also are clinical manifestations of pheochromocytoma; however, they are not major symptoms.

NPH is an intermediate-acting insulin with an onset of action in 3 to 4 hours, a peak action in 6 to 12 hours, and a duration of action of 18 to 28 hours. A hypoglycemic reaction is most likely to occur at peak time. 4:00 pm is the only option that represents a time frame within the peak hours after administration of the NPH insulin.

Normal albumin levels in children or adults varies from 3.5 g/dl to 5.4g/dl ...
the hematocrit (Ht or HCT) or packed cell volume (PCV) or erythrocyte volume fraction(EVF) is the proportion of blood volume that is occupied by red blood cells. It is normally about 48% for men and 38% for women

66

Extensive burns greater than 25% of the TBSA result in generalized body edema in both burned and unburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels are elevated in the first 24 hours after injury owing to hemoconcentration from the loss of intravascular fluid.HEMOCONCENRATION, HEMATOCRIT

Because the kidneys are located in the flank region of the body, trauma to the back area can cause the presence of hematuria, particularly in the child with hemophilia. The nurse would be most concerned about the childs airway and respiratory rate if the child sustained an injury to the neck region. Headache and slurred speech are associated with head trauma.

Aminophylline is a bronchodilator. The nurse monitors the theophylline blood serum level daily when a client is on this medication to ensure that a therapeutic range is present and to monitor for the potential for toxicity. The therapeutic serum level range is 10 to 20 mg/mL. If the laboratory result indicated a level of 5 mg/mL, the dosage of the medication would need to be increased.

Fluid in the water seal compartment should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed.

Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain often is characterized as stabbing or as similar to an electric shock. It is accompanied by spasms of facial muscles that cause twitching of parts of the face or mouth, or closure of the eye.

Bells palsy is a one-sided facial paralysis due to compression of the facial nerve. Manifestations include facial droop from paralysis of the facial muscles, increased lacrimation, painful sensations in the eye, face, or behind the ear, and speech or chewing difficulties.

A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a boneone side of the bone is fractured, and the other side is bent. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken and the resulting wound extends to the depth of the fractured bone. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement, but without breaking the skin.

A report of severe colicky abdominal pain in a healthy thriving child between 3 and 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest

Scoliosis does not occur as a sequela of inflammation According to the Rule of Nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and right and left arm were burned, according to the Rule of Nines, the total area involved would be 54%.

67

The frontal lobe controls voluntary muscle activity including speech, and an impairment can result in expressive aphasia. The parietal lobe contains association areas for concept formation, abstraction, spatial orientation, body and object size and shape, and tactile sensation. The occipital lobe contains areas related to vision. Auditory association and storage (MEMORY) areas are located in the temporal lobe and relate to understanding the spoken language.

DIdanosine (Videx) is toxic to both the pancreas and the liver. A serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis and may be potentially fatal in the client with AIDS. Therefore, the nurse monitors the results of amylase and liver function studies closely.

Benzonatate is a locally acting antitussive that decreases the intensity and frequency of cough without eliminating the cough reflex. Frequent side effects of pentamidine include leukopenia, thrombocytopenia, and anemia. The client should be routinely assessed for signs and symptoms of infection. Imipramine (Tofranil) The client should be instructed to take a single daily dose of the medication at bedtime, not in the morning, because of the side effects. The client should take the medication exactly as directed and, if a dose is missed, should take it as soon as possible unless it is almost time for another dose. The medication effects may not be noticed for at least 2 weeks, and the client should avoid alcohol or other central nervous system depressants during therapy.

At lithium levels of 2.0 to 2.5 mEq/L, the client will experience blurred vision, muscle twitching, severe hypotension, and persistent nausea and vomiting. With levels between 1.5 and 2.0 mEq/L, the client experiences vomiting, diarrhea, muscle weakness, ataxia, dizziness, slurred speech, and confusion. At lithium levels of 2.5 to 3.0 mEq/L or higher, urinary and fecal incontinence occurs, as well as seizures, cardiac dysrhythmias, peripheral vascular collapse, and death.

Lorazepam is contraindicated in hypersensitivity, cross-sensitivity with other benzodiazepines, comatose state, preexisting central nervous system depression, uncontrolled severe pain, and narrow angle glaucoma. It also is contraindicated in pregnancy and in women who are breast-feeding.

Methylphenidate (Ritalin) is best taken shortly before meals and no later than 1:00 PM for children or after 6:00 PM for adults because the stimulating effect of the medication may keep the client awake. Etanercept (Enbrel) is an antiarthritic medication that is administered via the subcutaneous route. Adverse effects include heart failure (noted by manifestations of dyspnea and congested lung sounds on auscultation), hypertension or hypotension, pancreatitis, or gastrointestinal hemorrhage. Headache, abdominal discomfort, and dizziness are not side effects of the medication.

Olanzapine is an antipsychotic medication that targets both the positive and the negative symptoms of schizophrenia. The antidote for hypertensive crisis (MAOI TOXICITY) is phentolamine, and a dosage of 5 to 10 mg is administered by intravenous injection. Hypertensive crisis may be manifested by hypertension, occipital headache radiating frontally, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia or bradycardia and constricting chest pain also may be present.

68

Baseline assessment of renal and liver function should be done before the initiation of therapy with risperidone. The medication is used with caution in clients with renal or hepatic impairment, in those with underlying cardiovascular disorders, and in geriatric or debilitated clients. These clients are started on the medication at a reduced dosage level.

Potentially fatal reactions may occur if sertraline is administered concurrently with phenelzine, a monoamine oxidase inhibitor (MAOI). MAOIs should be stopped at least 14 days before initiation of sertraline therapy. Likewise, sertraline should be stopped at least 14 days before initiation of MAOI therapy.

The caregiver is instructed to notify the physician if nausea, vomiting, diarrhea, rash, jaundice, or changes in the color of the stool occur, because these signs could indicate the development of hepatitis. Tacrine is administered between meals on an empty stomach but may be administered with food if gastrointestinal (GI) upset occurs. Flu-like symptoms without fever and GI symptoms are frequent side effects that may occur with use of this medication. The client or spouse should never double the dose of the medication. ZOLPIDEM- for Insomia The client should be instructed to take the medication at bedtime and to swallow the medication whole with a full glass of water. For faster onset of sleep, the client should be instructed not to take the medication with food or immediately after a meal. Antacids affect the absorption of the medication.

A frequent side effect of therapy with any angiotensin-converting enzyme (ACE) inhibitor, including quinapril, is a persistent, dry cough. In general, the cough does not resolve during the course of medication therapy, so clients should be advised to notify the physician if the cough becomes very troublesome. The other options are incorrect.

Headache is a frequent side effect of nitroglycerin, resulting from its vasodilator action. It often subsides as the client becomes accustomed to the medication and is effectively treated with acetaminophen (Tylenol).

Betaxolol is a -adrenergic blocking agent used to lower blood pressure, relieve angina, or decrease the occurrence of dysrhythmias. Side effects include bradycardia and signs and symptoms of congestive heart failure, such as weight gain and increased edema.

HALOPERIDOL- Toxic effects include marked drowsiness and lethargy, excessive salivation, a fixed stare, akathisia, acute dystonia, and tardive dyskinesia. Hypotension, nausea, and blurred vision are occasional side effects.

Quinidine gluconate is an antidysrhythmic medication used to maintain normal sinus rhythm after conversion of atrial fibrillation or atrial flutter. It is contraindicated in complete AV block, intraventricular conduction defects, and abnormal impulses and rhythms due to escape mechanisms, and with myasthenia gravis. It is used with caution in clients with preexisting asthma, muscle weakness, infection with fever, and hepatic or renal insufficiency.

69

Diarrhea, nausea, vomiting, loss of appetite, and dizziness all are common side effects of quinidine gluconate. If any of these occur, the physician or the nurse should be notified; however, the medication should never be discontinued abruptly. Rapid decrease in medication levels of antidysrhythmics could precipitate dysrhythmia. The other options indicate correct information.

Corticosteroids, thiazide diuretics, and lithium may decrease the effect of glyburide, thus causing hyperglycemia. Methylergonovine,- used to reduce bleeding an oxytocic, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose usually is given intramuscularly, and then if addition medication is needed, it is given by mouth. It increases the strength and frequency of contractions and may elevate the blood pressure. A priority assessment component before the administration of methylergonovine is blood pressure.

The client taking benztropine mesylate( Congentin) may have decreased tolerance to heat as a result of diminished ability to sweat and should plan rest periods in cool places during the day. The client also is instructed to avoid driving or operating hazardous equipment if drowsy or dizzy. The client should be instructed to stop taking the medication if difficulty swallowing or speaking develops or if vomiting occurs; to inform the physician if central nervous system effects occur; and to monitor urinary output and watch for signs of constipation.

Clients taking clozapine can experience hematological adverse reactions, including agranulocytosis and mild leukopenia. The WBC count should be assessed before initiation of treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever.

(ARICEPT) Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimers type. It increases concentration of acetylcholine, which slows the progression of Alzheimers disease.

Haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. Donepezil hydrochloride (Aricept) inhibits the breakdown of released acetylcholine. Fluoxetine hydrochloride (Prozac) is a potent serotonin reuptake blocker. Imipramine hydrochloride (Tofranil) blocks the reuptake of norepinephrine and serotonin.

Dimenhydrinate is used to treat and prevent the symptoms and signs of dizziness, vertigo, and nausea and vomiting that accompany motion sickness Omeprazole is a proton pump inhibitor and is classified as an antiulcer agent. The medication relieves pain from gastric irritation, which often is experienced as heartburn by clients. Ranitidine should be taken at bedtime, when it is given as a single daily dose. This allows for prolonged effect and provides the greatest protection of the gastric mucosa both during sleep and around the clock.

70

A client who chronically uses aspirin is prone to gastric mucosal injury, which causes epigastric pain as a symptom. Misoprostol is specifically given to prevent this occurrence. Diarrhea can be a side effect of the medication but is not an intended effect. Bleeding and joint aches are not relieved by misoprostol.

Side effects of scopolamine, an anticholinergic medication, are dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options state the opposite of a side effect of this medication.

The IV route is the route used when relief of nausea is needed. Docusate is a stool softener that relieves constipation because it promotes absorption of water into the stool, producing a softer consistency of stool. Cascara sagrada is a laxative that causes nausea and abdominal cramps as the most frequent side effects. Most rapid results from bisacodyl(DULCOLAX) occur when it is taken on an empty stomach. It will not have a rapid effect if taken with a large meal or with two glasses of milk. If it is taken at bedtime, the client will have a bowel movement in the morning.

LOMOTIL The client should understand that this medication may be habit-forming, so careful adherence to proper dose is important. The medication is an antidiarrheal and therefore should not be taken with a laxative (cathartic). Side effects of the medication include dry mouth and drowsiness. Drooling and irritability are not associated with the use of this medication.

Trimethobenzamide(Tigan) is an antiemetic agent used for relief of nausea and vomiting. Ondansetron(Zofran) is an antiemetic used for relief of postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy. (Comapzine) Prochlorperazine is a phenothiazine-type antiemetic and antipsychotic agent. A frequent side effect is blurred vision. Other frequent side effects of this medication are dry eyes, dry mouth, and constipation.

Pancrelipase is a pancreatic enzyme used as a digestive aid for clients with pancreatitis. It should reduce the amount of fatty stools (steatorrhea). Another recognized beneficial effect is improved nutritional status. It is not used to treat abdominal pain or heartburn and does not regulate blood glucose.

Calcium carbonate can be used as an antacid for the relief of heartburn and indigestion. It also can be used as a calcium supplement or to bind phosphorus in the gastrointestinal (GI) tract in clients with renal failure. Not for Muscle twitching.

Sodium bicarbonate is an electrolyte modifier and antacid. With large doses or long-term use, it can cause metabolic alkalosis. Procainamide(Procanbid) is an antidysrhythmic medication used to treat ventricular dysrhythmias unresponsive to lidocaine. The other options are not indications for giving this medication.

71

A common side effect of -adrenergic blocking agents such as pindolol is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects are rarer and include mental status changes, nervousness, depression, and insomnia. Increased appetite, difficulty swallowing, and mood swings are not side effects of this medication.

Clotrimazole- for Rashes is a topical antifungal agent used in the treatment of cutaneous fungal infections. It is not used for sneezing, fever, or pain.

Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication used preoperatively for surgical procedures on the eye.

Betaxolol is an antiglaucoma medication and a -adrenergic blocker. Systemic effects of this medication are hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea. The client should have the blood pressure monitored for hypotension and the pulse assessed for strength, weakness, irregular rate, and bradycardia. Bowel activity and evidence of congestive heart failure also should be assessed. The other options are incorrect. Tobramycin sulfate(Tobrex) Ringing in the ears and vertigo are two symptoms of ototoxicity that may indicate dysfunction of the eighth cranial nerve. This is a frequent adverse effect of therapy with the use of aminoglycosides and could result in permanent hearing loss. In clients with these symptoms, the nurse should withhold the dose of the medication and notify the physician OBSTETRICS

Amniotic fluid normally is pale strawcolored and may contain flecks of vernix caseosa. It should have a watery consistency, not be thick, and have no odor. Amber-colored fluid suggests the presence of bilirubin; greenish fluid may indicate the presence of meconium and suggests fetal distress.

MEDICAL SURGICAL NURSING Mild intoxication with aspirin is called salicylism and can be experienced by the client when the daily dosage of aspirin is more than 4 g. Tinnitus (ringing in the ears) is the most frequent effect noted with intoxication. Hyperventilation may occur because salicylates stimulate the respiratory center. Fever may result because salicylates interfere with the metabolic pathways coupling oxygen consumption and heat reduction

Codeine sulfate is an opioid analgesic and can cause constipation. The client is instructed to increase fluid intake to prevent constipation. The client also should consume foods high in fiber and should take a stool softener.

The best outcome of any type of surveillance is accuracy. Relying on health care providers initiative to report cases is a passive method that results in an upward swing of cases reported, based on the latest disease trend. Neither of these surveillance methods (options 1 and 3) results in clear indicators for interventions. An active surveillance method of assessment is best because it results in detection of a more accurate number of cases.

72

A low-residue (low-fiber) diet is less irritating to the intestines than are other diets because this type of food is easier to digest. This diet may be used for ulcerative colitis, diverticulitis, and irritable bowel syndrome. The food that contains high residue and thus would irritate the intestines is Corn.

Clients with hyperphosphatemia should avoid foods that are naturally high in phosphates. These include fish, eggs, milk products, vegetables, whole grains, and carbonated beverages. Coffee, tea, and grape juice are not high in phosphates.

Classic signs of pernicious anemia include weakness, mild diarrhea, and smooth, sore red tongue. The client also may have nervous system signs and symptoms such as paresthesias, difficulty with balance, and occasional confusion. The mucous membranes do not become dusky, and the client does not exhibit shortness of breath or dyspnea. RED BEEFY TOUNGE

The Schilling test is used to determine the cause of vitamin B12 deficiency, which leads to pernicious anemia. This test involves the use of a small oral dose of radioactive B12, followed by a large nonradioactive intramuscular (IM) dose. The IM dose helps to flush the oral dose into the urine if it was absorbed. A 24-hour urine collection is performed to measure the amount of radioactivity in the urine. A bone marrow biopsy is indicated in a client suspected of having leukemia. A white blood cell differential count and a clotting time are not significantly related to pernicious anemia and would not be helpful in determining the diagnosis.

An urticaria reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine such as diphenhydramine. Acetaminophen (Tylenol) may be prescribed before the administration to assist in preventing an elevated temperature.

Sickle cell anemia is a severe anemia that predominantly affects African Americans. It is characterized by the presence of HgbS. The client must have two abnormal genes encoding HgbS to have sickle cell disease. A client could have sickle cell trait by carrying one hemoglobin A gene and one HgbS gene. HgbS is not associated with aplastic anemia, acute lymphocytic leukemia, or infectious mononucleosis.

Iron deficiency anemia usually is characterized by decreased iron-binding capacity and increased transferrin saturation. Malnutrition can cause reductions in both iron-binding capacity and transferrin saturation. Sickle cell anemia is diagnosed by determining that the client has hemoglobin S. Infection is not associated with these laboratory values.

The most common sites for bone marrow aspiration in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing. The femur, scapula, and ribs are incorrect options.

The autocratic style of leadership is task oriented and directive. Situational leadership style uses a style depending on the situation and events. Democratic styles best empower staff toward excellence because this type of leadership allows nurses to provide input and an opportunity to grow professionally. Laissez faire allows staff to work without assistance, direction, or supervision.

73

Fluids are important to prevent dehydration, which could lead to sickle cell crisis. Warm weather and mild exercise does not need to be avoided, but the client should take measures to avoid dehydration during these conditions. The client should avoid infections, which can increase metabolic demands and cause dehydration, precipitating a sickle cell crisis.

Sickle cell crisis often causes pain in the bones and joints, accompanied by joint swelling. Pain
is a classic symptom of the disease and may require large doses of opioid analgesics when it is severe. Not Bradycardia

In the Chinese-American culture, head nodding does not necessarily mean that the client is in agreement with what is being presented, agrees with the plan, or is anxious. The nurse needs to be alert to nonverbal communication and validate the clients nonverbal communication.

The client with anemia is likely to experience shortness of breath and complain of fatigue, owing to the decreased ability of the blood to carry oxygen to the tissues to meet metabolic demands. The client is likely to have tachycardia, not bradycardia, as a result of efforts by the body to compensate for the effects of anemia. Increased respiratory rate is not an associated finding. Muscle cramps would be an unrelated finding.

Iron preparations can be very irritating to the stomach and are best taken after a meal. The tablet is swallowed whole and not chewed. Because iron supplements may be associated with constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy.

For most hematological laboratory studies, including CBC, no special care is needed either before or after the test. There is no reason to fast after midnight or avoid luncheon meats or cold cuts before the laboratory test being drawn.

The nurse should instruct the nursing assistant to assess restraints, circulatory status, and skin integrity every 30 minutes. Additionally, restraints need to be removed at least every 2 hours to permit muscle exercise and promote circulation. Restrains are not to be secured to the bedrails because this could cause injury to the client if the rails are lowered. The responsibility of the client should not be placed on the family members. Agency guidelines regarding the use of restraints should always be followed.

Aldactone antagonizes the effect of aldosterone and decreases circulating volume by inhibiting tubular reabsorption of sodium and water. Thus, it produces a decrease in blood pressure. It increases the excretion of sodium and plasma potassium. It has no effect on body metabolism.

A differential white blood cell count is the leukocyte count broken down (differentiated) according to the cell type. A right shift represents an increased number of mature neutrophils, which is seen with pernicious anemia and after tissue breakdown. Not seen on SEPSIS.

Granulocytes are blood cells that destroy bacteria. With fewer than 10,000 cells/L circulating granulocytes, the risk of infection increases significantly. Increased red blood cells- ( hematocrit level) are seen with decreased cardiac output, impaired pulmonary gas exchange, corticosteroid therapy, polycythemia vera, severe diarrhea, and dehydration, pernicious anemia

74

Decreased RBC counts occur in clients with vitamin B6 and B12 deficiencies, iron deficiency, chronic infection, bone marrow depression, multiple myeloma, leukemia, hemolytic anemia, and pernicious anemia. Also, a decrease in the RBC count may be noted in the older client.

The reticulocyte is an immature RBC. The reticulocyte count is increased any time there is an accelerated production of RBCs. It is decreased when the bone marrow has slowed production of RBCs. The normal hematocrit level is approximately 40% to 50% in the adult male and 37% to 47% in the adult female. The hematocrit level measures the percentage of red blood cells in whole blood. Elevated hematocrit levels are seen in persons with dehydration, pernicious anemia, or polycythemia.

A hematocrit of 30% or less indicates moderate to severe iron deficiency anemia. Decreased values occur in leukemia, acute hemorrhage, iron deficiency anemia, and hemolytic anemia. The normal hematocrit level is approximately 40% to 50% in the adult male and 37% to 47% in the adult female. Because hematocrit is measured as a proportion of red blood cells to a volume of blood, a decrease in fluids that make up the blood can cause an increase in hematocrit level. Conversely, an increase in fluid can cause a decrease in the hematocrit level. In a client with dehydration, the nurse would expect to note that the hematocrit level is increased.

Because the hematocrit measures a proportion of red blood cells to the volume of blood, a decrease in fluids that makes up the blood can cause an increase in hematocrit levels. Conversely, an increase in fluids can cause a decrease in the hematocrit level. A client with a diagnosis of fluid volume overload would have a decreased hematocrit level.

The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate in less than 5 minutes. This test determines abnormalities in the rate and percentage of the platelet aggregation. Increased platelet aggregation may occur after surgery or with acute illness, venous thrombosis, and pulmonary embolism.

(Neupogen) Filgrastim is used to promote the growth of neutrophils and enhance the function of mature neutrophils. Treatment is continued until the absolute neutrophil count reaches 10,000/mm3. PNEUMONECTOMY- The client should be instructed to perform arm and shoulder exercises two or three times a day. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the physician if these symptoms occur. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate.

Clinical manifestations of respiratory alkalosis include a decrease in the respiratory rate and depth,

headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the
fingers and toes, hypokalemia, hypocalcemia, tetany, and convulsions. NO HYPERACTIVITY & TACHYPNEA The psychosocial assessment is the least priority during the initial admission assessment. In the African-American culture, it is considered to be intrusive to ask personal questions on the initial contact or meeting. Additionally, cardiovascular, neurological, and respiratory assessments include physiological assessments, which would be the priority assessments

75

Cryptorchidism (undescended testes) may occur as a result of hormone deficiency, intrinsic abnormality of a testes, or a structural problem. Diagnostic tests for this disorder are performed to assess urinary and kidney function because the kidneys and testes arise from the same germ tissue. Babinski reflex reflects neurological function. Assessing DNA synthesis and a chromosomal analysis are unrelated to this disorder. Signs of infection include pain, redness, heat, and swelling of a localized area of the breast. If these symptoms occur, the client needs to contact the physician. ANY SWEATING DURING THE NIGHT ON BREAST FEEDING IS NORMAL.

Hot Sitz bath- Warm moist heat is used after the first 24 hours after tissue trauma from a vaginal birth to provide comfort and promote healing and reduce the incidence of infection. This warm moist heat is provided via a sitz bath. Ice is used in the first 24 hours to reduce edema and numb the tissue. Promoting a bowel movement is best achieved by ambulation.

The most effective and accurate measure for testing blood glucose is to test the level before each meal and at bedtime. Checking the level after the meal will provide an inaccurate assessment of diabetes control. Checking the level once daily will not provide enough data related to controlling the diabetes mellitus.

The client should be instructed that insulin injection sites should be rotated within one anatomical area before moving on to another area. This rotation process promotes uniform absorption of insulin and reduces the chances of irritation. Options 1, 2, and 3 are not associated with the condition (skin leakage of insulin) presented in the question.

Infection is a physiological stressor that can cause an increase in the level of epinephrine in the
body. An increase in epinephrine causes an increase

in blood glucose levels. When the client

is under stress, such as when an infection is present, an increase in the dose of insulin will be

required to facilitate the transport of excess glucose into the cells. The client will not
necessarily need an adjustment in the daily diet. ( For ulceration in the foot of D.M.. patient)

If a

bacterial infection of CSF

is present, findings would include a cloudy appearance, CSF

pressure over 200 mm H2O, protein level over 15 mg/dL, increased white blood cells, and

reduced glucose level. For Addisons disease- All adrenal cortex hormones Mgt. glucocorticoid during minor illnesses.

SUMMARY: DURING ILLNESS- DM- CORTISOL, ADDISONS CORTISOL, Bacterial infection cortisol
The Romberg test also assesses intactness of the cerebellum and proprioception. A round or oval darkened area on the eardrum would be seen in a client with a perforated eardrum. A red and bulging eardrum is indicative of acute purulent otitis media. Dense white patches are seen on the eardrum of a client with sequelae of repeated ear infections. A colony of black dots on the eardrum suggests a yeast or fungal infection.

76

The

confrontation test

is a gross measure of peripheral vision. It compares the persons

peripheral vision with the examiners, whose vision is assumed to be normal. LYME DISEASE-TICK BITE The hallmark finding in stage I is a skin rash that appears within 2 to 30 days of infection, generally at the site of the tick bite. The rash develops into a concentric ring, giving it a bulls eye appearance. The lesion enlarges to up to 50 to 60 cm, and smaller lesions develop farther away from the original tick bite. In stage I, most infected persons experience flu-like symptoms that last 7 to 10 days and may recur later in the disease course. Stage II of Lyme disease develops within 1 to 6 months in a majority of untreated persons. The most serious problems include cardiac conduction defects and neurological disorders such as Bells palsy and paralysis. Arthralgias and joint enlargement are noted in stage III. A rash appears in stage I. Cardiac and neurological dysfunction occurs in stage II. Paralysis of the extremity on which the bite occurred is not a characteristic of Lyme disease. After angioplasty, the client needs to be instructed regarding the specific dietary restrictions that must be followed. Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart. The initial symptom of ALS (AMYOTROPHIC LATERAL SCLEROSIS) is a mild clumsiness, usually noted in the distal portion of one extremity. The client may complain of tripping and drag one leg when the lower extremities are involved. Mentation and intellectual function usually are normal. Diminished gag reflex and muscle wasting are not initial clinical manifestations. SUPRATENTORIAL LESION- Level of consciousness is the most critical index of CNS dysfunction. Changes in level of consciousness can indicate clinical improvement or deterioration. Although blood pressure, temperature, and ability to speak may be components of the assessment, the clients level of consciousness is the most critical index of CNS dysfunction. STARTEGYSUPRATENTORIAL LESION- CEBROSPINAL FLUID Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the later stages.

Acetazolamide
increased ICP to

is a carbonic anhydrase inhibitor. It is used in the client with or at risk for

decrease cerebrospinal fluid production. Also for IOP ( Glaucoma)

NOT ON HYERTENSION & NOT TO MAINTAIN BLOOD PRESSURE

The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the

77

eyes roll. Excessive salvation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. TONIC PHASE OS SEIZURE- SUDDEN LOC, BODY STIFFENING, BRIEF EXTENSION OF EXTREMITIES

In

early Alzheimers disease, forgetfulness begins to interfere with daily routines. The client

has difficulty concentrating and difficulty learning new material. CONFUSION, WANDERING & FRUSTATIONS are characteristics of early dementia that occurs later as the disease

progresses.
Early symptoms of Huntingtons disease include restlessness, forgetfulness, clumsiness, falls,

balance and coordination problems, altered speech, and altered handwriting. Difficulty with
swallowing occurs in the later stages. Aphasia and agnosia do not occur. The

diagnosis of herpes simplex encephalitis can be made by brain biopsy

and

rarely is made from the culture of cerebrospinal fluid obtained from a lumbar puncture. The EEG findings are abnormal in many cases with temporal lobe involvement, but this study will not confirm the diagnosis. Appearance on the CT scan is normal up to the first 5 days, with low-signal-intensity lesions in the temporal lobe noted later.

(Diptropan) Oxybutynin is an antispasmodic used to relieve symptoms of urinary urgency,

frequency, nocturia, and incontinence in clients with uninhibited or reflex neurogenic bladder. Expected effects include improved urinary control and decreased urinary frequency, incontinence, and nocturia- USED IN MULTIPLE SCLEROSIS- ASK ABOUT GETTING UP AT NIGHT TO URINATE.

A hallmark clinical manifestation of Guillain-Barr syndrome is progressive muscle weakness that develops rapidly. The client does not have symptoms such as a fever or
headache. Cerebral function, level of consciousness, and pupillary responses are normal. Seizures are not normally associated with this disorder.

GUILLAIN-BARRE SYNROME & MYASTHENIA GRAVIS ARE JUST ALIKE WHEN IT COMES TO THE MANIFESTATION AS HAVING PROGRESSIVE MUSCLE WEAKNESS. GUILLAIN BARRE SYNDROME- ASCENDING PARALYSIS MYASTHENIA GRAVIS- DESCENDING PARALYSIS The client with a right (nondominant) hemispheric stroke may be alert and oriented to time and place. These signs of apparent wellness often suggest that the client is less disabled than is the case. However, impulsivity and confusion in carrying out activities may be very real problems for these clients as a

78

result of perceptual and spatial disabilities. The right hemisphere is considered specialized in sensory-perceptual and visual-spatial processing and awareness of body space. The left hemisphere is dominant for language abilities.- LEFT LANGUANGE In anosognosia, the client neglects the affected side of the body. The client either may ignore the presence of the affected side (often creating a safety hazard as a result of potential injuries) or may state that the involved arm or leg belongs to someone else. Global aphasia is a condition in which the affected person has few language skills as a result of extensive damage to the left hemisphere. The speech is nonfluent and is associated with poor comprehension and limited ability to name objects or repeat words. The client with conduction aphasia had difficulty repeating words spoken by another, and speech is characterized by literal paraphasias with intact comprehension. The client with Wernickes aphasia may exhibit a rambling type of speech.

Aphakia is the absence of the lens of the eye and is corrected by prescriptive glasses, contact lenses,
or intraocular lens. Although eyeglasses can be used for this disorder, they have several disadvantages. With the use of glasses, only central vision is corrected and peripheral vision is distorted. There is an approximately 30% magnification of central vision. This requires adjustment to daily activities and safety precautions. Because of the magnification, objects viewed centrally appear distorted. It is difficult for the client to judge distances, such as when driving a car.

Aphakia eyeglasses- central vision is corrected but the the peripheral vision is distorted due to the effect of magnification.

The client scheduled for cataract surgery should be instructed that oral intake is restricted for 6 to 8 hours preoperatively. It is not necessary that the client remain without oral intake for 24 hours before surgery.
In the preoperative period, the physician may prescribe medications such as 2% pilocarpine to constrict the pupil before keratoplasty. The nurse would question an order that indicated dilation of the pupil. Preoperative preparation may include obtaining conjunctival swabs for culture and sensitivity testing, instilling antibiotic eye medication, and cutting the eyelashes .

Keratoplasty- constrict pupil. After keratoplasty, sutures usually are left in place for as long as 6 months, depending on the surgeons preference. The client is instructed not to lie on the operative side and should avoid sudden head movement. The client is instructed to instill antibiotic medication because infection is a serious complication of this procedure. An eye shield should be worn during sleep for about 2 months postoperatively.

79

chalazion is a cyst and results from blockage of

sebaceous material in a meibomian gland.

Application of warm compresses over the affected eyelid three or four times per day is a common treatment in the early stages. The condition is not contagious, and it is not necessary for the client to use separate washcloths and towels. Therapeutic management of a hordeolum includes application of warm compresses for 15 minutes four times daily and instillation of antibiotic ointment to combat infectious organisms. The client is told not to press on or squeeze the stye because such pressure could force infectious material into the venous system of the eyelids and face, with the potential for spread of infection to the brain. Sulfasalazine is an anti-inflammatory sulfonamide.- for Ulcerative colitis. Constipation is not associated with this medication. The client with coronary artery disease should avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian. Agoraphobia is a fear of leaving the house and experiencing panic attacks when doing so. Obssesice-compulsive-fear of speaking in public, washing hands several times. Claustrophobia- fear of closed-spaces Eg. Elevator, MRI, CT- Scan Because potassium plays a major role in neuromuscular activity, Hyperkalemia initially causes muscle weakness. Mental status changes and confusion are most likely to be noted in the client experiencing hypocalcemia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia. HYPOKALEMIA & HYPERKALEMIA HAS THE SAME CLINICAL MANIFESTATIONS: 1. MUSCLE WEAKNESS 2. PARALYSIS 3. DYSRHYTHMIA 4. CARDIAC ARREST 5. RENAL DAMAGE The early signs of the complication of fat embolism include

changes in the clients mental

due to impaired perfusion distal to

status and signs of impaired respiratory function

the site of the embolus. Cardiovascular and renal impairment is likely to be secondary to

impaired respiratory function. Effects on the endocrine system are not usually seen. The clients
mobility status is unrelated to the signs of fat embolism EARLIEST SIGN FAT EMBOLISM- RESPIRATION- AIRWAY

80

Fat embolism

commonly causes signs and symptoms related to respiratory or neurological

impairment. Because the client is unable to speak, it may be difficult to immediately assess early changes in neurological status. However,

adventitious breath sounds and an increased heart

even before the client demonstrates labored

rate may be easily and quickly observed,

breathing

The nurse should be alert to signs and symptoms of adrenal insufficiency after adrenalectomy. These signs and symptoms include weakness, hypotension, fever, and mental status changes

After thyroidectomy, the nurse assesses the client for signs of hypocalcemia and tetany. Early signs
include tingling around the mouth and in the fingertips, muscle twitching or spasms, palpitations or arrhythmias, and Chvosteks and Trousseaus sign.

Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid
activity that represents a breakdown in the bodys tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever with temperatures greater than 100 F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.

Thyrotoxicosis usually is seen in clients with Graves disease in whom the symptoms are precipitated by a major stressor. This complication typically occurs during periods of severe physiological or psychological stress such as trauma, sepsis, delivery, or major surgery. It also must be recognized as a potential complication after thyroidectomy.

Clients with diabetes mellitus are instructed to make adjustments in their total daily intake to plan for meals at restaurants or parties. Some useful strategies include ordering a half-portion, salads with dressing on the side, fresh fruit for dessert, and baked or steamed entres. Clients are not instructed to skip meals or to increase their prescribed insulin dosage.

Constipation

is a common elimination problem with clients in a manic phase of bipolar disorder. Constipation may occur as the result of a combination of factors, including taking antipsychotic medications, suppressing the urge to defecate, and a decreased fluid intake as a result of the manic activity level. The symptoms listed in the question, dehydration, unkempt, and abdominal fullness and discomfort, in combination with antipsychotic medications, are indicators of constipation. A highfiber diet and increased fluids can reduce constipation. Giving Regular insulin by the intravenous route is the treatment of choice for DKA. This short-acting insulin is the only insulin that can be given intravenously and titrated to the clients blood glucose levels. NPH insulin is an intermediate-acting insulin and thus is not appropriate for treatment of DKA. Glucagon is used to treat hypoglycemia because it increases blood glucose levels, and glyburide is an oral hypoglycemic agent used to treat type 2 diabetes mellitus. Both of these agents also are inappropriate. Acetic acid solution is used for irrigating, cleansing, and packing wounds infected by P. aeruginosa. Glycerin is an emollient that is used for dry, cracked, and irritated skin. Aspercreme and Myoflex are used to treat muscular aches.

81

4th degree Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath from eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch with little or no pain.

The gastric pH should be maintained at 7 or greater with the use of prescribed antacids and histamine H2 receptorblocking agents. Lowered pH (to the acidic range) in the absence of food or tube feedings can lead to erosion of the gastric lining and ulcer development. The clients bowel sounds may be expected to be hypoactive in the absence of oral or NG tube intake. Absence of discomfort and bleeding (guaiac negative) are normal findings.

The use of Montgomery straps is recommended to prevent skin breakdown with frequent dressing changes. This limits the friction and shear that could irritate skin with frequent removal and reapplication of tape. Hypoallergenic tape is used on clients with thin and fragile skin or on those clients whose skin is sensitive to standard tape and who require less frequent dressing changes. Cleansing with povidoneiodine and obtaining a wound culture are not indicated. The client should not adjust the flexion and extension settings. These are determined by the orthopedic surgeon and are maintained as ordered. The client is instructed about how to stop and start the machine and to notify the nurse about knee discomfort. The client also should be aware of proper positioning, so that the nurse can be notified if the leg slips. Other important actions by the nurse with the use of this device are to assess the neurovascular status of the extremity and to ensure that the device is padded with manufactured disposable padding before the clients leg is placed in the device. TENS (Transcutaneous Electrical Nerve Stimulation- For chronic pain. Application of a TENS unit involves application of two electrodes to the skin from the machine and adjusting the level of stimulation to one lead at a time. The amount of stimulation is increased until the client feels discomfort, which indicates that the maximal stimulation necessary to block pain stimuli has been reached. The volume is then reduced by a small amount until no further muscle discomfort or contractions occur. The client who is underhydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.016 to 1.022. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.5 to 8.0 normal), and this value is not used in monitoring hydration status.

CSF leakage after cranial surgery may be detected by noting drainage that is serosanguineous (due to surgery) and surrounded by an area of clear or straw-colored drainage. The typical appearance of CSF drainage is that of a halo. The nurse also would further verify actual CSF drainage by testing the drainage for glucose, which would be positive.

With aneurysm precautions, any activity that could raise the clients intracranial pressure (ICP) is avoided. For this reason, activities such as straining, coughing, blowing the nose, and even sneezing

82

are avoided whenever possible. The other interventions (repositioning, deep breathing, and incentive spirometry) do not provide added risk of increasing ICP and are beneficial in reducing the respiratory complications of bedrest. The clients airway is most protected if all of the respiratory parameters measured fall within normal limits. Therefore, the respiratory rate should ideally be 16 to 20 breaths/min, the oxygen saturation should be greater than 95%, and the breath sounds should be clear. The client who cannot shift weight unassisted should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for this purpose are those that have a tendency to equalize the clients weight on the pad. These include foam, water, gel, and alternating air products. A plastic-lined pad and folded blankets provide no pressure relief. A pillow provides cushion but does not distribute weight equally. After laser surgery to remove any type of skin lesion, the skin should be protected from direct sunlight for a minimum of 3 months. There should be minimal or no discomfort after the procedure, and if present, it should be easily relieved with acetaminophen (Tylenol). The operated area should be cleansed gently with half-strength hydrogen peroxide twice a day after the dressing is removed (24 hours after the procedure). Redness and swelling are expected after this procedure. CLEFT PALATE REPAIR- The mother needs to be instructed that straws, pacifiers, spoons, and fingers must be kept away from the childs mouth

for 7 to 10 days. Additionally, the mother

should be advised to avoid taking an oral temperature. PACIFIER GIVEN IN 2 WEEKS IS ACCEPTED. Assessment findings in a child with hepatitis include right upper quadrant (RUQ) tenderness and hepatomegaly. The stools will be pale and clay-colored, and urine will be dark and frothy. Jaundice may be present and will be best assessed in the sclerae, nailbeds, and mucous membranes. The classic symptoms of

TSS (Toxic Shock Syndrome) are high fever (temperature of 101 Vaginal bleeding or
TSS typically is caused by

F or higher), vomiting, and severe diarrhea. Other typical symptoms include headache, myalgia, chills, abdominal pain, dizziness, lethargy, possible confusion, and agitation.

Vaginal discharge is not part of the clinical picture.

Staphylococcus aureus infection associated with tampon use during menses.

If the bladder irrigation solution is infusing at a sufficient rate, the urinary drainage will be pale pink. A dark pink color (sometimes referred to as punch-colored) indicates that the speed of the irrigation should be increased. Bright red bleeding and red urine with clots should be reported to the surgeon, because either finding could indicate complications.

83

Lindane can penetrate the intact skin and can cause convulsions if absorbed in sufficient quantities. Clients at highest risk for convulsions are premature infants, children, and clients with preexisting seizure disorders. Lindane should not be used in pediatric clients unless safer medications have failed to control the infection. The client who suddenly becomes disoriented and confused after TURP could be experiencing early signs of hyponatremia. This may occur because the flushing solution used during the operative procedure is hypotonic. If the solution is absorbed through the prostate veins during surgery, the client experiences increased circulating volume and dilutional hyponatremia. The nurse should notify the physician of these symptoms. Reorienting the client and ensuring that a clock and calendar are visible may be helpful but do not correct the problem. The nurse does not increase the flow rate of an intravenous infusion without an order. In addition, speeding up the flow rate could potentially worsen the problem, depending on the solution that is infusing.

Signs and symptoms of prostatism include reduced force and size of urinary stream,
intermittent stream, hesitancy in beginning the flow of urine,

inability to stop urinating,

sensation of incomplete bladder emptying after voiding, postvoid dribbling of urine, and an increase in episodes of nocturia. These signs and symptoms are the result of pressure of the enlarging prostate on the clients urethra. The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre.

Genital warts are characterized by cauliflower-like growths, or growths that are soft and
fleshy. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal. Scabies is characterized by erythematous, papular eruptions. Children with tetralogy of Fallot, or with physiology similar to that seen with this disorder, may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate physician notification is not required unless other appropriate nursing interventions are unsuccessful. Topical glucocorticoids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia) and lower from regions where penetrability is poor (back, palms, soles). TSS is caused by infection and often is associated with tampon use. The clients clinical signs in this question are compatible with DIC, which is a complication of TSS. The nurse assesses the client at risk and notifies the physician promptly when signs and symptoms of DIC are noted. Although signs of bleeding may be seen with each of the conditions listed in the incorrect options, the initial diagnosis of TSS makes DIC the logical correct option.

84

After cataract surgery, the cornea should be clear, round, and smooth. A cloudy or spotty appearance or a scattering of the light could indicate the presence of infection or increased intraocular pressure. The term sanguineous denotes blood; there should be no bleeding in the corneal area postoperatively.

Topical glucocorticoids can be absorbed in sufficient amounts to produce systemic toxicity. Principal concerns are growth retardation (in children) and adrenal suppression in all age groups. Systemic toxicity is more likely under extreme conditions of use such as with prolonged therapy in which extensive surfaces are treated with high doses of high-potency agents in conjunction with occlusive dressings. NOT ADRENAL HYPERACTIVITY.

Edema of the conjunctiva, sclera, and eyelids is normal after cataract removal surgery. This results from the trauma of surgery and should subside in 3 days or sooner after surgery. REASON FOR GIVING MYDRIATIC TO DILATE PUPILS THEREBY EDEMA.

Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic
nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any of a variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.

Malignant hypertension

occurs in women with toxemia of pregnancy, and persons with kidney

disorders or collagen vascular disorders. You are at high risk for malignant hypertension if you have had kidney failure or renal hypertension caused by renal artery stenosis.

Measuring postvoid residual gives specific information about the ability of the bladder to empty completely. Assisting the client to the bathroom and recording intake and output
are general interventions but do not provide information about the clients ability to empty the bladder

A 2% minoxidil solution is used for topical treatment of baldness. The usual dosage is 1 mL applied twice a day

For Parenteral Nutrition- Signs and symptoms of air embolism include

decreased level of consciousness, tachycardia, dyspnea, anxiety, feelings of

85

impending doom, chest pain, cyanosis, and hypotension. The signs and symptoms in the
question do not indicate hyperglycemia, an infection (sepsis), or an allergic reaction. Superficial burns are pink or red in color without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. Weeping blisters characterize partial-thickness superficial burns. A white color characterizes deep partial-thickness burns. Deep fullthickness burns are associated with insensitivity to pain and cold. Clotrimazole is a topical antifungal agent used in the treatment of cutaneous fungal infections. The nurse monitors the effectiveness of this medication by noting the presence or absence of a skin rash, characteristic of this infection.

Metformin should be used with caution in clients with kidney or liver disease, heart
failure, chronic lung disease, or a history of heavy alcohol consumption.

Metformin used with caution in Emphysema Acarbose is an antidiabetic medication that may be administered alone or in conjunction with another
antidiabetic medication. It is contraindicated in clients with significant renal dysfunction. It also is contraindicated in clients with inflammatory bowel disease, colonic ulceration, or partial intestinal obstruction.

Disulfiram is the medication of choice for alcoholism, and it aids in the maintenance of sobriety. Chlordiazepoxide hydrochloride is an antianxiety medication, and benzodiazepine is used in the

management of acute alcohol withdrawal symptoms. Clonidine is an antihypertensive medication. Pyridoxine hydrochloride is used in the treatment of pyridoxine deficiency. The best indicator that the behavior is controlled is if the client exhibits no signs of aggression after partial release of restraints Acting out is attention-seeking behavior. Tonometry is the method of measuring intraocular fluid pressure using a calibrated instrument that indents or flattens the corneal apex. Pressures between 10 and 21 mm Hg are considered within the normal range. Increased IOP is indicative of glaucoma. ECT as a form of treatment is considered when medication therapy has failed, when the client is at high risk for suicide, or when depression is judged to be overwhelmingly severe. Treatments are administered three times a week, with an average series involving 8 to 12 treatments over a duration of 2 to 4 weeks. The most common side effects are amnesia for events occurring near the period of the treatment. Memory deficits may occur and tend to resolve with time. Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are

predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors to CAD. Age greater than 40 is a nonmodifiable risk factor. The nurse places
priority on risk factors that can be modified.

86

For (Decrease Cardiac Output) Standard home care instructions for a client with this nursing diagnosis include among others, lifestyle changes such as decreased alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload.

The anterior fontanel is diamond-shaped and located on the top of the head. It should

be soft and flat and may range in size from almost nonexistent to 4 to 5 cm across.
It normally closes by 18 to 24 months of age. A depressed fontanel may indicate dehydration.

