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Monday, August 25, 2008

Nclex Tips 10 (Review for Nclex)

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The client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish.

The client undergoing LP is positioned lying on the side, with the legs pulled up against the abdomen and with the head bent down toward the chest. This position helps widen the spaces between the vertebrae.

Caloric testing provides information about the vestibular portion of CN VIII, which aids in differentiating between cerebellar and brainstem lesions. Usually ice-cold water is inserted into the auditory canal after patency of the ear canal is determined. If brainstem function is intact, the eyes move in a conjugate fashion slowly toward the irrigated side and then quickly move back to midline. With brainstem death, this nystagmus pattern does not occur.

The correct technique for administering parenteral iron is deep in the gluteal muscle using Z-track technique. This method minimizes the possibility that the injection will stain the skin a dark color.

Pernicious anemia can occur in a client who has not had gastric surgery, such as when the client has a disease that involves the ileum, where vitamin B12 is absorbed. The nurse checks the client's history for small bowel disorders to detect this risk factor.

Classic signs of pernicious anemia include weakness, mild diarrhea, and smooth, sore, red tongue. The client may also have nervous system symptoms such as paresthesias, difficulty with balance, and occasional confusion.

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.

Instructions to a femail client regarding the procedure for collecting a midstream urine sample includes telling the client that he should cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit. The client should begin the flow of urine, collecting the sample after starting the flow of urine. The specimen should be sent to the laboratory as soon as possible and not allowed to stand. Improper specimen handling can yield inaccurate test results.

Sickle cell anemia is a severe anemia that predominantly affects African Americans. It is characterized by the presence of only hemoglobin S.

The indirect Coombs' test detects circulating antibodies against red blood cells (RBCs), and is the “screening” component of the order to “type and screen” a client’s blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The direct Coombs' test is used to detect idiopathic hemolytic anemia, by detecting the presence of autoantibodies against the client’s RBCs. Eosinophil and monocyte counts are part of a complete blood count, a routine hematologic screening test.

The most common sites for bone marrow aspiration in the adult are the iliac crest and the sternum. These areas are rich in marrow and are easily accessible for testing.

Sickle cell disease 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 narcotic analgesics when it is severe.

The priority items in the management of sickle cell crisis are hydration therapy and pain relief. To achieve this, the client is given intravenous fluids to promote hydration and reverse the agglutination of sickled cells in small blood vessels. Narcotic analgesics may be given to relieve the pain that accompanies the crisis. Oxygen would be given, based on individual need. RBC transfusion also may be done in selected circumstances such as aplastic crisis or when the episode is refractive to other therapy. Genetic counseling is recommended, but not during the acute phase of illness.

Idiopathic autoimmune hemolytic anemia is treated with corticosteroids, particularly prednisolone (Prelone). Other treatments that can be initiated as necessary include splenectomy, transfusions, and sometimes immunosuppressive agents.

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

Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stools may also be noted.

Following pyloromyotomy, the head of the bed is elevated and the infant is placed prone to reduce the risk of aspiration.

Mumps generally affects salivary glands but can involve multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the physician.

Carditis is the inflammation of all parts of the heart, primarily the mitral valve.

Hypernatremia occurs when the sodium level is greater than 145 mEq/L. Clinical manifestations include intense thirst; oliguria; agitation and restlessness; flushed skin; peripheral and pulmonary edema; dry, sticky mucous membranes; and nausea and vomiting.

The two primary pathophysiological alterations associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased, because the red blood cell production cannot keep pace with the red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction accompanying this disorder, as well as from the normally decreased ability of the infant’s liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of pancreatic islet cells and increased levels of insulin.

Live measles vaccine is produced by chick embryo cell culture, so the possibility of an anaphylactic hypersensitivity in children with egg allergies should be considered. If there is a question of sensitivity, children should be tested before the administration of MMR vaccine. If a child tests positive for sensitivity, the killed measles vaccine may be given as an alternative.

Meperidine hydrochloride is contraindicated for ongoing pain management for a client admitted to the hospital with a diagnosis of sickle cell crisis, because of the increased risk of seizures associated with its use. Management of severe pain generally includes the use of strong narcotic analgesics, such as morphine sulfate or hydromorphone (Dilaudid). These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock.

