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Friday, July 11, 2008

Nclex-Rn: Saunders Nursing Review 3 (Level of Cognitive Ability)

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The sun rays are as damaging to the skin on cloudy, hazy days as they are on sunny days. Sun screens are recommended and should be applied before exposure to the sun and reapplied frequently and liberally at least every 2 hours. A hat, long sleeved shirt, and long pants should be worn when out in the sun. Tightly woven materials provide greater protection from the sun rays.
Homans' sign is positive when the client feels pain in the calf on dorsiflexion of the foot. It indicates irritation of the blood vessels caused by clot formation and may be indicative of thrombophlebitis. Checking leg circumference for swelling is not as accurate an indicator of thrombophlebitis as a positive Homans' sign. Fundal height and intake and output are not directly related to assessment for thrombophlebitis.

Stomatitis is a term used to describe inflammation and ulceration of the mucosal lining of the mouth. Dietary modifications for this condition include avoiding extremely hot or cold foods, spices, and citrus fruits and juices. The client should be instructed to eat soft foods and take nutritional supplements as prescribed.

The client with breast engorgement should be advised to feed frequently, at least every 2 ½ hours for 15 to 20 minutes per side. Moist heat should be applied to both breasts for about 20 minutes before a feeding. Between feedings, the mother should wear a supportive bra. During a feeding, it is helpful to gently massage the breast from the outer areas to the nipple to stimulate the letdown and flow of milk.

To provide relief from backache, the nurse would advise the client to use good posture and body mechanics, perform pelvic rock exercises, and to wear flat supportive shoes. The client would also be instructed to avoid overexertion and to sleep in the lateral position on a firm mattress. Back massage is also helpful. Eating small meals would more specifically assist in the relief of gastric reflux and dyspnea. Leg elevation assists the client with varicosities.

Aldactone is a potassium-sparing diuretic and the client needs to avoid foods high in potassium, such as whole grain cereals, legumes, meat, bananas, apricots, orange juice, potatoes, and raisins.

Lactulose retains ammonia in the colon, promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. It should be taken with water or juice to aid in softening the stool. An increased fluid intake and a high-fiber diet will promote defecation. If nausea occurs, the client should be instructed to drink cola, eat unsalted crackers, or dry toast. It is not necessary to notify the physician.

Neutrophil counts should range from 3000 to 5800/mm3. A low neutrophil count places the client at risk for infection. When the client is at risk for infection, he or she should avoid exposure to individuals with colds or infections. All live plants, flowers, or objects that harbor bacteria should be removed from the client's environment. The client should be on a low bacteria diet that excludes raw fruits and vegetables.

The parents should be provided with information on how to prevent crises from occurring in the child. High altitudes and flying in nonpressurized planes need to be avoided because oxygen tension is lowered under these conditions. Caution should be taken against becoming dehydrated and the parents should call a physician if vomiting, diarrhea, high fever, or any other cause of water loss develops in the child. Analgesics should not be increased.

Mild pain may occur and continue for several days following this procedure. A clear watery discharge is expected. This is followed by discharge containing debris, which may be malodorous. If the discharge continues longer than 8 weeks, an infection is suspected. Showers or sponge baths should be taken during this time and tub baths need to be avoided.

Digoxin is an antidysrhythmic. The most common early manifestations of toxicity are gastrointestinal (GI) disturbances such as anorexia, nausea, and vomiting. If these manifestations occur, the physician needs to be notified. Digoxin blood levels need to be obtained as prescribed to monitor for therapeutic plasma levels (0.5 to 2.0 ng/mL). The client is instructed to take the pulse, hold the medication if the pulse is below 60 beats per minute, and notify the physician. The client is instructed to wear or carry an ID bracelet or card.

Anginal episodes are triggered by events such as eating heavy meals, straining during bowel movements, smoking, overexertion, and experiencing emotional upset or temperature extremes. Medication therapy is monitored and regulated by the physician.

Following an IVP, the client should take in increased fluids to aid in the clearance of the dye used for the procedure. It is unnecessary to void frequently after the procedure. The client is usually allowed activity as tolerated, without any specific activity guidelines.

Caffeine and alcohol can irritate the bladder. Therefore, alcohol and caffeine containing beverages such as coffee, tea, and cocoa are avoided to minimize the risk. Water helps flush bacteria out of the bladder and an intake of 6 to 8 glasses per day is encouraged. Lemonade and fruit juice are acceptable items to drink.

