remediation

negative symptoms of schizophrenia

- apathy (lack of emotion) - social withdrawal - poverty of speech or content of speech - poor social skills - anhedonia (inability to feel pleasure) - socially withdrawn

Increased Intracranial Pressure (ICP) stuff

- head of bed elevated 15 to 30 degrees head should be in midline position - turning head is contraindicated

signs of labor

- lightening - return of urinary frequency - backache - stronger Braxton hicks contractions - weight loss of 05. to 1.5 kg (1 to 3 1/2 lbs) - surge of energy - increased vaginal discharge bloody show - cervical ripening - possible rupture of membranes

A client with Cushing syndrome asks why a low-sodium, high-potassium diet has been prescribed. Which response by the nurse is accurate?

"Excessive aldosterone and cortisone cause the retention of sodium and loss of potassium."

The nurse preceptor is monitoring a practical nurse (PN) who is preparing to instill prescribed ophthalmic ointment into the eye of an older client. Which response by the PN indicates safe nursing practice?

"I will gently pull upward on the upper lid to instill the ointment."

The nurse is reviewing discharge teaching instructions with an older client. Which response from the client indicates an understanding of what poses the greatest fall hazard in their home?

"I will have my son install grab bars in the shower." A client who understands the importance of installing grab bars to reduce the risk of falls in the tub or shower has correctly identified the greatest threat for fall injuries in the home. The bathrooms in homes poses the greatest risk for fall occurrences and injuries. Up to 80% of falls occur in the bathroom.

airway stuff

* remember to administer bronchodilator before corticosteroid

Hypercalcemia sign & symptoms

- Anorexia, nausea, vomiting - Behavioral changes, including confusion - Thirst, polyuria* - Renal calculi Decreased deep tendon reflexes • Constipation • Paralytic ileus • Lethargy, coma • Cardiac dysrhythmias, cardiac arrest • Hypertension • Decreased muscle tone* • Decreased GI motility • Bone pain

positive symptoms of schizophrenia

- abnormal thoughts - agitation - bizarre behavior - delusions - excitement - feelings of persecution - grandiosity - hallucinations - hostility - illusions - insomnia - suspiciousness

gross development in the infant progression to walking

- raises head and holds position (age 2wk-2months) - moves all extremities kicking arms and legs when prone (age 2months) - draws up knees and raises abdomen off table rocks back and forth while up on hands and knees rolls over (age 3-6 months) - sits alone using hands for support tripod fashion (age 7 months) - Crawls in one-sided manner (moves arm and leg on same side of body, then other side)6-9 mo - Crawls in regular fashion, alternating arm and opposite leg6-9 mo - begins to pull up (age 11 months) - cruises attempts to walk with support or holding on to something stable (age 12 months) - sits from a standing posture (age 12 months) - walks alone (age 15 months)

According to Bandura's Social Cognitive Theory, which are extrinsic factors that can motivate a client's behaviors?

- rewards - punishment - tradition - reinforcement

calcium sources other than dairy

- sardines - salmon - beans - tofu - cornbread - muffins - French toast - dried figs - orange juice - pesto sauce

Criteria for brain death

-Completion of all appropriate diagnostic and therapeutic procedures with no possibility of brain function recovery - Unresponsive coma (no motor or reflex movements) -No spontaneous respiration (apnea) - No brainstem functions (ocular responses to head turning or caloric stimulation; dilated, fixed pupils; no gag or corneal reflex [see Figures 15-3 and 15-4]) - Isoelectric (flat) EEG (electrocerebral silence) - Persistence of these signs for an appropriate observation period

A client with hypertension has a prescription for 8 mg of candesartan cilexetil PO daily. The medication is available as a 16 mg tablet. How many tablets should the nurse administer? (Enter numeric value only, rounded to the tenth.)

0.5 tablets 8/16=1/2 or 0.5 tablets

Nursing Process

1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation (check to see if desired outcomes and goals were achieved)

Kubler-Ross five stages of grief

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

stages of change

1. Precontemplation 2. Contemplation 3. Preparation 4. Action 5. Maintenance

A male client tells the home health nurse that he takes two tablespoons of a liquid antacid every day. How many mL of medication should the nurse document? (Enter numeric value only.)

30ml 1 tablespoon= 15ml 2 tablespoons= 30ml

The nurse is educating a client about changes that occur during pregnancy. The nurse is correct to tell the client that "lightening" occurs during which period?

38 to 40 weeks Lightening" describes the process during which fundal height decreases as the fetus engages in the pelvis. This typically occurs between 38 and 40 weeks.

peak flow meter

A peak flow meter is a portable, inexpensive, hand-held device used to measure how air flows from your lungs in one "fast blast." In other words, the meter measures your ability to push air out of your lungs. Green zone (good) readings are at least 80% of or above the "personal best." This is the ideal range for asthma control and indicates that no increases in drug therapy are needed. Yellow (okay) is a range between 50% and 80% of personal best. When a patient has a reading in this range, he or she needs to use the prescribed reliever drug. Within a few minutes after using the reliever drug, another PEF reading should be made to determine whether the reliever drug is working. Frequent readings in the yellow zone or increasing use of reliever drugs indicates the need to reassess the asthma plan for the need to change controller drugs. Red (bad) is a range below 50% of the patient's personal best, indicating serious respiratory obstruction.

which client should the nurse assess first?

A) an adult female client recovering from abdominal surgery and complaining that "something ripped" when she turned in bed. B) a young adult client complaining of chest tightness having a breathing treatment the adult female complaining of something ripping in the abdomen. the abdominal wooing might have eviscerated when turning in bed. this is the client that is most acute and must be assessed by the nurse first. the client with the chest tightness is having a breathing treatment which would assist with the chest tightness

The nurse is assessing a client who has been exposed to a noxious gas. The client is coughing up large amounts of mucus and having tearing of the eyes. Which type of immunity is the client experiencing?

Active immunity. results when exposure to a disease organism triggers the immune system to produce antibodies to that disease.

A child recently treated for strep throat presents with gross hematuria, facial swelling, and elevated blood pressure. Laboratory tests reveal proteinuria and azotemia. Which condition should the nurse suspect?

Acute glomerular nephritis. Acute glomerulonephritis (GN) usually manifests after strept throat or other streptococcal infection. Typical signs of acute GN include gross hematuria, facial edema, hypertension, and proteinuria.

What nursing care plan goal should the nurse establish for a client with multiple organ dysfunction syndrome (MODS)?

Adequate tissue oxygenation. Multiple organ dysfunction syndrome (MODS) results from uncontrolled inflammation. The goal for the nurse should be to provide adequate tissue oxygenation.

macular degeneration

Age-related macular degeneration (AMD) is an eye disease that may get worse over time. It's the leading cause of severe, permanent vision loss in people over age 60. It happens when the small central portion of your retina, called the macula, wears down

essential amino acids

Amino acids that are needed, but cannot be made by the body; they must be eatin in foods

Antispasmodic Medications

An antispasmodic is a pharmaceutical drug or other agent that suppresses muscle spasms. Antispasmodic medicines are used to treat symptoms such as tummy pain and cramp (spasm). They are most used for symptoms of irritable bowel syndrome.

