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Tuesday, July 15, 2008

Nclex-Rn: Saunders Nursing Review 6 (Level of Cognitive Ability)

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Triamterene (Dyrenium) is a potassium sparing diuretic. Side effects include frequent urination and polyuria. Occasional side effects include tiredness, nausea, diarrhea, abdominal distress, leg aches, and headache. An adverse effect or toxic effect is hyperkalemia. Although the concern with most diuretics is hypokalemia, this medication is potassium sparing, which means that the concern with the administration of this medication is hyperkalemia.

A mother who is HIV positive may have many fears particularly about the status of her newborn infant. Other fears can include lack of knowledge, loss of ability to breastfeed, other’s reactions to the diagnosis, quality of relationships, and financial fears regarding the cost of HIV treatments. However, the nurse would initially address the mother and the mother’s fears. This will provide the mother the opportunity to discuss specific issues.

Erythroblastosis fetalis is a hemolytic disease of the fetus or newborn resulting in excessive destruction of red blood cells (RBC) and stimulation of immature erythrocytes. It occurs in the majority of cases as a result of ABO incompatibilities or the failure to prevent maternal production of Rh antibodies. All pregnant women should be tested for Rh types, ABO groups, and screened for antibodies to these and other RBC antigens during the antenatal period. Hemoglobin and hematocrit levels measure maternal parameters. The diabetic screening test assists in the identification of the gestational diabetic, and the AFP screens for the potential of fetal neural tube defects or genetic abnormality such as trisomy 21.

The depressed individual who has a sudden mood elevation after a period of being down or depressed is identified as at risk to carry out a suicide intent.

Trimethobenzamide hydrochloride is an antiemetic. Older clients tend to develop mental confusion, disorientation, agitation, and psychotic-like symptoms.

A thrombolytic medication acts on the fibrinolytic system to convert plasminogen to plasmin, an enzyme that degrades fibrin clots, fibrinogen, and other plasma proteins. The nurse needs to monitor the client for bleeding during the administration of this type of medication. Severe internal hemorrhage can occur as an adverse effect of the medication. Signs of bleeding or internal hemorrhage would include a drop in blood pressure, a rise in pulse, or client complaints of abdominal or back pain. Positive peripheral pulses are normal findings.

Glycosylated hemoglobin values of less than or equal to 7.5% indicate good diabetic control.

Secondary hyperaldosteronism is due to the continuous secretion of aldosterone. The risk factors for secondary hyperaldosteronism include chronic heart failure, cirrhosis with ascites, nephrotic syndrome, and hypertension resulting from destructive renal artery disease. The preventive measures include successful treatment and control of the causative disease process. The more successfully the causative disease process is controlled, the less secondary hyperaldosteronism will occur.

Valproic acid is an anticonvulsant. An adverse effect is hepatotoxicity that may not be preceded by abnormal liver function tests, but may be noted as loss of seizure control, malaise, weakness, lethargy, anorexia, and vomiting. Blood dyscrasias may also occur. Frequent side effects include nausea, vomiting, and indigestion.

An increased production of androgens that accompanies a rise in cortisol levels with Cushing’s syndrome produces hirsutism and acne in women. Other clinical findings of Cushing’s syndrome include hypertension caused by sodium retention, impaired glucose tolerance or diabetes mellitus caused by cortisol’s anti-insulin effect and ability to enhance gluconeogenesis, and skin changes including bruising and purplish-red striae caused by protein catabolism.

Cushing's syndrome = increase secretion of cortisol.

Signs and symptoms of hypothyroidism may be nonspecific and may include feeding difficulty, prolonged jaundice, respiratory problems, hypotonia, constipation, large posterior fontanel, excessive sleepiness, large tongue, rare crying, dry and mottled skin, and slow relaxation of deep tendon reflexes.

Blood glucose levels are low in Addison’s disease, due to decreased secretion of glucocorticoids (cortisol). Edema is absent and aldosterone secretion is decreased so the client develops a deficient fluid volume. Facial hair increases with adrenocortical hyperfunction. Clients with Addison’s disease develop hypotension due to deficient fluid volume.

The most reliable information can be obtained by obtaining a baseline weight and weekly weights thereafter.

In displacement, a client transfers an emotion from its original object to a substitute object.

Excessive secretion of adrenocortical hormones results in water and sodium reabsorption, causing fluid retention. Stretch marks (striae) are a common feature and can result in a disturbed body image, but are not significant and do not represent a life-threatening situation. Goiter is not a manifestation of Cushing's syndrome. Melanosis is a common manifestation associated with Addison's disease.

An insufficient level of thyroid hormone causes a decrease in metabolic rate and heat production. Intolerance to cold would be noted.

pH: 7.35. PO2: 85, PCO2: 55, HCO3:25 >>> The pH is normal and therefore compensation has occurred. The O2 is within normal limits. The normal oxygen level is most likely due to compensatory hyperventilation. The CO2 is elevated and indicates an opposite effect of the pH (which is at the low end of normal); this finding indicates that the client is experiencing respiratory acidosis. The bicarbonate level is normal.

