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Tuesday, July 15, 2008

Nclex-Rn: Saunders Nursing Review 5 (Level of Cognitive Ability)

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Intermittent claudication is a symptom of peripheral vascular disease. It is described as a cramp-like pain that occurs with exercise and is relieved by rest. Intermittent claudication is due to ischemia, and is very reproducible; that is, a predictable amount of exercise causes the pain each time.

Assessment findings 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 blood pressure by greater than 10 mm Hg).

Spironolactone (Aldactone) is a potassium-sparing diuretic. The nurse should be alert to the fact that the client taking spironolactone may experience body image changes due to threatened sexual identity. These body image changes are related to decreased libido, gynecomastia in males, and hirsutism in females. Since the medication is a diuretic, edema and weight gain should not occur. Excitability is not associated with the use of this medication; rather, drowsiness may occur.

Calcium channel blocking agents, such as diltiazem hydrochloride (Cardizem), are used cautiously in clients with conditions that could be worsened by the medication. These conditions include aortic stenosis, bradycardia, heart failure, acute myocardial infarction, and hypotension. The nurse would assess for signs and symptoms that indicate worsening of these underlying disorders.

Hydralazine (Apresoline) is a powerful vasodilator that exerts it action on the smooth muscle walls of arterioles. After an intravenous dose is administered, the nurse should check the client’s blood pressure every 5 minutes until stable and every 15 minutes thereafter (or per agency procedure).

The nurse assesses the postoperative client for the presence of bowel sounds before resuming diet. Absence of bowel sounds would indicate paralytic ileus, making a diet contraindicated.

Adverse effects of suctioning include hypoxemia, cardiac irregularities due to vagal stimulation, mucosal trauma, and paroxysmal coughing. If these occur during the procedure, the procedure is stopped and the client is reoxygenated.

Clients with DKA accumulate large amounts of ketone bodies in extracellular fluids. A fruity odor to the breath develops due to the volatile nature of acetone.

Crackles are fine high pitched crackling and popping sounds heard during the end of inspiration. Crackles are not cleared by coughing and may be heard in pneumonia, congestive heart failure, chronic bronchitis, asthma, and other restrictive and obstructive diseases. High pitched musical sounds are characteristic of wheezing and are more commonly heard during expiration but may also be heard during inspiration. Coarse low pitched snoring sounds are characteristic of rhonchi and are heard primarily during expiration but may also be heard during inspiration. Low pitched grating sound heard during inspiration and expiration is characteristic of a pleural friction rub.

The Glasgow Coma scale is a method of assessing consciousness. In this scale, each response is given a number (high for normal and low for impaired) for eye opening, verbal response, and motor response. The scores for responses are added and a high number indicates normal functioning. A visual analog scale can be used to determine pain ratings. A pulse oximetry graph would be used to document pulse oximetry readings. A Snellen’s chart is used to assess visual acuity.

Renal cancer is commonly manifested by hematuria and flank pain (not abdominal or suprapubic), and a palpable mass may be palpated on physical examination. Because the hematuria is gross but intermittent, the client may delay seeking medical treatment. Foul smelling urine could indicate infection. Decreased urine output could indicate renal insufficiency.

Following urostomy, the stoma should be red and moist. It may be edematous, but this will decrease after the first few days. A dusky or cyanotic color indicates insufficient circulation, with impending necrosis, and warrants notification of the surgeon immediately.

Signs of fluid balance include equal intake and output for 24, 48, and 72 hours, stable body weight, moist mucous membranes, absence of tongue furrows, good skin turgor, and blood urea nitrogen and electrolytes within normal limits.

Signs of arterial damage can result when the artery is contused, thrombosed, lacerated, or becomes spastic. Signs include pallor or blotchy cyanosis, variable or absent distal pulse, swelling, pain, poor capillary refill, and distal paralysis or loss of sensation. Reddish discoloration would be more likely to occur with impaired venous return.

A dry plaster cast is white, odorless, close to room temperature to touch, and resonant to percussion. A plaster cast that is wet is gray, cool, musty smelling, and dull to percussion.

The number of cigarettes smoked daily and the duration of the habit are used to calculate the number of pack years, which it the standard method of documenting smoking history. The brand of cigarettes may give a general indication of tar and nicotine levels, but the information has no immediate clinical use. Desire to quit and number of past attempts to quit smoking may be useful when the nurse develops a smoking cessation plan with the client.

Steps in collecting sterile urine specimen are ... The nurse always explains the procedure to the client first. The nurse then performs hand hygiene and dons gloves to prevent the transfer of microorganisms. The nurse cleanses the sampling port to prevent the entry of microorganisms into the catheter, inserts the needle, draws the amount of urine needed, and places the specimen into the urine specimen container. The nurse then unclamps the catheter to allow the urine to flow by gravity. The specimen is labeled according to agency protocol and sent to laboratory. Incorrect identification of the specimen could result in diagnostic or therapeutic errors. The specimen is transferred to the laboratory immediately (at least within 30 minutes). If this is not possible the specimen may be refrigerated up to 2 hours.

