Medical Surgical NCLEX REVIEW

control (delusion)

"dont drink the tap water. that's how the government controls us"

grandeur (delusion)

"i need to get to Washington for my meeting with the president"

nihilistic (delusion)

"it doesnt matter if i take my medicine. im already dead"

superior vena cava syndrome

1. facial edema & plethora 2. tumor obstructing SVC 3. venous distension distal to obstruction Superior vena cava (SVC) syndrome (eg, dyspnea, facial and upper body edema, engorged upper body blood vessels) is an oncologic emergency caused by SVC compression (eg, tumors). Radiation or chemotherapy may relieve SVC compression.

5 year old pulse rate

70-120/min averages 100/min

mechanical ventilator alarms (eg, high or low pressure limit)

Mechanical ventilator alarms (eg, high- or low-pressure limit) alert the nurse to potential problems caused by a change in the client's condition, a problem with the artificial airway (eg, endotracheal or tracheostomy tube), and/or a problem with the ventilator. Any condition that abnormally decreases resistance in the tubing or airway can trigger the low-pressure limit alarm. When this alarm sounds, the nurse should assess for conditions that decrease airway resistance, causing air to flow freely without the expected resistance caused by physiologic lung compliance, such as: Loss of airway: Intentional or accidental removal of endotracheal tube (Option 1) Tubing disconnection: Disconnection of tubing at either client-end or ventilator-end of circuit (Option 5) Cuff leak in artificial airway: Deflation or displacement of the endotracheal or tracheostomy tube cuff (Option 3) (Options 2 and 4) Any condition that increases resistance can trigger the ventilator high-pressure limit alarm (eg, bronchospasm, secretions, pneumothorax, kinked tubing, coughing or gagging). Educational objective: When the mechanical ventilator low-pressure limit alarm sounds, the nurse should assess for conditions that decrease resistance in the airway or tubing (eg, loss of airway, tubing disconnection, cuff leak in artificial airway).

oculomotor III

Motor assessment: pupil constriction & extraocular movements

central venous pressure (CVP)

Normal value: 2-8 mmHg -elevation indicates increased systemic circulation volume and increased right ventricular preload

pacemaker

Pacemakers are implanted in clients with bradycardia, heart block, or cardiomyopathy. Most pacemakers are demand pacemakers, which sense the intrinsic electrical activity of the heart and fire only when the client's heart rate falls below the set rate of the pacemaker.

pyloric stenosis

Projectile vomiting that occurs after feeding is a sign of pyloric stenosis or obstruction. This client could be dehydrated but would not be a priority over a client with an airway obstruction.

scope of practice

RN 1. clinical assessment 2. initial client education 3. discharge education 4. clinical judgment 5. initiating blood transfusion LPN/LVN 1. monitoring RN findings 2. reinforcing education 3. routine procedures (eg, catheterization) 4. most medican administrations 5. ostomy care 6. tube patency & enteral feeding 7. specific assessments (limited assessments (eg, lung sounds, bowel sounds, neurovascular checks) UAP 1. activities of daily living 2. hygiene 3. linen change 4. routine, stable vital signs 5. documenting input/output 6. positioning

resilient people

Resilient people readily deal with the stress they face by using interventions such as deep breathing, meditation, thought interruption, and muscle relaxation. (Option 1) Stress and the anxiety it can cause are unavoidable; taking steps to manage the physical and emotional responses to stress encourages and supports an individual's resilience. (Option 2) Identifying one's anxiety triggers is helpful, but the individual must take action to deal with both the origin and response to the stress. (Option 4) Although anxiolytic therapy may be necessary to manage anxiety, resilience centers on the adaptive techniques an individual uses to address the resulting symptoms. Educational objective: Resilience plays a primary role in an individual's ability to prevent and recover from mental illness and to manage daily stressors. Resilience is strengthened by the practice of appropriate coping skills.

olfactory I

Sensory assessment: smell test

optic II

Sensory assessment: visual acuity & visual fields

albuterol (Ventolin)

a bronchodilator beta-adrenergic agonist expected side effects -tremor -tachycardia -palpitation

post mastectomy

after a mastectomy, tingling, numbness and itching are common at the incision site

rubeola (measles)

airborne precautions PPE: -N95 particle respirator -As needed for procedures with risk of splash or body fluid contact: Nitrile gloves, disposable gown, goggles/shield Rooms: -Negative air pressurization -High-efficiency particulate air filters

streptomycin

an aminoglycoside ABX difficulty hearing (tinnitus, subjective hearing loss) is an adverse reaction to streptomycin streptomycin, is a second-line drug sometimes used to treat multi-drug resistant TB with ototoxic and nephrotoxic adverse effects

atropine

an anticholinergic agent used to treat bradycardia

acetaminophen

analgesic and antipyretic that reduces fever and pain

yeast infection

antibiotics disrupt normal vaginal flora and may precipitate the development of yeast infection, which presents with vaginal discharge and itching

influenza

droplet precautions

glasgow coma scale of 12

indicates impairment requiring further care normal is 15

COPD

is a respiratory illness in which excess mucus, inflamed bronchioles, and easily collapsible airways trap air within the alveoli oral corticosteroids (eg, prednisone) may be used to reduce airway inflammation and improve ventilation in clients with acute COPD exacerbation

advance directive

makes clear a client's health care wishes (eg, do not resuscitate)

primrose

may be used for eczema or skin irritations

mydriasis

pupil dilation

national association for children of alcoholics (NACOA)

raises public awareness of alcoholism and its effects through leadership in public policy, advocacy for prevention services, and online resources.

maintenance

the client continues to uphold the new behavior and focuses on preventing relapse

somatic (delusion)

"the doctor said im fine, but i really have lung cancer"

ACE inhibitors (renal impairment)

(eg lisinopril, enalapril, ramipril) should be adjusted for clients with renal impairment a serum creatinine of 2.5 mg/dL indicates renal impairment (normal 0.6 - 1.3 mg/dL) the nurse should notify the HCP so that the dosage can be decreased or held hyperkalemia and hypotension are contraindications for giving ACE inhibitors evaluation of kidney function is essential for clients taking medications that are excreted renally or can worsen renal injury these include ACE inhibitors, aminoglycosides (eg, gentamicin) and digoxin

patent ductus arterious

a murmur is expected in a client with a patent ductus arteriosus it is best heard at the left infraclavicular area and has a continuous "machinery" quality

pruritus

aka itching is a known side effect of narcotic admin, particularly if the client is opioid naive it does not represent true allergy and is often treated with antihistamine nausea is also quite common when opioid therapy is initiated but clients quickly develop tolerance

pre-surgery

all clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems all clients should try not to smoke for at least 24 hours before surgery to help prevent oxygenation problems NSAIDs such as naproxen (naprosyn) should be discontinued 7 days before scheduled surgery as they can increase the risk for excessive bleeding acetaminophen can be taken to control pain up until surgery

removing PPE

1. gloves 2. goggles or face shield 3. gown 4. mask or respirator

normal serum sodium (children)

138-145

respiratory acidosis

any condition that causes a decrease in respiratory rate or tidal volume (eg, COPD, chest trauma, over-sedation, sleep apnea) increases the risk of developing resp acidosis breathing is shallow due to pain, impairing gas exchange and leading to buildup of acidic carbon dioxide in the blood

auditory hallucinations

are the most common form of hallucination, noted by falsely perceived sounds, most often in the form of voices

vitamin D deficiency

causes osteomalacia but not peripheral neuropathy

pertussis (whooping cough)

droplet precautions

femoral-popliteal angioplasty

is a surgical procedure to restore perfusion to the legs of clients with peripheral arterial disease after the procedure the client should be able to ambulate without evidence of extremity ischemia (eg, leg pain) should be able to ambulate without leg pain

autonomic dysfunction

is common in GBS and usually results in orthostatic hypotension, paralytic ileus, urinary retention and diaphoresis these complications need to be assessed

capillary refill time

is indicated to assess poor perfusion states, and a value of >3 seconds (delayed refill time) is seen in conditions such as dehydration, shock, and peripheral vascular disease

Alateen

part of Al-Anon; provides support to adolescent children of alcoholics (Option 3).

hydromorphone (dilaudid)

potent narcotic hypotension & bradycardia are expected adverse effects orthostatic hypotension occurs most often with ambulation or positioning in the semi-fowler's position clients are not ordinarily allowed to be ambulatory for 20-30 minutes after IVP administration of narcotics

adult children of alcoholics (ACOA)

provides assistance to adults who grew up in homes that were dysfunctional due to alcoholism.

alcoholics anonymous (AA)

provides help and support to individuals who want to stop drinking. AA uses a 12-step approach that provides guidelines on attaining and maintaining sobriety.

vagus X

sensory and motor assessment: say "ah" - uvular and palate movement

TPN

should never be discontinued abruptly (due to the risk for hypoglycemia)

methylpredisolone (Solu-medrol)

the nurse should monitor blood glucose level because the client was prescribed the corticosteroid methylprednisolone (solu-medrol) which can cause hyperglycemia, esp in clients with diabetes mellitus

catatonia

unable to move

morphine

undiluted morphine IV push should be administered slowly over 4-5 minutes; rapid infusion increases the risk of opioid-induced adverse reactions (eg, hypotension, flushing)

CN III compression

unilateral dilated pupils

filter needle

use a filter needle when withdrawing medication from a glass ampule to prevent aspiration and injection of glass after the medication is withdrawn, the filter needle can be discarded and an injection needle can be attached (eg, 20 gauge, 1 inch (2.5 cm) needle)

lateral violence (horizontal violence)

can be defined as acts of aggression carried out by a co-worker against another co-worker and designed to control, diminish, or devalue a colleague these behaviors usually take the form of verbal abuse such as name-calling, unwarranted criticism, intimidation, and blaming however, other acts, such as refusing to help someone, sabotage, exclusion and unfair assignments also fall under the category of lateral violence violence in the workplace should not be tolerated or ignored by either staff or management. actions that staff members can take if they become victims of lateral violence include: 1. documenting and keeping a file of all incidents 2. reporting the incidents to the immediate supervisor 3. letting the bully know that the behavior will not be tolerated 4. observing interactions between the bully and other colleagues (may validate the victim's experiences and serve as a source of support) 5. seek support from within the facility or from an external source the chain of command should be followed when reporting incidents of lateral violence. if the immediate supervisor takes no action, the employee can move up the chain lateral violence in the workplace (acts of aggression by an employee toward aother employee) should not be tolerated or ignored victims can take action against bullying, including documenting and reporting incidents, standing up to the bully in a professional way and seeking support

signs of increased ICP

-wide, bulging fontanelle -prominent scalp veins -increased head circumference -sunset eyes

weather-related emergency (home care visits)

1. high priority: unstable clients who need care and are at risk for hospitalization if not seen 2. moderate priority: clients who are moderately stable and will suffer no harm if a visit is postponed; telephonic care management can be provided to these clients 3. low priority: clients who are stable and can engage in self-care and/or have a caregiver who can provide or assist with care

behavioral interventions

1. oral care: use small, soft bristled toothbrush or a warm mouth wash 2. use lukewarm water; avoid beverages or food that are too hot or cold 3. room should be kept at an even and moderate temperature 4. avoid rubbing or facial massage. use cotton pads to wash the face if necessary 5. have a soft diet with high calorie content; avoid foods that are difficult to chew. chew on the unaffected side of the mouth

circumstances in which minors can provide their own consent

Emancipated minor: 1. homeless 2. parent 3. married 4. military service 5. financially independent 6. high school graduate Medically emancipated minor: 1. emergency care 2. sexually transmitted infection 3. substance abuse (most states) 4. pregnancy care (most states) 5. contraception

hydroxyzine (atarax)

Hydroxyzine (Atarax) is a commonly used, first-generation antihistamine similar to diphenhydramine (Benadryl) and chlorpheniramine. Anticholinergic side effects (eg, urinary retention, dry mouth, constipation, blurred vision) are common. This client needs to be called second.

Noninvasive positive airway pressure ventilation (NIPPV)

NIPPV is often prescribed short-term to support gas exchange in clients who have moderate to severe COPD exacerbations and acidosis (pH <7.3) or hypercapnia (PaCO2 >45 mm Hg). NIPPV can prevent the need for tracheal intubation and is administered until the underlying cause of the ventilatory failure is reversed with pharmacologic therapy (eg, corticosteroids, bronchodilators, antibiotics).

pulmonary artery wedge pressure (PAWP)

Normal value: 6-12 mmHg -elevation indicates increased left ventricular preload in the presence of increased CVP and PAWP, coarse crackles indicate left-sided failure the treatment goal is to decrease fluid volume and preload furosemide is a loop diuretic that will decrease both left- and right-sided preload

esophageal varices

The varices oozing blood are at risk for rupture and/or increasing ammonia (from the digestion of protein in the blood). This client needs treatment.

abducens VI

motor assessment: extraocular movements - lateral abduction

carbamazepine

seizure medication but highly effective for neuropathic pain is associated with agranulocytosis (leukopenia) and infection risk clients should be advised to report any fever or sore throat

acoustic VIII

sensory assessment: hearing and romberg test

phenytoin

the nurse should discuss the need to perform good oral hygiene with a soft bristle toothbrush and to visit the dentist regularly as phenytoin can cause gingival hyperplasia (overgrowth of the gum tissues or reddened gums that bleed easily) esp in high doses folic acid supplementation can also reduce this side effect other major side effects or phenytoin: 1. increase in body hair 2. rash 3. folic acid depletion 4. decreased bone density (osteoporosis) recommended diet: high in folic acid and calcium

opioids

(eg, morphine, hydromorphone, fentanyl) are controlled medications, regulated in the US by the controlled substances act and in canada by the controlled drugs and substances act these laws contain regulations (eg, methods of disposal) for various controlled substances to properly dispose of leftover opioid medication in a patient-controlled analgesia pump, the nurse must have a second licensed nurse witness the waste of the medication hospital policy should be followed to properly waste the medication and discard the empty cartridge when a controlled substance is discontinued, the nurse documents the date, time, amount used, reason for the waste, and amount wasted it is never appropriate to waste a controlled substance without the witness of another nurse in addition, nurses should never document or sign off on anything that was not personally witnessed or completed as this constitutes falsified documentation

long term therapy with PPI (proton pump inhibitor)

(eg, omeprazole, pantoprazole, esomeprazole) may decrease the absorption of calcium and promote osteoporosis a bone density test can assess if the client already has osteoporosis hospitalized clients also have an increased risk of diarrhea caused by c. diff PPIs cause suppression of acid that otherwise would have prevented pathogens from more easily colonizing the upper GI tract. this leads to increased risk of pneumonias it is not necessary to be upright for 30 mins after taking PPI medication should be taken prior to meals PPIs do not affect BP clients should be encouraged to increase calcium and vitamin D intake to help prevent osteoporosis

findings after trauma

-a brush is an expected finding after direct trauma it would be a concern if the ecchymosis were around the eyes (periorbital, "raccoon eyes") or postauricular (battle's sign) as this generally indicates a basilar skull fracture, a tear in the dura, and a potential CSF leak -a headache is an expected finding after trauma. it would be a concern if it were unrelieved by non-narcotic analgesics or accompanied by signs of increased ICP -the head is highly vascular and it is not unusual to have blood oozing after trauma. this is not as concerning as a potential CSF leak. however, it can become a problem if the nurse is unable to eventually stop the bleeding as substantial total blood loss is a concern

intramuscular

-acceptable sites include the deltoid, vastus lateralis, and ventrogluteal -the ventrogluteal is preferred as fewer large blood vessels and nerves are present -position the client supine, prone, or side-lying with the knee and hip flexed when administering ventrogluteal injections -flexing the knee and hip reduces muscle tension, improves access, and promotes client comfort needle length: 1 - 1 1/2 inches (2.5 - 3.8 cm) gauge: 18-25 usual site: deltoid, vastus lateralis, ventrogluteal

subcutaneous (SC, SQ)

-administer injections at 90 degrees if 2 in (5 cm) of subQ tissue can be grasped or at 45 degrees if only 1 inch (2.5 cm) can be grasped needle length: 3/8 - 5/8 inches (1-1.6 cm) gauge: 25-27 usual site: abdomen, posterior upper arm, thigh

intradermal

-administer injections at a 5 to 15 degree angle to reduce risk of injection into subQ tissue -apply firm pressure to the injection site to reduce bleeding -massaging the site introduces medication into deeper tissues and should be avoided needle length: 1/4 - 5/8 inches (0.6-1.6 cm) gauge: 25-27 usual site: inner forearm

Myocardial infarction presentation

1. Ischemic chest pain -Described as pressure, heaviness, tightness -May radiate to jaw, arm, back, or upper abdomen -Lasts more than 30 minutes -Not improved with rest or position change -Worsens with exertion 2. Associated symptoms -Shortness of breath -Nausea & vomiting -Sweating -Anxiety -Indigestion -Dizziness -Fatigue & weakness 3. Atypical presentation -Associated symptoms with no chest pain -More common in women, older adults & clients with neuropathy (diabetes)

tumor lysis syndrome

1. Risk -initiation of cytotoxic chemotherapy 2. manifestations -severe electrolyte abnormalities (increase phosphorus, potassium, uric acid) (decrease calcium) -acute kidney injury (due to uric acid/calcium phosphorus) -cardiac arrhythmias 3. treatment -continuous telemetry -aggressive electrolyte monitoring/treatment 4. prophylaxis -IV fluids -allopurinol or rasburicase Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: Hyperkalemia (eg, >5.0 mEq/L [5.0 mmol/L]) may progress to lethal dysrhythmias (eg, ventricular fibrillation) Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) overwhelm the kidneys, leading to hyperuricemia and acute kidney injury from uric acid crystal formation Hyperphosphatemia (eg, >4.4 mg/dL [>1.42 mmol/L]) can cause acute kidney injury and dysrhythmias TLS is best prevented by aggressive hydration and prophylactic allopurinol for hyperuricemia. (Option 1) Superior vena cava (SVC) syndrome (eg, dyspnea, facial and upper body edema, engorged upper body blood vessels) is an oncologic emergency caused by SVC compression (eg, tumors). Radiation or chemotherapy may relieve SVC compression. (Option 2) Syndrome of inappropriate antidiuretic hormone (SIADH) (eg, edema, dilutional hyponatremia) often occurs with central nervous system involvement of cancer. Effective cancer treatment corrects SIADH. (Option 4) Neutropenia from cancer treatment puts clients at high risk for infection and sepsis (eg, hypotension, elevated lactic acid). Fluid resuscitation should be promptly initiated, blood cultures drawn, and IV antibiotics started. Educational objective: Tumor lysis syndrome, an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in release of intracellular components into the bloodstream (eg, hyperkalemia, hyperphosphatemia). Released nucleic acids degrade into uric acid and cause hyperuricemia, leading to possible kidney injury.

heimlick maneuver: infant under 1

1. choking baby cant breathe, cough, or make sounds 2. position the baby face down with head lower than body and support the baby's head with forearm against thigh 3. provide 5 back slaps between shoulder blades with heel of hand 4. turn baby face up if still choking and give 5 chest thrusts on sternum with 2-3 fingers 5. repeat 5 back slaps and 5 chest thrusts until the object dislodges or perform CPR if the baby becomes unconscious

continuous enteral feeding

1. identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) and explain the procedure to the client. perform hand hygiene and apply clean gloves 2. elevate the head of the bed >30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration 3. validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. the tube should be marked at the nostril with a permanent marker during the initial x-ray validation 4. check gastric residual volume 5. flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration 6. administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump

interventions to promote safety when using crutches in the home

1. keep the environment free of clutter and remove scatter rugs to reduce fall risk 2. look forward, not down at the feet, when walking to maintain an upright position, which will help prevent muscle and joint strain, maintain balance, and reduce fall risk 3. use a small backpack, fanny pack, or shoulder bag to hold small personal items (eg, eyeglasses, cell phone), which will keep hands free when walking 4. wear rubber- or non-skid-soled slippers or shoes without laces to reduce fall risk 5. rest crutches upside down on the axilla crutch pads when not in use to prevent them from falling and becoming a trip hazard 6. keep crutch rubber tips dry. replace them if worn to prevent slipping interventions to promote safety and reduce the risk of falling when using axillary crutches in the home include looking forward when walking, maintaining a clutter-free environment, resting crutches upside down on the axilla pads when not in use, using a small bag to hold personal items, wearing sturdy rubber-soled shoes, and keeping crutches in good repair

seizure precautions

1. privacy provided as soon as possible 2. oxygen and suction apparatus available 3. side rails up and padded 4. pillow to protect head 5. side-lying position 6. bed in lowest position 7. loosened clothing Clients with seizures are at increased risk for injury during seizure activity. Seizure precautions are nursing interventions that can help protect a client during a seizure. These precautions typically include: Raising the upper side rails on the bed to prevent the client from falling to the floor during a seizure. The side rails are also padded to prevent client injury due to hitting the hard plastic rails during a seizure (Option 1). During a seizure, a client may be unable to control secretions, increasing the risk for an impaired airway. Suction equipment and oxygen equipment are set up at the bedside (Options 2 and 5). Some facilities also encourage the use of a continuous pulse oximeter. (Option 3) Clients may experience urinary incontinence during a seizure, but unless the health care provider prescribes a urinary catheter, it is not typically used as part of seizure precautions. Inserting a urinary catheter puts the client at risk for a urinary tract infection. (Option 4) It is not necessary to remove all linen from the client's bed. If a client has a seizure, any blankets or pillows that are in the way or pose a threat can be removed, but the client may have linen on the bed while on seizure precautions. Educational objective: Seizure precautions are safety measures that typically include raising the upper side rails, placing padding on the side rails, and preparing bedside suction and oxygen equipment.