A 12-year-old client presents suddenly with signs of shock; weak and rapid pulse; bronchoconstriction and laryngeal edema. What should the nurse suspect is the cause of this presentation?

Anaphylaxis. A sudden sharp decrease in blood pressure (shock) in this client is caused by vascular dilation; weak and rapid pulse; airway obstruction due to bronchoconstriction and laryngeal edema is consistent with anaphylaxis.

The nurse plans to assess function of a client's Cranial Nerve XI, the Spinal Accessory nerve. The nurse instructs the client to shrug both shoulders. What action should the nurse take while the client shrugs the shoulders?

Apply pressure on both shoulders. The nurse assesses Spinal Accessory nerve function by applying pressure while the client shrugs the shoulders. The nurse should check for symmetrical strength as the client shrugs the shoulders against the resistance applied.

preparation stage

At this time the patient has made a decision to change and is assessing how that decision feels. Patients can be helped to select realistic treatment goals and different ways to reach those goals. They need to be actively involved in designing their own strategies for change.

The nurse is teaching the parent of a 14-day-old infant. Which method of obtaining a temperature is best to teach the parent?

Axillary. Axillary temperature is recommended for infants younger than 1 month old.

bandura's theory

Bandura believed that four conditions are necessary for effective modeling of behaviors: • Attention: Certain variables affect how much attention is given to a behavior. Some of these variables are the complexity of the situation and the personal characteristics of the observer of the situation. • Retention: The ability to store the information that was given attention for later recall. Examples of tools used to aid retention are mental coding and symbolic images. Reproduction: The ability to reproduce the behavior at a later time. • Motivation: The reason for imitating the behavior. Tradition, imagined incentives, reinforcement, and punishment are motivators.

An 65-year-old client with terminal emphysema, says to the nurse, "If I quit smoking now and start to exercise regularly, I can beat this disease and live another 10 to 20 years." The nurse should recognize that the client is in which stage of grieving?

Bargaining. The bargaining stage involves the hope that the individual can avoid the finality of their condition; it usually involves the negotiation for an extended life in exchange for a reformed lifestyle.

A nurse notes that a newborn's direct antiglobulin test (DAT) test results is positive. What do these findings indicate?

Blood type incompatibility.

A client has been diagnosed with an ankle sprain. The nurse should anticipate that the client will need which medication?

Naproxen sodium. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen sodium, are recommended for treatment of sprains.

A child is admitted with a diagnosis of suspected acute lymphoblastic leukemia (ALL). Which test is performed to confirm this diagnosis of childhood leukemia?

Bone marrow aspiration. ALL is a form of cancer in which high numbers of abnormal white blood cells are produced. A bone marrow biopsy that reveals primary blast cells is confirmation of a leukemia.

maternity safety alert bone meal

Bone meal, which is sometimes used as a calcium source by pregnant women, is frequently contaminated with lead. Lead freely crosses the placenta; thus regular maternal intake of bone meal may result in high levels of lead in the fetus. Women should ask their provider about which calcium supplements are safe.

A client has recently been admitted for evaluation of sudden onset psychosis. In addition to a medical assessment and serum drug screen, which other tests should the nurse expect the client will undergo to find a cause for this change in mental status?

Brain MRI, PET scan. Magnetic resonance imaging (MRI) of the brain can detect structural abnormalities or changes. A PET scan can measure blood flow and glucose utilization in regions of the brain.

The nurse is counseling a pregnant client who is HIV positive. Which information should the nurse give to the client?

Cesarean delivery is encouraged. The pregnant HIV positive women continue with their medication regime during the pregnancy and C-sections are usually scheduled for the 38th week of pregnancy. Although vaginal deliveries are a possibility for a client with HIV, *cesarean delivery is highly encouraged to prevent transmission to the fetus.

maintenance stage

Change continues, and focus is placed on what the patient needs to do to maintain or consolidate gains. Anticipating potential threats for relapse and developing prevention plans are essential. Any relapses should be seen as part of the change process and not as failure.

coma and respiratory stuff

Children in lighter stages of coma may be able to cough and swallow, but those in deeper states of coma are unable to manage secretions, which tend to pool in the throat and pharynx. Dysfunction of CN IX and X (glossopharyngeal and vagus nerves) places the child at risk of aspiration and cardiac arrest. Therefore, position the child with the head and body to the side to prevent aspiration of secretions, and empty the stomach to reduce the likelihood of vomiting. In infants, the blockage of air passages from secretions can happen in seconds. In addition, upper airway obstruction from laryngospasm is a common complication in comatose children.

A client presents with hearing loss in the right ear. When the nurse performs a Weber test with a tuning fork, the client hears the sound better with the right ear. Which condition would the nurse suspect from these results?

Conduction hearing loss

A young adult client who has no known risk factors for vascular disease asks the nurse, "What they can do to prevent the development of the condition of arteriosclerosis?" Which is the most appropriate answer?

Continue living a healthy life style, but you are not able to stop the progression of this condition. Arteriosclerosis (thickening and the hardening of the artery wall) is part of the natural aging process. It is when the arterial walls naturally thicken or harden over the lifespan of a client as they aged. The client should be encouraged to continue living a healthy life style, in order to prevent the development of atherosclerosis which is the formation of plaque. Atherosclerosis is the leading risk for the development of cardiovascular conditions.

Which should the nurse recognize as a risk factor for the development of osteoporosis?

Decreased sex hormones. Loss of estrogen after menopause in women and reduction of testosterone in men contributes to the development of osteoporosis.

diarrhea

Diarrhea caused by infection is usually called gastroenteritis. Viral gastroenteritis is the major cause of diarrhea in children older than 1 year of age.If not treated, acute diarrhea in infants and children can lead to dehydration, electrolyte imbalance, and hypovolemic shock. Acute diarrhea can be life threatening in infants and small children if gastrointestinal fluid losses are not adequately replaced.

A newly admitted client diagnosed with schizophrenia who is physically healthy believes that they are in the process of dying and their body is actively decaying and falling apart. Which intervention for this client should the nurse implement?

Discuss what they are feeling and acknowledge their fear and anxiety. The nurse should identify and focus on the client's feelings and discuss those and try to divert the client's preoccupation of the delusion.

The nurse applied 6 lpm of oxygen via a non-rebreather mask to a ten-year-old child with a history of asthma in the emergency department and began a nebulizer treatment. The child upon arrival had a respiratory rate of 32 breathes per minute, SpO2 of 86% on room air; substernal and intercostal retractions; and audible expiratory and inspiratory wheezing audible three feet away. After the nebulizer treatment, the nurse noted the audible wheezing had lessen and the lower lobes of the lungs were absent of breath sounds. The nurse should prepare for which intervention next?

Endotracheal intubation. A child with shortness of breath, absent breath sounds, and a sudden rise in respiratory rate is in imminent danger of respiratory failure and the nurse should prepare the client for endotracheal intubation.