Iron should be administered with vitamin C rich fluids. Tomato juice contains a high content of ascorbic acid. Vitamin C enhances the absorption of the iron preparation. Water would not enhance absorption. Milk may affect absorption.

The client with pyelonephritis should take the full course of antibiotic therapy that has been prescribed and return to the physician’s office for follow-up urine cultures if so instructed. The client should learn the signs and symptoms of a urinary tract infection, and report them immediately if they occur. The client should also drink 3 liters of fluid per day.

Clients with polycystic kidney disease waste sodium rather than retain it, and therefore need an increase in sodium and water in the diet. Potassium, calcium, and phosphorus do not need to be increased in this condition.

The client is taught to hold the cane on the opposite side of the weakness. This is because, with normal walking, the opposite arm and leg move together (called reciprocal motion). The cane is placed 6 inches lateral to the fifth toe. If the client has right-sided weakness, the client is instructed to hold the cane in the left hand 6 inches lateral to the fifth toe.

Non–weight-bearing status does not allow the client to let the limb touch the floor. The client who has partial weight-bearing status places 30 to 50% of the body weight on the affected limb. Full weight-bearing status is placing full weight on the limb. Touch-down weight-bearing allows the client to let the limb touch the floor but not bear weight. There is no classification for 60 to 80% weight-bearing status.

Pyridostigmine is a cholinergic medication used to increase muscle strength for the client with myasthenia gravis. For the client who has difficulty chewing, the medication should be administered 30 minutes before meals to enhance the client’s ability to eat.

The client with RA should avoid remaining in one position and should change position or stretch every 20 minutes. To reduce efforts by joints, the client should slide objects rather than lift them. The client should avoid exercises and activities other than gentle range of motion when the joints are inflamed. The client is instructed to avoid stooping, bending, or overreaching.

Eye drop regimen is a critical component of treatment for a client with glaucoma to prevent blindness. Clients with arthritis or shaking hands have difficulty instilling their own eye drops. The client is instructed to lie down on a bed or sofa. Tilting the head back can lead to loss of balance. Placing eye drops in a refrigerator should not be done unless specifically prescribed.

In a scleral buckling procedure, the sclera is compressed from the outside by Silastic sponges or silicone bands that are sutured in place permanently. In addition, an intraocular injection of an air or a gas bubble, or both, may be used to apply pressure on the retina from the inside of the eye to hold the retina in place. If an air or gas bubble has been injected, it may take several weeks to absorb. Vigorous activity and heavy lifting is avoided. An eye shield or glasses should be worn during the day and a shield should be worn during naps and at night. The client is instructed to clean the eye with warm tap water using a clean washcloth.

The child should be undressed or wearing underpants only so the chest, back and hips can be clearly seen. The child stands with weight equally on both feet with the legs straight, and arms hanging loosely at both sides. Shoulder heights are observed for unequal alignment. Observation for equal leg lengths is also done.

Children with cystic fibrosis are managed with a high-calorie, high-protein diet, pancreatic enzyme replacement therapy, and fat-soluble vitamin supplements. Fats are not restricted unless steatorrhea cannot be controlled by increased pancreatic enzymes. Sodium intake is unrelated to this disorder.

Measures to prevent cystitis include increasing fluid intake to 3 liters per day; consuming an acid-ash diet; wiping front to back after urination; using showers instead of tub baths; drinking water and voiding after intercourse; avoiding bubble baths, feminine hygiene sprays, or perfumed toilet tissue or sanitary pads; and wearing clothes that “breathe” (cotton pants, no tight jeans, no pantyhose under slacks). Other measures include teaching pregnant women to void every 2 hours, and teaching menopausal women to use estrogen vaginal creams to restore vaginal pH.

The client with a nephrostomy tube needs to have adequate fluid intake to dilute urinary particles that could cause calculus and to provide mechanical flushing of the kidney and tube. The nurse encourages the client to take in 2000 mL of fluid per day, which is roughly equivalent to eight 8-oz glasses of water.

Treatment for a recurrent infection should be continued through the menstrual period because the vagina is more alkaline during this time and an exacerbation is likely to occur.

Cognitive therapy may be used to treat clients who have depression. This type of therapy is based on exploring the client’s subjective experience. It includes examining the client’s thoughts and feelings about situations as well as how these thoughts and feelings contribute and perpetuate the client’s difficulties and mood.

