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Friday, August 29, 2008

Nclex Tips 14 (Pearson Nclex)

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Dimenhydrinate (Dramamine) is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness.

Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory medications (Naprosyn and ibuprofen). The client should take acetaminophen for pain relief. Medication includes lansoprazole (Prevacid).

A client who has a long history of antisocial and acting-out behavior needs to demonstrate the motivation to change behavior, not just verbalization that change will occur. The nurse would be therapeutic by assisting the client to look at the behaviors that indicate the motivation to change.

A client in prison is knowledgeable about the rules for behavior in the correctional setting. Many clients will test the nurse’s capacity to be victimized and will make inappropriate statements. These behaviors need to be verbally confronted directly and then carefully documented in the client’s chart.

Acute toxicity of MAO inhibitors is manifested by restlessness, anxiety, and insomnia. Dizziness and hypertension may also occur.

The nurse working with chronically mentally ill clients in crisis should focus on the client’s strengths, modify and set realistic goals with the client, take an active role in assisting the client in the problem-solving process, and provide direct interventions that the individual might be able to do.

Methylphenidate hydrochloride (Ritalin) is a central nervous system (CNS) stimulant and can cause insomnia. Its usually prescribed to clients with ADHD. Taking the medication at breakfast and lunch and avoiding taking the medication in the evening can prevent insomnia. It is taken orally 30 to 45 minutes before breakfast and lunch.

When depressed, a client sees the negative side of everything. Neutral comments such as :You are wearing a new dress this morning" will avoid negative interpretations.

In psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. These activities include Ping-Pong, volleyball, finger-painting, drawing, and working with clay. These activities provide the client a more appropriate way of discharging motor tension than pacing or ringing the hands.

When a client is manic, solitary activities requiring a short attention span or mild physical exertion activities are best initially. These include writing, painting, finger-painting, woodworking, or walks with the staff. Solitary activities minimize stimuli, and mild physical activities release tension constructively. When less manic, the client may join one or two other clients in quiet, nonstimulating activities. Competitive games should be avoided because they can stimulate aggression and cause increased psychomotor activity.

An inappropriate affect refers to an emotional response to a situation that is not congruent with the tone of the situation. A flat affect is an immobile facial expression or blank look. A blunted affect is a minimal emotional response and expresses the client’s outward affect. It may not coincide with the client’s inner emotions. A bizarre affect such as grimacing, giggling, and mumbling to one’s self is marked when the client is unable to relate logically to the environment.

Poverty of speech is speech that is restricted in amount and ranges from brief to monosyllabic one-word answers. Poverty of content of speech is speech that is adequate in amount but conveys little information because of vagueness, empty repetitions, or use of stereotypes or obscure phrases. Thought blocking is when the client stops talking in the middle of a sentence and remains quiet.

When caring for a paranoid client, the nurse must avoid any physical contact and not touch the client. The nurse should ask the client’s permission if touch is necessary, because touch may be interpreted as a physical or sexual assault. The nurse should use simple and clear language when speaking to the client to prevent misinterpretation and to clarify the nurse’s intent and actions. A warm approach is avoided because it can be frightening to a person who needs emotional distance. Anger and hostile verbal attacks are diffused with a nondefensive stand. The anger a paranoid client expresses is often displaced, and when a staff member becomes defensive, anger of both the client and staff member escalates. A nondefensive and nonjudgmental attitude provides an environment in which feelings can be explored more easily.

In a paranoid client, The nurse should arrange solitary noncompetitive activities that take some concentration such as crossword puzzles, picture puzzles, photography, and typing. When the client feels less threatened, games such as bridge or chess or playing cards with another client may be appropriate. When the client is extremely distrustful of others, solitary activities are best and activities that demand concentration keep the client’s attention on reality and minimize hallucinatory and delusional preoccupation.

Propantheline (Pro-Banthine) is an antimuscarinic anticholinergic medication that decreases gastrointestinal secretions. It should be administered 30 minutes prior to meals.

The nurse would most appropriately assess the client’s eating patterns and food preferences and concerns about eating. Assessing previous and current coping skills is most appropriately related to a nursing diagnosis of Ineffective Coping. Assessing the client’s feelings about self and body weight is most appropriately related to a Disturbed Body Image. Assessing the client’s lack of control about the treatment plan is most closely related to the nursing diagnosis of Powerlessness.

Repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language pattern used by clients with schizophrenia. Clang associations often take the form of rhyming. Echolalia is the pathological repeating of another’s word by imitation and is often seen in people with catatonia. “Word salad” is a phrase used to identify a mixture of phrases that is meaningless to the listener and perhaps to the speaker as well. Thought broadcasting is the belief that others can hear one’s thoughts.

Whenever a client has been identified as a victim of abuse, priority must be placed on ascertaining whether the person is in any immediate danger. If so, emergency action must be taken to remove the person from the abusing situation.

A social phobia is characterized by a fear of appearing inadequate or inept in the presence of others and of doing something embarrassing. Thus, the client becomes anxious as the center of attention.

Physical assessment findings such as bruises, along with the other assessment findings noted in the question, should alert the nurse to the potential for elder abuse.

Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from ever occurring, and secondary prevention focuses on reducing the intensity and duration of the crisis during the crisis itself. A precrisis level of prevention is similar to primary prevention.

Thioridazine hydrochloride (Mellaril), an antipsychotic medication, has a higher likelihood of producing impotence than other neuroleptics

A nurse who is preparing a medication-teaching plan for a client who is receiving fluphenazine decanoate would be certain to advise the client to immediately report any clinical manifestations such as a sore throat or fever, because these signs could signal the onset of agranulocytosis. In addition, any extrapyramidal symptoms also require the physician’s immediate attention.

Trifluoperazine (Stelazine) can cause the client’s urine to turn pink to reddish-brown. This condition is not harmful; it disappears when the medication is discontinued. Nevertheless, the nurse will want to instruct the client to report its occurrence to the nursing staff or the medical staff.

One of the side effects of antipsychotic agents is that they decrease moisture around the eyes. This can cause difficulty for clients who wear contact lenses. Because the client has emphasized the importance of these lenses, it is a potential problem that may occur and lead to medication noncompliance by the client.

The most commonly occurring side effects of antipsychotic agents include dry mouth, blurred vision, nasal stuffiness, and weight gain. Additional side effects include difficulty in urinating, constipation, risk of infection, decreased sweating and increased sensitivity to heat, increased sensitivity to sunlight, yellowing of the eyes (especially the whites of the eyes), and decreased moisture around the eyes. Painful or interrupted menstruation, vaginal dryness, dizziness, drowsiness, breast enlargement/lactation, skin rash or itchy skin, and anhedonia can also occur.

Lithium and sodium, similar in chemical structure, compete to occupy sites within the body. Therefore, sodium levels often decrease, which causes lithium to be reabsorbed. When this happens, it increases the amount of lithium in the body, causing side effects. For this reason, the nurse instructs the client to drink 2 to 3 liters of water each day and eat a diet that is adequate in sodium. Once the client’s lithium level is established (usually within 2 weeks), a blood lithium level will be drawn every 1 to 2 months.

The most therapeutic response for the nurse to make to effectively teach the client about lithium is the one that emphasizes the necessity that the client does not discontinue the medication even if feeling an upset stomach. Clients who are taking this medicine are instructed to take their medication with meals to minimize the occurrence of an upset stomach.

Depersonalization constitutes a symptom that displays disturbance in the client’s sense of self. A flat affect is a symptom of schizophrenic disturbance in affect. Magical thinking is a symptom of the content of thought in schizophrenia. Word salad is a schizophrenic disturbance in the form of thought.

Fluphenazine decanoate (Prolixin) can decrease the normal bacteria in the oral cavity and increase sensitivity to infection. This can be prevented by instructing the client to avoid high-sugar foods; increase the frequency of mouth care (brushing, including the tongue, flossing, and gargling with mouthwash); and frequently inspect the tongue for a thick, white coating, which signals infection.

Lithium is contraindicated in pregnancy and for breastfeeding mothers. The client will be taught that breastfeeding is not possible while taking this medication and will be instructed to notify the physician immediately if pregnancy is even suspected or is being planned.