A client who is experiencing muscle spasms following a spinal cord injury at the T-5 level has been prescribed baclofen (Gablofen). Which medical condition of the client would the nurse need to monitor closely with the administration of this medication?

Epilepsy. baclofen is a muscle relaxant. This medication can cause seizures. lients with known seizure disorders need to be monitored closely while taking this medication. The nurse should initiate seizure precautions.

The nurse is providing emergency care for an unconscious child who presents with a head injury sustained in a fall. Which is the highest nursing priority?

Establish an airway. Respiratory obstruction can occur in an unconscious client due to the reduced ability to swallow secretions. This may lead to further complications and cardiac arrest. Establishing and maintaining an adequate, patent airway should be the nurse's first priority using the jaw thrust method before implementing the other interventions.

The nurse is working with the medical team to stabilize a client who is in shock. The nurse knows the physician will likely order a fluid challenge. Which action should the nurse take first?

Establish two IV catheters. IV access is needed to provide fluid resuscitation to clients in shock. The nurse's first action is to establish two IV catheters, one in a peripheral vein and one in a central vein.

food sources highest in iron

Food sources highest in iron are liver and beef, dried fruits (such as prunes), legumes, dark green leafy vegetables (which would include spinach), whole-grain and enriched bread and cereals, and beans.

GTPAL

G stands for pregnancies or gravida; T, term births or pregnancies delivered between 38 and 42 weeks of gestation; P, preterm births (births between the 20th and 38th week of gestation); A, abortions; and L, living children

A client is 28 weeks pregnant. Her obstetrical history consists of two spontaneous abortions before 20 weeks; one elective abortion at 10 weeks; one child who was born at 38 weeks and another child born at 27 weeks gestation. The children are now ages 5 and 3 years old. The nurse is using the GTPAL recording system to document obstetric history. How should the nurse document the GTPAL in this client's electronic medical record (EMR)?

G6-T1-P1-A3-L2. The EMR should indicate: G6-T1-P1-A3-L2. G= Gravida number of pregnancies total = 6 (include current pregnancy).T= Term; 1 term infant at 38 weeksP= Premature; 1 premature infant at 27 weeksA= Abortion; 2 spontaneous abortions and 1 elective abortionL=Living; 2 living children

Gablofen (baclofen)

Gablofen (baclofen) is a skeletal muscle relaxant used to treat severe spasticity, a very intense tightness of muscles that may cause pain and uncontrollable spasms of the arms, legs, hands, and feet.

A three-year-old child who is lethargic, vomiting and complaining of abdominal pain is being assessed for acetominophen poisoning. Which medication is used for treatment of acetaminophen poisoning?

N-acetylcysteine. the antidote for acetaminophen (Tylenol) is N-acetylcysteine.

Kawasaki disease (treatment)

IVIG high-dose intravenous immunoglobulin high-dose aspirin

hypertonic solution

If a cell is placed in a hypertonic solution, there will be a net flow of water out of the cell, and the cell will lose volume. A solution will be hypertonic to a cell if its solute concentration is higher than that inside the cell, and the solutes cannot cross the membrane. (cell will shrink)

hypotonic solution

If a cell is placed in a hypotonic solution, there will be a net flow of water intothe cell, and the cell will gain volume. If the solute concentration outside the cell is lower than inside the cell, and the solutes cannot cross the membrane, then that solution is hypotonic to the cell. (cell will swell and burst )

important measuring temp in infants

If an elevated or low oral, axillary, temporal artery, or tympanic temperature reading is obtained, consider measuring the temperature via another route (including the rectal route), if possible. Report a temperature measurement of less than 36° C (96.8° F) or more than 38° C (100.4° F). Such reporting is critical for an infant younger than 3 months of age. *Oral temperature measurement should not be used in any child who has had oral or tonsillar surgery or in whom epiglottitis is suspected (see Chapter 45).

sensorineural hearing loss

If the patient has sensorineural hearing loss, air conduction sound is heard for only slightly longer than bone conduction sound (AC > BC), if sound is heard at all.

precontemplation stage

In this stage people do not think that they have a problem; thus they are not likely to seek help or participate in treatment. In working with these patients the goal is to listen to the patient and create a climate in which the patient may consider, explore, or see value in the benefits of changing.

A client with macular degeneration reports increasing difficulty seeing things. This client is most likely experiencing which type of vision problem?

Increasing loss of central vision. Macular degeneration affects the central area of vision. Age-related macular degeneration affects the macula, a small area at the center of the retina which allows clear, sharp vision.

intotrope medication

Inotropes are a group of drugs that alter the contractility of the heart. Positive inotropes increase the force of contraction of the heart,

A 68-year-old client with type 2 diabetes calls the health clinic with reports of seeing flashing lights and the sensation of a curtain coming down over the right eye. Which is the correct course of action for the nurse to take?

Instruct the client to report to the emergency department immediately. Symptoms of retinal detachment include a gradual increase in the number of floaters and/or light flashes in the eye. It also manifests as a curtain coming down over the person's field of vision. Retinal detachment requires emergency medical treatment to prevent permanent visual loss.

A toddler presents to the clinic with cellutlitis on the sole of the right foot with a history of a laceration from stepping on a broken shell while walking on the beach. Which describes the appearance of cellulitis?

Intense red rash with swelling and poorly defined borders. Cellulitis is inflammation of the skin and subcutaneous tissues, usually caused by streptococcal and staphylococcal infections. It often presents as a poorly defined area of intense redness and swelling.

termination stage

It is based on the notion that one will not engage in the old behavior under any circumstances. As such, it may be more of an ideal than an achievable stage. Most people stay in the stage of maintenance where they are aware of possible threats to their desired change and monitor what they need to do to keep the change in place.

Kawasaki disease, also called mucocutaneous lymph node syndrome,

Kawasaki disease is a major cause of acquired heart disease in children in the United States. Coronary artery aneurysms are seen in 20% to 25% of children with untreated Kawasaki disease.

While assessing a client with long-standing diabetes, the nurse notes consistently elevated blood pressures and bilateral ankle edema. After notifying the health care provider, the nurse anticipates which test will be ordered?

Kidney function. A client with long-standing diabetes is at risk for diabetic nephropathy, or renal damage. Diabetes can lead to microvascular damage in the kidneys, inhibiting the kidneys' ability to regulate fluid volume and blood pressure. Due to signs of fluid volume overload (edema) and increased blood pressure, the nurse should anticipate the need for kidney function tests to evaluate the client's renal status.

Which information is important for the nurse to include when providing discharge teaching to the parents of a child with Kawasaki disease?

Live immunizations should be deferred for 11 months

The nurse organizes and facilitates a smoking cessation support group in the community. Which group characteristic should the nurse focus the most on?

Maintenance functions. Maintenance functions derive from maintenance norms, which is the process of augmenting group acceptance of all members.

A two-month-old infant is brought to the clinic with a temperature of 101° F (38.3° C), flaring of nostrils, respiratory rate of 36 breaths per minute, expiratory wheezing and intercostal retractions. The healthcare provider prescribes a test for respiratory syncytial virus (RSV). The nurse should be prepared to take what samples to test for the RSV antigen?

