Tourette's disorder involves motor and verbal tics that cause marked distress and significant impairment in social and occupational functioning. Motor tics usually involve the head but can also involve the torso and limbs. The most frequent first symptom is a single tic, such as eye blinking. Other motor tics include tongue protrusion, touching, squatting, hopping, skipping, retracing steps, and twirling when walking. Vocal tics include words and sounds such as barks, grunts, yelps, clicks, snorts, sniffs, and coughs. Coprolalia, the uttering of obscenities, is present in some individuals with this disorder.
Confabulation, a defensive maneuver, is an unconscious attempt to maintain self-esteem. Hiding is a form of denial and an unconscious protective defense against the terrifying reality of losing one’s place in the world. Perseveration is the repetition of phrases or behaviors. Apraxia is not a defensive maneuver and is characterized by the loss of purposeful movement in the absence of motor or sensory impairment.
The experience of flashbacks is characteristic of post-traumatic stress disorder. A flashback is a dissociative experience in which the person acts as though a prior traumatic experience is actually reoccurring. Flashbacks also occur with hallucinogen use. They do not occur in schizophrenia or obsessive-compulsive disorder. “Anxiety disorder” is an umbrella term that encompasses post-traumatic stress disorder as one of its components.
The best indicator that the client’s behavior is under control is when the client refrains from aggression after being partially released from the restraints. Restraints are initially placed around the waist, wrists, and ankles. The ankle restraints are removed first, one at a time, at regular intervals. The waist and wrist restraints are removed together when the client continues to exhibit nonaggressive behavior.
Obsessive-compulsive disorder is characterized by repetitive behavior that interferes with activities of daily living and functioning. Post-traumatic stress disorder occurs when a client continues to relive a traumatic event frequently, or avoids people and places associated with the event. Generalized anxiety disorder occurs when a client has excessive uncontrolled anxiety for more than 6 months. A phobia is an irrational fear of a situation or an object.
Disulfiram is used to help motivated clients avoid impulsive drinking, because this medication interacts with alcohol, causing unpleasant physical effects. The medication reaction begins from minutes to a half-hour after alcohol use, and effects last for up to 2 hours. The effects are flushing of the face, headache, neck pain, tachycardia, decreased blood pressure, sweating, nausea and vomiting, and respiratory distress. The client should avoid “hidden” sources of alcohol in foods and other medications. The client should also avoid inhaling alcohol-containing substances, such as wood stains, paint fumes, and furniture-stripping products.
The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of his or her life. Limiting fluids or reducing salt intake will not decrease intraocular pressure. Restricting the amount of time reading is not a component of the plan.
Complaints of a sudden burst of black spots or floaters indicates that bleeding has occurred as a result of the detachment of the retina. This is not a normal, expected finding and if it occurs, it indicates hemorrhage.
Case management represents an interdisciplinary health care delivery system that promotes 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.
Situational leadership style utilizes a style that depends on the situation and events. Democratic styles best empower staff toward excellence, because this style of leadership allows nurses an opportunity to grow professionally. The autocratic style is task oriented and directive. Laissez faire allows staff to work without assistance, direction, or supervision.
Confrontation is an important strategy to meet resistance head-on. Face-to-face meetings to confront the issue at hand will allow verbalization of feelings, identification of problems and issues, and an opportunity to develop strategies to solve the problem.
A traumatic injury with a blunt object is treated immediately with the application of ice. The client should receive a thorough eye examination to rule out the presence of other eye injuries, but this is not the initial action. Eye irrigation is not necessarily required for a blunt injury. The supine position would increase the amount of swelling in the eye.
If an eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist, because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea. The most appropriate action by the nurse from the options presented is to accompany the victim to the emergency room.
Emergency care following a chemical burn of the eye includes irrigating the eye immediately with tap water or sterile normal saline or ocular irrigating solution if available. The irrigation should be maintained for at least 10 minutes. Following this emergency treatment, visual acuity is assessed. The initial assessment in this situation should focus on the type of treatment that took place immediately following the injury.
If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the physician, because this can indicate hemorrhage.
In a voice test, the nurse stands 1 to 2 feet away from the client and asks the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately.