The main goals of treatment for Buerger’s disease are the same as for peripheral arterial insufficiency. Thus, the client is taught measures to increase circulation, which include enhancing vasodilatation through warmth, exercise, and smoking cessation.

The nurse monitors the client receiving anticoagulant therapy for adverse effects. These would include internal manifestations such as abdominal pain or swelling, backache, dizziness, headache, hematemesis, hemoptysis, hematuria, black or bloody stools, and Hematest positive urine, stool, or nasogastric tube drainage. Overt signs include ecchymoses, petechiae, hematomas, nosebleeds, and bleeding from the gums, wounds, and venipuncture sites.

Uterine inversion is a medical emergency requiring immediate recognition, replacement of the uterus into the pelvic cavity, and correction of associated clinical conditions. Tocolytics or halogenated anesthetics may be given to relax the uterus before attempting replacement. Medical management includes treating shock, repositioning the uterus, giving oxytocic agents after the uterus is repositioned, and initiating broad-spectrum antibiotics. The umbilical cord should not be pulled on unless the placenta has definitely separated. Fundal massage should be avoided if possible. If fundal massage is necessary and prescribed, it should be applied very carefully. Placing the newborn infant to the mother’s breast is inappropriate at this time. Additionally breastfeeding will cause uterine contraction. The nurse also needs to continuously monitor maternal vital signs, administer analgesics, and notify the anesthesia department that general anesthesia may be needed for a reinversion procedure.

Pyloric stenosis occurs when the circular muscle of the pylorus becomes grossly enlarged (hypertrophic) and causes constriction of the pylorus and obstruction of the gastric outlet. Infants with this disorder most commonly present with forceful and projectile vomiting. The emesis contains milk or formula and is not bile stained. Bile stained emesis is a sign of obstruction of the small intestine. Gastric peristalsis visible on examination occurs in some infants. Hypernatremia occurs because of depletion of electrolytes from extensive and prolonged vomiting.

Digoxin is a cardiac glycoside that is used to treat heart failure and to control the ventricular rate in clients with atrial fibrillation. There is a narrow margin of safety between a therapeutic and toxic drug level and the client needs to be aware of the signs of toxicity and report them to the physician immediately if they occur. The most common early manifestations are gastrointestinal disturbances such as anorexia, nausea, and vomiting. Visual disturbances are also signs of toxicity. Therefore, if nausea occurs, the client needs to contact the physician (not take an antacid). If visual changes occur, the client also needs to contact the physician because these are signs of toxicity. The client needs to check the pulse rate before taking the medication and withhold the dose and contact the physician if the pulse rate is below 60 beats per minute. The client should not skip or omit doses. The client should carry or wear a medication identification card and schedule and keep follow-up appointments with the physician.

Immediately after application of skeletal traction, neurovascular assessment of the affected limb should be performed every hour. The client is told to report any changes in movement or sensation, so that any complications can be detected and treated quickly.

Furosemide is a loop diuretic. It should be administered with food to prevent gastrointestinal upset. It is best taken in the morning with breakfast to prevent nocturia.

Signs and symptoms of spinal shock include loss of skeletal muscle movement, loss of bowel and bladder tone, and loss of autonomic reflexes below the level of the injury. Sexual function is also lost. The limbs have a flaccid paralysis, and there is bowel and bladder retention.

The acquisition of neonatal infections can occur during the antenatal, intrapartal, or neonatal period. Infections can occur via two routes: by the transfer of the infecting agent across the placenta, or ascending infection from the vagina. Three common alterations during pregnancy may further make the mother or fetus more susceptible to infection. The vaginal wall becomes hypertrophied exposing more cells to microorganisms. The vaginal epithelium produces more glycogen, which increases the pH of the vagina, resulting in an increased risk for bacterial infection. Finally, the maternal immune system is depressed as evidenced by suppressed lymphocyte function and decreased counts of CD4+T lymphocytes.

Manifestation of celiac's disease are malodorous stools, muscle wasting in buttocks and extremities, irritability and fretfulness, and severe abdominal distention.

Fat emboli can develop following fractures of the long bones or pelvis, multiple fractures, or crush injuries. Typical signs and symptoms include hypoxia, dyspnea, tachypnea, tachycardia, fever, and signs of cerebral hypoxia. Fat embolus often occurs within 24 to 72 hours after injury, but can occur from a few hours after injury up until a week later.

Following total knee replacement, the neurovascular status to the affected leg is assessed and findings should be within normal limits. The client should have intact capillary refill, and adequate color, temperature, sensation, and motion to the limb. The knee incision has a wound suction drain in place, which is expected to drain up to 200 mL in the first eight hours after surgery, which equals approximately 25 mL per hour.