Nasopharygneal secretions. There are many different types of laboratory tests available for diagnosing the RSV infection. The most common and effective way of diagnosing this virus is by obtaining nasopharygneal secretions and testing for the RSV antigen.

The nurse is caring for a client with gastroesophageal reflux disease (GERD) who has not responded to conventional medical treatments. The nurse should anticipate the need for which surgical intervention?

Nissen fundoplication. A NIssen fundoplication is the definitive surgical treatment for GERD where medical therapy has failed and to acheive a permanent solution to the problem of acid reflux backup into the stomach. During the Nissen fundoplication, the upper part of the stomach is wrapped around the LowerESosphagus to strengthen the sphincter, prevent acid reflux, and repair a hiatal hernia.

The clinic nurse is assessing the blood pressure of a client diagnosed hypertension. How should the nurse assess this client's blood pressure?

Obtain blood pressure readings from both the client's arms. It is best to obtain a blood pressure from both arms of the client and record in the client's electronic medical record documenting the blood pressure reading for each arm.

hearing loss in older adults

Older adults experience an inability to hear high-frequency sounds and consonants (e.g., S, Z, T, and G). Deterioration of the cochlea and thickening of the tympanic membrane cause older adults to gradually lose hearing acuity. They are especially at risk for hearing loss caused by ototoxicity (injury to auditory nerve) resulting from high maintenance doses of antibiotics (e.g., aminoglycosides).

A 10-year-old client with asthma arrives at an urgent care clinic with apparent bronchial constriction. Which class of drugs should the nurse expect to be administered for this condition?

Oral corticosteroids. Corticosteroids are fast-acting anti-inflammatory drugs. They are used to treat reversible airflow obstruction, control symptoms, and reduce bronchial constriction with the fewest side effects.

The parents of a 13-year-old male client are concerned that he may not have started puberty. The client's stage of puberty is assessed using the Tanner scale of development. Which type of test is performed to determine this child's Tanner stage?

Orchidometry. In males, the stages are partly based on testes volume, which is measured with an orchidometer.

Legg-Calve-Perthes Disease sign & symptoms

Pain in the hip or groin, or in other parts of the leg, such as the thigh or knee (called "referred pain."). Pain that worsens with activity and is relieved with rest. Painful muscle spasms that may be caused by irritation around the hip.

pain and ICU prevention in coma patient

Pain management for the unconscious child requires astute nursing observation and management. Responses to pain include motor reactions such as increased agitation or posturing; and alterations in vital signs such as tachycardia, tachypnea, or hypertension. Because these findings may not be specific for pain, the nurse should observe for their appearance during times of induced or suspected pain and their disappearance after the inciting procedure or the administration of analgesia. A pain assessment record should be used to document indications of pain and the effectiveness of interventions (see the " Pain Assessment" section in Chapter 30). The use of opioids such as morphine to relieve pain is controversial because they may mask signs of altered consciousness or depress respirations. However, unrelieved pain activates the stress response, which can elevate ICP. To block the stress response, some authorities advocate the use of analgesics, sedatives, and in some cases paralyzing agents via continuous IV infusion. A frequently used combination is fentanyl, midazolam, and vecuronium (Norcuron). If there are concerns about assessing the LOC or respiratory depression, naloxone (Narcan) can be used to reverse the opioid effects. Regardless of which drugs are used, adequate dosage and regular administration are essential to provide optimal pain relief (see the " Pain Management" section in Chapter 30). Other measures to relieve discomfort include providing a quiet, dimly lit environment; limiting visitors; preventing any sudden, jarring movement such as banging into the bed; and preventing an increase in ICP. The last is most effectively achieved by proper positioning and prevention of straining such as during coughing, vomiting, suctioning, and defecating. Antiepileptic drugs may be ordered for control of seizure activity.

A nurse is preparing a client diagnosed with advanced stomach cancer for tumor removal with surgical stomach resection followed by adjuvant chemotherapy. The nurse should understand the ultimate goal of this plan of care is what?

Palliative. the patient has advanced cancer that means the cancer is in the late stages. so this treatment is palliative meaning to improve the client's quality of life who may be experiencing an obstruction, hemorrhage or pain.

parity

Parity: The number of pregnancies in which the fetus or fetuses have reached 20 weeks of gestation

The community health nurse is assessing an older client and notices that the client walks with short, hesitant steps. The client walks with a slow, shuffling motion and with very little arm movement. At rest, the client has tremors. The nurse also notes that the client speaks in a very soft, low-pitched voice and has difficulty finding the right words. Which condition most likely explains the client's behaviors?

Parkinson's disease. The client is presenting clinical signs of Parkinson's disease. Parkinson's disease is a debilitating neurologic disorder involving the basal ganglia and substantia nigra. Clients with this condition experience depletion of dopamine which causes difficulty with initiation and coordination of voluntary movement. The disease is characterized by muscle rigidity, akinesia, postural instability, tremors, dysarthria, and a mask like facial appearance.

A client is undergoing treatment for schizophrenia. Which outcome provides evidence that the client's negative symptoms are improving?

Participates in music therapy and states that he enjoys playing the drums. An inability to experience pleasure and a desire to remain isolated are examples of negative symptoms exhibited by clients with schizophrenia. By participating in therapy and expressing enjoyment, the client shows a decrease in negative symptoms and evidence that the treatment is being effective.

action stage

Patients now have a firm commitment to change and have identified a plan for the future. They should be offered emotional support and help in evaluating and modifying their plan of action to be successful.

conductive hearing loss

Patients with conductive hearing loss will hear bone conduction sound for longer than, or as long as, air conduction sound (BC ≥ AC).

Which recommendation should the nurse give a school-aged athlete to help decrease the chances of injury?

Perform warm-up exercises. Warm up exercises five to ten minutes will help prepare the body for vigorous activity and reduce the risk of sports-related injuries such as muscle strains.

Presumptive signs of pregnancy

Period absent (amenorrhea) Really tired (fatigue) Enlarged breast Sore breast Urination increased Movement of fetus in uterus...woman perceives fluttering sensation in her lower abdomen (quickening) Quickening can occur at 16 weeks for 2nd time moms and around 20 weeks for 1st time moms Emesis (vomiting) and nausea

postoperative procedures for child with intestinal bleeding

Postoperatively, the child requires IV fluids and an NG tube for decompression and evacuation of gastric secretions.

The nurse is caring for a client who recently had a myocardial infarction. Which is the first action the nurse should take when a client begins exhibiting signs of cardiogenic shock?

Prepare to administer ionotropic agents. Cardiogenic shock occurs when the heart is no longer able to pump effectively, resulting in decreased perfusion. The nurse's first action should be to administer ionotropic agents.

preterm

Preterm: A pregnancy that has reached 20 weeks of gestation but ends before completion of 37 weeks of gestation

The nurse is assigned to provide care to a client with traumatic brain injury following a motor vehicle accident. Treatment has included intravenous fluid of hypertonic saline, a mannitol IV bolus, and a hypothermia blanket. The client hs been placed in a barbiturate coma and has been placed on a mechanical ventilator. What is the goal of these medical interventions?