Tranylcypromine (Parnate), an antidepressant, can cause serious and potentially fatal adverse reactions if used with other antidepressants. Its use is avoided within 2 weeks of another antidepressant.

For clients with somatoform disorder, they are told to exercise because it helps to release endorphins, which enhance the feeling of well-being.

If a client who is taking an antidepressant complains of tiredness, the nurse instructs the client to report the side effect to the psychiatrist, take medication at hour of sleep (except fluoxetine hydrochloride [Prozac], which must be taken in the morning), and avoid alcohol or alcohol-containing foods (even over-the-counter medications that contain alcohol). The client should also be instructed to lie down and rest.

Some of the side effects of benzodiazepines are drowsiness, lethargy and confusion, dizziness, blurred vision, rash or “itchy” skin, unusual irritability or nervousness, headache, and nausea.

The Abnormal Involuntary Movement Scale (AIMS) scale is used to assist the nurse to recognize tardive dyskinesia. The three areas of examination are facial and oral movements, extremity movements, and trunk movement. Tardive dyskinesia can occur from the use of antipsychotics.

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Thursday, August 28, 2008

Nclex Tips 13 (Nclex Test Bank)

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Abdominal pain is the most prominent symptom of acute pancreatitis. The main focus of nursing care is aimed at reducing discomfort and pain by the use of measures that decrease gastrointestinal tract activity, thereby decreasing pancreatic stimulation.

A diagnosis of gout is made on the basis of clinical manifestations, hyperuricemia, and the presence of uric acid crystals in the synovial fluid of the inflamed joint. Blood studies show an increased serum uric acid level of more than 7 mg/100 mL. The erythrocyte sedimentation rate and the white blood cell count may be elevated during an acute episode. T

Probenecid is a uricosuric medication. The client should be instructed to avoid alcohol, because it increases the urate levels and to avoid medications that contain aspirin. Increased fluid intake is encouraged to maintain an adequate urine output and prevent hematuria, renal colic, and stone development. The client is instructed to administer the medication with milk or meals to prevent gastric distress and is also told to limit high-purine foods.

Calcium supplements should not be taken with whole grain cereals, rhubarb, spinach, or bran, because these foods decrease the absorption of the calcium. Most supplements should be taken on an empty stomach (1 hour before meals or at bedtime) to promote absorption, but food might be necessary if gastric irritation develops. The client should be instructed to drink water while taking the supplements to prevent renal stones. Side effects include constipation, gastric irritation, a chalky taste, nausea, and gastric bleeding.

Blood glucose levels for an adult normally range between 60 and 120 mg/dL. A level of 33 mg/dL indicates hypoglycemia. Metabolic disorders can be an etiological factor of delirium.

The Romberg test is an assessment for cerebellar functioning related to balance. The client stands with feet together and arms at the side and then closes the eyes. Slight swaying is normal, but loss of balance indicates a problem and a positive Romberg test.

For the first 12 hours following a laparotomy, the NG tube drainage may be dark brown to dark red. The drainage should then change to a light yellowish brown color. The presence of bile may cause a greenish tinge. The physician should be notified at once of the possibility of hemorrhage if the dark red color continues or if bright red blood is observed. Due to the presence of small amounts of blood and the action of gastric secretions, coffee ground granules might be seen in the NG tube drainage.

The diagnosis of HIV is difficult to accept. Clients can exhibit a variety of reactions that are not necessarily a direct result of ineffective coping skills. The nurse must also know that persons with HIV are living well beyond 1 year. Ignoring the problem will not eliminate the client’s difficulty in understanding the disease process. The nurse must focus on the knowledge deficit of a disease process and other psychosocial interventions.

Sheet grafts are often used to graft burns in visible areas. Sheet grafts are done on cosmetically important areas, such as the face and hands, to avoid the meshed pattern that occurs with meshed grafts.

The incidence of invasive cervical cancer in situ peaks around age 45 and occurs twice as often in African American women than in other races. A classic symptom is painless vaginal bleeding; it can be accompanied by watery, blood-tinged vaginal discharge that can become dark and foul smelling as the disease progresses. A Papanicolaou smear is the initial diagnostic test performed.

Organisms present in the synovial fluid are characteristic of a septic joint condition. Urate crystals are found in gout. Bloody synovial fluid is seen with trauma. Cloudy synovial fluid is diagnostic of rheumatoid arthritis.

Trigeminal neuralgia affects cranial nerve V, causing sudden bursts of electric current–like pain in the face.

In atrial fibrillation with rapid ventricular response, the atrial chambers quiver, do not contract normally, and fill the ventricles with blood during the last part of diastole. This results in the loss of an important atrial contribution to cardiac output, called the “atrial kick.” Loss of the atrial kick and the rapid ventricular rate causes a reduction of cardiac output by as much as 25%.

Physical changes in the client's appearance can occur with Cushing's syndrome. Such changes include hirsutism, moon face, buffalo hump, acne, and striae. These changes cause a body image disturbance.

A fasciotomy is a treatment for compartment syndrome.

The client with unilateral neglect must learn to scan the environment and gradually come to a realization of the affected side

Alcohol can precipitate an attack of pancreatitis. Coffee and cola products, which contain caffeine, stimulate the pancreas. Carbohydrates actually should be encouraged, since they are less stimulating to the pancreas. Since smoking can overstimulate the pancreas, teaching is effective when the client will try to stop smoking.

Hypercalcemia is a phenomenon associated with multiple myeloma. Due to the hypercalcemia, pathological fractures are possible. Ambulation is important, because immobility increases the likelihood of hypercalcemia. Most clients with multiple myeloma will not tolerate aerobic exercise because of their anemia.

Even if testicular cancer is detected in an early stage, the client newly diagnosed with testicular cancer might be afraid he will be sexually handicapped, and feelings of sexual inadequacy may occur. An appropriate nursing diagnosis would be Ineffective Role Performance.

Ventilators need to be assessed routinely by the respiratory therapist. Ventilators are machines, and machines can fail.

The normal white blood cell count is 5,000 to 10,000/mm3. Chemotherapy agents cause medication-induced leukopenia, and treatment focuses on this side effect.

A fractured femur may require up to 20 weeks for healing in an adult. Full weight-bearing is permitted as soon as bony union is present. Ambulation with a cane requires at least partial to full weight-bearing status. Full weight-bearing is usually restricted until there is radiographic evidence of bony union of the fracture fragments. Callus formation is too weak, and the fracture site may refracture with full weight-bearing. The stage of fracture healing dictates the amount of weight-bearing, not range of motion, muscle strength, or pain.

Perforation of the gastrointestinal wall is a potential complication of any endoscopic procedure. Signs of perforation include abdominal pain, bleeding, and fever. Temperature elevation does not usually accompany internal hemorrhage. The temperature may be elevated in both severe dehydration and with a nosocomial infection, but the potential complication that can occur with this procedure is perforation of the intestine.

Clients who test positive for HIV antibody are at risk for opportunistic infection. The normal CD4+ T cell count is between 500 mcg/L and 1600 mcg/L. As the CD4+ T cell count falls, the client’s risk for infection increases. Clients with HIV infection or acquired immunodeficiency syndrome are commonly afflicted with diarrhea, not constipation.

Clients with chronic illness often experience feelings of anger and depression. Manifestations of chronic hepatitis include profound fatigue, resulting in an inability to pursue normal daily activities. Ineffective coping involves inappropriate use of defense mechanisms (alcohol consumption). It can also include the inability to meet role expectations (working). The destructive use of alcohol will contribute to the client’s illness and rehabilitation time, and further prolong fatigue and the inability to work.

Nocturnal attacks of reflux from hiatal hernias are common, especially if the person has eaten near bedtime. Large meals, alcohol, and smoking can also precipitate attacks. Therefore, if the client did more entertaining earlier in the day, attacks might be decreased or eliminated.