It is common for the client to feel fatigued after the

cardiac catheterization

procedure. Other pre-procedure teaching points include that the procedure is done in a darkened cardiac
catheterization room. A

local anesthetic is used, so little to no pain is experienced with catheter

insertion. General anesthesia is not used. The x-ray table is hard and may be tilted periodically, and the procedure may take 1 to 2 hours. The client may feel various sensations with catheter passage and dye injection.

The NG tube should remain in place until the client has bowel sounds. If bowel sounds do not return, the client could have a paralytic ileus, which could result in distention and vomiting if the NG tube is discontinued . It is normal for NG tube drainage to be Hematest
negative. The abdomen is likely to be slightly distended after surgery, and it also is likely that the client may be drowsy after experiencing a stressor such as cardiac surgery.

Transtentorial herniation occurs when part of the brain herniates downward and around the tentorium cerebelli. It can be unilateral or bilateral and may involve anterior or posterior

portions of the brain. If a large amount of tissue is involved, the risk of death is increased because
vital brain structures are compressed and become unable to perform their function.

Obtunded indicates that the child sleeps unless aroused and once aroused has limited interaction with the environment. Full consciousness indicates that the child is alert,
awake, orientated, and interacts with the environment. Confusion indicates that the ability to think clearly and rapidly is lost, and disorientation indicates that the ability to recognize place or person is lost.

Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists and an extension of the lower extremities with some internal rotation.

Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damages in the diencephalon, midbrain, or pons.

87

 Cranisynostosis (Premature closure of the skull)- A hard rigid immobile suture line

PEDIA

Babbling sounds are common between the ages of 3 and 4 months. Additionally, during this age, crying becomes more differentiated. Between the ages of 1 and 3 months, the infant will produce cooing sounds. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs between 9 and 12 months.

A 24-month-old would be able to open a door using the doorknob. At age 15 months, the nurse would expect that the child could build a tower of two blocks. At age 30 months, the child would be able to snap large snaps and put on simple clothes independently.

Peek-a boo- INFANT Push-pull toy Toddler Hand-sewing a picture- School age

Lactose intolerance causes frothy stools. Abdominal distention, crampy abdominal pain, and
excessive flatus also may occur. Profuse watery diarrhea & vomitting is a clinical manifestation of

celiac disease. Diffuse abdominal pain unrelated to meals or activity is a clinical manifestation of irritable bowel syndrome. Dietary management is the mainstay of treatment for the child with celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be needed in the early period of treatment to correct deficiencies.

Omphalocele is an abdominal wall defect. It involves a large herniation of the gut into the umbilical cord. The viscera are outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane.

Gastroschisis- viscera are outside the abdominal cacity and not covered with a sac.
Intussusception is an invagination of a section of the intestine into the distal bowel. It is the most common cause of bowel obstruction in children aged 3 months to 6 years.
Mineral oil is best tolerated when it is given chilled or mixed with cold drinks. Mixing the oil with chocolate milk, blending it with ice cubes and fruit juice, or chilling it helps to disguise the taste. Administering mineral oil before meals will affect the childs appetite.

Clinical manifestations associated with

hiatal hernia

specifically include vomiting,

coughing, wheezing, short periods of apnea, and failure to thrive

Esophageal atresia and tracheoesophageal fistula- excessive oral secretions

88

 Congenital diaphragmatic Hernia- bowel sounds heard over the chest

Although hiatal hernia & GERD has both have Pyrosis, they still have the difference when it comes to manifestations. Laboratory findings in an infant with hypertropic pyloric stenosis include metabolic alkalosis as a result of the vomiting that occurs in this disorder. Additional findings include decreased serum potassium and sodium levels, increased pH and bicarbonate level, and a decreased chloride level. A prolonged PR interval indicates first-degree heart block. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. Tall, peaked T waves may indicate hyperkalemia. The development of Q waves indicates myocardial necrosis. An ECG taken during a pain episode is intended to capture ischemic changes, which also includes ST-segment elevation or depression. Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthful habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that previously has caused the pain, and to take the medication at the first sign of chest discomfort. Thrombolytic agents are used to dissolve existing thrombi, and the nurse must monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes hematesting secretions for occult blood. Cardiac catheterization- Procainamide is an antiarrhythmic medication often used to treat ventricular arrhythmias that do not adequately respond to lidocaine (Xylocaine). The effectiveness of this medication is best determined by evaluating the clients cardiac rhythm. Thus, a cardiac monitor would be the most appropriate device for determining the clients response, although the blood pressure cuff and the pulse oximeter would provide general information about the clients cardiovascular status. A glucometer is not needed for this client with the information presented. CCU psychosis occurs in some clients in critical care milieus. The ability to focus fluctuates over the course of a day and usually is directly caused by sensory deprivation and/or medication-related or underlying medical conditions. The question presents no data indicating that alcohol is a concern Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. Auscultation of the lungs reveals crackles throughout the lung fields. As the clients condition improves, the amount of fluid in the alveoli decreases, which may be detected by

crackles in the bases. (Clear lung sounds would indicate full resolution of the episode.) Wheezes
and rhonchi are not associated with pulmonary edema. Morphine sulfate reduces anxiety and dyspnea in the client with pulmonary edema. Inamrinone is an inotropic agent used to relieve the manifestations of heart failure. Therapeutic effects include a decrease in edema, weight (fluid), dyspnea, and lung crackles. Blood pressure should

89

remain stable or increase (if the client is hypotensive). Hypotension is a cardiovascular adverse effect of the medication. Hypokalemia can result from long-term use of cascara sagrada, a laxative. The medication stimulates peristalsis and alters fluid and electrolyte transport, thus helping fluid to accumulate in the colon. DI can occur in a child with increased ICP. A urine specific gravity above 1.020, weight gain, and hypertension are indications of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion, not DI. A high urine output would be indicative of DI.

Hepatitis s easily fatigued, Vitamin K may be prescribed for prolonged clotting times.

The facial drooping associated with Bells palsy makes it difficult for the client to close the eyelid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bells palsy. Paroxysms of excruciating pain are characterisitc of trigeminal neuralgia.
Respiratory compromise is a major concern in clients with Guillain-Barr syndrome. Clients

often are intubated and mechanically ventilated when the vital capacity is less than 15 mL/kg. Although orthostatic hypotension is a problem with these clients, the BP drop in option 1 is less than 10 mm Hg and is not significant. Difficulty articulating words &Paralysis
progressing to toes & waist expected depending on the degree of paralysis that occurs. Although the incidence of cataracts increases with age, the older client with diabetes mellitus is at greater risk for the development of cataracts. The most frequent complaint is blurred vision that is not accompanied by pain. The client also may experience difficulty with reading, night driving, and intolerance of glare. A stage II ulcer is characterized by partial-thickness skin loss, and the wound may appear as an abrasion, a shallow crater, or a blister. A stage I ulcer is characterized by a reddened area and intact

skin. Stage III ulcers involve full-thickness skin loss. Stage IV ulcers also are full-thickness lesions, with exposed muscle, bone, or supportive tissue. Kegel muscles strengthen the perineal floor and are useful in the prevention and management of cystocele, rectocele, and enterocele. Several ways to perform Kegel exercises are acceptable. One method entails starting and stopping the flow of urine during a single voiding for about 5 seconds. Also, these exercises may be done by holding perineal muscles taut for up to 10 seconds several times a day, or for 5 minutes three or four times a day. Residual urine should not be held in the bladder for long periods because this could promote urinary tract infection. The clients reaction is one of fear. The client has verbalized the object of fear (dying), which makes anxiety incorrect. There is no evidence of denial or rage in the clients statement. OBSTETRICS Reassuring signs in the fetal heart tracing include an FHR of 120 to 160 beats/min, accelerations of the FHR, no variable decelerations, and the presence of short term variability. Variable decelerations would indicate cord compression. The short-term variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. PEDIA Rheumatic fever ASO TITER, ESR, ANA (antinuclear Antibody Assay)- LAHAT ELEVATED In the presence of rheumatic fever, the child will exhibit leukocytosis, positive result on CRP determination, elevated ASO titer, and elevated ESR. A positive result on ANA testing is used to

90

diagnose a wide variety of connective-tissue, vascular, and immune complex disorders and will be positive with rheumatic fever also. The client who has undergone thoracentesis should experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough, dyspnea (usually on exertion), decreased or absent tactile fremitus, and dull or flat percussion notes on respiratory assessment. The client with empyema usually experiences dyspnea, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus. Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats/min. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.04 to 0.10 second, respectively.

Sinus arrhythmia has all of the characteristics of normal sinus rhythm except for the presence of an irregular PP interval. This irregular rhythm occurs because of phasic changes in the rate of
firing of the sinoatrial node, which may occur with vagal tone and with respiration. Cardiac output is not affected.

Ventricular fibrillation is characterized by the absence of P waves and QRS complexes.

The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen.

PVCs are considered dangerous when they are frequent (more than 6/min), occur in pairs or couplets, are multifocal (multiform), or fall on the T wave. In each of these instances, the clients cardiac rhythm is likely to degenerate into ventricular tachycardia or ventricular fibrillation, both of which are potentially deadly arrhythmias. Carotid puls is palbable with each compression in CPR- Correct procedure for CPR with two rescuers includes a compression-to-ventilation ratio of 30:2. With adults, compressions are performed at a depth of 1.5 to 2 inches. The 30:2 compression-ventilation ratio yields an effective rate of 12 breaths/min. With effective compressions, carotid pulsations should be present. At its best, CPR produces only 30% of the normal cardiac output, so correct technique is vital. Temporal lobe herniation or uncal herniation refers to a shifting of the temporal lobe laterally across the tentorial notch. This produces compression of the third cranial nerve and ipsilateral pupil dilation. If pressure continues to rise, flaccid paralysis, pupil dilation, pupil fixation, and death will result. Total calcium levels are 7.0 to 12.0 mg/dL in a term infant younger than 1 week and 8.0 to 10.5 mg/dL in a child. Neonatal hypocalcemia is defined as a total serum calcium level of less than 7.0 mg/dL. Loose associations are speech patterns in which there is a lack of a logical relationship between thoughts and ideas that causes speech and thought to seem inexact, vague, unfocused, and diffuse. Flight of ideas is overproductive speech characterized by the clients quickly switching from one subject to another. Incoherence is characterized by speech that cannot be understood. Tangentially refers to an inappropriate response to a statement to which the content of the statement is disregarded. Clanging is a form of rhyming that is not comprehensible; a client whose speech features clanging seems to be caught up in the sound of the words. If a ventricular pacemaker is functioning properly, there will be a pacer spike followed by a QRS complex. An atrial pacemaker spike precedes a P wave if an atrial pacemaker is implanted. A demand pacemaker fires only when needed and should therefore discharge only when

91

no electrical activity is occurring in the clients own heart.- QUESTION FOR COMPLETE HEART BLOCK Cardiotoxicity can occur with the use of doxorubicin. The medication can produce irreversible toxicity to the heart, including ECG changes and congestive heart failure. Elevated values on renal function tests (options 1 and 2) are not associated with the use of this medication. A red coloration of the urine may occur with the use of this medication, but this effect is harmless. Mupirocin is a topical antibacterial agent active against impetigo caused by staphylococci or streptococci. Acyclovir is a topical antiviral agent that inhibits DNA replication in the virus. It inhibits the activity of herpes simplex types 1 and 2, varicella-zoster, Epstein-Barr virus, and cytomegalovirus. Triple antibiotic would not be effective in treating impetigo. Benzoyl peroxide is a keratolytic. Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for acidosis and if the acidosis becomes severe, the medication should be discontinued for 1 to 2 days. An elevated blood pressure may be expected in the client with pain. Hypotension is not associated with the use of this medication The wound should be cleansed with a sterile solution and gently patted dry. A thin layer of Elase is applied and covered with a petrolatum gauze. If a dry powder is used, for best effects the solution should be prepared just before use.- WET STERILE DRESSING FOR MECHANICAL DEBRIDEMENT Idiopathic autoimmune hemolytic anemia is treated with corticosteroids. Other treatments that may be prescribed as necessary include splenectomy, transfusions, and, occasionally, immunosuppressive medications. Radiation therapy is not used to treat this disorder. The client recovering from cardiogenic shock secondary to a myocardial infarction will require a progressive rehabilitation related to physical activity. The heart requires several months to heal from an uncomplicated myocardial infarction. The complication of cardiogenic shock will increase recovery period for healing. Paced activities with planned rest periods will decrease the chance of experiencing angina or delayed healing. Pulse is not needed in this diagnosis. Laboratory findings in an infant with hypertrophic pyloric stenosis include metabolic alkalosis due to vomiting. These include increased blood pH and bicarbonate level, decreased serum potassium and sodium levels, and a decreased chloride level. In the client with DKA, the nurse would expect to note blood glucose levels between 350 and 1500 mg/dL, ketonuria, serum pH less than 7.35, and serum bicarbonate below 15 mEq/dL. The serum potassium level would be inversely proportional to the pH. The normal range of serum phosphate is 2.7 to 4.5 mg/dL. The only option that indicates improvement in the clients condition

Braces for treatment of scoliosis usually are worn 16 to 23 hours a day. The skin should be kept clean
and dry and inspected for signs of redness or breakdown. Therefore, risk for impaired skin integrity is the nursing diagnosis that should be included in this childs plan of care. The child will not have a risk for delayed growth and development because normal developmental milestones can be met while wearing a brace. The brace assists with posture so mobility is not an issue. The brace does not compromise the respiratory status, so gas exchange is not impaired.

Cyclophosphamide (Cytoxan) is an alkylating agent used as a chemotherapeutic agent in children

with leukemia and other cancers. Its side effects include bone marrow depression (BMD), but it is platelet sparing. It also causes hemorrhagic cystitis. It does not cause constipation, as vincristine does. Vincristine, a plant alkaloid, also causes BMD.

92

The immunocompromised child with an HIV infection should not receive live vaccines. With both the varicella and the MMR vaccinations, live vaccines are given. Once the childs immune status improves, these vaccinations can then be given. Option 4 is correct because the varicella vaccination would be delayed until the child is not immunocompromised. Option 3 is incorrect because the MMR vaccine would not be administered at this time. The IPV is not a live virus so it can be administered. Option 2 is incorrect because influenza vaccinations do not typically involve live viruses, so the child could receive this vaccination. Highly active antiretroviral nucleoside (HAART) consists of the combination of two nucleoside analogues, which target viral replication during the reverse transcription phase of the cell cycle, and a protease inhibitor, which targets viral replication at a different phase Known altered immunodeficiency from long-term immunosuppressive therapy is a contraindication to MMR (measles-mumps-rubella) immunization because a live vaccine is given. The Parkland (Baxter) formula for estimating fluid requirements is 4 mL 90 83 = 29,880 mL, divided by 2 = 14,940 mL. Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Cherry-red, firm tissue can occur as a result of thermal injury. Intact blisters indicate a partial-thickness thermal injury. Glipizide is an oral hypoglycemic agent given to reduce the serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a decrease in polyuria (a symptom of hyperglycemia) would denote a beneficial response to glipizide. Excessive appetite (polyphagia) also is a symptom of hyperglycemia. Thus, an increase in appetite would not signify a therapeutic effect. A therapeutic fasting blood glucose should be less than 100 mg/dL, and the glycosylated hemoglobin should be less than 7%.

The normal cardiac output is 4 to 7 L/min. With cardiogenic shock, the CO falls below normal because of failure of the heart as a pump. The PCWP, however, rises because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure. nephrostomy tube is put in place after percutaneous ultrasonic lithotripsy for calculi in the
renal pelvis. The client also may have a Foley catheter to drain urine produced by the other kidney. The
nurse monitors the drainage from each of these tubes and strains the urine to detect elimination of the calculus fragments.

ACUTE RENAL FAILURE- Serum myoglobin levels increase in crush injuries when large amounts of myoglobin and hemoglobin are released from damaged muscle and blood cells. The accumulation may cause acute tubular necrosis, an intrarenal cause of renal failure. Prerenal causes are conditions that interfere with the perfusion of blood to the kidney. Postrenal causes include conditions that cause urinary obstruction distal to the kidney. The cause and the type of renal failure may determine the interventions used in treatment. EXTRA RENAL is not a category of acute renal failure.

93

Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected into the auditory canal. A normal response that indicates intact function of cranial nerves III, VI, and VIII is conjugate eye movements toward the side being irrigated, followed by eye movement back to midline. Absent or dysconjugate eye movements indicate brainstem damage. Most ongoing treatment for myasthenia gravis is done in outpatient settings, and the client needs to be aware of the lifestyle changes needed to maintain independence. Taking medications an hour before mealtime gives greater muscle strength for chewing and is indicated. The client should have portable suction equipment and a portable resuscitation bag available in case of respiratory distress. The client should carry medical identification about the presence of the condition. The client should avoid situations and other factors that could worsen the symptoms, including stress, infection, heat, surgery, and alcohol.- eg. Avoid going to the beach The onset or exacerbation of multiple sclerosis is preceded by a number of different factors, including physical stressors (e.g., vaccination, excessive exercise), emotional stress, fatigue, infection, physical injury, pregnancy, extremes in environmental temperature, and high humidity. No methods of primary prevention are known. Intake of fruit and vegetables is an unrelated item.

After total knee replacement, the client should report signs and symptoms of infection and
any changes in the shape of the knee. Any of these could indicate developing complications. With a metal implant, the client initially must be on anticoagulant therapy and should report adverse effects of this therapy, including bleeding from a variety of sources. With a metal implant, the client must notify caregivers because certain diagnostic tests (magnetic resonance imaging) will need to be avoided, and the client will need antibiotic prophylaxis for invasive procedures.

The client has just received a metal prosthesis, which indicates that the client is receiving anticoagulant therapy. This would make options 1 and 4 correct. Reporting signs and symptoms of infection is important, so eliminate option 2. Recalling that changes in the shape of the knee

could indicate developing complications with the prosthesis will direct you to option 3.
METAL PROSTHESIS SHOULD HAVE ANTICOAGULANT THERAPY

HERNIATED LUMBAR DISK- LOWER BACK CARE-The

client is taught to get out of

bed by sliding near the edge of the mattress.

The client then rolls onto one side and

pushes up from the bed using one or both arms. The client keeps the back straight and swings the legs over the side. Increasing fluid intake and dietary fiber helps prevent straining at stool, thereby preventing increases in intraspinal pressure. Walking and swimming are excellent exercises for strengthening lower back muscles. Proper body mechanics includes bending at the knees, not the waist, to lift objects.

94

BONE SCAN-No special restrictions are necessary after a bone scan. The client is encouraged to

drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system . The
very small amount of radioactivity from the isotope presents no hazards to the client or staff. Dantrolene- hepatotoxic- monitor liver function test Incoordination and drowsiness are common side effects of diazepam. If the result of the ELISA is positive, the Western blot is done to confirm the findings. If the result of the Western blot is positive, then the client is considered to be seropositive for the infection and to be infected with the virus. Options 2, 3, and 4 are incorrect.

The client with P. jiroveci infection usually has a

cough as the first sign, which begins as

nonproductive and then progresses to productive. Later signs and symptoms include fever, dyspnea

on exertion, and finally dyspnea at rest. Histoplasmosis usually starts as a respiratory infection in the client with AIDS and then becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver. Synthetic growth hormone comes in a powdered form that must be diluted for administration. It is given as a subcutaneous injection-(ROTATE INJECTION SITE) six or seven times per week as prescribed at bedtime. Parents are taught that once diluted, the hormone preparation is to be stored at 36 to 46 F (refrigerated). Injection sites should be rotated. In

moderate dehydration,

the fontanels would be slightly sunken, the mucous

membranes would be dry, and the skin color would be dusky. Also, present

oliguria

would be

Nephrotic syndrome is a kidney disorder. Clinical manifestations of nephrotic syndrome include edema, proteinuria, hypoalbuminemia, and hypercholesterolemia in the absence of hematuria and hypertension. No fever, bacteriuria, or weight loss would be noted with this syndrome.

Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. The child with acute glomerulonephritis will have an excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excess fluid volume would be an appropriate nursing diagnosis for this disease process. No risk for infection is associated with this disease; it is a postinfectious process, usually from a pneumococcal, streptococcal, or viral infection. Hematuria is present, but the loss of blood is not enough to constitute a risk for injury. The disease is acute as opposed to chronic, and almost all children recover completely. Renal disease- GOODPASTURE SYNDROME- TYPE 3 HYPERSENSITIVITY RESPONSE

95

Pyrimethamine is an antimalarial and an antiprotozoal medication used to treat toxoplasmosis or Pneumocyctis jiroveci pneumonia. Pyrimethamine is not used to treat nausea, vomiting, cardiac irregularities, or Kaposis sarcoma. A physician prescribes D5w containing 1.5 meq of k+ chloride per 100 ml to infuse at a rate at 110 ml/hr. at 7 am the nurse hangs the solution, at 11 am how much KCL has the client received? First, calculate how many millimeters the client has received in the 4 hours: 110 mL 4 hours = 440 mL. Next, calculate how many mEq of KCl are in 440 mL.Formula: 1.5 mEq KCl : 100 mL :: mEq KCl : 440 mL 100x = 660 and therefore x = 6.6 mEq KCl. The client who has aspirin toxicity will present with metabolic acidosis with respiratory compensation as seen when the pH is below 7.35 mm Hg, and the HCO3 is below 22 mEq/L. The pH is indicative of the acid-base imbalance. In this case, the pH is acidotic and the HCO3 is decreased, thus indicating metabolic acidosis. The PCO2 is alkalotic, indicating partial compensation.- EVEN IF THE MANIFESTATIONS STATES NAUSEA & VOMMITING & LETHARGY FLUORESCENT ANTINUCLEAR ANTIBODY (FANA) TITER- The antinuclear antibody test measures the titer of antibodies that destroy the nuclei cells and cause tissue death. When the fluorescent method is used, the test sometimes is referred to as FANA. If this test gives a positive result, a value greater than 1.8 will be present. The other options are incorrect. Generally, an ESR value of 30 to 40 mm/hr indicates mild inflammation, 40 to 70 mm/hr indicates moderate inflammation, and 70 to 150 mm/hr indicates severe inflammation. In dark-skinned clients, pallor results in the loss of normal red tones in the skin. The brownskinned client may have yellow-tinged skin when pallor is present. In the black-skinned client, pallor produces an ashen-gray color. Bluish discoloration of the skin most often is associated with cyanosis. Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. Redness around the wound edges may be difficult to note in the dark-skinned client. Swelling and drainage from the wound are not specific indicators of erythema. The client should be instructed that a lubricant is applied immediately after the bath while the skin is still damp to help increase hydration of the stratum corneum. The emergent phase of burn care generally extends from the time the burn injury incurred to the time when the client is considered physiologically stable. The acute phase lasts until all fullthickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society.- Nurse plans care

96

Multiple personality disorder or dissociative identity disorder is considered to be a dissociative disorder, rather than an anxiety disorder. Anxiety is a characteristic of panic disorder, OCD, and PTSD. Rigid and inflexible behaviors are characteristic of the client with OCD. Clients with this disorder usually are not hostile unless they are prevented from engaging in the obsession or compulsion, because this behavior is what decreases the anxiety. A repetitive behavior that interferes with activities of daily living and functioning is indicative of OCD. This repetitive behavior is not associated with generalized anxiety disorder, phobias, or PTSD. In OCD, the rituals performed by the client are an unconscious response that helps to divert and control the unpleasant thought or feeling to prevent acting on it.- Unconsciously controlling unpleasant thought of feelings In OCD, client is aware of performing his ritual. Emotional turmoil expressed in physical signs is the hallmark of somatization disorder. Salicylate serum levels are monitored on a regular basis in the client taking salicylates for rheumatoid arthritis. The normal therapeutic level ranges from 10 to 20 mg/dL
In the use of a CPM machine, the leg should be kept in a neutral position and not rotated either internally or externally. The knee should be positioned at the hinge joint of the machine. The nurse should monitor for pressure areas at the knee and the groin and should follow the physicians orders and institutional protocol regarding extension and flexion and speed of the CPM machine. Avoid the use of salicylates because they decrease the uricosuric effects of probenecid (benemid) for gout

Bone pain is the most common symptom of Pagets disease and may manifest in areas close to a
joint. The pain is related to progressive enlargement and deformity of the bone. Hearing loss, numbness of the face, or (more rarely) blindness can occur when the thickened bone of Pagets disease compresses vital nerves in the skull. Fatigue and difficulty with ambulation may occur but would not be the most common symptoms.

Diagnostic laboratory findings for Pagets disease include an elevated serum alkaline phosphatase and urinary hydroxyproline excretion

SIADH- HYPONATREMIA, & SERUM OSMOLALITY

SIADH is characterized by inappropriate continued release of antidiuretic hormone (ADH). This results in water intoxication, manifested as fluid volume expansion, hypotonicity of body fluids, and hyponatremia as a result of the high urine osmolality and low serum osmolality.

97

Osmolality measures the concentration of particles in solution. Osmolality

increases with
people,

dehydration and

decreases

with

overhydration.

In

normal

increased osmolality in the blood will stimulate secretion of ADH (antidiuretic hormone).

The normal range of serum osmolality is 285-295 mOsm/L.

The client is informed that the test aids in determining whether signs and symptoms are caused by abnormalities in the adrenal gland. The nurse assesses the client for allergies to iodine before the test. The client is told that a transient burning sensation may be experienced after the dye is injected, that the supine position is necessary, and that the insertion site will be locally anesthetized. An informed consent form is required. Stage I carcinoma is strictly confined to the cervix. In stage II, the carcinoma has extended beyond the cervix but has not extended to the pelvic wall. Stage III carcinoma has extended to the pelvic wall at the lower third of the vagina, and in stage IV, carcinoma has extended beyond the true pelvis or has clinically involved the mucosa of the bladder or rectum. The high pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set tidal volume. Causes include tubing obstruction or kinks, breathing out of phase or bucking the ventilator, accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax. A disconnection of the ventilator tubing, an exaggerated client inspiratory effort, Generation of extreme negative pressure by the client-------- causes for triggering the low-pressure alarm. Peritoneal Dialysis Brown-tinged returns suggest bowel perforation, which usually is accompanied by severe abdominal pain and diarrhea. Yellow-tinged returns suggest possible bladder perforation. Clients should be instructed to increase fluid intake to 3 L per day to help relieve dysuria and to flush bacteria out of the bladder. Medications such as vitamin C help acidify the urine. Additionally, an acid ash diet may be of some benefit. Juices such as cranberry, plum, and prune juice will leave an acid ash in the urine. Caffeine, alcohol, chocolate, and highly spiced foods are avoided to prevent potential bladder irritation. In the client with glomerulonephritis, characteristic findings in the urinalysis report are gross proteinuria and hematuria. The specific gravity is elevated, and the urine may appear dark and smoky. A colony count of less than 10,000 bacterial units/mL of urine is not significant. A colony count of 20,000 or 50,000 is inconclusive. A colony count of 100,000 is considered a positive culture and is indicative of pyelonephritis if accompanied by fever and flank pain. A positive culture that is accompanied by dysuria, frequency, and urgency is indicative of cystitis.

98

During the oliguric phase of acute renal failure, urine output is less than 100 mL in a 24-hour period. The specific gravity of the urine is low and fixed , and the urine osmolarity approaches that of the clients serum level, or about 300 mOsm/L. Serum creatinine levels increase approximately 1 mg/dL per day, and the BUN level increases approximately 20 mg/dL per day. The diuretic phase of acute renal failure develops about 14 days after the initial insult and lasts about 10 days. It is characterized by an increase in urine output of more than 1000 mL in a 24-hour period. This increase in urine output indicates the return of some renal function; however, BUN and creatinine levels continue to rise during the first few days of diuresis.

Osteomyelitis most frequently is caused by direct contamination of bone through an open wound. Other, less frequent causes include spread from local infection, such as a boil, poor
nutrition, or unhygienic conditions.

Hypothermia decreases the heart rate and blood pressure because the
metabolic needs of the body are reduced in this condition. With fewer metabolic needs, the workload of the heart decreases, with drops in both the heart rate and the blood pressure.

Dopaminergic receptors are found in the renal blood vessels and in the nerves. When these are stimulated, they dilate renal arteries and help modulate release of this neurotransmitter. Renal artery dilation helps to improve
urine output by increasing blood flow through the kidneys. Epinephrine and norepinephrine affect the and receptors in the body. Serotonin is a local hormone that is released from platelets after an injury. It constricts arterioles but dilates capillaries.- Dopamine BP

Surfactant- Collapse alveoli Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become stiff because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis

Shunting occurs when a portion of the lung area has adequate capillary perfusion but is not being ventilated. As a result, no gas exchange occurs. Anatomical dead space
normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.

The carina is a cartilaginous ridge that separates the openings of the two main (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected, because only the right lung will have breath sounds and rise and fall with ventilation.

99

The motor branch of cranial nerve V is responsible for the ability to chew food. The hypoglossal nerve aids in swallowing. The spinal accessory nerve is responsible for shoulder movement, among other things. The vagus nerve is active in parasympathetic functions of the autonomic nervous system. The uveal tract (ICCt is the middle vascular layer of the eye that furnishes the blood supply to the retina. The three structures that are part of this area are the iris, ciliary body, and choroid. The lens is not part of this tract but is suspended behind the iris by fibers called zonules, which connect it to the ciliary body. The function of the lens is to focus light on the retina. Lactulose is an osmotic laxative. The desired effect is two or three soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colons pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon. Diarrhea may indicate excessive administration of the medication Pancreatin aids in the digestion of protein, carbohydrate, and fat in the gastrointestinal tract. It is used to treat steatorrhea associated with postgastrectomy syndrome following bowel resection. The nurse should record the number of stools per day and stool consistency to monitor the effectiveness of this enzyme therapy. If it is effective, the stools should become less frequent and less fatty. Medications known to lower cyclosporine levels include phenytoin, phenobarbital, rifampin, and trimethoprim-sulfamethoxazole. Cyclosporine levels should be monitored and the dosage adjusted in clients taking these medications.

should be discontinued for at least 3 days (72 hours) before allergy skin testing to avoid false-negative readings. This client should have the appointment rescheduled
An antihistamine provides relief of symptoms caused by allergy. Antihistamines

for 3 days after discontinuing the medication.

Acetylcystine for acetaminophen overdose- lavage first before giving antidote

Acetylcystine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. Before giving the medication as an antidote to acetaminophen, the nurse ensures that the clients stomach is empty through emesis or gastric lavage. The solution is diluted in cola, water, or juice to make the solution more palatable. It is then administered orally or by nasogastric tube. Sennosides LAXATIVE

The client with an ileostomy is prone to dehydration because of the location of the ostomy in the gastrointestinal tract and should not take laxatives. This will compound the potential risk for the client. These clients are at risk for deficiency of iron, folate, and cyanocobalamin and should receive these as supplements if necessary. Infant expose to hepatitis- Give ( HBIG)+ Hepatitis B vaccine within 12 hrs. after birth.

100

 HBIG and the vaccine are given to infants with perinatal exposure to prevent hepatitis and achieve lifelong prophylaxis and is administered within 12 hours of birth. IG is given to prevent hepatitis A.
FLUCTUATION IN THE WATER-SEAL CHAMBER IN THE CHEST TUBE DRAINAGE With normal breathing, the water level rises with inspiration and falls with expiration. The opposite the level falls with inspiration and rises with expirationoccurs when the client is on positive-pressure mechanical ventilation. This is an expected normal occurrence in a chest tube drainage system; therefore, no action is necessary except to document the findings. Constant bubbling occurring in the water seal chamber may indicate a leak in the system. Among the options provided, the appropriate action is to notify the physician. The client taking a single daily dose of theophylline, a xanthine bronchodilator, should take the medication early in the morning. This enables the client to have maximal benefit from the medication during daytime activities. Additionally, this medication causes insomnia. The client should take in at least 2 L of fluid per day to decrease viscosity of secretions. The client should check with the physician before changing brands of the medication because levels of bioavailability may vary for different preparations. The client also should check with the physician before taking over-the-counter cough, cold, or other respiratory preparations because they could have interactive effects, increasing the side effects of theophylline and causing dysrhythmias. A lethality potential exists if the client appears disorganized and impulsive. Clients at higher risk include those with a history of a dual diagnosis of mental illness and substance abuse, a personal or family history of suicide attempts, depression, alcoholism, or psychotic episodes. Having a plan, particularly if the method is immediate and available, places the client at very high risk. Acetylsalicylic acid (aspirin) may be used to reduce the risk of recurrent transient ischemic attacks (TIAs) or stroke, or reduce the risk of MI in clients with unstable angina or with a history of a previous MI. The normal dose for clients being treated with acetylsalicylic acid (aspirin) to decrease thrombosis and MI is 300 to 325 mg daily, and some physicians may prescribe even a lower dose. Clients taking aspirin to prevent TIAs usually are prescribed 1.3 g daily in two to four divided doses. Clients with rheumatoid arthritis are treated with 3.2 to 6 g daily in divided doses. A positive variance occurs when the client achieves maximum benefits and is discharged earlier than anticipated on his or her critical path Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID). Interactions may occur with the use of anticoagulants, and the nurse should consult with the physician about a potential medication interaction if an anticoagulant is prescribed. Primidone (Mysoline) and phenytoin are anticonvulsant medications. Acetaminophen is a nonopioid analgesic. These medications are not contraindicated with diclofenac.

101

Aspiration is safeguarded against by keeping the client on NPO (nothing by mouth) status for 6 to 8 hours before ECT, removing dentures, and administering preprocedure medications as prescribed. Although options 1 and 2 also could be appropriate nursing diagnoses, they are not the priority. Disturbed Body Image is not associated with this procedure. In the forming or initial stage, the members are identifying tasks and boundaries. Storming involves responding emotionally to tasks. In the norming stage, members express intimate personal opinions and feelings around personal tasks. In the performing stage, members direct group energy toward the completion of tasks. Clients taking antihypocalcemic medications should be instructed to avoid the use of mineral oil as a laxative because it decreases vitamin D absorption, and vitamin D is needed to assist in the absorption of calcium. In an alkaline ash diet, all fruits are allowed except cranberries, blueberries, prunes, and plums

The throat of a child with suspected epiglottitis should not be examined or cultured because any stimulation with a tongue depressor or culture swab could cause laryngospasm, thus completing airway obstruction. Humidified oxygen and antipyretics
are components of management. Axillary rather than oral temperatures should be taken.

HYPOTHYROIDISM-

RESPIRATORY STATUS- DO NOT GIVE MORPHINE TO

RESPIRATORY DEPRESSION. Medications are administered very cautiously to the client with hypothyroidism because of altered metabolism and excretion and depressed metabolic rate and respiratory status. Morphine sulfate would further depress bodily functions. Hormone replacement with levothyroxine sodium (Synthroid), a thyroid hormone, is a component of therapy. Stool softeners, such as docusate sodium (Colace), are prescribed to prevent constipation. Acetaminophen (Tylenol) can be taken. Newborn infants of HIV-positive clients are recommended to receive antiviral medications for the first 6 weeks of life.

The normal maintenance dose of levothyroxine in an adult is 0.1 to 0.2 mg daily. Maintenance dose for infants 0 to 6 months of age is 0.025 to 0.05 mg daily; for children 1 to 5 years of age, 0.075 to 0.1 mg daily; and for children 6 to 12 months of age, 0.05 to 0.075 mg daily.

mastoidectomy, in which the mastoid bone is removed or partially removed, may be recommended to treat chronic otitis media.

Abacavir(ziagen)- Hypotension is the adverse effect.. Capecitabine is an antimetabolite used to treat metastatic breast cancer that is resistant to other therapy. It also is used to treat colon cancer

102

Decorticate rigidity indicates a hemispheric lesion of the cerebral cortex. Decerebrate rigidity indicates a lesion in the brainstem at the midbrain or upper pons. EMERGENCY DEPARTMENT --------treatment of DKA is the administration of Regular insulin by the intravenous (IV) route. Regular insulin is the only type of insulin that can be given by the IV route. OBSTETRICS Within 12 hours after delivery, the fundus may be approximately 1 cm above the umbilicus. Involution progresses rapidly during the next few days following delivery. By the sixth postpartum day, the fundus normally is located halfway between the symphysis pubis and the umbilicus.

The most likely cause of the PVCs in this client is hypokalemia. The normal sodium level is 135 to 145 mEq/L. A level of 150 mEq/L would indicate hypernatremia. Hypernatremia is noted in such conditions as congestive heart failure, Cushings disease, dehydration, diabetes insipidus, diaphoresis, diarrhea, and hypovolemia

The normal PT for an adult male ranges from 9.6 to 11.8 seconds (9.5 to 11.3 for a female client). A

PT may be noted in many conditions including arterial occlusion, deep vein thrombosis,

edema, myocardial infarction, peripheral vascular disease, and pulmonary embolism.

PT- HEPATIC DISEASE, CIRRHOSIS OF THE LIVER, FACTOR VII DEFICIENCY

The normal albumin level ranges from 3.4 to 5 g/dL. The albumin level is conditions such as acute infection, ascites, alcoholism, burns, and cirrhosis.

in many

ALBUMIN( LESS WATER)----- DEHYDRATION, DIARRHEA, MULTIPLE MYELOMA

ALBUMIN HAS AN OSMOTIC EFFECT. Carbamazepine is classified as an iminostilbene derivative and is used as an anticonvulsant, antineuralgic, antimanic, and antipsychotic. CARBAMAZEPINE- FOR TRIGEMINAL NEURALGIA the therapeutic blood serum level of digoxin ranges from 0.8 to 2 ng/mL. Therefore, a blood level of 2.1 ng/mL is just above the high end of the therapeutic range. The most common early manifestations of digoxin toxicity are gastrointestinal disturbances such as anorexia, nausea, and vomiting and neurological disturbances as fatigue, headache, weakness, drowsiness, confusion, and nightmares. Visual disturbances such as photophobia, light flashes, halos around bright objects, and yellow or green color perception also may be noted.

103

escalating drinking problem that results in tolerancea need for higher and higher doses to achieve the desired effect of the alcohol. alcohol dependence that involves the client drinking the alcohol and losing control over it.

Children with Down syndrome have an increased risk for developing leukemia compared with the average child. Bracing can halt the progression of most curvatures, although it is not curative for scoliosis.
A

Sengstaken-Blakemore tube typically is used in a client with a diagnosis of

cirrhosis and ruptured esophageal varices.

The physician performing a

lumbar puncture

is gaining access to the clients

subarachnoid space.

This is the area often accessed

for diagnostic testing,

such as with lumbar puncture or myelogram. The epidural space may be used to deliver medications to the client. The spaces between the vertebrae are widened when the client is positioned for lumbar puncture. The spinal needle passes between vertebrae, not into them. The spinal cord is not touched directly during lumbar puncture.

A key consideration in prescribing medications that will affect the brain is the ability of the medication to cross the blood-brain barrier. If the medication cannot pass into the brain, it will not be effective.

The vagus nerve is responsible for sensations in the thoracic and abdominal viscera. It also is responsible for the decrease in heart rate because approximately 75% of all parasympathetic stimulation is carried by the vagus nerve. CN IX is responsible for taste in the posterior two thirds of the tongue, pharyngeal sensation, and swallowing. CN XI is responsible for neck and shoulder movement. CN XII is responsible for tongue movement.

Early signs and symptoms of RA include fatigue, weight loss, fever, malaise, morning
stiffness, pain at rest joints appear edematous.

and with movement, and complaints of night pain. The involved

The function of the musculoskeletal system is particularly affected by several nutrients. These include protein (especially purines), calcium, phosphorus, fluid intake, and vitamins A, B, C, and D. Vitamins E and K are not as directly associated with musculoskeletal function as the other nutrients listed. An open (or compound) fracture is one in which the fractured bone protrudes through the skin, disrupting soft tissue.

104

The kidneys normally receive about 20% to 25% of the cardiac output if the client is at rest. If the cardiac output is 6 L/min, then the kidneys receive 1.2 to 1.5 L/min, which is equal to 1200 to 1500 mL/min. Elevations in body temperature cause a corresponding increase in respiratory rate. This occurs because the metabolic needs of the body increase with fever, requiring more oxygen. The client who has a decrease in body temperature will experience a decrease in respiratory rate. Clients with renal failure often have pruritus, or itchy skin. This is due to impaired clearance of waste products by the kidneys. The client who is markedly anemic is likely to have skin that is pale in color. Hypothyroidism may lead to complaints of dry skin. Diabetes mellitus may be noted with the presence of skin infections. Cardiopulmonary disorders may lead to clubbing of the fingers.

The greater trochanter is at greater risk of skin breakdown from excessive pressure when the client is in the side-lying position. When the client is lying supine, the heels, sacrum, and back of the head all are at risk, as well as the elbows and scapulae.
PSYCHE Major depression, recurrent, with psychotic behaviors alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one must also deal with a clients psychosis. Psychosis is defined as a state in which a persons mental capacity to recognize reality and communicate and relate to others is impaired, thus interfering with the persons capacity to deal with lifes demands. Disturbed thought processes generally indicates a state of increased anxiety in which hallucinations and delusions prevail. Antiretroviral therapy is begun when CD4+ counts are less than 500 cells/L or when signs or symptoms of HIV disease appear. manifests with signs and symptoms such as an complaints of headache, and cognitive impairment

Toxoplasmosis

altered mental status,

The antinuclear antibody test measures the titer of antibodies that destroy the nuclei cells and cause tissue death. When the fluorescent method is used, the test sometimes is referred to as FANA. If this test is positive, a value greater than 1:8 will be present.

The normal ESR range is 0 to 30 mm/hr. Generally, an ESR value of 30 to 40 mm/hr

indicates mild inflammation, 40 to 70 mm/hr indicates moderate inflammation, and 70 to 150 mm/hr indicates severe inflammation.

APLASTIC ANEMIA & SLE ( SYSTEMIC LUPUS ERYTHEMATOSUS)PANCYTOPENIA ( ALL CELL TYPES)

105

In the client with SLE, a complete blood count commonly shows pancytopenia, a decrease in the number of all cell types. This finding is most likely caused by a direct attack of all blood cells or bone marrow by immune complexes Early clinical manifestations of RA include complains of fatigue, generalized weakness, anorexia, and weight loss Herpes simplex manifests as painful, vesicular lesions that rupture and cause ulcers on the tongue, lips, and buccal mucosa.

Polydipsia and polyuria are classic symptoms of diabetes insipidus . The urine is pale in
color and the specific gravity is low. Anorexia and weight loss also may occur. Diarrhea is not indicative of the complication. Infection is not associated with diabetes insipidus.

Common manifestations of Addisons disease include postural hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea and vomiting, abdominal cramps, weight loss, depression, and irritability PTU is not used for relief of joint pain. It does not cause renal toxicity or hyperglycemia. Classic signs and symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. It is important to regularly assess the client for hyperglycemia to prevent the development of more serious complications, such as diabetic ketoacidosis DKA is marked by the presence of excessive ketone bodies. As a result of the acidosis, the pH and serum bicarbonate level would decrease. Hyponatremia is not related to DKA.

Hypercalcemia classically occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic dieresis- POLYURIA
The normal reference values for the oral glucose tolerance test are less than 140 mg/dL at 120 minutes; less than 200 mg/dL at 30, 60, and 90 minutes; and less than 115 mg/dL in the fasting state.
An acceptable measure of diabetic control is indicated by a serum level of glycosylated hemoglobin A1c of 7.5% or less. Specific values may vary slightly, depending on the laboratory and the procedure A sprain is an injury to a ligament caused by a wrenching or twisting motion. Signs and symptoms include pain, swelling, and inability to use the joint or bear weight normally. A strain results from a pulling force on a muscle. Symptoms include soreness and pain with muscle use. Typical signs and symptoms of fracture are variable but include pain, loss of function in the affected area, deformity, shortening of the extremity, crepitus, swelling, and ecchymosis. A contusion results from a blow to soft tissue and causes pain, swelling, and ecchymosis. Cardioversion- During the procedure, any oxygen is removed temporarily, because oxygen supports combustion, and a fire could result from electrical arcing.

