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Tuesday, August 26, 2008

Nclex Tips 11 (2008 Nclex)

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Usually, one tooth erupts for each month of age past 6 months up to 30 months of age. Proper dental care includes adequate cleaning, removal of plaque, use of fluoride, and good nutrition. The child should not be allowed to have a bottle in bed. A diet that is low in sweets and high in nutritious food promotes dental health.

The normal respiratory rate for a 3 year old is 20 to 30 breaths per minute. The nurse would document the findings.

The normal blood pressure of a 3-year-old child ranges from 72 to 110 mm Hg systolic and 40 to 73 mm Hg diastolic.

Age-related activities for adolescents include sports, videos, movies, reading, parties, hobbies, listening to favorite music on video or compact disc, and experimenting with makeup and hair styles.

The normal apical rate for a newborn infant is 120 to 160 beats per minute

A toddler has the skills required to feed himself or herself. The mother should be instructed not to feed a child who can feed herself and to never force-feed the child. To increase nutritious intake, the mother is instructed to limit juice intake to 6 ounces per day, and milk intake to 16 to 24 ounces per day. Additionally, the mother should limit the child to 2 nutritious snacks per day and should only provide the snacks at the toddler’s request.

Vomiting, pain, and an irreducible mass at the umbilicus are signs of a strangulated hernia. The parents should be instructed to contact the physician immediately if strangulation is suspected.

McBurney’s point is usually the location of greatest pain in the child with appendicitis. McBurney’s point is midway between the right anterior superior iliac crest and the umbilicus.

Kidney function tests should be monitored, because EDTA is nephrotoxic. The calcium level should also be monitored, because EDTA enhances the excretion of calcium.

Clinical manifestations of iron deficiency anemia will vary with the degree of anemia but usually include extreme pallor with a porcelain-like skin, tachycardia, lethargy, and irritability.

The mother should be instructed to administer oral iron supplements between meals. The iron should be given with a citrus fruit or juice high in vitamin C, because vitamin C increases the absorption of iron by the body.

The major complication of chronic transfusion therapy is hemosiderosis. In order to prevent organ damage from too much iron in the blood, chelation therapy with a medication called deferoxamine (Desferal) is used. Desferal is classified as an antidote for acute iron toxicity.

Oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth because it will stain the teeth. The parents should be instructed to brush or wipe the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum.

High fevers and severe illnesses are reasons to delay immunization, but only until the child has recovered from the acute stage of the illness. Minor illnesses such as a cold, otitis media, or mild diarrhea without fever are not contraindications to immunization.

Diagnoses of pinworm is confirmed by direct visualization of the worms. Parents can view the sleeping child’s anus with a flashlight. The worm is white, thin, about ½ inch long, and moves. A simple technique, the cellophane tape slide method, is used to capture worms and eggs. Transparent tape is lightly touched to the anus and then applied to a slide for examination. The best specimens are obtained as the child awakens, and before toileting or bathing.

Roseola is transmitted via saliva; therefore, others should not share drinking glasses or eating utensils.

IPV is devoid of serious adverse effects. As with other injected medications, local soreness may occur at the injection site. IPV contains trace amounts of streptomycin, neomycin, and bacitracin. Therefore, the nurse should ask the mother about allergies to these medications.

HBV is one of the safest vaccines. The most common reactions are soreness at the injection site and mild to moderate fever. Acetaminophen (Tylenol) may be used to relieve discomfort, but aspirin should be avoided. The only contraindication to HBV is a previous anaphylactic reaction to either the HBV immunization or to Baker’s yeast.

Care to the child with rubella involves contact isolation. Contact isolation requires the use of masks, gowns, and gloves for contact with any infectious material. Contaminated articles are also bagged and labeled per agency protocol. Goggles are not necessary to care for the child with German measles.

Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table is noted in hip dysplasia. Asymmetric abduction of the affected hip, when the client is placed supine with the knees and hips flexed, would also be an assessment finding in hip dysplasia in infants beyond the newborn period. An apparent short femur on the affected side is noted as well as limited range of motion.

SGA infants are at risk for developing hypocalcemia. The normal range for total serum calcium is 7.0 mg/dL to 8.5 mg/dL.

The classic picture of Osgood-Schlatter disease is that of a very active adolescent boy involved in sports activities. The child will complain of bilateral knee pain that is exacerbated by running, jumping, or climbing stairs. The child will point to the tibial tubercle as the site of pain.

Dunlop traction is used to treat supracondylar fractures of the humerus. A pin is inserted through the distal humeral fragments. The elbow is flexed at a 90-degree angle, with the forearm in neutral position. Correct alignment needs to be maintained to prevent contractures. Circulation should be assessed at least every 2 to 4 hours to monitor for vascular compromise. Pain, pallor, and cyanosis are indications of Volkmann's ischemia. The child should be asked to wiggle the finger to check for numbness, tingling, and decreased sensation.