Asparaginase is an antineoplastic medication. Adverse effects include hepatotoxicity, which usually occurs within 2 weeks of initial treatment. Severe bone marrow depression can also occur and an increased risk of allergic reactions can occur after repeated therapy. The normal WBC count is 5000 to 10,000/µl. The normal platelet count is 150,000 to 450,000 cells/µl. Normal BUN is 5 to 20 mg/dl. The normal alkaline phosphatase is 4.5 to 13 units/dl.

Exposure to or contact with flames, hot liquids, or hot objects causes thermal burns. Thermal burns are those sustained in residential fires, explosive accidents, scald injuries, or ignition of clothing or liquids. If the nurse notes facial burns or singed eyebrow or nasal hairs, the victim likely experienced the burn in an enclosed smoke filled space such as in a residential fire. Electrical burns are caused by heat that is generated by the electrical energy as it passes through the body. Radiation burns are caused by exposure to a radioactive source. Chemical burns are caused by tissue contact with strong acids, alkalis, or organic compounds.

Clinical manifestations of carbon monoxide poisoning are related to the levels of carbon monoxide saturation. A level between 5 to 10% would cause impaired visual acuity; 11 to 20% flushing and headache; 21 to 30% nausea and impaired dexterity; 31 to 40% vomiting, dizziness, and syncope; 41 to 50% tachypnea and tachycardia; and greater than 50% coma and death.

A partial-thickness superficial burn appears wet, shiny, and weeping, or may contain blisters. The wound blanches with pressure, is painful, and very sensitive to touch or air currents. Charring would occur in a deep full-thickness burn. Decreased or absence of wound sensation would occur in full-thickness or deep full-thickness burns.

A wheeze is a continuous musical or hissing noise that results from the passage of air through a narrowed airway. Wheezes are heard during inspiration or expiration or both. Severe wheezes are audible without a stethoscope. Wheezing is commonly associated with asthma and bronchoconstriction and edema, but foreign body obstruction can also cause airway narrowing and wheezing.

Pleural friction rub sounds are a creaking noise heard on inspiration and a grating noise heard on expiration.

Rhonchi sounds like a gurgling noise heard on expiration.

Subcutaneous emphysema (crepitus) occurs when air escapes from the tracheotomy incision into the tissues, dissects fascial planes under the skin, and accumulates around the face, neck, and upper chest. These areas appear puffy and slight finger pressure produces a crackling sound and sensation. Generally, this is not a serious condition, because the air will eventually be absorbed.

In the IMV mode, the ventilator delivers a preset number of mechanical breaths. However, it allows the client to breathe spontaneously in between the mechanical breaths with no assistance from the ventilator and at varying tidal volumes. Therefore, if the nurse assesses the respiratory rate to be 12 breaths per minute and the IMV mode is set at 8 breaths per minute, the client is breathing 4 additional breaths on their own.

Amlodipine is a calcium channel blocker. Adverse or toxic effects may produce excessive peripheral vasodilation and marked hypotension with reflex tachycardia. Frequent side effects include peripheral edema, headache, and flushing.

Pleural friction rubs are the result of pleural inflammation often associated with pleurisy, pneumonia, or pleural infarct. A pleural friction rub is described as a creaking or grating noise similar to that made by two pieces of leather rubbing together. A pleural friction rub is audible on inspiration and expiration over the area of inflammation.

Crackles are audible when there is a sudden opening of small airways that contain fluid.

Indications for emergency use of seclusion are as follows: to prevent imminent harm to the client and others if other means are not effective or appropriate; to prevent serious disruption of the treatment program or significant damage to the environment; as part of an ongoing behavior treatment program; or at the client’s request.

Pregnancy induced hypertension is a multiorgan disease process that develops as a consequence of pregnancy and regresses in the postpartum period. Although the cause is not understood, several factors are known to increase a woman’s risk. These risks include a previous history of pregnancy-induced hypertension, those having their first baby, those under 17 years if age, woman who are obese, have diabetes mellitus, chronic hypertension, or preexisting vascular disease, and women with a multifetal gestation.

Odor, drainage, and an elevated temperature indicate infection. If skin infection occurs, the cast over the skin area thought to be infected can be cut out or “windowed” so the infected skin area can be observed and treated.

Regression is a coping mechanism in which the person returns to an earlier time in life when needs were met more readily by others. The attempt involves a way in which the client gives up responsibility and allows or directs others to meet the person’s needs. Denial is the process of escaping unpleasant realities by ignoring their existence. Repression is excluding unpleasant or unwanted experiences, emotions, or ideas from conscious awareness. Rationalization is the process of justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations.

A partial-thickness deep burn appears dry and may be red or white in appearance. No blanching occurs and thrombosed vessels may be visible. Decreased wound sensation will be present. Blisters and a wet shiny weeping surface occur in partial-thickness superficial burns. Charring would occur in deep full-thickness burns. Total absence of wound sensation would occur in deep full-thickness burns.

Depression is more common among first-degree relatives of persons with this disorder than in the general population. Therefore, the nurse would assess the client’s family history.

Conization is the surgical removal of a cone-shaped area of the cervix. Complications associated with conization are hemorrhage, uterine perforation, incompetent cervix, cervical stenosis, and preterm labor in future pregnancies. Conization is used therapeutically for women who desire further childbearing.

