Tinnitus is the most common complaint of clients with ear disorders, especially disorders involving the inner ear. Symptoms of tinnitus can range from mild ringing in the ear that can go unnoticed during the day to a loud roaring in the ear that can interfere with the client’s thinking process and attention span.
Hydroxyzine (Vistaril) is an antiemetic and sedative/hypnotic that may be used in conjunction with narcotic analgesics for added effect. The injection can be extremely painful. Medications administered by the IM route generally take 20 to 30 minutes to become effective. Hydroxyzine causes dry mouth and drowsiness as side effects.
Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body utilize all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis.
Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid, which is a potent acid in the body. Thus, this situation results in an alkalotic condition.
The client with late-stage salicylate poisoning is at risk for metabolic acidosis because of the effects of acetylsalicylic acid in the body. Clinical manifestations of metabolic acidosis include hyperpnea with Kussmaul’s respirations, headache, nausea, vomiting, diarrhea, fruity smelling breath caused by improper fat metabolism, central nervous system depression, twitching, convulsions, and hyperkalemia.
N-acetylcysteine (NAC) is the antidote for acetaminophen (Tylenol) overdose. It is administered orally with juice or soda or via a nasogastric tube. Vitamin K is the antidote for warfarin (Coumadin). Protamine sulfate is the antidote for heparin. Succimer (Chemet) is used in the treatment of lead poisoning.
Sodium chloride 0.9% (not sodium chloride 0.45%) is the same solution as normal saline 0.9%. This solution is isotonic (not hypertonic), and isotonic solutions are frequently used for IV infusion because they do not affect the plasma osmolarity.
Pulmonary edema from heart failure may first be manifested as a cough. The cough occurs in response to fluid filling the alveolar spaces. Pulmonary edema develops as a result of left ventricular failure or acute fluid overload. Orthopnea is an assessment finding. Increased rather than decreased blood volume occurs in heart failure. A nonproductive cough is a late manifestation of right-sided heart failure.
All IV solutions should be free of particles or precipitates. A tourniquet is applied above the chosen vein site. Cool compresses will cause vasoconstriction, making the vein less visible. Armboards are applied after the IV is started and are used only if necessary.
Acute respiratory distress syndrome usually develops within 24 to 48 hours after an initiating event, such as pulmonary trauma. In most cases, tachypnea and dyspnea are the earliest clinical manifestations. Blood-tinged frothy sputum would present later, after the development of pulmonary edema. Breath sounds in the early stages of ARDS are usually clear but then may progress to bronchial breath sounds when pulmonary edema occurs. Chest x-ray findings may be normal during the early stages but will show infiltrates in the later stages.
Clinical manifestations of a Candida infection include pain, itching, and a thick, white vaginal discharge. Proteinuria, edema, and hypertension are signs of pregnancy-induced hypertension. Hematuria, proteinuria, and costovertebral angle pain are clinical manifestations associated with urinary tract infections.
When the hemoglobin level is below 11 mg/dL, iron deficiency is suspected. An indirect index of the oxygen-carrying capacity is the packed red blood cell volume or hematocrit level. Pathological anemia of pregnancy is primarily caused by iron deficiency.
Fever on the third or fourth day postpartum should raise concerns about possible endometritis until proven otherwise. A woman with endometritis normally presents with a temperature over 38° C. Lochia rubra on the second day postpartum is a normal finding. The white blood cell count of a postpartum woman is normally elevated. Thus, this method of detecting infection is not of great value in the puerperium.
The post-term infant (born after the 42nd week of gestation) exhibits dry, peeling, cracked, almost leather-like skin over the body, which is called desquamation. The preterm infant (born between 24 to 37 weeks of gestation) exhibits thick vernix covering the body, smooth soles without creases, and lanugo covering the entire body.
Tachypnea, grunting, retractions, and nasal flaring are symptoms of respiratory distress related to meconium aspiration syndrome, which can occur in post-term infants who have decreased amniotic fluid and are prone to cord compression. It develops when meconium in the amniotic fluid enters the lungs during fetal life or during labor. Transient tachypnea of the newborn is primarily found in infants delivered via cesarean section. Respiratory distress syndrome is a complication of preterm infants.
Deep vein thrombosis is a potentially serious complication of orthopedic injuries and surgery. Checking for a positive Homans’ sign assesses for this complication. Although bladder distention, extremity lengthening or shortening, or heel breakdown can occur, these complications are not potentially serious complications.
Torsemide (Demedex) is a loop diuretic. The medication can produce acute, profound water loss, volume and electrolyte depletion, dehydration, decreased blood volume, and circulatory collapse
Assessment of a client with Hodgkin’s disease most often reveals enlarged, painless lymph nodes, fever, malaise, and night sweats. Weight loss may be present if metastatic disease occurs. Headache and visual changes may occur if brain metastasis is present.
Increased urination is an early sign that the neonate’s respiratory condition is improving. Lung fluid, which occurs in RDS, moves from the lungs into the blood stream as the condition improves and the alveoli open. This extra fluid circulates to the kidneys, which results in increased voiding. Systolic murmurs usually indicate the presence of a patent ductus arteriosus, which is a common complication of RDS. Respiratory rates above 60 are indicative of tachypnea, which is a sign of respiratory distress. Edema of the hands and feet occurs within the first 24 hours as a result of low protein concentrations, a decrease in colloidal osmotic pressure, and transudation of fluid from the vascular system to the tissues.
