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Wednesday, August 20, 2008

Nclex Tips 6 (RN/ PN nclex testing)

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As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Placenta previa is the sudden onset of painless uterine bleeding in the latter half of pregnancy. Abruptio placentae is characterized by abdominal pain and vaginal bleeding. Uterine atony relates to a uterus that is not firmly contracted.

The fourth stage of labor is the stage of physical recovery for the mother and infant. It lasts from the delivery of the placenta through the first 1 to 4 hours after birth. A potential complication after delivery is hemorrhage. The most significant source of bleeding is the site where the placenta was implanted. It is critical that the uterus remain contracted and that the nurse monitors vaginal blood flow every 15 minutes for the first 1 to 2 hours.

Vaginal bleeding in a pregnant client most often is caused by placenta previa or a placental abruption. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax. Placental abruption is characterized by the presence of uterine pain and tenderness.

It is not advisable to bathe a newborn or infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the newborn, before feeding may be the best time.

Because the placenta is implanted in the lower uterine segment that does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The nurse then has to assess the client carefully for signs of postpartum hemorrhage.

DIC is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. The presence of petechiae, oozing from injection sites, and hematuria is indicative of the presence of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area.

With a client in shock, the goal is to increase perfusion to the placenta. The initial nursing action would be to turn the mother on her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels.

Chest tube drainage in the first 24 hours after thoracic surgery may total 500 to 1000 mL. Between 100 and 300 mL of drainage may accumulate during the first 2 hours.

After supratentorial surgery, the head of the bed is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This will promote venous return through the jugular veins, which will help prevent increases in intracranial pressure.

One of the complications of cranial surgery is meningitis. Signs of meningeal irritation include nuchal rigidity, which is characterized by a stiff neck and soreness, and is especially noticeable when the neck is flexed. Pupils that are equal and reactive at 4 mm in size are normal. Mild headache relieved by codeine sulfate is an expected finding at this time. Disorientation to date is not of most concern when the client has been hospitalized for cranial surgery.

The normal serum osmolality is 285 to 295 mOsm/kg H2O. A higher value indicates dehydration; a lower value indicates overhydration. After craniotomy, the goal is to keep the serum osmolality on the high side of normal, which would help to control cerebral edema. Because a serum osmolality of 280 mOsm/kg H2O is low, the client is overhydrated and is at risk for cerebral edema. The nurse should report this finding. Each of the other options represents fluid balance measurements that are normal or expected findings.

Codeine sulfate is the narcotic analgesic of choice for clients after craniotomy. It is often combined with a non-narcotic analgesic, such as acetaminophen (Tylenol) for added effect. It does not alter the respiratory rate or mask neurological signs, as other narcotics do. Side effects of codeine sulfate include gastrointestinal upset and constipation. The medication can lead to physical and psychological dependence with prolonged use.

The postcraniotomy client may find that loud noises, such as a loud television, are irritating. It is helpful to the client if the family keeps noise within normal ranges or softer. Seizures are a potential complication that can occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of doses administered. The family should learn seizure precautions and accompany the client while ambulating if dizziness occurs. The suture line is kept dry until sutures are removed to prevent infection.

Dexamethasone is an adrenocorticosteroid administered after craniotomy to control cerebral edema. It is given by IV push, and single doses are administered over a 1-minute period. Dexamethasone doses are changed to the oral route after 24 to 72 hours and are tapered in dose until discontinued.

Sensation is tested by using sharp and dull objects and having the client discriminate between them. The nurse starts at the shoulder level and works downward in a systematic manner to test sensation.

Crutchfield tongs are a type of skeletal traction, which have weights attached to the tongs. The weights exert pulling pressure on the longitudinal axis of the cervical spine and gradually realign the spine. The nurse and other personnel must not remove the weights to administer care. The client with Crutchfield tongs is placed on a Stryker frame or Roto-rest bed. The nurse ensures that weights hang freely, and the amount of weight matches the current order. The nurse also inspects the integrity and position of the ropes and pulleys.

The placenta is implanted low in the uterus in placenta previa, and a vaginal examination could cause the disruption of the placenta and initiate severe hemorrhage.

Adjusting to paralysis is difficult both physically and psychosocially for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client’s feelings while continuing to meet the client’s physical needs and encouraging independence.

The client with a Halo vest may not drive because the device impairs the range of vision. The Halo device alters balance and can cause fatigue because of its weight. The client should clean the skin daily under the vest to protect the skin from ulceration and should use powder or lotions sparingly or not at all. The client should use straws for drinking and have food cut into small pieces to facilitate chewing.

After SCI, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by Hematest positive NGT drainage or stool. This indicates development of an important complication and should be reported immediately. A single episode of diarrhea is not a cause for alarm, although the nurse should continue to watch for a pattern.

The client who has had a SCI experiences significant losses in most areas of daily living. It is important for the nurse to understand that the client may be looking for new areas of control as a result of feelings of helplessness.

The client should use a mirror to inspect the skin twice a day (morning and evening) to assess for redness, edema, and breakdown. To prevent pressure ulcers from developing, the paraplegic client should shift weight in the wheelchair every 2 hours and use a pressure-relief pad. While the client is in bed, the bottom sheet should be free of wrinkles and wetness.

