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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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