The pain of angina may radiate to the left arm, is often precipitated by exertion or stress, has few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI may radiate to the left arm, shoulder, jaw, or neck. It typically begins spontaneously, lasts longer than 30 minutes, is frequently accompanied by associated symptoms (nausea, vomiting, dyspnea, diaphoresis, anxiety), and requires opioid analgesics for relief.

The client with neuroleptic malignant syndrome experiences an elevation in temperature (sometimes up to 107° F.) and parkinsonian symptoms. There can be fluctuations in blood pressure and diaphoresis. The client will experience tachycardia and tachypnea as well as muscle rigidity. Mental status can progress from stupor to coma.

Recording assessment data reflects the requirement of the Nurse Practice Act to maintain adequate records. Verbal information and notes on worksheets are not part of the client’s permanent record.

Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. When encountered with this situation, nurses should report to the unit and identify tasks that can be safely performed. The nursing supervisor and the nurse educator may need to become involved in the situation at some point if the nurse requires assistance or education regarding a new skill,

If a woman has an active lesion at the time of labor, delivery should be by cesarean section. Clients are advised to abstain from sexual contact while the lesions are present. If it is an initial infection, the client should continue to abstain from sexual intercourse until the cultures are negative because prolonged viral shedding may occur. Douches are contraindicated and the genital area should be kept clean and dry to promote healing.

A client with type 2 diabetes mellitus and gradual development of central nervous system symptoms may be developing hyperglycemic hyperosmolar nonketotic syndrome (HHNS). The serum glucose level would provide the most rapid result and would initiate the process of diagnosis.

MUGA is a radionuclide study used to detect myocardial infarction, decreased myocardial blood flow, and left ventricular function. A radioisotope is injected intravenously. A nasogastric tube or Foley catheter is not needed for this procedure.

Signs of cardiogenic shock include low blood pressure and tachycardia. The CVP would rise as the backward effects of the left ventricular failure became apparent. Dysrhythmias commonly occur as a result of decreased oxygenation to the myocardium.

After a cardiac surgery, to maximize the effectiveness of coughing and deep breathing, the use of an incisional splint such as a “cough pillow” can ease discomfort during coughing and deep breathing, which is indicated every 1 to 2 hours. The client who is comfortable will do more effective coughing and deep breathing exercises. Use of an incentive spirometer is also indicated.

The mixture of arterial and venous manifestations (claudication and thrombophlebitis, respectively) in the young male client suggests thromboangiitis obliterans (Buerger’s disease). This is a relatively uncommon disorder, which is characterized by inflammation and thrombosis of smaller arteries and veins. This disorder is typically found in young adult males who smoke. The cause is unknown, but is suspected to have an autoimmune component.

Dopamine is a positive inotropic agent and vasopressor that is used to improve cardiac output, blood pressure, and urine output. The physician should be notified if the client experiences tachycardia, reduced urine output without hypotension, dysrhythmias, and decreasing pulse pressure. The infusion rate should be decreased or stopped temporarily if an adverse effect occurs. Usually, if a cardiac problem is present, hemodynamic measurements are high (not low), so falling values for CVP and pulmonary wedge pressure would be considered a therapeutic effect. Increased urine output is also a therapeutic effect.

Tacrine (Cognex) is a cholinergic agent. Frequent side effects of tacrine include nausea, vomiting, diarrhea, dizziness, and headache. Overdose of tacrine can cause cholinergic effects including increased salivation, lacrimation, urination, defecation, bradycardia, hypotension, and increased muscle weakness.

Prior to the initiation of lithium treatment, kidney function tests need to be performed because 95 percent of the lithium is eliminated through the kidneys. The liver does absorb some of the medication, but the percentage of lithium eliminated through the kidneys is much larger. The function of the lungs and brain would not be a concern before starting lithium therapy.

Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. There is no measurable rate and no visible P waves or QRS complexes. It results from electrical chaos in the ventricles. Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually fairly regular. In atrial fibrillation, multiple rapid impulses from many atrial foci, at a rate of 300 to 600 times a minute, depolarize the atria in a totally disorganized manner. The result is chaos with no identifiable P waves, no atrial contractions, loss of the atrial kick, and an irregular ventricular response. Asystole is the lack of any electrical activity of the heart.

Terbinafine hydrochloride is an antifungal medication. A frequent side effect of the medication is headache. Occasional side effects include diarrhea, rash, dyspepsia, pruritus, taste disturbances, and nausea. Abdominal pain, flatulence, urticaria, and visual disturbances can occur but are rare.

Cryptorchidism is an absense of the testes within the scrotum.

Phimosis, a narrowingh or stenosis of the preputial of the foreskin, complaints of a dribbling urinary stream is the usually complaint.

Inguinal hernia is a common defect that appears as a painless inguinal swelling when the child cries or strains



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