basic life support (BLS) for unconscious, pulseless client

1. verify unresponsiveness by tapping or gently shaking the client while calling by name or shouting "are you all right?" 2. activate the emergency response system by calling for help if in the hospital or by calling 911 and obtaining an automated external defibrillator (AED) if outside the hospital. the emergency response system should be activated for all unresponsive clients. this allows the nurse to quickly proceed with assessment of pulse and respirations without delaying to retrieve a defibrillator 3. simultaneously check the carotid pulse and check the client for breathing for no more than 10 seconds 4. attempt CPR if no pulse is felt, starting with chest compressions (circulation, airway, breathing; CAB sequence) -chest compression rate should be 100-120/min -chest compression depth should be 2-2.4 inches (5-6 cm) 5. notify HCP if not already on scene

tuberculosis

-airborne precautions PPE: -N95 particle respirator -As needed for procedures with risk of splash or body fluid contact: Nitrile gloves, disposable gown, goggles/shield Rooms: -Negative air pressurization -High-efficiency particulate air filters Isolation is mandatory for clients with conditions that involve airborne transmission, and rooms must use both negative air pressurization and high-efficiency particulate air (HEPA) filters to avoid contamination. A class N95 or higher particulate respirator must be worn during client care. All clients with symptoms consistent with a suspected airborne illness should be given a surgical mask to wear as soon as they are assessed during triage. Good hand hygiene is always the first and last element of infection control in any client care setting. (Options 1 and 2) Wearing a gown and face shield would be necessary only if the nurse suspected splash of body fluids from procedural client care, not from routine care such as assessment or medication administration. Contact precautions may also be necessary if the tuberculosis is extrapulmonary with draining lesions (eg, cutaneous tuberculosis). (Option 5) For client care involving airborne precautions, a class N95 or higher respirator must be used in lieu of a surgical mask to avoid potential exposure to aerosolized particles. Surgical masks are rated for barrier protection for droplet splashing and filtration of large respiratory particles only. Clients should be given surgical masks during their transportation. Educational objective: Tuberculosis requires airborne precautions. Clients suspected of having tuberculosis should be given a surgical mask to wear on entering any health care setting. Clients are placed in negative-pressure isolation rooms. Nurses must use a class N95 or higher particulate respirator.

nontherapeutic communication techniques

-asking personal questions -giving personal opinions -changing the subject -automatic responses -false reassurance -asking for explanations -approval or disapproval -defensive responses -arguing a nurse who does not acknowledge a client's feelings and gives the impression that there is nothing to worry about has devalued the client's concerns. this technique serves to block a therapeutic conversation as the client may feel that the verbalization of additional concerns or feelings will also be devalued the nurse must learn to use effective therapeutic communication skills to enhance the development of a trusting and therapeutic nurse-client relationship

administering ophthalmic medications

-if applicable, the nurse requests that the client remove contact lenses -nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection) the joint commission disallows the use of abbreviations for the right eye (OD), left eye (OS) and both eyes (OU) the nurse must verify the prescription if the HCP uses these abbreviations

heparin

-is a natural anticoagulant -its risk is heparin-induced thrombocytopenia (HIT), also known as heparin-associated thrombocytopenia -normal platelet (150,000-400,000) -a mild lowering of platelets may occur and resolve spontaneously around the 4th day of administration -the danger is type II HIT, a more severe form in which there is an acute drop in the number of platelets (more than 50% from baseline), which requires discontinuing heparing

activities for children with intellectual disabilities

Activities for children with intellectual disabilities should be based on the child's developmental age with consideration given to size, coordination, physical fitness, maturity, likes and dislikes, and health status. A child with moderate intellectual disability: Has academic skills at about the 2nd grade level and may be able to work in a sheltered workshop Performs self-care activities with some supervision Participates in simple activities May have limited speech capabilities Appropriate play activities for this child include simple puzzles, coloring books and crayons, modeling clay, watching cartoons or favorite movies, sticker books, playing with a large ball (eg, inflatable beach ball), simple card and board games, and being read to aloud. (Option 1) Most children would like having their favorite stuffed animal while hospitalized, but it is not the best choice for this child. The toy may be comforting but does not offer the child the opportunity to engage in active play. (Option 3) A 300-piece jigsaw puzzle would be too challenging and frustrating for a child with moderate intellectual disability. (Option 4) Keeping a journal about the hospital stay is a more appropriate activity for a child with a higher level of intellectual development (ie, one who has achieved high school level academic skills).

acute pericarditis

Acute pericarditis is inflammation of the pericardium, the double-walled sac that surrounds the heart. Pericardial inflammation can progress to pericardial effusion (fluid buildup between the pericardial layers) followed by cardiac tamponade. In cardiac tamponade, a potentially fatal complication, the heart is compressed by fluid buildup and prevented from pumping effectively (decreased atrioventricular filling and contractility). The nurse should monitor the client with pericarditis for signs of cardiac tamponade (eg, narrowed pulse pressure, jugular venous distension, muffled heart tones) (Option 2). (Option 1) Pericarditis is characterized by chest and neck pain that increases with inspiration and coughing. Supine positioning also aggravates pain, but sitting up and leaning forward relieves it. These are expected findings. (Option 3) A hallmark sign of pericarditis is pericardial friction rub, a creaky, grating sound on cardiac auscultation caused by friction between inflamed pericardial layers. This is an expected finding. (Option 4) ST-segment elevation across multiple ECG leads (rather than in specific leads, as seen with myocardial infarction) is common in pericarditis. The nurse does not need to report this expected finding. Educational objective: Clinical manifestations of pericarditis include pericardial friction rub; chest and neck pain worse with supine position, inspiration, and coughing; and ST-segment elevation. The nurse should monitor the client with pericarditis for signs of cardiac tamponade (eg, narrowed pulse pressure, jugular venous distension, muffled heart tones).

advance directive

Advance directives give people the chance to make decisions about their medical treatment ahead of time in case they are unable to personally make their wishes known. The 2 most common forms are living wills and durable power of attorney for health care (health care surrogate/proxy). A client who is alert and oriented can directly address a health care decision. Clients in a coma (GCS score ≤7) or with expressive aphasia would need an advance directive to make treatment decisions because they cannot directly express their wishes. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing (Options 2 and 4). (Option 1) Mental capacity is not affected in spinal cord compression. The client is able to speak. (Option 3) An adult who is mentally capable of making decisions has the right to refuse treatment for any reason at any time whether the health care provider believes it is in the client's best interest or not. (Option 5) A client who is oriented can make and communicate decisions for him/herself although unable to verbalize. The client could nod or write out wishes. Educational objective: Advance directives take effect when the client is unable to speak for him/herself due to such conditions as mental incapacity. Aphasia involves the inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing.

ostomy appliance placement

After a colostomy, the stoma should be beefy red and edematous but will begin to shrink over the course of a few days as inflammation subsides (Option 5). There should be no mucocutaneous separation (eg, separation of the stoma from the abdominal wall), unusual bleeding (eg, moderate to large amounts of blood in the ostomy pouch), or signs of inadequate circulation, including stoma ischemia (eg, pale, dusky) and necrosis (eg, dark red, purple, black). Appliances should be resized during the first several weeks to ensure proper fit, preventing skin breakdown (eg, excoriation) due to stool coming into contact with the skin (Option 1). Within 24 hours of surgery, the client should demonstrate signs of returning gastrointestinal motility, including resolution of nausea, active bowel sounds, and flatus (Option 3). Nausea and absent bowel sounds may indicate postoperative ileus and should be reported to the health care provider (Option 4). Clients should change the pouch according to the manufacturer's instructions (every 5-10 days) and when the skin surrounding the stoma is irritated (eg, burning). The nurse should also assess the client with a new ostomy for body image disturbance and ineffective coping (eg, client unwilling to care for the ostomy) (Option 2). Educational objective: Careful assessment of clients with new ostomies should include the stoma site (eg, perfusion, approximation to the skin), gastrointestinal function (eg, bowel sounds, flatus, stool), and self-care and body image. Appliances must be properly fitted to prevent skin breakdown (eg, excoriation).

alcoholism

Alcoholism can have profound, negative effects on family members. Individuals who have experienced physical or emotional abuse or other pathological conditions while living with a substance abuser may have a sense of powerlessness, loss of self-esteem, and a tendency to neglect personal needs to meet the demands of others. Many resources and self-help groups provide support to alcohol-addicted individuals and codependents, including: Alcoholics Anonymous (AA) - provides help and support to individuals who want to stop drinking. AA uses a 12-step approach that provides guidelines on attaining and maintaining sobriety. Adult Children of Alcoholics (ACOA) - provides assistance to adults who grew up in homes that were dysfunctional due to alcoholism. Al-Anon - provides help for spouses, significant others, family, and friends of alcoholics to share their personal experiences and coping strategies. Alateen - part of Al-Anon; provides support to adolescent children of alcoholics (Option 3). National Association for Children of Alcoholics (NACOA) - raises public awareness of alcoholism and its effects through leadership in public policy, advocacy for prevention services, and online resources. (Option 1) ACOA is for adults. (Option 2) Al-Anon provides help for the family and friends of alcoholics; however, Alateen is a resource specifically for adolescents, which would be more beneficial to this child. (Option 4) AA provides help to the individual with alcoholism. Educational objective: Alcoholism affects the whole family. Alcoholics Anonymous provides help to alcoholic individuals, Alateen provides support to adolescent children, and Al-Anon provides help for spouses and significant others.

sexually active women including those of a sexual minority (eg, lesbian, bisexual, transgender)

All sexually active women, including those of a sexual minority (eg, lesbian, bisexual, transgender), are at risk for sexually transmitted infections (STIs) (eg, human papillomavirus, HIV, herpes simplex virus, bacterial vaginosis). Common routes of STI transmission include oral-genital, oral-anal, skin-to-skin, and use of sex toys. Regardless of sexual orientation, all clients should receive education on infection prevention through the use of barrier methods (eg, latex barriers, dental dams, condoms) and hygienic use of single-person sex toys. Interview questions should be framed to elicit information about the client's current methods of risk reduction and infection prevention (Option 3). (Option 1) Asking the client about sexual orientation does not accurately assess risk as sexual orientation does not correlate with risk for STIs. In addition, clients may not identify with specific sexual labels (eg, lesbian, bisexual). (Option 2) Monogamy may decrease the risk for STIs, but the client cannot be assured that sexual partners have not been previously exposed or are not currently engaged in other relationships. (Option 4) STIs can be spread through various female/female sexual acts. Acts with risk of trauma to the genital tract (eg, penetrative intercourse) are more likely to transmit STIs, but risk is not eliminated with less invasive sexual acts. Educational objective: All women who engage in sexual activities are at risk for sexually transmitted infections, regardless of sexual orientation or history. Health-promotion activities and education should be aimed at safe sexual practices (eg, barrier methods, hygienic use of sex toys).

caring for client with radial, brachian or femoral arterial line

Although the Allen's test is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently. The nurse must assess color, capillary refill, sensation, temperature, and movement per institution policy. Impairment in any of these parameters must be reported immediately because it may indicate impaired circulation to the extremity, and removal of the catheter may be necessary. (Option 1) Capillary refill of less than 3 seconds is an indicator of normal arterial circulation. (Option 3) A mean arterial pressure of 65 mm Hg is adequate to perfuse the vital organs. (Option 4) To maintain patency of the arterial blood pressure monitoring system, an intravenous bag of normal saline solution is placed in a pressure infuser device. The device is set to maintain continual pressure at 300 mm Hg. The pressure drops as the volume of solution in the bag decreases and can be pumped back up. This does not pose an immediate threat to the client. Educational objective: When caring for a client with a radial, brachial, or femoral arterial line in place, the nurse must be able to assess for complications. These include hemorrhage, infection, thrombus formation, and circulatory and neurovascular impairment.

artificial nails

Although the new nurse is scrubbing underneath the artificial nails, it is still not advisable to wear artificial nails, especially in areas with high-risk clients (eg, intensive care units, surgery). Evidence suggests that wearing artificial nails can contribute to the transmission of health care-associated pathogens. Health care workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips, both before and after hand washing, than those who have natural nails. (Option 1) It is appropriate to remove soiled gloves before removing a mask because gloves are more contaminated. The gloves can be removed one at a time. The first glove is pulled off at the cuff by the opposite hand and is turned inside out while being removed. Next, the ungloved hand is placed under the cuff of the second glove, which is then also pulled off inside out. (Option 3) It is appropriate to use alcohol-based hand sanitizer when entering and exiting a client's room. Nurses should wash their hands periodically throughout the day and when visibly dirty or after contact with body fluids. (Option 4) Handwashing with soap and water should be for at least 15 seconds in order to thoroughly remove bacteria. Educational objective: Nurses should not wear artificial nails in the clinical setting, especially in areas with high-risk clients, due to the risk of spreading bacteria.

Lead V2

An ECG provides a visual tracing of the heart's electrical activity. Lead V2 is one of the precordial leads (V1-V6) that is placed on the client's chest at the fourth intercostal space, to the left of the sternum. It views the anterior portion of the heart and may sometimes be referred to as an anterior lead. Visualization of electrical activity of the anterior portion of the heart allows the nurse to localize any damage to this area (eg, ST elevation in lead V2 may suggest an anterior wall myocardial infarction). Interference or baseline sway in the tracing indicates that the lead is not accurately capturing the heart's electrical activity. Interference appears as an irregular, scribbled tracing, and baseline sway is a wavelike shift of the tracing away from baseline. Artifact may be caused by electrical interference from other equipment, muscle tremors on the chest wall or diaphragm, client movement or respirations, or a poorly connected or damaged lead. Artifact can be limited by ensuring proper adhesion of leads to clean, dry skin; limiting client movement and talking; and moving away any items that may be a source of electrical interference. Educational objective: Lead V2 is a precordial lead (ie, V1-V6) that is placed on the client's chest at the fourth intercostal space to the left of the sternum. When performing a 12-lead ECG, the nurse can limit artifact by ensuring proper adhesion of leads; limiting client movement and talking; and moving away items that may cause electrical interference.

asthma exacerbation

An asthma exacerbation occurs when a stimulus (eg, allergen [smoke], stress, illness) triggers acute inflammation and bronchoconstriction, causing shortness of breath and wheezing. Fear of not being able to breathe can cause severe anxiety, which may further exacerbate asthma symptoms (eg, hyperventilation). The nurse should reduce environmental stimuli and encourage coping mechanisms (eg, breathing exercises). If family members' actions are overstimulating an anxious client, the nurse should provide education about the importance of a calm environment and attempt to redirect the family member to assist in the client's care as able (eg, holding the client's hand, instructing on breathing techniques) (Option 3). (Option 1) Allowing the parent's behavior to continue contributes to the stressful environment and the client's anxiety. (Option 2) Asking the client's parent to leave without attempting to redirect first may only escalate the problem. An attempt to redirect and calm the parent and client would be the least invasive intervention to attempt first. (Option 4) This client requires education about the importance of smoking cessation; however, the nurse should provide education in a calm environment once the client is stable. Educational objective: Nurses should decrease sources of a client's anxiety during an asthma exacerbation, as anxiety exacerbates symptoms. If a family member is contributing to anxiety, the nurse should attempt to redirect that person to calm the client (eg, instructing on breathing techniques).

exacerbation of COPD

An exacerbation of COPD is characterized by the acute worsening of a client's baseline symptoms (eg, dyspnea, cough, sputum color and production). In a client with COPD exacerbation, it is most important for the nurse to monitor mental status frequently and report changes such as restlessness, decreased level of consciousness, somnolence, difficult arousal, and confusion to the HCP. These signs may indicate increased CO2 retention and worsening hypercapnia, which would necessitate an immediate change in therapy.

unaccompanied minor

An unaccompanied minor should be treated if the medical condition is an emergency and should be assessed and stabilized. This client clearly has a medical need and could suffer consequences if not treated. In this scenario, care should be rendered and then explained later to the parent or guardian. This approach is supported by the ethical principles of beneficence and nonmaleficence. In addition, underage clients may consent in certain circumstances without parental consent. These circumstances usually include treatment for substance abuse problems, psychiatric disorders, or sexual transmitted diseases. (Option 2) This client has signs/symptoms of systemic infection and possible dehydration or sepsis, an emergent condition. It is unknown when the parents or guardians can be reached. It would be negligent to not further assess and treat a potentially worsening condition. It is assumed that the parents or guardians would want safe, quality care for the client. (Option 3) Qualifications for the status of emancipated minor are subject to state legislation but usually include individuals age <18 who are parents or pregnant, married, living as financially independent, or in the military. This client needs care that should be rendered regardless of status. (Option 4) Providing follow-up advice will not stabilize a potentially serious medical condition. Care must be provided. Educational objective: An underage client whose parents or guardians cannot be contacted and who needs emergency care should receive all necessary medical care until a parent or guardian can be reached to provide consent.

arterial blood gases

Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results. (Option 2) Pre-oxygenation should occur prior to suctioning and possibly before position changes. It will affect ABG results. (Option 3) The head of the bed should be maintained at 30 degrees or higher in an intubated client to prevent aspiration and allow for adequate chest expansion. This position will not affect ABG results. (Option 4) If a client is being weaned from the ventilator, sedation may be reduced. A client with reduced sedation may become anxious and have an increased activity level; these could affect the ABG results. If the client's condition allows, the nurse should avoid suctioning or changing activity or oxygenation levels prior to drawing of ABGs. These actions can result in inaccurate ABG results.

assessment

Assessment is the first step in the nursing process, and it is always considered first when determining the nurse's priority action. Prior to investigating the family's concern regarding inadequate management of the client's pain, the charge nurse should assess the client's pain level on a subjective scale, such as the numerical pain intensity scale (Option 1). (Options 2, 3, and 4) Speaking with the nurse assigned to the client, evaluating the client's medication administration record, and reviewing the narcotic count in the medication dispensing system to look for discrepancies are all appropriate actions. However, the priority action is for the nurse to assess the client. Educational objective: Assessment is the first step in the nursing process. The nurse must first assess a client before determining the reason for the client's inadequate pain relief.

assignment and delegation

Assignment and delegation by the registered nurse (RN) require careful judgment and consideration of the five rights of delegation and the licensed practical nurse (LPN) scope of practice. Under RN supervision, LPNs may assume primary care of stable clients requiring routine care such as: Administering oral, subcutaneous (eg, insulin), and intramuscular medications (Option 4) Performing routine procedures (eg, blood glucose monitoring, ostomy care) A suicidal client requires one-on-one supervision and maintenance of a safe environment. The nurse should ensure the client's safety and prevent self-harm while assisting with routine care (eg, oral medications) and activities of daily living. This assignment is appropriate for an LPN (Option 1). Atrial fibrillation with intermittent onset and remission is termed paroxysmal. Paroxysmal atrial fibrillation can be a chronic, stable condition. There is nothing to indicate that this client would require assessment from the RN before medication administration (Option 5). (Option 2) A second-degree type II atrioventricular (AV) block is an unstable dysrhythmia that can deteriorate to a third-degree AV block and become fatal. This client requires ongoing assessment by the RN. (Option 3) Active gastrointestinal bleeding requiring frequent blood transfusions is best assigned to the RN as the client will need frequent initiation of transfusions and complex monitoring related to hemodynamic stability. Educational objective: Registered nurses can delegate client monitoring, procedural tasks, administration of most medications, reinforcement of client teaching, and limited assessments to licensed practical nurses (LPNs). Client acuity and LPN skill level and expertise are considered prior to delegation.

liquid iron supplement for infant (6 month old)

At birth, a newborn will have enough iron (received during the last trimester of pregnancy) to last until approximately age 4 months. After this age, formula-fed infants usually receive adequate iron intake from iron-fortified formula, whereas breastfed infants may require supplementation until they begin eating iron-rich foods. Oral iron supplements should be given on an empty stomach between meals for best absorption (Option 5). If gastric irritation occurs, iron may be given with meals; however, this will decrease absorption. If the child is old enough, the supplements should be offered with citrus fruit juice as vitamin C will increase absorption. Milk products and antacids also decrease the absorption of oral iron and should be avoided for 2 hours following administration (Option 3). (Options 1 and 2) Iron supplements may cause constipation and black or dark green, tarry stools. Parents should be taught not to be alarmed if these expected findings occur. (Option 4) Liquid iron supplements can stain teeth and so are administered with a medicine dropper toward the back of the infant's cheek. The dose may be diluted with water or juice to prevent staining and improve flavor. Older children should use a straw to take the supplement and drink water or juice after each dose. Educational objective: Oral iron supplements are best absorbed on an empty stomach; however, iron may be given with meals to avoid gastric irritation. Consuming vitamin C with iron supplements increases iron absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration.

bilevel positive airway pressure (BIPAP)

BIPAP involves the use of a mechanical device and facemask in a conscious client who is breathing spontaneously. BIPAP delivers oxygen to the lungs and then removes carbon dioxide (CO2). CO2 retention causes mental status changes. If the client becomes drowsy or confused, it is likely that more CO2 is being retained than what BIPAP can remove; this should be reported to the HCP. Arterial blood gas evaluation should be obtained to determine CO2 level and BIPAP effectiveness. Altered mental status poses the greatest threat to a client's survival as it can lead to decreased protective reflexes (eg, gag, swallow, cough), periods of apnea, and airway compromise (Option 4).