The client should eat small, frequent meals throughout the day. The client also should take in nutrient dense and high calorie meals and snacks. The client is encouraged to eat favorite foods to keep intake up, and plan meals that are easy to prepare. The client should also avoid consuming fluids with meals to increase food intake before satiety sets in.

The client with pulmonary sarcoidosis needs to have follow-up chest films every 6 months to monitor disease progression. If an exacerbation occurs, treatment is initiated with systemic corticosteroids that provide rapid improvement in symptoms. Home oxygen and ongoing use of an incentive spirometer are not indicated.

A hypocalcemic condition indicates a low calcium level in the body. Products that are naturally high in calcium are dairy products, including milk, cheese, ice cream, and yogurt. High calcium foods generally have greater than 100 mg of calcium per serving.

Aggressive pulmonary measures are used to prevent respiratory complications in the client who has impaired gas exchange as a result of a burn injury. These include turning and repositioning, positioning for comfort, using humidified oxygen, providing incentive spirometry, and suctioning the client on an as needed basis. The nurse would avoid maintaining the client in one position. This will ultimately lead to atelectasis and possible pneumonia.

Primary prevention for PID includes avoiding unprotected intercourse, avoiding multiple sexual partners, and avoiding douching.

Following vasectomy, the client must continue to practice a means of birth control until the follow-up semen analysis shows azoospermia, because live sperm remain in the ampulla of vas following this procedure.

Interventions for prostatitis include antiinflammatory medications or short-term antimicrobial medication. Sitz baths and normal sexual activity are recommended. Dietary restrictions are not necessary unless the client finds them to be associated with manifestations of the disorder.

The client needs to be instructed not to sit continuously for longer than one hour. The client should be instructed to stand, stretch, and take a few steps periodically. The client cannot drive a car for six weeks after surgery unless approved by a physician. A support stocking should be worn on the unaffected leg and an Ace bandage on the affected leg until there is no swelling in the legs and feet, and until full activities are resumed. The legs are abducted by placing a pillow between them when the client lies down.

Prevention of early-onset neonatal GBS disease and maternal illness includes providing intrapartum antibiotics to women who develop risk conditions at the time of labor or rupture of membranes. A major risk factor includes prolonged rupture of membranes greater than 12 to 18 hours. Other risk factors include prolonged labor, high number of vaginal exams during labor, low birth-weight infants, premature onset of labor, and premature rupture of membranes.

The client is instructed to take the medication in the morning to prevent insomnia. If the client experiences any chest pain it may indicate overdose and the physician needs to be notified. The dose needs to be adjusted if the client is pregnant or plans to get pregnant. Gastrointestinal complaints from thyroid supplements include increased appetite, nausea, and diarrhea.

The client needs to be instructed to take insulin even if vomiting and unable to eat. It is important to self-monitor blood glucose levels more frequently (every 2 to 4 hours) during illness. If the pre-meal blood glucose is greater than 250 mg/dL, the client should test for urine ketones and contact the physician.

If a hypoglycemia reaction occurs, the client will need to consume 10 to 15g of carbohydrate. Six to eight ounces of 2% milk contains this amount of carbohydrate. Tremors and diaphoresis are signs of mild hypoglycemia. Insulin is not taken as a treatment for hypoglycemia because the insulin will lower the blood glucose level. Hypoglycemic reactions can occur at anytime of the day or night.

Foods that raise urinary oxalate excretion include spinach, rhubarb, strawberries, chocolate, wheat bran, nuts, beets, tea.

The mother needs to be instructed that cough syrup and cold medicines are not to be administered because they may dry and thicken secretions. Sips of warm fluid will relax the vocal cords and thin mucus. A cool mist humidifier rather than a steam vaporizer is recommended because of the danger of a burn injury if the child accidentally pulls the machine over. Acetaminophen will reduce the fever.

Buspirone (BuSpar) may be administered without regard to meals and the tablets may be crushed. It is premature to advise the client to call the physician for a change in medication without first trying alternative interventions. Mixing the tablet uncrushed in custard will not ensure ease in swallowing. Dissolving the tablet in a cup of coffee is not the best instruction to provide to the client because this measure may not ensure that the client will receive the entire dose.

Following heart surgery, the child should not return to school until 3 weeks after hospital discharge at which time the child should go to school for half days for the first few days. No creams, lotions, or powders should be placed on the incision until it is completely healed and without scabs. The mother is instructed to omit play outside for several weeks. The physician needs to be notified if the child develops a fever greater than 100.5 degrees F.

