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Monday, July 14, 2008

Nclex-Rn: Saunders Nursing Review 4 (Level of Cognitive Ability)

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With early detection, tetracycline hydrochloride and chloramphenicol (Chloromycetin) have been found to be effective in treating RMSF. These medications inhibit the growth of the organism. However, if vascular damage has already occurred, the medications may not alter the course of the disease. Antibiotic therapy is continued until the child has been afebrile for at least 2 to 3 days. The usual duration of therapy is 6 to 10 days. Thioguanine and thiotepa are antineoplastic medications. Ticlopidine hydrochloride is a platelet aggregation inhibitor.

HIV infection is an acquired cell-mediated immunodeficiency disorder causing a wide spectrum of illnesses in children, ranging from no symptoms to mild and moderate symptoms to severe symptoms. Acquired immunodeficiency syndrome (AIDS) represents the most severe illness.

Rheumatic fever is an inflammalatory autoimmune disease that affects the connective tissue of the heart joints, and subcutaneous tissues

Systemic lupus erythematosus is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue

Kawasaki disease is a febrile generalized vasculitis of unknown etiology.

Rheumatic fever characteristically presents 2 to 6 weeks following an untreated or partially treated group A beta-hemolytic streptococcal infection of the upper respiratory tract

With late-stage emphysema, the retention of carbon dioxide can lead to carbon dioxide narcosis. This is manifested by occipital headache, drowsiness, and an inability to concentrate. Other signs that may occur are bounding pulse, arterial carbon dioxide level greater than 75 mm Hg, confusion, coma, and asterixis (flap tremor).

The purpose of Crutchfield tongs is to stabilize fractures or displaced vertebra in the cervical and thoracic areas. Tongs are inserted on the sides of the scalp through drill holes. Traction pull is always along the axis of the spine. The nurse should check the tongs at least every 8 hours and PRN for displacement and looseness. The child can be repositioned by logrolling or turned as a unit. Neurological status should be checked frequently because spinal cord injury frequently accompanies a cervical injury. Pin care is done every shift.

Signs and symptoms of JRA include painful, stiff, swollen, tender, and warm involved joints. Joints are especially stiff after sleeping or other periods of inactivity. Children are not always able to clearly identify the problem and therefore the nurse makes it a priority to note increased irritability, guarding of the painful joint, or reluctance to walk. Other non-specific symptoms include: anorexia, weight loss, growth failure, sleep pattern disturbance, lymphadenopathy, and hepatosplenomegaly.

The client’s complaints of reddened, painful breast and an elevated temperature may be indicative of mastitis. Based on the signs and symptoms presented by the client, particularly the elevated temperature, the physician needs to be notified because an antibiotic that is tolerated by the infant as well as the mother may be prescribed. The mother should continue to nurse on both breasts, but should start the infant on the unaffected breast while the affected breast lets down.

There are four mechanisms of heat loss. Evaporation of moisture from a wet body surface dissipates heat along with the moisture. Convection occurs when heat is transferred to air surrounding the infant. Heat loss occurs via conduction when the infant is on a cold surface, such as a table because the infant’s body heat is transferred to the table. Radiation occurs when heat from the body radiates to a cooler surface.

Having previous large newborns of 9 pounds or more is a risk factor for developing gestational diabetes mellitus and needs to be assessed at the first prenatal visit. Where the client received previous prenatal care is irrelevant to this pregnancy. The comparison of the fundal height with dates is objective data and is not important data for assessing risk factors for diabetes mellitus at six weeks gestation. A 24-hour diet recall is important information after a client has been diagnosed with gestational diabetes and client teaching has started.

Polyuria, polydipsia, and polyphagia are classic manifestations of hyperglycemia. Pain, frequency, and urgency with urination as well as voiding in small amounts may indicate a urinary tract infection, for which a urine culture and sensitivity would be helpful. Liver function studies would be significant if liver disease was suspected. A lipid profile would be helpful to screen a client for cardiac risk factors.

Bell’s palsy is a one-sided facial paralysis from compression of the facial nerve (cranial nerve VII). There is 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.

Several factors can increase the client’s risk for falls, including impaired vision, medications that cause dizziness or orthostatic hypotension, and problems with balance and coordination. The nurse assesses for these risks and provides preventive measures to eliminate the risk.