106

Seizures that originate with specific motor phenomena are considered focal and are indicative of a focal structural lesion in the brain, often caused by trauma, infection, or drug consumption PEDIA----- MOSBY QUESTION: After an emergency appendectomy, the nurse should place the child in a semi-Fowler's or right Sims' position because: Drainage is promoted by the principle of gravity, preventing fluid accumulation and possible abscess formation. The lungs aerate well in any position if a subdiaphragmatic abscess does not form; with an abscess, the child will splint breath. RESPIRATORY DISTRESS SYNDROMEMaintaining the infant in a warm environment- This is done because any attempt by the infant to maintain temperature further compromises physical status by increasing metabolic activity and O2 demands. M.S.-------MOSBY Purpose NGT: The tube feedings reduce the risk of infection and allow healing. Correct answer: This permits the esophageal suture line to heal before contact with food, which may increase the risk of infection. Aspiration is still possible with nasogastric tube feedings. Saunders: CEPHALHEMATOMA- JAUNDICE Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves and the blood is absorbed into the circulatory system. A negative direct Coombs test

result indicates that no maternal antibodies are present on fetal erythrocytes. The birth weight in option 2 is within the acceptable range for a term
newborn and therefore does not contribute to an increased bilirubin level. The classic Rh incompatibility situation involves an Rh-negative mother with an Rh-positive fetus/newborn. Atrial fibrillation HYPOTENSION. with 100beats/min. ventricular heart rate still has

The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats/min is at risk for low cardiac output due to loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. The normal total bilirubin level is less than 1.5 mg/dL.

107

Amenorrhea occurs in the client with Graves disease.

Dysmenorrhea, metrorrhagia, and menorrhagia also are disorders related to the female reproductive system; however, they are not typical manifestations of Graves disease.

Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is due to growth of the dominant follicle within the ovary, or to rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp in nature and is felt on the right or left side of the pelvis. It generally lasts 1 to 3 days, and slight vaginal bleeding may accompany the discomfort.
Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome late in pregnancy. Having the woman turn onto her left side or elevating the left buttock during fundal height measurement will correct or prevent the problem. Genital tract infection- Douching is to be avoided Nitroglycerin- Acetaminophen (Tylenol), rather than aspirin (acetylsalicylic acid), may be used to treat headache.

The excretion of potassium and maintenance of potassium balance are normal functions of the kidneys. In the client with renal failure, potassium intake must be
restricted as much as possible (to 30 to 50 mEq/day). The primary mechanism of potassium removal during ARF is dialysis. Vitamins, carbohydrates, and fats (options 1, 3, and 4) normally are not restricted in the client with ARF unless a secondary health problem warrants the need to do so.

Rheumatic fever

usually develops after a group A -hemolytic streptococcal infection,

particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoffs

bodies,

or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptosysin O titer; an elevated C-reactive protein; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkins disease. Fosphenytoin sodium (Cerebyx) is used for short-term parenteral (intravenous [IV]) infusion. A child who is not tolerating medications by mouth and has a seizure disorder would need an anticonvulsant administered by the parenteral route. Phenobarbital (Luminal) is an antiseizure medication that is given by mouth or parenterally, but because the child has been on phenytoin (Dilantin), the medication of choice in this case would be fosphenytoin. Valproic acid (Depakene) and clonazepam (Klonopin) usually are given by mouth FOR PROTEIN DEFICIENCY- Serum transferrin is an iron transport protein that can be measured directly or calculated as an indirect measurement of total iron-binding capacity.

Transferrin is a more sensitive indicator of protein status than albumin . When

serum transferrin is less than 100 mg/dL, the level of protein depletion is severe.

108

CONTRAINDICATED FOR OPIOD DEPENDENCY- Butorphanol tartrate (Stadol) is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. It is contraindicated if the client has a history of opioid dependency. Meperidine (Demerol), morphine sulfate, and fentanyl (Sublimaze) are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients. A soft and boggy uterus would indicate that the muscle is not contracting. Uterine Inversion- Maternal complaints of severe pain Signs of uterine inversion include a depression in the fundal area, visualization of the interior of the uterus through the cervix or vagina, severe pain, hemorrhage, and shock. Chest pain and a rigid abdomen are signs of a ruptured uterus. A soft and boggy uterus would indicate that the muscle is not contracting. Pain, helplessness, panicking, and fear of losing control are possible behaviors in the second stage of labor.- Not involuntary grunting

Anemic women

have a greater likelihood of cardiac decompensation during labor,

postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hemorrhage. Anxiety and low self-esteem are unrelated to physiological integrity.

Magnesium sulfate depresses the respiratory rate.

For abdominal surgery- highest risk for post-op complications -

alcohol abuse is at

risk for liver disease

due to alcohol withdrawal

Deferoxamine is a medication used to treat iron overload. Granisetron is an

antiemetic. Terbinafine and ketoconazole are antifungal medications. OBSTETRICS-The fundus can be palpated above the symphysis pubis between 12 and 14 weeks gestation. At 20 weeks gestation, the fundus can be palpated at the umbilicus. At approximately 28 weeks gestation, the fundus can be palpated midway between the umbilicus and the xiphoid process. At 36 weeks, the fundus can be palpated at the level of the xiphoid process. Nausea and vomiting during the first trimester constitute a common complaint. A possible cause is the increasing levels of human chorionic gonadotropin or altered carbohydrate metabolism. The client should be instructed to avoid fried foods and to eat 5 or 6 small meals throughout the day rather than fewer larger meals. The nausea and vomiting should lessen throughout the day, but if they continue, the clinic should be notified for further intervention. Dry crackers should be eaten before getting out of bed, rather than after arising.

109

Alcohol withdrawal is most likely to occur within the first 6 to 8 hours after abrupt cessation; however, it can occur over the next several days. Baclofen is the only skeletal muscle relaxant that can be administered intrathecally within the spinal column. (VITAMIN B 12) Pyridoxine reverses the therapeutic effects of levodopa. Epidural hematomas frequently are characterized by a lucid interval that lasts for minutes, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.

A complication of head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. This medication may already be ordered for the head-injured client. Ethacrynic acid and mannitol are diuretics, which would be contraindicated VASO-OCCLUSIVE SICKLE CELL CRISIS Splenectomy would not be done with a vaso-occlusive crisis. Acidosis is not present Baclofen is dispensed in tablets of 10 and 20 mg for oral use. (BACTERIAL PNEUMONIA) Legionnaires disease is spread through infected aeresolized water. The mode of transmission is not person to person. Antibiotics must be given for the entire duration of the prescription.

LATE STAGE OF CHRONIC RENAL FAILURE- Because of the potentially lifethreatening outcomes associated with hyperglycemia, hyperkalemia, and hypocalcemia, they are the most relevant to nursing management of the client with chronic renal failure. MOSBY NCLEX -RN REVIEW PSYCHE The usual age of onset of schizophrenia is

adolescence or early adulthood.

Antacids may interfere with complete absorption of Tagamet; therefore they should be administered at least 1 hour apart. Bilateral Hernnioraphy- Common problem is URINARY RETENTION, HYDROCELE IS NOT A COMPLICATION IN HERE. Because of pain and the proximity of the operative site to the lower urinary tract, voiding problems are common.

110

Rejection of the kidney

A. The WBC count would be elevated, not decreased, if the kidney were being rejected. B. LEUKOPENIA - The antirejection medications C. The WBC count can drop precipitously; if leukocytes are less than 3,000/mm3, the drug should be stopped to prevent irreversible bone marrow depression. HEMODIALYSIS- ----RISK: Hepatitis type B is transmitted by blood or blood products. The hemodialysis and routine transfusions needed for a client in renal failure constitute a great risk of exposure.---------------BLADDER INFECTION IS NOT RELATED. CARDIAC CATHETERIZATION

A. Using ice compresses to relieve swelling at the entry site- This is contraindicated; ice will cause vasoconstriction and could compromise circulation B. Returning to the clinic in 5 days for removal of the pressure dressing- The child is not sent home with a pressure dressing. C. Limiting fluid intake for the next 3 days to prevent nausea----Fluids should be encouraged to enhance excretion of the contrast media used during the procedure. D. Giving a sponge bath for the first 3 days at home- The catheter insertion site should not be submerged in water; sponge baths limit trauma and infection at the insertion site.
Estrogen appears to play a protective role against myocardial infarction. Estrogen retards bone loss.-------NOT ACCELERATE BONE LOSS. Statistics indicate a relationship between estrogen therapy and an increased incidence of endometrial cancer, although mortality is not increased. Blinking of the eyes will bathe the eyes and prevent corneal ulceration. The mask may irritate or scratch the eye if the client turns and lies on it during the night. Anticholinergics are prescribed for the frequency and urgency associated with a spastic bladder. Cholinergics- for FLACCID BLADDER intensify and prolong the action of acetylcholine, which increases the tone in the genitourinary tract, preventing urinary retention. Patient with leukemia taking Vincristine (Oncovin) should fluid intake----------Elevated uric

acid levels from destroyed cells may lead to renal problems; increased fluid intake helps dilute urine. A low-sodium diet can lead to hyponatremia, which must be prevented because it limits the excretion of lithium and can result in toxicity. Diuretics reduce serum sodium levels, and lithium is not excreted when sodium levels are decreased; the retention of lithium can result in toxic levels.

111

Lithium blood levels must be checked every 2 to 3 months-----------Lithium's therapeutic window is very narrow and toxic levels could occur without routine monitoring of the blood's drug level.

RHEUMATOID JOINT SWELLING--------Inflammation in the joint's synovial lining-------------This is caused by inflammation of the synovium, resulting in vascular congestion, fibrin exudate, and cellular infiltrate.

An amniocentesis does not detect all congenital defects.

Amniocentesis------This test is useful in detecting potential defects due to

chromosomal errors."
has proven useful in detecting potential defects resulting from chromosomal errors, such as Down syndrome, Tay-Sachs disease, hemophilia, and thalassemia.

Congenital defect____________

Congested heart failure----------Veins

cardiopulmonary system.-----------Not collapsed.

are distended because of congestion of the

Vincristine-----Peripheral neuropathy-----------Neurotoxicity is a specific common side effect to this drug; the client can become numb and ataxic. Alopecia is an expected side effect rather than a toxic response; it is not considered serious, and hair will regrow.

Hemorrhagic cystitis---------- toxic response to Cytoxan.

Swan Ganz- Catheter---- Pulmonary capillary wedge pressure------- More accurate

to use in measuring left ventricular pressure-------------- PCWP IS AN INDIRECT MEASUREMENT, FOR VENTRICULAR CONTRACTILITY

Abdomino perineal resection----

Left or right side-lying position -----The left or

right side-lying position puts the least strain or pressure on the perineal suture line. Left or right Sims' position ------ Flexion of one hip and knee would increase tension on the perineal suture line; depending on placement of the stoma, one of the Sims' positions would result in the client lying on the new colostomy, which would be traumatic.
Pancreas-----Fats and carbohydrates----------Formation of lipase necessary for digestion of fats is an exocrine function; the endocrine function is to secrete insulin, which is a hormone essential in carbohydrate metabolism.

112

A client with 25 yr. hx of Alcohol Abuse-----Small liver with a rough surface------Scar tissue that forms as cirrhosis progresses causes the liver tissue to contract, making the liver small with a rough surface; little lumps are formed as scar tissue pulls the liver at certain points.

Question: The nurse understands that a positive contraction stress test may be indicative of potential fetal distress because the test demonstrates that during contractions the fetal heart rate shows:

Late

decelerations---The fetus with a borderline cardiac reserve will show hypoxia

by a decreased heart rate when there is minimal stress, making the test positive.

Early decelerations------head compression. Variable decelerations-----There are nonuniform drops in FHR before, during, or after a contraction; they are related to partial, brief cord compression that can be eliminated by changing the mother's position. Down and back-------This is how the pinna of a child younger than 3 years should be positioned for otoscopic examination. Up and back-----The external auditory canal curves downward and forward in a child older than 3 years and is approximately 1 inch long; to adequately view the tympanic membrane in a child this age, the pinna must be pulled up and back; in a child younger than 3 years, the pinna should be pulled down and back. Question: At the scene of an accident, the nurse can minimize the immediate life-threatening systemic complication of injury to the long bones of the injured person by: Handling and transporting gently--------Gentle intervention reduces pain and shock and inhibits release of bone marrow into the system. Maintaining alignment will not prevent fat emboli. Encouraging deep breathing and coughing-----------This will not prevent fat emboli; it may prevent hypostatic pneumonia and atelectasis. Elevating the affected limb----This will not prevent fat emboli; it may limit edema and pain, a local effect. Question: A client with achalasia is to have bougienage to dilate the lower esophagus and cardiac sphincter. Following the procedure the nurse should assess the client for esophageal perforation, which is indicated by: Increased heart rate and abdominal pain-----An increased heart rate is related to an autonomic nervous system response; pain is related to the trauma of the perforation and possibly gastric reflux. Faintness and feelings of fullness------Dumping syndrome. After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client demonstrates cyanosis, tachycardia, dyspnea, and restlessness. Initially the nurse should: Administer oxygen by mask---The client probably has a fat embolus; oxygen reduces surface tension of the fat globules and reduces hypoxia. Place the client in the high-Fowler's position-This will cause hip flexion, putting stress on the fractured femur; the semi-Fowler's position is preferred.

113

A female client who is actively hallucinating approaches the nurse and states, "I am hearing voices that are saying bad things about me." The nurse should: State, "The staff understands that you are frightened and will stay with you while the voices are speaking."-- When the client's perceptions are especially frightening, the nurse must let the client know that the fears are recognized as real and frightening even if the nurse does not share these perceptions. Staying with the client will convey concern as well as reduce the fears Simply state, "I do not hear the voices."----- This is nontherapeutic; the voices are real to the client. Nausea and vomiting are related to excessive amounts of estrogen; these symptoms can usually be controlled by reducing the dose. Breastfeeding- expect that Breastfeeding stimulates oxytocin release and uterine contractions, resulting in increased lochial flow. Heat is not contraindicated, and the client may take warm showers; heat is also used if the mother experiences problems such as engorgement or sore nipples. The nurse recognizes that survival in the neonatal period is largely related to: Gestational age and birth weight-----------Adaptation to the extrauterine environment is largely dependent on the functional capacity of vital organ systems, which is established during intrauterine development; this is measurable in terms of gestational age and weight Subtotal gastrectomysmall blood clots-----Consider this a normal event----As a result of the trauma of surgery, some bleeding can be expected for 4 to 5 hours. Varicose vein----Increasing ankle edema over the day--When the legs are dependent, gravity and incompetent valves promote increased hydrostatic pressure in leg veins, and as a result, fluid moves into the interstitial spaces.
The nurse recognizes that to assist a couple to deal with their feelings about the husband's terminal illness, it would be important to: Assist the couple to express their feelings about his terminal illness to each

other----------It is important for the couple to discuss their feelings to maintain open communication and support each other.

Encourage the couple to verbalize their feelings to a therapist during their individual therapy sessions------This may elicit feelings but will not improve communication; this is a rather long-term goal. Thyroid Crisis: An increased temperature and pulse rate----------Thyroid crisis is severe hyperthyroidism; excessive amounts of thyroxine increase the metabolic rate, thereby raising the pulse and temperature. A decreased blood pressure------The blood pressure will rise to meet the oxygen demand caused by the increased metabolic rate during thyroid crisis.

114

A 3-year-old is admitted to the pediatric unit with a diagnosis of acute asthma. The child is short of breath, the respirations are 56, the pulse is 102, and there is a nonproductive cough. The nurse would expect the child's blood gas values to indicate a: pH of 7.32----This is less than the normal range of 7.35 to 7.45; hypoxia causes hypercapnia, resulting in a fall in the pH. A client is to receive doxorubicin (Adriamycin) as part of a chemotherapy protocol. The major lifethreatening side effect of Adriamycin that the nurse should assess the client for is: Cardiotoxicity----Congestive heart failure and dysrhythmias are the only life-threatening toxic effects unique to Adriamycin.

Pancytopenia---When bone marrow is depressed to precarious levels, the dose is altered and/or blood
components administered. The priority nursing action for a child admitted to the hospital with a diagnosis of salmonellosis should be to: Use standard precautions-----Bacteria are spread by contaminated stool; thus to protect others, standard precautions must be used at all tines. Weigh the child /Recent food History,----This is part of the initial assessment and would have been accomplished before admission. A 1-year-old visits the playroom. The toy selected and used that would indicate an appropriate growth and developmental level would be a: Plastic toy that squeaks- A plastic toy that squeaks provides auditory, tactile, and visual stimulation. Stuffed animal----- A stuffed animal would not be kept in a playroom because it could not be washed between use by different children. Nasogastric tube feeding for a pre-term-infant: "Sucking on a pacifier during tube feedings may help him associate sucking with food so that he'll adjust better to bottle feedings."--------- Research has demonstrated that preterm infants who are allowed to suck on a pacifier during tube feedings take bottle feedings more readily and are discharged sooner. The nurse recognizes that the diagnosis of celiac disease can be confirmed when a jejunal biopsy reveals: Atrophic changes in the mucosal wall----- Celiac disease is a primary defect in which the intestinal mucosal transport system is impaired; the inability to digest gliadin results in an accumulation of glutamine, which is toxic to mucosal cells and causes atrophy of the villi. The most prevalent nutritional disorder among young children in the United States is iron deficiency anemia. A major reason for this in young children is: Overfeeding of milk----

Milk is a very poor

source of iron. If fed in large amounts to the exclusion of solid foods after 4 to 6 months of age, iron
deficiency anemia results.

115

Introduction of solid foods too early for proper absorption--- Lack of absorption and early introduction of solid foods are not commonly the cause of anemia in infants. Lack of adequate iron reserves from the mother--- Iron stores received from the mother in the last trimester are usually adequate for the infant's first 4 to 5 months. Before preparing a client for cranial surgery, the nurse should: Obtain consent for shaving the head----- Because of cosmetic concerns, consent must be obtained before a client's head may be shaved.

Wash the client's hair with an antiseptic- This is usually unnecessary; the hair will be shaved to help prevent contamination of the surgical site. DURING HYPOVOLEMIC SHOCK (LATE)------ Metabolic acidosis----- Decreased O2 increases the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. The hormones responsible for the menstrual cycle are: Gonadotropins, estrogen, and progesterone---- The gonadotropins, follicle-stimulating hormone and luteinizing hormone, are concerned with ovarian changes that produce ovulation. Estrogen is increased because of secretion from the developing follicle. Progesterone is higher because of secretion from the corpus luteum. The hormones work in concert to stimulate the menstrual cycle.

Estrogen and progesterone- These must work in concert with FSH and LH; otherwise there is no cycle.

In establishing a nursing care plan, the nurse should understand that a male client's delusion that he is an important government adviser is most likely related to: A need to feel a sense of importance and control over his environment--- The client is fearful and suspicious; the feeling of being in a powerful position helps the client deal with anxiety.
A psychotic loss of touch with his real identity- The client is not out of touch with his real identity; he has given his real identity an important role. An attempt at wish fulfillment created to manipulate others- This is incorrect; the client is compensating for feelings of inadequacy.

The psychiatrist orders lithium carbonate 600 mg PO tid for a client. The nurse would be aware that the teaching about the side effects of this drug were understood when the client states, "I will call my doctor immediately if I notice any: Fine hand tremors or slurred speech."- These are common side effects of lithium carbonate.
Inability to urinate or difficulty when urinating."----- Lithium carbonate can cause polyuria and incontinence, not retention. REYES SYNDROME- "Use an antipyretic other than aspirin when your children have a respiratory infection."---------------- Reye's syndrome is associated with viral infections, such as

116

influenza or varicella, and commonly follows the ingestion of aspirin during the prodromal stage of these diseases.

When assessing a 4-month-old infant with gastroenteritis and dehydration, the nurse would expect to find a: Depressed anterior fontanel-- This is a classic sign of fluid volume deficit in infants. Twelve hours after a female client is admitted to the critical care unit following a motorcycle injury she begins to complain of increased abdominal pain in the left upper quadrant. A ruptured spleen is diagnosed, and she is scheduled for an emergency splenectomy. When preparing the client for surgery the nurse should emphasize the: Presence of abdominal drainage for several days after the surgery- Drains are usually inserted into the splenic bed to facilitate removal of fluid that could lead to abscess formation. Risk of the procedure with the other injuries- There is no need to frighten the client unnecessarily, but the operative risk increases with multiple injuries.
Complete safety of the procedure---- Splenectomy has a low mortality rate (5%) except when multiple injuries are present (15% to 40%). After Amputation of the residual limb purpose---- Promote shrinkage----- The wrapping of the residual limb is implemented to reduce swelling and shape it for fitting a prosthesis in the future.

PLACENTA PREVIA- 30-year-old, gravida 6, para 5- Multiple past pregnancies tend to make the endometrial lining more vulnerable to abnormal implantation.

When obtaining informed consent for sterilization from a mentally retarded adult client, the nurse must be sure that the: . Client comprehends the outcome of the procedure--------- The
client must be intellectually competent, that is, able to comprehend the outcome of the procedure in order to give informed consent.

Parent or guardian signs the permit-- Informed consent can only be obtained from a client who is intellectually competent to understand the outcome of the procedure.

A female client is receiving ethylestrenol (Maxibolin), an anabolic steroid, for the treatment of the catabolic processes associated with a burn injury. The nurse should observe the client for signs of:. Virilization - Anabolic agents are synthetic androgenic steroids, which may produce
masculinizing effects in women.

Hyperglycemia- This drug will not cause hyperglycemia; it may cause hypoglycemia in clients with diabetes mellitus.

117

Hyponatremia- The client may become hypernatremic, not hyponatremic; the client may become hypercalcemic as well.

Lethargy- With an increase in muscle mass and stimulation of erythropoiesis, the client should have an increase in energy.

A 28-year-old client is admitted to the psychiatric unit of the hospital with a diagnosis of conversion disorder. The client is unable to move either leg. The nurse would expect a person with this diagnosis to:. Appear calm and composed--- The client with a conversion disorder literally converts the anxiety to the symptom. Once the symptom develops, it acts as a defense against the anxiety and the client is diagnostically almost anxiety free.
Demonstrate anxiety when discussing symptoms- This is incorrect; just the opposite is true. Exhibit free-floating anxiety- The conflict is resolved by the paralysis of the legs; therefore the anxiety is under control.

Appear greatly depressed- In a conversion disorder the reactions the nurse would expect to encounter are not in proportion to the disability; therefore the client would not be greatly depressed.

PHEOCHROMOCYTOMA

Following an adrenalectomy, prior to maintenance steroid therapy, the nurse should monitor the client for:. Hypotension------ Because of instability of the vascular system and the lability of
circulating adrenal hormones after an adrenalectomy, hypotension frequently occurs until the hormonal level is controlled by replacement therapy.

HYPERGLYCEMIA---- This is a sign of excessive adrenal hormones; after an adrenalectomy,

adrenal hormones are not secreted.

A macular rash- Measles starts with a discrete maculopapular rash on the face and spreads downward, eventually becoming confluent.

A 5-year-old child is admitted to the hospital complaining of colicky abdominal pain with guarding, nausea, anorexia, and a low-grade fever. Palpation of the RLQ elicits pain. The nurse prepares to implement care associated with: , An inflamed appendix --- These are the classic

118

signs and symptoms related to acute appendicitis.They are caused by inflammation and altered gastrointestinal functioning.

To provide preoperative teaching the nurse should know that after a client has a hysterectomy: ,
The cyclical oscillation of hormones between the hypophysis and the ovaries continues---- In a hysterectomy the uterus is removed, but no other female organs. Consequently menstruation ceases but the hypophyseal and ovarian hormone cycles continue.

Menstruation ceases and ovarian hormone secretion decreases- Removal of the uterus does not affect the secretion of ovarian hormones.

Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this complication by: . Performing in-bed exercises- Inactivity causes
venous stasis, hypercoagulability, and external pressure against the veins, all of which lead to thrombus formation; early ambulation or exercise of the lower extremities reduces the occurrence of this phenomenon.

Encouraging adequate fluids- Although this may help, the primary intervention is to provide exercise of the extremities until ambulation is permitted.

When caring for clients in the operating room, the nurse knows that the last physiologic function the client loses during the induction of an anesthetic is: , Respiratory movement- There is no respiratory
movement in stage 4 of anesthesia; before this stage, respirations are depressed but present.

corneal reflex- The corneal reflex is lost in the second phase of stage 3 of anesthesia. When counseling the client with diabetes mellitus who requests contraceptive information, it would be most therapeutic for the nurse to focus on: .. A diaphragm-

---------This is the preferred method for clients with diabetes because it has no physiologic side effects. Oral Contraceptives are contraindicated for DIABETIC women.

119

The test that the physician might perform to determine the underlying cause of uterine pain is: ..
Laparoscopy- Laparoscopy involves direct visualization of the uterus via fiberoptics. The procedure is carried out through a transabdominal stab wound.

During the insertion of a nasogastric tube, the nurse would evaluate that the client was experiencing difficulty if the client demonstrated: .. Cyanosis- If the nasogastric tube is accidently
passed into the trachea rather than the esophagus, it will occlude the airway, causing cyanosis.

Choking- Choking may occur as the tube passes through the back of the throat. Gagging- Gagging may occur as the tube passes from the nasal passage through the pharynx. Flushing- Flushing may result if the client attempts to fight the passage of the tube.

The physician orders total parenteral nutrition (TPN) 1 L q12 hours. The primary nursing responsibility should be to monitor the client's: -Administration rate-- The solution is hyperosmolar and a very concentrated source of glucose; too rapid infusion can cause a shift of fluid into the intravascular compartment, resulting in overload; an infusion device should be used as an added precaution

A client with scleroderma complains of having difficulty chewing and swallowing. When providing dietary counseling, the nurse should advise the client to: Puree all foods before eating
Scleroderma causes chronic hardening and shrinking of the connective tissues of any organ of the body including the esophagus and face; pureed foods limit the need to chew and are easier to swallow. Psyche

"I know these voices are real to you, but I want you to know that I do not hear them."--- This statement demonstrates recognition and acceptance of the client's feelings and also points out reality.

A client undergoes pituitary surgery by the transsphenoidal route. After surgery the nurse should instruct the client to avoid food such as: Celery- Because roughage such as celery can
irritate the surgical wound and lead to hemorrhage, this type of food is contraindicated in the postsurgical period of transsphenoidal surgery.

A 3-month-old infant has a ventriculoperitoneal shunt inserted. The nurse plans to: Teach
the parents the signs of increased intracranial pressure- can develop if shunt

malfunction occurs.
Observe for signs of leakage of cerebrospinal fluid- Cerebrospinal fluid would NOT drain from the incision.

120

While the nurse is assisting a client with the diagnosis of schizophrenia with morning care, the client suddenly throws off the covers and starts shouting, "My body is disintegrating; I am being pinched." The term that best describes the client's behavior is:

Depersonalization-

Depersonalization is a feeling of change or unreality about the self or the environment caused by a loss of ego boundaries and a loss of reality testing.- out-of-body experience eg. BEING

PUNISH USING A VODOO DOLL.

Paranoid ideation-(
out for unfair treatment.

HIBANG) Paranoid ideations are beliefs that the individual is being singled

Ideas of reference ( Mga ASSUMING )- Ideas of reference are false beliefs that the words and
actions of others are concerned with or are directed toward the individual.
Shuffling gait------- this is seen with basal ganglia defects.

The sickling process of the red blood cell occurs in the presence of: , Hypoxia --- Under conditions of
decreased oxygen the relatively insoluble hemoglobin S changes its molecular structure to form long, slender crystals and eventually the crescent, or sickled, shape.

Generativity vs stagnation- This stage is associated with middle adulthood. Intimacy vs isolation( ADOLESCENT)- YOUNG ADULT- The major tasks of young adulthood are
centered around human closeness and sexual fulfillment; lack of love results in isolation.

OBSTETRICS: A few hours after being admitted in active labor, a primigravida becomes very restless, flushed, and irritable and perspires profusely. The client states that she is going to vomit. The nurse suspects that these symptoms are indicative of: ,

Transition stage-(Vomitting)

The physiologic

intensification of labor occurring during transition is caused by a greater energy expenditure and increased pressure on the stomach; this results in feelings of fatigue, discouragement, and

nausea.
Second stage- This stage is from full dilation to expulsion; a heavy bloody show and pushing are evident at this time. Late stage- This is unclear terminology; it does not indicate the specific time of labor.

To determine if there is cephalopelvic disproportion the birth attendent would order a test know as: ,
X-ray examination; X-ray pelvimetry is more definitive than digital pelvimetry, but because of radiation hazards it should be limited to clients in labor in whom it is clearly essential to the outcome of pregnancy.

121

A client is admitted to the intensive care unit with a diagnosis of adult respiratory distress syndrome. When assessing this client the nurse should expect to find: ,

An altered mental

status

, This is secondary to cerebral hypoxia, which accompanies ARDS; cognition and level

of consciousness are reduced. Hypertension- Hypotension occurs because of the hypoxia of the heart. Calendar method- calculating the BEGINNING OF FIRST FERTILE PERIOD- Subtract 18 days from the length of my shortest cycle."- The fertile period is determined by subtracting 18 days from the
length of the shortest cycle to determine the first unsafe day and subtracting 11 days from the length of the longest cycle to determine the last unsafe day.

A client who is newly diagnosed with multiple myeloma asks the physician what treatment will be necessary. The nurse should expect the physician to reply: "Chemotherapy employing a combination of drugs."- This is the treatment of choice; a variety of drugs affects rapidly dividing cells at different
stages of cell division. "Human leukocyte interferon therapy."- Although this may be done, it is not the primary treatment. "Surgery to remove the lesion and lymph nodes."-- Multiple myeloma is a diffuse disorder of the bone and no single lesion can be removed. "Radiotherapy on an outpatient basis."- Although this may be used to alleviate pain and treat acute vertebral lesions, it is not the primary approach. NGT / GASTRIC GAVAGE- "The tube feedings reduce the risk of infection and allow healing."-----This permits the esophageal suture line to heal before contact with food, which may increase the risk of infection.

To plan care for a client with undifferentiated schizophrenia, the nurse should recognize that the client's delusions are a defense against underlying feelings of:

Inferiority

The delusional

system contains grandiose ideation that allows the client to feel important rather than inferior.
Aggression- These individuals are usually able to express aggressive feelings without difficulty. Persecution- Delusions of persecution are not usually present in clients with undifferentiated schizophrenia. Guilt- Although these individuals often feel guilty, feelings of inferiority, not guilt, precipitate delusions.

An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. The nurse understands that a factor of special concern when caring for the older adult client is the client's: Inability to maintain an optimal level of functioning- The onset of disabling illness will divert an aged person's energies, making it difficult to maintain an optimum level of functioning.

122

Irritability in response to deprivation- This would be an expected response. Paroxysmal nocturnal dyspnea- Dyspnea at night, which usually requires the assumption of the

orthopneic position, is a symptom of left ventricular failure; orthopnea, a compensatory mechanism, limits venous return, which decreases pulmonary congestion and promotes ventilation, easing the dyspnea.

A client with a history of severe intermittent claudication has a femoral-popliteal bypass graft. An appropriate postoperative intervention on the day after surgery would be to: Assist the client with ambulation- Mobility will reduce venous stasis and edema as well as promote arterial perfusion and healing.
Encourage the client to keep the legs elevated- This would limit arterial perfusion. Keep the client on bed rest- Bed rest is contraindicated because it promotes the development of thrombophlebitis and pulmonary emboli.

The mother of a 15-year-old female who is being treated for allergies privately tells the nurse that she thinks her daughter is becoming a hypochondriac. The nurse can be most therapeutic by: Discussing the developmental behavior of adolescents- Adolescents are very aware of their changing bodies and become especially concerned with any alteration resulting from illness or injury.

Discussing the underlying causes of hypochondriasis- This does not educate the mother about concepts concerning the developing adolescent; a discussion about hypochondriasis may reinforce the mother's concern.

A mother of three children who was abandoned by her husband shortly after the birth of her youngest daughter brings the child, now 9 months old, into the hospital with a diagnosis of failure to thrive. As the mother leaves, the nurse is not surprised to see the daughter react by: Readily allowing
the nurse to take her but remaining stiff while being held- Going to a stranger without protest usually indicates the lack of a meaningful relationship with the mother.

Clinging to the mother and expressing fear of the nurse- This is a healthy, normal reaction to strangers that is uncommon in children with nonorganic failure to thrive syndrome.

The finding that would most significantly indicate that a client is hypertensive is: A diastolic blood pressure that remains greater than 90 mm Hg- A sustained diastolic pressure exceeding 90 mm Hg reflects pathology and indicates hypertension. An extended Korotkoff's sound- This is unrelated to hypertension.

123

A systolic blood pressure ranging from 140 to 150 mm Hg- This is not the most significant indicator; an elevated diastolic pressure is more important because it reflects the pressure while the heart is at rest. The nurse understands that after starting administration of diazepam (Valium), it is important to assess for potential side effects. Initially the nurse should: Monitor the client's blood pressureHypotension is a major side effect of Valium that occurs early in therapy.
Measure the client's urinary output- An alteration in urinary output is not a common side effect, but

it may occur after prolonged use.

Check the client's pupil size every 4 hours- CNS depression is not a common side effect, but it may

occur after prolonged use.

Assess the client for abdominal distention- may occur after prolonged use.

Question: A client with a coronary occlusion is experiencing chest pain and distress. The nurse should administer oxygen to: Increase oxygen concentration to heart cells- Administration of oxygen increases the transalveolar O2 gradient, which improves the efficiency of the cardiopulmonary system. This increases the oxygen supply to the heart.
Prevent cyanosis- Pallor is usually associated with myocardial infarction.

Increase oxygen tension in the circulating blood- Although this may be true, it is not specific to heart cells, which are hypoxic when there has been a myocardial infarction. The desensitization method that has been used successfully with clients experiencing phobias focuses on: Imagery- Imagery is a therapeutic approach used to facilitate positive self-talk; mental pictures under the control of and initiated by the client may correct faulty cognitions. Role playing- This is a useful general behavioral approach but is not a specific desensitization technique. While a client is receiving magnesium sulfate for severe pregnancy-induced hypertension, a primary nursing intervention would be: Restricting visitors and keeping the room darkened and quiet-- A quiet room helps to reduce stimuli, which is essential for limiting or preventing seizures. Preparing for the possibility of a precipitate delivery- Precipitous delivery is not a usual side effect of magnesium therapy.

124

Limiting her fluid intake to 1000 ml/24 hours- The urinary output for someone receiving magnesium sulfate should be at least 100 ml in 4 hours; thus fluid would not be restricted. Use an electric razor when shaving- Suppression of bone marrow increases bleeding susceptibility associated with decreased platelets.
. The nurse is aware that in an infant of 32 weeks gestation the: Areola and nipple are barely visible-

Breast tissue is not palpable in an infant of less than 33 weeks gestation.

Square window sign shows a 0 degree angle- A 0 square window sign is present in an infant of 40 to 42 weeks gestation.

The initial medications that the nurse anticipates that the physician would order for a child admitted to the hospital with acute glomerulonephritis with hypertension would include: Reserpine and hydralazine- Reserpine and hydralazine are used to control hypertension. Furosemide and Phenobarbital- Furosemide is used as a diuretic; phenobarbital would be used only if hypertensive encephalopathy caused convulsions. Burn- respiratory obstruction-

Hoarse quality to the voice- Hoarseness is a sign of potential

respiratory insufficiency as a result of inhalation burns, which cause edema in the surrounding tissues, including the vocal cords.

A small-for-gestational-age (SGA) newborn, who has just been admitted to the nursery, has a highpitched cry, appears jittery, and has irregular respirations. The nurse is aware that these symptoms may be associated with: Hypoglycemia- SGA infants may exhibit hypoglycemia, especially during the first 2 days of life, because of depleted glycogen stores and inhibited gluconeogenesis.
Hypovolemia-(HYPO, TACHY, TACHY)- Decreased BP, pallor with cyanosis, tachycardia, retractions, lethargy, and weak cry are present in hypovolemia. The nurse is aware that the most serious complication for a client with acute renal failure is: Infection- Infection is responsible for one-third of the traumatic or surgically induced deaths of clients with renal failure, as well as for medically induced acute renal failure (ARF); resistance is reduced in clients with renal failure because of decreased phagocytosis, which makes them very susceptible to microorganisms.

Weight loss- Weight loss is not life threatening in and of itself. Anemia- Anemia occurs often with ARF, but it is not the most serious complication and should be treated in relation to the client's symptoms; erythropoietin and iron supplements are usually used.

125

CRISIS SITUATION- SUPPORT BEHAVIOR Situational crises are usually resolved in a time period of: 2 to 6 months- A situational crisis is a sudden, unexpected event with which the individual is unable to cope using past coping behaviors; this time frame provides an opportunity for the individual to learn new coping behaviors. Potassium supplements can cause gastrointestinal ulceration and bleeding. At 3 years of age, children use 3- or 4-word sentences. At 5 years of age, children ask the definitions of new words. Because of expanded experiences and developing cognitive ability, the 4-year-old should have a vocabulary of approximately 1500 words. It is hoped that reducing dietary phenylalanine will prevent brain damage. Diets are planned to attempt to maintain the serum phenylalanine level between 5 and 10 mg/100 ml. When planning for a client's return from the operating room after a subtotal thyroidectomy, the nurse should consider that in this surgery: A small part of the gland is left intact- The remaining thyroid tissue may provide enough hormone for normal function. Late 20s Parents- Alteration in role- Emotionally immature individuals are often unable to deal with the role changes associated with parenthood.

A client with preeclampsia is told that she must remain on bed rest at home. The client starts to cry and tells the nurse that she has two small children at home who need her. The nurse's best response would be: "You'll need someone to care for the children."- The therapeutic regimen includes bed rest; peace of mind can best be achieved if the children are adequately cared for.

"You are worried about how you will be able to manage."---- This explores feelings without including a therapeutic regimen.- Neutral A client who is pregnant for the first time and is carrying twins is scheduled for a cesarean delivery. Preoperative teaching should include telling the client to expect to: Be ambulating whenever desired the day after surgery- Early postoperative ambulation helps prevent many postpartal complications such as thrombophlebitis and constipation.

126

Take sponge baths until the incision is completely healed- Clients are permitted to shower after 48 hours. A pregnant client asks the nurse for information about toxoplasmosis during pregnancy. The nurse teaches the client that: Pork and beef should be properly cooked before eating-- This avoids the possibility of ingesting infected cysts. The nurse should assess a recently hospitalized client with a tentative diagnosis of opiate addiction for signs of opiate withdrawal. These signs would include: ,

Muscle aches, pupillary

constriction, yawning

, These symptoms are all associated with opiate withdrawal, which occurs

after cessation or reduction of prolonged moderate or heavy use of opiates. In the second hour after delivery a client's uterus is found to be firm, above the level of the umbilicus, and to the right of midline. The appropriate intervention would be to: Assist the client to the bathroom to empty her bladder----- A full bladder commonly elevates the uterus and displaces it to the right; even though the uterus feels firm, it may relax enough to foster bleeding; therefore, the bladder needs to be emptied to increase uterine tone.

Observe for signs of retained secundines ----- If part of the placenta, umbilical cord, or fetal membranes are not fully expelled during the third stage of labor, their retention limits uterine contraction and involution; a boggy uterus and bleeding would be evident. Tell the client that this is a sign of uterine stabilization----- This is not a sign of uterine stabilization; the uterus cannot remain contracted over a full bladder. During the physical assessment of a recently delivered newborn, the nurse palpates the infant's femoral pulses. This is done to detect the presence of:

Coarctation of the aorta-,

Coarctation of the aorta results in diminished or absent femoral pulses.

A client appears very anxious, with respirations that are shallow and very rapid (40 per minute). The client complains of feeling dizzy and light-headed and of having tingling sensations of the fingertips and around the lips. The nurse should recognize that the client's complaints are probably related to:. Hyperventilation- The client is hyperventilating and blowing off excessive carbon dioxide, which leads to these symptoms; if uninterrupted this could lead to respiratory alkalosis. Kussmaul's respirations are deep, gasping respirations associated with diabetic acidosis and coma, not hyperventilation associated with anxiety.
In metabolic acidosis, breathing is first rapid and shallow
[1]

but as acidosis

worsens, breathing gradually becomes deep, slow, labored and gasping. T

127

Biot's respiration, sometimes also called cluster respiration,

[citation needed]

is an

abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.
[1]---------

Biot's

respiration is caused by damage to the medulla oblongata due to strokes or trauma or by pressure on the medulla due to uncal ortentorial herniation.

A mother is breastfeeding her newborn. She asks when she can switch the baby to a cup. The nurse would recognize that the mother understands the teaching about feeding when she says she will start to introduce a cup when the baby is: At about 6 months of age, infants are able to swallow independently of sucking and a cup can be introduced. An elderly female who has been a widow for 20 years comes to the community health center with a vague list of complaints. Her only child, a son, died at birth. She has lived alone since her husband's death and performs all of her own daily tasks of living. She has had a very active social life in the past but has outlived many of her friends and family members. When taking this client's health history, it is important for the nurse to ask: "What unfulfilled hopes do you have?"-- The answer to this question will provide the nurse with an idea of the client's hopes and frustrations without being threatening or probing. "Do you feel all alone?"- This question is probing, disregards the client's statement, and provides little information for the nurse to use in planning care. The home care nurse supervisor makes an initial visit to a 60-year-old widowed client who has right ventricular failure. The client lives with her divorced, drug-addicted daughter and her seven grandchildren. The nurse finds the client feeding a 6-month-old granddaughter and preparing dinner for the rest of the family. A 14-year-old grandson, disabled and in a wheelchair, states his mother is sleeping. The nurse should proceed by: Questioning the client to determine whether there is a private place to take a health history and perform an examination- The medical history could be obtained during assessment, and a relationship could be established if they were uninterrupted. Sitting down with the client and exchanging identifying data and information- Agency information and data could be obtained after the assessment data had been obtained and rapport established. Asking the client whether it is all right to look around the apartment to evaluate environmental conditions- Assessment of the environment could be less obviously done while obtaining the history and physical data. A client with a history of phenylketonuria, who was maintained on a low-phenylalanine diet until 9 years of age, is now pregnant. The nurse teaches this client that: . Reinstitution of the lowphenylalanine diet will protect her baby from PKU- The fetus is at risk for retardation prenatally from a buildup of metabolites in the PKU-affected mother if a prescribed diet is not followed by the mother.

The fetus is at no risk prenatally but will require immediate care at birth to prevent PKU- The fetus is at risk for mental retardation if the maternal diet contains phenylalanine; also, the infant can inherit phenylketonuria via an autosomal-recessive gene.

128

A pregnant client is admitted to the hospital with abdominal pain and severe vaginal bleeding. After assessment, the nurse makes a nursing diagnosis of decreased cardiac output related to hemorrhage. The first nursing action should be to:. Administer oxygen- The symptoms indicate loss of blood;
to compensate for the decreased cardiac output, oxygen is needed to maintain the well-being of both the mother and fetus

Give Demerol 50 mg IM for pain- This could mask abdominal pain and sedate an already compromised fetus.

When obtaining a health history from the parents of a toddler who is admitted to the hospital with
acute lymphocytic leukemia (ALL), the nurse would be surprised if the parents report that the first sign they observed was:, Sores in the mouth are not a presenting sign but often

result from chemotherapy.

A loss of appetite- Anorexia is a presenting symptom of leukemia and may be the result of enlarged lymph nodes and areas of inflammation in the intestinal tract. TAKING-IN PHASE--------- During the taking-in phase, a woman is primarily concerned with being cared for and being cared about. Infant feeding is best taught during the taking-hold phase of postpartum adjustment. A primigravida complains of

Perineal care

morning sickness.

The nurse should plan to teach her to:.

, Fasting results in

Avoid long periods without food

hypoglycemia, which can cause nausea; in addition, the developing fetus should not be deprived of nutrients for any length of time.

Eat three small meals a day- This intake would not be sufficient to meet the normal nutritional needs

of the mother and fetus.

Increase fluid intake- Fluids need not be increased but should be consumed between meals. Increase calcium in her diet- Calcium intake will not change the nausea. A client is scheduled for a laminectomy. Preoperatively the nurse should demonstrate the: Logrolling technique- This maintains vertebral alignment, decreasing trauma to the operative site. Contour position- This is contraindicated; the contour position flexes the vertebral column. When caring for the depressed client, the nurse usually has the most difficulty dealing with the: Contagious quality of depression- Depression is contagious; it affects the nurse as well as the client. Negative nonverbal responses- These clients usually do not offer negative responses; they offer no responses

129

Client's psychomotor retardation- The client's lack of energy really does not make nursing care difficult.

When intervening in a crisis situation, the initial concern of the nurse is:

Whether the individual can go back to daily activities

The assessment of the client's present status and ability to perform ADL is the priority because it will influence the choice of an appropriate therapeutic regimen. What was the precipitating factor- Although significant, it is not the priority. How will the client deal with successive crises- The present crisis must be dealt with first. How is the individual affecting others- Concern now is for the client, not how the client's behavior affects others. Past experiences are important and must be recognized because they set the parameters for the individual's values throughout life. A client, who has participated in caring for her infant in the neonatal intensive care unit for several days in preparation for the baby's discharge, comes to the unit on the last hospital day with alcohol on her breath and slurred speech. The nurse's most appropriate action would be to: Talk with the mother about her condition and assess her willingness to participate in an alternate discharge plan- Confrontation about the active substance abuse and the mother's diminished ability
to safely care for the infant at this time is necessary to help the mother get help and to also protect the baby.