Enclosed hemorrhage, such as with cephalhematoma, predisposes the newborn to jaundice by producing an increased bilirubin load as the cephalhematoma resolves and is absorbed into the circulatory system. A negative direct Coombs’ test result indicates that there are no maternal antibodies on fetal erythrocytes.
Clinical manifestations of cystitis usually include urinary frequency, urgency, dysuria, inability to void, or voiding only small amounts. The urine may be cloudy, with hematuria and bacteriuria. The client may complain of pain that is suprapubic or in the lower back.
The most accurate measurement of weight loss is daily weighing of the client at the same time of the day, in the same clothes, and using the same scale.
Fracture pain is generally described as sharp, continuous, and increasing in frequency. Bone pain is often described as a dull, deep ache. Strains result from trauma to a muscle body or to the attachment of a tendon from overstretching or overextension. Muscle injury is often described as an aching or cramping pain, or soreness.
Extracorporeal shock wave lithotripsy is done with conscious sedation or general anesthesia. The client must sign an informed consent form for the procedure and must be NPO for the procedure. The client needs an IV line for the procedure as well. A Foley catheter is not needed.
The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
Unresponsiveness may be an indication that the child is experiencing hearing loss. A child who has a history of cleft palate should be routinely checked for hearing loss.
Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on expiration. As the asthma attack progresses, the client may wheeze during both inspiration and expiration. Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure.
Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast, or the presence of “hot spots,” which are areas on the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired circulation in the distal extremity include coolness and pallor of the skin, diminished arterial pulse, and edema.
Side effects of chlorpromazine (Thorazine) can include hypotension, dizziness and fainting especially with parenteral use, drowsiness, blurred vision, dry mouth, lethargy, constipation or diarrhea, nasal congestion, peripheral edema, and urinary retention.
Following a renal transplant. Acute rejection usually occurs within the first 3 months after transplant, although it can occur for up to 2 years post-transplant. The client exhibits fever, hypertension, malaise, and graft tenderness. Treatment is immediately begun with corticosteroids and possibly also with monoclonal antibodies and antilymphocyte agents.
Adverse reactions or toxic effects of tobramycin sulfate include nephrotoxicity as evidenced by an increased BUN and serum creatinine; irreversible ototoxicity as evidenced by tinnitus, dizziness, ringing or roaring in the ears, and reduced hearing; and neurotoxicity as evidenced by headaches, dizziness, lethargy, tremors, and visual disturbances.
Malignant hyperthermia is a genetic disorder in which a combination of anesthetic agents (succinylcholine and inhalation agents such as halothanes) trigger uncontrolled skeletal muscle contractions. This quickly leads to a potentially fatal hyperthermia. Questioning the client about the family history of general anesthesia problems may reveal this as a possibility for the client.
The meninges, three membranes that envelope the brain and spinal cord, are predominantly for protection. Each layer (pia mater, arachnoid, and dura mater) is a separate membrane. The basal ganglia consist of subcortical gray matter buried deep in the cerebral hemispheres. The basal ganglia, along with the corticospinal tract, are important in controlling complex motor activity.
Methyldopa (Aldomet) is an antihypertensive medication. During the second or third month of therapy with methyldopa, drug tolerance can develop, which is evident by rising blood pressure levels. The physician should be notified, who may then increase the medication dosage or add a diuretic to the medication regimen. The client is also at risk of developing fluid retention, which would be manifested as dependent edema, intake greater than output, and an increase in weight. This would also warrant adding a diuretic to the course of therapy.
Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.
When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular checks including circulation, sensation, and motion should be checked at least every 2 hours. Level of pain is an important postoperative assessment, but circulatory status is most important.
A major risk associated with central line placement is the possibility of a pneumothorax developing from an accidental puncture of the lung. Assessing the results of a chest x-ray is one of the best methods to determine if this complication has occurred and to verify catheter tip placement before initiating intravenous (IV) therapy. A temperature elevation would not likely occur immediately after placement. Although BP assessment is always important in assessing a client’s status after an invasive procedure, fluid volume overload is not a concern until IV fluids are started. Labeling the dressing site is important but is not the priority.
The most accurate means of confirming the diagnosis of tuberculosis is by sputum culture. Establishing the presence of Mycobacterium tuberculosis is essential for a definitive diagnosis. Hemoptysis is not a common finding and is usually associated with more advanced cases of tuberculosis. A positive PPD indicates exposure to tuberculosis. A chest x-ray does not confirm the diagnosis of tuberculosis. Lung lesions may be indicative of diseases other than tuberculosis.
The Miller-Abbott tube is a nasoenteric tube that is used to decompress the intestine and to correct a bowel obstruction. The end of the tube should be located in the intestine. The pH of the gastric fluid is acidic and the pH of the intestinal fluid is alkaline (7 or higher). Location of the tube can also be determined by x-ray.
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