The client with Addison’s disease is experiencing deficits of mineralocorticoids, glucocorticoids, and androgens. Aldosterone deficiency affects the ability of the nephrons to conserve sodium, so the client experiences sodium and fluid volume deficit. The client needs to manage this problem with daily hormone replacement and increased fluid and sodium intake. Clients are instructed to weigh themselves daily as a means of monitoring fluid volume balance. Glucocorticoids and mineralocorticoids are essential components of the stress response. Additional doses of hormone replacement therapy are needed with any type of physical or psychological stressor. This information needs to be conveyed to the client and also requires that the client wear a Medic-Alert bracelet, so that health care professionals are aware of this problem if the client were to experience a medical emergency.

The client with ulcerative colitis is most likely anemic due to chronic blood loss in small amounts that occur with exacerbations of the disease. These clients often have bloody stools and are therefore at increased risk for anemia

If a transfusion reaction is suspected, the transfusion is stopped and then normal saline is infused, pending further physician orders. This maintains a patent IV access line and aids in maintaining the client’s intravascular volume. The IV line would not be removed, because then there would be no IV access route. Normal saline is the solution of choice over solutions containing dextrose, because saline does not allow red blood cells to clump.

A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as ramipril, is the appearance of a persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the physician if the cough becomes very troublesome to them.

Nitroglycerin is a coronary vasodilator used in the management of coronary artery disease. The client is generally advised to apply a new patch each morning and leave it in place for 12 to 14 hours as per physician directions. This prevents the client from developing tolerance (as happens with 24-hour use). The client should avoid placing the system in skin folds, hairy areas, or excoriated areas. The client can apply a new patch if it falls off, because the dose is released continuously in small amounts through the skin.

Verapamil is a calcium channel–blocking agent that can be used to treat rapid-rate supraventricular tachydysrhythmias, such as atrial flutter or atrial fibrillation. The client must be attached to a cardiac monitor to evaluate the effectiveness of the medication. A noninvasive blood pressure monitor is also helpful, but is not as essential as the cardiac monitor.

The client should take in increased fluids (2000 to 3000 mL/day) to make secretions less viscous. This can help the client to expectorate secretions. This is standard advice given to clients receiving any of the adrenergic bronchodilators, such as albuterol, unless the client has another health problem that could be worsened by increased fluid intake.

The client taking a potassium-wasting diuretic such as chlorothiazide needs to be monitored for decreased potassium levels.

Amiloride is a potassium-sparing diuretic used to treat edema or hypertension. A daily dose should be taken in the morning to avoid nocturia. The dose should be taken with food to increase bioavailability. Sodium should be restricted if used as an antihypertensive. Increased blood pressure is not a reason to hold the medication, although it may be an indication for its use.

When ranitidine is given as a single daily dose, it should be taken at bedtime. This allows for prolonged effect, and the greatest protection of gastric mucosa around the clock.

Urinary retention is a side effect of benztropine mesylate. The nurse needs to observe for dysuria, distended abdomen, infrequent voiding of small amounts, and overflow incontinence.

Quinapril hydrochloride is an angiotensin-converting enzyme inhibitor used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regards to food. If nausea occurs, the client should be instructed to consume a non-cola carbonated beverage and salted crackers or dry toast. A full therapeutic effect may take place in 1 to 2 weeks.

Quinidine gluconate is an antidysrhythmic medication used as prophylactic therapy to maintain normal sinus rhythm after conversion of atrial fibrillation and/or atrial flutter. It is contraindicated in complete AV block, intraventricular conduction defects, abnormal impulses and rhythms due to escape mechanisms, and in myasthenia gravis. It is used with caution in clients with preexisting asthma, muscle weakness, infection with fever, and hepatic or renal insufficiency.

Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding, and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. Venipuncture sites should be held for approximately 10 minutes. The medication does not have to be taken on an empty stomach. The medication may cause hypoglycemia, but not hyperglycemia.

Diarrhea, nausea, vomiting, loss of appetite, and dizziness are all common side effects of quinidine. If these should occur, the physician should be notified; however, the patient should not discontinue the medication. A rapid decrease in medication levels of antidysrhythmics could precipitate dysrhythmia.

Benzonatate (Tessalon) is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough without eliminating the cough reflex.

Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with Carbamazepine (Tegretol). Adverse reactions include blood dyscrasias. If the client developed a fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, this might be indicative of a blood dyscrasia and the physician should be notified.

Parlodel is an antiparkinson prolactin inhibitor used in the treatment of neuroleptic malignant syndrome. Vitamin K is the antidote for warfarin (Coumadin) overdose. Protamine sulfate is the antidote for heparin overdose. Vasotec is an angiotensin-converting enzyme (ACE) inhibitor and an antihypertensive that is used in the treatment of hypertension.

Hematological reactions can occur in the client taking clozapine, and include agranulocytosis and mild leukopenia. The white blood cell count should be assessed before treatment is initiated and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever.

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Wednesday, August 27, 2008

Nclex Tips 12 (Pediatric Nclex Questions)

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Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward supported by the arms, chin thrust out, and mouth open), nasal flaring, tachycardia, a high fever, and sore throat.

Familiar objects provide a sense of security for the child in a strange hospital environment. The child should be allowed to have a favorite toy or security blanket while in the mist tent.

The stinger from a bee should be carefully removed by scraping it out horizontally. The mother should be instructed to avoid squeezing the stinger because more venom will be released. Following removal of the stinger, the area is washed with soap and water and ice may be applied for discomfort.

Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for clients with Ménière’s disease.

Following mastoidectomy, the nurse should monitor vital signs and inspect the dressing for drainage or bleeding. The nurse should assess for signs of facial nerve injury to cranial nerve VII and assess the client for pain, dizziness, or nausea. The head of the bed should be elevated at least 30 degrees, and the client is instructed to lie on the unaffected side. The client would probably have sutures and an outer ear packing and a bulky dressing, which is removed on approximately the sixth postoperative day.

Unstable angina is triggered by an unpredictable amount of exertion or emotion, and may occur at night. The attacks increase in number, duration, and severity over time. Variant angina is triggered by coronary artery spasm, and the attacks are of longer duration than those of classic angina and tend to occur early in the day and at rest. Intractable angina is chronic and incapacitating, and is refractory to medical therapy. Nocturnal angina may be associated with dreaming that occurs with rapid eye movement (REM) sleep.

Bloody or clear watery drainage from the auditory canal indicates a cerebrospinal leak following trauma and suggests a basal skull fracture. This warrants immediate attention, and the physician should be notified.

Otoscopic examination of a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head.

Hearing loss can occur in a client with an inner ear disorder. However, hearing loss is not the most common complaint of a client with an inner ear disorder. Tinnitus is the most common complaint of clients with otological disorders, especially disorders involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can go unnoticed during the day, to a loud roaring in the ear, which can interfere with the client’s thinking process and attention span.

A hallmark sign of pemphigus is Nikolsky’s sign. Nikolsky’s sign is when the epidermis can be rubbed off by slight friction or injury. Other characteristics of pemphigus include flaccid bullae that rupture easily and emit a foul-smelling drainage, leaving crusted, denuded skin. The lesions are common on the face, back, chest, groin, and umbilicus. Even slight pressure on an intact blister may cause spread to adjacent skin. Trousseau’s sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Homans' sign, a sign of thrombosis in the leg, is discomfort behind the knee on forced dorsiflexion of the foot.

In severe cystic acne, isotretinoin is used to inhibit inflammation. Adverse effects include elevated triglycerides, skin dryness, eye discomfort such as dryness and burning, and cheilitis (lip inflammation). Close medical follow-up is required, and dry skin and cheilitis can be decreased by the use of emollients and lip balms. Vitamin A supplements are stopped during this treatment.

Scabies can be identified by the multiple straight or wavy threadlike lines noted beneath the skin. The skin lesions are caused by the female mite, which burrows beneath the skin and lays its eggs. The eggs hatch in a few days and the baby mites find their way to the skin surface where they mate and complete the life cycle.

The client with any renal disorder, such as renal failure, may become angry and depressed because of the permanence of the alteration. Due to the physical change and the change in lifestyle that may be required to manage a severe renal condition, the client may experience Disturbed Body Image.