Continue with the discharge procedure, alerting the home health nurse that immediate follow-up is needed for the mother- This would be unsafe; the mother may not be capable of caring for the infant. Speak to the mother about her condition and have her see a social worker about the baby's discharge to a foster home- Decisions should not be made without input from the mother. Cutting the left phrenic nerve results in:- Paralysis of the left side of the diaphragm- The phrenic nerves conduct motor impulses to the diaphragm; cutting one phrenic nerve will paralyze the portion of the diaphragm innervated by that nerve. A 7-year-old is brought to the clinic by her mother who tells the nurse that her child has been having trouble in school, has difficulty concentrating, and is falling behind in her school work since she and her husband separated 6 months ago. The mother reports that lately her daughter has not been eating her dinner and she often hears her crying in her room. The nurse realizes that the child: Probably blames herself for her parents' breakup- Children usually blame themselves for their parents' marital problems, believing that they are the reason one parent leaves. Is working through her feelings of loss- The child's response is not typical of grief work.

130

Feels different from her classmates- No data are presented to lead to this conclusion.

The position a client should be taught to avoid when she experiences back pain during labor is the: Supine position- Low back pain is aggravated when the client is in the supine position because of increased pressure from the fetus as the head rotates.

Sitting position ------ This position relieves back pain.Knee-chest position- The knee-chest position is not used in labor except in an emergency situation such as cord prolapse. Side-lying position -- This position relieves back pain. LIVER DISEASE- ALSO PRONE TO HYPOGLYCEMIA.- The client with liver disease has a decreased ability to metabolize CHO because of a decreased ability to form glycogen (glycogenesis) and to form glucose from glycogen (glycogenolysis). A client with Hodgkin's disease enters a remission period and remains symptom-free for 6 months, when a relapse occurs. The client is diagnosed at stage IV. The therapy option the nurse should expect to be implemented at this time is: , A protocol consisting of three or four chemotherapeutic agents that attack the dividing cells at various phases of development is the therapy of choice at this stage; alternating courses of different protocols may be used.

Combination chemotherapy-

Surgical removal of the affected nodes- This is not a therapy for Hodgkin's disease at any stage; nodes may be removed for biopsy; nodes may be irradiated as part of therapy. Radiation with chemotherapy- This is recommended for use in stage IIIA. Radiation therapy- Radiation, alone or in combination with chemotherapy, is used in stages IA, IB, IIA, IIB, and IIIA. The night nurse reports that a young client with paranoid schizophrenia has been awake for several nights. The day nurse reviews the chart and finds this client did not have an interrupted sleeppattern disorder prior to a transfer from a private to a four-bed room 3 days ago. The nurse recognizes that a cause of the client's sleeplessness might be related to: Fear of the other clients-

Since the client has paranoid feelings that other people are out to do harm, assignment to a four-bed room would be very threatening.

Watching for an opportunity to escape- This is possible but unlikely; planning an escape is not usually part of the schizophrenic pattern of behavior Trying to work out emotional problems- This is possible but not likely; clients with schizophrenia have difficulty working out problems. Infants receive immunizations made up of attenuated viruses. This means that these immunizations:-------- Cause the development of active antibodies-------- An attenuated virus is an inactivated antigen that causes a protective active response in the individual (the development of antibodies). The is especially conducive to therapy, since it:- Creates a new learning environment- The group setting provides the individual with the opportunity to learn that others

group setting

131

share the same problems and needs. The group also provides an arena where new, healthier methods of relating to others can be tried.

Fosters one-to-one relationships- Groups promote interaction among many people, rather than oneto-one relationships. Decreases the focus on the individual- The focus is still on the individual but more on the individual's learning how to relate to others The nurse understands that when a child with Duchenne's muscular dystrophy reaches adolescence, additional problems will probably develop with the: Cardiopulmonary systemMuscular degeneration is advanced in the adolescent; the disease process involves the diaphragm, auxiliary muscles of respiration, and the heart, resulting in life-threatening respiratory infections and heart failure. Neurologic system- Central nervous system functioning is not affected by Duchenne's muscular dystrophy.. Musculoskeletal system - Although the musculoskeletal system will exhibit marked degeneration, it is second in priority to the cardiopulmonary changes. Two umbilical arteries arise from the fetus and go to the placenta, where waste products are exchanged for oxygen and nutrients and then returned via one umbilical vein to the baby. Feelings of self-effacement are best demonstrated by a client's:- "No one listens to me" attitude- This attitude conveys to others that the client feels too insignificant for anyone to listen. Quiet and monotonous voice- This is indicative of feelings of sadness, not self-effacement. A client's respiratory status necessitates endotracheal intubation and positive pressure ventilation. The most immediate nursing intervention for this client at this time would be to: Assess the client's response to the equipment- Nothing is achieved if the equipment is working and the client is not responding.
Prepare the client for emergency surgery- This is presumptive; the data base is incomplete for the assessment that surgery is necessary.

If the physician plans to do a vaginal examination on a client with a placenta

previa, the nurse should have available: , Two units of typed and cross-

matched blood-

A vaginal examination may result in a sudden, severe hemorrhage because of the location of the placenta near the cervical os; whole blood should be ready for administration to prevent shock.

Vitamin K for intramuscular injection- Adults manufacture their own vitamin K, and an injection

would not help to prevent bleeding from the placenta.

132

 Myasthenia gravis- The drug should be taken as ordered, usually before meals, to limit dysphagia
and possible aspiration.

Laboratory studies reveal that a pregnant client's blood type is O and she is Rh positive. Problems related to incompatibility may develop in her infant if the infant is: Type A or B---- An A, B, O incompatibility may develop even in first-born infants under these conditions. The mother has antibodies against the antigens of the A and B blood cells. These antibodies are transferred across the placenta and produce hemolysis of the fetal RBCs. The infant is AB and an incompatibility may also occur.

Rh negative- No problems will occur if the mother is Rh positive and the baby is Rh negative; only the other way around. MOTHER BABY Rh ( )

Rh (+)- BAWAL

Rh(+) Rh(-), Rh (+)-PAREHAS NA PWEDE Delivered preterm - A preterm delivery will not produce an incompatibility; it may intensify problems if an incompatibility exists. Type O AB -----Ang pwede A O AB

A mother whose child has glomerulonephritis is fearful that her other child may get the disease. To allay the fears of the mother, the nurse should tell her that: ,, "Acute glomerulonephritis is
caused by an antigen-antibody response secondary to group A beta-hemolytic streptococcus."----PARANG KATULAD NG RHEUMATIC FEVER.

"Acute glomerulonephritis is caused by an antigen-antibody response secondary to group A beta-hemolytic streptococcus." After a thoracentesis for pleural effusion a client returns to the physician's office for a follow-up visit. The nurse would suspect a recurrence of pleural effusion when the client says: . "I get a sharp, stabbing pain when I take a deep breath."- Tension is placed on the pleura at the height of inspiration and causes pain. "Lately I can only breathe well if I sit up."- This is typical of congestive heart failure. "I'm coughing up larger amounts of thicker mucus for the last 2 days."- This may indicate
pulmonary infection.

133

Streptococcal infection within the last 2 weeks in view of the smoky urine and the other symptoms, the nurse may suspect glomerulonephritis, which usually occurs after a recent streptococcal infection. To foster sound interpersonal relationships during an nurse should assume the role of:

initial meeting

with a family, the

Stranger-, The role of stranger is the initial

role in any relationship.

Counselor- If the nurse moves in too quickly, future relationships may be severely hampered Surrogate- If the nurse moves in too quickly, future relationships may be severely hampered Teacher- Teacher- If the nurse moves in too quickly, future relationships may be severely hampered

During labor a client has an internal fetal monitor applied. The nurse should be concerned about a fetal heart rate that: Occasionally dropped to 90 beats unrelated to contraction.s This fetal heart pattern is known as type III dip, or deceleration; it indicates cord compression that may lead to fetal hypoxia.

Beat-to-beat variability indicates a fetus with no nervous system depression and warrants no concern.
Varied from 130 to 140 beats per minute-

A client is placed on progesterone oral contraceptives (minipills) and is instructed by the nurse to take 1 pill daily: , Throughout the menstrual cycle----Maintenance of serum progesterone levels keeps cervical mucus thick and hostile to sperm at all times.

Throughout the first 21 days of the menstrual cycle-

Combined estrogen and

progesterone oral contraceptives are taken during the second, third, and fourth weeks
of the cycle.

During the first 5 days of the menstrual cycle-

Fertility drugs are often taken during

not contraception.

the first part of the cycle to encourage ovulation,

134

During the 5 days surrounding ovulation-

Progesterone-only pills do not

interfere with ovulation.

Estrogen Suppress Ovulation.

Clomid contains an ingredient called clomifene citrate. This is an anti oestrogen drug- Ovarian Stimulant.

A client visits her gynecologist to confirm a suspected pregnancy. During the nursing history the client states that her last menstrual period began on April 11. The client states that some spotting occurred on May 8. The nurse calculates that the client's due date is: January 18- Using Nagele's rule, subtract 3 months and add 7 days to the first day of the last menstrual period, April 11.--------wlang babaguhin kahit may spotting nung May 8 A 54-year-old client has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After being found disoriented and seminaked walking down a street, the client is admitted to the hospital, and a diagnosis of Alzheimer's disease is made. The client expresses fear and anxiety. Considering the client's diagnosis, the best approach would be for the nurse to: , Reassure the client by the frequent presence of staff- The client needs constant reassurance because forgetfulness blocks previous explanations; frequent presence of staff serves as a continual reminder.

Initiate a program of planned interaction and activity- The client needs continual reassurance and would not remember times for planned interactions or activities. Making babbling sounds- Babbling is normal communication for an 8-month-old infant, even one with a moderate hearing loss. 18 mos. - Using at least six words- A vocabulary consisting of a minimum of 6 words with
telegraphic-type speech is normal for a child this age.

After a client has a total gastrectomy, the nurse should plan to include in the discharge teaching the need for: Weekly injections of vitamin B12- Intrinsic factor is lost with removal of
the stomach, and vitamin B12 is needed to maintain the hemoglobin level.

Regular daily use of a stool softener- Adequate diet, fluid intake, and exercise should prevent constipation.

135

FOR GENTAMICIN UNDER IVPB, MEASURING PEAK LEVEL------ Between 30 to 60 minutes after the IVPB- Because the drug was just administered, the blood level of the drug would be at its highest level.

Auditory- Most hallucinating clients hear voices without external stimuli. A client with pain and paresis of the left leg is scheduled for an electromyography.

Before the test, the nurse should explain that: Needles will be inserted into the affected muscles during the test- This is done to assess electrical activity and determine whether
symptoms are primarily musculoskeletal or neurologic.
The client will be kept in a recumbent position after the procedure- No special care is required after the procedure. The client's heart rate and rhythm will be frequently monitored- No special care is required during the procedure.

When planning care for a client who has abused multiple drugs and has completed the withdrawal period, the nurse should take into consideration that the client is probably: Unable to delay gratification- The addict is unable to delay gratification because of inadequate ego strengths. The addict is concerned with the present and the self.
Unable to give up drugs ----- It is possible, although not easy, but it does require a change in attitude and a deconditioning process. Unconcerned with reality- Drug users are concerned with reality; their drug use is an attempt to blur the pains of reality.

In addition to raising the head of the bed of an infant who has had a surgical repair of a diaphragmatic hernia, the nurse should place the infant in the: Side-lying position on the operative side- Placing the infant on the operative side promotes gas exchange in the unimpaired lung.

Supine position with the knees flexed- This would not maximally promote aeration of the unaffected lung.

A 15-year-old high school student with hay fever has been taking a prescribed long- acting antihistamine/decongestant q8h for the past 3 days. The adolescent tells the nurse, "This

136

medication is making me sleepy. Can you change it to something else?" The nurse's best response would be: "The drowsiness will usually diminish after a few days."- This reply addresses the client's concern; CNS depressant effects may diminish or spontaneously disappear after several days.
"I'll ask the physician to change you to a medication containing ephedrine."- This is unnecessary because the side effect of drowsiness should diminish in several days; the client needs teaching about the drug. A transient ischemic attack (abbreviated as TIA, often colloquially referred to as mini

stroke)

is a change in the blood supply to a particular area of

the brain, resulting in

brief neurologic dysfunction that persists, by definition, for

less than 24 hours. If symptoms persist longer, then it is categorized as a stroke. A client has a history of progressive carotid and cerebral atherosclerosis and transient ischemic attacks (TIAs). The nurse understands that TIAs are: Temporary episodes of neurologic

dysfunction- Narrowing of arteries supplying the brain causes temporary neurologic deficits that last for a short period; between attacks the neurologic examination is normal.

Transient attacks caused by multiple small emboli- Emboli result in a CVA; the damage is
usually permanent.

Ischemic attacks that result in progressive neurologic deterioration --This occurs with multiple small cerebrovascular accidents; TIAs do not result in permanent damage. Periods of alternating exacerbations and remissions- This is not the description of a TIA;
remissions and exacerbations occur with progressive degenerative neurologic disorders.- Eg. Parkinsons

Thromboangiitis obliterans (also known as Buerger's disease)

is a recurring progressiveinflammation and thrombosis (clotting) of small and medium arteries and veins of the hands and feet. It is strongly associated with [1] use of tobacco products, primarily from smoking, but also from smokeless tobacco.

TAO/BUERGER- MNEMONIC- ANG BURGER AY KINAKAIN NG TAO If the client exhibits emotional instability, it is usually caused by lesions affecting the thalamic area in the part of the neural system most responsible for emotions.

Before a prescribed intravenous solution that contains potassium chloride is administered, the assessment by the nurse that should be brought to the physician's attention would be: . A

137

urinary output of 200 ml during the previous shift- A decreased urinary output will result in the

retention of potassium, causing hyperkalemia.

Behaviors indicating irritability and confusion-Reporting this is unnecessary; these indicate

dehydration, which is probably the rationale for the fluid ordered. Poor skin turgor with "tenting"- Reporting this is unnecessary; this is a sign of dehydration, which can be corrected with appropriate hydration.

A female client confides to the nurse that she has been thinking about suicide.

The nurse recognizes that the client: Is fearful of her own impulses and is seeking protection from them- Clients frequently report suicidal feelings so the staff will have the chance to stop them. They are really asking, "Do you care enough to stop me?"
Feels safe and can share her feelings with the nurse- This may be true but, more importantly,

the client is seeking help and protection.

The diaphragm should remain in place for at least 6 hours after intercourse; if coitus occurs within those 6 hours, additional spermicide should be added and the 6 hour time frame begins again.

A male client with thrombophlebitis is apprehensive about the possibility of a clot

reaching his heart and causing sudden death. The nurse's initial intervention should be to: Clarify his misconception- The client's misconception that the clot can cause sudden death when it reaches the heart must be corrected first; this may reduce the apprehension.

Encourage discussion of his concern- Once the client's understanding is corrected, this may or may not be necessary. SAUNDERS
The typical signs and symptoms of CRF include proteinuria or hematuria, not glycosuria. The nurse would observe anorexia and nausea in this client, not polyphagia.

BUN and creatinine are the byproducts of protein metabolism , so monitoring protein intake is
important, with care taken to include proteins of high biological value. The sounds that the nurse hears are bronchial breath sounds. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and a distinct pause can be heard between the inspiration and expiration phases. Bronchial breath sounds normally are heard only over the

trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When heard in these areas, they indicate abnormal

138

sound transmission because of consolidation of lung tissue, as in a lung mass, atelectasis, or pneumonia. A pleural friction rub is a superficial, low-pitched, coarse rubbing or grating sound that sounds like two rough surfaces rubbing together and is heard in the client with pleurisy. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low-pitched and resemble a sighing or gentle rustling. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at T4 medial to the scapula posteriorly. These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity. A pericardial friction rub is heard when inflammation of the pericardial sac is present, during the inflammatory phase of pericarditis. Chest pain that worsens on inspiration is characteristic of both pericarditis and pleurisy. Anterior chest pain may be experienced with angina pectoris and myocardial infarction. Weakness and irritability are nonspecific complaints and could accompany a wide variety of disorders. Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. PVCs are abnormal ectopic beats originating in the ventricles. They are characterized by an absence of P waves, presence of wide and bizarre QRS complexes, and a compensatory

pause that follows the ectopy.

Brown-Squard syndrome results from hemisection of the spinal cord, resulting in ipsilateral
paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation is lost because these fibers decussate after entering the cord

Peritoneal dialysis may be the treatment option of choice for clients with severe cardiovascular disease. , Contraindications to peritoneal dialysis include diseases of the abdomen such as ruptured diverticula or malignancies; extensive abdominal surgeries; history of peritonitis; obesity; and a history of back problems, which could be aggravated by the fluid weight of the dialysate
PD is used as an alternative to hemodialysis, s a treatment for patients with severe chronic kidney disease.

Hemodialysis- Renal failure/ kidney-

pulsus paradoxus (PP), also paradoxic pulse or paradoxical pulse, is an exaggeration of the normal variation during the inspiratory phase of respiration, in which the blood pressure declines as one inhales and increases as one exhales. It is a sign that is indicative of several conditions including cardiac

139

tamponade, pericarditis, chronic sleep disease (e.g. asthma, COPD).

apnea,croup,

and obstructive

lung

Assessment findings with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention, and a falling blood pressure (BP), accompanied by pulsus paradoxus (a drop in inspiratory BP by greater than 10 mm Hg). HYPERTHYROIDISM ( CUSHINGS)----- WT. LOSS------- HYPOKALEMIA Hypokalemia is a common characteristic of Cushings syndrome, and the client is instructed to consume foods high in potassium. Clients with this condition experience activity intolerance, osteoporosis, and frequent bruising. Fluid volume excess results from water and sodium retention.-kaya meron ankle swelling. Hyperglycemia is caused by an increased cortisol secretion.

WBC COUNT- LEFT SHIFT- immature neutrophils, or an increased number of bands. This
signals the presence of an acute infectious process. NEUTROPHILS RIGHT SHIFT MATURE

Chemical exposure is associated with cancer of the pancreas. The umbilicus should be in the midline, with a concave appearance. The presence of pulsation between the umbilicus and the pubis could indicate an abdominal aortic aneurysm and should be reported to the physician. Bowel sounds vary according to the timing of the last meal and usually range in frequency from 5 to 35 per minute. Bruits normally are not present. The client with heart failure may present with different symptoms according to whether the right or the left side of the heart is failing. Peripheral edema, jugular vein distention, and hepatojugular reflux all are indicators of impaired right-sided heart function. Breath sounds are an accurate indicator of left-sided heart function. PULMONARY CONTUSION- IS ONLY A BLUNT TRAUMA- LESS PRIORITY IN PULMNONARY EMBOLISM PRIORITY IN PULMONARY EMBOLISM IS STILL BEDRIDDEN PATIENT. Acetaminophen is a potentially hepatotoxic medication.

DIABETES- CATARACT- A,B, c, d.

number of pack-years, which is the standard method of documenting

smoking history.
140

Urge incontinence occurs when the client experiences involuntary loss of urine soon after experiencing urgency. Reflex incontinence occurs when incontinence occurs at rather predictable times that correspond to when a certain bladder volume is attained. Stress incontinence occurs when the client voids in increments of less than 50 mL under conditions of increased abdominal pressure. Total incontinence occurs when loss of urine is unpredictable and continuous. Clients with Guillain-Barr syndrome have dysphagia-due to Clients with dysphagia are more likely to aspirate clear liquids Because clients with Guillain-Barr syndrome are at risk for bradycardia, and respiratory depression, frequent monitoring of ROM exercises can help prevent contractures, and assessing calf deep vein thrombosis, for which these clients are at risk. progressive muscle weakness. than thick or semisolid foods. hypotension or hypertension, vital signs is required. Passive measurements can help detect

Tissue hypertrophy (lipodystrophy) involves thickening of the subcutaneous tissue at the injection sites. Intravenous nitroprusside is a potent vasodilator that reduces preload and afterload. It is the medication of choice for the client with pulmonary edema. Digoxin is a cardiac glycoside that increases cardiac contractility. Morphine sulfate is an opioid analgesic. Furosemide is a loop diuretic and can reduce preload by enhancing the renal excretion of sodium and water, which reduces circulating blood volume. Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the clients legs increases venous return to the heart, increasing cardiac workload. The supine position increases respiratory effort and decreases oxygenation. This increases cardiac workload. Seasonings may be high in sodium. The classic rash of erythema infectiosum, or fifth disease, affects the face. The discrete rosepink maculopapular rash is the rash of exanthema subitum (roseola). The highly pruritic, profuse macule-to-papule rash is the rash of varicella (chickenpox). The discrete pinkish red maculopapular rash is the rash of rubella (German measles). Hyperpyrexia with body temperatures up to 107 F may be present in Nueroleptic Malignant Syndrome. Signs and symptoms develop suddenly and may include respiratory distress and muscle rigidity. As the condition progresses, evidence of tachycardia, hypertension, increasing respiratory distress, confusion, and delirium may appear. The frequency and severity of symptoms are compounded when two or more antipsychotics are taken concomitantly. A

subdural hematoma -BRAIN can cause pressure on a specific area of

the cerebral tissue. Especially if the infant is actively bleeding, such pressure can cause changes in the stimuli responses in the extremities on the opposite side of the body
Because the client has had epidural anesthesia and is anesthetized, she cannot feel pain, pressure, or a tearing sensation. Changes in vital signs indicate hypovolemia in the

141

anesthetized postpartum woman with vulvar hematoma. Option 2 (heavy bruising) may be visualized, but vital sign changes indicate hematoma caused by blood collection in the perineal tissues.

An increase in the rate of respirations and a decrease in the depth of respirations together indicate a deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present with some but not all clients. A hyperinflated chest
(barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.

NG tubes are discontinued when normal function returns to the GI tract.

The tube will

be removed before GI healing. Food

would not be administered unless bowel function returns. Although the physician determines when the NG tube will be removed, option 4 does not determine effectiveness of teaching. MASTITIS In most cases, the mother can continue to breast-feed with both breasts. If the affected breast is too sore, the mother can pump the breast gently. Regular emptying of the breast is important to prevent abscess formation. Antibiotic therapy assists in resolving the mastitis within 24 to 48 hours. Additional supportive measures include ice packs, breast supports, and analgesics.

With a uric acid stone, the client should limit intake of foods high in purines.

Organ

meats, sardines, herring, and other high-purine foods are eliminated from the diet. Intake of
foods with moderate levels of purines, such as red and white meats and some seafood, also is limited. Options MILK and CHOCOLATE are recommended dietary changes for calculi composed of calcium phosphate and calcium oxalate, respectively. Cranberry juice commonly is recommended to help lower the pH of urine, rendering it more acid to prevent the development of urinary tract infections. However, uric acid stones form most readily in acid urine, and cranberry juice would therefore be contraindicated in this client with uric acid stone formation. THYROIDECTOMY

Any postoperative tingling in the fingers, toes, and lips probably is due to injury

to the parathyroid gland during surgery, resulting in hypocalcemia. These signs and symptoms need to be reported immediately.

After a clients fall, the nurse must frequently reassess the client, because potential complications do not always appear immediately after the fall. Generally, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent

142

The normal magnesium level is 1.6 to 2.6 mg/dL. Common food sources of magnesium include avocado, canned white tuna, cauliflower, green leafy vegetables such as spinach and broccoli, milk, oatmeal, peanut butter, peas, pork, beef, chicken, potatoes, raisins, and yogurt. Bacon is high in sodium. Oranges are high in potassium. The normal therapeutic range for digoxin is 0.5 to 2.0 ng/m In the test result for glycosylated hemoglobin A1c, 7% or less indicates good control, 7% to 8% indicates fair control, and 8% or higher indicates poor control. Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding and custard, soups that are strained, and strained vegetable juice A clear liquid diet consists of foods that are relatively transparent to light and are clear and liquid at room and body temperature. These foods include items such as water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, Popsicles, and regular or decaffeinated coffee or tea. A total nutrient admixture (TNA) is a solution that combines dextrose, amino acids, and lipids in one solution. A

1.2-m filter

or larger filter should be used because the lipid

particles are too large to pass through a smaller (0.22- or 0.10-m) filter. A 0.22-m filter is used for 2-in-1 solutions containing only dextrose and amino acids. A 0.10-m filter is smaller than a 1.2-m filter. Administering the solution without using a filter is not an appropriate action.

FAT EMULSION (LIPIDS) FLOATING FAT ON TOP OF SOLUTION- OBATAIN A DIFFERENT BOTTLE- PALITAN AGAD CHANGING TPN TUBE

The client should be asked to perform the Valsalva maneuver during tubing changes. This helps avoid air embolism during tubing changes. The nurse asks the client to take a deep breath, hold it, and bear down. If the IV line is on the right, the client turns his or her head to the left. This position will increase intrathoracic pressure. TPN DISCONNECTED TUBING POSSIBLE FOR AIR EMBOLISMLEFT SIDE LYING, HEAD LOWER THAN THE FEET When the client who is receiving PN spikes a temperature, a catheter-related infection should be suspected. The solution and tubing should be changed, and the discontinued materials should be cultured for infectious organisms.

143

The solution containing the highest amount of glucose should be hung until the new PN solution becomes available. Because PN solutions contain high glucose concentrations, the 10% dextrose in water solution is the best of the choices presented. The solution selected should be one that minimizes the risk of hypoglycemia. Options 1, 3, and 4 will not be as effective in minimizing the risk of hypoglycemia. P.2036 The appropriate action by the nurse is to replace the tubing. A 0.22-m filter is appropriate for the administration of PN, but fat emulsion should be administered without a filter. If fat emulsion is mixed into the PN solution, then a 1.2-m or larger filter should be used to allow the fat emulsion to pass through. The pulse and blood pressure are important parameters to assess, but they do not relate specifically to the effects of PN. PICC ( PERIPHERALLY INSRTED CENTRAL CATHETER) The client should be taught that only activity restrictions apply with this type of catheter. The client should protect the site during bathing and should carry or wear a MedicAlert identification. The client should have a repair kit in the home for use as needed because the catheter is for long-term use. An adhesive bandage may be used to cover the site once hemostasis has occurred. Before beginning administration of IV solution, the nurse should assess whether the chest radiograph reveals that the central catheter is in the proper place. This is necessary to prevent infusion of IV fluid into pulmonary or subcutaneous tissues. The other options represent items that are useful for the nurse to be aware of in the general care of this client, but they do not relate to this procedure.- FOR CENTRAL VENOUS CATHETER. If the IV is scheduled to run over 8 hours, then the hourly rate is 125 mL/hr. Using 500 mL as the reference point, the next hourly marking would be at 375 mL, which is 125 mL less than 500. Blood banks do not provide extra screening on request. If several units of blood are to be administered, a blood warmer should be used. Rapid transfusion of cool blood places the client at risk for cardiac dysrhythmias. To prevent this, the nurse warms the blood as needed, using a blood-warming device. Pulse oximetry and cardiac monitoring equipment are useful for the early assessment of complications but do not reduce the occurrence of cardiac dysrhythmias. Electronic infusion devices are not helpful in this case because the infusion must be rapid, and infusion devices generally are used to control the flow rate. In addition, not all infusion devices are made to handle blood or blood products.
The tubing used for blood administration has an in-line filter. The filter helps ensure that any particles larger than the size of the filter are caught in the filter and are not infused into the

minor

144

client. The tubing should be macrodrip, not microdrip, to allow blood to flow freely through the drip chamber. An air vent is unnecessary because the blood bag is not made of glass. Option 4 is incorrect and, in addition, blood does not need to be protected from light.

If the client has a temperature higher than 100 F, the unit of blood should not be hung until the physician is notified and has the opportunity to give further orders. The physician likely will prescribe that the blood be administered regardless of the temperature, but the decision is not within the nurses scope of practice to make. Blood must be hung as soon as possible (within 30 minutes) after obtaining it from the blood bank. After that time, the blood temperature will be higher than 50 F and could be unsafe for use Two registered nurses (RNs) or one RN and a licensed practical nurse (LPN) (depending on agency policy) must check the label on the blood product together against the clients identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag and thereby minimizes the risk of harm or injury to the client. A blood bank technician will verify data with the nurse when the blood is obtained from the blood bank, but will not verify information on the nursing unit or at the clients bedside. A change in vital signs during the transfusion from baseline may indicate that a transfusion reaction is occurring. This is why the nurse assesses vital signs before the procedure and again after the first 15 minutes. The other options do not identify assessments that are required just before beginning a transfusion The nurse must remain with the client for the first 15 minutes of a transfusion, which is usually when a transfusion reaction may occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other assigned clients during this time. Sodium chloride 0.9% (normal saline) is a standard isotonic solution used to precede and follow infusion of blood products. Dextrose is not used because it could result in clumping and subsequent hemolysis of red blood cells. Lactated Ringers is not the solution of choice with this procedure. Meningitis is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis (TB). When appropriate, a mask must be worn by the client and not the staff when the client leaves the room. The nurse should instruct the nursing assistant to assess restraints and skin integrity every 30 minutes. Vest Restraint- q 2 hrs.

145

If a poisoning occurs, the Poison Control Center should be contacted immediately. Vomiting should not be induced if the victim is unconscious or if the substance ingested is a strong corrosive or petroleum product. Anthrax is caused by Bacillus anthracis and can be contracted through the digestive system, abrasions in the skin, or inhaled through the lungs. It cannot be spread from person to person or animal to person and it is not contracted via bites from ticks or deer flies. 3- yr old- Between umbilicus & xiphoid process (below the tip of the xiphoid process) In a child between the ages of 1 and 8 years, 12 to 20 breaths per minute are delivered.

In an infant, the rate of chest compressions is at least 100 times per minute. PACU- q 15 PACU TRANSFERRED TO SURGICAL UNIT= ASSESS AIRWAY PATENCY LAPARASCOPIC CHOLECYSTECTOMY- The type of planning and instruction required varies with each individual and the type of surgery. Specific instructions that the client needs to receive before discharge should include wound care, activity restrictions, dietary instructions, postoperative medication instructions, personal hygiene, and follow-up appointments. Deepbreathing exercises are taught in the preoperative period.- LEAST APPROPRIATE IN THE POSTOP CARE Wound dehiscence is the separation of the wound edges. Wound evisceration is protrusion of the internal organs through an incision. If wound dehiscence or evisceration occurs, the surgeon is notified immediately. The client is placed in a low-Fowlers position, kept quiet, and instructed not to cough. Protruding organs are covered with a sterile saline dressing. Ice is not applied because of its vasoconstrictive effect. The treatment for evisceration is immediate wound closure under local or general anesthesia. The nurse also documents the findings and actions taken. The amputated limb is supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the amputated limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques An obturator and a Kelly clamp are kept at the bedside of a client with a tracheostomy. Dislodged tracheostomy tube- If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway

146

Blood pumped by the embryos heart leaves the embryo through two umbilical arteries. Once oxygenated, the blood then is returned by one umbilical vein. Arteries carry deoxygenated blood and waste products from the fetus, and veins carry oxygenated blood and provide oxygen and nutrients to the fetus. The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/min in the first trimester but slows with fetal growth to 120 to 160 beats/min near or at term. At or near term, if the fetal heart rate is less than 120 or more than 160 beats/min with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse should notify the physician The normal duration of the menstrual cycle is about 28 days, although it may range from 20 to 45 days. Significant deviations from the 28-day cycle may be associated with reduced fertility. The first day of the menstrual period is counted as day 1 of the womans cycle. The tubal isthmus remains contracted until 3 days after conception to allow the fertilized ovum to develop within the tube. This initial growth of the fertilized ovum promotes its normal implantation in the fundal portion of the uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone secreted by the corpus luteum of the ovary, adrenal glands, and placenta during pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by the anterior pituitary gland. The survival of the fertilized ovum does not depend on it staying in the fallopian tubes for 3 days. The placenta provides an exchange of oxygen, nutrients, and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, drugs, antibodies, and viruses can pass through the placenta. Ballottement is a technique of palpating a floating structure by bouncing it gently and feeling it rebound. In the technique used to palpate the fetus, the examiner places a finger in the vagina and taps gently upward, causing the fetus to rise. The fetus then sinks, and the examiner feels a gentle tap on the finger. Quickening is fetal movement and may occur as early as the 16 to 20 week of gestation. The expectant mother first notices subtle fetal movements during this time, which gradually increase in intensity. TWINS ARE COUNTED AS 1 IN GRAVIDA- ONE TIME LNG IPINABUBUNTIS ANG TWINS. Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy,

147

NON-STRESS TEST AY PARANG ULTRASOUND The nonstress test takes about 20 to 30 minutes. The test is termed nonstress because it consists of monitoring only; the fetus is not challenged or stressed by uterine contractions (medication is not given) to obtain the necessary data. The test is noninvasive (an informed consent is not required), and an ultrasound transducer that records fetal heart activity is secured over the maternal abdomen, where the fetal heart is heard most clearly. A tocotransducer that detects uterine activity and fetal movement also is secured to the maternal abdomen. Fetal heart activity and movements are recorded. More than one medication may be used to prevent the growth of resistant organisms in the pregnant client with tuberculosis. Treatment must continue for a prolonged period of time. The preferred treatment for the pregnant client is isoniazid (INH) plus rifampin (Rifadin) daily for a total of 9 months. Ethambutol is added initially if medication resistance is suspected. Pyridoxine (Vitamin B6) often is administered with isoniazid to prevent fetal neurotoxicity. It is not necessary for the client to stay at home during treatment and therapeutic abortion is not required. The three classic signs of preeclampsia are hypertension, generalized edema, and proteinuria. A low-grade fever, increased pulse rate, or increased respiratory rate is not associated with preeclampsia.

(P-G-H)

The FHR is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things to check after an amniotomy. Once the membranes are ruptured, minimal vaginal examinations will be done because of the risk of infection.

Effleurage

is a specific type of cutaneous stimulation involving light stroking of the

abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus
The second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes; some agency protocols
recommend assessment

after each contraction

Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. TYPE OF ACCELERATION and FREQUENCY OF CONTRACTION are important to assess, but not as the first priority. Fetal heart rate is

148

evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is not necessary following this procedure. The fetal heart rate, however, needs to be monitored frequently. Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood. Option 1 is incorrect because the IV infusion should be increased to increase the maternal blood volume. Option 2 is incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and improve fetal perfusion. Option 3 is incorrect because the oxytocin stimulation of the uterus is discontinued if fetal heart rate patterns change for any reason. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the third trimester until a diagnosis is made and placenta previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The hemoglobin and hematocrit levels are monitored, and external electronic fetal heart rate monitoring is initiated. Electronic fetal monitoring (external) is crucial in evaluating the status of the fetus that is at risk for severe hypoxia. Hypotonic labor contractions are short, irregular, and weak and usually occur during the active phase of labor. Hypertonic dystocia usually occurs during the latent phase of labor and contractions would be painful, frequent, and usually uncoordinated. Precipitous labor is that which lasts in its entirety for 3 hours or less. Preterm labor is the onset of labor after 20 weeks of gestation and before the thirty-seventh week of gestation. During a precipitous birth, when the infants head crowns, the nurse instructs the client to breathe rapidly( PANTING) to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the mother and to the fetus. PANT-BLOW----DONE ON 2ND STAGE OF LABOR Women who have experienced precipitous labor and delivery often describe feelings of disbelief that their labor has progressed so rapidly. To assist the client to process what has happened, the best option is to support the client in her reaction to the newborn infant. HYPERTONIC LABOR- PRIORITY-------PAIN RELIEF MEASURES. NO NEED TO MONITOR FOR OXYTOCIN(CONTRACTION INTENSITY)- DAHIL HYPERTONIC NA ITO DAPAT EH HYPOTONIC.

149

Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic dysfunction; however, these treatments may be used in clients with hypotonic dysfunction. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes but would be encouraged to rest. HYPOTONIC CONTRACTION-----MONITOR CONTRACTION INTENSITY FUNDAL ASSESSMENT FOR POST-PARTUMEMPTY THE BLADDER Before starting the fundal assessment, the nurse should ask the client to empty her bladder so that an accurate assessment can be done. When the nurse is performing fundal assessment, the nurse asks the client to lie flat on her back with the knees flexed. Massaging the fundus is not appropriate unless the fundus is boggy or soft, and then it should be massaged gently until firm. Normally, a few small clots may be found in the first 1 to 2 days after birth from pooling of the blood in the vagina. Clots larger than 1 cm are considered abnormal.

37.8C STILL NORMAL DUE TO THE DEHYDRATING EFFECT OF LABOR- MGT. ORAL FLUIDS

The clients temperature should be taken every 4 hours while she is awake. Temperatures up to 100.4 F (38.0 C) in the first 24 hours after birth often are related to the dehydrating effects of labor. The appropriate action is to increase hydration by encouraging oral fluids, which should bring the temperature to a normal reading. Although the nurse also would document the findings, the appropriate action would be to increase the hydration. Contacting the physician is not necessary. Taking the temperature in another 15 minutes is not a necessary action. The normal amount of lochia may vary with the individual but should never exceed 4 to 8 peripads a day. The average number of peripads used is 6 per day. The Moro reflex is elicited by a loud noise such as a hand clap or slap on the mattress to startle the newborn infant. Symmetrical extension and abduction of the arms are seen, fingers fan out and form a C with the thumb and forefinger, a slight tremor may be noted, and the arms are adducted in an embracing motion and then return to a relaxed flexion state. Legs may follow a similar pattern of response. This reflex disappears at 6 months of age. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure.

Assessing skin integrity and fluid status of the newborn infant is an essential component of

phototherapy.

Contact with the newborn infant is important. Lotions are not used to minimize skin breakdown and to ensure the therapeutic effect of light exposure in subcutaneous tissue. Adequate oral fluids are essential to prevent dehydration, because diarrhea is a common side effect of therapy. In addition, safe care for the newborn infant during

150

phototherapy requires shielding the eyes with a soft eye shield to prevent retinal damage, keeping the newborns skin exposed except for a diaper, and changing the newborns position frequently.

Bathing should start at the eyes and face, usually the cleanest area Bathing should start at the eyes and face, usually the cleanest area. Next, the external ear and the area behind the ears are cleansed. The infants neck should be washed because formula, lint, or breast milk will often accumulate in the folds of the neck. Hands and arms are then washed. The infants legs are washed next and the diaper area is washed last.

Betamethasone is a corticosteroid administered to enhance fetal lung maturity.

According to Erikson, the caregiver should not try to anticipate the newborn infants needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to
signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infants signal would inhibit the development of trust and lead to mistrust of others.

According to Erikson, the child focuses on independence between ages 1 and 3 years. Gaining
independence often means that the child has to rebel against the parents wishes. Saying things like no or mine and having temper tantrums are common during this period of development. Being consistent and setting limits on the childs behavior are necessary elements.

The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths/min. The normal apical rate is 90 to 130 beats/min, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.

Informing the child of bedtime a few minutes before it is time for bed is the most

appropriate option.

Most toddlers take an afternoon nap and, until their second birthday, also may require a morning nap. Firm, consistent limits are needed for temper tantrums or when toddlers try stalling tactics. The transition point for switching to the forward-facing position is defined by the manufacturer of the convertible car safety seat but is generally at a body weight of 9 kg (20 lb) and 1 year of age. Convertible car safety seats are used until the child weighs at least 40 lb. The normal apical heart rate for a 3 year old is 80 to 120 beats/min. Because the apical rate is within the normal range, In the hospitalized preschooler, the best option is to accept regression if it occurs. Regression is most often a result of the stress of the hospitalization. Parents may be overly concerned about

151

regression and should be told that their child may continue the behavior at home. When regression does occur, the best approach is to ignore it while praising existing patterns of appropriate behavior. Calling the physician is not necessary.

In Reyes syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be in a head-elevated position to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

A tracheotomy is not performed during a seizure. An emergency cart would not be

left at the bedside but would be available in the treatment room or nearby on the nursing unit. Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child also is placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count. The newborn with spina bifida(MYELOMENINGOCELE) is at risk for infection before the closure of the sac. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure may be difficult to assess during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. A thermometer will be needed to assess temperature, but in this newborn the priority is to maintain sterile normal saline dressings over the sac. Proteinuria is not specific to hydrocephalus.

Risk for altered growth and development is a problem for the infant with myelomeningocele, but preventing infection has priority in the preoperative period. Strabismus is a condition in which the eyes are not aligned because of lack of coordination of the extraocular muscles. In a child diagnosed with strabismus, surgery may be indicated to realign the weakened muscles. Surgery most often is indicated when amblyopia (decreased vision in the deviated eye) is present. The surgery should be performed before the child is 2 years old

The child should be placed in a prone or side-lying position following tonsillectomy to facilitate drainage After Epi for status asthmaticus, give Beta 2 AGONIST

152

Asthma is a chronic inflammatory disease of the airways. Inhaled aerosolized short-acting 2 agonists are quick relief medications and recommended for clients with status asthmaticus after epinephrine has been administered. Leukotriene modifiers, antiallergic medications, and nonsteroidal anti-inflammatory medications are long-term control medications. Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands, and meticulous hand washing is necessary to decrease the spread of organisms. The infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are not necessary. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A silent chest is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the childs condition is improving. Warm, dry skin indicates an improvement in condition, because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/min. The normal respiratory rate in a 10-year-old is 16 to 20 breaths/min. RIGHT LOWER LOBE PNEUMONIA

Splinting of the affected side by lying on that side may decrease discomfort. To advise the mother to increase the dose or frequency of the acetaminophen is
inappropriate. Lying on the left side will not be helpful in alleviating discomfort. LU-TU PA- PNUEMONECTOMY/B LOWER LOBE PNEUMONIA. For children with human immunodeficiency virus infection, a minimum of 12 months of treatment with isoniazid is recommended. Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula is used, cross-cutting of the nipple may be required. LACTOSE INTOLERANCE- GIVE CALCIUM FOR CHILD INFANT- PROTEIN AND CALORIES Phenylketonuria is an autosomal recessive disorder. Treatment includes dietary restriction of phenylalanine intake. Phenylketonuria is a genetic disorder that results in central nervous system damage from toxic levels of phenylalanine in the blood. When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink calorie-free liquids. Bringing the child to the clinic immediately is not necessary. Insulin doses should not be adjusted or changed.

153

Providing electrolyte replacement therapy intravenously is an intervention to treat diabetic ketoacidosis. Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. In glomerulonephritis, activity is limited and most children, because of fatigue, voluntarily restrict their activities during the active phase of the disease. Catheterization may cause a risk of infection. Fluids should never be forced. Visitors should be limited to allow for adequate rest. The most common complications associated with orchiopexy are

bleeding and

infection.
Anticholinergics are prescribed for the relief of bladder spasms and are not necessary following orchiopexy. Measurement of intake and output is not required. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the childs abdominal contents, resulting from lengthening of the childs body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or those who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome The Pavlik harness should be worn 16 to 23 hours a day and should be removed only to check the skin and for bathing. The infant can be moved when out of the harness, but the hips and buttocks should be supported carefully. The harness does not need to be removed for diaper changes or feedings. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum. Iron is not added to formula or mixed with cereal or other food items.

Leukemic child feeling nauseated

When the child is nauseated, offering cool, clear liquids is best because they are soothing and better tolerated. One should not offer favorite foods when the child is nauseated because foods eaten during times of nausea will be associated with being sick. Supportive nutritional measures should include oral supplements with high-protein and high-calorie foods.

Colorless drainage on the dressing indicates the presence of cerebrospinal fluid and should be reported to the physician immediately Fever, hematuria, and hypertension are clinical manifestations associated with Wilms tumor.

154

Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. Pneumococcal and influenza vaccines also are recommended. The varicella (chickenpox) vaccine is avoided in the child who is HIV-infected and severely immunocompromised. The hepatitis B vaccine is administered according to the recommended immunization schedule The human immunodeficiency virus (HIV) attacks the immune system by destroying T lymphocytes. Infants born to HIV-positive women test positive for HIV antibody, not HIV virus. This is actually a measure of maternal antibody and is not indicative of true infection in the infant. The virus attacks the immune system. T4 cells are depleted in number and cannot signal B cells to form protective antibodies to fight off the invading virus.