barium

Barium, a contrast medium, aids in the visualization of tumors, obstructions, polyps, and other abnormalities. Barium can be administered rectally (ie, enema) to fill the lower gastrointestinal tract and facilitate clear x-ray images of the large intestine. After the procedure, clients should increase fluid intake and consume foods high in fiber to facilitate removal of the barium. Retention of barium can cause fecal impaction or bowel obstruction, resulting in severe complications such as bowel perforation and peritonitis. Reports of constipation should be assessed further as intervention (eg, laxatives, suppositories) may be needed to help evacuate the barium and prevent complications. (Option 2) A bowel obstruction causes gas and fluid to accumulate, stretching the lumen. Flatulence is an expected finding after the obstruction is cleared and the bowels are decompressed. (Option 3) Clients with irritable bowel syndrome may experience diarrhea, constipation, or both. This client may need fluid and electrolyte replacement from loss through stools, but it is not a priority. (Option 4) Bloody diarrhea is an expected finding in clients with ulcerative colitis; fewer than 4 stools a day indicates mild disease. Although this client should be assessed, the client with a potential bowel obstruction related to barium is higher priority. Educational objective: After a barium enema, evacuation of the barium through bowel movements is crucial for preventing impaction or obstruction. Reports of constipation after the procedure should be assessed to prevent the development of severe complications (eg, bowel perforation).

before blood transfusion

Before a blood transfusion, the nurse should verify the client's identity, crossmatch the client's determined ABO blood-type and Rhesus (Rh) factor with the unit's blood group label, and verify the unit donor number and expiration date against the blood bank receipt. The nurse should also inspect the blood product for any signs of blood product contamination. Blood products are a protein- and sugar-rich medium for bacterial growth. Indications of contaminated blood include: Green, black, white, or dusky discoloration Accumulations of air Evidence of clotting or presence of inclusions Malodor Units exhibiting any of these signs should be returned to the blood bank (Option 4). (Option 1) Regardless of the expiration date, potentially contaminated blood products should be returned to the blood bank for investigation. (Option 2) It is not necessary to notify the health care provider unless there will be a critical delay in administration of the prescribed blood products or a contaminated product is administered. An incident report may be required later but is not the priority. (Option 3) Although air may be caught by the drip chamber, large accumulations of air or gasses in the bag often indicate a problem with the safety and freshness of the product. This blood should not be transfused. Educational objective: Blood products that are found to have impaired packaging, are expired, or show signs of contamination (eg, discoloration, gas formation, clots/inclusions, malodor) must not be transfused and should immediately be returned to the blood bank for investigation.

wound irrigation

Before an open wound is closed, irrigation is performed to wash out debris and bacteria to ensure appropriate wound healing. This is important for wounds obtained in an outdoor environment (eg, playground) as contamination with soil or dirt greatly increases the risk of infection. To perform wound irrigation: Administer the analgesic 30-60 minutes before the procedure to allow medication to reach therapeutic effect (Option 1). Don a gown and mask with face shield to protect from splashing fluid and sterile gloves to maintain surgical asepsis and prevent infection. Fill a 30- to 60-mL sterile irrigation syringe with the prescribed irrigation solution. Attach an 18- or 19-gauge needle or angiocatheter to the syringe and hold 1 in (2.5 cm) above the area. Use continuous pressure to flush the wound, repeating until drainage is clear (Option 5). Dry the surrounding wound area to prevent skin breakdown and irritation. Immunization history is reviewed to determine tetanus vaccination status (Option 4). Typically, a tetanus vaccination is administered if the client has not had one within the last 5-10 years, depending on the contamination level of the wound. (Option 2) Wounds should be cleaned from the least to the most contaminated area to prevent recontamination. (Option 3) A 10-mL syringe would require frequent refilling; a larger syringe is more appropriate. The narrow lumen of a 27-gauge needle would provide excessive irrigation pressure. Educational objective: Open wounds must be free of dirt and bacteria prior to closure to reduce the risk of infection. Wound irrigation requires surgical asepsis.

nutrition for client that has acute manic episode of bipolar disorder

Bipolar disorder is a psychiatric condition characterized by cycling periods of depression and mania. Clients with acute mania often display elevated mood, increased and excessive activity levels, and altered decision-making that can result in high-risk behavior (eg, hypersexuality, excessive spending). Clients with mania are also easily distractible, leading to neglect of personal needs (eg, hydration, nutrition, sleep, hygiene) and the need for medical intervention. When managing the nutritional needs of clients with mania, the nurse should frequently offer energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars). These "on-the-go" foods promote nutritional intake in clients who are unable to sit down and complete a traditional meal (Option 2). (Option 1) Sweet potatoes and kale are low in energy and protein and difficult to eat on the go. (Option 3) Spaghetti with meatballs and fruit salad are difficult to eat on the go. (Option 4) Vegetable soups and salads are often low in protein and energy and difficult to eat on the go. Caffeinated drinks (eg, soda, tea, coffee) should be avoided as they may increase mania and activity. Educational objective: Clients with acute mania often have elevated activity levels that increase their risk for malnutrition and dehydration. Nurses should provide easily carried and consumed foods high in energy and protein (eg, burgers, sandwiches, shakes) to promote adequate nutritional intake.

bullying, harassment, or disparaging behaviors

Bullying, harassment, or disparaging behaviors between coworkers in the workplace, or horizontal violence, is an issue in nursing that results in job dissatisfaction, decreased productivity, anxiety, burnout, and decreased quality of care. Nurses must be aware of horizontal violence and work to eliminate disparaging practices in the work environment. Horizontal violence behaviors may be verbal (eg, belittling, gossiping, using a hostile tone of voice) and/or nonverbal (eg, ignoring, eye-rolling). Anonymous reporting (eg, suggestion boxes, tip lines) may encourage staff participation and identify aggressors (Option 2). Current trends and behaviors related to professionalism should be analyzed to work toward identifying solutions. All staff should receive education regarding the importance of a positive work culture and the facility's expectations for behavior and consequences of horizontal violence (Options 1 and 3). Addressing factors that increase stress in the workplace (eg, increased workload, high client-staff ratios, unfair scheduling) can reduce horizontal violence. The vast majority of horizontal violence is in response to perceived or actual inequality in workplace dynamics (eg, manager gives raises to personal friends) or feeling professionally threatened (eg, new nurses being hired preferentially over experienced nurses). (Option 4) Although gender and age diversity play a role in overall collaboration, diversification is not known to decrease workplace hostility and horizontal violence. Educational objective: Horizontal violence (eg, harassment, bullying, disparaging behaviors) is common in the health care environment and often occurs between nurses. Nurses should analyze their workplace culture, create anonymous reporting systems, and provide staff education to remediate factors contributing to horizontal violence.

central line dressing change

Central line dressing changes are sterile procedures and must be performed correctly to prevent infection. Steps should be performed in the following order: Perform meticulous hand hygiene. Don a surgical mask, and apply a mask to the client (or ask client to turn the head away from the dressing). Apply clean gloves (Option 4). Remove the old dressing, including the chlorhexidine gluconate (CHG)-impregnated patch, making sure not to touch the insertion site (Option 5). Inspect the site for drainage, erythema, heat, or inflammation. Discard the clean gloves, perform hand hygiene, and apply sterile gloves (Option 3). Cleanse the site with antimicrobial solution (eg, CHG) in a back-and-forth motion, using friction, for at least 30 seconds; allow to completely air dry (Option 2). Apply the CHG-impregnated patch over the catheter insertion site and cover with the sterile transparent dressing (or use CHG gel transparent dressing), making certain the edges of the dressing adhere well (Option 1). Sign, date, and initial the dressing. Document the procedure. Educational objective: The correct order for a sterile central line dressing change is: perform hand hygiene; apply surgical masks (nurse and client) and clean gloves; remove the old dressing; assess the insertion site; perform hand hygiene; apply sterile gloves; clean site with antimicrobial solution; allow to completely air dry; apply the new dressing; and sign, date, and initial the new dressing.

chronic pancreatitis

Chronic pancreatitis is an inflammatory disease that causes the tissue of the pancreas to become fibrotic, impairing pancreatic endocrine and exocrine functions. Chronic pancreatitis is most commonly caused by alcohol abuse, but may also result from biliary tract disease (eg, cholelithiasis), autoimmune processes, or cystic fibrosis. Lifestyle modification is a key component of treatment and includes cessation of alcohol and smoking as well as dietary modifications. Clients with pancreatitis often cannot secrete lipase in sufficient quantities to digest consumed fats. Therefore, clients should follow a low-fat diet, with the degree of fat restriction based on the severity of disease. Due to lack of endogenous lipase, oral supplementation of pancreatic enzymes is often required before meals. To avoid exacerbating gastric discomfort, the client should avoid spicy and gas-forming foods. Low-fat food choices include lean meats (eg, fish, chicken), nonfat dairy products, vegetables/fruits prepared without added fat, and low-fat carbohydrates (eg, green peas) (Option 1). (Options 2, 3, and 4) Dairy-containing foods (eg, macaroni and cheese, creamed soup), baked goods (eg, biscuits, cornbread, croissants), and some meats (eg, roast beef) are high in fat. Refried beans also contribute to gas formation and promote bloating. Salsas and spicy foods should be avoided. Educational objective: Clients with pancreatitis often cannot secrete lipase in sufficient quantities to digest consumed fats, requiring the client to follow a low-fat diet. Low-fat food choices include lean meats, non-fat dairy products, vegetables/fruits prepared without added fat, and low-fat carbohydrates.

circulatory overload

Circulatory overload is a life-threatening complication occurring when blood or fluids are infused more rapidly than the client can tolerate. The client develops pulmonary edema (coughing, dyspnea, lung crackles), headache, hypertension, and tachycardia. The nurse should immediately slow the infusion rate if the transfusion is still ongoing, place the client upright with the feet in the dependent position, and contact the health care provider. The client may require emergent respiratory support and administration of diuretics (Option 3). (Option 1) Clients with sickle cell disease are chronically anemic. The nurse should educate the client about managing anemia symptoms (eg, dyspnea on exertion, fatigue), but this instruction is not a priority. (Option 2) Severe pain related to vasoocclusion is expected during sickle cell crisis. The nurse should administer IV analgesics, but this treatment is not a priority over pulmonary edema. (Option 4) Itching following a blood transfusion is a symptom of a mild allergic reaction (eg, itching, hives) and can be treated with diphenhydramine (Benadryl). The nurse can safely delay treatment of a mild allergic transfusion reaction unless symptoms of an anaphylactic reaction (eg, wheezing, bronchospasm) or hemolytic reaction (eg, fever, chills, flank pain; usually within first 15 minutes of transfusion) are present. Educational objective: Circulatory overload is a life-threatening complication of blood transfusion characterized by pulmonary edema, headache, hypertension, and tachycardia. When a client displays symptoms of pulmonary edema (eg, dyspnea, lung crackles), excess fluid volume is the nursing diagnosis with highest priority.

restraints

Clients in any form of restraints should not be in the supine position because it can cause aspiration, especially in those with altered mental status. Unless contraindicated, clients in restraints should be placed in the side-lying, semi-Fowler, or high-Fowler position to promote airway patency and expectoration of secretions or emesis. The supine position may also increase anxiety and agitation, especially in a restrained client. (Options 1 and 4) Belt and vest restraints are secured around the client's waist. A client in a belt or vest restraint can be safely placed in the side-lying, semi-Fowler, or high-Fowler position. (Option 2) Mitten restraints cover the client's hands and contain the fingers to help prevent removal of lines, tubes, and drains. These restraints are made of soft cushion and fabric that allow some movement of the hand and fingers within the mitten. The client in mitten restraints is able to reposition independently and can safely be placed in the side-lying, semi-Fowler, or high-Fowler position. Educational objective: Clients in restraints should not be in the supine position as it can cause aspiration. Clients in restraints should be placed in the side-lying, semi-Fowler, or high-Fowler position.

complementary and alternative medicine (CAM)

Clients may use complementary and alternative medicine (CAM) with conventional medicine. Generally, CAM is categorized into 5 groups: Biologically based medicine: Aromatherapy, whole-food diets Complete medical systems: Homeopathy Energy-based medicine: Acupuncture, Reiki, magnet therapy Osteopathic or body-based practices: Chiropractic, massage Mind-body therapies: Biofeedback, meditation/prayer, hypnosis CAM modalities are often low risk when used appropriately, but some practices may cause adverse interactions or place the client at risk for injury. Clients on anticoagulants (eg, apixaban, rivaroxaban, edoxaban) or with a bleeding disorder (eg, hemophilia) should not undergo acupuncture (thin needle insertion) without first consulting their health care provider as it increases the risk for bleeding (Option 1). (Option 2) The use of garlic supplements has been shown to slightly reduce cholesterol levels, and there is no known interaction with statin medications (eg, atorvastatin). (Options 3 and 4) Massage and biofeedback are low-risk CAM modalities that can be used for a variety of conditions. However, massage should be avoided in clients with unstable orthopedic conditions. Biofeedback, learning to control physiological responses (eg, muscle tension, heart rate) by monitoring and feedback, has not been correlated with significant adverse effects. Biofeedback therapy can assist with strengthening pelvic floor muscles after birth. Educational objective: Clients taking anticoagulants or with bleeding disorders should not use acupuncture due to the risk for bleeding.

huntington disease

Clients with Huntington disease or other degenerative neurological conditions advance through several phases over the course of their illness. Each stage represents further progression of the disease and decline of the client's physical, emotional, and cognitive abilities. Family members' grief in response to the disease progression is expressed in different ways. Many family members feel that their loved one is being "lost" to the illness and that they have little control over its course. Others are in denial and have difficulty acknowledging the client's worsening condition. Most important for the nurse is to explore family members' concerns, thoughts, and feelings about the situation through therapeutic communication, which may help them accept the reality of the client's condition (Option 3). (Option 1) Although a hospital bed can better meet the client's needs, the nurse should first explore the spouse's resistance. (Option 2) To facilitate open communication, the nurse should ask open-ended questions and avoid limiting conversation by asking closed-ended (ie, yes or no) questions. (Option 4) Changing the subject is a nontherapeutic approach that shows a lack of empathy and does not allow the nurse to explore the spouse's resistance. Educational objective: Family members of a client with a degenerative disease may be resistant to care recommendations during periods of grief (eg, denial). The nurse should use therapeutic communication that focuses on exploring family members' concerns and validating their feelings.

MRSA

Clients with a health care-associated infection, such as methicillin-resistant Staphylococcus aureus, are placed on contact precautions to limit the transmission of microorganisms. In addition to standard precautions implemented for all clients, contact precautions include use of a gown and gloves and equipment that is designated for use with a single client only (eg, stethoscopes, blood pressure cuffs, glucometer). Disposable stethoscopes and other dedicated equipment should be kept in the room after each client use and then disinfected or discarded after no longer needed (eg, upon discharge) (Option 1). (Option 2) The urine specimen should be placed in a leak-proof specimen cup and then in a sealed biohazard bag before transport to the laboratory. (Option 3) To prevent contaminating the urine specimen or introducing bacteria into the client's urinary tract, the nurse should scrub the Foley collection port with alcohol or chlorhexidine solution for 15 seconds before withdrawing a specimen. (Option 4) Hand hygiene with an alcohol-based antiseptic solution is appropriate except when caring for clients with Clostridium difficile - for these clients, the nurse should instead perform hand hygiene with soap and water to remove spores from hands. Educational objective: Contact precautions require use of a gown and gloves, and equipment that is designated for single client use. Hand hygiene using soap and water is necessary when caring for a client with Clostridium difficile. For all clients, the nurse should practice hand hygiene, use aseptic technique when collecting a urine specimen from a Foley catheter, and transport specimens in sealed biohazard bags.

getting dental work done, the nurse should be aware of

Clients with a history of congenital heart disease and those with prosthetic valves are at risk for developing infective endocarditis, an infection of the endothelial lining of the heart, with oral surgery and certain procedures (eg, dental work). These clients should receive prophylactic antibiotic therapy prior to any such procedure or surgery. Clients on warfarin therapy due to the presence of prosthetic valves or for other reasons will have a therapeutically elevated International Normalized Ratio (2.0-3.0) to inhibit blood clot formation. However, this will place these clients at risk for excessive bleeding during surgical procedures (Options 3, 4, and 5). (Option 1) A history of obesity and a calorie-restricted diet are not significant for oral surgery. (Option 2) This creatinine level is within normal limits (0.6-1.3 mg/dL [53-115 µmol/L]) and would not require reporting. Educational objective: Prior to oral surgery, it is necessary to report findings that will place a client at risk for the development of endocarditis (eg, presence of prosthetic valves, history of congenital heart disease) and bleeding (eg, elevated International Normalized Ratio).

ileostomy

Clients with inflammatory bowel disease may undergo a total colectomy with ileostomy creation to control symptoms of chronic abdominal pain and diarrhea. Peristomal skin irritation is the most common ileostomy complication. Peristomal skin care and prevention or treatment of irritation include: Cleansing peristomal skin with mild soap and water Ensuring that the ostomy appliance fits well so that skin is protected from liquid stool drainage Trimming the appliance opening to 1/8 inch (0.32 cm) larger than the stoma so that it "hugs" the stoma without touching stoma tissue (Option 3) (Option 1) Ileostomies are formed from small intestine that bypasses the colon, which results in incontinence of liquid stool that cannot be regulated with irrigation. Irrigation is used to achieve regular emptying of the colon in clients with descending colostomies. (Option 2) To prevent skin irritation, stoma appliances are changed only every 5-10 days. The bag is emptied whenever one-third full to prevent it from becoming heavy and pulling away from the skin. (Option 4) Clients with ileostomies are at risk for dehydration, hyponatremia, and hypokalemia due to increased fluid loss through liquid stool. Clients are encouraged to increase fluid intake. Educational objective: When caring for a client with an ileostomy, the nurse encourages the client to cleanse peristomal skin with mild soap and water, ensure that the ostomy appliance fits well, change appliances every 5-10 days, and increase fluid intake.

disseminated intravascular coagulation (DIC)

Clients with sepsis are at risk for developing disseminated intravascular coagulation (DIC), a condition that initially causes clotting within the microvessels. Platelets and clotting factors are consumed in clotting and become unavailable for body use, leading to bleeding complications. The initial clotting also disrupts blood flow to extremities and organs. Signs of DIC include frank external bleeding (eg, venipuncture site bleeding), signs of internal bleeding (petechiae, ecchymosis, hematuria, hematemesis, and bloody stools), and respiratory distress (eg, bleeding/clotting into lungs). Signs of DIC need immediate assessment and emergency intervention. Rapid replacement of clotting factors (fresh frozen plasma), platelets, and blood is needed to save the client from death. (Option 1) Stool leaking from an ileostomy bag is not a priority. (Option 2) It is common for clients with chronic obstructive pulmonary disease to have diminished breath sounds; the goal SpO2 level in this population is generally ≥90%. (Option 3) Although missing warfarin can increase the risk of clotting, most clients will usually have a therapeutic INR for 1-2 days. This is not a priority over the DIC client. Educational objective: Disseminated intravascular coagulation (DIC) results from abnormal activation of clotting cascade followed by consumption of clotting factors and platelets; this quickly leads to life-threatening external and internal bleeding. Any signs of DIC should be assessed immediately as emergent replacement of clotting factors, blood, and platelets is needed to save the client.

unilateral weakness

Clients with unilateral weakness from stroke may have limited mobility and control on the affected side. Clients being taught to dress independently should first clothe the affected side, which decreases the need for movement of impaired extremities and allows unrestricted use of unaffected limbs for assistance (Option 2). Unilateral neglect is an alteration in sensory perception that causes clients to ignore input from the affected side, leading to performing actions only on one side (eg, eating food on only the right side of the plate). Teaching clients to turn the head to fully scan the environment reduces the tendency to neglect one side (Option 4). Clients with right-sided cerebrovascular accidents tend to be impulsive and unaware of deficits. Teaching the client's family to expect disinhibition and emotional outbursts helps family members cope with the behavioral changes and reduces frustration during interactions (Option 5). (Option 1) The nurse should approach clients with unilateral blindness from the unaffected side to avoid startling the client. (Option 3) Receptive aphasia (ie, Wernicke aphasia) is impairment of verbal and written language comprehension. Visual aids and hand gestures may be more effective means of communication. Educational objective: Neurological impairments from a stroke may include unilateral weakness and neglect, impulsiveness, and aphasia. The nurse should teach the client methods to improve visual perception (eg, turning head to affected side, scanning the environment) and overcome unilateral weakness (eg, dressing affected side first).

elevation of extremity

Correct client positioning promotes healing and prevents complications. Elevation promotes mobilization of fluids (eg, blood, lymph drainage, edema) back into circulation. Elevating a limb with deep vein thrombosis promotes venous return and reduces edema. The nurse should elevate the affected extremity without applying direct pressure at the thrombus site (Option 4). Cellulitis is characterized by an edematous rash from subcutaneous tissue inflammation. The nurse should elevate the extremity to promote lymphatic drainage of edema (Option 5). (Option 1) For a client with an above-the-knee amputation, the affected limb is elevated by raising the foot of the bed for the first 24 hours only, to reduce edema. After 24 hours, the client is placed in a prone position twice daily to promote stretching of the flexor muscles and prevent contractures. (Option 2) For a client with a hip fracture, the affected extremity is kept abducted using splints or pillows between the legs; elevation is contraindicated due to the risk of affecting alignment. (Option 3) To prevent bleeding (eg, insertion site, retroperitoneal, hematoma) following percutaneous coronary intervention, the client should lie flat with the affected hip extended (straight) while sheaths remain in place and for a few hours after sheath removal. Educational objective: Therapeutic positioning must be evaluated carefully by the nurse. Elevating an extremity can reduce edema, promote comfort, and increase venous return. Elevation is inappropriate for clients with hip fractures, recent percutaneous coronary intervention, or above-the-knee amputation more than 24 hours ago.

culture and sensitivity testing (16 month old)