Athletes often have sinus bradycardia because exercise increases the stroke volume of the heart. Since the cardiac output is a product of stroke volume and heart rate, fewer beats are needed per minute at rest to maintain the normal cardiac output. The vital signs are normal for this client.

With classic presentation of herpes zoster, the clinical examination is diagnostic. A viral culture of the lesion provides the definitive diagnosis. Herpes zoster is caused by a reactivation of the varicella zoster virus, the cause of the virus for chicken pox. In a Wood’s light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin. A patch test is a skin test that involves the administration of an allergen to the skin’s surface to identify specific allergies.

The primary lesion of herpes zoster is a vesicle. The classic presentation consists of grouped vesicles on an erythematous base along a dermatome. Because they follow nerve pathways, the lesions do not cross the body’s midline.

Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and have a potential for metastasis. Melanomas are pigmented malignant lesions originating in the melanin-producing cells of the epidermis. This type of skin cancer is highly metastatic, and a person’s survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures.

A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue-toned color. Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border. Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration. Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry rough adherent yellow or brown scale.

Premature ventricular contractions are generally easily recognizable on the ECG. They occur early in relation to the timing of previous normal beats, have no visible P wave, and have a characteristically wide and bizarre QRS complex. There is a compensatory pause.

With onset of ventricular fibrillation, the client loses consciousness and becomes pulseless and apneic. There are no heart sounds or blood pressure. Death will occur if not treated.

Assessment findings in frostbite include a white or blue color, and the skin will be hard, cold, and insensitive to touch. As thawing occurs, the skin becomes flushed, blisters or blebs develop, or tissue edema appears. Gangrene develops in 9 to 15 days.

Acute frostbite is ideally treated with rapid and continuous rewarming of the tissue in a water bath for 15 to 20 minutes or until flushing of the skin occurs. Slow thawing or interrupted periods of warmth are avoided because this can contribute to increased cellular damage. Thawing can cause considerable pain, and the nurse administers analgesics as prescribed.

Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau’s sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. A hallmark sign of pemphigus is Nikolsky’s sign. In Nikolsky’s sign, the epidermis can be rubbed off by slight friction or injury. Homans' sign, a sign of thrombosis in the leg, is discomfort behind the knee on forced dorsiflexion of the foot.

Histoplasmosis usually starts as a respiratory infection in the client with AIDS. It then becomes a disseminated infection, with enlargement of lymph nodes, spleen, and liver.

The client who suffers a spinal cord injury experiences spinal shock at the time of the injury. The client loses all motor, bowel, bladder, and sexual function, and loses all reflexes below the level of the injury. Spinal shock resolves in 7 days to 3 months. Indications of resolving spinal shock include hyperreflexia and positive Babinski reflex.

As the first symptom, the client with Pneumocystis carinii infection usually has a cough that begins as nonproductive and then progresses to productive. Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.

If the results of two ELISA tests are positive, the Western Blot is done to confirm the findings. If the result of the Western Blot is positive, then the client is considered to be positive for HIV, and infected with the HIV virus. The CD4 count identifies the T-helper lymphocyte count and is performed to determine progression and treatment.

Hyperglycemia is characteristic of newly diagnosed diabetes mellitus. Newly diagnosed diabetics present a variety of symptoms, which may include polydipsia, polyuria, polyphagia, weakness, weight loss, dehydration. The definitive diagnosis is verified by hyperglycemia.

Renal biopsy is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound discriminates between a fluid-filled cyst and a solid mass. Renal arteriography outlines the renal vascular system. While some types of cancer grow more quickly than others, it is not possible to determine this by biopsy.

Radiation therapy to the brain can cause cerebral edema. Clients may also experience nausea and vomiting because of the effects of the radiation on the brain’s chemoreceptor trigger zone. Because hair follicles are destroyed by radiation, clients receiving radiation to the head may also experience hair loss.

Anxiety varies with an individual's perception, which in turn depends on a person's psychosocial makeup, education, degree of maturity, and life experiences. The nurse should know that anxiety is exhibited in many various forms. People can communicate their anxiety both verbally and nonverbally. The nurse needs to identify cues, interpret them, and seek to validate them.

Oral, subcutaneous, and intramuscular routes for administering medications are contraindicated for the burned client because of the poor absorption. When fluid balance is stabilized, oral narcotic agents can be used.

A hydrocele is an abnormal collection of fluid within the layers of the tunica vaginalis that surrounds the testis. It may be unilateral or bilateral and can occur in an infant or adult. Hydrocelectomy is the excision of the fluid filled sac in the tunica vaginalis. The client needs to be instructed that the sutures used during the hydrocelectomy are absorbable.

The client undergoing a radioactive iodine uptake test needs to be reassured that the amount of radioactive iodine used is very small, that it is not harmful to the client, and that the client will not be radioactive.

Since tuberculosis is transmitted by droplet, it cannot be carried on clothing, eating utensils, or other possessions. It is important to perform proper hand washing after contact with body substances, tissues, or facemasks. The client should cover the mouth with a tissue when laughing, coughing, or sneezing, and dispose of tissues carefully.

The client with tuberculosis usually experiences cough (either productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

The signs identified in the question indicate an occlusion of the femoral artery. Prior to the procedure, the nurse should mark the peripheral pulses distal to the catheter insertion site with a felt-tipped pen, and record the quality of the pulses in the chart. This will aid in locating the pulses after the procedure. Pulses are checked before the procedure for post-procedure comparisons and to detect possible occlusion of the vessel undergoing cannulation. The physician is notified immediately if the client experiences numbness or tingling in the affected extremity, if the extremity becomes cool, pale, or cyanotic, or if sudden loss of peripheral pulses occurs. These manifestations represent serious impairment of circulation.

Vaccines for hepatitis A using live activated and inactivated virus have been tested and seem safe and effective. Havrix, a vaccine containing the inactive virus of hepatitis A, is available and can replace gamma globulin for travelers. A single dose of this vaccine is given intramuscularly. For maximum antibody titer, a booster dose is recommended 6 to 12 months after the initial injection. The hepatitis B vaccine (Engerix-B, Recombivax-HB) provides active immunity to hepatitis B.

Subcutaneous emphysema can follow a thoracentesis, because air in the pleural cavity leaks into subcutaneous tissues. The tissues feel like lumpy paper and crackle when palpated (crepitus). Usually, subcutaneous emphysema causes no problem unless it is increasing and constricting vital organs, such as the trachea.

In Bell’s palsy, the client experiences weakness on an entire half of the face. The client is unable to close the eye on the affected side and experiences paralysis of the ipsilateral facial muscles. The client also experiences pain, drooling, decreased taste, and increased tearing. Tinnitus, vertigo, and deafness are not associated with Bell’s palsy but can be seen in Ménière’s disease. Muscle spasms in the jaw and cheek area are most likely associated with trigeminal neuralgia.

Therapeutic management for the client with Bell’s palsy includes providing moist heat packs to the affected area. The client is instructed to eat small meals and soft foods frequently, and to protect the affected eye by using an eye patch. The client is also instructed to use artificial tears four times daily and to manually close the affected eye from time to time.

For the first 24 hours postoperatively, the nurse should elevate the stump as prescribed to decrease swelling and promote comfort. Stumps with compromised circulation must not be elevated. A lower extremity stump is elevated at intervals, because elevation for long periods of time can cause flexion contractures of the hip. To prevent flexion hip contractures, the client should be positioned on the abdomen for a 30-minute period every 4 to 6 hours.

In general, only the area in the treatment field is affected by radiation. Skin reactions, fatigue, nausea, and anorexia may occur with radiation to any site, whereas other side effects occur only when specific areas are involved in treatment. A client receiving radiation to the neck is most likely to experience a sore throat.

Pallor is best seen in the buccal mucosa or conjunctiva, particularly in dark-skinned clients. Cyanosis is best seen in the nail beds, conjunctiva, and oral mucosa. Jaundice is best seen in the sclera, the junction of the hard and soft palate, and over the palms.

Abdominal pain is the most prominent symptom of acute pancreatitis. The main focus of nursing care is aimed at reducing discomfort and pain by the use of measures that decrease gastrointestinal tract activity, thereby decreasing pancreatic stimulation.