Imparting the common fears and questions expressed by other clients often encourages the client to ask questions that were thought of but not spoken. The nurse should plan to spend additional time with the client.
If a transfusion reaction is suspected, the transfusion is stopped and then normal saline is infused, pending further physician orders. This maintains a patent IV access line and aids in maintaining the client’s intravascular volume. The IV line would not be removed, because there would be no IV access route. Normal saline is the solution of choice over solutions containing dextrose because saline does not allow any red blood cells to clump.
The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine and correct a bowel obstruction. Initial insertion of the tube is a physician’s responsibility. The tube is mercury weighted, and either advances by gravity or may be advanced manually. Advancement of the tube can be monitored by measuring the tube and by taking serial x-rays. If tube is advanced, nurse should never pull it out but should notify the physician.
Pain control is a priority because the chest pain indicates cardiac ischemia. Pain also stimulates the autonomic nervous system and increases preload, increasing myocardial demands. The ECG can provide evidence of cardiac damage and the location of myocardial ischemia. However, pain control is the priority to prevent further cardiac damage
Late decelerations are caused by uteroplacental insufficiency that occurs as a result of decreased blood flow and oxygen transfer to the fetus through the intervillous space during the uterine contractions. This causes hypoxemia; therefore, oxygen is necessary. Late decelerations are considered an ominous sign but do not necessarily require immediate birth of the baby. The oxytocin infusion should be discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because the medication stimulates contractions and leads to increased uteroplacental insufficiency. Although the finding needs to be documented, documentation is not the immediate action in this situation.
When the membranes rupture in the birth setting, the nurse immediately checks the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord.
Placement of a dressing over a sucking chest wound could convert an open pneumothorax to a closed (tension) pneumothorax. This could result in a sudden decline in respiratory status, mediastinal shift, twisting of the great vessels, and circulatory compromise. If this occurs, the nurse removes the dressing immediately, allowing air to escape. The dressing would not be reinforced.
A child with a diagnosis of pertussis is being admitted to the pediatric unit, the nurse should determine first if the child is getting enough oxygen, the child is attached to a pulse oximeter, which will then provide ongoing information on the child’s oxygen level. The child is also immediately connected to a cardiorespiratory monitor to provide early identification of periods of apnea and bradycardia. The nurse would then perform an assessment, including taking the child’s temperature, weight, and asking the parents about the child.
Chest pain that is unrelieved by rest and three doses of nitroglycerin taken 5 minutes apart may not be typical anginal pain, but may signal myocardial infarction (MI). Since the risk of sudden cardiac death is greatest in the first 24 hours after MI, it is imperative that the client receives emergency cardiac care. The nurse would call an ambulance to transport the client to the emergency room. The nurse would not drive the client, because the client should not exert energy and place an increased workload on the heart.
Clients are at risk for becoming hypovolemic after surgery, and often the first sign of hypovolemia is a decreasing urine output. However, the nurse needs additional data to make an accurate interpretation. The nurse should check the client's overall intake and output record first.
Autonomic dysreflexia, also known as autonomic hyperreflexia, is a life-threatening syndrome. It is a cluster of clinical manifestations that results when multiple spinal cord autonomic responses discharge simultaneously. Exaggerated autonomic nervous system reactions to stimuli result in sudden hypertensive episodes with severe headache. The client may sweat profusely above the level of the cord lesion and complain of a stuffy nose. Pupil and knee jerk response are not affected. While a distended bladder is often the precipitating event, not all clients with bladder distention exhibit dysreflexia.
Spinal shock represents a temporary but profound disruption of spinal cord function, which occurs immediately after injury and is clinically evident within 30 to 60 minutes. It is a state of areflexia characterized by the loss of all neurological function below the level of injury. Flaccid paralysis, bradycardia, and hypotension occur. The body is unable to use either shivering or perspiring as a means of controlling body temperature.
When PVCs occur, there is also a decrease in cardiac output. This occurs because there is a premature depolarization of the cardiac cells. The prematurity does not allow for optimal filling of the ventricular chambers, causing reduced stroke volume, and hence, decreased cardiac output.
Atrial fibrillation is a very disorganized twitching of the atria at a rate greater than 350 beats per minute. The ventricular response is very irregular because of the low percentage of atrial impulses that are actually conducted. A characteristic of atrial fibrillation is an absent or unidentifiable P wave.