The Centers for Disease Control and Prevention (CDC) recommends wearing gowns and gloves for close contact with a person infested with scabies. Masks are not necessary. Mafenide acetate the medication will cause local discomfort and burning- NORMAL BURNING SENSATION. Lindane is applied in a thin layer to the body below the head. No more than 30 g (1 oz) should be used. The medication is removed by washing 8 to 12 hours later. In most cases, only one application is required. A Penrose drain should not be clamped because this action will cause the accumulation of drainage within the tissue. Penrose drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing. Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery. Driving a car and sitting for long periods of time are restricted for at least 3 weeks. A high daily fluid intake should be maintained to limit clot formation and prevent infection. Chemoptheraputic Agent Normally, the medication is injected into the bladder through a urethral catheter, the catheter is clamped or removed, and the client is asked to retain the fluid for 2 hours. The client changes position every 15 to 30 minutes from side to side and from supine to prone or resumes all activity immediately. The client then voids and is instructed to drink water to flush the bladder. Stomatitis rinse the mouth with baking soda or saline. The client should avoid toothbrushing and flossing when stomatitis is severe. Regular insulin is used in an insulin pump. If ketones are found in the urine, it possibly may indicate the need for additional insulin. To
minimize the discomfort associated with insulin injections, insulin should be administered at room temperature. Injection sites should be rotated systematically within one anatomic site.

BUT, STORAGE OF UNOPENED INSULIN SHOULD BE REFRIGERATED.

155

HYPOPHYSECTOMY- HAS NO RELATION WITH URINARY GLUCOSE LEVEL- ANG MERON LANG EH GLUCOSE SA NOSE,EARS FROM CSF WALA SA URINARY- D.M. YUN!!!!!!!!!!!!!!!!!1 HYPOPHYSECTOMY WHO COMPLAINS OF THIRSTY & FREQUENT URINATING- ASSESS FOR URINE SPECIFIC GRAVITY Following thyroidectomy, weakness and hoarseness of the voice can occur as a result of trauma from the surgery. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. The nurse does not need to notify the physician immediately. These signs do not indicate bleeding or the need to administer calcium gluconate. Lack (absolute or relative) of insulin is the primary cause of DKA . Treatment consists of insulin administration (regular insulin), IV fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Applying an electrocardiogram monitor is not a priority action. The client with pheochromocytoma needs to be provided with a diet high in vitamins, minerals, and calories. Of particular importance are the foods or beverages that contain caffeine, such as cocoa, coffee, tea, or colas. These foods are prohibited because they can precipitate a hypertensive crisis

Diaphoresis and confusion are signs of moderate hypoglycemia. , Chronic ingestion of iodine can produce iodism. The client needs to be instructed about the
symptoms of iodism, which include a , soreness of gums and teeth, vomiting, and abdominal pain. The client needs to be instructed to notify the physician if these symptoms occur.

brassy taste

The client who is taking an antihypocalcemic medication(calcium supplements) should be

instructed to avoid eating too much spinach, rhubarb, bran, or whole-grain cereals because they decrease calcium absorption. Good dietary sources of calcium are milk products, dark green, leafy vegetables (although spinach needs to be avoided), clams, oysters, sardines, and orange juice fortified with calcium.

Corticosteroids (glucocorticoids) should be administered before 9 AM. Administration at this

time helps minimize adrenal insufficiency and mimics the burst of glucocorticoids released naturally by the adrenal glands each morning.

FOR DM TYPE 2 Acarbose (Precose) is an alpha-glucosidase inhibitor. Taken with the first bite of each major meal, acarbose delays absorption of ingested carbohydrates, decreasing postprandial

156

hyperglycemia. Abdominal pain and flatulence are the most common side effects of this medication. It is not taken at bedtime. The solution GoLYTELY is a bowel evacuant used to prepare a client for a colonoscopy by cleansing the bowel. The solution is expected to cause a mild diarrhea and will clear the bowel in 4 to 5 hours.

Following cholecystectomy, drainage from the T tube is initially bloody and then turns to a
greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.

Dumping syndrome - avoid high-carbohydrate foods, including fluids such as fruit nectars;

Coughing is avoided following

umbilical hernia repair to prevent disruption of tissue integrity, which can occur because of the location of this surgical procedure. Bed rest is not required following this surgical procedure. The client should take analgesics as needed and as prescribed to control pain. A drain is not used in this surgical procedure, although the client may be instructed in simple dressing changes.
low-fiber diet can cause constipation. ILEOSTOMY-------- Fluid intake should be at least six to eight glasses of water per day to prevent dehydration.--------KAHIT NA MAY WATERY STOOL ODOR FROM COLOSTOMY- The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor but is a

gas-forming food as well. Broccoli, cucumbers, and eggs are gas-forming foods.

Crohns disease is alleviated by massaging the abdomen, and lying with the legs flexed.NOT STRAIGHT LEGS.

Peritonitis after liver biopsy- Abdominal pain is the most common symptom of

peritonitis. Tachycardia, rather than bradycardia, will occur.

Viral Hepatitis- NOT EVENING SUPPER, Frequently, appetite is better in the morning, so it is
easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

During the acute phase of diverticulitis, the goal of treatment is to rest the bowel and allow the inflammation to subside. The client remains NPO and is placed on bed rest. Pain occurs from bowel spasms and increased intraabdominal pressure may precipitate an attack.---anticholinegic not cholinergic, NOT AMBULATE, BED REST DISCOMFORT OF REFLUX FOR GERD- The left side-lying position with the head of the bed elevated is most likely to give relief to the client.

157

If bisacodyl is taken at bedtime, the client will have a bowel movement in the morning. S/E OF METOCLOPRAMIDE FOR LONG TERM USE- TARDIVE DYSKINESIA ZOFRAN (ONDASETRON)- antiemetic used to treat postoperative nausea and vomiting, as well as nausea and vomiting associated with chemotherapy
Magnesium citrate is available as an oral solution and is used commonly as a laxative in preparation for or after certain studies of the gastrointestinal tract. Magnesium citrate should be served chilled and not be allowed to stand for prolonged periods, which would reduce the carbonation and make the solution even less palatable

Calcium carbonate antacids should not be taken with milk, milk products, or foods or supplements high in vitamin D because milk-alkali syndrome (headache, urinary frequency, anorexia, nausea, vomiting, fatigue) can occur. The best item to consume when taking calcium carbonate is water. Aluminum hydroxide tablets should be chewed thoroughly before swallowing. This prevents them from entering the small intestine undissolved. They should not be swallowed whole. Antacids should be taken at least 1 hour apart from other medications to prevent interactive effects. Constipation is a side effect of the use of aluminum products, but it is not correct for the client to take a laxative with each dose. This promotes laxative abuse; the client should first try other means to prevent constipation. Cimetidine- confusion Ranitidine is a histamine 2 (H2)-receptor antagonist. A single daily dose of ranitidine is scheduled to be given at bedtime. This allows for a prolonged effect, and the greatest protection of the gastric mucosa. To obtain a sputum specimen, the client should rinse the mouth to reduce contamination, breathe deeply, and then cough into a sputum specimen container. The client should be encouraged to cough and not spit so as to obtain sputum. Sputum can be thinned by fluids or by a respiratory treatment such as inhalation of nebulized saline or water. The optimal time to obtain a specimen is on arising in the morning. Before bronchoscopy Atropine and midazolam would be administered before the procedure, not after RADIAL ARTEIAL BLOOD GASES- Allens test. This involves compressing the radial and ulnar arteries and asking the client to close and open the fist, which should cause the hand to become pale. The nurse then releases pressure on one artery and observes whether circulation is restored quickly. The nurse repeats the process, releasing the other artery. The blood sample may be taken safely if collateral circulation is adequate.

158

Instructions for using a metered-dose inhaler include shaking the canister, holding it right side up, inhaling slowly and evenly through the mouth, delivering one spray per breath, and holding the breath after inhalation. A nonsteroidal anti-inflammatory drug, which has an analgesic effect, will relieve pain and allow the client to cough and deep-breathe more effectively On transfer from the coronary care unit, the client is allowed self-care activities and bathroom privileges. Supervised ambulation in the hall for brief distances is encouraged, with distances gradually increased (50, 100, 200 feet).

Edema, the accumulation of excess fluid in the interstitial spaces, can be measured by intake greater than output and by a sudden increase in weight. Diuretics should be given in the morning whenever possible to avoid nocturia. Strict sodium restrictions are reserved for clients with severe symptoms. The nurse should encourage regular use of pain medication for the first 48 to 72 hours after cardiac surgery because analgesia will promote rest, decrease myocardial oxygen consumption resulting from pain, and allow better participation in activities such as coughing, deep breathing, and ambulation. Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with

unstable

ventricular tachycardia.

The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented.

FOR RAPID HEART RATE OF ATRIAL FIBRILLATION- Carotid sinus massage is one maneuver used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm. The client may be defibrillated up to three times in succession. The energy levels used are 200, 300, and 360 J for the first, second, and third attempts, respectively. AUTOMATIC EXTERNAL DEFIBRILLATOR- The nurse or rescuer puts two large adhesive patch electrodes on the clients chest in the usual defibrillator positions. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if defibrillation is necessary. The first signs and symptoms of digoxin toxicity in adults include abdominal pain, nausea,

vomiting, visual disturbances (blurred, yellow, or green vision, halos around lights), bradycardia, and other dysrhythmias.-------- diarrhea & hypotension are
unrelated.

159

PULMONARY EDEMA- FOLEY CATHETER, MORPHINE IV, NOT LOW FOWLERS SIDE LYING

Tissue plasminogen activator is a thrombolytic.

Activator, altepase,( Activase, tPA) .Hemorrhage is a complication of any type of thrombolytic medication. The client is monitored for bleeding.--------------- Heparin is given after thrombolytic therapy

Aminocaproic acid is the antidote for thrombolytic therapy

. Enalapril (Vasotec) is an angiotensin-converting enzyme inhibitor. Angioedema is an adverse effect. Swelling of the tongue and lips can result in airway occlusion . Nausea, insomnia, and a cough can occur as side (not adverse) effects of the medication.

Scrubbing the catheter with povidone-iodine is done at the time of connection or disconnection of peritoneal dialysis.
After renal biopsy------Serial urine samples are assayed by Hematest with urine dipsticks to evaluate bleeding Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria. Glomerulonephritis and pyelonephritis would be accompanied by fever and are thus not applicable to the client in this question. Renal cancer would not cause pain that is felt in the low abdomen; rather pain would be in the flank area.
classic symptom of polycythemia vera is itching,

URETHRIRTIS CAUSED BY CHLAMYDIAL INFECTION Follow-up cultures are typically done in 4 to 7 days to evaluate the effectiveness of the medication. Using a spermicide does not change the perineal pH. The infection can be prevented by the use of latex condoms. Chlamydial infection is treated with doxycycline for 7 days or with azithromycin (Zithromax) as a single dose. All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary Steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and a diminished pulse distal to the fistula. The client also complains of pain distal to the

160

fistula, caused by tissue ischemia. Warmth, redness, and pain probably would characterize a problem with infection

The client may have an elevated temperature following dialysis because the dialysis machine warms the blood slightly. If the temperature is elevated excessively and remains elevated, sepsis would be suspected and a blood sample would be obtained as prescribed for culture and sensitivity determinations. Disequilibrium syndrome may be caused by the rapid decreases in the blood urea nitrogen level during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs of disequilibrium syndrome and appropriate treatments with anticonvulsive medications and barbiturates may be necessary to prevent a life-threatening situation. The physician must be notified. Increasing the glucose concentration makes the solution more hypertonic. The more hypertonic the solution, the higher the osmotic pressure for ultrafiltration and thus the greater the amount of fluid removed from the client during an exchange.

Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, the pain usually disappears after 1 to 2 weeks of treatment. The infusion amount should not be decreased, and the infusion should not be slowed or stopped. Frequent dressing changes around the Penrose drain are required to protect the skin against breakdown from the urinary drainage. If urinary drainage is excessive, an ostomy pouch may be placed over the drain to protect the skin. A Penrose drain is not irrigated. Weighing the dressings is not necessary. Placing the client on the affected side will prevent a free flow of urine through the drain. The purpose of applying traction to the Foley catheter is to control bleeding. The client with an uncomplicated cystoscopy should not require a Foley catheter and should not be experiencing bleeding. Bleeding is a complication following cystoscopy. Onions, fish, eggs, and cheese are odor-producing foods. A client with an ileal conduit should be taught to avoid these foods

Syringes with a -inch needle are used for subcutaneous injection. A 1-inch needle may be used for intramuscular injection. Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately Enucleation-If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician, because this indicates hemorrhage. In the voice test, the examiner stands 1 to 2 feet away from the client and asks the client to block one external ear canal. The nurse whispers a statement and asks the client to repeat it. Each ear is tested separately.

161

Motor testing in the unconscious client can be done only by testing response to painful stimuli. Nail bed pressure tests a basic peripheral response. Cerebral responses to pain are tested using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight

catheterization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.------DO NOT LIMIT CATHETERIZATION

Before the client with dysphagia is started on a diet, the gag and swallow reflexes must have returned. The client is assisted with meals as needed and is given ample time to chew and swallow. Food is placed on the unaffected side of the mouth. Liquids are thickened to avoid aspiration.

Unilateral neglect is an unawareness of the paralyzed side of the body, which increases the clients risk for injury. The nurses role is to refocus the clients attention to the affected side. The nurse moves personal care items and belongings to the affected side, as well as the bedside chair and commode. The nurse teaches the client to scan the environment to become aware of that half of the body and approaches the client from the affected side to increase awareness further. Speaking loudly may help overcome a deficit of cranial nerve VIII (vestibulocochlear). Cranial nerve VII (facial) and IX (glossopharyngeal) control taste from the anterior two thirds and posterior third of the tongue, respectively. The limbic system-PARANG THALAMIC SYNDROME is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relates to function of the frontal lobe. The cerebral hemispheres, with specific regional functions, control orientation. Recall of recent events is controlled by the hippocampus. Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) have only motor components and control, in a coordinated manner, the six cardinal fields of gaze. This is tested by moving an object in six directions (involving horizontal and diagonal movements). Corneal reflex is the function of the trigeminal nerve (cranial nerve V). Pupillary response and accommodation is the function of cranial nerve III (oculomotor) alone. The client with

Guillain-Barr syndrome is at risk for respiratory failure because of

ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic

162

monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely.

After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by Hematest-positive nasogastric tube aspirate or stool. A history of diarrhea is irrelevant. Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills.

Bucks extension traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps immobilize the fracture. Traction does not lengthen the leg for the purpose of preventing blood vessel severance. Traction also does not allow for bony healing to begin. Bucks extension traction is a type of skin traction. The nurse inspects the skin of the limb in traction at least once every 8 hours for irritation or inflammation. Massaging the skin with lotion is not indicated. The nurse never releases the weights of traction unless specifically ordered by the physician. There are no pins to care for with skin traction.

A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. The client is taught to hold the cane on the side opposite from the weakness. The reason is that with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 4 to 6 inches lateral to the fifth toe. 12 inches forward. Clients with diabetes mellitus are more prone to wound infection and delayed wound healing because of the disease. Postoperative stump edema and hemorrhage are complications in the immediate postoperative period that apply to any client with an amputation. Slight redness of the incision is considered normal, as long as it is dry and intact. Low back pain that radiates into one leg (sciatica) is consistent with herniated lumbar disk The client with systemic lupus erythematosus (SLE) is at risk for cardiovascular disorders such as coronary artery disease and hypertension. The client is advised of lifestyle changes to reduce these risks, which include smoking cessation and prevention of obesity and hyperlipidemia. The client is advised to reduce salt, fat, and cholesterol intake. Lyme disease cannot be transmitted from one person to another. Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. Toxoplasmosis is caused by the ingestion of cysts from contaminated cat feces. The nurse should never promise to keep a secret. Secrets are appropriate in a social relationship but not in a therapeutic one. The nurse needs to be honest with the client and tell the client that a promise cannot be made to keep the secret.

163

If a client is monopolizing the group, the nurse must be direct and decisive. The best action is to thank the client and suggest that the client stop talking and try listening to others All treatment team members are viewed as significant and valuable to the clients successful treatment outcomes in milieu therapy. Behavior modification is based on rewards and punishment. Rational emotive therapy deals with the correction of distorted thinking. Interpersonal therapy on the other hand is based on a one-to-one or group therapy approach in which the therapist-client relationship is often used as a way for the client to examine other relationships in his or her life.

Mania- Tetherball

is an exercise that uses the large muscle groups of the body and is a great way to expend the increased energy this client is experiencing. DELIRIUM- DISORIENTED & CONFUSED-------- DAPT LESS STIMULUS DEPRESSION- STRUCTURED ENVIRONMENT Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake. The nurse must provide for appropriate exercise and place limits on rigorous activities.------INTERRUPT CLIENT IN EXERCISE & OFFER HER TO TAKE A WALK

One-to-one suicide precautions

suicide.

are required for the client who has attempted

A nurses initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option 3 will assist in determining data related to the precipitating event that led to the crisis.----- What leads you to seek help

Crisis times may occur between appointments. Contracts facilitate the client feeling a

responsibility for keeping a promise. This gives the client control

Risperidone (Risperdal) can cause orthostatic hypotension. If an oil-based dye is used during myelography, the dye is removed at the end of the procedure.
The client is positioned flat in bed for 6 to 8 hours after the dye is removed. When a waterbased contrast medium is used, the client is positioned with the head of bed elevated for at least 8 hours to keep the dye from irritating the cerebral meninges.

NPH insulin is an intermediate-acting insulin. Its onset of action is 3 to 4 hours, it peaks in 4 to 12 hours, and its duration of action is 16 to 20 hours.

164

Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of client care TRANSPHENOIDAL HYPOOHYSECTOMY- AVOID BRUSHING TEETH FOR 2 WEEKS. -------spinal anesthesia is NOT used. Radiation therapy is usually delayed until a child is 8 years of age, whenever possible, to prevent retardation of bone growth and soft tissue development. Page 2692 from Saunders Talks about FILIPINO Filipinos view pain as part of living an honorable life. The client may appear stoic and be tolerant of a high degree of pain. Health care providers need to offer, and in fact encourage, pain relief interventions for the Filipino client who does not complain of pain despite physiological indicators. A child with transposition of the great arteries(TOGA) may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing are inadequate to maintain adequate cardiac output

An expected outcome of surgery is warmth, redness, and edema in the surgical

extremity because of increased blood flow.

. A differential white blood cell count is the leukocyte count broken down (differentiated)
according to the cell type. A right shift represents an increased number of mature neutrophils, which is seen with pernicious anemia and after tissue breakdown

Signs of infection include pain, redness, heat, and swelling of a localized area of

the breast.

Russells traction uses skin traction to realign a fracture in the lower extremity and immobilize the hip and knee in a flexed position. It is important to keep the hip flexion at the prescribed angle to prevent fracture malalignment. The traction may also relieve pain by reducing muscle spasms, but this is not the primary reason for this traction. The child can still move in bed with some restriction as a result of the traction. Traction is never used to restrain a child.

. To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights are not to be kept resting on a firm surface. The head of the bed is usually kept low to

provide countertraction.- NOT 45 90 ANGLE

Patching may be used in the treatment of strabismus to strengthen the weak eye. In this treatment, the good eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist.

165

The most common metabolic complication in the small-for-gestational age (SGA) newborn infant is hypoglycemia, A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. The size and appearance of the tympanostomy tubes should be described to the parents after surgery. They should be reassured that if the tubes fall out, it is not an emergency, but that the physician should be notified Collecting a 24-hour urine and frequent ambulation can most appropriately be provided by the nursing assistant, licensed practical (vocational) nurse is skilled in wound irrigation and dressing changes, so this client would be assigned to this staff member. Cleft lip repair is usually performed during the first few weeks of life. INVERTED NIPPLES- Wearing breast shells and using a breast pump before each feeding will make it easier for the newborn infant to grasp the nipple The nurse assesses the client with fibrocystic breast disorder for worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Intussusception occurs when a proximal segment of the bowel prolapses into a distal segment of the bowel. It is a common cause of acute bowel obstruction in infants and young children. It is not an inflammatory process. The artificial larynx is an electronic device that assists the client after laryngectomy to produce speech. There are two typesone is held at the side of the neck and the other is inserted into the mouth. The vibration produces a mechanical sounding speech that is monotone in quality but is intelligible. A Pap smear is usually painless. The test cannot be performed during menstruation. The client needs to be instructed to avoid douching for at least 24 hours prior to the test. There is no reason to restrict fluids on the day of the test. Lypressin is an antidiuretic hormone-----------used in the treatment of diabetes insipidus. It promotes renal conservation of water by acting on the collecting ducts of the kidney to increase the permeability to water, which results in increased water reabsorption.--------------IT DOES NOT STIMULATE ALDOSTERONE

LISPRO INSULIN ( HUMALOG)- ------------------------Because of its rapid onset, it can be administered immediately before eating. EMERGENCY INSULIN- REGULAR THROUGH IV ROUTE.

166

Insulin should not be frozen. If the nurse notes that the vial of insulin is frozen, the insulin is discarded and a new vial is obtained. For most hypothyroid clients, replacement therapy must be continued for life. NASOGASTRIC TUBE-----------BRUSH TEETH FREQUENTLY, USE MOUTHWASH AND WATER. Small sips of water are contraindicated when the client is on gastric suction. The sigmoid and descending colons are located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colons. Acute flexion of the right leg allows for adequate exposure of the anus. FLUID ASPIRATED IN NGT-------------POURED INTO THE NGT THROUGH A SYRINGE WITHOUT A PLUNGER. Respiratory rates are generally higher in older adults. In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass into the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis

Persons at greatest risk for pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a physicians prescription. SUICIDAL CLIENT------IS UNABLE TO COPE UP WITH STRESSORS--------DAPAT AS A NURSE PROVIDE AUTHORITY, ACTION, AND PARTICIPATION. The client must have sputum cultures performed every 2 to 4 weeks after initiation of antituberculosis drug therapy. The client may return to work when the results of

sputum cultures are negative,

point.

because the client is considered noninfectious at that

167

ROOM OF TB PATIENT- The client is admitted to a private room that has at least six air exchanges per hour, and that has negative pressure in relation to surrounding areas. The room should be vented to the outside, and should have ultraviolet lights installed.

The client in a severe state of anxiety would not be able to learn relaxation techniques.------BETTER TO REMAIN ON THE CLIENT.
ACUTE PANCREATITIS--------EXPERIENCING SEVERE PAIN. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) may alleviate some of the pain associated with pancreatitis. The pain is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior peritoneal wall with these positions. Because acetylcysteine has a pervasive flavor of rotten eggs, it must be disguised in a flavored ice drink and is preferably drunk through a straw to minimize contact with the mouth. In the preicteric phase, the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. In the posticteric phase, jaundice decreases, the color of urine and stool return to normal, and the clients appetite improves. Chemotherapy may cause distortion of taste. Often, beef and pork are reported to taste bitter or metallic. The principle adverse effect of insulin therapy is hypoglycemia, a blood glucose level lower than 50 to 60 mg/dL.
The gown must be rolled from inside out to prevent the organisms on the outside of the gown from
contaminating other areas.

Constipation is the probable cause of the clients lack of bowel movements------- A high-fiber diet often is indicated for constipation because it will promote bulk and encourage intestinal peristalsis.

Clear liquid diet offers foods that are liquid at body temperature. Clear liquid diets have little or no residue-------FOR FIBEROPTIC PROCEDURE.

168

Although increased fluids are important for the client with emphysema to maintain thin respiratory secretions, this action is not specific to the use of corticosteroids The definition of hyperinsulinism is an excessive insulin secretion in response to consuming carbohydrate-rich foods. This leads to hypoglycemia. It is often treated with a diet that provides for limited stimulation of the pancreas. Carbohydrates can produce a rapid rise in blood glucose levels. However, carbohydrates are necessary in the diet. Proteins do not stimulate insulin secretion. Fats are needed in the diet to provide calories. The best diet for hyperinsulinism will contain proteins and fats whenever carbohydrates are consumed. Diets high in soluble fiber may be beneficial. ASPIRATION ON NGT - a common complication is aspiration pneumonia, which is caused by regurgitation of formula contents from the stomach into the respiratory tract. GASTROSTOMY-------MAY STOMA----KAYA CHECK FOR SKIN IRRITATION.

Aseptic, not sterile, technique is necessary when administering

feedings.

Crutches and a walker can be difficult to maneuver for a client with weakness on one side. A cane is better suited for the client with weakness of the arm and leg on one side; however,
the

quad cane would provide the most stability because of the structure of the cane and

because a quad cane has four legs.

Crystals form in a mannitol solution if the solution is cooled but will quickly dissolve if the
container is placed in warm water, then cooled to body temperature before administration. Shaking the vial should not be done and will not dissolve the crystals. The medication is not returned to the pharmacy because it is not defective. The nurse would not discard the medication.

Butorphanol tartrate (STADOL)is an opioid analgesic Disseminated intravascular coagulation (DIC) is a complication of TSS.

ELEVATED KNEE GATCH-------COMPROMISES BLOOD CIRCULATION----THEREBY CAUSES VENOUS STASIS----RESULTING INTO THROMBOSIS OR THROMBOPHLEBITIS After a vaginal hysterectomy, the client is at risk for deep vein thrombosis or thrombophlebitis.

169

CLEFT PALATE REPAIR---------PWEDE NA AFTER 7 TO 10 DAYS VOMIT CONTAIN SOUR, UNDIGESTED FOOD WITHOUT BILE, AND IS CONSTIPATED are classic symptoms of pyloric stenosis. Crying during the evening hours, appearing to be in pain, eating well, and gaining weight are clinical manifestations of colic. An infant who suddenly becomes pale, cries out, and draws the legs up to chest is demonstrating physical signs of intussusception. Stools that are ribbon-like and eating poorly are signs of congenital megacolon (Hirschsprungs disease). BIOPHYSICAL PROFILE------MEASURES AMNIOTIC FLUID & FETAL ACTIVITY
BPP test may include a nonstress test with electronic fetal heart monitoring and a fetal ultrasound.
LACTOSE INTOLERANCE----DI PWEDE ANG CHEESE DAPAT AY DRIED FRUIT Homes that are older than 25 years may have lead paint and will most likely have lead pipes, which can contribute to lead poisoning. DIC----HINDI PWEDE ASPIRIN DIC ----RISK FOR IMPAIRED SKIN INTEGRITY- USE SOFT FIRM MATRESS If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To promote adequate oxygen for the mother and her fetus, the mother is turned to her side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen by face mask at 8 to 10 L/min is applied to the mother.

Sources of folic acid include green leafy vegetables, whole grains, fruits, liver, dried peas, and beans. Chicken, rice, and cheese are not high in folic acid. Cheese is a dairy product and is high in calcium. Chicken is a good source of protein. Pork is a good source of thiamine.

A high-carbohydrate diet could increase the episodes of nausea.

Bradycardia is not part of the clinical picture for any form of renal failure. Epoetin alfa------ chronic renal failure. The medication may be administered subcutaneously or intravenously.

Because the 24-hour urine is a timed, quantitative determination, it is essential to start the test with

an empty bladder. The collected urine should be refrigerated or placed on ice to prevent changes in the urine. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection.

acute glomerulonephritis------REMOVE PITCHER FROM THE BEDSIDE---RISK FOR FUILD VOLUME EXCESS----KASI MERONG EDEMA.------------------ It is unnecessary to monitor the temperature as frequently as every 2 hours.

170

ET TUBE PROPER PLACEMENT ------USE AMBU BAG & ASESS FOR BILATERAL SOUNDS . During the abdominal examination, the client lies supine (flat on their back) with the head raised slightly and with the knees slightly flexed. Bloody or clear drainage from either the nasal or the auditory canal after trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the physician Warfarin (Coumadin) ORAL HEPARIN- SUB Q/ IV It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. A tube with a large lumen and an air vent is a Salem sump tube. A tube with a single lumen is called a Levins tube. A Sengstaken-Blakemore tube is used to control bleeding in the esophagus. A Dobbhoff weighted tube is used for feedings. MASTOIDECTOMY---------signs of facial nerve injury (cranial nerve VII) When a client is experiencing psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. Such activities can include Ping-Pong, volleyball, fingerpainting, drawing, and working with clay PARANOID----The nurse should avoid a warm approach because warmth can be frightening to a person who needs emotional distance. Liquids are thickened to prevent aspiration. A stiff or frozen shoulder can develop as a complication of a cast on an upper extremity. The client should be instructed to lift the shoulder of the casted arm over the head periodically throughout the day to prevent this complication. The client should not keep a sling on the arm at all times or wear the sling at nighttime. Range-of-motion exercises to the casted extremity would assist in preventing this complication. . Serous drainage is normal drainage from a healing wound or incision. Serosanguinous drainage also NORMAL DVT----ACETAMINOPHEN NOT OPIOD ANALGESICS. DVT-WARM MOIST PACK NOT COLD

Sclerotherapy is the injection of a sclerosing agent into a varicosity. The agent damages the
vessel and causes aseptic thrombosis that results in vein closure..

VEIN LIGATION & STRIPPING- A sensation of pins and needles, or feeling as though the surgical
limb is falling asleep, may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias.

URINATY CATHETER-the drainage tubing is not placed under the clients leg. The tubing must drain freely at all times.

171

Foods that are allowed on an acid-ash diet include meat, fish, shellfish, cheese, eggs, poultry, grains, cranberries, prunes, plums, corn, lentils, and foods with high amounts of chlorine, phosphorus, and sulfur.----baked haddock NEPRHROTIC SYNDROME------EDEMA WITH ACTIVITY LEVEL NOT DIURETICS The client with nephrotic syndrome usually has a standard limit set on sodium intake. Fluids are not restricted unless the client also is hyponatremic. Diuretics are ordered on a specific schedule, and doses are not titrated according to the level of edema. The client is taught to adjust the activity level according to the amount of edema. As edema decreases, activity can increase. Correspondingly, as edema increases, the client should increase rest periods and limit activity. Bed rest is recommended during periods of severe edema. walker is beneficial to the client with greater or bilateral weakness, or the client who is at risk for falls. Wooden crutches often are used by clients with a leg cast. Lofstrand crutches aid clients who need crutches but have limited arm strength. Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The fasciotomy site is not sutured but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. Pain with knee extension is a common complaint of clients after knee replacement. This is because preoperatively, these clients placed the knee in flexion to reduce pain, and flexion contracture has resulted. The nurse should encourage the client to keep the knee extended and administer analgesics as needed. Clients with low back pain often are more comfortable when placed in Williams position. The bed is placed in semi-Fowlers position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Common areas that are under pressure and are at risk for breakdown include the elbows (if they are used for repositioning instead of a trapeze) and the heel of the good leg (which is used as a brace when pushing up in bed). Other pressure points caused by the traction include the ischial tuberosity, popliteal space, and Achilles tendon.

172

Common GI side effects of benztropine(CONGENTIN) therapy include constipation and dry mouth Precipitation will occur if phenytoin is mixed with any solution other than 0.9% (normal) saline. This is especially true with solutions containing dextrose. An in-line filter reduces the chance of precipitants entering the bloodstream. Phenytoin is very irritating to the vein wall or other tissues.

Pyridostigmine is a cholinergic medication used to increase muscle strength in the client with myasthenia gravis. For the client who has difficulty chewing, the medication should be administered 30 minutes before meals to enhance the clients ability to eat. Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. The client may experience some side effects, such as sedation, dry mouth, constipation, and blurred vision (anticholinergic). However, these effects are transient and will diminish as times goes on. A more common adverse effect is orthostatic blood pressure changes,---------MONITOR BP Lithium blood levels are recommended for the client taking lithium, but these tests generally are prescribed every 3 to 4 months. The side effects of lithium include fine hand tremors, polyuria, mild thirst, and mild nausea. Diarrhea, vomiting, nausea, drowsiness, muscle weakness, and lack of coordination may be early signs of toxicity. The medication is withheld and the physician notified so that the client can be further evaluated to determine the presence of toxicity. In cognitive-behavioral therapy, the client with a phobia who experiences panic attacks will be treated with a combination of cognitive restructuring, exposure therapy, and paradoxical intention. In paradoxical intention, the client is instructed to do what he fears and if possible to exaggerate it to the point of humor. When this occurs, the client is taught to prevent the anxiety by variety of coping mechanisms. This assists the client to regain an internal locus of control or feeling of empowerment and to master response to the anxiety-provoking issue, situation, or person.

VIVO THERAPY--------CONFRONTING THE SUPPORT

ANXIETY-PROVOKING SYIMULUS & PROVIDING

It is recommended that clients with anxiety disorder abstain from or limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety. A barium swallow should be done after a barium enema or gallbladder series to prevent the contrast used in the barium swallow from obstructing the view of other organs. It takes several days for swallowed barium to pass completely out of the gastrointestinal tract. BARIUM SWALLOW IS LAST TO BE DONE.

173

After cholecystectomy, respirations tend to be shallow because deep breathing is painful as a result of the location for the surgical procedure. Although all of the options are correct, teaching coughing and deep breathing exercises is the priority.------DUE TO HIGH ABDOMINAL INCISION For the first 4 to 6 weeks after colostomy formation, the client should take in a low-residue diet. The client with a mild to moderate case of ulcerative colitis often is prescribed a diet that is low in roughage and does not include milk. This will help to reduce the frequency of diarrhea for this client FOR VIRAL HEPATITIS
If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that a majority of calories should be eaten in the morning hours, because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

BEFORE REMOVAL OF THE ET TUBE------------SUCTION THE ET TUBE Immediately after an ET tube is inserted, tube placement is verified by both auscultation and chest radiography. Auscultating the lungs would be the immediate action, and the nurse would auscultate for bilateral breath sounds. aluminum hydroxide(AMPHOGEL) should take the medication with meals. The phosphate-binding effect is most effective when it is taken with food. If tablets are used, they should be chewed well before swallowing.

The anticonvulsant medications carbamazepine and phenytoin help relieve the pain in many clients with trigeminal neuralgia. They act by inhibiting the reactivity of neurons in the trigeminal nerve. Opioid analgesics (meperidine hydrochloride, codeine sulfate, oxycodone) are not very effective in controlling pain due to trigeminal neuralgia.

HYPERTHERMIA-Ice packs are not used because they could cause shivering, which increases cellular oxygen demands, with the potential for increase in intracranial pressure.------------------USE HYPOTHERMIA BLANKET

Placement of a dressing over a chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This may result in a sudden decline in respiratory status, mediastinal shift with twisting of the great vessels, and circulatory compromise. If clinical changes occurs, the nurse removes the dressing immediately, allowing air to escape.

RIFAMPIN & ISONIAZID-----------TAKEN TOGETHER O.D. TAKEN 1 HR. BEFORE OR AFTER MEALS NOT WITH MEALS.

174

Clients with ESRD also are likely to experience mood swings or to express hostility, anger, and depression, among other responses. The nurse acknowledges the clients feelings, allows the client to express those feelings, and is supportive.------DO NOT SET LIMITS IN ESRD. Side effects of meperidine hydrochloride include respiratory depression, orthostatic hypotension, tachycardia, drowsiness and mental clouding, constipation, and urinary retention. Early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.-----GOOD High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast.

Baclofen, a skeletal muscle relaxant, also is a central nervous system (CNS) depressant, which can cause urinary retention. The client should not restrict fluid intake. Constipation, rather than diarrhea, is an adverse effect of baclofen. Fatigue is a CNS effect that is most intense during the early phase of therapy and diminishes with continued medication use. It is not necessary to notify the physician if fatigue occurs.

ASPARAGINASE FOR ACUTE LYMPHOCYTIC LEUKEMIA-----NOTIFY FOR PROLONGED BLOOD CLOTTING TIME.

Phentolamine is an -adrenergic blocking agent that prevents dermal necrosis and sloughing after infiltration of norepinephrine or dopamine.

Potassium -rich foods, such as citrus fruits and bananas. Potassium iodide solution. These symptoms include a brassy taste, burning sensation in the mouth, and soreness of the gums and teeth. The client should be instructed to withhold the medication and notify the physician if these symptoms are noted.

LUGOLS SOLUTION-------BRASSY TASTE IS DANGEROUS-----REPORT TO PHYSICIAN When uterine atony occurs, the initial nursing action would be to massage the uterus until it is firm. If this does not assist in controlling blood loss, then the nurse would contact the physician. Additionally, once bleeding is under control, the nurse would monitor the vital signs and estimate the amount of blood loss.

175

A method of testing for

proprioception

is to hold the sides of the clients great toe and while

moving it, asking the client what position it is in.-------NEUROLOGICAL ASSESSMENT FOR BRAIN ATTACK (STROKE) Profuse sweating and shakiness would be noted in a hypoglycemic condition. Scald burns and tar or asphalt burns are treated by immediate cooling with water if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. No attempt is made to remove tar from the skin at the scene. In a chemical burn injury, the burning process continues so long as the chemical is in contact with the skin. All clothing including gloves and shoes is removed immediately, and water lavage is instituted before and during the transport to the emergency department. Powdered chemicals are first brushed from the clothing and also the skin before lavage is performed. Vasopressin it should be administered intravenously. FOR ESOPHAGEAL VARICES.

The major action of vasopressin is constriction of the splanchnic blood flow. Continuous electrocardiogram and blood pressure monitoring is essential because of the constrictive effects of the medication on the coronary arteries.
Toxoplasmosis is caused from the ingestion of cysts from contaminated cat feces. VARICOSE VEINS

In the client with a venous disorder, the legs are elevated HIGHER THAN the level of the heart to assist with the return of venous blood to the heart. On removal of the chest tube, a sterile petrolatum gauze and a sterile 4 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa, Neosporin ointment, hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the physician as the tape of choice to make the dressing occlusive.

ABG APLLY ING PRESSURE RADIAL ARTERY ---- 5 MINS. FEMORAL ARTERY-----10 MINS. ANTI-COAGULANT THERAPY------LONGER PERIOD OF TIME

Surfactant production does not become stable until after 32 weeks of gestation, and if adequate amounts of lung surfactant are not present, respiratory distress and death of the newborn infant could result. Delivery should be delayed for at least 48 hours after administration of bethamethasone to allow time for the lungs to mature.
Rifampin causes orange-red discoloration of body secretions and will permanently stain soft contact lenses.

176

Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the clients breathing patterns. The client should be placed in a semi-Fowlers position to allow for free diaphragm movement.
BUCKS TRACTION CAUSES WEALK PEDAL PULSE, hypotension is not associated. POLYCYSTIC KIDENY DISEASE----- FLANK PAIN & HEMATURIA ESWL----Extracorporeal shock wave lithotripsy is done with the client under epidural or general anesthesia. The client must sign a consent form for the procedure and must have no oral intake beginning the night before the procedure.---INVASIVE PROCEDURE.

Side effects of chlorpromazine

can include hypotension, dizziness, and fainting, especially

with parenteral use. Additional side effects include drowsiness, blurred vision, dry mouth, lethargy, constipation or diarrhea, nasal congestion, peripheral edema, and urinary retention.

Addisonian crisis

is a serious, life-threatening response to acute adrenal insufficiency that most

commonly is precipitated by a major stressor. The client in addisonian crisis may demonstrate any of the signs and symptoms of Addisons disease, but the primary problems are sudden profound

weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal failure.----wlang diaphoresis

Signs and symptoms of congenital neonatal syphilis may be nonspecific initially, including poor feedings, slight hyperthermia, and snuffles. By the end of the first week of life, a copper-colored maculopapular dermal rash typically is observed on the palms of the hands, soles of the feet, and diaper area and around the mouth and anus

Quinidine sulfate is administered for atrial flutter or fibrillation only after the client has been digitalized.

ADDISONS DISEASE------LAHT KULANG ,

LAHAT MABABA

GLUCOCORTICOIDS DURING ILLNESS/STRESS

IN THE OTHER SIDE Eg. D.M. DURING ILLNESS/ STRESS---GLUCOSE

177

NEPHROTIC SYNDROME---------Controlling edema is a critical aspect of therapeutic management of the client with nephrotic syndrome. A diet high in protein may help the body restore normal plasma oncotic pressure, thus decreasing edema. Dietary modifications may include salt restrictions and fluid restriction and is based on the clients symptoms.
Complications associated with PN therapy include hypoglycemia or hyperglycemia, infection, fluid overload, air embolism, and electrolyte imbalance. It is standard care to monitor blood glucose levels at 6-hour intervals to assess for hyperglycemia.

Before administering any medication, the nurse must assess for allergy or hypersensitivity to substances used in producing the medication. Fat emulsions such as Intralipids may contain an emulsifying agent obtained from egg yolks. Clients sensitive to eggs are at risk for developing hypersensitivity reactions.

Tolbutamide is an oral hypoglycemic agent. Amiloride is a potassium-sparing diuretic used to treat edema or hypertension. The daily dose should

be taken in the morning to avoid nocturia, and the medication should be taken with food to increase bioavailability. Sodium should be restricted or limited as prescribed. Increased blood pressure is not a reason to withhold the medication; rather, it may be an indication for its use.

An adverse reaction to carbemazepine is blood dyscrasia.

Bromocriptine, (PARLODEL)
Parlodel also for Parkinsons

an antiparkinsonian prolactin inhibitor, is used in the

treatment of neuroleptic malignant syndrome.

Prozac(FLUOXETINE) is administered in the early morning. Simethicone is an antiflatulent used in the relief of pain due to excessive gas in the gastrointestinal (GI) tract. Magnesium hydroxide is an antacid and laxative, and droperidol relieves postoperative nausea and vomiting. Acetaminophen is a non-opioid analgesic. Older clients are especially susceptible to the CNS effects of cimetidine, of which confusion is most frequent. Enoxaparin is an anticoagulant that is administered to prevent deep vein thrombosis and thromboembolism in clients at risk Amiodarone is an antiarrhythmic A client with mild preeclampsia can be managed at home. The priority intervention of the home care nurse is to monitor for fetal movement. The expectant mother also is asked to keep a record of fetal movements. Bedrest with bathroom privileges is prescribed; complete bedrest is not necessary. Urine

178

should be checked for protein. A maternal blood glucose would not provide specific data related to preeclampsia. Sodium restriction is not necessary .LIMIT ONLY

The normal clotting time is 8 to 15 minutes, and the normal ammonia value is 15 to 45 mcg/dL. Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. The highest priority is to monitor lung sounds for the presence of crackles, which may indicate pulmonary toxicity.
The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, and oysters. Other good sources of iron are kidney beans, whole wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, and apricots.

IRON DEXTRAN----- DO NOT MASSAGE TO

STAINING.

. The indirect Coombs test detects circulating antibodies against RBCs. This test is used in addition to the ABO typing that normally is done to determine blood type.

Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of care. Case management manages client care by managing the client care environment.

The priorities in management of sickle cell crisis are hydration therapy and pain relief. Cottage cheese (1 cup) contains approximately 31 g of protein.----HIGHEST PROTEIN Green leafy vegetables are a good source of vitamin A Potatoes would provide the highest amount of vitamin C If a client with a tracheostomy is allowed to eat, and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The head of the bed should always be elevated; low Fowlers position could lead to aspiration. The cuff would not be deflated, because of the risk of aspiration. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. Allen test should be performed to determine adequate ulnar circulation.

179

Meal times must be approximately the same each day to maintain a stable blood glucose level. The client should not be instructed that meal times can be varied depending on blood glucose levels, insulin administration, or consumption of snacks. REGULAR & NPH INSULIN 1. 2. 3. 4. Inject air to NPH Inject air to Regular Aspirate Regular Aspirate NPH

The nurse tests for accommodation by asking the client to focus on a distant object. This process dilates the pupils. The client is then asked to shift the gaze to a near object, such as a finger held about 3 inches from the nose. A normal response includes pupillary constriction and convergence of the axes of the eyes. A 3- to 4-week course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with intravenous antibiotics, such as penicillin G. Ultraviolet light therapy is not a component of the treatment plan for Lyme disease.

The classic signs of meningitis include severe headache, fever, stiff neck, and a change in the level of consciousness. Photophobia also may be a prominent early symptom and is thought to be related to meningeal irritation. Although nausea, confusion, delirium, and back pain may occur in meningitis, these are not the classic signs. In anosognosia, the client exhibits neglect of the affected side of the body. The nurse will plan care activities that remind the client to perform actions that require looking at the affected arm or leg, as well as activities that will increase the clients awareness of the affected side.-----INCREASE AWARENESS ON THE AFFECTED SIDE After enucleation, if the nurse notes any staining or bleeding on the surgical dressing, the physician needs to be notified immediately

A caloric test is contraindicated in a client with a perforated tympanic membrane (air may be used as a substitute) or if the client has an acute disease of the labyrinth. An otoscopic examination should be performed before the caloric test to rule out perforation and to determine if the ear canal contains cerumen, which must be removed before the test.

Adults who were born deaf or became deaf before learning to speak usually are not candidates for this type of surgery. Criteria for a cochlear implant procedure are bilateral profound hearing loss, use
of speech as the primary mode of communication, lack of benefit from conventional hearing aids,

180

evidence of strong family and social support, and realistic client expectations for the outcome of the implant procedure.

If a client complains of chest pain, the initial assessment question would be to ask the client about the pain intensity, location, duration, and quality. The signs of

fat embolism

will be associated with alterations in respiratory status or

neurological status. Dyspnea, petechiae, and chest pain are signs of fat embolism.