The harness should be worn 23 hours a day and should be removed only to check the skin, and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings.

A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child’s abdominal contents, resulting from lengthening of the child’s body. It results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or those who have undergone spinal fusion warrants attention, because of the possibility of superior mesenteric artery syndrome.

The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis can occur with any open fracture. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature.

The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. It is not appropriate for the nurse to file charges against the father or mother. It is also inappropriate to ask the mother to identify the abuser, because the abuser may be mother. If so, the possibility exists that the mother may become defensive and leave the emergency room with the child.

Late signs of increased ICP include tachycardia leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing. An altered level of consciousness is an early sign of increased ICP.

Hydrocephalus is a condition characterized by an enlargement of the cranium due to an abnormal accumulation of cerebrospinal fluid within the cerebral ventricular system. This characteristic causes the increase in the weight of the infant’s head. The infant’s head becomes top heavy. Supporting the infant’s head and neck when picking the infant up will prevent hyperextension of the neck area and keep the infant from falling backward. Hyperextension of the infant’s head can put pressure on the neck vertebrae, causing injury.

Intracranial pressure and encephalopathy are major symptoms of Reye’s syndrome.

Safety with all activities is a priority in planning activities with the child. The child with autism is unable to anticipate danger, has a tendency for self-mutilation, and has sensory perceptual deficits. Although social interactions, verbal communications, and providing familiarity with activities and orientation are also appropriate interventions, the priority is safety.

The adolescent should not stop taking antiepileptic medications suddenly or without discussing it with a physician or nurse. Acne or oily skin may be a problem for the adolescent, and the adolescent is advised to call a physician for skin problems. Alcohol will lower the seizure threshold and it is best to avoid the use of alcohol. Birth control pills may be less effective when the client is taking antiepileptic medication.

Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arm and wrist and extension of the lower extremities with some internal rotation.

The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants physician notification.

Cushing’s response is a late sign of ICP and consists of an increased systolic blood pressure with widening pulse pressure, bradycardia, and a change in the respiratory rate and pattern. Cushing’s response is usually apparent just before or when the brain stem herniates.

The hallmark symptoms of children with brain tumors are headache and morning vomiting related to the child’s getting out of bed. Headaches worsen on arising but improve during the day. Fatigue can occur but is a vague symptom. Visual changes might occur, including nystagmus, diplopia, and strabismus, but these signs are not the hallmark of symptoms with a brain tumor.

Following amputation, phantom limb pain is a temporary condition that some children may experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the child. The child needs to be reassured that the condition is normal and only temporary.

If a child is severely thrombocytopenic, with a platelet count less than 20,000/mm3, precautions need to be taken because of the increased risk of bleeding. The precautions include limiting activity that could result in head injury, using soft toothbrushes or toothettes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. Additionally, suppositories and rectal temperatures are avoided. The normal platelet count ranges from 150,000 to 400,000/ mm3.

Once the marrow is infused, nursing care focuses on preventing the immunocompromised child from developing a life-threatening infection until the child engrafts and produces his or her own white blood cells with which to fight infections.

Sun protection is essential during radiation treatments. The child should not be exposed to sun during these treatments.

Orchiopexy (or orchidopexy) is a surgery to move an undescended testicle into the scrotum. The most common complications associated with orchiopexy are bleeding and infection. Discharge instructions should include demonstrating proper wound cleansing and dressing and teaching the mother to identify signs of infection, such as redness, warmth, swelling, or discharge. The testicles will be held in a position to prevent movement, and great care should be taken to prevent contamination of the suture line.

Cryptorchidism is the absence of one or both testes from the scrotum. This usually represents failure of the testis to move, or "descend. When a child returns from surgery, the testicle is held in position by an internal suture that passes through the testes and scrotum and is attached to the thigh. It is important not to dislodge this suture, and this body area should be immobilized for 1 week. The most common complications are bleeding and infection.

Epispadias is a congenital malformation with the absence of the upper wall of the urethra. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine.

In bladder exstrophy, the bladder is exposed and external to the body. The highest priority is impaired tissue integrity related to the exposed bladder mucosa.

The “huff” maneuver (forced expiratory technique) is used to mobilize secretions. This technique reduces the likelihood of bronchial collapse. The child is taught to cough with an open glottis by taking a deep breath, then exhaling rapidly whispering the word “huff.”

Removal of foreign bodies from the respiratory tract may need to be performed by direct laryngoscopy or bronchoscopy. After the procedure the child should remain hospitalized for observation of laryngeal edema and respiratory distress. Cool mist is provided, and antibiotic therapy is prescribed if appropriate.

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