Culture and sensitivity testing is used to identify the causative agent of an infection and to determine the susceptibility of the infectious agent to various medications (eg, antibiotics). To ensure that the correct organism is identified, sterile technique is required when obtaining a sample to prevent contamination with microorganisms from the skin. Infants and toddlers who are not toilet trained are unable to control voiding, making it difficult to prevent contamination and determine the timing of urination; therefore, sterile intermittent catheterization is the most appropriate means of collecting a sterile urine specimen. (Option 1) A nonsterile specimen can be obtained by adhering a sterile urine collection bag around the genitalia inside the diaper. This method is appropriate for obtaining a sample for urinalysis or calculating intake and output; however, there is a high risk of contamination as the urine may come into contact with the perineum, making this method inappropriate for culture and sensitivity testing. (Option 2) The indwelling catheter collection bag contains stagnant urine that can grow bacteria and therefore is inappropriate for urine culture and sensitivity testing. (Option 4) Cotton balls are sometimes placed in the diaper to absorb urine while the infant voids. After the cotton balls are saturated, they are removed, and the urine is squeezed into a collection cup. This method has high likelihood of contamination and therefore cannot be used to obtain urine for culturing. Educational objective: Sterile intermittent bladder catheterization is the recommended method for collecting a sterile urine specimen in infants and young children who are not toilet trained.

cyclosporine

Cyclosporine is an immunosuppressant prescribed to manage rheumatoid arthritis (RA) and psoriasis, and to prevent transplant rejection. This medication inhibits the normal immune response by interfering with T cell response, which slows the progression of certain autoimmune diseases. Clients taking cyclosporine have an increased risk for infection and are instructed to avoid large crowds (eg, concerts, movie theaters) and known sick contacts (Option 1). It can take 1-2 months for the full effect of therapy and relief of symptoms from autoimmune disease (eg, joint stiffness in RA, psoriasis symptoms) to occur. This medication is for long-term use, and it is therefore important to monitor clients for adverse effects. The incidence of secondary malignancies (eg, skin cancer, lymphoma) is increased in these clients. (Option 2) Cyclosporine can cause increased hair growth (ie, hirsutism). Waxing and hair removal creams are safe for use. Gingival hyperplasia is also common and clients require education on proper oral care. (Option 3) Cyclosporine is associated with hypertension and nephrotoxicity. (Option 4) Grapefruit juice can increase serum levels of cyclosporine and is avoided during therapy. Educational objective: Cyclosporine is an immunosuppressant. Clients are at increased risk for infection and secondary cancers (eg, skin cancer, lymphoma). Consuming grapefruit increases the risk for drug toxicity. Gingival hyperplasia, hirsutism, uncontrolled hypertension, and kidney toxicity are other common adverse effects.

delusions

Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational or untrue, the client continues to believe it is real. Clients experiencing delusions of reference will believe that songs, newspaper articles, and other events are personal and significant to them. Other examples of delusions are below: Grandeur - "I need to get to Washington for my meeting with the president." Control - "Don't drink the tap water. That's how the government controls us." Nihilistic - "It doesn't matter if I take my medicine. I'm already dead." Somatic - "The doctor said I'm fine, but I really have lung cancer." Delusions are a positive symptom of schizophrenia. Delusions of reference cause clients to feel as if songs, newspaper articles, and other events are personal to them

mass casualty events

During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged using various systems (eg, Simple Triage and Rapid Transport/Treatment [START]; Sort, Assess, Lifesaving interventions, Treatment/Transport [SALT]) and placed into 4 categories: Immediate (red tag): Life-threatening injuries with good prognoses after minimal intervention (eg, airway obstruction, open long-bone fractures, second- or higher-degree burns covering 15%-40% body surface area) Delayed (yellow tag): Requiring treatment within hours (eg, stable abdominal wounds, soft-tissue injuries) Minimal (green tag): Requiring treatment within a few days (eg, minor burns or fractures, small lacerations) Expectant (black tag): Extensive injuries, poor prognosis regardless of treatment (eg, C1-C2 spinal cord injuries) A client with an open femur fracture is triaged as "immediate." Delaying treatment leads to hemorrhage. The femur fracture can be quickly immobilized with a good prognosis (Option 3). (Options 1 and 2) The client with fixed pupils and head injury and the client with a broken neck have poor prognoses and are triaged as "expectant." Palliative care should be provided. (Option 4) A client with small lacerations is triaged as "minimal" as the condition is unlikely to worsen within the next few days. After immediate and delayed needs are addressed, lacerations should be cleaned and dressings applied to prevent infection. Educational objective: During mass casualty events, the goal is the greatest good for the greatest number of people. Priority is given to clients with life-threatening injuries who have good prognoses after minimal intervention.

end of life care (hospice)

End-of-life care (eg, hospice) keeps clients as comfortable as possible throughout the dying process. Symptom management and pain control take priority over treating disease because the client and/or family have elected to forgo aggressive and painful treatments and allow a natural death (Option 5). The nurse can use nonverbal pain assessment tools (eg, Face Legs Activity Cry Consolability [FLACC]) to assess symptoms of pain (eg, grimacing, restlessness) in the dying client. An improved FLACC score (eg, less agitation, relaxed facial expression) is a reliable indicator that the client's pain level has improved (Option 1). Education for staff and family members at a client's end of life includes: Reminding the family that pain relief measures are priority and should not be denied or delayed. Encouraging family members to continue to speak with the client even if the client is unable to respond. As senses decline, hearing is often the last one lost. Nurses should assume the client can hear and understand, and continue to verbally explain all interventions (Option 3). Supporting family presence and culturally appropriate physical contact (eg, holding hands) during care to nurture client security, provide comfort, and decrease anxiety (Options 2 and 4). Educational objective: Hospice care helps the client live as comfortably as possible throughout the dying process. Nonverbal pain assessment tools can be used to assess symptoms of pain (eg, grimacing, restlessness) in the dying client. Nurses should manage client's pain, encourage family presence and physical contact, and continue verbally communicating with the client.

endotracheal (ET) suctioning

Endotracheal (ET) suctioning improves ventilation in mechanically ventilated clients by removing mucus and secretions from the ET tube. Suctioning is performed based on clinical findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or signs of acute respiratory distress. Frequent suctioning increases the risk of tracheal and bronchial trauma, bleeding, and hypoxia. Suctioning should be performed only when needed to reduce the risk for injury (Option 2). (Option 1) Auscultating the neck to monitor for an ET tube cuff leak is a standard component of respiratory assessment in mechanically ventilated clients. The presence of a cuff leak increases the risk of accidental extubation, impairs ventilation, and allows aspiration of secretions from the mouth and throat. (Option 3) Oral care with oral suctioning is performed every 2 hours to prevent ventilator-associated pneumonia (VAP). Secretions in the mouth and throat often contain bacteria that can cause pneumonia. (Option 4) Repositioning clients at least every 2 hours reduces the occurrence of VAP. Turning clients side-to-side promotes mobilization of secretions and prevents secretions from pooling in dependent areas of the lungs. Educational objective: Endotracheal suctioning in mechanically ventilated clients should be performed based on assessment findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or acute respiratory distress. Suctioning should be performed only when needed to reduce the risk of lung trauma and hypoxia.

enteral tube feeding

Enteral tube feeding is the preferred route for providing nutrition to clients who cannot intake oral nutrition (eg, dysphagia, prolonged intubation). The nurse assesses tube feeding tolerance by monitoring for signs of potential complications: Diarrhea: May occur if tube feeding formula is too concentrated (hyperosmolar) or administered too rapidly (Option 2). The presence of hyperosmolar feedings in the intestines causes the osmotic movement of water into the intestinal lumen, resulting in diarrhea. Fluid overload: Manifested as rapid weight gain and peripheral edema; due to excess water flushes or too-dilute (hypo-osmolar) formula (Option 3) Nausea and vomiting: Due to delayed gastric emptying or rapid administration (Option 1) (Option 4) A low volume of gastric residuals suggests that the client has adequate gastric emptying and is tolerating tube feedings. (Option 5) A serum blood glucose of 110 mg/dL (6.1 mmol/L) is an expected finding in a client receiving enteral nutrition. The recommended target serum glucose range for clients receiving nutritional support is 140-180 mg/dL (7.8-10.0 mmol/L). Hyperglycemia (>180 mg/dL [10.0 mmol/L]) would require intervention (eg, sliding scale insulin, alternate tube feeding formula). Educational objective: The nurse assesses for complications of tube feeding by monitoring bowel movements (eg, diarrhea), fluid status (eg, rapid weight gain), and the presence of delayed gastric emptying (eg, high gastric residuals, nausea/vomiting).

epiglottitis

Epiglottitis refers to inflammation of the epiglottis that may result in life-threatening airway obstruction. Haemophilus influenzae type b (Hib) was the most common cause, but the incidence has decreased dramatically with widespread Hib vaccination. Symptoms begin with abrupt onset of high-grade fever and a severe sore throat, followed by the 4 Ds: drooling, dysphonia, dysphagia, and distressed airway (inspiratory stridor). Children are typically toxic-appearing and may be "tripoding" (sitting up and leaning forward) with inspiratory stridor. This client should be assessed first due to being unstable from an airway disorder. The client has a respiratory illness and is drooling, which indicates respiratory distress (Option 4). (Option 1) Purulent drainage is expected in a 1-day post tubal myringotomy client. The drainage shows the procedure was successful. (Option 2) A fever of 102 F (38.8 C) and petechiae in a post valve replacement client could indicate endocarditis. This client would need to be seen second, as this is a circulation disorder. (Option 3) A murmur is expected in a client with a patent ductus arteriosus. It is best heard at the left infraclavicular area and has a continuous "machinery" quality. Educational objective: The nurse should assess clients with airway disorders first, breathing second, and circulation last. Epiglottitis refers to inflammation of the epiglottis that may result in life-threatening upper airway obstruction.

erythropoiesis-stimulating agents (ESAs)

Erythropoiesis-stimulating agents (ESAs) (eg, epoetin alfa [Epogen, Procrit], darbepoetin alfa [Aranesp]) are used to treat chronic anemia related to chronic kidney disease (CKD) or bone marrow suppression (chemotherapy). ESAs are synthetic forms of the naturally occurring hormone erythropoietin, which stimulates the production of red blood cells (ie, erythropoiesis) by the bone marrow. Erythropoietin is normally produced by the kidneys, so clients with CKD may develop anemia due to decreased erythropoietin production. ESAs are administered on a regular schedule (eg, once weekly) and may be self-administered subcutaneously at home or IV during hemodialysis as needed. A total of 2-3 months is required to reach a target hemoglobin level. ESAs are held if hemoglobin exceeds 11 g/dL (110 g/L) due to an increased risk of thrombotic events (eg, myocardial infarction, stroke) (Option 3). ESAs increase blood pressure and are contraindicated in clients with uncontrolled hypertension. (Options 1, 2, and 4) Creatinine and blood urea nitrogen are expected to be elevated in clients with CKD. Laboratory results for creatinine, platelet, and blood urea nitrogen do not indicate the effectiveness of epoetin alfa. Educational objective: Erythropoiesis-stimulating agents (eg, epoetin alfa, darbepoetin alfa) treat chronic anemia by stimulating red blood cell production. Hemoglobin level should not exceed 11 g/dL (110 g/L) due to an increased risk of thrombotic events (eg, myocardial infarction, stroke).

falls

Falls can occur with any client; however, advanced age, incontinence, confusion, and presence of lines, tubes, and drains increase the risk for falls and injury. Interventions to reduce falls in high-risk clients include: Hourly rounding (eg, assessing pain, offering toileting and nutrition) (Option 2) Moving the client to a room close to the nurses' station (Option 4) Activating bed alarms to alert staff if the client gets out of bed unassisted (Option 1) Asking family members or visitors to stay at the bedside with the client (Option 3) Lines, tubes, and drains (eg, indwelling urinary catheter, IV tubing) tether (ie, tie) the client to the bed or equipment and limit mobility, increasing fall risk. In addition, indwelling urinary catheters increase risk for infection and should be used only when clinically indicated (eg, strict hourly output, critical illness), not for the nurse's convenience (eg, clients requiring frequent toileting or incontinence care). The nurse can reduce urinary urgency and incontinence episodes by offering clients toileting with hourly rounding. (Option 5) Raising all side rails is considered a physical restraint and is associated with more severe fall injuries from clients attempting to climb over the side rails. Educational objective: Interventions to reduce falls in high-risk clients include hourly rounding, moving the client to a room close to the nurses' station, and using bed alarms. Lines, tubes, drains (eg, indwelling urinary catheters), and restraints (eg, all side rails raised) increase fall risk and should be used only when clinically indicated.

febrile seizures

Febrile seizures are benign seizures that occur in response to an elevated temperature. A child with a febrile seizure would not take priority over a child with an obstructed airway.

fetal tachycardia

Fetal tachycardia is defined as a baseline heart rate above 160 beats per minute. Tachycardia can be an early indicator of fetal hypoxia and acidosis. Other common causes include infection, maternal fever, maternal dehydration, maternal hypotension, and drug side effects. Maternal temperature should be taken to assess for fever, and blood pressure should be assessed to rule out hypotension (Options 1 and 5). Certain medications can lead to fetal tachycardia (eg, terbutaline, bronchodilators, decongestants), and the nurse should review the medication administration record to determine whether potential causative medications were administered recently (Option 4). (Option 2) Reassessment at a later time results in an inappropriate delay in care. Fetal tachycardia is considered an abnormal finding requiring timely intervention. (Option 3) Maternal dehydration, hypovolemia, and subsequent hypotension are possible causes of fetal tachycardia. The IV fluid rate may need to be increased (not decreased) if hypotension is identified. Educational objective: Fetal tachycardia can be an indicator of early fetal hypoxia and acidosis. Potential etiologies should be addressed to identify the cause and determine appropriate interventions. Other common causes include maternal fever, maternal dehydration, maternal hypotension, and drug side effects.

prioritization of care

First-level priority problems: 1. airway 2. breathing 3. circulation & cardiac (become first priority in cardiac arrest) 4. vital signs Second-level priority problems: 1. altered mental status 2. acute pain 3. untreated medical problems (eg, hyperglycemia in a client with diabetes) 4. chronic pain 5. acute elimination issues 6. abnormal laboratory results 7. risk for infection, safety

accidental eye exposure to body fluids (eg, blood, urine) or chemicals

Following accidental eye exposure to body fluids (eg, blood, urine) or chemicals, health care workers should immediately flush the affected eye with water or saline for at least 10 minutes to reduce exposure to potentially infected material and prevent/reduce injury (eg, burn). The risk of HIV transmission through urine is low unless there is visible blood in the fluid; however, flushing the eye is the priority action with any accidental exposure. (Option 2) The nurse should address the fears of the unlicensed assistive personnel (UAP), but the most urgent action is for the UAP to flush the eye. (Option 3) All exposure incidents should be reported to appropriate personnel, including the occupational health department, which is responsible for managing immediate postexposure (eg, testing, prophylaxis) and follow-up care (eg, testing, counseling). However, flushing the eye is the priority. (Option 4) Depending on the facility, the UAP may have additional eye irrigation in the emergency department, confidential medical evaluation for HIV by a qualified heath care provider, and occupational HIV postexposure prophylaxis if medically indicated. However, these actions are not the priority. Educational objective: Following accidental eye exposure to body fluids or chemicals, the health care worker should immediately flush the eye with water or saline. After reporting the incident to appropriate personnel, the health care worker may be sent to the facility's emergency or occupational health department to receive postexposure care.

preparing medication for pediatric patients

For pediatric clients, liquid medications should be measured with oral syringes, which have small, well-defined increments and provide accuracy for small doses (Option 3). Household measuring devices (eg, teaspoon) are inaccurate due to variability of size and differences in measuring methods. Pediatric clients may refuse medication due to a fear of an unpleasant taste. Preschool children (age 3-6) typically start to take initiative and affirm power over the environment (Erickson's initiative vs. guilt). Encouraging participation (eg, allowing the child to depress the syringe plunger) promotes initiative and cooperation by giving the child a sense of control (Option 4). (Option 1) The child may not finish eating food mixed with medication and would receive only a partial dose. In addition, some medications cannot be given with food. (Option 2) Parents should notify the health care provider if the child vomits after oral medication administration; additional medication may cause an overdose, as some of the medication may have been absorbed. (Option 5) Preschool children respond best to positive reinforcement and rewards (eg, stickers) as incentives for desired behavior. A time-out is more effective in interrupting undesired behavior. Educational objective: For pediatric clients, liquid medication should be measured with an oral syringe for accuracy. To prevent inaccurate dosing, parents should not mix medications with meals or give additional medication if vomiting occurs. To promote initiative and cooperation from preschool children (age 3-6), parents should provide positive reinforcement (eg, stickers) and allow children to participate in self-administration.

head trauma

Head trauma may cause a rise in intracranial pressure (ICP). Elevated ICP is a life-threatening condition that decreases cerebral blood flow, risking brain ischemia, infarction, or herniation. Late manifestations of severely increased ICP, impending brainstem herniation, and possible brain death include changes in vital signs (eg, Cushing triad) and pupil response. Cushing triad is a neurologic emergency characterized by bradycardia, irregular respirations, and hypertension with a widening pulse pressure (Option 1). The body attempts to increase perfusion to the brain by increasing blood pressure, which causes systolic hypertension with a widening pulse pressure. Other late signs may include motor abnormalities (eg, posturing) and cranial nerve deficits (eg, loss of cough and gag reflexes). (Option 2) Although irregular respirations are present in Cushing triad, increased ICP causes hyperthermia due to injury to the hypothalamus. (Option 3) Fixed, dilated pupils are seen late in neurologic decline due to increased ICP compressing oculomotor nerve III. Otorrhea (cerebrospinal fluid leaking from the ear) indicates possible skull fracture but is not directly related to increased ICP. (Option 4) Decreased level of consciousness is the most sensitive and reliable sign of increased ICP. An increase in alertness suggests an improvement in neurologic function. In the case of increasing ICP and herniation, level of consciousness eventually deteriorates to a state of coma. Educational objective: Late manifestations of increased intracranial pressure indicate impending brainstem herniation and include changes in vital signs (eg, Cushing triad) and pupil response.

hepatic encephalopathy (HE)

Hepatic encephalopathy (HE), a potentially reversible disturbance in central nervous system function, results when the liver fails to detoxify the body of ammonia. Clients with cirrhosis or other forms of liver disease are at risk for developing HE. Clinical findings include: Cognitive deficits - Confusion and disorientation, impaired thinking and judgment (eg, inability to perform basic math), loss of meaningful conversation Mental status changes - Sleep disturbances and progressively altered level of consciousness, leading to coma if not effectively treated (Option 2) Motor alterations - Asterixis (ie, flapping hand tremor when arms and hands are extended), hyperreflexia, apraxia (ie, inability to draw simple figures) (Option 3) Fetor hepaticus (ie, musty, sweet odor to the breath) (Option 1) (Option 4) Constipation is a risk factor for HE. The lactulose goal in clients with cirrhosis or HE is to have 2-3 soft bowel movements a day. (Option 5) Constricted pupils are seen with use of opioids. Pupillary changes are not significant in HE. Educational objective: Hepatic encephalopathy, a complication of liver disease, results from the accumulation of ammonia in the bloodstream. Clinical findings include changes in level of consciousness, asterixis, and fetor hepaticus.

herpes zoster (shingles)

Herpes zoster (shingles) is caused by the varicella-zoster virus (VZV), the same virus that causes chickenpox. After initial VZV infection earlier in life, the virus remains dormant in the sensory nerves. Reactivation of VZV can occur when the immune system is compromised (eg, aging, immunosuppression), resulting in the formation of pruritic, painful, fluid-filled blisters. These blisters can manifest along the distribution of one or more nerves (dermatomal distribution), causing a characteristic unilateral linear pattern, or the lesions can be disseminated (spreading beyond adjacent dermatomes). The fluid in the blisters carries a high viral load and is contagious to those who have not had chickenpox or received the varicella vaccine. For the client with disseminated shingles, airborne and contact precautions should be followed. An eye shield should be used if there is a chance of virus-containing fluid splashing into the eyes (eg, bathing). Once the lesions have crusted over, the likelihood of transmitting the virus is greatly reduced, and therefore only standard precautions are required. (Options 2, 3, and 4) Surgical masks are not appropriate for diseases requiring airborne precautions. Surgical caps are not required for airborne and contact precautions; they should be used for flea infestations as fleas jump and are attracted to hair. Educational objective: Herpes zoster (shingles) is a viral infection that occurs as a result of the reactivation of the varicella-zoster virus in individuals who previously had chickenpox. Airborne and contact precautions are necessary when lesions are fluid-filled and disseminated as the fluid from the blisters carries a high viral load.

occupational HIV postexposure prophylaxis

High-risk contact (prophylaxis recommended) 1. Exposure of -Mucous membrane, nonintact skin, or percutaneous exposure 2. Exposure to -Blood, semen, vaginal secretions, or any body fluid with visible blood (uncertain risk: cerebrospinal fluid, pleural/pericardial fluid, synovial fluid, peritoneal fluid, amniotic fluid) Low-risk contact (prophylaxis not recommended) 1. Exposure to -Urine, feces, nasal secretions, saliva, sweat, tears (with no visible blood) Timing -Initiate urgently, preferably in the first few hours -Continue for 28 days Regimen 1. ≥3-drug regimen recommended: -Two nucleotide/nucleoside reverse transcriptase inhibitors (eg, tenofovir, emtricitabine) 2. Plus -Integrase strand transfer inhibitor (eg, raltegravir), protease inhibitor, or non-nucleoside reverse transcriptase inhibitor

hypothermia

Hypothermia occurs when the core temperature is below 95 F (35 C) and the body is unable to compensate for heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate defibrillation in these clients. (Option 2) Covering the client's head is indicated to prevent heat loss; however, this can be done after the cardiac monitor has been attached. Depending on the severity of the hypothermia, the trunk should be warmed before the extremities to reduce the risk of afterdrop (core temperature drops further). This is due to cold peripheral blood returning to the central circulation. (Option 3) A blood draw for laboratory testing is important but should be performed after the cardiac monitor is attached. (Option 4) Two large-bore IV catheters are preferred; this can be accomplished after the cardiac monitor has been attached. Educational objective: Cardiac monitoring and gentle handling of the client are a high priority with hypothermia. The cold myocardium is extremely irritable and prone to dysrhythmias. The nurse should anticipate defibrillation in these clients.