Prevent increased intracranial pressure.

diarrhea treatment in children

Preventing dehydration is a primary issue in the management of the infant or child with diarrhea. ORS(oral rehydration therapy) is given to replace each loose stool. In addition to continuing an age-appropriate diet, children weighing less than 10 kg should have losses replaced with 60 to 120 mL of ORS for each episode of diarrhea. Children weighing more than 10 kg should receive 120 to 240 mL of ORS (CDC, 2014a). For infants with mild to moderate diarrhea who have not become dehydrated, fluid loss replacement is started at home.

The wound care nurse has documented on a wound that is in the process of healing. The nurse documentation noted the presence of granulation tissue and buds in the wound bed. What phase of healing is this?

Proliferative Phase. A wound that has granulation tissue present in the wound bed and the presence of "buds" which are capillaries from surrounding tissues which will develop into new blood vessels in the wound bed. This proliferative phase of healing begins around the 4th day after the disruption/injury to intact skin.

A middle-aged client who was admitted for a multi-traumatic accident is suspected of developing "Systemic Inflammatory Response" (SIRS). Which set of vital signs would the nurse anticipate the client to display?

RR- 24 breaths/min; HR- 120 beats/minute; and temperature of 100.8 F

Which action should the nurse perform during preoperative management of a child with intestinal bleeding?

Record appearance of blood in stools. Preoperative nursing care of the child with intestinal bleeding includes monitoring for signs and symptoms of severe bleeding, as this increases the risk of surgical complications. Interventions include recording the approximate amount of bleeding occurring, by documenting the appearance of blood in the client's stools. Hematochezia is the medical terminology which is bright red blood noted in the stool and is indicative of bleeding in the lower portion of the GI tract.

In assessing the plantar reflex of an adult, the nurse uses the end of a reflex hammer to lightly stroke up the lateral side of the sole of the foot and then across the ball of the foot. The nurse observes that the client's toes curl downward in response. What should the nurse do next?

Record the normal response of plantar flexion in the record. Plantar flexion, or downward curling of the toes, is the normal response to stimulating the lateral side of the sole of the foot in the adult and should be recorded in the client's healthcare record without further action.

Which assessment data supports a diagnosis of acrophobia?

Refuses to drive or walk across any type of bridge. Acrophobia is defined as the fear of heights

The emergency department nurse triages a twelve-year-old client with a history of a bike accident approximately 2 hours ago. The client is now reporting seeing dark floating spots in the right eye. The nurse notes that the sclera is white and there is bruising and swelling with a small deep jagged laceration on the outer aspect of the right orbital socket. The client is not reporting eye pain or headache. Which condition is consistent with the nurse's assessment?

Retinal detachment.

The nurse is administering IV fluid resuscitation to an elderly client diagnosed with sepsis. The nurse should be alert for which possible complication of this treatment?

Shortness of breath. When administering IV fluid resuscitation to an elderly client, the nurse should monitor for symptoms of fluid overload, which include shortness of breath and respiratory compromise.

While assessing a client's health history, the nurse notes that the client has been prescribed timolol (Timoptic) for open-angle glaucoma. Which health outcome would indicate this medication is effective?

Slowing of the loss of peripheral vision. The glaucoma medication will not reverse or cure the disease, but it will slow any further loss of peripheral vision if administered properly by decreasing the intraocular pressure that was causing loss of peripheral vision.

Miller-Abbott tube

The Miller-Abbott tube is often used in the treatment of intestinal obstruction. Care must be used in irrigating the tube and inattaching it to a suction apparatus because of the possibility of confusing the two lumina. The lumen marked "suction" is usedfor irrigations and suction; the other lumen leads to the small rubber bag intended to hold the tube in place. The introductionof too large an amount of fluid into the bag could lead to rupture of the intestine.

The nurse is developing a nursing care plan (NCP) for a 5-year-old child who is newly diagnosed with Legg-Calve-Perthes disease. Which nursing outcome would be the most appropriate for this client?

The client is smiling while quietly coloring pictures. The initial treatment when diagnosed with Legg-Calve-Perthes disease is rest and non-weight bearing to help reduce inflammation and restore motion of the joint. The nurse's care plan should include interventions such as diversional activities that help encourage the client to rest the joint while helping the client from becoming bored or distraught.

The nurse is caring for a client with multiple organ dysfunction syndrome (MODS). What expected patient outcome should the nurse include in the plan of care?

The client will remain free of infection. Multiple organ dysfunction syndrome (MODS) occurs as a result of uncontrolled inflammation in the body. The nurse should list an expected outcome that the client will remain free of infection.

1st stage of labor

The first stage of labor is considered to last from the onset of regular uterine contractions to full effacement and dilation of the cervix. Commonly the onset of labor is difficult to establish because the woman may be admitted to the labor unit just before birth, and the beginning of labor may be only an estimate. The first stage is much longer than the second and third stages combined. Great variability is the rule, however, depending on the factors discussed previously in this chapter. The first stage of labor has traditionally been divided into three phases: a latent phase, an active phase, and a transition phase. In women who labor with epidural anesthesia, however, a separate transition phase may not always be identified based on maternal physical sensations and behavior (Simpson & O'Brien-Abel, 2014). During the latent phase there is more progress in effacement of the cervix and little increase in descent. During the active and transition phases there is more rapid dilation of the cervix and increased rate of descent of the presenting part.

lightening

The movement (dropping) of the fetus down into the pelvis late in pregnancy.

A client from a nursing home is admitted with diagnoses of diabetes mellitus, chronic pancreatitis and alcoholism. The healthcare provider has prescribed the client pancrelipase (Creon, Pancrease). How should the nurse document the effectiveness of this prescribed medication?

The number, frequency and consistency of stools per day. Pancrelipase is a pancreatic enzyme to aid in the digestion of food due to pancreatic insufficiency from the chronic pancreatitis. To evaluate the effectiveness, the nurse should record the number, frequency and consistency of the client's daily stools. If the medication is being effective the stools should become less frequent and have less steatorrhea.

contemplation stage

This is characterized by the notion of "yes, but." Often patients recognize that a change is needed, but they are unsure and indecisive about whether it is worth the time, effort, and energy to achieve it. They are ambivalent about what they might have to give up if they make a change. In working with these patients, the goal is to create a supportive environment in which the patient can consider changing without feeling pressured to do so. If patients are pushed to change in this phase, they are likely to actively resist.

The nurse is assigned a client who was admitted for a basilar fracture. Which finding is indicative of a complication that should be reported to the healthcare provider immediately?