The client needs to be instructed to use a second birth control method during the first pill cycle. Additionally, the client needs to be instructed that if she misses three pills, she will need to discontinue use for that cycle and use another birth control method.

The client needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals because these items stimulate pancreatic secretions and produce attacks of pancreatitis. The client is also instructed of the benefit of eating small frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.

Tylenol is avoided in the client with cirrhosis because it is hepatotoxic and can cause fatal liver damage. Adequate rest and nutrition is important. Fat restriction is not necessary and the diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000. The client’s weight should be monitored on a regular basis.

Foods containing high amounts of purines should be avoided in the client with uric acid stones. This includes limiting or avoiding organ meats, such as liver, brain, heart, and kidney. Other foods to avoid include herring, sardines, anchovies, meat extracts, consomm├ęs, and gravies. Foods that are low in purines include all fruits, many vegetables, milk, cheese, eggs, refined cereals, sugars and sweets, coffee, tea, chocolate, and carbonated beverages.

The perineal area should be cleansed twice daily and following each bowel movement with soap and water. The drainage bag should be lower than the level of the bladder, and the tubing should be free of kinks and compression. Adequate fluid intake is necessary to prevent infection and to provide natural irrigation of the catheter from increased urine flow.

The skin around the stoma is cleansed at each appliance change using a mild, nonresidue soap and water. The skin is rinsed, and then dried thoroughly. The appliance is cut so that the opening is not more than 3 mm larger than the stoma. An opening smaller than the stoma will prevent application of the appliance. Fluids are encouraged to dilute the urine, decreasing the incidence of odor. The stoma is inspected for color, moisture, and protrusion. The skin surrounding the stoma is also inspected for excoriation or skin breakdown.

A severe complication of atrial fibrillation is the development of thrombi. The blood stagnates in the “quivering” atria, because of the loss of organized atrial muscle contraction. The blood that pools in the atria can then clot, which increases the risk of pulmonary and cerebral emboli.

Measures to provide relief of heartburn include small frequent meals, avoiding fatty fried foods, coffee, and cigarettes. Frequent sips of milk, hot tea, or water is helpful.

When taking cloraxepate (Traxene) for management of an anxiety disorder, drowsiness occurs as a side effect of the drug and usually disappears with continued therapy. The client should be instructed that if dizziness occurs to change positions slowly from lying to sitting, before standing. Smoking reduces medication effectiveness. Gastrointestinal disturbances can occur as an occasional side effect and the medication can be given with food if this occurs.

Antibiotics are not taken prophylactically to prevent chlamydia. The risk of reinfection can be reduced by limiting the number of sexual partners and by the use of condoms. In some instances, follow-up culture is requested in four to seven days to confirm a cure.

When taking levodopa (L-dopa) for anti-parkinson's, Signs and symptoms of Parkinson’s disease usually begin to resolve within 2 to 3 weeks of starting therapy, although in some clients marked improvement may not be seen for up to 6 months. Clients need to understand this concept to aid in compliance with medication therapy.

The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication, and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above this range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication. In this case, the dose should be adjusted downward.

Clients with fractures and a cast have some degree of decreased mobility and should optimize nutrition to aid in healing and prevent complications of the immobility. This can be accomplished by increasing intake of dietary fiber, drinking extra fluids, and consuming a well-balanced diet with adequate protein.

The client must sign an informed consent, since the procedure is invasive. The client is not allowed to eat or drink for approximately 6 hours before the procedure. If the client wears contact lenses, dentures, or another prosthesis, it is removed before the client is given preprocedure sedation.

The client who is not immunosuppressed or is not at high risk is considered positive for tuberculosis testing if there is an area of induration at the site of testing that measures 15 mm or more. The reading is generally done 48 to 72 hours after being planted in the forearm. A positive result indicates that the client has been exposed to tuberculosis and requires further diagnostic work-up. It does not indicate the presence of active disease.

If the physician prescribes a set of arterial blood gases (ABGs) on room air, the client should have the oxygen removed before the ABGs are drawn. When the physician is deciding whether to discontinue oxygen therapy, ABGs will be obtained on room air and evaluated to see how the client tolerates oxygen removal.

Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45.

Fifth disease is characterized by the presence of an intense fiery red edematous rash on the cheeks, which gives an appearance that the child has been slapped.

Koplik spots are small bluish-white spots with a red base found on the buccal mucosa.

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