Mechanical valves carry the associated risk of thromboemboli, which requires long-term anticoagulation with warfarin (Coumadin).
Clients with depression or a history of depression have experienced an exacerbation of depression after beginning therapy with beta-adrenergic blocking agents. These clients should be monitored carefully if these agents are prescribed. The medication would cause bradycardia, not tachycardia. Fatigue is a possible side effect but is not the most important item. Hypoglycemia is a sign that is masked with beta-blockers.
A life-threatening diagnosis such as HIV will stimulate the anticipatory grief response. Anticipatory grief occurs when the client, family, and loved ones know that the client will die. The prenatal HIV client is forced to make important changes in her life, frequently resulting in grief related to lost future dreams and diminished self-esteem because of an inability to achieve life goals.
The major side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure would not be an anticipated side effect and would be a cause for concern. If hypertension occurred following ECT, the physician should be notified.
Ruptured esophageal varices are often a complication of cirrhosis of the liver, and the most common type of cirrhosis is caused by chronic alcohol abuse. It is important to obtain an accurate history about alcohol intake from the client. If the client is ashamed or embarrassed, he or she may not respond accurately.
Insight, judgment, and planning are part of the function of the frontal lobe. Level of consciousness is controlled by the reticular activating system. Feelings and emotions are part of the role of the limbic system. Eye movements are under the control of cranial nerves III, IV, and VI.
Rape trauma syndrome refers to the acute or immediate phase of psychological disorganization and the long-term process of reorganization that occurs as a result of attempted or actual assault. During the acute phase, immediately after the assault, emergency assessment and treatment are provided and forensic evidence is collected. The nurse would always assess the degree of injury sustained during the rape and immediately treat any injury that is life threatening. The client should not be left alone at this time and should be provided with calm and supportive interventions. Encouraging the client to talk about the cause of the rape is inappropriate. The nurse needs to encourage the client to talk about any mixed feelings that she may have and remind the client that she is in no way responsible for the rape. The nurse would obtain the client’s written permission for examination and treatment. This is necessary because two types of specimens will be collected during the examination. One part of the specimen will be sent to the laboratory for evaluation, and another part will be sent to a forensic laboratory and will be considered evidence in the event that the offender is caught and the client presses charges. The decision to press charges is made by the client, and the nurse needs to support the client in the decision-making process. Sexual assault is the ultimate invasion of privacy and safety. The nurse needs to explain to the client that her emotional responses to the attack are normal and may continue for weeks after the rape. Time and counseling are needed before the victim feels safe, secure, and in control.
Fear can range from a paralyzing, overwhelming feeling to a mild concern. Therefore, the nurse would first assess the nature of the client’s fears in order to know how best to help the client. Next, the nurse would help the client express his fears. The client’s fear may not be limited to the fear of dying, and the nurse needs this information in order to help the client. Once the nurse is aware of the client’s fears, the methods that the client used to cope with fear in the past are identified. From the interventions listed, the nurse would lastly document verbal and nonverbal expressions of fear and any other significant data.
Clients with anxiety disorder are advised to limit their intake of caffeine, chocolate, and alcohol. These products have the potential of increasing anxiety.
Asterixis is an abnormal muscle tremor often associated with hepatic encephalopathy. Asterixis is sometimes called “liver flap.” Asterixis (also called the flapping tremor) is a tremor of the wrist when the wrist is extended (dorsiflexion), sometimes said to resemble a bird flapping its wings.
To assess the function of the 12th cranial (hypoglossal) nerve, the nurse would assess the client’s ability to extend the tongue. Impairment of the 12th cranial nerve can occur with a CVA.
Clients at risk for HHNS should immediately report signs and symptoms of dehydration to health care providers. Dehydration can be severe and may progress rapidly.
Obesity, hypertension, hypercholesterolemia, smoking, and use of oral contraceptives are all modifiable risk factors for CVA. Oral contraceptive use is discouraged in some clients because of the side effect of clot formation.
LDL is more directly associated with CAD than other lipoproteins. LDL levels, along with cholesterol, have a higher predictive association for CAD than triglycerides. Additionally, HDL is inversely associated with the risk of CAD. Lipase is a digestive enzyme that breaks down ingested fats in the gastrointestinal tract.
Two basic but important risk factors for testicular cancer are age and race. The disease occurs most frequently in Caucasian males between the ages of 18 and 40 years. Other risk factors include a history of undescended testis and a family history of testicular cancer. Marital status and number of children do not pose a risk factor for males and testicular cancer.
Clients who are prone to barotrauma should perform any of a variety of mouth movements to equalize pressure in the ear, particularly during ascent and descent of an aircraft. These can include yawning, swallowing, drinking, chewing, or sucking on hard candy. Valsalva maneuver may also be helpful. The client should avoid sitting with the mouth motionless during this time, because this aggravates pressure build-up behind the tympanic membrane.
Primary prevention interventions are those measures that keep illness, injury, or potential problems from occurring, secondary prevention measures that seek to detect existing health problems or trends.
Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in this vitamin. Other good sources include nuts, whole-grain cereals, and legumes. Chicken is high in protein. Broccoli is high in iron and vitamin K. Milk is high in calcium.
Hydrocephalus is a condition characterized by an enlargement of the cranium caused by an abnormal accumulation of cerebrospinal fluid within the cerebral ventricular system. This characteristic causes an 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 the hyperextension of the neck area and the infant from falling backward. Hyperextension of the infant’s head can put pressure on the neck vertebrae, causing injury.