cerebrovascular accident (CVA)

In a cerebrovascular accident (CVA), blood flow in the brain is compromised due to either bleeding or occlusion of a blood vessel. After a CVA, mental status may continue to decline, especially within the first 24-48 hours. The nurse should immediately notify the health care provider of decorticate (flexion) posturing, which is characterized by arms rigidly flexed at the elbow, hands raised to the chest, and legs extended (Option 4). This posturing suggests worsening cerebral impairment (eg, increased intracranial pressure) that may be reversible with proper interventions. (Option 1) Hemiparesis and hemiplegia are expected findings in a client with a CVA. (Option 2) An impaired gag reflex may indicate an impaired airway; however, a patent airway has already been established in an intubated and mechanically ventilated client. An impaired gag reflex can occur after intubation if sedation was required for placement of the endotracheal tube. (Option 3) Bladder dysfunction (eg, retention, incontinence) can be an expected finding in a client who has experienced a CVA, depending on the level of neurological impairment. Educational objective: Mental status may continue to decline in the first 24-48 hours following a cerebrovascular accident. Decorticate (flexion) posturing (arms rigidly flexed at the elbow, hands raised to the chest, and legs extended) is a sign of worsening neurological function that should be reported immediately to the health care provider.

reporting suspected child abuse

In discussing the reporting aspect of suspected child abuse with a caregiver, the nurse needs to convey an attitude that is not judgmental, punitive, or threatening. Whether or not the parent has actually harmed or abused the child, the parent needs to know that a report will be made, why it is being filed, and an investigation will be conducted by a CPS worker and/or by the police. The nurse should emphasize that the primary concerns are for the safety and well-being of the child and that reporting is mandatory for the types of injuries sustained by the child. It is not unusual for a parent to react to this information with denial and/or anger. The nurse needs to anticipate that such a reaction may occur and maintain a supportive, empathetic, and nonaccusatory approach. (Option 1) This response also diverts the need for the nurse to provide a response or explanation to the parent. The child's caregiver should be told why the report is being filed. (Option 2) This response is nontherapeutic. It diverts the need for the nurse to respond to the parent's question, and it does not provide information or education. (Option 4) This response is confrontational and could give the parent the impression that the nurse and health care team do not believe the story of how the child sustained the injuries. The parent could react with a heightened sense of anger. Educational objective: When discussing suspected child abuse with a caregiver, the nurse needs to be supportive and empathetic and maintain a neutral, nonpunitive and nonaccusatory manner. The parent needs to be told that the safety and well-being of the child are the primary concerns and that certain types of injuries and/or situations must be reported to the appropriate CPS agencies.

wandering clients with dementia

Individuals with dementia may wander and become lost during any stage of the disease. The most effective strategy to prevent wandering is to make modifications to secure the environment. These include: Placing locks above or below eye level on doors that lead to the outside. Clients with Alzheimer disease (AD) lose their peripheral vision; they cannot see objects unless they are directly in front of them or they purposely move their heads (Option 3). Adding a motion sensor or alarm that goes off when someone tries to exit Placing a large stop sign on door exits Disguising a door with a curtain or wall hanging Using childproof doorknob covers Placing a black mat or black strip by an exit. The client may perceive this as an impassable black hole due to changes in depth perception. (Option 1) Clients with AD should not be left alone; however, it is impossible for any caregiver to watch another person every minute of the day. Clients with AD can walk out of their homes while family members are sleeping. (Option 2) Notifying neighbors can be helpful if the client leaves the residence but will not prevent wandering. (Option 4) Safe return or identification bracelets are important, but they will not prevent wandering. A bracelet should be placed on the dominant hand to minimize the chance of removal. Educational objective: The most effective strategy to prevent clients with dementia from wandering is to make modifications to secure their environment. These include installing locks above or below eye level on doors, hiding exits with wall hangings or curtains, placing a black mat in front of exits, and using doorknob covers, motion detectors, and alarms.

airborne infections (measles, tuberculosis, varicella, severe acute respiratory syndrome)

Infectious agents that are spread by air currents are among the most contagious of pathogens. Therefore, clients with airborne infections (measles, tuberculosis, varicella, severe acute respiratory syndrome) should be isolated first using airborne precautions. These infections are spread via very small particles that circulate in the air. Clients with airborne infections are placed in an isolation room with negative pressure that provides air exchange or with a high-efficiency particulate air filtration system. (Option 1) Clients with scabies will be placed in contact isolation. The 4-year-old is contagious, but only if direct contact is made. Therefore, isolating the client with airborne precautions is the priority. (Option 3) Clients with influenza are placed on droplet precautions. The 12-year-old can spread pathogens via large droplets released into the air when coughing, sneezing, or talking. The client would be the second priority for isolation. (Option 4) Clients with methicillin-resistant Staphylococcus aureus infection are placed on contact precautions. The 14-year-old is contagious, but only if direct contact is made. The client requires isolation but is not a priority over the client whose pathogens are airborne. Educational objective: Airborne infections (eg, measles, tuberculosis, varicella) are spread by air currents and are among the most contagious of diseases. Clients with these infections require airborne precautions and should be isolated first

intimate partner violence (IPV)

Intimate partner violence (IPV) is physically, emotionally, verbally, sexually, or economically abusive behavior inflicted by one partner against another in an intimate relationship, to maintain power and control. Nurses must be aware of the risk factors and signs of IPV to recognize victims of abuse and to intervene (eg, separating the victim from the abuser during the health history interview, providing information about community resources). Features of IPV include: The abusive partner exhibits intense jealousy and possessiveness (Option 3). The victim of IPV chooses to stay in the relationship for a variety of reasons (eg, fear for life, financial or child custody concerns, religious beliefs) (Option 4). The abuse begins or intensifies during pregnancy (Option 5). (Options 1 and 2) IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. Educational objective: Intimate partner violence (IPV) is abusive behavior inflicted by one partner against the other in an intimate relationship. IPV occurs in all religious, socioeconomic, racial, and educational groups, and in both heterosexual and same-sex partnerships. IPV often begins or intensifies during pregnancy. Victims often stay in the relationship due to fear, financial or child custody concerns, or religious beliefs, among other reasons.

measuring BP with arterial line and manual cuff

Invasive arterial line and manual cuff readings measure BP via 2 different methods. The arterial line measures flow of the blood past a catheter, and the manual cuff measures pressure based on compression of the artery. Because of the differences, the 2 pressures may not match. The arterial line can be highly useful to the clinician as it gives a continuous measurement of accurate BP. The manual cuff will give a reading of the pressure only at the moment the pressure is measured. The following steps should be instituted to ensure accuracy of invasive pressure readings: Position the client supine, flat, prone, or with the head of the bed <45 degrees Confirm zero reference stopcock (port of the stopcock nearest to the transducer) to be at the level of the phlebostatic axis (4th intercostal space, midaxillary line), which approximates the level of the atria of the heart Zero the system after initial setup, with disconnection of the transducer or when accuracy of the measurements is questioned Perform a dynamic response test (square wave test) every 8-12 hours, when the system is opened to air or when accuracy of measurements is questioned Measure pressures at the end of expiration (Option 2) The client does not need to be flat for all pressure readings. As long as the zero reference stopcock is level with the phlebostatic axis, the position can be supine, flat, prone, or with the head of the bed <45 degrees. (Option 3) Comparison of the 2 methods of blood pressure measurement will not facilitate accurate functioning of the arterial line. Educational objective: Blood pressure measurement via an invasive arterial line is a very effective clinical tool in client care management. For accurate measurements, the nurse should follow systematic assessment and management of the arterial line.

blood transfusion reaction

It is important for the nurse to remain with the client for 15 minutes after starting a blood transfusion to monitor for signs of a reaction. These signs include fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. The client may report a variety of symptoms ranging from none to a feeling of impending doom. If signs of a transfusion reaction occur, the nurse should: Stop the transfusion immediately (Option 4). Using new tubing, infuse normal saline to keep the vein open (Option 5). Continue to monitor hemodynamic status and notify the health care provider and blood bank. Administer any emergency or prescribed medications to treat the reaction; these may include vasopressors, antihistamines, steroids, or IV fluids (Option 1). Collect a urine specimen to be assessed for a hemolytic reaction (Option 2). Document the occurrence and send the remaining blood and tubing set back to the blood bank for analysis (Option 3). Educational objective: If signs or symptoms of a blood transfusion reaction occur, the nurse should stop the infusion immediately and use new tubing to keep the vein open with normal saline. The nurse should continue to monitor the client's hemodynamic status, and administer prescribed drugs. The nurse should also collect a urine specimen to be assessed for a hemolytic reaction.

organ procurement services (OPS)

Local organ procurement services (OPS) are notified for every client death, per hospital protocol (Option 2). If the client is deemed appropriate as a donor, then OPS collaborate with hospital staff in approaching the client's family about organ donation. Cardiac support (eg, dopamine, epinephrine) and respiratory support (eg, ventilator) continue as organ donation is discussed and/or performed. Life support is withdrawn only if the client is not a candidate for donation due to physiological reasons or the client/family does not consent. (Option 1) Organ donation is discussed before final arrangements and funeral plans are made. In most cases, the family is referred to the hospital chaplain or someone outside the hospital for assistance with final arrangements. (Option 3) Medical and nursing care would continue as organ donation is discussed due to organ and tissue perfusion being necessary for viable donation. (Option 4) Local OPS are contacted before life support is removed so that physiological support is continued in the event that the client is a viable donor. Educational objective: All client deaths are reported to local organ procurement services, per hospital protocol. Life support is continued until a decision for organ donation is reached so that organs and tissues continue to receive perfusion and oxygenation.

lovenox (enoxaparin)

Low-molecular-weight heparins (LMWHs) (eg, enoxaparin, dalteparin) are anticoagulants commonly used for prevention and treatment of deep venous thrombosis and pulmonary embolism. LMWH is administered subcutaneously and is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose. During injection, the air bubble follows the medication out of the syringe, ensuring that no medication is left behind. The nurse should not expel the air bubble prior to administration as this could result in an incomplete dose and medication error (Option 2). (Option 1) After subcutaneous anticoagulant injection, the client should not rub the injection site as this increases bruising and the risk for hematoma. (Option 3) A 90-degree angle is appropriate for a subcutaneous injection in an obese client. In general, subcutaneous injections are administered at a 90-degree angle if 2 in (5 cm) of tissue can be grasped or a 45-degree angle if only 1 in (2.5 cm) of tissue can be grasped. (Option 4) Subcutaneous anticoagulants are best absorbed when administered in the lower part of the right or left lateral abdominal wall (ie, "love handles"), at least 2 in (5 cm) away from the umbilicus. Educational objective: Low-molecular-weight heparin is often available in a prefilled syringe, which contains an air bubble to ensure delivery of the entire dose during injection. The nurse should not expel the air bubble prior to administration as this could result in some medication being left in the syringe and an incomplete dose delivery.

malfunctioning health care equipment

Malfunctioning health care equipment must be taken out of service to prevent client injury. If an automatic, noninvasive blood pressure (BP) machine malfunctions (eg, overinflates, displays error message), it may cause an inaccurate reading and pain and bruising to the client. The nurse should tag any malfunctioning piece of equipment and take it out of service until it can be checked by maintenance personnel (Option 4). The nurse should take the client's BP with a manual cuff so that the maximum inflation can be controlled. A BP cuff needs to be inflated only approximately 30 mm Hg above the pressure at which the client's brachial pulse disappears. (Option 1) Placing a washcloth under the cuff can make the blood pressure measurement less accurate and does not address malfunctioning equipment. (Option 2) If the nurse suspects that health care equipment is malfunctioning, it should not be used. Troubleshooting malfunctioning equipment on the client may harm the client. (Option 3) BP cuffs that are too small or too large for a client will affect the accuracy of the BP measurement, so the nurse should always verify that the correct size of cuff is being used. Educational objective: Malfunctioning health care equipment, such as an automatic, noninvasive blood pressure machine that is overinflating and displaying an error message, must be taken out of service to prevent client injury. The nurse should verify the correct cuff size and take a manual blood pressure.

if client expresses concern about a medication,

Medications appear different when produced by different manufacturers, and the client's home medications may vary in color, size, or dosage per tablet. If a client expresses concern about a medication, the nurse should first compare the actual tablet with the client's current prescription (Option 2). (Option 1) Once the nurse verifies that the administered medications match the current prescriptions, the nurse can compare them with the client's home medications and explain any changes in prescriptions. In acute care settings, clients may be on different medication regimens than they are at home. Additional medications may be given in the hospital and some medications may be withheld or decreased/increased in dose (eg, antihypertensives are withheld if the client is hypotensive). (Options 3 and 4) Reassuring a client that an unknown medication was given the previous day or prescribed by the health care provider does not address the client's concern about taking the medication. The nurse should first investigate to ensure that the medication is correct before providing reassurance or education. Educational objective: If the client is concerned about an unknown medication, the nurse should investigate to ensure that the appropriately prescribed medication is being administered before reassuring and educating the client about the medication.

meniere disease

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks). Fall precautions that should be instituted include assisting the client when arising and ambulating (Option 1), placing the bed in low position, and raising side rails. However, raising all side rails is considered a restraint and would be inappropriate. The nurse would need to intervene and instruct the UAP that 2 or 3 side rails lifted up would be sufficient (Option 3). (Options 2 and 4) Vertigo may be minimized by staying in a quiet, dark room and avoiding sudden head movements. The client should reduce stimulation by not watching television and not looking at flickering lights. Educational objective: Safety is a priority for the client experiencing an acute attack of Meniere disease. Fall precautions include placing the bed in low position, raising 2 or 3 side rails, and assisting the client with arising and ambulating. Vertigo can be minimized by staying in a quiet, dark room without a television or flickering lights.

myasthenia gravis

Myasthenia gravis is an autoimmune disease in which antibodies attack acetylcholine receptors. This results in weakness in skeletal muscles, especially in the bulbar region that involves eye movement, swallowing/speaking, and breathing. Such clients become more exhausted as the day progresses. The client can be discharged home as ptosis is an expected finding (Option 5).

Net intake and output

Net intake and output is calculated by subtracting total output from total intake. The nurse should record all occurrences of intake and output. Clients with a significant discrepancy in fluid intake and output are at risk for a fluid volume imbalance; however, daily weights are always the best indicator of fluid balance. Net intake and output can be calculated by performing these steps: Convert oral intake to mL using the following equivalents: 1 cup = 8 oz 1 oz = 30 mL 1 cup = 240 mL Calculate total intake and total output: 3. subtract total output from total intake

nursing responsibilities prior to surgery

Nursing responsibilities prior to surgery include assessment, client teaching, and communication with the health care provider. Client allergies and history are confirmed while baseline vital signs are collected. Other nursing preoperative responsibilities include: Confirming that informed consent has taken place and signed documents are placed in the client's chart (Option 3). Encouraging the client to void to reduce the risk of retention in the immediate recovery period (Option 1). Ensuring that the client has been on NPO status to avoid aspiration during surgery and documenting when it started (Option 2). Witnessing and documenting preoperatively that the correct surgical site is marked by the surgeon with a permanent marker. Verify this with the client, ensuring that surgery will take place on the correct side/site (Option 5). (Option 4) If an IV line has not been started, an 18-gauge catheter is preferred. However, if a functioning IV line is already present, a 20-gauge is acceptable. Blood products, if needed during surgery, can be transfused through a 20-gauge catheter if necessary. Educational objective: When preparing a client for surgery, the nurse needs to ensure that informed consent has taken place and signed documents are in the chart. The nurse also witnesses that the correct operative site is marked and verified by the client and ensures that the client is NPO and voids prior to surgery.

organ and tissue donation

Organ and tissue donation involves surgical transfer of organs to living clients. Whenever a client's death is considered imminent, or in cases of irreversible neurologic injury (eg, brain death), nurses are responsible for initiating contact with the regional organ procurement organization (OPO) or facility organ donation coordinator. Nurses should utilize careful therapeutic communication to provide support for the client's family following brain death. However, nurses should never directly approach family members about organ donation, as it involves many legal and ethical concerns and complex eligibility factors that should be addressed by the OPO. The OPO arranges for specialized health care professionals to contact the family directly to determine the client's eligibility, provide information, and obtain consent. The OPO also extensively screens the client for disease, as immunosuppressive therapy makes organ recipients vulnerable to infection and cancer. (Option 2) Some regions have organ donor registries that allow individuals to express their wishes, but in most cases the client's family consents for donation. (Option 3) Nurses should not promote organ donation as a means to cope with emotions. This may provide false hope that organ donation will facilitate or ease grieving. (Option 4) Brain death is considered irreversible, and nurses should not offer false reassurance about possibility for recovery. Educational objective: Whenever a client's death or brain death is considered imminent, nurses initiate contact with specialized professionals who determine a client's eligibility for organ donation. Nurses provide therapeutic support to family members but should never directly approach them about organ donation.

palliative care

Palliative and end-of-life care for end-stage heart failure focuses on client-centered interventions to provide symptom and pain relief and psychological and spiritual support, rather than on curative interventions. The client with end-stage heart failure, a terminal illness, would be most appropriate to transfer as palliative care can be provided in any health care setting. (Option 1) Cardiac troponins are proteins released into the blood by damaged cardiac muscle (ie, myocardial infarction). Serial troponin I levels are normal (<0.5 ng/mL [0.5 mcg/L]) in clients with unstable angina as there is no muscle injury; however, cardiac ischemia is present. This client requires continual cardiac monitoring and interventions to restore blood flow to the heart. (Option 2) Atrial fibrillation involves the rapid firing of irritable foci in the atria and an irregular, sometimes rapid, ventricular response. To slow the heart rate (goal <100/min), an IV infusion of the calcium channel blocker diltiazem (Cardizem) is prescribed; this requires continual cardiac monitoring. (Option 3) Complete heart block is life-threatening and requires a pacemaker. This client should not be transferred. Educational objective: Clients with unstable angina experiencing chest pain and clients newly admitted with complete heart block or atrial fibrillation with a rapid ventricular response are unstable and require continual monitoring in an intensive care unit.

paraphimosis

Paraphimosis occurs when the uncircumcised male foreskin cannot be returned (reduced) to its original position, after being pulled back (retracted) behind the glans penis, resulting in pain, progressive swelling of the foreskin, and impaired lymph and blood flow. Paraphimosis can occur when a health care worker accidentally leaves the foreskin in the retracted position for an extended period of time (eg, under a condom catheter sheath). It is critical for the precepting nurse to intervene when the student nurse retracts the foreskin before applying the condom catheter to avoid permanent damage to the glans resulting from impaired circulation (Option 3). (Option 1) The drainage tubing is attached to a leg collection bag in a mobile client to enable ambulation, prevent tube kinking, and facilitate gravity drainage. (Option 2) A 1-2 in (2.5-5 cm) space should be left between the tip of the penis and the end of the condom to prevent penile irritation and pooling of urine in the condom. (Option 4) If the condom catheter is not self-adhesive, elastic adhesive is used in a spiral fashion to secure the device to the penis. Adhesive tape may cause irritation and/or injury, and should not be used. Educational objective: Health care providers should ensure a client's foreskin is fully reduced before applying a condom catheter, as prolonged retraction can cause paraphimosis, progressive swelling of the foreskin, vascular compromise, and permanent damage to the glans.

parvovirus B-19

Parvovirus B-19 is a common childhood infection also known as "fifth disease." Infected clients display a characteristic "slapped cheek" rash on the face. Symptoms range in severity; however, most children do not require intervention. Transmission of the infection is usually through person-to-person contact, especially with respiratory secretions. Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies (eg, hydrops fetalis, stillbirth). It is recognized as a TORCH infection (Toxoplasmosis, Other [parvo-B19/varicella zoster], Rubella, Cytomegalovirus, Herpes simplex virus), a group of infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is inappropriate due to potential harm to the fetus. (Option 1) A combative toddler should not be a hazard to the pregnant nurse. Appropriate precautions should be taken to ensure safety around combative clients. (Option 2) Group A Streptococcus infection requires droplet precautions; however, it does not pose a perinatal infection risk. Group A Streptococcus may manifest as sore throat. (Option 4) Extreme caution should be taken while handling cytotoxic medications; however, intrathecal administration days prior to contact should not pose a risk to the pregnant nurse. The nurse should use standard precautions if contact with the client's blood or bodily fluids is anticipated. Educational objective: Clients with infectious diseases that can be transmitted to the fetus (eg, TORCH infections) should not be assigned to a pregnant nurse. These infections, including parvovirus B19, can cause severe anomalies in the developing fetus.

peripheral IV catheter

Peripheral IV (PIV) catheter sites should be changed usually no more frequently than every 72-96 hours unless signs of complications develop. Signs of phlebitis include erythema, edema, warmth, pain, and palpable venous cord. Manifestations of infiltration include edema and coolness to the touch around the insertion site (Option 1). The nurse should also monitor for edema related to infiltration under the involved limb. Infiltrated fluid may leak into loose skin, causing edema in dependent areas without obvious signs of infiltration at the PIV site, particularly in the elderly (Option 3). If a PIV site is leaking fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter; all of these issues require a site change (Option 5). (Option 2) Potassium is a known irritant to veins. Discomfort is not a sign of infiltration, although the site should be regularly monitored for complications. (Option 4) Locations where flexion occurs (eg, antecubital region) are generally avoided; however, these sites may be required for certain medications or situations. Unless a problem develops, PIV sites are not changed based solely on location. Educational objective: Peripheral IV catheter sites should be changed no more frequently than every 72-96 hours unless signs of complications develop. The nurse should check for signs of infiltration by assessing the insertion site and areas dependent from it (ie, edema, cool skin).