The presence of new onset of post nasal drip. The presence of post nasal drip needs to be investigated and reported immediately because it could be signs of of cerebral spinal fluid leaking from the nasal cavity and dripping down the back of the client's throat.

the second stage of labor

The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. It is composed of two phases: the latent (passive fetal descent) phase and the active pushing phase. During the latent phase the fetus continues to descend passively through the birth canal and rotate to an anterior position as a result of ongoing uterine contractions. The urge to bear down during this phase is not strong, and some women do not experience it at all. During the active pushing phase the woman has strong urges to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor.

third stage of labor

The third stage of labor lasts from the birth of the fetus until the placenta is delivered. The placenta normally separates with the third or fourth strong uterine contraction after the infant has been born.

passive immunity

is provided when a person is given antibodies to a disease rather than producing them through his or her own immune system. A newborn baby acquires passive immunity from its mother through the placenta.

A six-year-old client, who received a kidney transplant presents with signs including fever, decreased urine output, and tenderness over the transplanted organ. Laboratory results reveal an elevated serum creatinine level. This presentation is likely due to which cause?

Transplant rejection. Transplant rejection is caused by the recipient's immune system response to foreign tissue. Signs that may alert the nurse to rejection of a kidney transplant include fever, tenderness over the graft area, decreased urine output, and elevated serum creatinine.

Intraosseous Access

Use an IO access device for emergency resuscitation when IV access cannot be obtained. Insertion sites include sternum, proximal and distal tibia, and proximal and distal humerus. • Remove IO devices within 24 hours of insertion or as soon as possible after peripheral or central IV access is obtained. • Monitor for complications: extravasation of drugs and fluids into the soft tissue, fractures caused during insertion, and osteomyelitis.

Which assessment finding is considered a positive sign of pregnancy?

Visualization of the fetus on ultrasound. Positive signs are those which can only be linked to the presence of a fetus; these include visualization of the fetus on ultrasound.

preoperative procedures for child with intestinal bleeding

When intestinal bleeding is present, specific preoperative considerations include frequent monitoring of vital signs including blood pressure, keeping the child on bed rest, and recording the approximate amount of blood lost in stools.

written learning materials

When writing teaching materials, use several techniques to keep the reading level at a fifth-grade level. These include the following: (1) place key information first using bold or italics; (2) use short, common words of one or two syllables; (3) define medical words in simple language if used; (4) keep sentences under 10 words if possible, and 15 at the most; (5) use pictures or drawings; and (6) use an active voice in the manner you would normally say something

nonessential amino acids

amino acids that the body can synthesize

anosognosia

anosognosia (the inability of a person to recognize that he or she has an illness because of the illness itself).

The nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes that the client has thin, shiny skin; decreased hair growth; and thickened toenails. Which condition might this indicate?

arterial insufficiency

a group of college students bring a young adult female to the ER because the client is breathing funny after drinking heavily at a party. what should the nurse do first?

ask client to state name and date of birth the nurse should follow the ABC framework. the nurse's number one priority is to assess for a compromised airway. this involves having the client talk (stating name and date of brith) observe for stridor, snoring or increased salivation assessing gag reflex and performing quick level of consciousness assessment

Macronutrients

carbohydrates, proteins, and fats

The nurse is assessing an elderly client who reports that it is becoming increasingly difficult to drive at nighttime because the headlights of the on-coming cars cause blurriness and create a glare making it difficult to see the road. The client's symptoms are most likely due to which condition?

cataracts Cataracts is the loss of the transparency of the lens causing blurriness, sensitivity to glare and decrease of vision as the plaque builds up in the lens. Cataracts formation begins in the 4th decade of life, but generally causes disruption of functionality in a client's mid-60s.

The nurse is assessing a client that is experiencing indigestion and vague abdominal pain that radiates to the right shoulder, increase passing of gas, burping and nausea whenever they eat greasy fried food. The client has clay-colored stool, urine that appears dark colored and foamy. Based on the clients presenting signs and symptoms which condition is this client most likely to be diagnosed?

cholecystitis The obstructed duct causes the entrapment of the bile which in turn causes inflammation of the gallbladder. The entrapped bile then causes the client's stool to be clay-colored due to lack of bile and their urine becomes dark and foamy as the kidneys attempt to excrete the excess circulating bilirubin out through the urine. The gastric symptoms of flatulence, dyspepsia, eructation and abdominal pain that radiates to the (R) shoulder occur whenever fatty or large volume of food is ingested.

Screening for large bowel abnormalities is accomplished with which procedure?

colonoscopy is a procedure that allows the healthcare provider to view the entire length of the large intestine (colon). It can often help identify abnormal growths, inflamed tissue, ulcers, and bleeding. It involves inserting a colonoscope, a long, flexible, lighted tube, in through the rectum up into the colon.

shock albumin use

don't use in cardiogenic and neurogenic shock

agrophobia

fear of heights

The nurse is caring the pregnant client who is lactose intolerant. Which food should the nurse recommend to ensure that the client receives sufficient amounts of calcium?

figs Pregnant women who are lactose intolerant need to consume sufficient amounts of calcium from non-dairy sources. Recommended non-dairy sources of dietary calcium include low-mercury fish, greens, beans, and certain fruits, such as figs.

The nurse is interviewing a client who has recently been admitted for evaluation of a thought disorder manifested by paranoid behavior. According to the client's mother, the client was previously treated for anxiety, but has become more isolated and withdrawn over the last few weeks. He refuses to leave his room, and he states that he is the "King of Mars" and someone is trying to assassinate him. Which type of delusion should the nurse document?

grandiose Individuals may suffer from several different types of delusions. In this example, the client is experiencing grandiose delusions (irrational ideas regarding his self-worth and identity), as well as persecutory delusions (thoughts of being persecuted or treated malevolently).

The nurse is providing nutritional counseling to a pregnant adolescent client who needs to increase her fiber intake. Learning has occurred if the client identifies which type of food as a good source of fiber?

green leafy vegetables Constipation is a common discomfort of pregnancy and a diet of fiber should help alleviate that problem. Green leafy vegetables are also a good source of vitamin A and C.

A 10-year-old child has undergone a cardiac catheterization through the left femoral artery. During a postprocedural assessment, the nurse finds the left foot is pulseless and cool to touch. Which is the likely cause?

hematoma

compartment syndrome stuff

if compartment syndrome develops interventions such as splitting a tight fitting cast should be immediately implemented to receive pressure

a middle aged male with a body mass index of 35 (obese) is complaining of morning fatigue and an increase in body aches and pains. the client is coughing and has a respiratory rate of 22. what will the nurse assess first during the health history?

if the client snores when asleep the cline tis

The nurse is caring for a client who takes metoprolol. The nurse should monitor the client for which side effect?

low heart rate Metoprolol belongs to a class of antihypertensive medications known as beta blockers, which lower heart rate and blood pressure. Use of beta blockers can cause an abnormally low heart rate.

The nurse is providing care to an older client with early stages of diabetic retinopathy. Which recommendation should the nurse provide the client to help minimize worsening of the disease?

maintain your blood glucose in your target range. Diabetic retinopathy is a condition in which the blood vessels of the retina become damaged; this condition results from elevated blood glucose levels in clients with diabetes. Strict control of blood glucose, cholesterol, and blood pressure, along with completion of annual dilated retinal examinations, is essential.