Signs and symptoms of respiratory alkalosis include: tachypnea, hyperpnea, giddiness, dizziness, syncope, convulsions, coma, weakness, paresthesia, and tetany. Etiologies of respiratory alkalosis include congestive heart failure and pulmonary edema.

Hyperventilating = respiratory alkalosis

Hypoventilating = respiratory acidosis

fulminating meningococcemia is uniquely associated with a rash in addition to the other symptoms.

Candidiasis, a fungal infection, adheres firmly to the tongue and/or mucous membranes of the mouth and throat. Bleeding may occur after the trauma of trying to remove the patches. A red circle on the skin may be associated with other disorders such as Lyme disease but is not seen in candidiasis. Candidiasis can occur on the oral mucous membranes as well as on the tongue.

A blood glucose level is an indicator of diabetes mellitus. Type 1 diabetes mellitus is an autoimmune disease, which if untreated provides an ideal environment for frequent infections. In females, infections of the genitourinary tract are the most common manifestation. Papanicolaou smears are specific for cancer of the cervix, which is usually asymptomatic. A throat infection is not normally chronic. An infection of the blood is systemic and is not likely the cause of frequent vaginal infections.

Developmental milestones of the six month old include: head control with no head lag; an interest in environmental stimuli that includes repetitive performance of learned skills; and motor skills such as throwing objects to see them drop. Early behavioral signs suggestive of cognitive impairment include diminished spontaneous activity, irritability, slow feeding, and decreased alertness to voice or movement.

One potentially life-threatening complication of cancer is hypercalcemia, which is characterized by calcium levels above 11 mg/dl.

The use of sunscreen is believed to decrease the risk of skin cancer. Protective measures are warranted throughout the lifespan since harmful effects from sun exposure are cumulative and skin damage can be severe by age 20.

Standing before a mirror inspecting the breasts for puckering, dimpling, or changes in the contour of the breasts is an important initial part of BSE.

Shades of blue in a mole are considered ominous for malignant melanoma. Genital warts may be associated with cancer of the cervix. Dimpling of the skin in the breast area may be associated with breast cancer. A mole with round, smooth borders would indicate a normal finding.

A flat brown circular nevi is a description of a classic benign mole.

A diagnosis of tuberculosis should be considered for any client with a persistent cough or other symptoms compatible with tuberculosis, such as weight loss, anorexia, fatigue, night sweats, or fever.

While performing a skin assessment on a client, moles with a variegated color, irregular borders and/or an irregular surface should be considered as suspicious.

Reddened, extremely tender breast tissue along with chills and a fever are symptoms of mastitis.
In the client with a musculoskeletal injury, neurovascular compromise can occur by increased pressure within a compartment. The pressure occurs because fascia is unable to expand when muscle swelling occurs.

An internal AV fistula is created through a surgical procedure in which an artery in the arm is anastomosed to a vein. To assess patency, the nurse palpates over the fistula for a thrill and auscultates for a bruit. With an internal AV fistula, the nurse would not note white fibrin specks. A feeling of warmth at the site of the fistula may indicate a potential inflammatory process.

Back pain, bladder spasms, and feelings of fullness and burning in the bladder may be experienced by the client following a cystoscopy. Warm tub baths, mild analgesics and antispasmodics will provide relief. Pink tinged urine is common but any bright red bleeding or clots in the urine should be reported to the physician.

In a client with tuberculosis, negative sputum cultures indicate that a client is no longer infectious to others. However, the client needs to continue taking the prescribed medication for 9 months or longer.

Signs and symptoms of Pneumocystis carinii pneumonia include dyspnea on exertion, tachypnea, and a persistent dry cough. Crackles are heard on auscultation. Signs and symptoms of cryptosporidiosis range from mild diarrhea to a cholera-like syndrome with body wasting and electrolyte imbalances. There can be a voluminous diarrhea with a volume loss of up to 15 to 20 liters per day. Signs and symptoms of malignant lymphoma include weight loss, fever, and night sweats. Signs and symptoms of toxoplasmosis include changes in mental status, neurological deficits, headaches, and fever.

Hematoma is suspected when pain or pressure is reported by the client. Massive hemorrhage can occur into the tissues resulting in hypovolemia and shock; therefore, the client’s complaints must be assessed so that interventions may begin immediately.

The newborn infant is having respiratory distress. Hyperglycemia during pregnancy delays fetal lung maturity. An L/S ratio is needed to predict sufficient surfactant to prevent respiratory distress syndrome (RDS).

Bromocriptine (Parlodel) is an antiparkinson, prolactin inhibitor. Frequent side effects include hypotension, dizziness, lightheadedness, nausea, and confusion. Adverse effects include visual or auditory hallucinations.

A drain connected to gentle suction prevents blood or serum to collect in the operative site. Following surgery, it is expected that bloody fluid will collect in the drain. Pain at the incisional site is an expected occurrence. Additionally, numbness may occur and the sensation of numbness resolves in time. Arm edema is a common complication and can occur immediately postoperatively, or months or even years following surgery.

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