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Saturday, July 19, 2008

Nclex Review Materials 2 (Saunders Nclex Notes)

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Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, sensations of pain and temperature are lost because the fibers associated with them decussate after entering the cord.

The most likely medication to be prescribed for a newly diagnosed spinal cord injury client is dexamethasone. This medication is a short-acting glucocorticoid and would be given to reduce traumatic edema.

Clients with AIDS frequently have opportunistic infections. Candida albicans, the causative organism of thrush, is a common opportunistic infection. Thrush presents as white patches in the oral cavity.

Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. The trachea deviates to the unaffected side in the presence of a tension pneumothorax. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from a decreased area available for diffusion of gases. Chest pain and shortness of breath are more commonly associated with myocardial ischemia or infarction. Clients requiring chest tubes exhibit decreasing oxygen saturation but will more likely experience tachypnea related to the hypoxia. Peripheral cyanosis is caused by circulatory disorders. Hypotension may be a result of a tracheal shift and impedance of venous return to the heart. It may also be the result of other problems, such as a failing heart.

In order for the pH to be lowered, there must be an accumulation of acid from a respiratory source (i.e., carbonic acid) or from a metabolic source or loss of bicarbonate from the body. In this case, the increase is in the PCO2, which is carried in the blood stream as carbonic acid.

In newborn males, the prepuce is continuous with the epidermis of the glans and is nonretractable. Forced retraction may cause adhesions to develop. It is best to allow separation to occur naturally, which will occur between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently for cleaning once a week.

With immediate-release preparations, oral aminophylline should be administered in 4 to 6 hours after discontinuing the IV form of the medication. If the sustained-release form is used, the first oral dose should be administered immediately upon discontinuation of the IV solution.

Hyponatremia is defined as a serum sodium level of less than 135 mEq/L. When it is caused by hypervolemia, it may be treated with fluid restriction because the low serum sodium value is due to hemodilution. IV hypertonic saline (3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L. A 4 gm sodium diet is a no-added-salt diet; this diet and a 2 gm sodium restriction would not raise the serum sodium level.

The head tilt/chin lift should be avoided because in infants the trachea is flexible and the head of the infant is relatively large. Additionally, hyperextension should be avoided. The jaw-thrust is used in adults to open the airway when a neck injury is suspected. The tongue-jaw lift should be used to open an infant’s airway.

The pulse oximeter passes a beam of light through the tissue, and a sensor attached to the fingertip, the toe, or earlobe measures the amount of light absorbed by the oxygen-saturated hemoglobin. The oximeter then gives a reading of the percentage of hemoglobin that is saturated with oxygen (SaO2). Motion at the sensor site changes light absorption. The motion mimics the pulsatile motion of blood and because the detector cannot distinguish between movement of blood and movement of the finger, results can be inaccurate. The sensor should not be placed distal to blood pressure cuffs, pressure dressings, arterial lines, or any invasive catheters. The sensor should not be taped to the client's finger because vasoconstriction may reduce arterial blood flow to the sensor. If values fall below preset norms (usually 90 to 91%) the client should be instructed to deep-breathe, if this is appropriate.

Buerger’s disease is an antiinflammatory disease of the small and medium sized arteries and veins of the extremities. Interventions are directed at preventing progression of Buerger’s disease and include conveying the need for immediate smoking cessation and providing medications prescribed for vasodilation, such as the calcium channel blocker nifedipine (Procardia) or the alpha-adrenergic blocker prazosin (Minipress). The client should maintain warmth to the extremities, especially by avoiding exposure to cold. The client should inspect extremities and report signs of infection or ulceration.

A social phobia is characterized by a fear of appearing stupid or inept in the presence of others and of doing something embarrassing. Thus, the client becomes anxious when the attention is on him or her. T

Typical symptoms of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output.