Amyotrophic leteral sclerosis (ALS)

nerves continue to break down When the motor neurons die, the ability of the brain to initiate and control muscle movement is lost. With voluntary muscle action progressively affected, people may lose the ability to speak, eat, move and breathe. The typical symptoms of ALS are limb weakness, dysarthria, and dysphagia. Muscle wasting and fasciculations result from the denervation of the muscles and lack of stimulation and use. Other symptoms include pain, sleep disorders, spasticity, drooling, emotional lability, depression, constipation, and esophageal reflux.[26] Death usually results from respiratory tract infection secondary to compromised respiratory function. Unfortunately, there is no cure for ALS. Riluzole (Rilutek) slows the progression of ALS. This drug works to decrease the amount of glutamate (an excitatory neurotransmitter) in the brain.

incomplete (or low-quality) proteins

plant source of protein

The nurse is caring for a child who has just recovered from a transient period of low cardiac output. Which complication should the nurse be vigilant in assessing for in this client?

renal failure if the kidneys do not receive enough blood this can lead to kidney failure. Renal failure is a potential complication when a child suffers from a transient period of low cardiac output. The nurse should carefully measure and document intake and output.

A 78-year-old client's wife reports that her huband is having difficulty hearing. Which hearing test should the nurse perform to compare bone conduction with air conduction?

rinne The Rinne test is done with the use of a tuning fork and compares the length of time sound is heard by bone conduction versus air conduction. Air-conducted sound should be heard twice as long as bone-conducted sound.

The nurse is caring for an older client who has been diagnosed with age-related macular degeneration. Which risk factor doubles the client's risk for macular degeneration?

smoking Smoking doubles a person's risk of AMD.

The nurse is admitting and preparing a ten-year-old for an appendectomy. Appendicitis may result when the lumen of the appendix becomes obstructed by what type of foreign matter?

stool Appendicitis may result when the lumen of the appendix becomes obstructed by foreign matter, usually hardened fecal (stool) material. Appendicitis can also be caused by an infection in another part of the abdomen.

An older client reports to the nurse that she "leaks a little bit of urine" whenever she lifts a heavy object, laughs, or coughs. What type of urinary incontinence best describes this client's symptoms?

stress Stress incontinence is leakage of urine during circumstances such as exercise, lifting heavy objects, laughing, coughing, or sneezing. This problem is most commonly observed in women. The amount of urine lost is generally small.

The nurse is caring for a client who takes carbidopa/levodopa for treatment of Parkinson's symptoms. What side effect of this medication should the nurse be aware of when helping the client ambulate?

syncope Carbidopa/levodopa (Sinemet) is a baseline medication used to treat clients with Parkinson's disease. Clients who take Sinemet may experience syncope, so the nurse should be aware of an increased risk of falling.

statin and liver disease

they are contraindicated in patients with liver disease or during pregnancy. tatins also have the potential for interactions with other drugs, such as warfarin, cyclosporine, and selected antibiotics. Statins are discontinued if the patient has muscle cramping or elevated liver enzyme levels.

digital (hands) removal of stool

this is the last resort in treatment of severe constipation. HCP order is required for a nurse to perform this. Excess rectal manipulation can cause irritation to the mucosa, bleeding, and *stimulation of the vagus nerve, which results in a reflex slowing of the heart rate. Stop the procedure if the heart rate drops significantly or the rhythm changes.

A client is admitted with coffee ground emesis. This symptom is indicative of which diagnosis?

upper GI bleed Stomach enzymes breaks down any blood from an upper GI bleed, which leads the vomitus to appear as dark coffee ground emesis. Coffee ground emesis is a clinical sign of an upper GI bleed.

A female client requests an examination after her partner has been diagnosed with gonorrhea. Which test should be performed on the client?

urine testing Gonorrhea may be diagnosed by collecting a urine sample and testing for the presence of the Neisseria gonorrhoeae bacteria.

Asthma NSAIDs and beta blockers

use caution with giving NSAIDs/beta blockers to people with asthma they can trigger asthma attack

Which assessment finding indicates a client is progressing into stage II of shock?

"Bowel sounds are diminished." During this stage, the client's bowel sounds may diminish.

The nurse is caring for a client who has a fiberglass long leg cast on the right leg. Which nursing actions should be implemented in the cast care of this client?

- Smelling the cast and feeling for the presence of hot spots on the cast. - Checking neurovascular status of the right exposed foot and toes every four hours. - Placing the nurse's finger in the client's cast while performing cast care. - Covering the perineal area of the cast with plastic before client uses the fracture bedpan.

negative symptoms of Schizophrenia

- alogia (lack of speech) - anergia (lack of energy) - asocial behavior - avolition ( lack of motivation) - blunted effect (difficulty expressing emotions) - communication difficulty - passive social withdrawal - poor grooming and hygiene - poor relationships

complete (or high-quality) proteins

Animal sources (red meat, eggs, milk and milk products, poultry, fish)

Bronchiectasis

Bronchiectasis is a condition where the bronchial tubes of your lungs are permanently damaged, widened, and thickened. These damaged air passages allow bacteria and mucus to build up and pool in your lungs. This results in frequent infections and blockages of the airways.

A child with cystic fibrosis (CF) is experiencing recurrent lung infections. Which lung condition is this client likely to develop?

Bronchiectasis. Recurrent lung infections may cause permanent damage to the small airways (bronchial tubes). Clients with CF typically develop bronchiectasis, a condition marked by permanent thickening and widening of the bronchi.

bloody show

Brownish or blood-tinged cervical mucus (bloody show)

gavage feeding

If gavage (orogastric or nasogastric) feedings are ordered, placement is verified prior to the start of the feeding. Determine and document the pH and color of the aspirate before each feeding to confirm tube placement. The pH results need to match the stomach pH results according to the test strip manufacturer. These feedings may be done by gravity bolus feed or via pump, as with G-button feedings. The head of the bed (HOB) should be elevated unless contraindicated. Position the child onto the right side following the feeding as with G-button feeds. Intake is recorded upon completion of the feeding as well as the time of the feeding, type of formula, any residual, and how the feeding was tolerated.

diet needed to heal wounds

In addition to local wound care, the client must be provided with a diet that is high in protein, fat, carbohydrates, vitamins, and minerals to facilitate healing. Regardless of the client's actual body weight (e.g., obesity), healing a wound is not the time to begin a weight-loss diet. The wound must be healed first.

Legg-Calve-Perthes Disease

Legg-Calve-Perthes disease is a childhood condition that occurs when blood supply to the ball part (femoral head) of the hip joint is temporarily interrupted and the bone begins to die. This weakened bone gradually breaks apart and can lose its round shape. The body eventually restores blood supply to the ball, and the ball heals. But if the ball is no longer round after it heals, it can cause pain and stiffness

Which instruction should the nurse include in the parents' discharge teaching plan for a three-year-old child with diarrhea?

Monitor for absence of tears when crying. The parents should be taught to monitor for absence of tears when crying and dry, sticky mucous membranes may be a sign of dehydration related to the vomiting and diarrhea

lactose intolerance

People with lactose intolerance are unable to fully digest the sugar (lactose) in milk. As a result, they have diarrhea, gas and bloating after eating or drinking dairyproducts.