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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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Monday, August 25, 2008

Nclex Tips 10 (Review for Nclex)

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The client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish.

The client undergoing LP is positioned lying on the side, with the legs pulled up against the abdomen and with the head bent down toward the chest. This position helps widen the spaces between the vertebrae.

Caloric testing provides information about the vestibular portion of CN VIII, which aids in differentiating between cerebellar and brainstem lesions. Usually ice-cold water is inserted into the auditory canal after patency of the ear canal is determined. If brainstem function is intact, the eyes move in a conjugate fashion slowly toward the irrigated side and then quickly move back to midline. With brainstem death, this nystagmus pattern does not occur.

The correct technique for administering parenteral iron is deep in the gluteal muscle using Z-track technique. This method minimizes the possibility that the injection will stain the skin a dark color.

Pernicious anemia can occur in a client who has not had gastric surgery, such as when the client has a disease that involves the ileum, where vitamin B12 is absorbed. The nurse checks the client's history for small bowel disorders to detect this risk factor.

Classic signs of pernicious anemia include weakness, mild diarrhea, and smooth, sore, red tongue. The client may also have nervous system symptoms such as paresthesias, difficulty with balance, and occasional confusion.

An urticaria reaction is characterized by a rash accompanied by pruritus. This type of transfusion reaction is prevented by pretreating the client with an antihistamine, such as diphenhydramine.

Instructions to a femail client regarding the procedure for collecting a midstream urine sample includes telling the client that he should cleanse the perineum from front to back with the antiseptic swabs that are packaged with the specimen kit. The client should begin the flow of urine, collecting the sample after starting the flow of urine. The specimen should be sent to the laboratory as soon as possible and not allowed to stand. Improper specimen handling can yield inaccurate test results.

Sickle cell anemia is a severe anemia that predominantly affects African Americans. It is characterized by the presence of only hemoglobin S.

The indirect Coombs' test detects circulating antibodies against red blood cells (RBCs), and is the “screening” component of the order to “type and screen” a client’s blood. This test is used in addition to the ABO typing, which is normally done to determine blood type. The direct Coombs' test is used to detect idiopathic hemolytic anemia, by detecting the presence of autoantibodies against the client’s RBCs. Eosinophil and monocyte counts are part of a complete blood count, a routine hematologic screening test.

The most common sites for bone marrow aspiration in the adult are the iliac crest and the sternum. These areas are rich in marrow and are easily accessible for testing.

Sickle cell disease often causes pain in the bones and joints, accompanied by joint swelling. Pain is a classic symptom of the disease and may require large doses of narcotic analgesics when it is severe.

The priority items in the management of sickle cell crisis are hydration therapy and pain relief. To achieve this, the client is given intravenous fluids to promote hydration and reverse the agglutination of sickled cells in small blood vessels. Narcotic analgesics may be given to relieve the pain that accompanies the crisis. Oxygen would be given, based on individual need. RBC transfusion also may be done in selected circumstances such as aplastic crisis or when the episode is refractive to other therapy. Genetic counseling is recommended, but not during the acute phase of illness.

Idiopathic autoimmune hemolytic anemia is treated with corticosteroids, particularly prednisolone (Prelone). Other treatments that can be initiated as necessary include splenectomy, transfusions, and sometimes immunosuppressive agents.

At age 15 months, the nurse would expect that the child could build a tower of two blocks. A 24-month-old would be able to open a doorknob and unzip a large zipper. At age 30 months, the child would be able to put on simple clothes independently.

Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or activity. Alternating constipation and diarrhea with the presence of undigested food and mucus in the stools may also be noted.

Following pyloromyotomy, the head of the bed is elevated and the infant is placed prone to reduce the risk of aspiration.

Mumps generally affects salivary glands but can involve multiple organs. The most common complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the physician.

Carditis is the inflammation of all parts of the heart, primarily the mitral valve.

Hypernatremia occurs when the sodium level is greater than 145 mEq/L. Clinical manifestations include intense thirst; oliguria; agitation and restlessness; flushed skin; peripheral and pulmonary edema; dry, sticky mucous membranes; and nausea and vomiting.

The two primary pathophysiological alterations associated with hemolytic disease are anemia and hyperbilirubinemia. The red blood cell count is decreased, because the red blood cell production cannot keep pace with the red blood cell destruction. Hyperbilirubinemia results from the red blood cell destruction accompanying this disorder, as well as from the normally decreased ability of the infant’s liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated with hypertrophy of pancreatic islet cells and increased levels of insulin.

Live measles vaccine is produced by chick embryo cell culture, so the possibility of an anaphylactic hypersensitivity in children with egg allergies should be considered. If there is a question of sensitivity, children should be tested before the administration of MMR vaccine. If a child tests positive for sensitivity, the killed measles vaccine may be given as an alternative.

Meperidine hydrochloride is contraindicated for ongoing pain management for a client admitted to the hospital with a diagnosis of sickle cell crisis, because of the increased risk of seizures associated with its use. Management of severe pain generally includes the use of strong narcotic analgesics, such as morphine sulfate or hydromorphone (Dilaudid). These medications are usually most effective when given as a continuous infusion or at regular intervals around the clock.

Dietary sources of iron that are easy for the body to absorb include meat, poultry, and fish. Vegetables, fruits, cereals, and breads are also dietary sources of iron but contain less iron and are harder for the body to absorb.

Intravenous immune globulin (IVIG) will increase the platelet count. It is thought to act by interfering with the attachment of antibody-coded platelets to receptors on the macrophage cells of the reticuloendothelial system. Corticosteroids can be prescribed to enhance vascular stability and decrease the production of antiplatelet antibodies.

Koplik spots appear approximately 2 days before the appearance of the rash of rubeola. These are small, blue-white spots with a red base found on the buccal mucosa. The spots last approximately 3 days, after which time they slough off

A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle.

Ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during fetal life. It generally closes spontaneously within a few hours to several days after birth. When patent, it allows abnormal blood flow from the high- pressure aorta to the low-pressure pulmonary artery, resulting in a left-to-right shunt.

Discharge instruction to the parents of a child who has had heart surgery includes the child may return to school the third week after hospital discharge, but should go for half days for the first few days. The child should avoid crowds of people for 1 week after discharge, including day care centers and churches. Play outside should be avoided for several weeks, although inside play is allowed. If any difficulty with breathing occurs, the parents should notify the physician.

A toddler derives comfort and security from familiar routines and people. The new sights, sounds, and smells are a source of anxiety during hospitalization.

The crisis of Autonomy vs Shame and Doubt is related to the developmental task of gaining control of self and environment as exemplified by toilet training.    Initiative vs Guilt is the crisis of the preschool and early school-aged child. Initiative vs Inferiority is the crisis of the 6- to 12-year-old, and Trust vs Mistrust is the crisis of the infant.

The Somogyi effect is a rebound hyperglycemia that occurs as a result of the secretion of counter regulatory hormones such as epinephrine, growth hormone, and corticosteroids. The 3:00 a.m. blood glucose level is low, followed by a high level a few hours later, demonstrating the rebound effect.

Children suspected of having acute rheumatic fever are tested for the presence of recent streptococcal infection antibodies. An increased antibody level, evidenced by an elevated or rising antistreptolysin-O (ASO) titer, will assist in confirming the diagnosis. An increased erythrocyte sedimentation rate would occur in acute rheumatic fever. A leukocyte count and hemoglobin count will not confirm the diagnosis of acute rheumatic fever.

A diarrhea stool has an alkaline pH that can cause skin breakdown. A damp washcloth is an ineffective way to clean the skin. The mother should be taught to thoroughly clean the skin, using a mild soap.

Spina bifida occurs during fetal growth and development and has genetic predispositions. Parents who have children with congenital defects blame themselves for the child’s defects. Parents, at times, have difficulty bonding with their newborn because they are grieving the loss of their perfect baby. Integrating the new baby with special needs into the parent’s life is a stressful adjustment.

Complications from pertussis include pneumonia, atelectasis, otitis media, convulsions, and subarachnoid bleeding. Decreased breath sounds are indicative of both pneumonia and atelectasis.

Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of a chronic tissue hypoxia and polycythemia.

In hemophilia A, the partial thromboplastin time is prolonged. The white blood cell count, sedimentation rate, and clot retraction time are unrelated to the diagnosis of hemophilia A.

The stools of a child with celiac disease are characteristically malodorous, pale, fatty, large (bulky), and soft (loose). Excessive flatus is common, and bouts of diarrhea may occur.

Rehydration is the initial step in resolving diabetic ketoacidosis (DKA.) Normal saline is the initial IV rehydration fluid. Regular insulin will be administered by continuous IV infusion. Dextrose solutions are added to the treatment regime when the blood glucose levels reach an acceptable level. IV potassium may be required, depending on the potassium levels, but would not be part of the initial treatment. Glucagon hydrochloride is used to treat severe hypoglycemia.

If a child is being treated with propylthiouracil, the increased risk for neutropenia and hepatotoxicity exists. Contact sports should be limited to decrease the possibility of injury and damage to the liver. If the child develops a sore throat or fever, the physician should be notified, because these signs could indicate neutropenia. A yellow discoloration of the skin could indicate the presence of liver damage or hepatitis, and if this occurs, it is not normal and the physician must be notified.

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Sunday, August 24, 2008

Nclex Tips 9 (Pediatric Nclex Questions)

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Signs of infection include fever (greater than 100° F), increased pulse and BP, high WBC count with a shift to the left (indicating rapid proliferation of WBCs), and positive cultures, such as from wound drainage, urine, sputum, or blood. If the client meets expected outcomes, the client is free of signs and symptoms of infection.

TB is spread by droplet nuclei, which become airborne when the infected client laughs, sings, sneezes, or coughs. An individual must inhale the droplet nuclei for the chain of infection to continue.

The client taking isoniazid is at risk for hepatotoxicity. For this reason, the client’s hepatic enzymes are measured before and periodically during therapy with this medication. BUN and creatinine are measured during therapy with streptomycin, which is a nephrotoxic medication. Vision testing is done during treatment with ethambutol (Myambutol).

The most common symptom of Pulmonary embolism (PE) is a sudden-onset chest pain. The next most frequent symptoms are dyspnea and tachypnea. Other manifestations include tachycardia, diaphoresis, cough, fever, hemoptysis, and syncope.

When a client is severely depressed, the client should be involved in quiet one-to-one activities. Because concentration is impaired when the client is severely depressed, these types of activities maximize the potential for interacting and may minimize anxiety levels.

It is important to ask the client to identify preferred foods and drinks and to offer choices when possible. The client is more likely to eat the foods provided if choices are offered. The client should be offered high-calorie, high-protein fluids and snacks frequently throughout the day and evening. When possible, it is best to remain with the client during meals. This action reinforces the idea that someone cares, can raise the client’s self-esteem, and can serve as an incentive to eat.

In a depress client who has trouble sleeping, the client should be provided rest periods after activities during the day because fatigue can intensify feelings of depression. The nurse should spend more time with the client before bedtime to help allay anxiety and increase feelings of security. Reduced environmental and physical stimuli should be provided in the evening, such as soft lights, soft music, and quiet activities. Exercise should be avoided before bedtime. The client should be encouraged to get up and dress and stay out of bed during the day because this routine minimizes sleep during the day and increases the likelihood of sleep at night.

Eskalith is the medication of choice for treating the manic phase of a bipolar disorder. It is a mood stabilizer and is the prototypical antimanic medication. Often it can calm manic clients, prevent or modify future manic episodes, and prevent future depressive episodes.

A normal diet and normal salt and fluid intake should be maintained while the client is taking lithium. This agent decreases sodium reabsorption by the renal tubules, which could cause sodium depletion. A low-sodium intake causes a relative increase in lithium retention, which could lead to toxicity. The client should avoid taking any over-the-counter medications without checking first with the physician. Lithium is irritating to the gastric mucosa; therefore the client should take the medication with meals. Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely, more frequently at first, and then once every few months thereafter.

A flat affect is an immobile facial expression or blank look. A blunted affect is indicated by a minimal emotional response. An inappropriate affect refers to an emotional response to a situation that is not congruent with the tone of the situation. A bizarre affect is especially prominent in the disorganized form of schizophrenia and is characterized by grimacing, giggling, or mumbling to one’s self.

A bizarre affect is especially prominent in the disorganized form of schizophrenia. Grimacing, giggling, and mumbling to one’s self are included in this description. A bizarre affect is marked when the client is unable to relate logically to the environment. A flat affect is an immobile facial expression or blank look. A blunted affect is a minimal emotional response, commonly seen in schizophrenia. In schizophrenia, the client’s outward affect may not coincide with inner emotions. An inappropriate affect refers to an emotional response to a situation that is not congruent with the tone of the situation.

Thought-blocking occurs when a client stops talking in the middle of a sentence and remains quiet. Poverty of speech occurs when there is a restriction in the amount of speech and answers consist of brief, often monosyllabic or one-word answers. Speech that is adequate in amount but conveys little information because of vagueness, empty repetitions, or the use of stereotypes or obscure phrases is described as poverty of content of speech.

Accupril is an angiotensin-converting enzyme inhibitor. It suppresses the renal angiotensin-aldosterone system and reduces peripheral arterial resistance and blood pressure (BP). It is used in the treatment of hypertension, either alone or in combination with other antihypertensive agents.

Quinidine gluconate (Duraquin) is an antidysrhythmic medication. The BP should be monitored before administering the medication. Although pulse oximetry, temperature, and respirations may be components of the assessment, monitoring the BP is specific to the administration of this medication.

Quinine sulfate is an antimalarial, antimyotonic medication. Its antimalarial effect elevates the pH in intracellular organelles of parasites, producing parasitic death. It relaxes the skeletal muscle by increasing the refractory period, decreasing excitability of motor end plates, and affecting distribution of calcium within muscle fiber.

The catheter should be advanced for 1 to 2 more inches beyond the point where the flow of urine is first noted. This ensures that the balloon is fully in the bladder before it is inflated.

Anorexia nervosa is an eating disorder characterized by a determination to lose weight mainly by restricting food intake, even when emaciated. It generally occurs in young adults who have distorted views of the body’s shape and weight and the self. Through dieting and weight loss, these persons believe they will experience control, autonomy, and competence. Bulimia nervosa is characterized by eating binges followed by maladaptive or inappropriate reparative behaviors, such as dieting and purging, occurring at least two times each week for 3 or more months.

A desirable target weight should be discussed with the client with anorexia nervosa. A weekly weight gain of 1 pound is generally acceptable for the emaciated client. In the client with bulimia, a desirable goal is weight stabilization without binge-purge behavior.

Nitrofurantoin (Macrodantin) is specifically indicated for the treatment of urinary tract infections when due to susceptible strains of Escherichia coli, enterococci..

During the immediate postpartum period, vital signs are taken every 15 minutes during the first hour after birth, every 30 minutes for the next 2 hours, and every hour for the next 2 to 6 hours. Vital signs are monitored thereafter every 4 hours for the first 24 hours and every 8 to 12 hours for the remainder of the hospital stay.

During the first week after birth, transient episodes of bradycardia are common. The woman’s pulse may be as low as 40 to 50 BPM the first 1 to 2 days after delivery. It is not necessary to notify the physician.

The position of the fundus should be midline. Displacement to the side indicates that the bladder may be full. It is not necessary to notify the physician. Fundus massage is performed when the uterus is soft and boggy.

The presence of cyanosis can be best seen in the nailbeds, the conjunctivae, and the oral mucosa. Pallor is best seen in the buccal mucosa or the conjunctivae, particularly in dark-skinned clients. Jaundice can be best assessed in the sclera near the limbus at the junction of the hard and soft portions of the palate and over the palms.

After elbow arthroplasty, elbow-flexion and elbow-extension exercises are allowed as tolerated. The client should not lift more than 5 pounds and should not begin triceps- and biceps-strengthening exercises for 3 months. The client will not be able to lift heavy items or play sports with the operative arm.