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

The client who attempts suicide is usually depressed and has feelings of hopelessness, worthlessness, inadequacy, or guilt. When psychosis is present such as with command auditory hallucinations (or voices telling the client to commit suicide), the likelihood of a suicide attempt increases. The formulation of a suicide plan indicates the client’s intent to commit suicide, and an active method rather than a passive method increases risk as well.

When a pulse rate is irregular, the apical pulse should be auscultated for the irregularity and the radial pulse should be palpated for the pulse deficit. Pulse deficit is a difference between the apical rate and the radial pulse rate, which is a characteristic of atrial fibrillation.

A common presenting symptom of herniated lumbar disc is low back pain that is usually aggravated by activity and relieved by rest. Muscle weakness and sensory loss may occur and there may be a change in tendon reflexes. Pain in the shoulders is more typical of cervical disc disease or myocardial infarction. Loss of voluntary muscle control and bladder and bowel control is not a typical manifestation of a herniated lumbar disc.

Intussusception is an invagination or telescoping of one portion of the intestine into another. A report of severe colicky abdominal pain in a healthy thriving child between 3 to 17 months of age is the classic presentation of intussusception. Typical behavior includes screaming and drawing the knees up to the chest.

Scoliosis is defined as an abnormal lateral curvature in any area of the spine.

Kyphosis is an excessive posterior curvature of the thorasic spine

Lordosis is an abnormal anterior curvature of the lumbar spine that may be noted in pregnancy or in perons who are obese.

An irregular apical heart rate and rhythm may be present in a client with a history of cardiac disease and is a cause of some types of cerebrovascular accident.

The client undergoing pericardiocentesis is positioned supine with the head of the bed raised to an angle of 45 to 60 degrees. This places the heart in close proximity to the chest wall for easier insertion of the needle into the pericardial sac.

A neonate born before the end of 37 weeks' gestation is considered preterm, regardless of weight. The small for gestational age neonate is designated by a weight that is below the 10th percentile or is two standard deviations below normal. A term newborn is older than 37 weeks, born between the beginning of week 38 and the end of week 41. A post-term newborn is born at week 42 or after.

The client with thrombophlebitis, also known as deep vein thrombosis, exhibits redness and/or warmth of the affected leg, tenderness at the site, possible dilated veins (if superficial), low grade fever, edema distal to the obstruction, and possible positive Homans' sign in the affected extremity. Pedal pulses are unchanged from baseline because this is a venous, not an arterial problem.

An Automatic cardioverter defibrilator (AICD) detects and delivers an electric 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.

A normal P wave indicates that the impulse that depolarized the atrium was initiated in the sinoatrial (SA) node. A change in the form or the absence of a P wave can indicate a problem at this part of the conduction system, with the resulting impulse originating from an alternate site lower in the conduction pathway.

Assessment of a client with Hodgkin’s disease most often reveals enlarged but painless lymph node or nodes. Enlarged lymph nodes are the earliest manifestation of Hodgkin’s disease. More specific clinical manifestations depend on the site of malignancy and the extent of the disease.

Classical clinical manifestations of cardiogenic shock include altered sensorium (confusion), tachycardia, hypotension, tachypnea, oliguria, and cold, clammy, cyanotic skin.

A delusion is an important personal belief that is almost certainly not true and resists modification. An illusion is a misperception or misinterpretation of externally real stimuli. A hallucination is a false perception. Loose association is thinking characterized by speech in which unrelated ideas shift from one subject to another.

A characteristic of unstable angina is that it tends to increase in frequency, duration, and severity over time.

A characteristic of stable angina is paroxysmal chest discomfort triggered by predictable physical or emotional factors.

Angina decubitus is a chest discomfort that increases when reclining.

Norturnal angina is when the patient experience chest discomfort associated with sleep.

A sweet or foul smelling odor to stool is characteristic of a diarrhea stool regardless of the feeding method. A breastfed infant’s stool is expected to be loose and pasty and pale yellow in color. Grimacing and grunting during defecation are normal behaviors.

ST segment elevation usually occurs immediately or during the early stages of acute myocardial infarction. T wave inversion and abnormal Q wave changes occur later, within hours to several days after the acute myocardial infarction. Absent P wave or P waves that are difficult to discern are noted in atrial fibrillation.