Peritoneal dialysis may be the treatment option of choice for clients with severe cardiovascular disease, which would be worsened by the rapid shifts in fluid, electrolytes, urea, and glucose that occur with hemodialysis. Contraindications to peritoneal dialysis include diseases of the abdomen, such as ruptured diverticuli or malignancies, extensive abdominal surgeries, history of peritonitis, obesity, and history of back problems, which could be aggravated by the fluid weight of the dialysate. Severe disease of the vascular system may also be a contraindication.

Reduced outflow may be due to catheter position and adherence to the omentum, infection, or constipation. Constipation may contribute to reduced outflow in part because peristalsis seems to aid in drainage. For this reason, bisacodyl suppositories are sometimes used prophylactically, even without a history of constipation.

Crackles in the lung fields of the peritoneal dialysis client result from overhydration or from insufficient fluid removal during dialysis. An intake that is greater than the output of peritoneal dialysis fluid would overhydrate the client, resulting in lung crackles. Adherence to medication and diet therapy should control this sign, not exacerbate it. If dialysis is effective, there is no connection between the progression of renal failure and the development of signs of overhydration.

A peak flow meter is used to give an objective measure of the client’s peak expiratory flow. The client is instructed to take the deepest possible breath, form a tight seal around the mouthpiece with the lips, and exhale forcefully and rapidly. The final position of the indicator on the meter is recorded.

There are key advantages to the use of a spacer for medications administered by inhalation. One is that it reduces the incidence of yeast infections, since large medication droplets are not deposited on oral tissues. The medication is also dispensed more deeply and uniformly than without a spacer. There is less need to coordinate the effort of inhalation with pressing on the canister of the inhaler. Finally, the use of a spacer may decrease either the number or the volume of the puffs taken.

Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and a milder severity of dyspnea.

The nurse would ensure that the client has been informed about the procedure and has signed an informed consent. Once this has been done, the nurse would ensure that at least an 18- or 19-gauge IV needle is inserted into the client. Blood has a thicker and stickier consistency than IV solutions and using an 18- or 19-gauge catheter ensures that the bore of the catheter is large enough to prevent damage to the blood cells. The blood is obtained from the blood bank next, once the nurse is assured that the client has been informed and signs an informed consent form and has an adequate access for administering the blood. Once the blood has been obtained, two RN's or one RN and a licensed practical nurse (depending on agency policy) must together check the label on the blood product against the client's identification number, blood group, and complete name. This minimizes the risk of error in checking information on the blood bag, and thereby minimizes the risk of harm or injury to the client. Vital signs should be taken and lung sounds should be assessed before the transfusion is hung and again after the first 15 minutes and every hour until 1 hour after the transfusion has completed.

A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will allow utilization of excess energy, yet not endanger others during the process. Tetherball is an exercise that utilizes the large muscle groups of the body and is a great way to expend the increased energy that this client is experiencing.

The client’s cardiac rhythm indicates paired premature ventricular contractions (PVCs). Lidocaine hydrochloride is an antidysrhythmic that may be used to treat this dysrhythmia. Other medications that may be used are beta-adrenergic blockers, procainamide (Pronestyl), or amiodarone (Cordarone). Lanoxin is a cardiac glycoside; metoprolol is a beta-adrenergic blocking agent; verapamil is a calcium channel-blocking agent.

Ruscus aculeatus (Butcher’s Broom) is an evergreen found in the Mediterranean and the southern region of the United States. It has been used to treat varicose veins, peripheral vascular disease, arthritis, hemorrhoids, and leg edema. It has also been used as a laxative, as a diuretic, and to treat diabetic retinopathy.

Sambucus nigra (Elderberry) is a shrub found in the United States and Europe. It has been used to treat colds, diaphoresis, toothache, headache, sinusitis, hay fever, wounds, skin disorders, hepatic conditions, and inflammation.

Valeriana officinalis (Valerian) is a perennial that is cultivated throughout the world. It has been used to treat nervous disorders such as anxiety, restlessness, and insomnia.

A post-mature infant is normally poorly nourished and has wasting and growth restriction due to placental dysfunction. These infants need frequent feedings to help compensate for the period of poor nutrition in utero. These infants are at risk for hypoglycemia and cold stress. It is not appropriate to allow the infant to sleep through the scheduled feeding times because of the risk for hypoglycemia.