permanent pacemakers

Permanent pacemakers consist of a generator that is implanted subcutaneously in the chest and lead wires that terminate in the heart. Infection of the incision site can easily travel down the pacemaker lead wires into the heart, causing myocarditis and/or endocarditis. Infection may disrupt pacemaker function and result in failure to sense or pace that causes decreased cardiac output and life-threatening arrhythmias. Signs and symptoms of pacemaker malfunction (eg, hypotension, bradycardia, dizziness) and infection (eg, redness, fever, purulent drainage) should be assessed immediately (Option 3). (Option 1) Redness at the umbilicus with fever may indicate infection due to a retained umbilical cord. This requires parent teaching on proper care and an antibiotic but is not the priority. (Option 2) Post-tussive emesis (vomiting after coughing) can occur in children during frequent or severe coughing spells. A respiratory rate of 27/min is slightly elevated for a 2-year-old (normal: 25/min). This child should be assessed for the cause of the cough (eg, respiratory infection) but is not the priority. (Option 4) This client needs to be evaluated second for possible concussion or hemorrhage; however, the client is currently alert and responsive. Educational objective: Infection of a pacemaker incision site can travel down the lead wires to the heart, causing myocarditis and/or endocarditis. Infection may disrupt pacemaker function, resulting in failure to sense or pace that causes decreased cardiac output and life-threatening arrhythmias. Signs and symptoms of pacemaker malfunction (eg, dizziness) and infection (eg, purulent drainage at incision site) should be assessed immediately.

priority assessment of pregnant client (3rd trimester)

Priority assessment of the pregnant client during the third trimester emphasizes early identification of complications and differentiation from normal physiologic changes and discomforts of pregnancy. Leukorrhea (ie, whitish, mucoid vaginal discharge) increases dramatically during pregnancy. However, copious, clear vaginal discharge that is thin or watery could indicate leaking of amniotic fluid, especially in the third trimester. Assessing for rupture of membranes should be a priority (Option 1). Frequent urination throughout pregnancy may be caused by uterine enlargement, hormonal influences, increased blood volume, and changes in glomerular filtration rate. However, dysuria, cloudy urine, or flank pain should not be present and may indicate infection (Option 2). Headache, right upper quadrant pain, and visual changes could indicate preeclampsia and need priority assessment (Option 4). (Option 3) During pregnancy, total blood volume increases by 30%-50%, and estrogen contributes to increased vascularity of the mucous membranes. These physiologic changes cause capillary engorgement and hyperemia, which may lead to nasal stuffiness and a sense of fullness in the ears. (Option 5) Colostrum, a precursor to breast milk, is yellow-orange in color and may be seen leaking from the nipples during the second and third trimesters. Educational objective: Common physiologic changes in pregnancy include nasal stuffiness, ear fullness, and colostrum secretion. Findings warranting further investigation and evaluation include dysuria; flank pain; headache with blurred vision; and copious amounts of watery, clear vaginal discharge.

rabies

Rabies is caused by a virus present in the saliva of an infected animal (eg, bat, dog) and can be transmitted to a human through a bite, a scratch, or mucous membrane contact. Rabies affects the central nervous system, and can cause viral encephalitis with eventual death from cardiovascular and respiratory collapse if untreated. Clients with actual or suspected rabies exposure should receive rabies postexposure prophylaxis, including: Immediate wound care: Aggressive scrubbing and cleaning with povidone-iodine solution or soap and water to decrease the viral count and the rabies transmission risk (Option 4) Administration of tetanus toxoid vaccine (if the client is not current with immunizations): Tetanus is associated with a high mortality rate and can be transmitted through animal bites (Option 2) Administration of the human rabies immunoglobulin: Provides passive immunity and is injected into the proximal wound area (Option 3) Administration of the human rabies vaccine: Provides active immunity and is administered intramuscularly on the day of exposure and again on days 3, 7, and 14 postexposure (Option 1) Educational objective: The rabies virus affects the central nervous system and is transmitted by the saliva of infected animals (eg, bat, dog) usually via a bite or scratch. Postexposure prophylaxis includes immediate wound care with povidone-iodine or soap and water; vaccines for tetanus and rabies, or rabies immunoglobulin, may be given afterward.

rapid fluid infusions

Rapid fluid infusions can cause hypervolemia as excess fluid accumulates within the extracellular space, especially in clients with heart failure or kidney disease. The infusion should be stopped and the client assessed for pulmonary edema (eg, dyspnea, lung crackles) and other signs of fluid overload (eg, peripheral edema, jugular venous distension) (Option 2). If signs are present, the health care provider should be notified as fluid overload can cause respiratory and cardiovascular compromise. (Option 1) Itching is common post surgery from side effects of narcotics (generalized) and the wound healing process (localized). Generalized itching may indicate an allergic drug reaction and should be assessed. This client with localized itching may need ice packs or diphenhydramine but would not be a priority. This client would be seen second. (Option 3) An angry client waiting for discharge should be addressed before the situation escalates. However, clients with physiologic needs take priority. (Option 4) The nurse should notify the health care provider of this client's potassium level and prescribed IV fluids. If IV fluids are still required, the prescription should be changed to normal saline (without potassium chloride). This client is not a priority as the potassium level is still within normal limits (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). The value is critical if potassium level is >5.5 mEq/L (5.5 mmol/L). Educational objective: Fluid overload (ie, dyspnea, lung crackles, peripheral edema, jugular venous distension) can occur with increased infusion rates and should be addressed promptly to prevent respiratory or cardiovascular compromise.

moving client who is uncooperative

Recommended bed-to-chair transfer method Weight bearing Transfer method Full -Independent; no assistance required -1-person standby assistance or observation for clients who are uncooperative or at high risk for falls Partial -1-person assist stand & pivot transfer with gait belt or motorized assist device if cooperative -2-person assist with full-body sling if client is uncooperative None -Motorized assist device if client is cooperative & has upper body strength -2-person assist with full-body sling if client is uncooperative &/or has no upper body strength ***Client should use as much of his or her own strength as possible. ***Use assistive devices when lifting >35 lb (15.9 kg) of client's body weight. To determine the most appropriate method to transfer a client safely for the first time, the nurse should assess 2 factors: Whether the client can bear weight: Neurological deficits (eg, paralysis, paresis [weakness]) Decreased muscle strength (eg, prolonged immobility, multiple sclerosis, muscular dystrophy) Trauma (eg, amputee, hip fracture) Whether the client is cooperative and able to follow instructions: Altered mental status (eg, delirium, drug intoxication) Decreased cognitive ability (eg, dementia, head injury) Given this client's weakness and inability to cooperate with instructions during the transfer, a pivot transfer would be unsafe. A standing-assist lift may also be unsafe as it also requires the client to follow directions. Therefore, a full-body sling with mechanical lift should be used to safely transfer this client (Option 4). This prevents musculoskeletal injuries to the health care worker and provides the safest method of transfer for this client. (Option 1) A 1-person standby assistance is appropriate for a client with full weight-bearing ability who is either uncooperative or at high risk for falls. (Options 2 and 3) A pivot transfer or standing-assist lift transfer requires client cooperation with instructions to promote safety during the transfer. Educational objective: A client who can bear weight partially but is unable to cooperate with instructions requires a full-body sling with mechanical lift and 2 caregivers for safe transfer.

rituximab (rituxan)

Rituximab (Rituxan) is a monoclonal antibody (end in -mab) that affects the lymphocytes. It is commonly prescribed to treat certain forms of cancer (eg, lymphoma) and autoimmune diseases (eg, lupus). Like many monoclonal antibodies, rituximab can produce a powerful immune response (eg, bronchospasm, dyspnea, tachypnea, hypotension, angioedema) (Option 3). The nurse should closely monitor the client during and after the infusion. If life-threatening symptoms develop, the nurse should stop the infusion and immediately notify the health care provider. The symptoms will be treated (eg, corticosteroids) and, when resolved, the infusion is usually restarted at a slower rate. (Options 1, 2, and 4) In many clients, monoclonal antibody therapies, like many oncology pharmaceuticals, invoke flu-like responses (eg, fever, chills, diarrhea, nausea, vomiting). Clients are often pretreated with acetaminophen and diphenhydramine in anticipation of these reactions. Clients' symptoms are treated as needed (eg, antiemetics, antidiarrheals). Educational objective: Rituximab can produce a powerful immune response (eg, bronchospasm, dyspnea, tachypnea, hypotension, angioedema). Clients should be closely monitored during and after the infusion.

cardiac cycle & heart sounds

S1 and S2 are the normal "lub-dub" heart sounds that result from closure of valves. Systole occurs between S1 and S2, with S1 indicating closure of the atrioventricular (tricuspid, mitral) valves and S2 indicating closure of the pulmonic and aortic valves. S3, the third heart sound, is an adventitious (extra) heart sound that is heard as a "DUB" sound immediately following S2 (Option 3). S3 occurs during early diastole as a result of rapid ventricular filling and is a normal finding in children and young adults. In older adults, S3 is an abnormal finding that often indicates heart failure as the sound results from decreased ventricular compliance. S3 can be difficult to distinguish from S4. S4 is a "LUB" sound that occurs immediately before S1, during late diastole, and indicates ventricular hypertrophy. (Option 1) A pericardial friction rub is a creaky, grating sound heard throughout systole and diastole. Friction rub occurs with pericarditis and is due to friction between the inflamed layers of pericardium. (Option 2) S1 and S2 are the normal heart sounds heard during cardiac auscultation. (Option 4) A murmur is a swooshing, blowing, or rumbling sound due to turbulent blood flow (eg, from valve regurgitation or stenosis). Educational objective: S3, the third heart sound, is a "DUB" sound that immediately follows S2. It is a normal finding in children and young adults. S3, an abnormal finding in older adults, often indicates heart failure.

SBAR

SBAR (Situation, Background, Assessment, Recommendation/Request) is a model used for communication and hand-off reporting. It allows for standardized, organized, and thorough communication among nurses, health care providers, and other personnel. The nurse should first state the situation, including the nurse's name, the client's name and room number, and a brief description of the concerning matter. (Options 2 and 3) The client's code status, admission date, and admitting diagnosis are important to include when describing the background, not the situation. (Option 4) Current vital signs or clinical findings are a key aspect of communicating the assessment, not the situation. Educational objective: SBAR (Situation, Background, Assessment, Recommendation/Request) is a model that allows for standardized, organized, thorough communication among nurses, health care providers, and other personnel. The nurse should first state the situation, including the nurse's name, client's name and room number, and a brief description of the concerning matter.

medication administration

Safe medication administration is conducted according to 6 rights: Right client using 2 identifiers Right medication Right dose Right route Right time Right documentation When a mentally competent client questions a drug administration, the safest option is to first check the prescription to verify the 6 rights of medication administration (Option 1). If an error is ruled out (eg, different brand, new order) the nurse should follow up with appropriate teaching. (Option 2) The nurse must first verify all aspects of proper medication administration. If they are correct, the nurse should provide appropriate teaching on why the health care provider prescribed the medication. Explaining that the nurse is just following orders is rarely the correct answer. (Option 3) A pharmacology reference can verify information about the medication but will not confirm that the client is the correct recipient. Acceptable identifiers include first and last name, medical record number, and birth date. (Option 4) The nurse can teach the client about the purpose of the medication after the 6 rights have been verified. Educational objective: When a competent client questions a new medication, the nurse should first verify the 6 rights of safe medication administration: right client, medication, dose, route, time, and documentation. If safe administration has been confirmed, the nurse should then provide appropriate teaching to the client.

sedated infants are at risk for skin breakdown

Sedated infants are at increased risk for skin breakdown due to limited mobility, sensory deficits, and incontinence. Ischemia occurs when tissues are compressed between a bony area (eg, occiput) and an exterior surface (eg, bed), causing a pressure injury. The occiput is the highest pressure point in infants due to the increased weight of the head in proportion to the body; shearing may occur as the infant slides down in bed. The head of the bed is elevated ≤30 degrees to reduce pressure on the head and prevent sliding (Option 3). To prevent skin breakdown, moisture barriers (eg, barrier cream) are used to protect the skin from incontinence, perspiration, and drainage (Option 1). Baby powder is not recommended for preventing moisture and friction. The powder's texture can be very abrasive to skin, which increases pressure injury risk. It also carries the risk of respiratory irritation and damage if inhaled. Pulse oximetry sites should be changed every 4 hours to prevent burns and breakdown of the infant's thin skin (Option 2). (Option 4) Donut pillows reduce pressure in the center of the occiput; however, they increase pressure in surrounding areas, causing venous congestion, edema, and skin breakdown. Educational objective: Sedated infants are at increased risk of pressure injuries due to limited mobility, sensory deficits, and incontinence. The nurse should elevate the head of the bed ≤30 degrees to reduce pressure, apply a moisture barrier to any vulnerable tissue areas, reposition the pulse oximeter every 4 hours, and avoid the use of baby powder and donut pillows.

SSRI (selective serotonin reuptake inhibitors)

Selective serotonin reuptake inhibitors (SSRIs) (eg, escitalopram [Lexapro]), which are commonly prescribed antidepressants, usually take 1-4 weeks from the first dose to improve depression symptoms. If a client experiences no improvement after 2 months, re-evaluation is necessary (Option 2). Noncompliance is common with SSRIs due to intolerance of side effects (eg, nausea, weight gain, sexual dysfunction). The nurse should first assess if the client is taking the medication as prescribed (Option 3). Clients may require education on symptom management (eg, taking with food for nausea, nutritional education to manage weight). If the client is compliant but the medication has not relieved depressive symptoms, the health care provider may change the prescribed dose or medication. (Option 1) Assessing for stressors is important when a client is taking an SSRI. However, this can be asked later in the assessment as the priority is to determine compliance. (Option 4) The nurse should assess the client's medication compliance before discussing a change in the prescription with the health care provider. Educational objective: Selective serotonin reuptake inhibitors (eg, escitalopram, sertraline, fluoxetine) take about 1-4 weeks from the first dose to improve depression symptoms. If the medication is ineffective, the nurse should determine client compliance prior to notifying the health care provider.

septic arthritis (infectious arthritis)

Septic arthritis (infectious arthritis) is acute joint inflammation due to an infection. Pathogens may enter the joint from the bloodstream (eg, current infection elsewhere in the body), direct penetration (eg, intraarticular injection), or infected adjacent tissue (eg, osteomyelitis). Septic arthritis can lead to irreversible joint damage if not treated promptly. Clinical manifestations of septic arthritis include: Severe, pulsating pain, usually with sudden onset and exacerbated by movement Erythema, warmth, effusion (ie, excess synovial fluid) Limited range of motion due to swelling in the joint Systemic immune response to the joint infection (eg, fever) (may not be present in elderly or immunocompromised clients) The goal of treatment is to limit joint destruction and promote pain relief. Management may include aspirating synovial fluid; immobilizing the joint; restricting weight bearing; and administering antibiotics, analgesics, and antipyretics. (Option 5) Numbness in the lower extremity related to spinal nerve compression can be associated with arthritic diseases (eg, spinal stenosis) but is not characteristic of septic arthritis. Educational objective: Septic arthritis can lead to irreversible joint damage if not treated promptly. Characteristic manifestations include severe pain of sudden onset, erythema, warmth, swelling, limited range of motion, and fever.

severe anxiety

Severe anxiety impairs the ability to attend to stimuli in the environment other than the anxiety-producing event or factor. Physiological responses to anxiety include hyperventilation, palpitations, shortness of breath, and diaphoresis. Behavioral responses (eg, fixation on specific details, pacing) serve as coping mechanisms to manage anxiety. Unrelieved anxiety may become severe and escalate to a panic attack. The nurse should ensure safety and support the client with severe anxiety to prevent injury and escalation. The client is unable to attend to details, so the nurse should communicate in a calm, accepting manner; answer questions directly; and use simple statements (Option 4). (Option 1) Clients with severe anxiety are unable to attend to their own safety or needs. The nurse should not leave the client alone at this time. (Option 2) Anxiety is "contagious," so nurses' anxiety can exacerbate clients' anxiety (ie, reciprocal anxiety). Nurses should accept their own feelings about the situation and remain calm without transferring their frustrations to clients. (Option 3) Clients should be allowed to engage in coping behaviors (eg, repetitive acts, pacing) during episodes of severe anxiety as long as they do not risk harm. These behaviors relieve tension and prevent escalation. Educational objective: When caring for a client experiencing severe anxiety, nurses should provide a calm presence, reassure clients of safety, use simple statements, and answer questions directly. Nurses should not leave the client alone, interfere with coping behaviors, or transfer their own frustrations to the client.

singed facial hair

Singed facial hair may indicate a smoke inhalation injury from close proximity to a fire. Inhaled smoke causes injury to the airway and lung tissue, which may result in life-threatening pulmonary or tracheal edema. The nurse should assess for any indications of inhalation injury (eg, singed facial hair, hoarse voice, burned clothing around the chest and neck) and prepare for emergent intubation to protect the airway. (Option 1) A child who has a headache after a head trauma may have a concussion and will require a neurologic examination. This client is alert enough to verbalize pain and will likely be discharged with instructions to the parents to observe for changes in neurologic status. (Option 2) A client who is unable to raise an injured arm above the head may have a rotator cuff tear. This client will require joint rest, application of ice or heat, and analgesia with nonsteroidal anti-inflammatory drugs but is not the priority. (Option 4) An elderly client with severe diarrhea is at risk for dehydration. The client may require IV fluids and further workup, but this treatment may be delayed until treatment of higher-priority clients. Educational objective: Smoke inhalation injuries may cause life-threatening pulmonary or tracheal edema. The nurse should assess for any indications of inhalation injury (eg, singed facial hair, hoarse voice, burned clothing around the chest and neck) and prepare for emergent intubation to protect the airway.

sleep disturbances in clients with major depressive disorder

Sleep disturbances are part of the diagnostic criteria for major depressive disorder. Clients may experience insomnia (early in the night, in the middle of the night, or in the early morning hours) or hypersomnia. Long-term treatment with medication alone is not necessarily the best approach to treat insomnia. Nonpharmacological strategies for improving sleep hygiene include: Avoiding naps throughout the day Engaging in physical activity or exercise, preferably at least 5 hours before bedtime Receiving at least 20 minutes of natural sunlight each day, ideally in the morning, to improve sleep patterns Avoiding caffeinated beverages after noon Avoiding alcohol and/or smoking at bedtime Participating in a relaxing activity before bedtime (eg, warm bath, reading, listening to soft music) Decreasing environmental stimuli; making sure the bedroom is dark, cool, and quiet Avoiding heavy meals or large amounts of fluids at bedtime Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime, which promotes comfort and relaxation to aid sleepiness (Option 2) Napping during the day interferes with normal sleep patterns. (Option 3) Exercising right before going to bed increases brain metabolic activity and wakefulness. Educational objective: Nonpharmacological strategies for improving sleep hygiene include exercising during the day, engaging in a relaxing activity before bedtime, having a relaxing sleep environment, avoiding naps during the day, avoiding caffeine after noon, and receiving at least 20 minutes of sunlight each day.

sleep hygiene

Sleep hygiene refers to a group of practices that promote regular, restful sleep. Components of sleep hygiene include: Keep a consistent sleep schedule, even on nonworking days. Avoid daytime naps; if needed, they should be brief (less than 20-30 min). Go to bed early enough to get at least 7 hours of sleep. Get out of bed if sleep does not occur after 20 minutes (Option 3). Engage in regular, relaxing activities (eg, warm bath, reading) before bedtime. Sleep in a cool, quiet, dark room (Option 4). Avoid brain-stimulating substances or activities at least 4 hours before bedtime (eg, caffeine, computer usage, exercise) (Option 1). Reduce fluid intake before bedtime to prevent nocturia. Use sleeping pills cautiously or avoid them as they may affect daytime functioning, and rebound insomnia may occur on withdrawal. (Option 2) Alcohol may help to induce sleepiness at bedtime; however, it can cause early awakening and fragmented sleep. (Option 5) Clients should not watch television at bedtime as it is stimulating and produces ambient light. The bed should be used only for sleep and sex. Educational objective: Practices to promote sleep hygiene include establishing a regular sleep routine; sleeping in a cool, quiet, comfortable environment; avoiding caffeine and alcohol and reducing fluid intake before bedtime; and limiting stimulating light (eg, computer, television) before bedtime. A client unable to sleep after 20 minutes should get out of bed.

somatic symptom disorder (SSD)

Somatic symptom disorder (SSD) is a psychological disorder that develops from stress, resulting in medically unexplainable physical symptoms (eg, abdominal pain) that disrupt daily life. Clients with SSD focus an excessive amount of time, thought, and energy on the symptoms, often seeking medical care from multiple health care providers. Nursing interventions focus on minimizing indirect benefits and developing client insight. To minimize the indirect benefits from being "sick" (secondary gains), the nurse should: Redirect somatic complaints to unrelated, neutral topics Limit time spent discussing physical symptoms (Option 2) To promote insight and healthy coping mechanisms, the nurse should assist the client to: Identify secondary gains (eg, increased attention, freedom from responsibilities) Recognize factors that intensify symptoms (eg, increased stress, reminders of a deceased family member) Incorporate appropriate coping strategies (eg, relaxation training, physical activity) (Option 1) An elimination diet would increase the client's focus on the symptoms and is inappropriate, as physiological causes have already been ruled out. (Option 3) The client's symptoms are real despite the lack of diagnostic findings. The nurse should administer analgesics as prescribed. (Option 4) Disputing the validity of the client's symptoms may increase the client's stress level and exacerbate symptoms. Educational objective: Somatic symptom disorder occurs when stress causes medically unexplainable physical symptoms that disrupt daily life. Nursing interventions include limiting discussion of symptoms and identifying secondary gains, factors that intensify symptoms, and coping strategies.