ROM to the hands is helpful to prevent contractures but does not actively strengthen muscle groups needed for self-mobilization with paraplegia. Other activities that are more effective in moving larger muscle groups include push-ups from a prone position, sit-ups from a sitting position, extending the arms while holding weights, and squeezing rubber balls or crumpling newspaper.

The client with SCI is at risk for autonomic dysreflexia if the injury is above the level of T7. It is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. It is very important that the nurse recognize this complication so that quick action may be taken to remove the noxious stimulus.

Episodes of autonomic dysreflexia can be caused by stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. Linens are kept free of wrinkles, and bed clothing is kept loose around the client to prevent mechanical irritation of the skin. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and a Foley catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. A bowel movement every 5 days is too infrequent.

Key nursing actions are (in order of priority) to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. The nurse also can clearly label the client’s chart, identifying the risk for autonomic dysreflexia. The client and family should be taught to recognize, and later manage, the signs and symptoms of this syndrome.

The client with Parkinson’s disease experiences bradykinesia and can be taught to rock back and forth to initiate movement. The client should avoid sitting in soft, deep chairs, because they are difficult to get up from. The client should buy clothes with Velcro fasteners and slide locking buckles to support independence in getting dressed. The client should exercise in the morning when energy levels are highest.

Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain is often characterized as stabbing or is similar to an electric shock. It is accompanied by spasms of facial muscles, which cause twitching of parts of the face or mouth, or closure of the eye.

The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, and drinking. Symptoms also can be triggered by thermal stimuli such as a draft of cold air.

The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as that for the client undergoing craniotomy. This client requires hourly neurological assessment, as well as monitoring of cardiovascular and respiratory status. Suctioning is done very cautiously and only when necessary to avoid increasing the intracranial pressure (ICP).

Bell’s palsy is a one-sided facial paralysis from compression of the facial nerve (CN VII). Facial droop occurs from paralysis of the facial muscles, increased lacrimation, painful sensations in the eye, face, or behind the ear, and speech or chewing difficulties.

Clients with Bell’s palsy should be reassured that they have not experienced a stroke and that symptoms often disappear spontaneously in 3 to 5 weeks. The client is given supportive treatment for symptoms.

Prevention of muscle atrophy with Bell’s palsy is accomplished with the use of facial massage, facial exercises, and electrical stimulation of the nerves. Local application of heat to the face may improve blood flow and provide comfort. Exposure to cold or drafts is avoided.

Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, it has been triggered by vaccination or surgery.

Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, it has been triggered by vaccination or surgery.

To manage constipation effectively, the client should take in a high-fiber diet, bulk formers, and stool softeners. A fluid intake of 2000 mL per day is recommended. The client should initiate the bowel program on an every-other-day basis. This should be done approximately 45 minutes after the largest meal of the day, to use the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. Laxatives and enemas should be avoided whenever possible because they lead to dependence.

Venography is similar to arteriography, except it evaluates the venous system. A radiopaque dye is injected into selected veins to evaluate patency and blood-flow characteristics. Allergies to shellfish or iodine must be noted, because this could mean that the client would be allergic to the contrast dye. The client signs an informed consent because it is an invasive procedure. Peripheral pulses are assessed so comparisons can be made after the procedure. The client is usually given clear liquids for 3 to 4 hours before the procedure to help with dye excretion afterward.

A blackened appearance on an ulcerated area indicates necrosis and developing gangrene, which must be reported to the physician. Pressure dressings or dry sterile dressings will not help the serious circulatory problem presented here. Turning up the heat in the room may be partially helpful, but again will not address the concern addressed in the question.

Raynaud’s phenomenon is a condition in which the small arteries and arterioles constrict in response to various stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, stress, and trauma, or jarring movements of the fingertips.

Raynaud’s phenomenon is a condition in which the small arteries and arterioles constrict in response to various stimuli. Raynaud’s phenomenon is frequently seen associated with collagen disorders such as rheumatoid arthritis, scleroderma, and lupus erythematosus. Other factors that may contribute to the disorder include occupationally related trauma or pressure to the fingertips such as seen in typists, pianists, use of hand held vibrating tools, and exposure to heavy metal.

Intermittent claudication is a classic symptom of peripheral vascular disease, also known by other names, including peripheral arterial disease and chronic arterial insufficiency. It is described as a cramplike pain that occurs with exercise and is relieved by rest.

The classic manifestations of peripheral arterial disease include color changes (pallor, rubor, cyanosis), temperature changes, and trophic changes in the affected extremity. The pedal pulse diminishes and becomes absent as the disease progresses. Progression of pain from intermittent claudication to rest pain indicates a severe degree of occlusion and a critical state of ischemia.

Causes of autonomic dysreflexia include bladder distention, bowel distention from constipation or fecal impaction, and stimulation of the skin from pain, pressure, or changes in temperature. The client and family should learn the triggering factors, methods of preventing them from occurring, and how to manage an episode.

Signs and symptoms of spinal shock include loss of skeletal muscle movement, loss of bowel and bladder tone, and loss of autonomic reflexes below the level of the injury. Sexual function also is lost. The limbs have a flaccid paralysis, and bowel and bladder retention occurs. The client in spinal shock has special needs, and it is important for the nurse to recognize this condition.

Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure (ICP) and trigger bleeding or rupture of the aneurysm.

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