The client with Cushings syndrome and a nursing diagnosis of excess fluid volume should be maintained on a high-potassium, low-sodium diet. Decreased sodium intake decreases renal retention of sodium and water instruct the client in the signs and symptoms of both hypoadrenalism and hyperadrenalism . After thyroidectomy, the client should be placed in an upright position to facilitate air exchange. The nurse should assist the client with deep breathing exercises, but coughing is minimized to prevent tissue damage and stress to the incision. A pressure dressing is not placed on the operative site. The nurse should monitor the dressing closely and should loosen the dressing if necessary. Neck circumference is monitored every 4 hours to assess for the occurrence of postoperative edema. The client with hypoparathyroidism is instructed to follow a calcium-rich diet and to restrict the amount of phosphorus in the diet. The client should limit meat, poultry, fish, eggs, cheese, and cereals. Vegetables

are allowed in the diet.

VEGETABLES RICH IN CALCIUM DUMPING SYNDROME---MGT.---REMOVE FLUIDS FROM THE MEAL TARY/ AVOID HIGH CARBOHYDRATE The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal (GI) tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst. Semipermeable film dressings such as Op-Site or Duoderm are used on superficial wounds, ulcers, and, occasionally, some deep, draining, or necrotic ulcers. Gelfoam sponge dressings are a type of enzyme dressing used in the treatment of necrotic tissue.

181

The client who is placed on contact precautions has a high microorganism count in some type of body secretions (such as feces or wound drainage). This client is placed in a private room whenever possible and is removed from the room only when absolutely necessary. Client transport should be done only for essential purposes. Notification of departmental personnel and disinfection of any environmental surfaces with which the client has contact are imperative.--BAWAL LUMABAS The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.
MATAGAL GUMALING ANG PATIENT--------The most helpful approach by the nurse is to emphasize

progress that is being made in a realistic manner

Skin color may be more difficult to assess in the client with dark skin. The best areas to use to detect pallor and cyanosis include the tongue, mucous membranes, and the nailbeds. The most useful in evaluating

sclerae are

jaundice.

MALATHION (OVIDE)---FOR HEAD LICE----LEAVE IT FOR 8 -12 HRS.

Lindane shampoo is worked into dry hair in the affected area and left in place for 4 minutes. Then the shampoo is rinsed off with warm water. Dead nits can be removed with a comb or tweezers. Although one treatment usually is sufficient, a second application in 7 days may be required. EMOLIENTS ARE APPLIED INTO DAMP SKIN,,,,, NOT DRY SKIN. The client who has been diagnosed with PID should avoid frequent douching because this decreases the natural flora that controls the growth of infectious organisms. Lithium is an antimanic medication and is used to treat the manic phase Esophageal atresia with TEF---- NG tube must be in place and aspirated every 5 to 10 minutes Cleft palate repair usually is performed between 6 months and 2 years of age, After heart surgery, the child may return to school in 3 weeks but needs to go half-days for the first few days. The mother also should be told that that the child cannot participate in physical education for 2 months

182

PID----SUPINE IN SEMI FOWLERS Preparation for a barium enema includes maintaining a low-fiber diet for 1 to 3 days before the test.

After three sessions of ECT, the client should start to demonstrate improvement in 1 week The normal heart rate for a newborn infant ranges from approximately 110 to 160 beats/min.

The parenteral nutrition solution line is used only for the administration of the solution. Any other intravenous medication must be run though a separate IV

access site.

Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats are introduced one at a time and can begin at 6 months of age.

Prinzmetals angina results from spasm of the coronary vessels and is treated with calcium channel blockers
-Blockers are contraindicated because they may actually worsen the spasm. Diet therapy is not

specifically indicated.

In the absence of continuous direct arterial pressure (intra-arterial) monitoring, the nurse should use an automatic noninvasive blood pressure monitor. Abductor splint used in repositioning the client side to side. Traction, analgesics, and heat all may be used to relieve the pain of muscle spasm in the client with a vertebral fracture. Ice is applied to a painful site only for the first 48 to 72 hours (depending on the physicians preference) after an injury. Application of ice to the spine of a client could be uncomfortable and result in feelings of being chilled. The risks to the cardiovascular system from smoking are noncumulative and are not permanent. 3 to 4 years after cessation, a clients cardiovascular risk is similar to that of a person who never smoked.
PARENTERAL NUTRITION CAUSED BY AIR EMBOLISM----- LEFT SIDE IN TRENDELENBURG POSITION.

183

Lying on the left side may prevent air from flowing into the pulmonary veins. Trendelenburg position increases intrathoracic pressure, which decreases the amount of blood pulled into the vena cava during inspiration. The physician is notified, but this is not the first action. Stopping the parenteral nutrition solution will not treat the problem
If the child is receiving an IV infusion of calcium EDTA, the infusion should be stopped for 1 hour before obtaining a blood level lead concentration. Otherwise, the blood lead concentration will indicate a falsely elevated reading.

-Adrenergic blocking agents such as timolol reduce intraocular pressure by decreasing the

production of aqueous humor. Miotic agents (such as pilocarpine) increase contractions of the ciliary muscle and constrict the pupil, thereby increasing the outflow of aqueous humor. This medication does not reduce intracranial pressure.
DIAMOX (ACETAZOLAMIDE)---- ASK IF ALLERGIC TO SULFA DRUGS.

Acetazolamide is a carbonic anhydrase inhibitor that contains sulfonamide properties. Gemfibrozil is a lipid-lowering agent. It is given as part of a therapeutic regimen that also includes dietary counselingspecifically, the limitation of saturated and other fats in the diet.-----AVOID BEEF The client who has been placed in a body cast is at risk for the development of cast syndrome. This results from pressure on the mesenteric artery and can lead to intestinal obstruction. The important action is to report the clients complaints to the physician. Cast syndrome usually is treated with nasogastric decompression, intravenous therapy for hydration, and possibly application of a new cast. In atrial fibrillation, the walls of the atria fibrillate. The physician may prescribe a daily aspirin. This will prevent embolus secondary to clot formation along the walls of the atria. Atrial fibrillation puts the client at risk for mural thrombi because of the sluggish blood flow through the atria that occurs as a result of loss of the atrial kick. LONG- STANDING EMPYEMA UNDERGOES DECORTCATION OF THE AFFECTED AREA.--------After any procedure involving thoracotomy, the nurse positions the client in semi-Fowlers position. This position allows for maximal lung expansion and promotes drainage through chest tubes that may be placed during surgery.

In a young child, aged 3 to 6 years, the maximum volume of medication that can be safely injected into the ventral gluteal muscle is 1.5 mL.

184

The client may be taking hot showers, which can cause vasodilation with a consequent decrease in venous return to the heart. Decreased venous return decreases cerebral blood flow, leading to symptoms of dizziness. The two-point gait closely resembles normal walking. During the first 24 to 72 hours following surgery, mucuos and serosanguineous drainage is expected from the stoma. This is an expected finding. The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness or warmth of the affected leg, tenderness at the site, possibly dilated veins (if superficial), low-grade fever, edema distal to the obstruction, Homans sign, and increased calf circumference in the affected extremity. Pedal pulses are unchanged from baseline because this is a venous, not an arterial, problem. Often, thrombophlebitis develops silently; that is, the client does not present with any signs and symptoms unless pulmonary embolism occurs as a complication. Fenofibrate (Tricor) is a fibric acid derivative that is used to treat hyperlipidemia. Contraindications to the use of fibrates include known medication allergy, severe liver or kidney disease, cirrhosis, and gallbladder disease. Range of motion is related to musculoskeletal status, not neurovascular status. Signs and symptoms of hypoglycemia include hunger, nervousness, anxiety, dizziness, blurred vision, sweaty palms, confusion, and tingling and numbness around the mouth. Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. The varicella vaccination is recommended to be administered between 12 and 18 months of age. Hair regrowth with the use of minoxidil is most likely to occur when baldness has developed recently and has been limited to a small area. On discontinuation of the medication, newly gained hair is lost in 3 to 4 months, and the natural progression of hair loss resumes. Trolamine salicylate is one of many products used for the temporary relief of muscular aches, rheumatism, arthritis, sprains, and neuralgia. These products contain combinations of antiseptics, local anesthetics, analgesics, and counterirritants. Inapsine (Droperidol) is used to treat postoperative nausea and vomiting.

185

No specific precautions are necessary after a renal scan. Urination into a commode is acceptable without risk from the small amount of radioactive material to be excreted. The nurse wears gloves to maintain body secretion precautions. Oxalate is found in dark green foods such as are rhubarb, strawberries,

spinach.

Other foods that raise urinary oxalate

chocolate, wheat bran, nuts, beets, and tea

. After a myelogram, the client is placed on bedrest for 6 to 8 hours after the procedure. When a water-based contrast medium is used, the client is positioned with the head of bed elevated 15 to 30 degrees. With an air contrast study, the head of the bed is positioned flat. Use of limb restraints will not alleviate spasticity and could harm the client.----PARANG SA SEIZURES---NO RESTRAINT DAPAT Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bedboard under it should be used. The client with myasthenia gravis may experience episodes of respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. For this reason, an Ambu bag, intubation tray, and suction equipment should be available at the bedside. The client avoids swallowing any type of food or drink with the head lifted upward, which could actually cause aspiration by opening the glottis. Clients with Bells palsy should be reassured that they have not experienced a brain attack (stroke) and that symptoms often disappear spontaneously in 3 to 5 weeks. The client is given supportive treatment for symptoms. Bells palsy usually is not caused by a tumor, and the treatment is not similar to that for migraine headaches. RISK FOR FALL-Removal of wall-to-wall carpeting is not necessary. Respiratory failure is the most common cause of death after fat embolus. The client may be intubated and mechanically ventilated with positive end-expiratory pressure to treat the significant hypoxemia and pulmonary edema. The use of corticosteroids is controversial; when given, these agents are used to treat inflammatory lung reactions and control cerebral edema. After femoral head replacement for a fractured hip with an intracapsular fracture, the client is turned to the affected side or the unaffected side as prescribed by the surgeon. Before moving the client, the nurse places a pillow between the clients legs to keep the affected leg in abduction. The nurse then

186

repositions the client while maintaining proper alignment and abduction. A trochanter roll is useful in preventing external rotation, but it is used once the client has been repositioned. A trochanter roll is not used while the client is being turned.

After a client has spinal fusion after a herniated lumbar disk, the head of bed generally is kept flat. The client is logrolled from side to side as ordered. Pillows may be placed under the entire length of the legs, in accordance with surgeon preference, to relieve tension on the lower back. The use of an overhead trapeze may decrease control of spinal movement and is contraindicated because its use could promote twisting of the spine after surgery. The part of the bed under an area in traction usually is elevated to aid in countertraction. For the client in Bucks extension traction (which is applied to a leg), the foot of the bed is elevated. The cane is moved forward with the affected leg. The client leans on the cane for added support while the leg on the stronger side swings through. The client with AIDS who has nausea and vomiting should avoid fatty products such as dairy products and red meat. Meals should be small and frequent to lessen the chance of vomiting. The client should avoid spices and odorous foods because they aggravate nausea. Foods are best tolerated cold or at room temperature.----NOT WARM FOOD Blood glucose results between 80 and 120 mg/dL are considered to be euglycemic (normal) and the prescribed dose would be administered to maintain euglycemia. In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Cyanosis is best noted in the palms of the hands and soles of the foot. Jaundice would best be noted in the sclera of the eye. OXYTOCIN INFUSION/ AMNIOTOMY---- IS FOR HYPOTONIC UTERINE DYSFUNCTION ONLY.--------MONITOR OXYTOCIN CLOSELY NOT FOR HYPERTONIC During the immediate postpartum period, the nurse takes vital signs every 15 minutes in the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. The nurse monitors vital signs thereafter every 4 hours for 24 hours and every 8 to 12 hours for the remainder of the hospital stay. Laboratory findings do not establish the diagnosis of appendicitis, but there is often a moderate elevation of the white blood cell (WBC) count (leukocytosis) to 10,000 to 18,000/mm3 with a shift to the left (an increased number of immature WBCs). Weight and edema are priority interventions for the client with preeclampsia, COLONOSCOPY The client should be instructed that a clear liquid diet is permitted for 1 to 3 days before the procedure (per physician preference) and then oral intake is avoided for 8 hours immediately before the procedure. Oral intake is withheld for 2 hours after the procedure because of the procedural risk of perforation. If a polyp has been removed, the client is instructed that the stool may be tinged with

187

blood. Any signs of tenderness, abdominal pain, and bloody stools, however, should be reported to the physician. Laxatives are prescribed before the procedure to cleanse the bowel.

A client undergoing liver biopsy with use of a local anesthetic will be positioned supine with the clients right hand placed under the head. The client also will be asked to remain as still as possible during the test. CHOLECYSTOGRAM----The nurse instructs the client to eat a fat-free meal the evening before the procedure and then to avoid oral intake except for water on the day of the procedure. The client may be given a high-fat meal or drink during the test to stimulate the emptying of the gallbladder. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM-------After this procedure, the nurse monitors the clients vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate post-procedure period in case surgery is necessary to control hemorrhage or bile extravasation. A compulsion is a repetitive act and an obsession is a repetitive thought. The client with a phobia is likely to experience repetitive fears. Illusions are characteristic of schizophrenia. OBSESSIVE-COMPULSIVE DISORDER OBESSIVE----THOUGHT COMPULSIVE------ACTION SEVERE EMOTIONAL TRAUMA EXPERINCING PARALYSIS OF THE RIGHT ARM-----------ASSESS FOR ORGANIC BASIS OF PHYSIOLOGICAL PROBLEM. The initial nursing action would be to assess for any physiological causes of the paralysis. Although a component of the plan of care would be to encourage the client to discuss feelings, this would not be the initial nursing action. It is not appropriate to encourage the client to use the arm without ruling out a physiological cause of the paralysis. Although the client may be referred to a psychiatrist, this also is not the initial action. NURSING CARE OF PLAN/ NCP The priority would include developing individualized goals and objectives in the plan of care. Goals and objectives are a mutual working tool between the client and the nurse. Although the medical diagnosis of the client is considered in planning care, it is not specifically a component of a nursing care plan. Blepharoplasty is the use of plastic surgery to restore or repair the eyelid or eyebrow (brow lift). Postoperatively, the client is assessed for swelling, bruising, bleeding, and eye pain. The function of extraocular eye muscles also is assessed. The head of the bed should be elevated, and iced eye compresses (using gauze pads) are applied to the area----FOR VASOCONSTRICTION NOT WARM GAUZE PAD- CAUSE TO CILATE & BLEED

188

Elevated thyroid hormone levels also constitute a risk factor for osteoporosis. Early cancer of the cervix usually is asymptomatic. The two chief symptoms are leukorrhea (vaginal discharge) and irregular vaginal bleeding or spotting. Radiation causes scarring and fibrosis of the vagina with a decrease in normal vaginal secretions. The client is instructed to use a vaginal dilator to prevent vaginal narrowing and stenosis. If a chest tube becomes disconnected, the nurse should as quickly as possible place the end of the tube in a container of sterile water or saline until the drainage system can be replaced---------------

Asking the client to perform a Valsalva maneuver is not appropriate

RENAL FAILURE & UREMIA-----Dietary management usually is aimed at restricting protein, sodium, and potassium. The diet may be high in calories. Clients with oxalate stones should avoid foods high in oxalate such as tea, instant coffee, cola drinks, beer, rhubarb, beans, asparagus, spinach, cabbage, chocolate, citrus fruits, apples, grapes, cranberries, and peanuts and peanut butter. Large doses of vitamin C may help increase oxalate excretion in the urine. low-purine diet. The intake of fish and meats (especially organ meats) should be restricted. CYSTOSCOPY & POSSIBLE BIOPSY UNDERGOING GENERAL ANESTHESIA--------PREPROCEDURE SEDATIVES + GENERAL ANESTHESIA-------PWEDE

LEFT VENTRICLE---------HEART
PRIMARILY AFFECTED

FAILURE as a complication of Hypertension------------

MITRAL AREA----------- MONITORING FOR APICAL PULSE USING STETHOSCOPE

S1 & S2

Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop Found in the peripheral arteries and veins, 1-adrenergic receptors cause a powerful vasoconstriction when stimulated. IBA PA YUNG SA ALPHA-2- ADRENERGIC RECEPTORS Cardiac index is an artificial number used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting the cardiac output by body surface area.

189

Sustained inhalation helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. POSTURAL DRAINAGE-------LOBES -------GIVE GRAVITY An ACE inhibitor is used to treat hypertension or heart failure. An adverse effect of ACE inhibitors is a characteristic dry, nonproductive cough. This can be quite bothersome to a client, and the medication may need to be changed. The cough is reversible with discontinuation of therapy. Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It does not flow against a pressure gradient. As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage, to promote lung expansion. This process occurs during the inspiratory phase of the respiratory cycle. The incorrect options occur with exhalation and relaxation of the diaphragm. Room air contains 21% oxygen. The nurse would place the stethoscope just under the left clavicle. The apex of the lung is the rounded, uppermost part of the lung. GAS EXCHANGE---------DIFUSSION Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient. Osmosis is the process of movement according to a concentration gradient. Active transport is movement of molecules by carrying them across a cell membrane. Ionization refers to the process whereby a molecule gains or loses electrons. Pancreatic juice is rich is bicarbonate, which helps to neutralize the gastric acid in food entering the small intestine from the stomach. The duodenal papilla, which is an opening about 10 cm below the level of the pylorus, is responsible for carrying bile and pancreatic juices into the duodenum. The appendix, sometimes referred to as the vermiform appendix, is attached to the apex of the cecum Blockage of the common bile duct impedes the flow of bile from the gallbladder to the duodenum. Bile acids or bile salts are produced by the liver to emulsify or break down fats.

190

Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes. The total protein level also may decrease if the albumin level is low. Albumin is responsible for maintaining the osmolality of the blood Vagotomy is a procedure that can reduce innervation to the stomach, thereby reducing the production of gastric acid. The portal vein drains venous blood from the stomach. The celiac artery brings arterial blood to the stomach. The pyloric valve separates the stomach from the duodenum. The pyloric valve may undergo surgical repair if it becomes stenosed (known as pyloroplasty). Uric acid is produced when purine is catabolized. Probenecid is a medication used for clients with gout to inhibit the reabsorption of uric acid by the kidney and promote excretion of uric acid in the urine. Clients are instructed to modify their diets to limit excessive purine intake. High-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, yeast, wine, and alcohol. Arcus senilis is an age-related change, characterized by formation of a yellow-gray ring around the periphery of the cornea surrounding the iris. Ptosis is a sagging of the upper lid of the eye so that it covers part of the pupil. It can be caused by edema or be the result of third cranial nerve disorders or neuromuscular disorders. The lacrimal apparatus consists of the lacrimal gland (in the upper lid over the outer canthus) and the secretory ducts that direct tears to the lacrimal sac in the inner canthus. Thenurse examines part of this apparatus by retracting the upper eyelid and asking the client to look down. Abnormal findings would include edema and tenderness. Consensual response is a normal finding: One pupil contracts even though the examiners light is shined into the other The nurse who obtains a positive Mantoux test reading calls the physician immediately. The physician would order a chest x-ray study to rule out whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on TB precautions prophylactically until a final diagnosis is made. Although the results of the test would be documented and the employee health service department would be notified, these are not the actions of highest priority from the options provided. Because of the risk of anaphylaxis during the administration of cyclosporine by the IV route, epinephrine and oxygen must be immediately available for use.

Naloxone hydrochloride

is an antidote to opioids, and it also may be given to the postoperative client to treat respiratory depression. When given postoperatively for respiratory

191

depression, it Therefore, the nurse must assess the client for a sudden increase in level of postoperative pain.

also may reverse the effects of analgesics.

Serosanguineous drainage-------CHANGE THE DRESSING-------to prevent infection---No need to monitor for the drainage A replacement tube of the same size and an obturator are kept at the bedside at all times in case the tracheostomy tube is dislodged. Additionally, a curved hemostat that could be used to hold the trachea open if dislodgment occurs should also be kept at the bedside. An oral airway and epinephrine would not be needed. LOW- PRESSURE ALARM SOUND------ DISCONNECTION, LEAK, DISPLACEMENT HIGH PRESSURE ALARM--------KINK TUBE-------OBSTRUCTION-------MGT.----- Suction the Client When the high-pressure alarm sounds on a ventilator, it is most likely due to an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucus plugging requiring suctioning. Epoetin alfa is administered parenterally either by the intravenous or the subcutaneous route After EGD, the nurse places the client in a semi-Fowlers to Fowlers position to aid in comfort and to prevent aspiration. The client remains on NPO (nothing by mouth) status until the gag reflex returns (usually in 2 to 4 hours); the nurse can check the gag reflex by using a tongue depressor to stroke the back of clients throat. Therefore, saline gargles would not be allowed until the gag reflex returns. The vital signs are checked frequently, usually every 30 minutes, until sedation wears off. Wound dehiscence is the partial or complete separation of the outer layers of the wound, sometimes described as splitting open of the wound. If this is noted, the nurse applies a sterile nonadherent dressing, such as a Telfa dressing or a saline dressing, to the wound and notifies the physician. A dry dressing could disrupt the integrity of the underlying tissues. The nurse would document the findings, but this would not be the initial action. Asking the client to cough could cause an extension of the separation of the outer layers of the wound. METASTATIC Breat Cancer Spinal cord compression should be suspected in a client with metastatic disease, particularly with sudden onset of new back pain. Spinal cord compression causes back pain before neurological changes occur. Spinal cord compression constitutes an oncological emergency, so the physician should be notified. Although the nurse would document this finding, this is not the priority action. The nurse would not administer pain medication or place a heating pad on

192

the client unless the cause of the new pain has been determined. Additionally, a physicians order is needed for the use of a heating pad

A blood glucose below 70 mg/dL indicates hypoglycemia. I-A-PE-PA------START SA RLQ To auscultate bowel sounds, the nurse should begin at the ileocecal valve area, because bowel sounds are always present there normally. The diaphragm end piece is used because bowel sounds are relatively high-pitched. The stethoscope is held lightly against the skin because pressing too hard may stimulate more bowel sounds. A Pavlik harness is a device that is used to treat congenital hip dislocation. It keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. The Pavlik harness is worn continuously for 3 to 6 months. It promotes the development of muscle and cartilage, resulting in a stable hip. (DIPRIVAN)----- Propofol is an anesthetic agent that is used to provide continuous sedation in a client receiving mechanical ventilation. It is diluted only with 5% dextrose (D5W). Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its anti-inflammatory, antipyretic, and anticoagulant properties. Serum blood levels may be determined periodically to assess for an effective antiarthritic effect. The therapeutic serum level for an antiarthritic effect is 20 to 30 mg/dL. Toxicity occurs if levels are above 30 mg/dL. ASA (ASPIRIN)------- Occasional side effects include gastrointestinal distress such as cramping, mild nausea, heartburn, and abdominal distention WALANG CONSTIPATION SA ASA!!!!!! BETA-BLOCKER----OLOL-------SLOWS THE HEART RATE A complete health database is the framework for a complete health history and full physical examination. The patient information thus obtained describes the current and past health state and forms a baseline against which all future changes can be measured. The complete health database is used in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, womans health care agency, visiting nurse agency, or community health agency. An episodic database is used for a limited or short-term problem. It focuses mainly on one problem or one body system. A follow-up database evaluates an identified problem at regular and appropriate intervals. An emergency database is used for rapid collection of the data, often compiled concurrently with lifesaving measures. Edema is accumulation of fluid in the intercellular spaces and is not normally present. To check for edema, the nurse would imprint his or her thumbs firmly against the ankle malleolus or the tibia. Normally, the skin surface stays smooth. If the pressure leaves a dent in the skin, pitting

193

edema is present. Its presence is graded on the following 4-point scale: 1+, mild pitting, slight indentation, no perceptible swelling of the leg; 2+, moderate pitting, indentation subsides rapidly; 3+, deep pitting, indentation remains for a short time, leg looks swollen; 4+, very deep pitting, indentation lasts a long time, leg is very swollen.

Scleral icterus is a yellowing of the sclera extending up to the cornea, indicating jaundice. Bronchovesicular breath sounds are heard over major bronchi. Vesicular breath sounds are heard over the peripheral lung fields. Bronchial (tracheal) breath sounds are heard over the trachea and larynx. The upper sternum area is where major bronchi are located. Milk, eggs, meats, and dairy products are high in niacin. Cabbage, tomatoes, potatoes, and strawberries are some of the foods that are high in vitamin C. Milk contains vitamins A and D and some B vitamins. Eggs contain B vitamins. Liver contains vitamins B6 (pyridoxine), B9 (folic acid), and K. LIVER & SPINACH------HIGHEST

VIT. K

Hydrochlorothiazide is a diuretic and antihypertensive medication used to treat mild

to moderate hypertension, edema associated with heart failure, and nephrotic syndrome . The

medication is a sulfonamide derivative. A a history of hypersensitivity to

contraindication to the use of this medication is

sulfonamides.

The CNS is monitored because of the risk of infiltration of blast cells into the CNS. The nurse will check the childs LOC and also will look for signs of irritability, vomiting, and lethargy. Color, motion, and sensation of the extremities are concerns in a neurovascular assessment. Changes in pupillary reaction most often are noted in conditions related to increased intracranial pressure. The presence of petechiae in the sclera is an objective sign of leukemia. Recall of recent events (such as breakfast) is controlled by the hippocampus. The cerebral hemispheres with specific regional functions control orientation. The limbic system is responsible for feelings (affect) and emotions. Calculation ability and knowledge of current events relate to the function of the frontal lobes of the cerebrum. The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A raised toilet seat would be useful if the client did not have sufficient mobility or ability to flex the hips. A slider board would be used in transferring a client with weak or paralyzed legs from a bed to stretcher or wheelchair. Adaptive eating utensils would be beneficial if the client had partial paralysis of the hand.

194

Foods

high in calcium

include milk and milk products, dark green leafy

vegetables, hard water.

tofu and other soy products, sardines, salmon with bones, and

Carpal tunnel syndrome is caused by excessive pressure on the median nerve from injury, overuse, or disease. The brachial and radial arteries bring blood to the upper extremity. The peroneal nerve is in the leg. Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) used to treat depression. A tyramine-restricted diet is required during therapy with this medication, to avoid hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided are meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausage ( pepperoni, bologna). In addition, figs, bananas, aged cheese, yogurt and sour cream, beer, red wine, alcoholic beverages, soy sauce, yeast extract, chocolate, caffeine, and aged, pickled, fermented or smoked foods need to be avoided. Many over-the-counter medications also include tyramine and must be avoided as well.

salami,

Subluxation is an incomplete dislocation of the joint surfaces. The kidneys normally receive about 20% to 25% of the cardiac output and require adequate perfusion to function properly. With significant or prolonged decrease in blood supply, the kidneys can fail. Cardiac failure is referred to as a prerenal cause of kidney failure, because the insult occurs outside the renal system. SIADH---------ADH REABSORBS WATER IN:

The distal tubule and the collecting duct of the nephron require the presence of ADH for water reabsorption. The hormone increases the permeability of the membranes to allow water to flow more easily along the concentration gradient. The glomerulus filters but does not reabsorb. The calices are responsible for collecting the urine. The proximal tubule and the loop of Henle reabsorb water without the assistance of ADH. IRON-----TOMATO JUICE ----------Highest Vitamin C

NOT PINEAPPLE JUICE CYANOSIS-------Ecchymosis is a type of purpuric lesion and also is known as a bruise. Purpura is an umbrella term that incorporates ecchymoses and petechiae. Petechiae are pinpoint hemorrhages and are another form of purpura. Erythema is an area of redness on the skin. Decreased blood glucose levels trigger autonomic nervous system signs and symptoms such as nervousness, irritability, and

tremors. Hot, dry skin accompanies hyperglycemia.

Anorexia and muscle cramps are unrelated to

hypoglycemia.
195

After hypophysectomy, temporary diabetes insipidus can result from antidiuretic hormone (ADH) deficiency. This deficiency is related to surgical manipulation. The nurse should assess urine specific gravity and notify the physician if the result is less than 1.005 Fasciculations are fine muscle twitches that normally are not present. Hypertrophy, or increased muscle size, on the clients dominant side of up to 1 cm is considered normal. Muscle strength is graded from 0/5 (paralysis) to 5/5 (normal power). Symmetrical muscle movement is a normal finding. The groin may be shaved for an angiogram, and inhalation of the radioisotope may be prescribed with positron emission tomography (PET). Orthostatic changes can occur in the client with cardiomyopathy as a result of venous return obstruction. Sudden changes in blood pressure may lead to falls. Vasodilators normally are not prescribed for the client with cardiomyopathy.

Complications following pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse has a

chest tube and drainage

system

available at the bedside for use if hemothorax or pneumothorax develops. An

intubation tray is not indicated. parathyroidectomy. An emergency tracheotomy set is always routinely placed at the bedside of the client who has undergone this type of surgery, in anticipation of this potential complication. Valproic acid is an anticonvulsant Sinus tachycardia often is caused by fever, physical and emotional stress, heart failure, hypovolemia, certain medications, nicotine, caffeine, and exercise. Exercise and fluid restriction will not alleviate tachycardia.

For cardioversion procedures, the defibrillator is charged to the energy level ordered by the physician. Countershock usually is started at 50 to 100 joules.

196

Clients with Parkinsons disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa, which also can cause postural hypotension and increase the clients risk for falls. Clients with Parkinsons disease generally have resting tremor, not intention tremor. BRAIN DEATH TO MAINTAIN VIABILITY OF THE KIDNEY----ADMINISTER IV FLUID

The client with arterial bleeding from a neck wound is in immediate need of treatment to save the clients life. This client is classified as such and would wear a color tag of red from the triage process. The client with a penetrating abdominal injury would be tagged yellow and classified as delayed, requiring intervention within 30 to 60 minutes. A green or minimal designation would be given to the client with a fractured tibia, who requires intervention but who can provide self-care if needed. A designation of expectant is applied to the client with massive head or other injuries and minimal chance of survival; the corresponding color code is black in the triage process. Such clients receive supportive care and pain management but are given definitive treatment last. Unresponsiveness may be an indication of hearing loss. A child who has a history of cleft palate should be routinely checked for hearing loss. PANIC DISORDER HAVING HEART ATTACK-----------ASESS V/S Because mild tactile stimulation of the face can trigger pain in trigeminal neuralgia, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal nerve pain. Assessment should be specific to the area of the brain involved. Assessing the respiratory status and cranial nerve function is a critical component of the assessment process in a client with a brain stem injury. Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in both structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium. Primary dysmenorrhea refers to menstrual pain without identified pathology.

197

The nurse asks the client to void at the beginning of the collection period and then to discard this urine sample. All subsequent voided urine is saved in a container, which is placed on ice or refrigerated. The client is asked to void at the finish time, and this sample is added to the collection. The container is labeled, placed on fresh ice, and sent to the laboratory immediately. Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. The nurse should discontinue an oxytocin infusion in the presence of fetal heart rate decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion. Monitoring the fetal heart rate every 30 minutes will not prevent fetal heart rate decelerations. Many nursing actions are available to prevent fetal heart rate decelerations, without necessitating surgical intervention. As a result of the sedative effect of the magnesium sulfate, the client may not perceive labor. This client is not at high risk for infection. A nonstress test may be done, but not every 4 hours. Daily ultrasound exams are not necessary for this client. The first step in attempting to unclog a feeding tube is aspirating the tube. If this is not successful, flushing the tube with warm water can be tried PARATHYROIDECTOMY--------AIR MIST OR OXYGEN NEEDS HUMIDIFICATION By gestational week 5, double heart chambers are visible by ultrasound and the heart begins to beat. The fetal heart is only two parallel tubes at week 3. At week 5, the heart can be visualized only by ultrasound. To be heard by Doppler, the gestation must be 12 weeks; to be heard by fetoscope, the gestation must be at 20 weeks. Clients with hemorrhagic stroke usually have the head of the bed elevated to 30 degrees to reduce intracranial pressure that can occur from the hemorrhage. The head should be in a midline, neutral position to facilitate venous drainage from the brain. Extreme hip and neck flexion should be avoided to prevent an increase in intrathoracic pressure and to promote venous drainage from the brain. For clients with ischemic stroke, the head of the bed usually is kept flat to ensure adequate blood flow and thus oxygenation to the brain. The physicians orders are always followed with regard to positioning the client after stroke

198

After supratentorial surgery (surgery above the tentorium of the brain), the head of the clients bed usually is elevated 30 degrees to promote venous outflow through the jugular veins The clients blood glucose level should be monitored every 4 to 6 hours during PN therapy. Depending on agency policy, this may be done every 8 hours instead. --LOW SODIUM-----Chicken breast has 70 mg of sodium, compared with 457 for cottage cheese, 700 mg for grilled cheese, and 800 mg for beef bouillon. Naoloxone hydrochloride (Narcan) should be titrated every 2 to 5 minutes according to client response. MAGICAL THINKING-------PRE-SCHOOLER The diet for the client with ulcerative colitis should be a low-fiber (low-residue) diet. The nurse should avoid providing foods such as whole-wheat grains, nuts, and fresh fruits or vegetables. Typically, lactose-containing foods also are poorly tolerated. The client also should avoid caffeine, pepper, and alcohol. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When they are heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue such as in a lung mass, atelectasis, or pneumonia. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at T4 medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity. CONGENTIN-----URINARY RETENTION------MONITOR I & O If significant flail chest is present, the nurse applies firm yet gentle pressure to the flail segments of the ribs to stabilize the chest wall, which will ultimately help the victims respiratory status

MASSIVE CELL DESTRUCTION ON CHEMOTHERAPY- URIC ACID LEVEL

199

The client undergoing pericardiocentesis is positioned supine with the head of bed raised to a 45- to 60-degree angle. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac. There is no need to avoid straining with exophthalmos. . Soft contact lenses may be permanently damaged by the orange discoloration in body fluids caused by rifampin. Any sign of possible jaundice (yellow-colored skin) should always be reported. If rifampin is not tolerated on an empty stomach, it may be taken with food. The client may be on the medication for 12 months even if cultures give negative results. Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Dyskinesias occur in cerebellar disorders so this is not as important a concern as in cord-injured clients, unless head injury is suspected.

Bumetanide is a loop diuretic that is not potassium sparing. Lithium is used to treat manic disorders, not depression. Side effects of lithium are nausea, tremors, polyuria, and polydypsia. Serum lithium concentration is assessed approximately every 2 to 4 daysNOT DAILY during initial therapy, and at longer intervals thereafter. Toxic levels of lithium may induce electrocardiogram changes; however, performing weekly ECGs is unnecessary if therapeutic levels are maintained. Cystitis is an infection of the bladder. The client should consume 3000 mL of fluids per day. Sitz baths and ice would be appropriate interventions for perineal discomfort. Hemoglobin and hematocrit levels would be monitored with hemorrhage. Raynauds disease produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Palpation for diminished or absent peripheral pulses checks for interruption of circulation. The nails grow slowly, become brittle or deformed, and heal poorly around the nail beds when infected. Skin changes include hair loss, thinning or tightening of the skin, and delayed healing of cuts or injuries. Although palpation of peripheral pulses is correct, a rapid or irregular pulse would not be noted. Peripheral pulses may be normal, absent, or diminished.

7 YEAR OLD----BOARD GAMES

200

LARGE PUZZLE ----TODDLER The school-aged child becomes organized with more direction with play activities. Such activities include collections, drawing, construction, dolls, pets, guessing games, board games, riddles, hobbies, competitive games, and listening to the radio or television. Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the affected lower extremity to improve venous return also may be recommended. Warm packs may be applied to the affected area to promote healing. There is no need for anticoagulants or antiinflammatory agents unless the condition persists. After 5 to 7 days of bed rest, and when symptoms disappear, the woman may ambulate gradually. If pulmonary embolism is suspected, oxygen should be administered at 8 to 10 L/min by face mask. Oxygen is used to decrease hypoxia. The woman also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this action would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of the oxygen. PREVENTION:!!!!!!!!!!!! Stasis is believed to be a predisposing factor in the development of thrombophlebitis. Because cesarean delivery is also a risk factor for thrombophlebitis, new mothers should ambulate early and frequently to promote circulation and prevent stasis. Options elevate legs, remain on bed rest and moist packs are interventions for the client diagnosed with thrombophlebitis. Many kidney stones are composed of calcium oxalate. Foods that raise urinary oxalate

excretion include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, and tea.

The client needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates. In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients.

201

Sensible losses are those of which the person is aware, such as through wound drainage, gastrointestinal tract losses, and urination. Insensible losses may occur without the persons awareness. Insensible losses occur daily through the skin and the lungs . Respiratory acidosis is most often caused by hypoventilation. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease. In end-stage disease, pathological changes lead to airway collapse, air trapping, and disturbance of ventilationperfusion relationships Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. Kussmauls respirations are abnormally deep, regular, and increased in rate. Apnea is described as respirations that cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The normal range for total serum protein level in the adult client is 6.0 to 8.0 g/dL. T TPN is usually indicated for clients receiving long-term nutritional support and PPN is usually used for short-term support. PPN can supplement oral intake, whereas TPN is usually administered to clients who are NPO. TPN can provide a greater number of calories than PPN. PPN is used to deliver isotonic or mildly hypertonic solutions and TPN can be used to deliver highly hypertonic solutions. HYPERGLYCEMIA HAS WEAKNESS ALSO LIKE HYPOGLY The most common postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary edema usually results from failure of the left side of the heart and can be caused by medications or fluid overload. Carbon dioxide retention results from an inability to exhale carbon dioxide in conditions such as chronic obstructive pulmonary disease.

202

The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely, maintains the body temperature of the fetus, and helps measure kidney function, because the amount of fluid is based on the amount of urination from the fetus. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the mother and the fetus. 2ND TRIMESTER----- PULSE RATE Constipation may occur as a result of decreased gastrointestinal motility or pressure of the uterus. During pregnancy, there is an accelerated production of RBCs. PRE-OPERATIONAL-------FANTASY & REALITY

CONCRETE OPERATIONAL-----LOGICAL THOUGHT (7-11yrs.old) SCHOOL AGE---- COLLECT VARIOUS OBJECTS FORMAL OPERATIONAL------ABSTRACT THOUGHT (11 to 15 yrs.old)

SENSORIMOTOR-------ENVIRONMENT (Up to 2 yrs.) coordination of secondary schemata,

Tertiary circular reactions

In the preconventional stage, morals are thought to be motivated by punishment and reward Kohlbergs theory states that individuals move through the six stages of development in a sequential fashion. During stage 0 of egocentric judgment, between birth and 2 years of age, the infant has no awareness of right or wrong. Stage 1, punishment-obedience, from 2 to 3 years of age, is when children view the world in a selfish way and require discipline with simple explanations of why it is wrong and the use of distraction. Stage 2, instrumental relativist, from 4 to 7 years of age, is when the conscience emerges and the emphasis is on external control. From 7 to 10 years of age, stage 3, the focus is on good boynice girl, when being good also means maintaining mutual relationships, such as trust, loyalty, respect, and gratitude. Stage 4, from 10 to 12 years of age, focuses on law and order, and is when the child wants to be considered as good by persons whose opinion is important to them. The adolescent in stage 5, social contract and legalistic orientation, gives and takes and does not expect to receive something without paying for it. During the final stage, universal ethical principles, the control

203

of conduct is internal; the individual can acknowledge a conflict between two socially accepted standards and try to decide between them.

Ageism is a form of prejudice in which older adults are stereotyped by characteristics found in only a few members of their group. Fundamental to ageism is the view that older persons are different from me and will remain different from me. Therefore, they are portrayed as not experiencing the same desires, needs, and concerns. Option 4 suggests that the older adult is not worthy of aggressive treatment and demonstrates ageism. The pineal gland is a major site of melatonin biosynthesis. The thymus gland plays an immunological role throughout life.

Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown origin In tricuspid atresia, no communication exists from the right atrium to the right ventricle. A SINGLE VESSEL OVERRIDES BOTH VENTRICLES describes truncus arteriosus. NO COMMUNICATION EXIST BETWEEN SYSTEMIC & PULMONARY CIRCULATION describes transposition of the great arteries. Frequent episodes of hypercyanotic spells occur in tetralogy of Fallot. In DDH, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. In the Ortolani maneuver, the examiner reduces the dislocated femoral head back into the acetabulum. A positive finding is the palpable click or clunk on movement of the femoral head over the acetabular ring. This maneuver does not result in permanent relocation. Its purpose is to note the possibility of correction by means of the Pavlik harness or spica casting. In the Barlow maneuver, the examiner pushes the unstable femoral head out of the acetabulum. If it dislocates, it usually relocates immediately. The purpose is to note the presence of instability.

The confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate and biopsy. A lumbar puncture may be done to look for blast cells in the spinal fluid that indicate central nervous system disease. The white blood cell count may be normal, high, or low in leukemia. An altered platelet count occurs as a result of the disease but also may occur as a result of chemotherapy and does not confirm the diagnosis.

204

Hodgkins disease is a neoplasm of lymphatic tissue. The presence of giant, multinucleated cells (Reed-Sternberg cells) is the hallmark of this disease. The presence of blast cells in the bone marrow indicates leukemia. The Epstein-Barr virus is associated with infectious mononucleosis. Elevated levels of vanillylmandelic acid in the urine may be found in children with neuroblastoma. In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms of the hands and soles of the feet at regular intervals for subtle color changes. In a client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge. With the classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This skin cancer is highly metastatic, and a persons survival depends on early diagnosis and treatment. A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or bluetoned color. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale. Multiple myeloma is a B-cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. Cytoreductive or debulking surgery may be used if a large tumor cannot be completely removed as is often the case with late-stage ovarian cancer (e.g., the tumor is attached to a vital organ or spread throughout the abdomen). When this occurs, as much tumor as possible is removed and adjuvant chemotherapy or radiation may be prescribed.

Hormone therapy (androgen deprivation) is a mode of treatment for prostatic cancer. The goal is to limit the amount of circulating androgens because prostate cells depend on androgen for cellular maintenance. Deprivation of androgen often can lead to regression of disease and improvement of symptoms Chemotherapy agents are usually given in combinations (also called regimens or protocols). The goal of administering combination chemotherapy in cycles or specific sequences is to produce

205

additive or synergistic therapeutic effects. Administering combination therapy by administering several medications with different mechanisms of action and different onset of nadirs and toxicities enhances tumor cell destruction while minimizing medication resistance and overlapping toxicities.

Cyclophosphamide (Cytoxan, Neosar) is an antineoplastic medication of the alkylating class. Medications of this type affect all phases of the reproductive cell cycle. Cell cycle phase-specific medications affect cells only during a certain phase of the reproductive cycle. Antimetabolite medications are cell cycle phase-specific and affect the S phase. Vinca alkaloids are cell cycle phase-specific and act on the M phase. A high-complex carbohydrate and high-protein diet will be prescribed for the client with Addisons disease. To prevent excess fluid and sodium loss, the client is instructed to maintain a normal salt intake daily (3 g) and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting, or diarrhea. A high-fat diet is not prescribed. Lugols solution is administered to hyperthyroid individuals in preparation for thyroidectomy to suppress thyroid function. Initial effects develop within 24 hours; peak effects develop in 10 to 15 days. In most cases, plasma levels of thyroid hormone are reduced with propylthiouracil (PTU) before Lugols solution therapy is initiated. Then, Lugols solution along with propylthiouracil is administered for the last 10 days before surgery. A pyloroplasty involves making an incision and resuturing of the pylorus to relax the muscle and enlarge the opening from the stomach to the duodenum. A vagotomy involves cutting the vagus nerve. A subtotal gastrectomy involves removing the distal portion of the stomach. A Billroth II procedure involves removal of the ulcer and a large portion of the tissue that produces hydrochloric acid. A vagotomy, or cutting of the vagus nerve, is done to eliminate parasympathetic stimulation of gastric secretion Senna works by changing the transport of water and electrolytes in the large intestine, which causes accumulation of water in the mass of stool and increased peristalsis.

Variant angina--- occurs at rest AT THE SAME TIME Unstable Angina-occurs at rest LESS PREDICTABLE---- M.I. Therapeutic levels for digoxin range from 0.5 to 2 ng/mL. Warfarin sodium works in the liver and inhibits synthesis of four vitamin K-dependent clotting factors (X, IX, VII, and II), but it takes 3 to 4 days before the therapeutic effect of warfarin is exhibited. Bells palsy is a one-sided facial paralysis from compression of the facial nerve. The exact cause is unknown, but may include vascular ischemia, infection, exposure to viruses such as herpes zoster or herpes simplex, autoimmune disease, or a combination of these factors.