stevens-johnsons syndrome

Stevens-Johnson syndrome is an immune-mediated reaction triggered by certain classes of medications (eg, sulfonamide antibiotics, allopurinol, anticonvulsants [eg, phenytoin]). Initial symptoms are nonspecific and flu-like (eg, fever, fatigue) and are followed by blistered lesions and skin detachment on the face, trunk, and palms (Option 4). Stevens-Johnson syndrome can cause fatal complications (eg, sepsis, multiple organ dysfunction) and requires immediate hospitalization and follow-up by the health care provider. Treatment includes prompt discontinuation of the causative medication and initiation of supportive care (eg, fluids, nutrition, wound care). (Option 1) Capsaicin cream (Zostrix) is a topical analgesic. Capsaicin, a component of hot peppers (eg, cayenne, jalapeño), can cause a burning sensation; therefore, clients are taught to wash their hands after application to avoid getting the cream in their eyes. (Option 2) Carbidopa-levodopa (Sinemet) is an anti-Parkinson medication. Orthostatic hypotension is a common side effect. (Option 3) Hydroxyzine (Atarax) is a commonly used, first-generation antihistamine similar to diphenhydramine (Benadryl) and chlorpheniramine. Anticholinergic side effects (eg, urinary retention, dry mouth, constipation, blurred vision) are common. This client needs to be called second. Educational objective: Stevens-Johnson syndrome is an immune-mediated reaction triggered by certain classes of drugs (eg, sulfonamide antibiotics, allopurinol, anticonvulsants). It is characterized by blistered lesions on the face, trunk, and palms and may be fatal if left untreated.

successful behavior modification

Successful behavior modification (eg, diet and exercise for effective weight loss) requires client readiness and motivation to change, which can be assessed using the Stages of Change Model. With the appropriate support (eg, listening, not pressuring the client), clients can move from one stage to the next: Precontemplation: The client does not believe a problem exists, although others may point it out (eg, encouraging healthy eating) (Option 4). Contemplation: The client recognizes a change is needed but is undecided whether it would be possible or worthwhile (Option 2). Preparation: The client has decided to change, explores emotions related to the decision, and begins establishing goals (eg, fitting into a dress) (Option 3). Action: The client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans), and actively takes steps toward new behavior (eg, choosing activity over television) (Option 1). Maintenance: The client continues to uphold the new behavior and focuses on preventing relapse. Termination: The client has achieved the desired change. This stage may be theoretical, as relapse to former behaviors is always possible. Educational objective: Successful behavior modification requires client readiness and motivation to change, as evidenced by the client developing and acting on a plan. Clients often do not initially see the need for change, but with the appropriate support they begin contemplating change, preparing to change (eg, goal setting), and then actively changing.

asthma peak flow

The best indication of moving air in a client with asthma is peak flow. The results are categorized as green (≥80% of personal best and good control), yellow (50%-79% of personal best and caution), and red (<50% of personal best - a medical alert). This client is currently in good control. Other findings to note include effortless breathing, no cough or wheeze, and sleeping well all night (Option 3).

administration of blood

The blood type O- is the "universal donor" as it has no anti-A or anti-B antigens; AB+ is the "universal recipient" as the lack of antibodies allows any blood type to be transfused (Option 1). Blood is always transfused with normal saline, not dextrose. The line should be established prior to obtaining the blood. Most facilities have a policy to start the blood within 30 minutes of obtaining it to prevent bacterial growth (Option 3). The most likely time for a serious ABO incompatibility/transfusion reaction is when the infused blood first enters the client's body. The registered nurse (RN) should remain in the room for the first 15 minutes/50 mL of the transfusion. However, the fourth set of vital signs would be taken after 1 hour of infusion; it would be safe to delegate this data collection to the unlicensed assistive personnel (the RN will analyze the vital signs) (Option 2). (Option 4) Most facilities want the transfusion completed in 2-4 hours. "Old" blood is more likely to break apart and cause hyperkalemia from the intracellular potassium leak. (Option 5) Most policies have the RN checking with another RN or qualified health care professional prior to blood administration. At least 2 identifiers such as name, medical record number, or date of birth can be used. Client identifiers never include a room number. Educational objective: Safe blood transfusion protocol includes checking of at least 2 client identifiers by 2 qualified health professionals, using normal saline to prime, and giving the infusion in 2-4 hours. The unlicensed assistive personnel can take vital signs during the later part of the transfusion. O- is the universal donor blood type and AB+ is the universal recipient.

closed head injury

The client whose head hit the steering wheel may have a closed head injury. This client is the priority and requires ongoing assessments for deficits related to the injury (eg, impaired movement, verbal communication, vision). The client should be evaluated for concussion (neurologic changes after a blow to the head), contusion (bruise on the brain), skull fracture, and epidural or subdural bleeding. The client's Glasgow Coma Scale score must be monitored closely; a reduction in this score may necessitate further intervention (eg, intubation). This potentially unstable client requires immediate evaluation. (Option 2) After a fall with or without abdominal trauma, pregnant clients undergo continuous fetal monitoring to observe for signs of fetal distress and placental abruption. However, a client with a head injury poses a more imminent risk and should be assessed first. (Option 3) The stab wound requires thorough cleaning and irrigation once bleeding is controlled. A tetanus vaccine should be administered if it has been more than 5 years since the last one. This client's vasculature, nerves, and tendons may be damaged; however, the unstable client is a higher priority. (Option 4) The laceration should be thoroughly cleaned and irrigated and tetanus vaccine status evaluated. Sutures and an x-ray to rule out a fracture may be required; however, the unstable client is a higher priority. Educational objective: A blow to the head may cause serious brain injury. Regular neurologic assessments should be performed, and the client should be evaluated for concussion, contusion, skull fracture, and epidural or subdural hematoma.

artifact pleythysmograph wavform

The erratic pulse oximeter tracing is representative of an artifact plethysmograph waveform caused by motion. When an electronic assessment reading is questionable, the nurse should always assess the client first for possible etiology. The assessment includes the client's oxygenation and perfusion status (skin temperature, color), the level of consciousness (in sedated clients), and restlessness or agitation. This assessment data guides the nurse in the correct analysis of the tracing. (Option 2) The artifact is most likely from movement or loose contact between the sensor and the area of the body to which it is attached. It is not an electrical artifact and does not require the device to be disconnected from this client. (Option 3) The pulse oximeter reading is 95%. Unless there are audible or visual secretions, increased ventilator peak pressure readings, coughing, or rhonchi, this client does not require immediate endotracheal suctioning. (Option 4) The reading on the device is 95% and the low alarm is set to 90%. Therefore, alarm parameters do not need to be reset. Educational objective: When the nurse assesses an erratic plethysmograph waveform, the first action is to assess the client's oxygenation/perfusion status and assess for a motion artifact. This assessment data guides the nurse in the correct analysis of the tracing.

low pressure alarm on arterial line

The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client to the ICU. Zeroing the monitor should be done if measurement accuracy is questioned. However, this should be done after the client has been taken care of. A low pressure alarm for an arterial line can indicate the presence of hypotension or disconnected tubing. Hemorrhage can rapidly occur with a disconnected arterial catheter line. The nurse should check the client for the presence of hypotension and its causes before troubleshooting the system.

medication administration

The nurse must follow the 6 rights of medication administration: The right client The right medication The right dose The right time The right route The right documentation Additionally, one of the National Patient Safety Goals (NPSGs) is to "improve the safety of using medications." This includes labeling all medications as soon as prepared, discarding any medications that are found unlabeled, and taking extra care for clients who take anticoagulant drugs. (Option 4) Individual dose packages should be opened at the client's bedside and should be placed in a medication cup only immediately prior to administration. (Option 5) Gloves are generally not required during medication preparation or handling of unopened packages or vials, although hand hygiene should be performed both prior to preparation or handling and again prior to administration. The nurse should wear gloves during medication administration when coming into contact with a route that is potentially contaminated by blood or body fluids (eg, administering intramuscular or subcutaneous injections, accessing a closed IV tubing system, placing a pill into a client's mouth using fingers). Educational objective: The nurse should follow the 6 rights of medication administration when preparing and administering drugs to a client. Additionally, the NPSGs of improving the safety of using medications should be followed, including labeling all medications, discarding medications found unlabeled, and taking extra care for clients taking anticoagulant drugs.

domestic abuse victims

The priority for possible domestic abuse victims is to remove them from any sources of immediate danger, including suspected abusers. Such clients should be questioned and assessed alone so that the suspected abusers do not guide their answers or intimidate them from providing truthful responses. In this case, the spouse appears angry and should, as a priority, be removed from the room to prevent further potential harm to the client or staff (Option 3). (Option 1) Notifying social services of suspected abuse should occur with the client's permission after any immediate threats are removed and after physiological needs are met. This should not be done in the presence of any potential abusers. (Option 2) Cleaning the laceration and preparing for sutures are appropriate interventions but are done after a suspected abuser is removed. The nurse also follows facility guidelines for documenting, gathering evidence, and/or photographing injuries before cleaning and further treatment. (Option 4) The arm should be x-rayed to assess for fractures and may require a sling for immobilization, but potential sources of harm are removed from the room first. Educational objective: If a client shows possible signs of abuse or neglect, the priority is to remove any sources of immediate danger (eg, suspected abuser) from the room to prevent further harm. Assessments and further interventions can occur after ensuring the client's safety.

urine dipstick

The protein test pad measures the amount of albumin in the urine. Normally, there will not be detectable quantities. Albumin is smaller than most other proteins and is typically the first protein that is seen in the urine when kidney dysfunction begins to develop. Proteinuria is characterized by elevated urine protein and can be an early sign of kidney disease. Occasional loss of up to 150 mg/day of protein in the urine, which may reflect as negative or trace protein on a dipstick, is typically considered normal and usually does not require further evaluation. Common benign causes of transient proteinuria include fever, strenuous exercise, and prolonged standing. (Option 2) Glucose in the urine is suspicious for diabetes mellitus. This client's glucose test strip result is negative. (Option 3) Nurse should obtain more information and assess before reporting to the HCP. (Option 4) There is no indication for the test to be repeated. Educational objective: The results of point-of-care testing, such as using urine test strips, are often interpreted by the nurse. Occasional loss of up to 150 mg/day of protein in the urine is typically considered normal and usually does not require further evaluation. Common benign causes of transient proteinuria include fever, strenuous exercise, and prolonged standing.

blunt force head injury

The transference of kinetic energy to the client's body from an opposing force during sudden deceleration (eg, fall, motor vehicle collision) causes bodily injury. If the client is not wearing a seatbelt during an automobile crash, the client may strike (or be propelled through) the windshield, causing blunt-force trauma to the head, neck, or spine. The unconscious client should first be assessed for adequate breathing and the presence of a pulse (using the rule of airway, breathing, and circulation [ABCs]) (Option 1). Using a rigid cervical collar, cervical spine immobilization must be maintained throughout the client assessment to minimize further injury (Option 4). The client should be removed and placed on a backboard after the cervical spine has been stabilized (Option 5). The nurse should also perform Glasgow Coma Scale scoring to determine the level of neurological impairment (Option 2). (Option 3) If a client with possible spinal injuries is not breathing, or if the airway is occluded, the nurse should use the jaw-thrust technique. The head-tilt/chin-lift maneuver may hyperextend the neck, compromising the cervical spine. Educational objective: After sudden deceleration with blunt-force head injury, the nurse first checks if the client is breathing and has a pulse (using the rule of airway, breathing, and circulation [ABCs]). Spinal injury should be presumed, and the cervical spine should be stabilized (eg, cervical collar). The jaw-thrust maneuver may be used to open the airway.

unconscious client arriving to ED

The unconscious client requires a thorough head-to-toe assessment on admission to assess for foreign objects, devices, or belongings that have potential for harm. This includes checking for: Medical alert bracelets/necklaces: Indicating allergy status, emergency contact, or code status (Option 2) Contact lenses: Remove to prevent corneal injury (Option 5) Medication patches: To prevent drug interactions and determine conditions currently being treated Tampons (in female clients): Remove to prevent toxic shock syndrome or infection (Option 4) Rings and jewelry: Remove to prevent constrictive injury or vascular damage if edema develops (Option 3) (Option 1) Medication patches should not be removed without first consulting the health care provider. Clients are often prescribed transdermal patches for chronic conditions (eg, clonidine for hypertension, nitroglycerin for angina). Removing and discarding a medication patch without additional information may harm the client. Educational objective: When caring for an unconscious client during admission, the nurse should assess for medical alert devices and any prescriptive materials (eg, medication patches, contact lenses). The nurse should remove personal belongings and foreign objects that could harm the client if not removed (eg, tampons, rings/jewelry).

water seal chamber

The water seal chamber of the chest tube drainage system is filled with sterile water and acts as a one-way valve preventing air from entering the client's chest cavity. The water level in the water seal chamber rises and falls with inspiration and expiration, a process known as tidaling. This movement occurs in section B of the water seal chamber and indicates that the system is functioning properly and maintaining appropriate negative pressure. (Section A) This is the suction control chamber, which is usually set at -20 cm H2O to maintain negative pressure in the system. Bubbling will occur when suction is applied. (Section C) The air leak gauge (part of the water seal chamber) allows for assessment of air leaks. Continuous bubbling indicates an air leak in the system. (Section D) This is the drainage collection chamber in which fluid from the client's pleural cavity will collect; the nurse will assess the color and amount and record the output. Educational objective: Tidaling is the fluctuation that occurs in the water seal chamber in relation to the client's respiratory movements. The level of sterile water will rise with inspiration and fall with expiration, indicating proper function of the chest tube drainage system.

client with painful right hip, fever, and limited ROM (priority)

This client is exhibiting localized (eg, pain, limited range of motion) and systemic infection symptoms (eg, fever), which may indicate septic arthritis. Possible causes include recent surgery, injections, trauma, or spread from adjacent infection (eg, cellulitis). A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular necrosis (eg, damage to the femoral head) from compromised blood supply due to infection or injury (eg, fracture). This can result in sequelae that are significant in both the short term (eg, sepsis, death) and long term (eg, joint destruction). Management includes culturing synovial fluid and blood, giving antibiotics, and debriding the infected joint. (Option 1) Bronchitis is linked to viral upper respiratory infections and is common during childhood. Congestion and a productive cough are anticipated. This client is currently able to maintain an airway and manage secretions and therefore is not the priority. (Option 2) This client with epistaxis should be instructed to sit slightly forward while pinching the nose. The client should be reevaluated in 10-20 minutes for resolution of bleeding. (Option 3) Urinary tract infections may present with urinary frequency, burning with urination, and fever. This is not a priority over potential septic arthritis. Educational objective: Pain, limited range of motion, and fever indicate joint infection (septic joint). A septic hip is a surgical emergency as impaired blood supply may lead to permanent joint destruction, sepsis, and/or death. The nurse should expect management to include cultures, antibiotics, and surgical debridement.

neurogenic shock

This presentation is classic for neurogenic shock, a distributive shock. Vascular dilation with decreased venous return to the heart is present due to loss of innervation from the spine. Classic signs/symptoms are hypotension, bradycardia, and pink and dry skin from the vasodilation. Neurogenic shock usually occurs in cervical or high thoracic injuries (T6 or higher). Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion. (Option 2) Testing for the presence of blood in the urine is important in determining if kidney damage has occurred, but circulation stability is a priority. (Option 3) A neurological assessment is essential, but circulation stability is a priority ("C before D" [disability]). (Option 4) Bladder and stool impaction are etiologies for autonomic dysreflexia and generally occur in a client with a high-level fracture at T6 or above with a stimulation below the fracture. Autonomic dysreflexia is a medical emergency that presents with severe headache, hypertension, piloerection, and diaphoresis. It is seen weeks to years after the injury. Neurogenic shock/distributive shock can occur from vasodilation soon after spinal injury. Classic symptoms are hypotension, bradycardia, and pink and dry skin. The hypotension must be treated with isotonic fluids to maintain vital organ perfusion.

auscultating the heart

To auscultate the heart, the nurse should listen at each of the valve areas (aortic, pulmonic, tricuspid, mitral) and Erb's point in a Z pattern. The S1 and S2 heart sounds, as well as any adventitious sounds (eg, S3, S4, murmurs), should be identified. The rate and rhythm should also be assessed, listening for a full minute at the apex (apical pulse). If heart sounds are difficult to auscultate, the nurse can ask the client to either sit up and lean forward (best for aortic and pulmonic areas) or lie down on the left side (best for the mitral area). These positions move the heart closer to the chest wall. (Option 2) Exhaling and holding the breath aid in auscultating heart sounds that are difficult to hear. Inhaling introduces more air into the lung, which may muffle heart sounds. (Option 3) Raising the arm over the head helps to flatten the breast tissue, making any lumps more pronounced. It does not help with auscultation. (Option 4) The diaphragm of the stethoscope is best for auscultating higher-pitched sounds (S1 and S2). The bell is better for lower-pitched sounds (eg, extra heart sounds [S3, S4]). Educational objective: The nurse should assess normal (S1, S2) and any adventitious (eg, S3, S4, murmurs) heart sounds at each of the valve areas (aortic, pulmonic, tricuspid, mitral) and Erb's point in a Z pattern. Listening while the client is sitting up and leaning forward or lying on the left side improves auscultation.

calculating urine output in a client with continuous bladder irrigation

To calculate urine output in a client with continuous bladder irrigation, subtract the total amount of irrigating solution infused from the total amount in the urine drainage bag. Urine output approximates input minus insensible losses.

infusion of enema solution

Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation. (Option 1) Having the client take slow, deep breaths may be helpful, but the infusion should be stopped first. (Option 3) This response disregards the client's cramping and pain and is not appropriate. (Option 4) Withdrawing the tube will risk not instilling the fluid high enough into the rectum/colon to be effective. Educational objective: If a client reports cramping or pain during instillation of an enema, the infusion should be stopped for 30 seconds and then resumed at a slower rate.

torsades de pointes

Torsades de pointes (ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. Torsades de pointes may be the result of a prolonged QT interval (normal 0.34-0.43 sec or less than half the RR interval), usually due to medications or electrolyte imbalances. The nurse should review the client's medical record for any condition or medication that may prolong the QT interval and precipitate another episode of torsades de pointes, including: Antiarrhythmics (eg, sotalol, amiodarone, ibutilide, dofetilide) (Option 1) Macrolide antibiotics (eg, erythromycin, azithromycin) Electrolyte abnormalities: Hypokalemia and hypomagnesemia (Option 2) Anticoagulant medications (eg, warfarin, dabigatran, rivaroxaban) are commonly used to prevent clot formation in clients with atrial fibrillation. These medications do not prolong the QT interval. (Options 3 and 4) Magnesium and potassium deficiency can increase irritability of the myocardium and precipitate dysrhythmias. This is a normal magnesium level (1.5-2.5 mEq/L [0.75-1.25 mmol/L]) and a normal potassium level (3.5-5.0 mEq/L [3.5-5.0 mmol/L]). Magnesium and potassium supplements may be prescribed to maintain adequate electrolyte balance and prevent recurrent episodes of torsades de pointes. Educational objective: Torsades de pointes is a polymorphic ventricular tachycardia that may result from a prolonged QT interval. The nurse should question administration of any medications that may prolong the QT interval (eg, antiarrhythmics, macrolide antibiotics) and assess for electrolyte imbalances (eg, hypokalemia, hypomagnesemia).

orthodox jews

Traditional Orthodox Jews believe that the body of the deceased should not be desecrated and is to be treated with respect. Therefore, autopsies are generally not permitted (Option 3). An autopsy is performed only when required by law, if the client provided consent before death, or if the client had a hereditary disease and an autopsy would help save others. Orthodox Jews believe that the body belongs to God and that a complete burial is required to enter heaven. In the event that an autopsy is required, all fluids and body parts are to be returned to the body before burial. (Option 1) It is customary for a member of the client's family to remain with the body until burial to ensure that it is not dishonored. (Option 2) Many cultures and religions prefer to take part in postmortem care (eg, cleansing of the body, dressing). Family beliefs should be clarified before postmortem care is performed. (Option 4) Orthodox Jews believe the dead are disrespected if the effects of death present on the face are seen by others. Therefore, a sheet is placed over the face after death. Educational objective: Orthodox Jews do not permit autopsies unless certain conditions are met (eg, required by law, consent signed by client, investigating hereditary disease to benefit others). Often, the client's family performs postmortem care, covers the face with a sheet, and remains with the body until burial. Families should always be consulted for specific beliefs prior to providing postmortem care.

varicose veins

Varicose veins are tortuous, distended veins. The condition is usually accompanied by discomfort (eg, heavy feeling, aching, pruritus). It occurs frequently in clients with a family history, certain chronic conditions (eg, heart disease, obesity), or jobs that require prolonged sitting, standing or heavy lifting. Over time, increased pressure on the legs leads to weakening and dilation of healthy veins. To promote improved venous return and prevent further complications (eg, rupture of the vein, venous stasis ulcer), the nurse should encourage the 3 Es: elevation (Option 4), exercise (Option 5), and elastic compression hose (Option 2). Elevating the legs uses gravity to promote venous return. Low-impact exercise (eg, walking, swimming) helps muscles pump blood back to the heart more effectively. Graduated elastic compression hose help maintain venous tone, preventing the backward flow of blood. In addition, weight reduction improves mobility and places less body pressure on the legs, improving venous return (Option 1). (Option 3) Prolonged sitting may be as damaging for varicose veins as prolonged standing, as venous return is decreased due to lack of movement. The client who is required to sit at a desk should flex the ankles periodically, elevate the legs when able, and get up and walk whenever possible. Educational objective: Varicose veins are tortuous, distended veins that occur frequently in clients with a family history, certain chronic conditions, or jobs requiring prolonged sitting, standing, or heavy lifting. To improve venous return, the client should follow the 3 Es: elevation, exercise, and elastic compression hose, and should maintain an appropriate weight.