In a full-thickness fourth-degree burn injury, charring is visible. Extremity movement is limited and wound sensation is absent. Blisters and a wet shiny weeping surface would be noted in a partial-thickness second-degree burn injury. A dry wound surface would be noted in a full-thickness third-degree burn injury.

The emotional and behavioral reactions of a client following acute myocardial infarction are varied. Depression may be manifested by withdrawal, crying, and/or apathy.

Sulindac (Clinoril) is a nonsteroidal antiinflammatory medication (NSAID). Frequent side effects include gastrointestinal (GI) disturbances including constipation or diarrhea, indigestion, and nausea. Dermatitis, a rash, dizziness, and a headache are also frequent side effects.

Not all clients with an AAA exhibit symptoms and when they occur, they may include a subjective feeling of the “heart beating” in the abdomen when lying 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 associated with an AAA.

Elder exploitation includes: paying exorbitant fees for services and goods provided by family members, friends, or caretakers; transferring large sums of money or holdings to family members, caregivers, friends, or employees; adding names of the individuals on which the client is dependent to bank accounts, deeds, stock portfolios, or wills; experiencing losses of large sums of money; inability to participate in a decision to move in with adult children; and exclusion from decision making about own health, welfare, and lifestyle.

The initial family assessment should focus on a careful history of each family member. Once the coping style of each family member is known then other factors can be assessed. How an individual family member copes will determine how the individual will deal with the abusive situation.

Beta-adrenergic blocking agents, such as atenolol, mask the signs and symptoms (such as tachycardia, sweating, and feelings of anxiety) of acute hypoglycemia. Therefore, the client receiving this medication should adhere to the therapeutic regimen and monitor blood glucose levels carefully.

Bell’s palsy, the most common type of peripheral facial paralysis, affects the motor aspects of the seventh cranial nerve. It causes temporary paralysis of one side of the face with unilateral paralysis of expression. It is most common between the ages of 20 and 40, occurring equally in both males and females. Clinical manifestations include: widened palpebral fissure (distance between upper and lower eyelids), drooping of the mouth, flattened nasolabial fold, a slight lag in closing the eye, and stated difficulty eating.

Thrombolytic agents dissolve existing clots, and bleeding can occur anywhere in the body. The nurse monitors for any obvious signs of bleeding and also for occult signs of bleeding, which would include monitoring hemoglobin and hematocrit levels, blood pressure and pulse, neurological signs, presence of abdominal and back pain, and the presence of blood in the urine or stool. A change in neurological signs could indicate cerebral bleeding; abdominal and back pain could indicate abdominal bleeding; a change in blood pressure and pulse could be general indicators of hemorrhage. The characteristic of bowel sounds is not specifically associated with this medication.

Separation from family is the most stressful aspect of hospitalization in young children. Under the age of 5, a primary goal is to prevent separation from family. Assessing for the ability and willingness of family members to stay with the child takes priority over favorite toys or diversional activities.

Hiatal hernia is herniation of a portion of the stomach into the esophagus through an opening in the diaphragm. The cause is unknown, but certain factors have been associated with development. Large meals are associated with clinical manifestations because the full stomach may cause reflux.

Scoliosis is a spinal deformity usually involving a lateral curvature. Screening generally begins in the fifth grade. There is no routine screening test for meningitis. Screening for congenital hip disorder and phenylketonuria is done in newborns.

Pain or discomfort from a problem that originates in the kidney is felt at the costovertebral angle on the affected side. Ureteral pain is felt in the ipsilateral labium in the female client, or the ipsilateral scrotum in the male client. Bladder infection is often accompanied by suprapubic pain and pain or burning at the urinary meatus when voiding.

Normal sinus rhythm is defined as a regular rhythm with an overall rate of 60 to 100 beats per minute. The P-R and QRS measurements are normal, measuring 0.12 to 0.2 seconds and 0.04 to 0.10 seconds, respectively. Sinus bradycardia is defined as a heart rate below 60 beats per minute. In first-degree heart block the P-R interval is prolonged beyond the normal 0.2 second. Atrial fibrillation is characterized by erratic or no identifiable P waves.

Selegiline hydrochloride (Eldepryl) is an antiparkinson medication. Side effects of the medication include nausea, dizziness, lightheadedness, faintness, abdominal discomfort, and confusion. Adverse effects and toxic effects vary from central nervous system depression (sedation, apnea, cardiovascular collapse, death) to severe paradoxical reaction (hallucinations, tremors, seizures).