To assess cutaneous nerve status, flexion of the biceps is checked by having the client raise the forearm. Poor biceps flexion may indicate compromise of the cutaneous nerve

The client is at risk for impairment of skin integrity owing to the presence of the catheter, exposure to moisture, and irritation from tape and cleansing solutions. The client should be instructed to use paper or nonallergenic tape to prevent skin irritation and breakdown. It is proper procedure for the client to use aseptic technique and to self-monitor vital signs and weight on a daily basis.

A client with anemia should be taught the basics of good nutrition and encouraged to consume a diet high in protein, iron, and vitamins. The nurse should encourage the client to consume foods cooked in iron pots and to ingest foods such as liver, which has the highest source of iron of the foods identified in the options. Other foods that may provide high sources of iron include oysters, lean meats, kidney beans, whole-wheat bread, kale, spinach, egg yolks, turnip tops, beet greens, carrots, apricots, and raisins.

One major risk factor for the development of pernicious anemia is gastric resection. Inadequate iron in the diet is not specifically associated with this type of anemia but is associated with iron-deficiency anemia. Central nervous system and musculoskeletal manifestations may occur as a result of pernicious anemia.

Polycythemia vera is defined as the increase in both the number of circulating erythrocytes and the concentration of hemoglobin within the blood. It is classified as a myeloproliferative disorder, meaning overgrowth of bone marrow. The cause remains unknown, although it is possibly a form of malignancy similar to leukemia and is often considered a premalignant condition, sometimes referred to as myeloproliferative dyscrasia. Iron-deficiency anemia occurs as a result of poor intake of iron. The lack of the intrinsic factor produces pernicious anemia.

Bone marrow aspiration biopsy is a key diagnostic tool for confirming the diagnosis of leukemia and for identifying malignant cell types. Lumbar puncture may determine the presence of blast cells in the central nervous system. Radiographic tests may detect lesions and sites of infection. A lymphangiogram may be performed to locate malignant lesions and accurately classify the disease.

When the neutrophil count is less than 500/mm3, the client is at risk for infection; therefore, monitoring the oral temperature is a critical nursing intervention.

When the neutrophil count is less than 1000/mm3, the client is at risk for infection. A platelet count less than 20,000/mm3 would place the client at risk for hemorrhage.

The breasts become tender early in pregnancy as a result of the increased levels of estrogen and progesterone. A self-care measure for breast tenderness includes wearing a well-fitting brassiere that provides support for the breasts and decreases discomfort.

Constipation may result from slowing of peristalsis, caused by increased levels of progesterone, displacement of the intestines by the expanding uterus, lack of activity, and inadequate fluid intake. Self-care measures for constipation include increasing daily fluid intake and whole grains and roughage in the diet and exercising regularly.

Vaginal discharge called leukorrhea is common in pregnant women because of the increased mucus production by the endocervical gland. The mucus should be clear or slightly whitish and mucoid in appearance.

Clinical manifestations indicative of alcohol abuse during the prenatal period include poor weight gain, hypoglycemia, tremors at rest, nausea, weakness, anxiety, slurred speech, unsteady gait, and sweating, especially of the palms and forehead, as well as generalized sweating.

After assessment of pitting edema, if the nurse notes a slight indentation, it is documented as a 1+ edema. A 2+ edema is an indentation approximately 1/4-inch deep. A 3+ edema is an indentation approximately 1/2-inch deep, and a 4+ edema is an indentation approximately 1-inch deep.

To evaluate the deep tendon reflexes, the client’s lower leg is exposed, and one hand is placed under the knee to raise it slightly off the bed. A percussion hammer is used to strike the patellar tendon just below the patella. The normal response is extension and thrusting of the foot upward.

The normal response is extension and thrusting of the foot forward. A 1+ response indicates a diminished response, 2+ indicates normal, 3+ indicates increased, or brisker than average, and 4+ indicates very brisk, or hyperactive.

The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board would be useful in transferring a client who cannot move from a bed to a stretcher or a wheelchair.

The facial nerve (CN VII) has both motor and sensory divisions. Common symptoms of dysfunction of this nerve include an inability to close the eye and to blink automatically, facial asymmetry, drooling and inability to swallow secretions, loss of the ability to form tears, and possible loss of taste on the anterior two thirds of the tongue. Bell’s palsy, fracture of the temporal bone, and parotid lacerations or contusions are often responsible for these symptoms.

The vestibulocochlear nerve (CN VIII) is responsible for auditory acuity as well as bone and air conduction. The audiometer assesses the client’s hearing, whereas the tuning fork tests bone and air conduction.

Nystagmus is characterized by fine involuntary eye movements. Ataxia is a disturbance in gait. Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and eyes closed. This assessment technique may be done to detect small changes in muscle strength that might not otherwise be noted. Hyperreflexia is an excessive reflex action.

With an impaired corneal (blink) reflex, the client is at risk for the eyes becoming dry and also for corneal abrasions if foreign matter comes in contact with the eye. Use of sterile saline drops helps keep the eyes lubricated. An eye patch would have to be used carefully because corneal abrasion could result if the cornea comes in contact with the patch. Introduction of a foreign object (a cotton ball) inside the lower eyelid also risks corneal abrasion. Taping the eye shut could impair the client’s vision, putting the client at risk for another injury, such as a fall.

Clients with confusion from neurological dysfunction respond best to a stable environment, which is limited in the amount and types of sensory input. The family can provide sensory cues and give clear, simple directions in a positive manner. Confusion and agitation are reduced when environmental stimuli (television and multiple visitors) are minimized and when personal articles are visible to the client.

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Saturday, August 23, 2008

Nclex Tips 8 (Nclex Answers)

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Ménière’s disease results from a disturbance in the fluid of the endolymphatic system. The cause of the disturbance is unknown. Attacks may be preceded by a feeling of fullness in the ear or by tinnitus. Headaches are not associated with this disorder.

The three characteristic symptoms of Ménière’s disease are tinnitus, sensorineural hearing loss on the involved side, and severe vertigo accompanied by nausea and vomiting.

After the acute phase of Ménière’s disease, remission occurs, but symptoms of the disease will recur with two or three acute attacks occurring per year. As this pattern of attacks and remissions develops, fewer symptoms occur during the acute phase. A complete remission eventually occurs with some degree of hearing loss, varying from slight to complete. It takes several weeks before all symptoms subside after an attack, leaving a loss of hearing in the involved ear.

Medical interventions during the acute phase of Ménière’s disease include using atropine or diazepam (Valium) to decrease the autonomic nervous system function. Diphenhydramine (Benadryl) may be prescribed for its antihistamine effects, and a vasodilator also will be prescribed. The client will remain on bed rest during the acute attack, and when allowed to be out of bed, the client will need assistance with walking, sitting, or standing.

Management during remission includes the use of diuretics to decrease the fluid and thereby decrease pressure in the endolymph. Antihistamines, vasodilators, and diuretics may be prescribed for the client. A low-salt diet is prescribed for the client to reduce fluid retention. The major goal of treatment is to preserve the client’s hearing, and careful medical management helps achieve this in most clients with Ménière’s disease.

After stapedectomy, the client is instructed to keep water out of the ear canal for at least 3 weeks and to avoid swimming for 6 weeks. The client also is instructed to avoid coughing and sneezing and to avoid bending and lifting heavy objects or other strenuous activities for at least 3 weeks. Air travel is avoided for 4 weeks. If sudden hearing loss, fever, or severe persistent vertigo or dizziness develops, the physician should be notified.

The client with urethritis from chlamydial infection should not engage in any form of sexual activity (intercourse, as well as oral-genital or oral-anal contact) until the client is fully cured. At that point, the client also should use condoms to prevent reinfection.

To conduct a hearing test, The examiner should stand 1 to 2 feet away from the client and ask the client to block one external ear canal. The nurse quietly whispers a statement and asks the client to repeat it. Each ear is tested separately.

Spinal shock occurs immediately after an injury as a result of disruption of the communication pathways. These assessment findings noted in the question indicate spinal shock. Hypertension is noted in autonomic dysreflexia.

Insects that make their way into an ear are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration, and the impaction becomes worse.

Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.

Clients with meniere's disease are instructed to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Clients are advised to stop smoking because of its vasoconstrictive effects.

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 also may include hypotension, ileus, irritability, and fatigue. Nausea may or may not occur.

Killed or inactivated vaccines are vaccines that contain pathogens made inactive by either chemicals or heat. These vaccines, which are noninfectious, cause the body to produce antibodies. Their disadvantage is that they elicit a limited immune response from the body; therefore several doses are required. Examples of this type of vaccine include the Salk polio, the rabies, and the pertussis vaccines.

Animal serums (antitoxins) are derived from the serum of immunized animals. These vaccines have the disadvantage of being foreign substances, which may cause hypersensitivity reactions. Thus a history and sensitivity testing should precede vaccine administration. The serums derived with this method are used to stimulate production of antibodies for hepatitis, chickenpox, rabies, diphtheria, smallpox, cytomegalovirus (CMV), botulism, snakebites, and spider bites.

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), 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.

When giving DPT, Hib, and hepatitis B vaccines simultaneously, the nurse should administer the most reactive vaccine (DPT) in one leg and inject the others, which cause a smaller reaction, into the other leg.

Any immunization may cause an anaphylactic reaction. All offices and clinics administering immunizations must have epinephrine 1:1000 available. Pediatric syringes are needed to administer the immunization. Generally, a needle that is 2/8-inch or longer is adequate to administer immunizations for a normal 4-month-old infant.

The client with fractured ribs is predisposed to atelectasis and pneumonia owing to the effects of shallow breathing, which leads to decreased coughing, accumulation of secretions, and subsequent pneumonia. The client could have hemoptysis or pneumothorax at the time of injury if the rib has pierced lung tissue or the pleural cavity, but these problems are not likely to occur after the first 24 to 48 hours after the injury.

The normal respiratory rate is 12 to 20 breaths/minute, whereas the normal oxygen saturation range is 95% to 100%.

The care of the client in respiratory failure is focused on maintaining effective respirations and conserving energy. Fluid balance and nutrition are important, but energy conservation takes priority. Energy conservation will conserve oxygen.

Rubella has an incubation period of 14 to 21 days. The infectious period ranges from 10 days before the onset of symptoms to 15 days after the rash appears.

The client with rheumatoid arthritis may be prescribed a dose of aspirin of 1000 to 1600 mg/day. At these high doses, aspirin is frequently toxic. Clients should be instructed to take aspirin with food and to watch for clinical manifestations of gastrointestinal (GI) bleeding, easy bruising, and tinnitus.

The incubation period for mumps is usually 16 to 18 days but may extend to 25 days. The infectious period is usually 1 to 2 days (7 days before swelling to 9 days after onset).

The incubation period for scarlet fever is 1 to 7 days. The infectious period is the acute stage until 36 hours after antimicrobial therapy is initiated.

Rubeola is transmitted via airborne particles or by direct contact with infectious droplets.

Mumps is transmitted via airborne droplets, salivary secretions, and possibly the urine.

Rubeola has an infectious period that ranges from 1 to 2 days before the onset of symptoms to 4 days after the rash appears.

Infectious period for mumps usually ranges from 1 to 2 days

Rubeola is transmitted via airborne particles or direct contact with infectious droplets. The treatment of measles is symptomatic, whether the child is hospitalized or remains at home. If hospitalized, however, the child will require respiratory isolation. During the febrile period, the child should be restricted to quiet activities and bed rest. Respiratory isolation for a child with measles requires masks for those in close contact with the child. Gowns and gloves are not specifically indicated. Strict hand washing is necessary. Articles that are contaminated should be bagged and labeled before reprocessing.

In infants and non–toilet-trained children, a urine specimen may be collected by attaching a bag to the perineum. The perineal area must be meticulously cleansed and the specimen collected within 30 minutes. If the child or infant does not void within 30 minutes, the bag is changed. Urine can be collected by urethral catheterization, but this is not the best method because it will introduce bacteria into the bladder.

Glomerulonephritis is characterized by inflammation of the capillaries contained in the glomerulus. It can result from different causes, such as an infection, a systemic disease process, or a primary defect in the glomerulus itself.

In the child with glomerulonephritis, fluid intake should be limited, as prescribed. In children with fluid excess, pulmonary edema may develop. A low-sodium diet is followed as prescribed because excessive sodium will increase fluid retention. Weight should be obtained to determine fluctuations in fluid status. The child may tire easily, so playtime should be limited to short periods and extended as the condition improves.

Hypospadias is a congenital anomaly in which the actual opening of the urethral meatus is below the normal placement on the glans penis.

Bladder exstrophy is a congenital anomaly characterized by the extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall.

Postoperative instructions for parents of a child who underwent a myringotomy with insertion of tympanostomy tubes includes that if a small amount of reddish drainage is normal for the first few days after surgery; however, the parents should report any heavier bleeding or bleeding that occurs after 3 days. The parents should be instructed to report any fever or increased pain. The child should not blow the nose for 7 to 10 days. Baths and lake water are potential sources of bacterial contamination, and chlorinated swimming pools can be irritative to the tympanic membranes with tubes. The child should place earplugs or cotton balls covered with petroleum jelly in the ears during baths and shampoos. Swimming is allowed only with earplugs and with the physician’s approval. Diving and swimming deeply underwater are prohibited.

Discharge instructions to a mother regarding the care of her 10-year-old child who has pharyngitis includes antibiotics should be taken for the entire prescribed course, even if the child is feeling better and is free of symptoms. The older child may gargle with saline. Warm or cool compresses may be applied to the throat. A follow-up with a repeat throat culture should be done 3 to 5 days after completing the course of the antibiotics.

Clear, cool liquids are provided when the child is fully awake. Citrus, carbonated, and extremely hot or cold liquids are avoided because they irritate the throat. Milk and milk products, including puddings and ice cream, are avoided initially until the child has tolerated clear liquids well. This is done because milk products can coat the throat and cause the child to clear it, thus increasing the risk of bleeding.

Acute epiglottitis is caused by bacteria, usually Haemophilus influenzae type B. Viral epiglottitis is rare. It has an abrupt onset, causes swelling and inflammation of the epiglottis, and may rapidly progress to complete airway obstruction.

Virazole is an antiviral respiratory medication that is used to interfere with RNA and DNA synthesis, inhibiting viral replication. Administration is via hood, facemask, or oxygen tent.

Atrial septal defect is an opening between the two atria that allows oxygenated and unoxygenated blood to mix. Left-to-right shunting of blood occurs because of the higher pressure on the left side of the heart. Ventricular septal defect is an opening between the two ventricles allowing oxygenated and unoxygenated blood to mix. Patent ductus arteriosus involves an artery that connects the aorta and the pulmonary artery during fetal life. Atrioventricular canal defect occurs as a result of inappropriate fetal development of endocardial cushions.

Atrial septal defect is a left-to-right heart shunt. In a left-to-right shunt, blood is shunted to the right side of the heart because the left side is normally functioning under a higher pressure than the right side. This shunting allows oxygenated blood and unoxygenated blood to mix. This results in increased pulmonary blood flow because the abnormal communication, or opening, sends more blood to the right side of the heart through the opening than is normal.

An atrioventricular canal defect is a left-to-right shunt. Blood is shunted to the right side of the heart because the left side is normally functioning under a higher pressure than the right side. This shunting allows oxygenated and unoxygenated blood to mix. It results in increased pulmonary blood flow because the abnormal communication, or opening, sends more blood to the right side of the heart through the opening than is normal.

In some children with patent ductus arteriosus, no symptoms occur, and the defect closes spontaneously. Measures to reduce symptoms of congestive heart failure (CHF) must be undertaken. Surgical closure, if performed, is done via a left thoracotomy and without cardiopulmonary bypass. Indomethacin (Indocin) is sometimes used to promote ductal closure in premature infants.

Fear is the most appropriate problem because the breathlessness and dyspnea are making the client upset.

A limited fluid intake can predispose the client to dehydration and respiratory infection. This is because dehydration impairs the action of the cilia in the respiratory tree.

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