A child with hemophilia is at risk for bleeding if injury occurs. Therefore the mother is instructed to pad table corners and crib rails, provide extra “joint” padding on clothes, observe a mobile child at all times, and keep out of reach any items that can be pulled down onto the child. Contact sports are avoided because of the risk of injury and resultant bleeding. Rectal temperatures and the use of aspirin are contraindicated for hemophiliacs. Rectal mucosa is very friable and if injured will bleed. Aspirin has antiplatelet properties.
Cardiac tamponade is a life-threatening complication of pericarditis and results from the accumulation of fluid in the pericardium. In cardiac tamponade, assessment reveals hypotension, tachycardia, jugular vein distention, cyanosis of the lips and nails, dyspnea, muffled heart sounds, diaphoresis, and paradoxical pulse. A paradoxical pulse is a decrease in systolic arterial pulsation exceeding 10 mm Hg during inspiration. Cardiac tamponade requires immediate intervention.
Cigarette smokers have twice the risk of having a myocardial infarction as nonsmokers and have two to four times the risk of having sudden cardiac death. Smoking cessation will reduce its damaging effects on the cardiovascular system.
The client with myocardial infarction should avoid activities that tense the muscles, such as isometric exercises. These increase intraabdominal and intrathoracic pressures and can decrease the cardiac output. They can also trigger vagal stimulation, causing bradycardia.
Biological dressings are obtained from living or deceased humans (homograft or allograft) or animals (heterograft or xenograft). Heterograft is skin from another species. The most commonly used type of heterograft is pigskin, because of its relative compatibility with human skin. Homograft is skin from another human, which is usually obtained from a cadaver and is provided through a skin bank.
Posturing is a late sign of deterioration in the client’s neurological status and warrants immediate physician notification. Decerebrate posturing (abnormal extension), which is associated with dysfunction in the brain stem area, consists of extension of the extremities and the pronation of the arms.
Intermittent claudication is a symptom that is characterized by sudden onset of leg pain that occurs with exercise and is relieved by rest. It is a classic symptom of peripheral arterial insufficiency. Venous insufficiency is characterized by an achy type of leg pain that intensifies as the day progresses.
Standard therapy for DVT consists of bed rest, leg elevation, and application of warm moist heat to the affected leg. The client may have calf measurements ordered once per shift or once per day, but they would not be obtained hourly.
Serum digoxin levels are most often drawn immediately before a scheduled dose, although they may be drawn 4 to 10 hours after a previous dose. Recall that the purpose of the sample is to record the serum concentration of the medication to ensure that it is in the therapeutic range. Drawing the medication before a scheduled dose ensures that the level is not falsely elevated. The normal therapeutic range for digoxin is 0.5 to 2.0 ng/mL.
Clients on a sodium-restricted diet should avoid the use of commercially prepared bread or bread products, because these products often contain sodium as a preservative. Products made with natural grains that do not contain added salt are best.
The best meat choices to lower the intake of cholesterol include lean cuts of beef with the fat trimmed, lamb, pork (except spare ribs), veal (except ground), skinless baked poultry, fish, and shellfish. Meats that have larger amounts of cholesterol include prime grades of beef, pork spare ribs, goose, duck, organ meats (liver, brain, kidney), sausage, bacon, luncheon meats, frankfurters, and caviar.
There should be no open flames or smoking within 10 feet of the oxygen source. The tank should remain secured in its holder, not lying on the floor, and the concentrator should be away from walls or other close quarters (to allow adequate air circulation around the unit). The oxygen source should also be removed from sources of heat or sunlight.
After suctioning a client either with or without an artificial airway, the nurse auscultates the breath sounds to determine the extent to which the airways have been cleared of respiratory secretions.
There should be enough room for two fingers to slide comfortably under the tracheostomy tape. This ensures that they are tight enough to prevent tracheostomy dislocation, while preventing excessive constriction around the neck.
Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. This observation does not indicate that the chest tube system can be discontinued. A cleared pneumothorax would show absence of bubbling with respiration in the water seal chamber. Suction control does not affect the water seal chamber.
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