* if someone with asthma stops wheezing its not a good thing this means they have an airway obstruction

Status Asthmaticus. Status asthmaticus is a severe, life-threatening acute episode of airway obstruction that intensifies once it begins and often does not respond to usual therapy. The patient arrives in the emergency department with extremely labored breathing and wheezing. Use of accessory muscles for breathing and distention of neck veins are observed. If the condition is not reversed, the patient may develop pneumothorax and cardiac or respiratory arrest. IV fluids, potent systemic bronchodilators, steroids, epinephrine, and oxygen are given immediately to reverse the condition. Prepare for emergency intubation. *Sudden absence of wheezing indicates complete airway obstruction and requires a tracheotomy. When breathing improves, management is similar to that for any patient with asthma.

A 5-year-old cries and screams continuously from the time their mother drops them off at kindergarten until she picks him up 4 hours later. He is calm and relaxed when he is with his mother. The mother seeks advice from a friend who is a nurse. Which response by the nurse is best?

Talk with your healthcare provider about referring him to a mental health clinic." Professional help is needed to learn how to cope with anxiety effectively.

rinne test

The Rinne test compares bone and air conduction. It is carried out by gently placing the base of a vibrating tuning fork against the mastoid process behind the ear. The nurse asks the patient to indicate when sound is no longer audible. After the patient has indicated that sound is no longer audible, the tines of the tuning fork are placed in front of the external auditory canal and the patient is again asked to indicate when sound is no longer heard (Figure 20-17). The length of time sound was heard by bone conduction (BC) versus air conduction (AC) is determined. Air-conducted sound should be heard twice as long as bone-conducted sound. Patients with conductive hearing loss will hear bone conduction sound for longer than, or as long as, air conduction sound (BC ≥ AC). If the patient has sensorineural hearing loss, air conduction sound is heard for only slightly longer than bone conduction sound (AC > BC), if sound is heard at all.

fourth stage of labor

The fourth stage of labor begins with the delivery of the placenta and includes at least the first 2 hours after birth. During this stage the woman begins to recover physically from birth, so it is an important time to observe for complications, such as abnormal bleeding

water intoxication

Water Intoxication Water intoxication, or water overload, is observed less often than dehydration. However, it is important that nurses and others who care for children be alert to this possibility in certain situations. Children who ingest excessive amounts of electrolyte-free water develop a concurrent decrease in serum sodium accompanied by central nervous system (CNS) symptoms. There is a large urinary output, and because water moves into the brain more rapidly than sodium moves out, the child may also exhibit irritability, somnolence, headache, vomiting, diarrhea, or generalized seizures. The affected child usually appears well hydrated but may be edematous or even dehydrated. Fluid intoxication can occur during acute intravenous (IV) fluid replacement, too rapid dialysis, tap water enemas, feeding of incorrectly mixed formula, or excess water ingestion (Greenbaum, 2016). Patients with CNS infections occasionally retain excessive amounts of water. Administration of inappropriate hypotonic solutions (e.g., 0.45% sodium chloride) may cause a rapid reduction in sodium and result in symptoms of water overload. Infants are especially vulnerable to fluid overload. Their thirst mechanism is not well developed; therefore, they are unable to "turn off" fluid intake appropriately. A decreased glomerular filtration rate does not allow for repeated excretion of a water load, and antidiuretic hormone levels may not be maximally reduced. Consequently, infants are unable to excrete a water overload effectively. Administration of inappropriately prepared formula is one of the more common causes of water intoxication in infants (Greenbaum, 2016). Families who cannot afford to buy enough formula may dilute the formula to increase the volume or even substitute water for the formula. A family may run out of formula and dilute the remaining amount to make it last until they are able to purchase more. In addition, water is sometimes used for pacification. Water intoxication can also occur in infants who receive overly vigorous hydration during a febrile illness. A number of clinicians have reported water intoxication in children after swimming lessons, in water births, and with excessive enema administration. Although they hold their breath while swimming, some children apparently swallow a large amount of water during repeated submersion. Anticipatory guidance to parents should include a discussion of swimming instruction and advice to stop a lesson if the child swallows unusual amounts of water or exhibits any symptoms of hyponatremia

Bandura's theory

believed that people learn from one another through their interactions, observations, and imitation of others. He theorized that there is a continuous interaction of cognitive, environmental, and behavioral influences. Bandura believed that four conditions are necessary for effective modeling of behaviors:

The nurse is reviewing labs for a client who is taking clozapine, 25mg QD for treatment of disorganized schizophrenia. The labs are documented as follows: RBC 4.5 million/mcL, WBC 1000/mcL, TSH 1.2 mc-IU. Based on these results, which order should the nurse anticipate the health care provider to write?

discontinue clozapine *Agranulocytosis is an adverse side effect of clozapine that can cause lethal infections. Based on the client's results, clozapine should be discontinued; the thyroid and RBC results are normal and do not need to be treated.

an adolescent client newly diagnosed with type 1 diabetes mellitus. the nurse provides the client with the prescribed morning dose of insulin aspart (Novolog). immediately after eating breakfast the client vomits and is refusing to take any oral fluids. what action should the nurse take?

obtain an order for an call dose of D50W since the client vomited right after eating he is at risk for hypoglycemia. since he is refusing an oral fluids an order for D50W should be ordered

The nurse is caring for a 2-week-old infant, who was just diagnosed with developmental dysplasia of the hip (DDH). Which treatment should the nurse expect to be implemented for this client?

pavlik harness The preferred treatment for infants involves splinting with a Pavlik harness, to align the hip joint with the proximal femur centered in the acetabulum in the flexed position.

A 12-year-old athlete reports severe ankle pain and an audible "popping" sound in the ankle after a fall at soccer practice. The nurse upon inspection observes moderate swelling, bruising, and joint instability. Initial radiographs of the ankle appear normal. Which type of injury should the nurse suspect?

sprain The ankle is a common site for sprain injuries. Ankle sprains can range from mild (grade 1) to severe (grade 3), with complete tearing of a ligament in the most severe sprains. A "popping" sound is likely an indication of a partial or complete ligament tear; joint instability may be detected at the end-ranges of passive motion.

Legg-Calve-Perthes Disease stages

stage 1 initial necrosis: the blood supply to the femoral head is disrupted and bone cells die. The area becomes intensely inflamed and irritated and your child may begin to show signs of the disease, such as a limp or different way of walking. stage 2 fragmentation: Over a period of 1 to 2 years, the body removes the dead bone beneath the articular cartilage and quickly replaces it with an initial, softer bone ("woven bone"). It is during this phase that the bone is in a weaker state and the head of the femur is more likely to collapse into a flatter position. stage 3 reossification: New, stronger bone develops and begins to take shape in the head of the femur. The reossification stage is often the longest stage of the disease and can last a few years. stage 4 healed: In this stage, the bone regrowth is complete and the femoral head has reached its final shape. How close the shape is to round will depend on several factors, including the extent of damage that took place during the fragmentation phase, as well as the child's age at the onset of disease,