The Ventriculo-Peritoneal (VP) shunt is small tubing that is placed inside the brain’s ventricle and tunneled underneath the skin to the peritoneum. If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which then causes a high-pitched cry in the infant. The infant should not be positioned on the side of the shunt because this will cause pressure on the shunt and skin breakdown. This type of shunt affects the gastrointestinal system, not the genitourinary system, and an increased urinary output is not expected.
Checking for jaundice will assist in identifying the presence of liver complications that are characteristic of Reye’s syndrome. If vomiting occurs in Reye’s syndrome, it is caused by cerebral edema, is a sign of increased intracranial pressure, and needs to be reported. Decreasing stimuli and providing rest decreases stress on the brain tissue.
The practice of coating pacifiers with honey or using commercially available hard-candy pacifiers is discouraged. Besides being cariogenic, honey may also cause botulism, and parts of the candy pacifier may be aspirated. Additionally, a bottle at nap or bedtime that contains sweet milk or other fluids such as juice bathes the teeth, producing caries. Fluoride, an essential mineral for building caries-resistant teeth, is needed beginning at 6 months of age or as directed by the physician if the infant does not receive adequate fluoride content. A diet that is low in sweets and high in nutritious food promotes dental health.
The child should not be forced to sit on the potty for long periods of time. The physical ability to control the anal and urethral sphincters is achieved some time after the child is walking, probably between ages 18 and 24 months. Bowel control is usually achieved before bladder control.
Simple words such as “mama” and the use of gestures to communicate begins between 9 and 12 months of age. A 1- to 3-month-old infant will produce cooing sounds. Babbling is common in a 3- to 4-month-old infant. Between 8 and 9 months, the infant begins to understand and obey simple commands such as “wave bye-bye.” Using single-consonant babbling occurs between 6 and 8 months.
Active relaxation includes specific relaxation exercises and conditioned responses such as distraction from the discomfort of labor. The woman is an active participant in the use of the technique, which focuses on relaxing uninvolved muscles while the uterus contracts.
HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure of infected blood, and transmission from an infected woman to her fetus. Women who fall into the high-risk category for HIV infection include those with persistent and recurrent sexually transmitted diseases, those with a history of multiple sexual partners, and those who have used IV drugs. A heterosexual partner, particularly a partner who has had only one sexual partner in 10 years, is not a high-risk factor for developing HIV.
Home care measures for a mild preeclampsia patient includes the needs to be instructed to report any increases in blood pressure, +2 proteinuria, weight gain greater than one pound per week, presence of edema, and decreased fetal activity to the physician or health care provider immediately to prevent worsening of the preeclamptic condition. It is important to keep physician appointments even if the client is receiving visits from a home care nurse. Blood pressures need to be taken in the same arm, in a sitting position, every day in order to obtain a consistent and accurate reading. The weight needs to be checked at the same time each day, wearing the same clothes, after voiding, and before breakfast in order to obtain reliable weights.
Following cataract surgery, the client should not sleep on the side of the body that was operated on. The client should also avoid bending below the level of the waist or lowering the head because these actions will increase intraocular pressure.
Acidification of the urine inhibits multiplication of bacteria. Fluids that acidify the urine include apricot, plum, and prune, or cranberry juice. Carbonated drinks should be avoided because they increase urine alkalinity.
Bathing should start at the eyes and face and with the cleanest area first. Next, the external ears and behind the ears are cleaned. The newborn infant’s neck should be washed because formula, lint, or breast milk will often accumulate in the folds of the neck. Hands and arms are then washed. The newborn infant’s legs are washed next, with the diaper area washed last.
The cord should be kept clean and dry to decrease bacterial growth. The cord should be cleansed two to three times a day using alcohol or other agents. Cord care is required until the cord dries up and falls off between 7 to 14 days after birth. Additionally, the diaper should be folded below the cord to keep urine away from the cord.
In male newborn infants, prepuce is continuous with the epidermis of the gland and is not retractable. If retraction is forced, this may cause adhesions to develop. The mother should be told to allow separation to occur naturally, which usually occurs between 3 years old and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning once a week.
To administer ear drops in a child older than 3 years of age, the ear is pulled upward and back. The ear is pulled down and back in children younger than 3 years of age.
The lip repair site is cleansed with sterile water using a cotton swab after feeding and as prescribed. The parents should be instructed to use a rolling motion starting at the suture line and rolling out. Tap water is not a sterile solution. Hydrogen peroxide may disrupt the integrity of the site.
The parents of a child with an umbilical hernia need to be instructed in the signs of strangulation, which include vomiting, pain, and irreducible mass at the umbilicus. The parents should be instructed to contact the physician immediately if strangulation is suspected.
A limb encased in a cast is at risk for nerve damage and diminished circulation from increased pressure caused by edema. Signs of increased pressure from the cast include numbness, tingling, and increased pain. A plaster of Paris cast can take up to 48 hours to dry and generates heat while drying. Some drainage may occur initially with a compound (open) fracture.
The main nursing consideration with celiac disease is helping the child adhere to dietary management. Treatment of celiac disease consists primarily of dietary management with a gluten-free diet.
The mother needs to be taught to observe for bleeding and to assess the site hourly for 8 to 12 hours following the circumcision. Voiding needs to be assessed. The mother should call the physician if the baby has not urinated within 24 hours because swelling or damage may obstruct urine output. When the diaper is changed, Vaseline gauze should be reapplied. Frequent diaper changing prevents contamination of the site. Water is used for cleaning because soap or baby wipes may irritate the area and cause discomfort.
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