Dietary sources of iron that are easy for the body to absorb include meat, poultry, and fish. Vegetables, fruits, cereals, and breads are also dietary sources of iron but contain less iron and are harder for the body to absorb.

Intravenous immune globulin (IVIG) will increase the platelet count. It is thought to act by interfering with the attachment of antibody-coded platelets to receptors on the macrophage cells of the reticuloendothelial system. Corticosteroids can be prescribed to enhance vascular stability and decrease the production of antiplatelet antibodies.

Koplik spots appear approximately 2 days before the appearance of the rash of rubeola. These are small, blue-white spots with a red base found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off

A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle.

Ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during fetal life. It generally closes spontaneously within a few hours to several days after birth. When patent, it allows abnormal blood flow from the high- pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt.

Discharge instruction to the parents of a child who has had heart surgery includes the child may return to school the third week after hospital discharge, but should go for half days for the first few days. The child should avoid crowds of people for 1 week after discharge, including day care centers and churches. Play outside should be avoided for several weeks, although inside play is allowed. If any difficulty with breathing occurs, the parents should notify the physician.

A toddler derives comfort and security from familiar routines and people. The new sights, sounds, and smells are a source of anxiety during hospitalization.

The crisis of Autonomy vs Shame and Doubt is related to the developmental task of gaining control of self and environment as exemplified by toilet training.    Initiative vs Guilt is the crisis of the preschool and early school-aged child. Initiative vs Inferiority is the crisis of the 6- to 12-year-old, and Trust vs Mistrust is the crisis of the infant.

The Somogyi effect is a rebound hyperglycemia that occurs as a result of the secretion of counter regulatory hormones such as epinephrine, growth hormone, and corticosteroids. The 3:00 a.m. blood glucose level is low, followed by a high level a few hours later, demonstrating the rebound effect.

Children suspected of having acute rheumatic fever are tested for the presence of recent streptococcal infection antibodies. An increased antibody level, evidenced by an elevated or rising antistreptolysin-O (ASO) titer, will assist in confirming the diagnosis. An increased erythrocyte sedimentation rate would occur in acute rheumatic fever. A leukocyte count and hemoglobin count will not confirm the diagnosis of acute rheumatic fever.

A diarrhea stool has an alkaline pH that can cause skin breakdown. A damp washcloth is an ineffective way to clean the skin. The mother should be taught to thoroughly clean the skin, using a mild soap.

Spina bifida occurs during fetal growth and development and has genetic predispositions. Parents who have children with congenital defects blame themselves for the child’s defects. Parents, at times, have difficulty bonding with their newborn because they are grieving the loss of their perfect baby. Integrating the new baby with special needs into the parent’s life is a stressful adjustment.

Complications from pertussis include pneumonia, atelectasis, otitis media, convulsions, and subarachnoid bleeding. Decreased breath sounds are indicative of both pneumonia and atelectasis.

Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of a chronic tissue hypoxia and polycythemia.

In hemophilia A, the partial thromboplastin time is prolonged. The white blood cell count, sedimentation rate, and clot retraction time are unrelated to the diagnosis of hemophilia A.

The stools of a child with celiac disease are characteristically malodorous, pale, fatty, large (bulky), and soft (loose). Excessive flatus is common, and bouts of diarrhea may occur.

Rehydration is the initial step in resolving diabetic ketoacidosis (DKA.) Normal saline is the initial IV rehydration fluid. Regular insulin will be administered by continuous IV infusion. Dextrose solutions are added to the treatment regime when the blood glucose levels reach an acceptable level. IV potassium may be required, depending on the potassium levels, but would not be part of the initial treatment. Glucagon hydrochloride is used to treat severe hypoglycemia.

If a child is being treated with propylthiouracil, the increased risk for neutropenia and hepatotoxicity exists. Contact sports should be limited to decrease the possibility of injury and damage to the liver. If the child develops a sore throat or fever, the physician should be notified, because these signs could indicate neutropenia. A yellow discoloration of the skin could indicate the presence of liver damage or hepatitis, and if this occurs, it is not normal and the physician must be notified.

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