Renal angiography involves injection of a contrast medium. Therefore the procedure is invasive and an informed consent for the diagnostic procedure needs to be signed. A local anesthetic may be used at the needle insertion site but an anesthesia consent form is not necessary. The nurse checks for client allergies to determine whether the client has an allergy to the contrast medium. A baseline assessment of circulation to the legs is important to assist in monitoring for complications in the post-procedure period.

Constant bubbling in the water seal chamber indicates an air leak. This is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires physician intervention.

Following a segmental resection of the uppder lobe, it is most important for the nurse to assess active ROM exercises as prescribed, failure of the client to perform active ROM exercises as prescribed allows the formation of adhesions of the incised muscle layer and leads to a dysfunction syndrome.

Dyspnea is a late sign of a laryngeal tumor and occurs when the tumor growth is beginning to cause airway obstruction. Early signs are voice changes, hoarseness and hemoptysis.

The traction setup is checked routinely to ensure that the ropes are in the grooves of the pulleys; ropes are not frayed; knots are tied securely; and weights are hanging freely from the ropes. Weights that rest against another object do not exert the full pulling force that is intended and ordered with the traction.

Common nutritional problems following gastrectomy include vitamin B12 and folic acid deficiency. This may result from a deficiency of the intrinsic factor and/or inadequate absorption of food, because food may enter the bowel too quickly after this type of surgery.

Signs of anxiety include behaviors such as clenched hands, a heightened awareness, wide eyes, pupil dilation, startle response, furrowed brow, clinging to the family or staff, or physical lashing out. Since anxiety stimulates the sympathetic nervous system, the client may also exhibit palpitations and chest pain, tachycardia, increased respiratory rate, elevated blood glucose, and hand tremors.

Pyelonephritis is an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney (nephros in Greek).

Typical manifestations of acute pyelonephritis include high fever, chills, nausea and vomiting, flank pain on the affected side with costovertebral angle tenderness, general weakness, and headache. The client often exhibits the typical signs and symptoms of cystitis, with production of urine that is foul-smelling, cloudy or bloody, and with an increased urinary white blood cell count.

The client with nephrotic syndrome typically presents with edema, hypoalbuminemia, and proteinuria. The nurse carefully assesses the fluid balance of the client, which includes daily monitoring of weight, intake and output, edema, and girth measurements. Albumin levels are monitored as they are ordered, as are the BUN and creatinine levels. The client’s activity level is adjusted according to the amount of edema and water retention. As edema increases, the client’s activity level should be restricted.

Cranial nerve XII, the hypoglossal nerve, has motor function only and controls movement of the tongue. It is assessed by asking the client to protrude the tongue and move it quickly side to side. The strength of the tongue can be assessed by having the client push against the inside of the cheek with the tongue while external pressure is applied to the cheek.

Asking the client to open the mount and say "Ah", Swallowing a sip of water and vocalize the sounds "lala", "mi-mi", and "kuh-kuh" are all assessed are part of glossopharyngeal nerve (cranial nerve IX) and the vagus nerve (cranial nerve X) testing, which are done together.

Remote memory or long term memory is tested by asking the client about something from the past (ex. date of birth). The nurse must be able to verify this information, though. Recent memory tests information within days, weeks, or months (ex. last night's supper meal tray?). New memory is tested by asking the client to repeat three unrelated words that the examiner speaks. The client repeats them immediately so the nurse knows they have been heard correctly, and the nurse asks the client to repeat them again 5 minutes later.

Water does not damage the synthetic cast; however the client should know that it may take a while for the cast padding to dry. Water may soften a plaster cast but has no effect on a synthetic cast. A shower will not cause an infection.

According to the Rule of Nine’s, 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 1%.

Nausea and vomiting should not occur if the NG tube is patent. The NG tube should not be repositioned after gastric surgery because it is placed directly over the suture line. The NG tube is irrigated only with a physician’s order and would be irrigated with small amounts of fluid only. In this situation, the nurse should assess for distention and notify the surgeon.

In leukemia, infiltration of leukemic cells occurs in the bone marrow. Bone marrow aspiration and biopsy provides examination of blast cells and determination of the presence of other hypercellular activity. Physical manifestations, complete blood counts, and the client’s history will also be considered when diagnosing the client but will not provide a definitive diagnosis.