206

Cognitive behavioral therapy is used to help the client identify and examine dysfunctional thoughts and to identify and examine values and beliefs that maintain these thoughts All stomach contents are aspirated and measured prior to administering a tube feeding. This procedure measures the gastric residual. The gastric residual is assessed to confirm whether undigested formula from a previous feeding remains, thereby evaluating absorption of the last feeding. It is important to assess gastric residual because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwicks sign, is one of the earliest signs of pregnancy. Montgomerys tubercles are sebaceous glands located in the areola. The ovarian cycle consists of three phases, the follicular, ovulatory, and luteal phases. The proliferative phase is a phase of the endometrial cycle. During a menstrual period, a woman loses about 40 mL of blood. Because of the recurrent loss of blood, many women become mildly anemic during their reproductive years, especially if their diets are low in iron.

Although frequency and intensity of bowel sounds will vary depending on the phase of digestion, normal bowel sounds are relatively high-pitched clicks or gurgles. Loud gurgles (borborygmi) indicate hyperperistalsis. Bowel sounds will be more high-pitched and louder (hyperresonance) when the intestines are under tension, such as in intestinal obstruction. A swishing or buzzing sound represents turbulent blood flow associated with a bruit. Bruits are not normal sounds. McBurneys point is midway between the right anterior superior iliac crest and the umbilicus. It is usually the location of greatest pain in the child with appendicitis. Sodium polystyrene sulfonate (Kayexalate) is a cation exchange resin used for the treatment of hyperkalemia. The resin passes through the intestine or is retained in the colon. It releases sodium ions primarily in exchange for potassium ions. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration. The uterus has three divisions, the corpus, isthmus, and cervix. The upper division is the corpus or body of the uterus. The uppermost part of the uterine corpus, above the area where the fallopian tubes enter the uterus, is the fundus of the uterus. Refrigeration preserves the elements of urine. If the specimen stands at room temperature, the warmth causes bacteria and WBCs to decompose. Also, when urine is allowed to stand

207

unrefrigerated, the urea breaks down to ammonia and becomes more alkaline. The pH decreases in an acidic condition.

The typical schedule for hemodialysis is 3 to 4 hours of treatment three days per week. Individual adjustments may be made according to variables such as the size of the client, type of dialyzer, the rate of blood flow, personal client preferences, and others. Hypothalamic damage causes persistent hyperthermia, which also may be called central fever. It is characterized by a persistent high fever with no diurnal variation. Another characteristic feature is absence of sweating. The reticular activating system in conjunction with the cerebral hemispheres is responsible for arousal. The temporal lobe, hippocampus, and frontal lobe are responsible for memory. The limbic system is responsible for feelings and affect.

The normal serum amylase level ranges from 53 to 123 Somogyi units/dL in the adult, depending on the laboratory running the test. The normal serum ammonia level ranges from 19 to 60 mcg/dL Laennecs cirrhosis results from long-term alcohol abuse. Cardiac cirrhosis most commonly is caused by long-term right-sided congestive heart failure. Exposure to hepatotoxins, chemicals, or infections, or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts. The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 second. The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help to meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client. A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female pelvis. An anthropoid pelvis has an oval shape, and an android pelvis is heart shaped.

208

A client advocate is a person who speaks out for or supports the best interests of the client. This includes encouraging independence as well as speaking for the client. The researchers goal is to identify factors that alter health care outcomes. A resource linker is a person who helps a client make a contact with an appropriate community agency. In the role of collaborator, the nurse works with the client, family, community, and other health care providers to organize the plan of care.

The role of the case manager is to organize, manage, and balance

health care services needed for the client.

. Primary prevention activities are actions designed to prevent a disease from occurring and reduce the probability of the occurrence of a specific illness. Periodic well-baby examinations focus on health education, nutrition, concerns related to adequate housing, recreation, and genetics. Selective placement of the infant is vague and does not provide any specific information.

The stomach capacity of a newborn infant is 10 to 20 mL; 30 to 60 mL for a 1-week-old infant; 75 to 100 mL for a 2- to 3-week-old infant; and 90 to 150 for a 1-month-old. A severe febrile illness is a reason to delay immunization but only until the child has recovered from the acute stage of the illness. Minor illness, such as a cold, otitis media, or mild diarrhea, is not a contraindication to immunization. Honeydew melon, spinach, and strawberries are high-potassium foods and average 10 mEq per serving. Cranberry juice is low in potassium and averages 5 mEq per serving. Compartment syndrome is caused by bleeding and swelling within a tissue compartment that is lined by fascia, which does not expand. The bleeding and swelling put pressure on the nerves, muscles, and blood vessels in the compartment, triggering the symptoms. The ideal number of clients in a psychotherapy group ranges from 7 to 10. Having more than 10 members is not recommended because the group will subdivide, which is counterproductive. Too large a group also can create more opportunities for acting out as opposed to working through issues. Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall. The cause is not known, and a higher incidence is seen in males. JUVENILE IDIOPATHIC ARTHRITIS-- . JIA is twice as likely to occur in girls than in boys.

209

B lymphocytes have the job of making antibodies and mediating humoral immunity. They do not activate T cells. T cells attack and kill target cells directly. The primary function of macrophages is phagocytosis. The immune system has five major types of cells: B lymphocytes, or B cells; helper T lymphocytes, or CD4+ cells; cytolytic T lymphocytes (CTLs), or CD8+ cells; macrophages; and dendritic cells. RBC-----WALANG KINALAMAN SA IMMUNE SYSTEM Specific immune responses have three main phases. These include the recognition phase, the activation phase, and the effector phase.

Memory is not a feature of an immune

response.

. Eosinophils attack and destroy foreign particles that have been coated with antibodies of the IgE class. Their usual target is helminths (parasitic worms). Basophils mediate immediate hypersensitivity reactions. Dendritic cells perform the same antigen-presenting task as that of macrophages. Neutrophils phagocytize foreign particles such as bacteria. Interferon is produced by several types of cells and is effective against a wide variety of viruses. It works on the host cells to induce protection and differs from an antibody, which inactivates viruses found outside the cells. MAJOR SERUM ANTIBODY-----IgG---Most Abundant
The major serum antibody is IgG, constituting about 70% of the total circulating antibodies. It is antiviral, antibacterial, and effective against toxins. IgA makes up about 21% of the total circulating antibodies. IgM is the first antibody produced in response to antigen and makes up about 7% of the total serum antibodies, and IgE accounts for only about 0.5% of the total antibody level in the blood.

Chemical barriers include various acids and enzymes found in body fluids. The skin, the mucous membranes, and the action of cilia lining the respiratory tract are physical barriers.

Toxoids only are toxins produced by bacteria that have been altered so that they are no longer toxic. Their important antigenic receptor sites remain intact, enabling antibodies to be produced to the antigen-producing toxin.

210

Active immunity lasts much longer and is more effective at preventing subsequent infections than passive immunity. Active immunity lasts for years and can be easily reactivated by a booster dose of antigen. Passively received human antibodies have a half-life of about 30 days. Protection from active immunity takes 5 to 14 days to develop after the first exposure to the antigen and 1 to 3 days after subsequent exposures. Passive immunity provides protection immediately.

Active immunity lasts much longer and is more effective at preventing subsequent infections than passive immunity. Active immunity lasts for years and can be easily reactivated by a booster dose of antigen. Passively received human antibodies have a half-life of about 30 days. Protection from active immunity takes 5 to 14 days to develop after the first exposure to the antigen and 1 to 3 days after subsequent exposures. Passive immunity provides protection immediately. The liver contains a large number of macrophages called Kupffer cells. These cells help filter blood by phagocytizing microorganisms and other foreign particles passing through the liver

Peyer patches are lymphoid nodules located in the small intestine where T cells congregate. These organs are most important in the secondary immune response, although they play a role in the primary immune response as well. These organs may enlarge as they become highly active in the immune response Specific immunity is the second line of defense against infection. The body uses this process to identify specific antigens. With this type of immunity, different reactions occur in response to different antigens, and the response must be learned and developed

Pecific Immunity econd line of defense learnning The test for rheumatoid factor detects measures the presence of unusual antibodies of the IgG and IgM type, which develop in a number of connective tissue diseases.

The pancreas produces both endocrine and exocrine secretions as part of its normal function. The organ secretes insulin as a key endocrine hormone to regulate the blood glucose level. Other pancreatic endocrine hormones are glucagon and somatostatin. The exocrine pancreas produces digestive enzymes such as amylase, lipase, and trypsin.

211

Epinephrine and norepinephrine are produced by the adrenal medulla. The other substances listed (cortisol, aldosterone, and the androgens) are produced by the adrenal cortex.

The hypothalamus exerts an influence on both the anterior and posterior pituitary gland. Abnormalities can result in excess or deficit of substances normally mediated by the pituitary. ADH could be affected by disease of the hypothalamus because the hypothalamus produces ADH and stores it in the posterior pituitary gland. The adrenal cortex is responsible for the production of glucocorticoids and mineralocorticoids. The pineal gland is responsible for melatonin production. Parathyroid hormone is responsible for maintaining serum calcium and phosphorus levels within normal range. Thyroid hormone is responsible for maintaining a normal metabolic rate in the body. Follicle-stimulating hormone and adrenocorticotropic hormones are produced by the anterior pituitary gland. They are responsible for growth and maturation of the ovarian follicle and stimulation of the adrenal glands, respectively. Overactivity of the thyroid gland causes increased metabolism, including fat metabolism. This leads to decreased levels of fat in the bloodstream, including cholesterol, and decreased body fat stores. Weight loss occurs as a result of the increased metabolic activity. Glucose tolerance is decreased, and the client experiences hyperglycemia. Although the client has an increased appetite, food intake does not meet energy demands, and nutritional deficiencies can develop. Cushings syndrome is characterized by an excess of cortisol, a glucocorticoid. Glucocorticoids are produced by the adrenal cortex. Epinephrine and norepinephrine are produced by the adrenal medulla. Calcium is unrelated to this disorder. As the blood glucose levels rise when glucose is not being carried into the cells, the body interprets that more glucose is needed. The initial response by the body is to use up the stores of glycogen in the liver. The conversion of glycogen to glucose for use by the body is called glycogenolysis. When this mechanism fails, the body then breaks down fats and proteins and converts them into glucose. This process is called gluconeogenesis. Glucose binds onto cell membranes and is transported across them into the cells when there is sufficient circulating insulin.

glucose level-----glycogenolysis worsen it

212

. Ketones are a byproduct of fat metabolism. When this process occurs to an extreme, the resulting condition is called ketoacidosis. The causes of type 1 diabetes mellitus include an involvement of genetic factors, specifically, the presence of the human leukocyte antigen (HLA). This factor is found in many clients with type 1 diabetes mellitus. Autoimmune factors and viruses are also thought to play a role in its development. The problem with type 1 diabetes mellitus is destruction of the beta cells. It is not due to a primary failure of glucagon secretion. Pagets disease is characterized by skeletal deformities due to abnormal bone resorption, followed by abnormal regeneration. It is not due to problems with muscles, joints, or nervous system functioning.

MITRA T

-----LA+LV ICUSPID-----RA+RV

The primary effect of a decreased blood pressure is reduced blood flow to the myocardium. This in turn decreases the oxygenation to cardiac tissue. Cardiac tissue is likely to become more excitable or irritable in the presence of hypoxia. Correspondingly, the heart rate is likely to increase in response to this change, not decrease. The effects of tissue ischemia will lead to decreased contractility over time. The normal calcium level is 8.6 to 10 mg/dL. A low calcium level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization, and move back during repolarization. Depolarization is responsible for cardiac contraction. The cardiac cycle consists of contraction and relaxation of the heart muscle. The heart normally sends out about 5 L of blood every minute to the body. The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the BP will decrease, it is not the earliest indicator.

213

The normal cardiac output for the adult can range from 4 to 8 L/min and varies greatly with body size. The heart normally pumps 5 L of blood every minute. The LAD bifurcates from the left main coronary artery to supply the anterior wall of the left ventricle and a few other structures. The RCA supplies the right side of the heart, including the atrium and ventricles. The circumflex coronary artery bifurcates from the left coronary artery, and supplies the left atrium and the lateral wall of the left ventricle. The PDCA supplies the posterior wall of the heart. When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because one of the normal functions of the nose is to stimulate appetite through the sense of smell.

The chief cells of the stomach secrete pepsinogen, a precursor to pepsin, which helps to digest proteins. The parietal cells of the stomach secrete hydrochloric acid (gastric acid) and intrinsic factor. The UES is formed by the cricopharyngeus muscle attached to the cricoid cartilage. The pyloric sphincter joins the stomach and the duodenum and is responsible for proper gastric emptying. The cardiac sphincter is another name for the lower esophageal sphincter, which joins the esophagus and the stomach. The jejunum and ileum are the two portions of the small intestine. Intrinsic factor is produced in the stomach but is used to aid in the absorption of vitamin B12 in the small intestine. This vitamin is not absorbed in the large intestine STOMACH-PRODUCED SMALL INTESTINE- ABSORB LACTASE-----REMAIN NORMAIL IN PANCREATITIS AMYLASE---ELEVATES IN PANCREATITIS Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Lipase, amylase, and trypsin are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.

214

The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. This enzyme normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Enterokinase and lactase are enzymes produced by the small intestine. Enterokinase activates trypsin, whereas lactase splits lactose into galactose and fructose. The small intestine is responsible for absorption of a majority of nutrients. The client who has undergone removal of a segment of the small bowel resection is the one who has a decreased area with which to absorb nutrients. The principal reflex center for defecation is located in the parasympathetic center, which in turn is located in the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes.

During deamination of proteins in the liver, the amino group splits from the carbon-containing compound, which results in formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result. Gluconeogenesis is the production of glucose for energy from protein and fat stores in the body. This can occur with extreme dieting and also with diabetes mellitus. The body normally burns glucose for energy. Glycogenolysis is the production of glucose from glycogen stores in the liver. Lactic acidosis occurs with excess production of lactic acid due to anaerobic metabolism. Gluconeogenesis---------weight loss due to diet The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi. It then flows into the right and left hepatic ducts and then into the common hepatic duct. From here, the bile can be stored in the gallbladder through the cystic duct. Otherwise, it can flow directly into the duodenum by way of the common bile duct. An important function of the liver is to break down medications and other toxic substances. The older client with liver disease is at increased risk for toxic medication effects and should be monitored carefully for adverse effects.

215

Hyperopia occurs when the client experiences blurred vision because the focal point falls behind the retina. Commonly called farsightedness, this condition may be caused by an eyeball that is shorter than usual, or by a cornea that has less curvature than normal. It is corrected by use of a convex or plus lens for close work, such as reading. The other options do not describe this condition. HYPEROPIA- BEHIND MYOPIA-FRONT CONJUCTIVA---PROVIDES PROTECTIVE COVERING FOR THE EYE Myopia results when the light rays come into focus in front of the retina. In many cases, this abnormality is due to an eyeball that is too long, which may be a familial trait. This condition, referred to as nearsightedness, is corrected by the use of concave or minus lenses in contact lens or eyeglasses. Astigmatism most often is due to a misshapen cornea that is not perfectly spherical. As a consequence, the cornea cannot bend light rays equally in all directions, with resulting impairment of both near and far vision. This condition is corrected by cylindrical lenses Primary open-angle glaucoma results from obstruction by the trabecular meshwork and is the most common form of glaucoma. It is insidious in onset, bilateral, and slow to progress. Because it occurs gradually, the client may not notice the loss of vision, which is irreversible. Angleclosure glaucoma results from sudden blockage of the anterior angle by the base of the iris. Low-tension glaucoma resembles primary open-angle glaucoma to some degree, except that the changes develop despite normal intraocular pressures. Secondary glaucoma often is due to edema or delayed corneal wound healing as a complication of eye surgery. The ability of each eye to focus on the same point in space, coupled with the ability of the brain to fuse the images into a single mental impression, permits binocular vision. Optic nerve function is responsible for transmitting visual images to the brain for interpretation. Ocular muscle control governs eye movements. Depth perception is the ability to see images in three dimensions instead of two.

DIPLOPIA-----LOSS OF BINOCULAR VISION

216

The ciliary body is responsible for producing aqueous humor, which then circulates from the posterior chamber to the anterior chamber, and is filtered out through the trabecular meshwork into Schlemms canal. The optic disk has no visual ability, because it is the head of the optic nerve, which transmits visual impulses to the brain. It has no sensory fibers and therefore represents a blind spot in the eye. The rods are found in the periphery of the retina and function best in dim light. Because of this, impaired rod function results in night blindness. Cones are responsible for perception of detail and color vision. Because they are located in the center of the retina, damage to cones can result in reduced central vision or color blindness

RO

IM LIGHT

NIGHT BLINDNESS

LOR VISION

COLOR BLINDNESS

NES The iris controls the amount of light that enters the eye; the lens focuses that light on the retina. The most likely cause for rheumatoid arthritis is the activation of an autoimmune response. This response is thought to trigger antigen-antibody responses and release of lysosomes from phagocytic cells, which ultimately attack the cartilage and synovia, with resultant synovitis. Other theories related to the cause of rheumatoid arthritis have been proposed, but the most likely cause is an autoimmune reaction. The normal range for the fasting blood glucose level is 70 to 110 mg/dL. Physiological responses to chronic pain include normal blood pressure, heart rate, and respiratory rate, along with normal pupils and dry skin. Acute pain causes an increased blood pressure (initially), increased pulse and respiratory rate, dilated pupils, and perspiration. Older adults should not take meperidine hydrochloride because of the prolonged half-life of its medication metabolite, normeperidine. Normeperidine, an excitotoxin, accumulates with

217

repeated dosing, which can lead to life-threatening seizures. Because of the physical changes of aging, older clients excrete this medication slowly, leading to a risk for cerebral irritation and seizures.

Substance abusers often are tolerant to the pain-relieving effects of opioids and require increasingly higher doses. The danger of physiological withdrawal exists when opioid agonists are abruptly withdrawn from the substance-abusing client. PCA is achieved through the use of a PCA infusion pump. The nurse programs the dosing parameters into the PCA delivery device, and the client can control the dosage of opioid analgesia received. Clients can obtain pain relief more quickly by administering the medication themselves and therefore feel that they have more control of their surroundings and their general state of health. This approach to pain control can improve pain relief and increase client satisfaction. It also can decrease the amount of opioid consumption per day when compared with intermittent dosing methods. Meperidine hydrochloride is used for the relief of acute pain. However, the use of meperidine hydrochloride for pain control is reserved for short-term use (usually less than 48 to 72 hours) because its toxic metabolite, normeperidine, may accumulate in the blood, potentially leading to confusion and seizures. Epidural analgesia (also known as peridural or extradural analgesia) refers to the instillation of a pain-blocking agent into the epidural space. Complications that occur with epidural analgesia are directly related to catheter placement, catheter maintenance, and the type of analgesia. Epidural catheters are not sutured in position and must be taped in place, so they are more easily dislodged. Low concentrations of local anesthetics are used, to avoid the significant sensory and motor deficits that can accompany epidural analgesia. A complaint of pain by an older client should be addressed promptly because the pain indicates a physiological problem. Options 1, 2, and 3 are incorrect. Pain is not a natural and expected outcome of aging. Nonpharmacological relief measures such as massages and warm soaks may be effective. The cause of the pain is always assessed before the pain is treated.

The normal PT for an adult female ranges from 9.5 to 11.3 seconds (9.6 to 11.8 for a male client). The normal platelet count ranges from 150,000 to 400,000/ L

218

The normal albumin level is between 3.4 and 5 g/dL. Higher-risk methods, often called hard methods, include using a gun, jumping off a high place such as a bridge, hanging, staging a car crash, and carbon monoxide poisoning. Lower risk or soft methods include slashing ones wrists, ingesting pills, and inhaling natural gas. Affect and emotions are part of the role of the limbic system and involve both hemispheres of the brain. The response to verbal stimuli is part of the level of consciousness, which is under the control of the reticular activating system and both cerebral hemispheres. Insight, judgment, and planning are part of the functions of the frontal lobes of the brain, in conjunction with association fibers connecting to other areas of the cerebrum. Pain is a complex experience, involving several areas of the central nervous system.

Insomnia, agitation, mania, and delirium are due to excessive arousal of the reticular activating system in conjunction with the cerebral hemispheres. The temporal lobe, hippocampus, and frontal lobe are responsible for memory. The limbic system is responsible for feelings and affect. STEREOGNOSIS----PARIETAL LOBE The parietal lobe of the brain is responsible for spatial orientation and awareness of sizes and shapes. The ability to distinguish an object by touch is called stereognosis, which is a function of the right parietal area. The left parietal area is responsible for mathematics and right-left orientation. DELIRIUM----RAS & CEREBRAL HEMISPHERE The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The reticular activating system is responsible for the sleep-wake cycle. The limbic system is responsible for emotions.

HIGH CARBON DIOXIDE IN THE BLOOD STREAM----BRAIN:

Carbon dioxide is one of the metabolic end products that can alter the tone of the blood vessels in the brain. High carbon dioxide levels cause vasodilation, whereas low carbon dioxide levels cause vasoconstriction. As a result, the client may experience headache and lightheadedness, respectively.

219

The basilar artery is not part of the circle of Willis. Rather, it is part of the vertebral-basilar system, which is known as the posterior circulation to the brain. Other parts of the posterior circulation are the vertebral artery, posterior inferior cerebellar artery, and the spinal arteries. The circle of Willis is a ring of blood vessels located at the base of the brain. It is referred to as the anterior circulation to the brain and is composed of the posterior cerebral arteries, posterior communicating arteries, internal carotid arteries, anterior and middle cerebral arteries, and the anterior communicating branches. Alzheimers disease is characterized by changes in the dendrites of the neurons. The decrease in the number and composition of the dendrites is responsible for the symptoms of the disease. The tentorium cerebelli is a landmark used by neurologists in describing the location of cranial incisions. A supratentorial incision is made above this level and generally includes cerebral tissues and other structures that lie above this landmark. An infratentorial incision refers to an incision made below this level, such as the cerebellum and brain stem. The foramen of Monro allows cerebrospinal fluid to flow from the lateral ventricles into the third ventricle. The falx cerebri separates the right and left cerebral hemispheres. The superior sagittal sinus collects blood from the upper lateral and medial cortices. The closure of cranial sutures during childhood prevents expansion of the cranial vault when there is hydrocephalus in the adult. This leads to increased neurological changes with lesser degrees of hydrocephalus than is apparent during early childhood The withdrawal reflex is one of the spinal reflexes. cough, swallow, sneeze reflex are found in the brain stem. Radiculitis is a term used to describe spinal nerve root compression at the intervertebral foramen. Radiculitis may be caused by a number of factors, such as whiplash or ruptured intervertebral disk. In many cases it is caused by malalignment that occurs with degenerative disease or bone spur formation.

Shoulder pain with LESION on rotator cuff------TENDON Lesions of the rotator cuff often involve the supraspinatus tendon of the shoulder. Although the entire joint is painful, the etiology does not involve synovial fluid, ligaments, or nerves. Usually the problem involves one or more of the tendons and muscles in the musculotendinous cuff. It

220

most often is the result of minor repeated traumas or degenerative changes in the older client, or severe trauma in the younger client.

The epiphyseal line is the area that is responsible for longitudinal bone growth. A fracture affecting this area places the client at risk for uneven future growth if proper healing does not occur. The epiphyses are located at the proximal and the distal ends of a bone and are the insertion sites for muscles. The metaphysis is an area of flaring of bone, located between the epiphysis and the diaphysis. The diaphysis is the shaft or main longitudinal portion of a long bone. Acetylcholine is the neurotransmitter found in the myoneural (or neuromuscular) junction, which allows muscle cells to respond to nervous system stimulation & CONTRACTION

MENISCUS-KNEE A meniscus is an interarticular fibrocartilage that partially or completely separates the components of a joint. The knee is a common area for meniscal tears because it is a frequently injured joint as a result of falls and sports injuries. The ureterovesical junction is the point at which the ureters enter the bladder. At this juncture, the ureter runs obliquely for 1.5 to 2 cm through the bladder wall before opening into the bladder. This anatomical pathway prevents the reflux of urine back into the ureter and, in essence, acts as a valve to prevent urine from traveling back into the ureter and up to the kidney. Hydrogen ions are cations that are acidotic to the body. The renal tubules secrete hydrogen ions and potassium very effectively, and in lesser amounts secrete ammonia and uric acid. The tubules reabsorb carbon dioxide molecules. Phosphates are anions that tend to neutralize cations. Release of low levels of dopamine exerts a vasodilating effect on the renal arteries.----Increase blood flow to kidney Metabolic acidosis & Alkalosis -------both needs Hydrogen IONS

Since hydrogen ions contribute to acidosis in the body, the kidneys retain hydrogen ions in

221

alkalosis to restore acid-base balance. Chloride is an anion that will contribute to alkalosis if these are retained, because anions combine with cations to neutralize them. Secretion of potassium also will increase the level of anions in the bloodstream. Secretion of water affects fluid balance.

The client must produce increased ADH, which will increase reabsorption of water in the renal tubules and increase circulating volume. The client does not require increased erythropoietin to restore circulating volume. The production of angiotensin is stimulated, not inhibited, so that vasoconstriction may occur. Clients in renal failure do not manufacture adequate amounts of erythropoietin, which is a glycoprotein needed to synthesize red blood cells. Renin, angiotensin, and aldosterone are substances that assist in maintaining blood pressure.

As part of the normal aging process, the GFR decreases, as well as each of the other functional abilities of the kidney. The kidneys have decreased ability to metabolize medications. Urineconcentrating ability and tubular reabsorption also decrease. With increased potassium retention, the kidneys excrete more sodium- BALIKTARAN LANG SILA Sodium is a cation. With increased retention of sodium, the kidneys also increase reabsorption of chloride and bicarbonate, which are anions. kidney also actively secretes creatinine from the nephron in the proximal tubule. Collagen is the fiber responsible for the skins toughness and resiliency and plays an important role in the healing process. Reticular cells are connective tissue fibers, and elastic fibers provide elasticity to the skin. Langerhans cells are a type of cell found in the spinous layer of skin, and are believed to play a role in delayed hypersensitivity reactions. Arrector pili muscles in the hair follicles are responsible for the raised flesh response of goose flesh or goosebumps. Arterioles bring blood to the cutaneous area. Collagen fibers provide strength to the skin. Sweat glands aid in the elimination of water. The skin cells that slough off during bathing and normal wear and tear are from the stratum corneum. Skin cells originate in the stratum basale. The next upper layer is the stratum

222

spinosum, followed by the stratum granulosum, or granular layer. The stratum lucidum has clear, flat dead cells, and the outermost layer is the stratum corneum and contains the horny or cornified cells.

Melanocytes are responsible for producing melanosomes, which contain melanin, the pigment that determines skin color. Keratinocytes are chief cells of the epidermis that undergo changes as they rise through the layers of skin. Fibroblasts are a type of dermal cell that produce the major fibers and ground substance and have been called the master cells. Macrophages have phagocytic capability and play an active role in the immune response to foreign substances.] Apocrine gland activity is responsible for sweat production. Reticular skin lesions resemble a net in appearance. Annular lesions are ring-shaped, whereas linear lesions appear in a straight line. Arciform lesions are shaped like an arc. Purpura results from hemorrhage into the skin. Cherry angioma occurs with increasing age and has no clinical significance. It appears as a small, round, bright redcolored lesion on the trunk or extremities CO2 acts as an acid in the body. Therefore, in a respiratory disorder with a rise in CO2, a corresponding fall in pH occurs The carina is a cartilaginous ridge that separates the openings of the two main (right and left) bronchi. A CD4+ lymphocyte count is performed to establish the stage of HIV infection, and to help with decisions regarding the timing of the initiation of antiretroviral therapy and prophylaxis for opportunistic infections. Cryptococcosis can occur in the lungs or the gastrointestinal tract. Diagnostic tests to confirm its presence include chest x-ray studies and sputum culture if it occurs in the lungs.---HIV Down syndrome is a form of mental retardation and is a congenital condition that results in moderate to severe mental retardation. Most cases are attributable to an extra chromosome (group G)hence the name trisomy 21. Animism means that all inanimate objects are given living meaning. 2.Egocentric speech occurs when the child talks just for fun and cannot see anothers point of view. Object permanence, the

223

realization that something out of sight still exists, occurs in the later stages of the sensorimotor stage of development. 4. Global organization means that if any part of an object or situation changes, the whole thing has changed. Options 2 and 4 occur during the preoperational stage.

At gestational week 36, the fetus weighs 2500 g and is approximately 42 to 48 cm in length. The skin is pink and the body is rounded. Lanugo is disappearing, and the L/S ratio is greater than 2:1. At gestational week 8, the eyelids begin to fuse. The fetal heart begins to beat at week 5. The fetal skin is transparent at week 16. At 28 weeks of gestation, the fetus weighs approximately 1200 g.

The fetal heart rate depends on gestational age and ranges from 160 to 170 beats/min in the first trimester but slows with fetal growth to approximately 120 to 160 beats/min near or at term. At or near term, if the fetal heart rate is less than 120 or more than 160 beats/min with the uterus at rest, the fetus may be in distress. bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The nurse has primary responsibility for managing the milieu in an inpatient psychiatric setting. The psychiatrist, social worker, and psychologist all contribute to maintaining a therapeutic environment, but it is the nurse who has overall responsibility for management of the unit. The purpose of behavioral therapy is to create effective changes in behavior. Insight to maladaptive behavior is a useful outcome of psychotherapy but does not always result in behavior change. Option 3 is a treatment modality effective for reducing stress. Option 4 describes aspects of milieu management. Behavioral therapy------FOSTER POSITIVE BEHAVIORAL CHANGE

224

MATERNAL & CHILD Taking in 1 to 2 days Taking hold 10 days Letting go--- new role/ continues into child growing years. INCREASE BLOO PLASMA---------it creates blood dilution------- DECEREASE ANG Hgb & HEMATOCRIT TERBUTALINE ----HYPOKALEMIA
CALIUM= PLASMA BLOOD VOLUME

MECONIUM ASPIRATION SYNDROME--- HYPOGLYCEMIA, ACIDOSIS, HYPORESONANCE IS NOT ASSOCIATED WIT MAS RESP. DISTRESS-----THERE IS NO EXCESSIVE COUGHING MONGOLIAN SPOT------GRAY, blue or Black--- more on buttocks Port wine stain-----red lesion NEONATES TEMPERATURE----AXILLA NOT RECTUM ALBUMIN IN THE URINE ----KIDNEY & HEART MINERAL OIL-INTERFERES WITH THE ABSORPTION OF FAT-SOLUBLE VITAMINS (ADEK) NUBAIN/ NALBUPHINE----ANALGESIC

PIH------CHECK FACE

225

 PIH- FACIAL & FINGER EDEMA & EXCESSIVE

WEIGHT GAIN

CHECKING THE REFLEX, PULSE---NO EFFECT ON PIH

ANKLE EDEMA/ SWELLING OF FEET ON LEG IS NORMAL IN PREG.------NOT RELIABLE ON PIH------KASI NORMAL ITO!!!!!!!!!1
3RD TRIMESTER EDEMA------- ALTHOUGH MAY EDEMA PREVENT DHN
FLUID INTAKE PARIN TO

CORD PROLAPSE---TRENDELENBURG----NOT COVER THE CORD WITH SALINE 24- hrs after delivery-------FUNDUS IS SLIGHTLY BELOW THE LEVEL OF UMBILICUS ABOVE THE LEVEL OF UMBILICUS--- URINARY RETENTION/-PLACENTAL FRAGMENTS THROMBOCYTOPENIA---COMPONENT OF HELLP SYNDROME (HEMOLYSIS ELEVATED LIVER ENZYME & LOW PLATELET COUNTASSOCIATED WITH SEVERE PRE-ECLAMPSIA OPEN-GLOTTIS---2ND STAGE OF LABOR & DELIVERY PROCESS DEEP ABDOMINAL BREATHING---EARLY LABOR PANT & BLOW BREATHING-----TRANSITION PHASE MODIFIED PACE BREATHING SLOW PACE BREATHING LOWER BACK ACHE---------TAILOR SITTING SQUATTING IS NOT HELPFU SPITTING OR VOMMITING-----CURLDLED APPEARANCE PKU-----LATERAL HEEL

226

PIH------RELATED TO MOLAR PREGNANCY PUSH WHEN THERE IS URGE TO PUSH REST BETWEEN CONTRACTIONS ORAL CONTACEPTIVE HAS NO EFFECT ON CERVICAL MUCUS ADMITTING TO BIRTHING AREA MULTI GRAVID WITH CLASS 2 HEART DSE-------ASK FOR FREQ. DUR. & INTENSITY UTERINE ATONY------SOFT & BOGY///NOT CONTRACTING/ NOT FIRM MATERNAL & NEWBOR NUTRIRION-----DURING THE FIRST TRIMESTER FRANK BREECH POSITION-----WOF FETAL BRADYCARDIA MATERNAL TACHYCARDIA---------INDICATES INFECTION MECONIUM STAINED AMNIOTIC FLUID---------COMMON ON BRECCH PRESENTATION BOTH HANDS PREVENTS UTERINE INVERSION ONE HAND------SIZE OF FUNDUS CHORIOAMNIONITIS--------FETAL TACHYCARDIA, HYPOTONIC CAUSES PNEUMONIA LABOR PATTERN-------

CHILDBIRTH PREPARATION CLASSESS------USES LESS PAIN MEDICATION IN

LABOR

BAWAL ANG WHOLE MILK/ COWS MILK AS AN ALTERNATIVE FOR FORMULA UNTIL 4 MOS. MIRROR THE CONTRACTION--------EARLY DECELERATION---NORMAL----2ND STAGE OF LATE OF LABOR

PROM ------INFECTION------CHECK FOR FOUL SMELLING AMNIOTIC FLUID

TETANIC UTERINE CONTRACTION------OXYTOCIN ADMINISTRATION

227

CHLAMYDIAL INFECTION---------10 DAY- ERYTHROMYCIN NOT CS VARICOSITIRS AFTER PREGNANCY DO NOT DISAPPEAR POST-PARTUM-----MENSTRUATION RESUMES 6- 10 WEEKS. THROMBOPHLEBITIS IS CONTRAINDICATED WITH ORAL CONTRACEPTIVES. TERBUTALINE---GIVEN WITH 5% DEXTROSE & WATER NOT NORMAL SALINE TO PREVENT EDEMA & CARDIAC WORK LOAD. Formula feeding decreases breat milk supply TERBUTALINE------ASESS FOR MATERNAL HEART RATE NOT CONTRACTION INTENSITY Post term----wrinkled peeling skin Flattened nose--------- syphilis SLOW DARK TRICKLE OF BLOOD------POST-PARTUM HEMORRHAGE---MASSAGE THE FUNDUS & NOTIFY THE PHYSICIAN. IT IS DUE TO UTERINE ATONY LUMBAR EPIDURAL ANESTHESIA----NORMAL LANG ANG NUMBNESS FOR 1ST HOUR

FALLOPIAN TUBE BLOCK----IVF NOT ZIFT

ZIFT-----HINDI PWEDE KAPAG BLOCK ANG FALLOPIAN TUBE INTA-FALLOPIAN TUBE-----WITHIN THE FALLOPIAN TUBE. IN VIRO FERTILIZATION KASI DERECHO SA UTERUS. OVARIAN DYSFUNCTION--------PERGONAL THERAPY( MENOTROPIN)

228

JAUNDICE IN BABY----------BLANCH THE FOREHEAD/////BONY PROMINENCE CHEST, TIP OF THE NOSE EARLY LABOR ---------YOGURT----EASY TO DIGEST PRE -TERM (MERON)

POST-TERM (WALA)

ABUNDANT LANUGO

ABSENCE OF LANUGO NO VERNIX CASEOSA

THERE IS VERNIX CASEOSA

ABUNDANT SCALP HAIR

SOLE CREASES

OILY SKIN

LONG, THIN BODY; NAILS DRY SKIN THIN, CRACKED OR PEELING

SKIN

SCARF SIGN-------NORMAL GAVAGE-------------INSERTING TUBE---USE--------STERILE WATER NOT KY-JELLY MONITOR TEMP. -------FOR POST TERM ----LESS SUB-Q FAT NOT DEEP BREATHING-----KASI SHALLOW BREATHER ANG MGA BABY PRE-TERM-------THIN WASTED APPEARANCE

STATION 0----HINDI IBIG SABIHIN AY MANGANGANAK NA.

IBIG SABIHIN AY START PALANG NG 2ND STAGE OF LABOR WHICH IS EXPULSION STAGE DELIVERY OF BABY IN NEXT FEW MINUTES---------

-X

COLD STRESS----RESP. DISTRESS------HYPERACTIVE/ AGITATED

229

NOT SLOW RESP.

COLD STRESS---------MERON HYPOGLYCEMIA

NORMAL GLUCOSE 20 TO 60mg/dl HYPERACTIVITY & TWITCHING------SIGNS OF HYPOGLYCEMIA-------NEWBORN PRONE TO HYPOTHERMIA & HYPOGLYCEMIA PUDENDAL ANESTHESIA------EPISIOTOMY REPAIR

SIDE EFFECT: INFECTION, initiation of lactation, g.i. bleeding, edema, pulmonary edema.
BETHAMETHASONE + TOCOLYTIC= No urinary frequency METHLYDOPA (ALDOMET)----DOC FOR CHRONIC HYPERTENSION

MGSO4-----FOR PIH----------CAUSES DEPRESSION-----MONITOR RESPIRATION

RESPIRATORY MATERNAL

MGSO4 NOT FOR CHRONIC HYPERTENSION----METHYLDOPA DAPAT.. MATERNAL HYPERTHYROIDISM----------COMMON IN PRE-TERM LABOR & LOW BIRTH WEIGHT. EPIDURAL BLOCK-------REGIONAL ANESTHESIA---REMAINS CONSCIOUS MGSO4---------------- CNS DEPRESSANT FHR---UMBILICAL CORD COMPRESSION YELLOWISH AMNIOTIC FLUID------------RH SENSITIZATION

230

R/T FETAL ANEMIA & BILIRUBIN ABNORMAL PRESENTATION-----EG. BREECH------COMMON ANG MECONIUM STAINED AT GREEN COLORED STOOL AMNIOTIC FLUID EMBOLISM---------DIFFICULT LABOR OR HYPERSTIMULATION OF THE UTERUS HYPERVENTILATION-----MORE CO2 EXCRETED= LIGHTHEADED/ DIZZY BLOODY SHOW--------INDICATES INCREASE IN CERVICAL DILATION MGT. PEFORM VAGINAL EXAMINATION TO DETERMINE CERVICAL DILATION. ABRUPTIO PLACENTA----------BLEEDING IS CONCEALED OXYTOCN INDUCTION--------PRONE FOR WATER INTOXICATION------WAG NG MAGBIGAY NG 500 ML BOLUS IV FLUID FOR PREVENTION OF HYPOTENSION 1 cm CERVICAL DILATION----TOO EARLY FOR EPI BLOCK AFTER 1ST BREAST FEEDING------EVERY 2- 3 HRS. FOR THE 1ST 48 HRS. AMNIOCENTESIS------DETECTS GENETIC DEVIATION, FETAL LUNG MATURITY PERCUTANEOUS UMBILICAL BLOOD SAMPLING- DETECTS GENETICALLY TRANSMITTED (INHERITED) BLOOD DISORDERS, ACIDOSIS OR INFECTION. ALPHA-FETO PROTEIN----15TH TO 20TH WEEK OF GESTATION -----FOR NEURAL TUBE DEFECT DO NOT USE PILLOW ON THE CRIB-------SUFFOCATION 12 HR. POST-PARTUM---SOFT NOT TENDER BREAST BREAST MILK PROCUCTION DOES NOT BEGIN UNTIL THE 2 ND OR 3RD POST-PARTUM DAY LOW FORCEPS DELIVERY-------URINE IN BLOOD----CONTACT PHYSICIAN

231

PALPATING FUNDUS-------------NO EFFECT FACE PRESENTAYION--------ASSOCIATED WITH SMALL MATERNAL PELVIS, PLACENTA PREVIA,PREMATURITY FETAL CHIN IS POSTERIOR---UTERINE DYSFUNCTION OR TRANSVERSE ARREST----CS PHOTOTHERAPY ---------BRONZE SKIN COLOR--------NORMAL CHECK V/S q 2-4 HRS.-----PRONE TO HYPERTHERMIAMAGNESIUM SO4----PRIMARY PURPOSE: INHIBIT CONTRACTION IT DOES NOT COMBAT HYPOMAGNESEMIA PRIMIGRAVIDAS OF 3RD TRIMESTER------------------------------------ADVANCED MATERNAL AGE + PIH AS WELL AS CHRONIC HYPERTENSION THE INCIDENCE OF

PIH IS GREATER AMONG PRIMIGRAVIDAS

UTERINE INVERSION------PRESSURE FROM PALPATION PUSHES THE UTERUS OUTSIDE THE VAGINA. FIRM FUNDUS BUT RIGHT TO MIDLINE---------URINARY RETENTION NON-PALPABLE & MIDLINE----------EMPTY BLADDER PERINEAL HEMATOMA-----------EPISIOTOMY COLOR DOPPLER IMAGING ULTRASONOGRAPHY---------DETECTS THROUGH THE UMBILICAL CORD BLOOD FLOW

ECTOPIC PREGNANCY---------MOST IMPORTANT TO ASSESS IS LAST MESTRUAL PERIOD 1ST STAGE OF LABOR--------SERIOUSNESS NEXT EXCITED TRANSITION------FEAR & PANIC

232

AFTER INSERTING GAVAGE CATHETER-------ASPIRATE CONTENTS 1ST BEFORE INSTILLING 10 ML OF NORMAL SALINE. OR INJECT 10 ML OF AIR AND LISTEN TO BOWEL SOUNDS MULTIPARA--------- CRAMPING EVERY BREAST FEEDING-------PRESCRIBED ANALGESIC AMBULATION IS NOT HELPFUL BECAUSE THE CAUSE IS OXYTOCIN NOT GAS ACCUMULATION/ CONSTIPATION HX OF PRE-TERM LABOR-------SHOULD NOT GERT SEXUALLY AROUSED & AVOID NIPPLE STIMULATION

SEXUAL INTERCOURSE MAYBE RESUMED 3-4 WEEKS POST-PARTUM GENERAL RULE WAIT FOR EPISIOTOMY TO HEAL 3 WEEKS POST-PARTUM PWEDE ANG SEXUAL INTERCOURSE KAHIT NA MAY LOCHIA SEROSA SEROSA----UP TO 6 WEEKS METABOLIC ACIDOSIS------ASSOCIATED WITH COLD STRESS TRANQUILIZER-----DECREASES BLOOD PRESSURE METHERGINE------FOR POST-PARTUM HEMORRHAGE NEWBORN ASESSMENT----------MIDWAY BETWEEN FEEDINGS NOT NPO 4 HRS.----RISK FOR HYPOGLYCEMIA ELECTRONIC FETAL MONITORING--------EITHER EXTERNAL OR INTERNAL---------IT CAUSES DISCOMFORT NEONATES CIRCUMCISION ---------CHECK BLEEDIND q 15 BLEEDING IS NOT COMMON

233

D&C-------MISSED/FETAL DEMISE////////INCOMPLETE ABORTION NOT FOR RUPTURED ECTOPIC PREGNANCY CLASS 2 HEART DISEASE----EASILY FATIGUED--------LET THE STAFF TAKE CARE FOR YOUR BABY NOT BED REST CONTINOUSLY. TRANSITION PHASE NA,,,, 8-10 CM---------ANESTHESIA IS TOO LATE DM ---------GREATER IN 35 YRS.OLD AND ABOVE----------GLUCOSE TESTING CHORIONIC VILII SAMPLING --------TO DETECT MOLAR PREGNANCY PWEDE PARIN PREGNANCY MAKIPAG-SEX KAHIT BUNTIS---------PROVIDED UNCOMPLICATED

PWEDE MAKIPAG-SEX KAHIT BUNTIS---------------DURING THE LAST TRIMESTER RAPID SHALLOW BREATHING-----------------APLLICABLE FOR TRANSITION PHASE. KAHIT TEENAGER PALANG EG. 12-14 YRS.OLD-----------PWEDE MAGKAROON NG PIH/ HYPERTENSION] WALANG ABRUPTIO PLACENTAE SA TEENAGER EPISIOTOMY---------SHORTENS THE 2ND STAGE OF LABOR HAS NO EFFECT ON PELVIC INLET PARTIAL PLACENTA PREVIA------BED REST HYDRATION, MONITO BLEEDING PLATELETS ARE NOT AFFECTED BREAST-FEEDING-------COMPRESS & RELEASE THE BREAST AT THE EDGE OF AREOLA

234

EPIDURAL ANESTHESIA---------HEADACHE IS NOT A SIDE EFFECT----THERE IS NO NEED TO LIE FLAT ON BED CANNOT FEEL THE URGE TO PUSH FLAT ON BED----APPLICABLE FOR SPINAL ANESTHESIA.