Maternal smoking (use of tobacco) interferes with placental flow and oxygenation. This in turn impairs fetal growth, resulting in an infant that may be SGA

Constipation causes the client to use the Valsalva maneuver. This causes blood to rush to the heart and overload the cardiac system. Therefore a diet adequate in fluids and fiber is helpful to prevent constipation. Absence of weight gain is not recommended during pregnancy. Diets low in fluid and fiber would cause a decrease in blood volume, which in turn deprives the fetus of nutrients.

Symmetrical versus asymmetrical growth serves to determine whether the growth restriction began early or late in the pregnancy. It is determined by collecting information about head circumference, length, and weight

Hypoglycemia is a major metabolic complication associated with LGA infants. These infants are at risk for hypoglycemia, which can lead to brain damage.

An exchange transfusion for polycythemia and hyperviscosity is primarily done with 5% albumin. Normal saline is normally used in a partial exchange.

Cardiac irregularities are a major complication of an exchange transfusion.

Acidosis is a major manifestation of RDS that develops due to the hypoxemia that is associated with RDS. The results of the arterial blood gas would indicate an acid-base imbalance.

PTT measures the activity of thromboplastin, which is dependent on intrinsic factors. In hemophilia, the intrinsic clotting factor VIII (antihemophilic factor) is deficient, resulting in a prolonged PTT.

Hypokalemia is indicated by a potassium level of less that 3.5 mEq/L. Clinical manifestations include muscle weakness, paralysis, leg cramps, decreased bowel sounds, weak and irregular pulse, and cardiac dysrhythmias (tachycardia or bradycardia). Clinical manifestations may also include hypotension, ileus, irritability, and fatigue. Nausea may or may not occur.

The ventral gluteal site may be used for intramuscular injections in older children. In children who have not yet developed the gluteal muscle (those younger than 2 years of age), the preferred site for intramuscular injections is the anterolateral aspect of the thigh. The deltoid muscle can be used in children 18 months or older; however, in an 11-year-old child, the ventral gluteal muscle is the preferred site.

Haloperidol is an antipsychotic. The nurse evaluates for a therapeutic response by noting the client’s interest in surroundings, improvement in self-care, increased ability to concentrate, and a relaxed facial expression.

Famotidine (Pepcid) is an H2 blocker that decreases the production of gastric acid in the stomach. When gastric acid is decreased, there is less likelihood that esophageal irritation will occur from reflux.

Immediately after delivery, the infant is extremely prone to heat loss by evaporation of amniotic fluid and needs to be thoroughly dried. The infant may then be placed in a pre-warmed radiant warmer. If the infant does not need resuscitation, the infant may be wrapped in a warmed blanket and given to the mother to hold. SGA infants are at higher risk for hypothermia, and therefore should not be placed in a warm water bath, which could cause a decrease in body temperature. The infant is placed in a pre-warmed transport isolette in preparation for transfer to the nursery.

Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart. This can result in tachycardia.

A comprehensive health data base includes a complete health history and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured. The comprehensive health data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, woman’s health care agency, visiting nurse agency, or community health agency. An episodic data base is performed for a limited or short-term problem. It focuses mainly on one problem or one body system. A follow-up data base evaluates an identified problem at regular and appropriate intervals. An emergency data base calls for a rapid collection of the data, often compiled concurrently with lifesaving measures.

An episodic data base is performed for a limited or short-term problem. It focuses mainly on one problem or one body system. The history and examination will focus primarily on the upper respiratory system in this client. A comprehensive health data base includes a complete health history and a full physical examination. It describes the current and past health state and forms a baseline against which all future changes can be measured. A follow-up data base evaluates an identified problem at regular and appropriate intervals.

If the client is alert and cooperative and if the situation is not life threatening, then the nurse should attempt to obtain as much subjective and objective data as possible while caring for the client.

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