Monitoring weight and noting changes on a daily basis provides the most reliable data related to fluid balance.

To test a cliet for pupillary reaction to light, turn the penlight on, and move the light from the client's temporal area to the eye while the client looks straight ahead.

When assising accomodation of the eye to light, check pupil size using a penlight; then have the client alternate watching the light and the examiner's finger

To elicit the plantar reflex, the nurse would firmly stroke the lateral sole of the foot and under the toes with a blunt instrument. Normally, the toes plantar flex; if the response is abnormal, the toes dorsiflex and fan out.

To elicit gastrocnemius muscle contraction, taps te achilles tendon using a reflex hammer.

Two-point discrimination - gently pricks the client's skin on the dorsum of the foot in two places.

Proprioception - holds the sides of the client's great toe and whle moving it, ask the client what position it is in.

Amoxicillin is a penicillin. Adverse effects include superinfection, such as potentially fatal antibiotic-associated colitis, that results from altered bacterial balance. Symptoms include abdominal cramps, severe watery diarrhea, and fever. Frequent side effects of the medication include gastrointestinal disturbances (mild diarrhea, nausea, vomiting), headache, and oral or vaginal candidiasis.

To be an effective leader, the nurse must work collaboratively with others to solve common problems

The nurse has a duty to protect the client from harm. If the nurse believes a physician’s order to be in error, the nurse is responsible for clarifying the order before carrying out the order. Checking with the pharmacist can assist the nurse in determining whether the dose ordered is incorrect, but neither the nurse nor pharmacist is licensed to prescribe drugs. They cannot alter the dose without an order from the physician. Withholding the drug until the physician makes rounds and rescheduling the chemotherapy are incorrect actions and delay administration of the chemotherapy.

Acetazolamide (Diamox) is a carbonic anhydrase inhibitor. Nephrotoxicity and hepatotoxicity can occur and is manifested by dark-colored urine and stools, pain in the lower back, jaundice, dysuria, crystalluria, and renal colic and calculi. Bone marrow depression may also occur.

A low cardiac output will cause an increased build-up of blood in the heart and pulmonary system, causing crackles to be heard in the lung fields. An S3 heart sound is also known as a ventricular gallop and is an abnormal finding if heard in an adult over 30 years of age. S3 is the third heart sound produced during the rapid filling phase of ventricular diastole, when blood flows from the atrium to a noncompliant ventricle. Bronchial breath sounds are normal breath sounds heard over the manubrium in the large tracheal airways. These sounds are loud and high-pitched and have a hollow or harsh quality.

Nausea, vomiting, and diarrhea occur secondary to acidosis. There may be increased bowel sounds secondary to increased peristalsis but true borborygmi primarily suggest a mechanical obstruction of the small intestine. Melena results from bleeding in the upper gastrointestinal tract and usually is a sign of a peptic ulcer or small bowel disease.

Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and esophagus, called tracheoesophageal fistula. The fistula allows air to escape into the stomach causing abdominal distention. It also promotes aspiration of gastric contents.

The three stages of separation anxiety are protest, despair, and detachment. Loudly crying and kicking both legs is a protest behavior that is seen in the first stage of separation.

The kidneys normally receive 20 to 25% of the cardiac output, even under conditions of rest. In order for kidney function to be optimal, adequate renal perfusion is necessary. Perfusion can best be estimated by the blood pressure, which is an indirect reflection of the adequacy of cardiac output.

Amphotericin B is an antifungal medication. Adverse effects include nephrotoxicity evidenced by a decrease in urinary output and the nurse needs to monitor fluid balance and renal function tests for potential signs of this adverse effect. Cardiovascular toxicity, evidenced by hypotension and ventricular fibrillation, can occur but is rare. Anaphylactic reactions are also rare. Vision and hearing alterations, seizures, hepatic failure and coagulation defects may also occur.

Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Tremors and diaphoresis are signs of hypoglycemia.

Compartment syndrome occurs with impedance to the arterial circulation. The pain of compartment syndrome is not relieved by narcotic analgesics. The pain is aggravated by limb elevation, which further impairs blood supply. The compartment is painful when moved. Paresthesias occur early in the syndrome, which progress to paralysis if the pressure in the compartment is not relieved.

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