IN VITRO FERTILIZATION----------AFTER
TRANSFERRED TO THE CERVIX.

FERTILIZATION 3 OR 4 EMBRYO ARE

SUCCESS RATE IS ONLY 20%

NOT 50 % VARIABLE DECELERATION-----CORD COMPRESSION---MGT. POSITIONING---------IF NOT EFFECTIVE--------------AMNIOINFUSION-----ADMINISTRATION OF NSS TOHELP TAKE THE PRESSURE OFF THE CORD. VITAMIN C----FOR BLOOD CLOT AND COLLAGEN FORMATION VIT. C DEFICIENCY------ASSOCIATED WITH PROM & PIH EXCESSIVE VIT. C------SCURVY METABOLISM CARBOHYDRATES--------THIAMINE PALPATE FUNDUS q 15 FOR 1 HR.-----------ASESSING

UTERINE ATONY AFTER

CS----------KAPAG NARAMDAMAN MONG SOFT & BOGGY ANG UTERUS

ASSESING BP & PULSE RATE

SA UTERINE ATONY IS JUST A

LATE

SIGN OF HYPOVOLEMIC SHOCK

HYPOTENSION & TACHYCARDIA.

235

STRETCHING PERINEAL MUSCLES-----------PREVENTS LACERATION

DURING PUSHING, AVOID VALSALVA MANUEVER---------FETAL COMPROMISE & INCREASE MATERNAL ICP
HOLDING FETAL BACK DURING PUSHING/DELIVERY-----------CAUSES INJURY

HIGH PITCHED SPEECH WITH TONAL VARIATIONS---------BEST FOR TALKING TO NEONATES------NOT LOW PITCH
WITH SAMENES OF VOICE

PERSISTENT CIRUMORAL CYANOSIS-------------CONGENITAL

ANOMALIES MOTTLING-----VASOMOTOR INSTABILITY NEWBORNS----HIGH ERYTHROCTE COUNT.

WHILE PREPARING THE MOTHER FOR CS DELIVERY,

BEFORE TRANSFERRING TO OPERATING SUITE--------------NO NEED TO EMPTY THE BLADDER--------BECAUSE NUNG UNA PALANG EH MAY EXISTING INDWELLING CATHETER NA SYA

PERCUTANEOUS UMBILICAL BLOOD SAMPLING--------BLOOG HGB & HCT---- BABY HEART RATE DROP (TRANSIENT FETAL BRDYCARDIA), NEEDS BLOOD TRANSFUSION ,NEEDLE IS INSERTED.

236

VERY HIGH PITCHED-------NEUROLOGIC PROBLEM ---- ICP NOTIFY THE PHYSICIAN PREVENTION OF DECREASED UTERINE TONE------BREAST FEED TO STIMULATE OXYTOCIN FOR CONTRACTION. TO PREVENT BLEEDING. GENTLE MASSAGE THE FUNDUS

NOT CONTINOUS MASSAGE----THIS WILL

DECREASE BLEEDING

UTERINE

CONTRACTION-

DM THAT IS

WELL-CONTROLLED

DOES NOT NEED TO MONITOR BLOOD

SUGAR LEVELS BEFORE PERFORMING ANY EXERCISE PROGRAM-----

BAKIT: KASI STABLE NAMAN YUNG BLOOD SUGAR LEVEL PWEDE MAGEXERCISE KAHIT BUNTIS----PROVIDED OF HIGH CARBOHYDRATES OR PROTEIN SNACK BEFORE EXERCISING. RESP.DEPRESSION & FETAL ANOXIA ARE NOT RELATED WITH PRECIPITOUS LABOR/ UTERINEATONY/ POST-PARTUM HEMORRHAGE PICA------ANEMIC Nursing care for children Cocainelarge eyes Heroin-----pinpoint eye Adolescent-----IDENTITY

237

YOUNG ADULTHOOD- INTIMACY PRE-SCHOOL----INITIATE SCHOOL----INDUSTRY INFANT TEMPORARY COLOSTOMY------GIVE PLENTY OF FLUIDS HINDI GUMAGAMIT ND DIAPER PARA SA COLOSTOMY KAILANGAN NG APPLIANCE REDDISH-PINK----NORMAL DUSKY RED------IMPAIRED CIRCULATION FLUSH EYE WITH TAP WATER---15 TO 20 MINUTES---CAUSTIC MATERIAL IPECAC----SHOULD BE FOLLOWED BY 10 -20 ML OF CLEAR LIQUIDS 4 YR. OLD PRE-SCHOOL-----ALLOW SOME DECISIONS ON FOOD CHOICES VENTRO GLUTEAL------ALTHOUGH FREE OF MAJOR NERVES, VASTUS LAT. IS STILL THE BEST DORSO GLUTEAL----C/I. TO INFANT NOT WALKING UP TO 1 YR LENGTH IN PERCENTILE SHOULD BE PARALLEL TO THE HEAD CIRCUMFERENCE ASEESSING MOTOR & SENSORY FUNCTION-------DONE WHEN FONTANELS & SUTURES ARE ABNORMAL SCOLIOSIS-----TARGET IS PRE ADOLESCENT AT HE BEGINNING OF GROWTH SPURT SPASTIC CEREBRAL PALSY------TOE-WALKING----INCREASE MUSCLE TONE & STRETCH REFLEXES DROOLING, FACIAL GRIMACING-------DYSKINETIC & ATHETOID CEREBRAL PALSY due to poor tounge & swallowing-----SLOW WORM LIKE WRITHING MOVEMENTS

238

WIDE-BASED GAIT- ATAXIC CREBRAL PALSY ATHETOID-------TREMORS & LACK OF ACTIVE MOVEMENT YELLOW FEVER----INSECT BITE BRUCELLOSIS (UNDULANT) FEVER------CONTAMINATED COWS MILK POLIO---RESP. INFECTION STOOL CHARACTERISTICS OF DIARRHRA--------------CONSISTENCY PROVIDING INFO---PRIMARY PREPARING PARENTS PSYCHOLOGICALLY--- SECONDARY REPORTING CHROMOSOME ANALYSIS----SECONDARY ECZEMA-----AVOID STUFFED TOY-----HARBORS DUST PRE-CONVENTIONAL LEVEL ------RIGHT OR WRONG----PRE-SCHOOL STAGE 1----PUNISHMENT-OBEDIENCE AUTONOMOUS,PRINCIPLED (POST-CONVENTIONAL)-STAGE 3----VALUES & PRINCIPLES CONVENTIONAL-----7 TO 12----LOYALTY & CONFORMITY PALPATING PYLORIC STENOSIS------WHILE EATING SUPINE DAPAT NOT SIDE LYING JUST BEFORE INFANT VOMITS------DISTENDED ABDOMEN. IQ IS 40---------TASK ANALYSIS-------TRAINABLE EDUCABLE-----VOCATIONAL TRAINING 50-70 LETHARGIC---------DHN------NUMBER OF WEIGHT DIAPERS IN THE PAST 24 HRS.

239

PUPILLARY RESPONSE-----MENINGITIS

PAIN & SWELLING-----INFILTRATION

OTHER SIGN----SKIN PALLOR & COLDNESS INTRAVENOUS SITE IS USED TOO LONG-----INFLAMMATION---REDNESS & WARMTH CRAMPS, BACKACHE, NAUSEA, WITH MENSTRUATION-----

PHYSIOLOGIC

SKETAL TRACTION WHO HAS OSTEOMYELITIS---------GOOD NUTRITION NOT ANTIBIOTIC, ----GIVEN ONLY IF THERE IS BACTERIAL INFECTION ; NOT GIVEN PROPHYLACTICALLY FOR SKELETAL TRACTION. CROUP-----GO TO BATHROM AND RUN HOT WATER-----STEAM
PRE-TERM NEONATE-PRONE TO HYPOTHERMIA & HYPOGLYCEMIA

DIGOXIN----1 hr. BEFORE EATING No need for large fluid

PTT (PEDIA)------25 TO 40 SECS.

NORMAL PLATELET COUNT--------150-300x10mm

(150,000-300,000)
8x10 mm = 8,000---LOW

LICE (KUTO) ARE NOT TRANSMITTED BY ANIMALS & PEST

SCABIES DOES TRANSMIT CAME FROM ANIMALS.

240

 FAILURE TO THRIVE IN 5 MONTH-----FUSINESS DURING

FEEDING

TRACHEOESOPHAGEAL FISTULA--RISK FOR ESOPHAGEAL STRICTURE AFTER REPAIR

INFANT GROWS RAPIDLY CHILD FEET WERE IN DEPENDENT POSITION---EDEMA-VENOUS INSUFFICIENCY COOL & SWOLLEN-ARTERIAL-----CHID OUTGROWN THE SPICA CAST GALANT SIGN----STROKING BACK OF SPINE---NORMAL HIP MOVES

MOTOR VEHICULAR ACCIDENTS ARE THE LEADING CAUSE OF DEATH------CHILD RESTRAINTS IN

AUTOMOBILES/ SEAT-BELTS

LOWER UTI----NO FEVER

. UPPER UTI---HAS FEVER CHILD WITH AIDS----VACCINE DtAP (DIPTHERIA, TETANUS ACELLULAR PERTUSIS) BRACHIAL PULSE---------1 yr.old CAROTID PULSE-----Greater than 1 yr.old/ 2yr.old LEUKEMIA

PREVENTING COMPLICATIONS OF LOW PLATELETSTOOL SOFTENER LOW NEUTROPHILS---ELIMINATE RAW VEGETABLES & FRUIT MAGKAIBA ANG RHEUMATIC ARTHRITIS SA RHEUMATIC FEVER

RHEUMATIC FEVER--------LIMIT MOVEMENT MASSAGE-NO EFFECT, EXERCISE---DI PWEDE

241

ABNORMAL CONVEX ANGULATION(posterior)------KHYPOSIS LORDOSIS ANTERIOR SCOLIOSIS---lateral

Blood

glucose

of

250mg/dl--------MATAAS----diabetic

ketoacidosis

AFTER ADMINISTERING ANTIBIOTICS GIVE HEPARIN/SALINE IMMEDIATELY DO NOT WAIT FOR 20 MINUTES. TRACHEOESOPHAGEAL FISTULA------

CHOKE

NEUTROPHIL------3,000 to 5,000 NORMAL

THE MOST COMMON CAUSE OF DEATH IN LEUKEMIA IS

INFECTION------SO MONITOR TEMPERATURE.

.TYMPANOSTOMY TUBE-----NATATANGGAL (FALL OUT) ABOUT 6 MONTHS. INTUSSECEPTION=-----------WEIGHT &

GASTRIC OUTPUT
MAINTENANCE &

NOT STOOL OUTPUT----IT IS NOT USED FOR CALCULATING REPLACEMENT FLUID. SALICYLATE TOXIXITY---------DIZZINESS PINK COLORED URINE NOT ASSOCIATED ORTOLANI -----HEAD OF FEMUR SLIP INTO BARLOWHEAD OF FMUR SLIP OUT

242

GALEAZZI SIGN ----SHORTENING OF AFFECTED LIMB ASSOCIATED WITH CONGENITAL HIP DYSPLASIA REPEATED WITHDRAWALS OF BLOOD-----MONITOR AMOUNT OF BLOOD

VITAL SIGNS ARE NOT RELIABLE INDICATOR FOR BLOOD VOLUME

SLIPPED EPIPHYSIS-----FOR MOTION OF THE HIP INTERMITTENT HIP PAIN PHYSICAL DEXTERITY---ASESSING WHAT A CHID CAN DO. EG. RIDING A BIKE, PUTTING A PUZZLE CYSTIC FIBROSIS----EXCESSIVE LOSS OF SALT THROUGH PERSPIRATION HOT WEATHER IS HAZARDOUS FOR ESOPHAGEAL ATRESIA & TEF----NO STOOL WILL BE PASSED DUE TO LACK OF AMNIOTIC FLUID SWALLOWED ALLERGIC RHINITIS------NASAL CREASE(nasal itching)

Mouth breathing -------usually occurs when the child has enlarged tonsils or adenoids.
Fluoride -----do not give calcium/milk NPO 30 minutes after swallowing fluoride

INCREASE OXYGEN FO FEEDINGS

.COLIC------EXPULSION OF FLATUS COLIC DO NOT EXPERIENCE DIFFCULTY IN BURPING HYPERTHYROIDISM-----SWEATING

243

ANOREXIA-------THYROID INSUFFICIENCY

CONGENITAL HYPOTHYROIDISM------TREATMENT IS EFFECTIVE IF LESS ANG

MONITORING OF BONE

AGE.

METABOLIC RATE IS NOT HELPFUL. HEMOPHILIA A ------MINIMIZE BLEEDING----ELEVATE ARM ABOVE THE LEVEL OF THE HEART. NOT APPLYING CONTINOUS PRESSURE, 10 -15 MINS. IS ENOUGH D5W in ISULIN ADMINISTRATION------PURPOSE---- D5W ---GIVEN IF CHID HILD IS NPO

I.M. INJECTION IN NEONATE-------------USE SUB-Q NEEDLE GAUGE 25 5/8

.IMPETIGO----HONEY CORED CRUST] HEART RATE NORMAL IS 70 -110bpm 150bpm IS HIGH

RESPIRATORY ALKALOSIS------HYPOCALCEMIATETANY

ANIMISM------ATTRIBUTES THE QUALITY OF CONSCIOUS THOUGHT INTO INANIMATE OBJECT. (Animate non-living things of thoughts)- Pre-operational phase 2 to 4 yrs. REVERSIBILITY---(operational phase) school age CONSERVATION OF MATTER---Object are Still the same regardless its change in shape or size. (School Age)

INGUINAL HERNIORAPY PRIOR TO DISCHARGE, CHECK-----ABILITY TO RETAIN ORAL FEEDINGS. CLUBBING OF FINGERS----ASSOCIATED WITH POLYCYTHEMIA PYLOROPLASTY------NOT SUPINE, RISK FOR ASPIRATION DUE TO VOMIT

244

DAPAT, START FEEDINGS 10-15 ml INITIALLY 18 YRS. OLD -----CONVENTIONAL-----EVERYONE DOES IT SO ITS ALRIGHT. RULR BREAKING BEHAVIOR. ACETAMINOPHEN TOXICITY------NAUSEA & VOMITING SALICYLATE POISONING------NOSE BLEED & DEEP & RAPID RESPIRATION CLEFT LIP REPAIR----EXERT DOWNWARD PRESSURE TO THE CHIN------PARA MA-OPEN

YUNG MOUTH.

VENTRICULAR SEPTAL DEFECT- EXCESS FLUID VOLUME, EXCESS SWEATING. LEFT TO RIGHT SHUNTING-----LARGE VENTRAL SEPTAL DEFECT NORMAL URINE OUTPUT (pedia)-----24-28 ml/HR.

CROMOLYN SODIUM----PROPHYLACTIC AGENT FOR ASTHMA. IT PREVENTS

RELEASE OF HISTAMINE. IT IS NOT GIVEN DURING AN ASTHMATIC ATTACK BECAUSE IT IS NOT A BRONCHODILATOR.

LIVER, DUODENUM, PYLORIC SPHINCTER

MOIST CRACKLES IN THE LUNG FIELDS----TOO RAPID DELIVERY OF FLUIDS-------------- O V E R H Y D R A T I O N-----------

ABDOMINAL GIRTH ----WOULD NOT PROVIDE FLUID STATUS

245

PHYSICAL PUNISHMENT---Eg. Spanking,Violence

Aversion technique-----teaching lesson, what NOT to do by physically harming.

NEPHROTIC SYNDROME----MARK DEPENDENT EDEMA & HYPOALBUMENIMIA

-------BLOOD PRESSURE 100/60mmHg-----NORMAL

ECHOCARDIOGRAM---CARDIAC MUSCLE STRUCTURE PHONOCARDIOGRAMVARIOUS SOUNDS CARDIAC CATHETERIZATION----AMT. OF BLOOD ENTERING THE HEART/ MEASURE OF PRESSURE . TODDLER Eg. 18 MONTH------PHYSICAL ASSESSMENT----HAVE THE BABY LIE MOTHERS LAP HEAD To TOE assessment-------------------Older Child ON

Food fads last only for a short time------namimili ng kakainin (Toddler)

Binocular vision assist in depth- perception UNTIL 7 yrs. of AGE---------NORMALLY NEAR-SIGHTED/MYOPIC

eg. 2 yr.old

LUMBAR PUNCTURE FOR A 4 yr.old CHILD--------APPLYING SMALL BANDAGE--------------SANBAG IS NOT NEEDED.

Overflow incontinence

with constant dribbling is common in neonates with

MYEOMENINGOCELE-------Mgt. INTERMITTENT CLEAN CATHETERIZATION

DO NOT APPLY PRESSURE ON SUPRAPUBIC AREA INDWELLING CATHETER ------DONE ONLY IF NEONATE IS UNABLE TO VOID.
DDST ----------SOCIAL AND PHYSICAL ABILITIES HYPERGLYCEMIA------------LETHARGY & THIRST HYPOGLYCEMIA------------HEADACHE , SWEATING
CLEAR & INVERTED TYMPANIC MEMBRANE------BLOCKED EUSTACIAN TUBE

ANTIBIOTICS ARE NOT ROUTINELY ADMINISTERED PRE-OPERATIVE LY IN APPENDICITIS

246

10 gr= 0.65g 1gr=.065g 100gr=6.5g 1000gr=65g

ALLEN PICTURE CARD-----VISUAL

CANNOT READ ALPHABET

ACUITY OF 4 yrs.old WHO

CROSS OVER TEST-----------strabismus

.SNELLEN CHART----8-9 yrs.old
UNCOMPLICATED ABDOMINAL SURGERY------AUSCULTATE BOWEL SOUNDS

UPPER G.I. PROCEDURES----Eg. BRONCHOSCOPY-------CHECK GAG REFLEX

ASIMILATION & ACCOMODATION---INFANT SENSORIMOTOR DEVT REPRESENTATIONAL THOUGHT-----pre-conceptual phase 2-4yrs. Old CONSERVATION PROBLEM-SOLVING------concrete operations4-7 yrs. Old CAPACITY TO DEAL WITH ABSTRACT POSSIBILITIESADOLESCENT

Increased respiratory rate----secondary to bronchospasm r/t asthma Sickle cell----if both parents are both carrier------1

chance in 4 for each pregnancy-

will get the disease

1 chance in 2 each pregnancy-----will get the trait (carrier)

BINGES-----FEELING OUT OF CONTROL AND DISGUSTED WITH SELF Results in thoughts of depreciation OCD----MEDITATION IS LEAST HELPFUL OCD----WASHES FEET FREQUENTLY: NURSING DIAGNOSIS; RISK FOR IMPAIRED SKIN INTEGRITY r/t to frequent foot wahing NOT ANXIETY CLOZAPINE (CLOZARIL)--TCA----AGRANULOCYTOSIS--------WEEKLY BLOOD TEST-----------------------------MANDATORY----------------------------------------

247

ZOLOFT(SERTALINE) ---- CAUSES IMPOTENCE, LIGHTHEADEDNESS/DIZZINESS, EFFECT- 1 to 2 WEEKS WILL----CONSULT AN ATTORNEY not a nurse. Self- directed violence------hurting himself. Eg. Drowning head in the toilet bowl SARCASM-------INDIRECT ANGER Not shouting to another clientangry negative feelings REFUSING, CURSING-----DIRECT ANGER ORIENTATION PHASE--------CHALLENGES THE BOUNDARIES OR OUTER RELATIONSHIP DYSFUNCTIONAL GRIEVING---------MATAGAL SURVIVOR GUILT------Eg. A MONTH AGO Asocial behavior,anergia,alogia,and affective flattening-----NEGATIVE SYMPTOMS OF SCHIZOPHRENIA---maybe improved by risperidal(risperdone) IRRATIONAL FEAR-------PHOBIA TCA-----ELAVIL(amitriptyline), TOFRANIL, ANAFRANIL LIMITS OF THE

WORKING PHASE---------------MAKES AN EFFORT TO DESCRIBE PROBLEMS IN DETAIL.

COCAINE---------NASAL SEPTUM PERFORATION

.MARIJUANA LSD-ORAL HEROIN-ORAL/IV

IS SMOKED NOT SNORTED

HYPERSALIVATION-----PARADOXICAL EFFECT OF CLOZARIL (CLOZAPINE)

O.C.D.------UNABLE TO DO ACTIVITIES OF DAILY LIVING A Person with OCD cannot perform ADLs because of their ritualistic behavior.

,urge to drink from alcohol withdrawal---------support from other alcoholic clients Not one-to one approach-IMPRACTICAL FLUOXETINE(PROZAC)--- ANXIETY & DIARRHE ANG S/E--------DUE TO DECREASE OF DOSAGE OR CHANGE IN MEDICATION.

WITHDRWAL EFFECT OF COCAINE IS------------------DEPRESSION

They experience formication-as if bugs are crawling under their skin. 2 to 4 weeks -----anafranil (clomipramine) HINDI PWEDE PAGSABAYIN ANG MAOI & SSRI = SEROTONIN SYNDROME- hyperreflexia,hyperthermia, myoclonus, & neuroleptic malignant syndrome. After discontinuation of MAOI, wait for 14 days befor starting with SSRI Hepa A- NEVER DONATE BLOOD

248

Can drink alcohol in moderation. TOFRANIL (ANAFRANIL)-----ECG 1 before starting with this drug---cause tachycardia/ECG changes
ST

Delusion of Grandeur----1 try------satisfy the clients implied need to feel important.

st

Gatungan/sakyan mo muna ang delusion nya!!!!!!this is to compensate FEELINGS OF INADEQUACY FOLLOW UP CARE IS STILL UNDER In-patient treatment program Out-patient alcohol treatment program------No follow up BORDERLINE PERSONALITY DISORDER------ASSIST & SUPPORT LANG Offering solutions to problems--------dapat patient mismo ang gumawa nyan!!!! Interact in superficial levels Minimize fears regarding responsibility for self-----patient dapat mismo ang gumawa.
MAJOR DEPRESSION----ANTI-DEPRESSANT--------6 TO 12 MOS. CONCRETENESS----INTERPRETING CLIENTS WORD LITERALLY NEOLOGISM----WORD COINED BY THE CLIENT. OXYCODONE (OxYCoNTin)-----NARCAN is the antidote. CHLORDIAZEPOXIDE (LIBRIUM) PARALDEHYDE(PARAL), TEMAZEPAM (RESTORIL)---HYPNOTIC & SEDATIVE

BATTERED WOMEN COMMONLY DENY BEING ABUSED BECAUSE THEY ARE AFRAID THAT THRY ARE SOMEHOW TO BLAME OR DESERVING THEIR SITUATION.
.FEARING SHE IS TO BLAME OF HER PLIGHT.

BATTERED WIFE--------DENIAL QUEEN

ANGER IS A LOW RISK FOR SUICIDE COMPARE TO AGE 60 OR OLDER

CHECKING MONEY IN WALLET 12 TIMES.-----------CHANNEL EMOTIONS UNACCEPTABLE TO HIM INTO ACCEPTABLE ACTIVITY.

1ST CLIENT WILL VERBALIZE THE DESIRE TO STOP DRINKING ALCOHOL.

DUAL DIAGNOSES OF MAJOR DEPRESSION & ALCOHOL ABUSE-----ANG HIRAP NGA NAMAN MAKIPAG-PARTICIPATE SA TREATMENT PROGRAM FOR COPING METHOS FOR INDUCING SLEEP KUNG ANG PATIENT AY BANGAG AT SABOG!!!!!!! 2 --------COPING METHODS FOR INDUCING SLEEP.
nd

PROVIDING A MILIEU THERAPY-----DAPAT FOR CLIENTS ONLY

249

BAWAL ANG EPAL NA NURSE/ WITHOUT EXPECTING THE NURSE NEED TO BE MET. DAPAT: ACCEPTING BEHAVIOR AS MEANINGFUL & MOTIVATED. Delusional persecutory (non-bizzare)- someone is going to hurt or beliitle; take advantage against you. Aasault cycle----trigerring, escalation, crisis. Trigerring---changes in breathing & voice quality Escalation-----swearing; yelling Crisis- loss of control There is no aggressive When a nurse feels disgusted--------------She can ask for a help of a colleague in attempt to resolve the problem.

ABUSE--------THERE IS NO EMPATHY
A DEPRESSED CLIENT HAS A AMBIVALENT FEELING------SO DAPAT
DONT GIVE CHOICES THAT HE MAY SAY NO, GO DIRECT TO THE POINT. DEPRESSED CLIENTS ARE TYPICALLY

DEPENDENT ON OTHERS.

PESSIMISM (NEGATIVISTIC) AROUSES FRUSTRATION & ANGER IN OTHERS. CHEMICAL DEPNDENCY REHABILITATION

CALLING NARCOTICS ANONYMUS GROUP IS CLIENTS RESPONSIBILITY

NURSE SHOULD NOT CALL THE ANONYMUS GROUP. ITS THE PATIENT ITSELF TO BECOME INDEPENDENT. RAPID WEIGHT LOSS OF ANOREXIA NERVOSA---------------BRADYCARDIA, HYPOTENSION, & COLD SENSITIVITY.---------LAHAT AY DOWN

HYPERTHYROIDISM IS UNRELATED TO ANOREXIA NERVOSA.

.heroin overdose-------decreased respiration,constricted pupils & pallor. HEROIN, MARIJUANA= DOWNER

250

COCAINE----UPPER DELUSION OF GRANDEUR---THERE IS FEELING OF INADEQUACY; THEY WANT TO FEEL IMPORTANT. 1 WEEK MAJOR DEPRESSION--------OK 2 WEEK MAJOR DEPRESSION------WORSENING/ CALL DOCTOR/RISK FOR SUICIDE. CONFUSION & SEVERE EMORY LOSS-------DIVERT ATTENTION DISULFIRAM(ANTABISE)-----DETER ALCOHOL CONSUMPTION NOT DECREASE ALCOHOL.

GRIEF INDICATES ACCEPTANCE OF TERMINATION.

ONE-TO-ONE RELATIONSHIP ALCOHOL WITHDRAWAL------HEALTHY COPING MECHANISM.

MOSBY

Prior to a client's discharge following a thyroidectomy, the nurse teaches the client to observe for signs of surgically induced hypothyroidism. The nurse would know that the teaching was understood when the client states that the physician should be notified if: Dry skin and fatigue occur- Dry skin is most likely caused by decreased glandular function, and fatigue is caused by a decreased metabolic rate.- hypothyroidism- weight gain.

Progressive weight loss is evident- This is associated with hyperthyroidism, not hypothyroidism.

Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa related to several factors including prematurity, hypoxemia, and high-solute feedings; it includes shunting of blood from the GI tract, decreased secretion of mucus, greater permeability of
the mucosa, and increased gas-forming bacteria, eventually causing

intrestinal

obstruction.
DEPRESSED CLIENT

251

Useless and then saying the wrong thing to a more alert client The greatest fear of an inexperienced nurse is of saying the wrong thing and doing harm to a client; it is important to recognize that it can actually become a therapeutic encounter whereby both the client and the nurse can learn from the situation. UNEQUAL MORO REFLEX & FLACCID ARM UPON ADDUCTION-----Brachial palsy Brachial palsy results from excessive stretching of the nerve fibers that run from the neck, through the shoulder, and down toward the arm; the muscles of the upper arm are involved, and the infant holds the arm at the side with the elbow extended and the hand rotated inward. Candidiasis Candidiasis (Candida infection) arises in certain individuals when local resistance is decreased through prolonged antibiotic therapy or with certain diseases (e.g., diabetes) and debilitating conditions (e.g., drug addiction). "Frequent checks for ticks are a defense against infection."------------ This response identifies concern and presents an appropriate protective intervention; regular and prompt removal of ticks decreases the chances of the spread of Lyme disease to humans. About 3 to 4 days----------Untreated ophthalmia neonatorum becomes apparent on the third or fourth postnatal day and is evidence that the mother may have had gonorrhea or a chlamydia infection. First-degree atrioventricular block------A first-degree atrioventricular block pattern has a prolonged PR interval and is regular. Atrial fibrillation causes irregular rhythm. Sinus tachycardia---The presence of a P wave before each QRS complex indicates a sinus rhythm. A heart rate over 100 beats per minute is referred to as tachycardia. 5-year-old girl with a fractured femur In children with nephrotic syndrome, infection is always a threat because of anemia and lowered resistance; the child with a fractured femur is noninfectious and therefore is appropriate as a roommate; in addition, the closeness of age will provide for preschool socialization. "You really must feel upset about this."-------- This response focuses on the client's feelings rather than the statement, and it serves to open channels of communication. AUTOMOBILE ACCIDENT BP 100/60mmHg; REDUCED ARTERIAL PRESSURE Reduced peripheral pulses Hypovolemia results in a decreased cardiac output and a decreased arterial pressure, which are reflected by a feeble, weak peripheral pulse.

252

SCHIZOPRHENIAApathy and flatness---------Disinterest in or fear of personal involvement creates distancing behavior and lack of response to the environment. Anger and hostility---These may or may not be present. HIGH-DOSAGE OF CHLORPROMAZINE (THORAZINE) EXPERIENCES TREMORS-------Report the symptoms to the physician-------------The physician is responsible for medication orders but depends on the nurse's observations before making decisions. The nurse, after talking with the client's family, anticipates that a recently admitted elderly hospitalized client will be transferred to a nursing home. The nurse should begin preparing the client for the transfer: Immediately after admission Preparation of a client for discharge to either their own home or a nursing home should begin the day of admission. CHILD WITH TOF & CONGESTIVE HEART FAILURE Provide small, frequent feedings-----Small, frequent feedings with adequate rest periods in between may improve the child's intake at each feeding; these children become extremely fatigued while sucking.

The physician discusses the need for an abdominoperineal resection and a colostomy with a male client. After the physician leaves, the client tells the nurse that he is pleased only minor surgery is necessary. The nurse recognizes that the client's reaction is an example of:
Repudiation----------A refusal to recognize anticipated loss in an attempt to protect oneself against the overpowering stress of illness is called repudiation. ( DENIAL)

When assessing a child with glomerulonephritis, the nurse should expect to find : The presence of
periorbital edema-----------------------Because of glomerular dysfunction, there is decreased filtration of plasma, leading to excessive water accumulation and sodium retention; this leads to congestion and edema.

The occurrence of an intermittent fever---This does not occur with glomerulonephritis.

The nurse knows that when a client has a tracheostomy tube with a high-volume, low- pressure cuff, it is used primarily to prevent: . Mucosal necrosis--------These cuffs do not compress the capillary
beds and thus do not cause tracheal damage. . Tracheal secretion---Secretions will be increased because the cuff is a foreign body in the trachea. Leakage of air--A minimal air leak is desirable to ensure the lowest possible pressure in the cuff while still maintaining placement of the tube.

253

A client has been in a coma for 2 months and is maintained on bed rest. The nurse understands that to prevent the effects of shearing force, the head of the bed should be at an angle of: (dumudulas) 30 degrees---------Shearing force occurs when two surfaces move against each other; when the bed is at an angle greater than 30 degrees, the torso tends to slide and cause this phenomenon. . A male client comes to the emergency room because he has a discharge from his penis. The

physician suspects gonorrhea and asks the nurse to obtain a specimen and to send it for a culture. The nurse should: Obtain a specimen of the drainage from the anterior urethra - . This method
obtains a specimen uncontaminated by environmental organisms. Teach the client how to obtain a clean catch specimen of urine--This would dilute and possibly contaminate the specimen. When glucagon is administered for reversal of the hypoglycemic state, it acts by: Liberating glucose

from hepatic stores of glycogen----Glucagon, produced by the alpha cells in the islets of Langerhans, is an insulin antagonist. It mobilizes glycogen storage in the liver, leading to an increased blood glucose level.
Glucagon is not a glucose substitute.

A client is to receive a tuberculin test as part of her prenatal workup. Before administering the test, the most important information for the the nurse to collect is whether the client has: . Ever had a positive tuberculin test----------A tuberculin test should not be administered to a client with a previous positive tuberculin test because severe reactions can occur at the test site in individuals previously sensitized.
Previously had a tuberculin test -------------It is more important to know whether the test was positive than if it was done.

An adolescent client with an antisocial personality disorder was admitted to the hospital because of drug abuse and repeated sexual acting-out behavior. The nurse could evaluate that nursing actions directed toward modifying the behavior of this client had been successful when the client:-----.. Identifies the feelings underlying the acting-out behavior-----------The expression of feelings by this individual would demonstrate the development of some insight and a willingness to at least begin to look at underlying causes of behavior.
Recognizes the need to conform to society's norms--------------These words would probably have little meaning to the client.

To help a disturbed, acting-out child develop a trusting relationship, the nurse should:---------- Offer support and emphasize safety in play activities-------This action would set a foundation for trust because it allows the child to see that the nurse cares.
Implement daily 30-minute one-to-one interactions-----This would be too infrequent to develop trust.

254

A client who recently delivered a baby is transferred to the postpartum unit by the nurse. To avoid a charge of abandonment, the nurse should first: .Give a detailed report of the client's condition to the responsible staff member---------Since the nurse is responsible for the client's care until another nurse assumes that responsibility, the nurse should report directly to the nurse in charge.
Assess the client and determine that all findings are within normal limits------Making an assessment of the client's condition is not enough; the information must be recorded and reported. Document all aspects of the client's condition and the transfer-------Documentation is important, but a verbal report to the nurse who will be responsible for the care of the client is necessary.

Vomiting and bulging fontanels are symptoms of increased intracranial pressure in the young child; a malfunctioning shunt would produce these symptoms of hydrocephalus. A mother delivers a male infant at 35 weeks gestation. When visiting her infant in the neonatal intensive care nursery (NICU) for the first time, the mother asks, "When will I be able to breastfeed my son?" The nurse's most appropriate response would be:------------- "Even though he is preterm, he is stable. You may try now if you would like."---------- A preterm infant may have a weak suck but usually can be breastfed; the mother may at least attempt it, if the infant's condition is stable. "Pump your breasts now and then feed him the milk by bottle to conserve his energy."------ Pumping the breasts may be necessary, but bottle-feeding is not needed because this only deters the mother and infant; at 34 weeks if the infant is stable and the mother so desires, breastfeeding should be attempted.
A child, recently returned from a camping trip, complains of a rash, chills, fever, and a headache and is taken to the clinic by the parents. The nurse in the clinic recognizes that this child's history and physical assessment should include: A history of allergies and duration of symptoms-------r/t many factors

A developmental screening and history of exposure to chickenpox----------A developmental screening is not necessary in an acute situation. A client who has undergone a cesarean delivery because of the presence of active genital herpes is transferred to the postpartum unit 2 hours after delivery. The nurse on the unit should plan to institute: Contact isolation-------Contact precautions include wearing gown and gloves; these protect the nurse from the virus. Protective isolation ----This is done for the client's protection, not the nurse's; when caring for a client with herpes, the nurse needs to be protected. Probenecid results in better utilization of the penicillin by delaying the excretion of the penicillin through the kidneys. The spots in the mucous membrane of the soft palate in rubella are called Forschheimer spots; Koplik's spots are present with measles.

erman measles-

Forschheimer spots
255

The symptoms that would most probably lead the nurse to suspect that a 3-year-old child has rubella are: Lymphadenopathy and the development of a rash after a day of fever, sneezing, and coughing characterize rubella. Conjunctivitis and sensitivity to light-------- These are symptoms of rubeola, not rubella.----for measkes The most important nursing responsibility during a myringotomy procedure on an 18-month-old child is to: Keep the child restrained and completely immobilized-------- Movement by the child will impede the procedure and may cause additional injuries to the surrounding structures. Have the mother stay and hold the child in her arms--------- This will not guarantee that the child will keep still during the procedure. A client who has been drinking heavily since the death of a child 3 years ago is brought to the mental health unit in a stupor by the spouse. Taking the client's history into consideration, the nurse makes a tentative nursing diagnosis of: Dysfunctional grieving----------- The history of the loss of a child and the intensity of the client's drinking since the child's death should lead to this nursing diagnosis. Substance abuse, alcohol--------- This is a symptom or a medical diagnosis, not a nursing diagnosis. Cranial radiation destroys leukemic cells in the brain because chemotherapeutic agents are poorly absorbed through the blood-brain barrier. A client who is to have a uterine aspiration abortion at 10 weeks gestation should be told that: The laminaria tent will have to be retained in the cervical canal for 4 to 24 hours- ---As the laminaria tent is left in place for this length of time, it increases in size from absorption of moisture and dilates the cervix 2 to 3 times its original diameter before the suction procedure is done. Suction is used after removal of the laminaria tent; a D & C procedure would be used subsequently only if placental tissue were retained. An increased amount of bleeding will be present for 3 to 5 hours after the abortion-------- Cervical bleeding is reduced by the use of the laminaria tent and is usually equivalent to a heavy menstrual period; the client is usually observed for 1 to 3 hours following the procedure. Fatigue will influence the successful use of other coping strategies such as distraction; this may lead to the client's requiring pain medication. The nursing staff has a team conference on AIDS and discusses the routes of transmission of the human immunodeficiency virus (HIV). The discussion reveals that an individual has no risk of exposure to HIV when that individual: - Makes a donation of a pint of whole blood----------Equipment used is disposable; the donor does not come into contact with anyone else's blood. Condoms offer some protection but are subject to failure because of condom rupture or improper use; risks of infection are present with any sexual contact.

256

Has intercourse with just the spouse---- The risk would depend on the spouse's prior behavior. Limits sexual contact to those without HIV antibodies-------- An individual may be infected for many weeks before testing positive for the antibodies; the individual could still transmit the virus. Following a prostatectomy the client's Foley catheter is pulled taut and taped to the thigh. The client complains that the catheter is pulled too tight. The nurse's best initial action would be to: Explain to the client that the traction is required to help control bleeding---------- Traction on the Foley catheter pulls the balloon tight against the prostatic fossa, which promotes hemostasis. Adjust the tension on the catheter to relieve pressure---------- This is unsafe; the tension on the catheter must be maintained until the physician determines that there is no longer a risk of bleeding. The parents of an adolescent female are very upset about their daughter's diagnosis of anorexia nervosa and the treatment plan proposed. The best intervention by the nurse when the client's parents ask to bring food in for the client is to state: . "For now, allow the hospital staff to handle her food needs."---------- It is most therapeutic for the staff to control food needs, thus removing the parents from the struggle. "It is important that you bring in whatever you think she'll eat."-------- This is nontherapeutic; it only continues the struggle between the parents and the client. "Your concerns about food contribute to her problem."------- This may be interpreted as accusatory and increase the parents' guilt. Insulin, dietary control, and exercise--------------- Most juveniles are insulin-dependent diabetics and have little or no endogenous insulin; diet control and exercise reduce the amount of exogenous insulin needed. The nurse explains to a pregnant client undergoing a nonstress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with:------ Fetal physical activity------ Under normal conditions the heart rate increases with physical activity; the test looks for accelerations of 10 to 15 beats with fetal movements. Maternal uterine contractions---- This is used in the contraction stress test (CST)./oxytocin challenge test. Fetal gestational age----- This is not a part of the evaluation of the fetus in the nonstress test. When assisting the family to help an aphasic member to regain as much speech function as possible, the nurse should instruct them to: Encourage the client to speak while being patient with all attempts-------- In addition to the extent of injury, a factor in relearning speech is the client's motivation and effort; the more the client attempts to talk, the more likely speech will progress to its optimal level; relearning is a slow process. Give positive reinforcement for correct communication----- Although the nurse should instruct the family to approve and support every effort by the client to communicate, their action would provide external rather than internal motivation and is therefore not as effective.

257

Because of the vascularity of the involved tissue, hemorrhage and shock constitute the immediate postoperative danger after a suprapubic prostatectomy. A disturbed client is scheduled to begin group therapy. The client refuses to attend. The nurse should: Accept the client's decision without discussion------ This is all the staff can do until trust is established and the client is able to give up some of these defenses; forcing the client to attend will disrupt the group. Have another client ask the client to reconsider---- This will serve only to create a confrontation between clients. An agitated, acting-out, delusional client is receiving large doses of haloperidol (Haldol) and the nurse is concerned, because this drug can produce untoward side effects. The nurse should be aware that the drug will be immediately stopped if the client exhibits: Jaundice--------- Jaundice signifies liver function interference and requires stopping the medication. Extrapyramidal symptoms---- These symptoms usually require that the dose be reduced; if symptoms do not subside, the drug is stopped. Reye's syndrome affects the liver, causing problems with blood coagulation because the liverdependent clotting factors such as prothrombin are diminished. Cystic fibrosis---- Dysfunction of the exocrine glands leads to an abnormal accumulation of thick mucus, a slower flow rate of mucus, and incomplete expectoration of mucus, all of which contribute to airway obstruction. Hypospadia-------- Arm and leg restraints are necessary to maintain the position of the urethral stent to ensure optimum healing of the newly formed urethra. Because intussusception creates intestinal obstruction where the intestine "telescopes" and becomes trapped, passage of intestinal contents is lessened; stools are red and currant jelly-like from the mixing of stool with blood and mucus Flat feet----- The arch of the newborn's foot is covered with a fat pad giving the appearance of being flat----------------- The fat pad is present in newborns and infants; the arch develops when the child begins to walk. When obtaining the health history from a client who is seeking contraceptive information, the nurse should consider that oral contraceptives are contraindicated in a client who:------- Has a history of borderline hypertension------ Oral contraceptives may cause hypertension and place the client at risk for the development of a CVA. Smokes a pack of cigarettes per day------- Clients should be strongly cautioned about smoking even 15 cigarettes a day. A client comes to the infertility clinic for a carbon dioxide insufflation test to determine whether her fallopian tubes are patent. As part of the teaching before the test the nurse tells the client: "You may

258

have some persistent shoulder pain for 24 hours after the test."----- This is referred pain from the passage of carbon dioxide through the tubes; this is usually indicative of tubal patency.

To assess orientation to place in a client suspected of having dementia, Alzheimer's type, the nurse should ask:------- "Where are you?" "Where are you?" is the best question to elicit information about the client's orientation to place because it encourages a response that can be assessed. "Do you know where you are?"------- This question would probably be answered by "yes" or "no"; this could not objectively determine the client's orientation. In cryptorchidism, sperm-producing abilities of the testes are destroyed, resulting in sterility. Itchiness in Cast--------- Pat the area with an alcohol swab."------- Alcohol is a drying agent; it may temporarily diminish the stimulation of the itchy areas and inhibit the release of histamine. A client's clinical symptoms indicate a possible gastric ulcer. Considering the symptoms of epigastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations, and the laboratory results that demonstrate metabolic alkalosis, the primary nursing diagnosis for this client would be: Fluid volume deficit related to vomiting-------- The stomach produces about 3 L of secretions per day; fluid lost through vomiting can produce a fluid volume deficit. The priority is fluid volume deficit, which can lead to dysrhythmias and death. Impaired gas exchange related to pain------- Shallow respirations are not related to a primary respiratory problem or pain; they are a compensatory mechanism to conserve CO2 to combine with H+ to form carbonic acid (H2CO3) and lower the plasma pH level. Pain related to hypersecretion of gastric acids---------- This would be true for duodenal ulcer; the gastric acid secretory rate is normal in persons with gastric ulcers; in gastric ulcers there is a decreased resistance of the gastric mucosa to acid-pepsin injury and a reflux of bile-containing duodenal contents back into the stomach. Before a client with syphilis can be treated, the nurse must determine the: Existence of allergies----Although the treatment of choice is penicillin, clients who are allergic must be given other antimicrobial agents to avoid an anaphylactic reaction.

The portal of entry does not influence treatment. Size of the chancre----- The chancre is present only in the primary stage; it does not alter treatment. Based on an understanding of normal preschool behavior, during hospitalization the nurse is aware that a 4-year-old will probably: Cry when the parents leave and return but not during their absence---------- Preschoolers can tolerate brief periods of separation from their parents; however, emotions associated with separation and perhaps anger at being left are difficult to hide when parents arrive or leave. Refuse to cooperate with nurses during the parents' absence------ Preschoolers usually are quite docile and cooperative because they are afraid of being totally abandoned. Demonstrate despair if parents do not visit at least once a week------- The child would demonstrate despair long before the week was over.

259

The nurse is aware that a client understands the instructions about an appropriate breathing technique for COPD when the client: Holds each breath for a second at the end of inspiration--------- This pause allows added time for gaseous exchange at the alveolar capillary beds. Progressively increases the length of the inspiratory phase----- The expiratory phase should be lengthened, and exhalation should be through pursed lips. Inhales through the mouth- Inhalation should be through the nose to moisten, filter, and warm the air. ANAEROBIC METABOLISM in shock---- Metabolic acidosis----- This occurs during the progressive stage of shock as a result of accumulated lactic acid.

260