verapamil

Verapamil is a calcium channel blocker sometimes used for the prevention of migraines. Calcium channel blockers may decrease neurovascular inflammation, thereby reducing the occurrence of migraines. Because verapamil affects the cardiac system, the pulse rate should be checked prior to administration due to possible bradycardia (Option 2). The medication should be held, and the client's health care provider contacted, if the heart rate is <60/min. Clients should also have periodic blood pressure evaluations to ensure that hypotension is not occurring. Intake of grapefruit (including grapefruit juice) should be avoided, as it can increase serum levels of verapamil by reducing hepatic clearance of the drug (Option 1). Increasing fluids and fiber helps to prevent constipation, a common side effect of most calcium channel blockers, particularly verapamil (Option 4). (Option 3) Verapamil is taken daily to prevent migraines and does not provide relief during an acute migraine episode. The most common treatment for acute migraine symptoms is administration of nonsteroidal anti-inflammatory drugs (eg, naproxen) or triptan medications (eg, sumatriptan). Educational objective: Clients taking verapamil, a calcium channel blocker, for the prevention of migraines should take the medication daily, check their pulse prior to administration, avoid grapefruit, and increase their intake of fluids and fiber to prevent constipation.

weaning for infant

Weaning is less difficult for mother and child when accomplished gradually over weeks to months based on readiness cues from the child. This helps avoid breast engorgement, which can occur with sudden cessation of breastfeeding. Gradual, spontaneous weaning of exclusively breastfed infants usually begins around age 6 months with the introduction of solid foods. At this age, solid foods may be offered in addition to breast milk or formula, but these milk sources should not be eliminated. Most children are able to begin drinking from a cup with a lid around age 1 year and can begin weaning from bottles at this time. Whole cow's milk may be offered starting at age 12 months (Option 2). (Option 1) Bottles should not be given to children overnight or while sleeping, as this increases the risk for tooth decay, aspiration, and ear infections. (Option 3) Milk is a good source of important nutrients (eg, calcium, protein, fat) required for appropriate growth in childhood. After solids are introduced, nutrients are obtained from complementary sources (eg, yogurt, eggs, cottage cheese) in addition to milk. (Option 4) Infants often breastfeed for comfort as well as hunger, and abrupt cessation may cause emotional distress in addition to breast engorgement. Educational objective: Weaning is best achieved gradually to avoid breast engorgement and infant distress. Gradual weaning from breastfeeding may begin with the introduction of solid foods at age 6 months. Whole cow's milk may be given to children after age 12 months.

wheezing

Wheezing is caused by air moving through narrow airway passages. As long as wheezing is heard, ventilation is occurring. A client who was initially wheezing loudly and suddenly has no audible wheezing may be exhibiting signs of worsening airway obstruction and should be assessed immediately (Option 3). Wheezing can occur in clients as the result of an asthma attack or other airway obstruction (eg, foreign body aspiration, tumor). (Option 1) Tricuspid atresia is a congenital heart defect in which the tricuspid valve does not develop; therefore, blood is unable to flow from the right atrium to the right ventricle and on to the lungs. Cyanosis would be a normal finding as deoxygenated blood from the right atrium flows through a patent foramen ovale and mixes with oxygenated blood in the left ventricle before being pumped throughout the body. (Option 2) Projectile vomiting that occurs after feeding is a sign of pyloric stenosis or obstruction. This client could be dehydrated but would not be a priority over a client with an airway obstruction. (Option 4) Febrile seizures are benign seizures that occur in response to an elevated temperature. A child with a febrile seizure would not take priority over a child with an obstructed airway. Educational objective: A client who suddenly stops wheezing may be experiencing impending respiratory failure and should be assessed immediately.

client refusing medication

When a client refuses a medication or therapy, the nurse should investigate the reason for refusal and educate the client about regimens prescribed in the management of health alterations (Option 1). (Option 2) If the client still has questions after the nurse has explained the effects of the medication and reasons why it is being prescribed, the nurse can help the client prepare a list of those questions for the health care provider. (Option 3) Although it is the client's right to refuse prescribed medications, the nurse must investigate why the client is refusing. A common reason is misunderstanding the justification for treatment. (Option 4) Responses that may be perceived as paternalistic or coercive, dismiss clients' concerns, and do not provide information are nontherapeutic and do not improve adherence to treatment.

violent client threatens safety

When a violent client threatens the safety of clients and staff, nurses should use crisis-management techniques to ensure the safety of all clients. Interventions for crisis management of violent clients include: Assemble a crisis team, including security personnel, and identify a leader (eg, charge nurse). Form a plan for the crisis team, with specific tasks (eg, restraining an arm) assigned to each member. Remove all other clients from the area to prevent any further injury (Option 1). Restrain, seclude, and/or medicate (eg, intramuscular haloperidol injection) the client, as needed. Calmly explain the necessity of all interventions to the client. (Option 2) Therapeutic communication may be helpful for calming a client, but in a crisis, the nurse's priority is to ensure the safety of other clients in the area. (Options 3 and 4) Seclusion or restraint of a violent client may be necessary to ensure the safety of other clients and staff, but the priority is to remove other clients from the area. Both seclusion and restraints are restrictive interventions that are traumatic to the client and would violate client rights, if used inappropriately (eg, convenience of staff). Educational objective: When dealing with a violent client, nurses should use crisis-management techniques to ensure the safety of all clients. Interventions include assembling a crisis team to create a specific plan, removing other clients from the area, communicating calmly, and implementing restrictive interventions (eg, restraints, seclusion).

transferring a client safely

When determining the most appropriate method to transfer a client safely, the nurse should assess: Whether the client can bear weight Whether the client is cooperative This client is able to bear full weight despite having a heavy body and can cooperate during the transfer. Therefore, such clients should be encouraged to do as much as they can for themselves, anticipating discharge in the near future. It is appropriate to transfer this client with 1 person standing by for safety. If the client was unable to bear full weight, more assistance would be needed. The number of caregivers providing assistance during the transfer of a heavier client should be increased to promote safety for the client and staff. When working with bariatric clients, equipment that has the capacity to bear the client's full weight and accommodate their size should be used while maintaining the client's dignity throughout the process. (Options 2 and 3) These would not be necessary as this client can fully bear weight and cooperate with caregiver instructions during the transfer. (Option 4) A 4-person sling lift transfer is appropriate for the bariatric client who cannot bear weight or cooperate with the transfer. Educational objective: A client who is able to fully bear weight and cooperate can transfer independently with standby assistance for safety. If there is any concern for caregiver or client safety during the transfer of a bariatric client, the type of equipment should be reconsidered and the number of caregivers should be increased.

disruptive behavior

When there is inter-staff disagreement, it is important to not have a public "show." The first action should be to take the conflict "off stage." This is especially true when there is a power/authority difference (eg, HCP/nurse). Rather than suggest and wait, the nurse should immediately leave and go to a private area. That way the disruptive person has to either follow the nurse or stop talking because there is no longer an audience. Once in private, the nurse can acknowledge the HCP's concerns and work to resolve the issue (Option 4). (Option 1) Confrontation and aggressive response usually do not resolve or diffuse the situation and will still involve an audience. (Option 2) The nurse should first take the conversation private as the HCP is not likely to calm down soon. The nurse can offer a blameless apology (eg, "I'm sorry there has been a problem") and then focus on the solution. This should occur out of the public eye. (Option 3) This response involves avoidance rather than working to resolve the situation. It does not benefit staff or clients to see providers having a public disagreement. Educational objective: The first response to public displays of disruptive behavior is to take action to make the conversation private.

post surgery patients

a client who just arrived in the PACU after general anesthesia would be expected to be difficult to arouse and have small pupil size associated with drugs used to induce general anesthesia, sedating drugs, and opioid drugs to control pain hypothermia is common in the immediate postop period due to anesthetic-induced vasodilation, decreased basal metabolic rate and a cool environment this can be managed by the nurse hyperthermia (fever) is also common due to the blood products and trauma from surgery stiffness/rigidity is concerning

MRSA

a client with a positive nose swab for methicillin-resistant Staphylococcus aureus (MRSA) is colonized and can transmit the bacteria to others if signs of infection are absent, treatment is not required colonized clients are at increased risk for infection with MRSA; if signs (eg, fever, wound drainage, purulent mucus) are present, treatment is required the CDC recommends placing a colonized client on CONTACT precautions in a private room. The CDC also recommends that the highest priority be given to placing a colonized client who may transmit the bacteria through body secretions or excretions (eg, sputum, wound drainage) in a private room. therefore, the client with pneumonia should be placed in the private room The CDC recommends standard precautions for clients with hep C and those who are HIV positive

HIPPA

a client's medical treatment information is private in this situation, answering the HCP's question will promote further conversation, making it likely that the client's privileged health care information will be discussed. a client's medical information should not be heard by others. the best response is to exchange the information with the HCP privately conversations with HCPs, even those regarding the client's presence in the hospital, should be private

fire

a small fire can quickly become dangerous during an emergency situation, such as a fire, anxiety can narrow a person's focus, causing hesitation or difficulty in responding to the situation esp when operation of unfamiliar equipment (eg, fire extinguisher) is involved the mnemonic PASS is often used to help people remember the steps used in operating a fire extinguisher P - pull the pin on the handle to release the extinguisher's locking mechanism A - aim the spray at the base of the fire S - squeeze the handle to release the contents/extinguishing agent S - sweep the spray from side to side until the fire is extinguished the extinguisher does not need to be shaken before use, and doing so would delay extinguishing the fire PASS is the mnemonic to help people remember the steps used in operating a fire extinguisher

incident report

all incidents, accidents, or occurrences that cause actual or potential harm to a client, employee, or visitor must be reported the person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system using an electronic form alternately, a paper form may be completed and filed. the purposes of the report are to inform risk management of the occurrence, allowing them to consider changes that might prevent similar incidents, and to notify administration of a potential litigation claim the nurse SHOULD NOT DOCUMENT THAT AN INCIDENT REPORT WAS FILED, or refer to the incident report in the medical record because the incident report is not a part of the medical record, an objective note should be placed in the client's medical record documenting the facts and events of the incident, HCP notification and findings, prescriptions, treatment, follow up care, and monitoring the person who witnesses an unusual occurrence or event must file an incident report in the institution's computer documentation system, using an electronic form. the nurse should not document that an incident report was filed or refer to the incident report in the medical record

school phobia

also known as school refusal or school avoidance is a childhood anxiety disorder in which the child experiences an irrational and persistent fear of going to school having the child return to school immediately is the best approach for resolving school phobia and is associated with a faster recovery if necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few hours and then gradually increase the time to a full day a gradual approach may decrease the child's sensitization to the classroom if the child is allowed to remain out of school, the problem will only worsen, with potential deterioration of academic performance and social relationships allowing the child to stay home will only reinforce the acting-out behaviors associated with refusal to attend school the parent/caregiver needs to support the child and talk about the cause of the anxiety, but the child needs to go to school having the parent/caregiver stay in the classroom with the child is not a permanent solution to relieving the child's anxiety and is not recommended determining the cause of the school phobia is important in helping to alleviate the child's symptoms and in coping with the return to school. however, returning the child to the classroom immediately is the most important action a child with school phobia needs to return to the classroom immediately insisting on school attendance along with other supportive interventions will help the child make a faster adjustment

AED

an automated external defibrillator (AED) should be used as soon as it is available pediatric AED pads or pediatric dose attenuator should be used for children age birth to 8 years if available standard adult pads can be used as long as they do not overlap or touch if adult AED pads are used, one should be placed on the chest and the other on the back ("sandwiching the heart") if an AED is available, it should be placed on the client as soon as possible. research shows that survival rates increase when CPR and defibrillation occur within 3-5 minutes of arrest standard placement of adult AED pads on a 2 year old would cause the pads to touch or overlap. touching or overlapping of pads allows the shock to move directly from one pad to the other without travelling through the heart both AED pads are necessary for the defibrillator to work effectively

command hallucinations

are a specific type of auditory hallucination, during which voices instruct the client to perform specific actions, often demanding harm to the client or others clients who are alone and experiencing command hallucinations that are homicidal or suicidal in nature require immediate intervention to ensure the safety of themselves and others A client who is alone with command hallucinations that are homicidal or suicidal in nature requires immediate intervention to prevent harm. Clients who are homicidal or suicidal but are with another person should be addressed after those who are alone.

hallucinations

are false sensory perceptions that have no external stimuli they can occur in any of the 5 senses auditory hallucinations: -are the most common followed by visual, tactile (touch), olfactory (smell) and gustatory (taste) additional ways to deal with hallucinations include: -telling the client that you know they are real to the client but that you do not hear the voices (or see the vision, feel the sensation) -not arguing with or challenging the client about the hallucinations -directing the client to a reality-oriented topic of conversation or activity the priority nursing action is to explore the content of the hallucinations. this client may be experiencing command auditory hallucinations that could lead to self-directed or other-directed injury and harm after the content of the hallucinations has been explored, implementing an intervention may be necessary to reduce the potential for violence

statins (rosuvastatin, atorvastatin, simvastatin)

are the most preferred agents to reduce low-density lipoprotein (LDL) cholesterol, total cholesterol and triglyceride levels HDL is good cholesterol a therapeutic response to statin medication includes a decrease in a client's LDL cholesterol, total cholesterol, and triglyceride levels to within normal range an increase in HDL cholesterol to within normal range is also an expected outcome potential adverse effects include hepatic dysfunction and muscle injury

melatonin supplements

are thought to help the body adjust quickly to new surroundings and time zones (jet lag) most practitioners agree that the lowest possible dose should be used and should be taken only for a short time there are no long-term studies on the safety of melatonin higher doses may cause side effects such as vivid dreams and nightmares research suggests that taking melatonin once a person has reached the travel destination is sufficient and that starting it prior to or during air travel may actually slow the recovery of jet lag, energy and alertness

norepinephrine, dopamine

are vasopressors initiate if client remains hypotensive following a fluid bolus vasopressor medications are not effective without first restoring circulatory fluid volume as there is insufficient volume to compress within the vascular space

brain herniation

bilateral fixed, dilated pupils

vancomycin

can cause nephrotoxicity which occurs most often in clients who already have some degree of renal impairment serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days if an increasing trend is identified, the nurse should consult with the HCP and/or pharmacist before administering the dose blood cultures may be checked periodically during vanco therapy mag levels are not affected by vanco therapy wbc count may be helpful in determining the effectiveness of vanco therapy in treating infection but this lab result is not likely to influence the nurse's decision on whether to administer the dose

vitamin B12 deficiency

can cause peripheral neuopathy; however it is not seen in INH therapy

cerebrospinal fluid rhinorrhea (CSF ottorhea)

can confirm that a skull fracture has occurred and transversed the dura if the drainage is clear, dextrose testing can determine if it is CSF. however, the presence of blood would make this test unreliable as blood also contains glucose in this case, the halo/ring test should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF identification of this pattern is very important as CSF leakage places the client at risk for infection the client's nose should not be packed. no NG or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull thorugh the frature site and having the tube ascend into the brain. these tubes are placed under fluoroscopic guidance in clients with such fractures

causes of mechanical ventilator pressure alarms

causes of high pressure limit alarm 1. ventilator circuit --kinked ventilator tubing --condensation (water) in circuit tubing 2. endotracheal or tracheostomy tube --kinked endotracheal tube --obstruction (secretions) in tube --biting endotracheal tube 3. client --increased airway resistance (eg, bronchospasm, excessive secretions) --decreased lung compliance (eg, pneumothorax, atelectasis, pulmonary edema, acute respiratory distress syndrome) --ventilator dyssynchrony (eg, anxiety, pain, coughing) causes of low pressure limit alarm 1. ventilator circuit --tubing disconnect 2. endotracheal or tacheostomy tube --endotracheal or tracheostomy tube cuff leak 3. client --loss of airway (eg, total or partial extubation or decannulation)

nitroglycerine

causes vasodilation and can lower blood pressure systolic blood pressure should be >90 mmHg to ensure renal perfusion

cefazolin

cephalosporin ABX may be prescribed prophylactically to prevent intra-abdominal infection after major abdominal surgery medications timed "now" should be administered within 90 minutes

neck dissection

chewing may be difficult after a neck dissection due to tissue trauma

influenza

clients are placed on droplet precautions

carotid endarterectomy

clients having undergone carotid endarterectomy, a surgical procedure removing plaque from carotid arteries, would be expected to show no evidence of hemorrhage (eg, hypotension, tachycardia) or neurological impairment (eg, decreased level of consciousness, altered mental status) clients should remain free from hemorrhage and neuro impairment

furosemide

clients receiving IV furosemide, a loop diuretic, should maintain adequate blood pressure and avoid developing symptoms of electrolyte imbalance (eg, muscle weakness, cramps, cardiac arrhythmia) those receiving loop diuretics should maintain electrolytes within normal limits

alcoholism

clients with alcoholism can have hypoglycemia they can also have thiamine (vitamin B1 deficiency) related to poor nutrient intake (a healthy diet contains enough thiamine) and alcohol-induced suppression of thiamine absorption thiamine deficiency can result in Wernicke encephalopathy (WE) untreated WE can lead to death or neurologic morbidity (korsakoff psychosis) in the setting of alcoholism, administered glucose is oxidized by using all the existing thiamine in the body; this can worsen thiamine deficiency, which in turn can precipitate the development of WE in a previously unaffected individual because the signs of alcohol intoxication and WE are similar, all intoxicated clients should be given IV thiamine before or with IV glucose

large body casts

clients with large body casts are at risk for bowel obstruction, which can be caused by decreased peristalsis or by cast syndrome (ie, superior mesenteric artery SMA) cast syndrome is a rare complication of an overly tight cast that involves compression of the duodenum by the SMA immobilization of clients in body casts decreases peristalsis and may cause a paralytic ileus (ie, bowel obstruction) if severe, bowel obstruction can result in bowel ischemia the nurse should immediately report symptoms of a bowel obstruction (eg, abd pain, distension, nausea, vomiting) if cast syndrome is suspected, the cast may have a window cut out over the abdomen to relieve pressure

persecutory (paranoid) delusion

clients with such delusions believe that they are being threatened or treated unfairly in some way ex: "those martians are trying to poison me with the tap water"

Huff cough

coughing is an important lung defense mechanism clients with COPD have weakened muscles and narrowed airways that are prone to collapse when under increased pressure they are therefore unable to generate the high pressure needed to create the explosive rush of air to cough effectively the low-pressure "huff" cough which uses a series of mini-coughs is more effective in mobilizing and expectorating secretions with COPD when this technique is done correctly, there is less airway collapse, less energy and oxygen consumption and greater secretion removal. steps include: 1. position upright: maximizes lung expansion and gas exchange 2. inhale through the nose using abdominal breathing and prolong the exhalation through pursed lips for 3 breaths - deflates excess air from lungs 3. hold breath 2-3 seconds following an inhalation, keeping the throat open - opens glottic structures and prevents a high-pressure cough 4. deeply inhale and, while leaning forward, force the breath out gently using the abdominal muscles while making a "ha" sound (huff cough); repeat 2 more times (eg, "ha, ha, ha") - keeps airways open while moving secretions up and out of the lungs 5. inhale deeply using abd breathing and give one forced huff cough - the last, increased force ("ha") usually results in mucus being expectorated from the larger airways the normal cough reflex creates high pressure in the airways because the airways of clients with COPD are prone to collapse with increased airway pressure, clients are taught the low-pressure cough technique (huff) to expectorate mucus

therapeutic aPTT

depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2 times the baseline value). the nurse should stop the heparin infusion, notify the HCP, and review administration guidelines for possible administration of protamine (reversal agent for heparin) the nurse should stop the infusion of heparin when there is evidence of bleeding. the HCP should be notified immediately and the nurse should be prepared to give protamine if ordered there is no reason to redraw blood for lab workup at this time as the abnormal aPTT result is consistent with the client's bleeding lab studies may need to be redone within 1 hour of stopping the infusion or giving a reversal agent

power of attorney (POA)

designates a representative to act on a person's behalf it is important to clarify that the client has the type of POA who can make health care decisions (durable POA for health care, POA for health care (canada))

peritonitis

diffuse pain and a rigid abdomen (eg, from ruptured appendicitis or perforated bowel) peritonitis is also an emergency

TB drugs (isoniazid, pyrazinamide, rifampin)

drugs to treat TB dark-colored urine and yellow skin can indicate the presence of hepatotoxicity which is associated with many drugs used to treat TB

NG tube insertion

during NG tube insertion, the tube sometimes slips into the larynx or coils in the throat which can result in coughing and gagging the nurse should withdraw the tube slightly and then stop or pause while the client takes a few breaths after the client stops coughing, the nurse can proceed with advancement asking the client to take small sips of water to facilitate advancement to the stomach the client should not be asked to swallow during coughing or aspiration may occur if resistance or obstruction occurs during tube advancement, the nurse should rotate the tube while trying to advance it if resistance continues, the tube should be withdrawn and inserted into the other naris if possible coughing and gagging commonly occur during NG tube insertion if the tube coils in the throat or slips into the larynx when this happens, the nurse should pull back on the tube slightly and then pause to give the client time to recover and breathe before advancing the tube

decerebrate posture

extensors predominate

UTI (females)

fever suprapubic pain dysuria

acute diverticulitis

fever and left lower quadrant pain in an elderly client are usually due to acute diverticulitis the client needs bowel rest, ABX, and IV fluids

decorticate posture

flexors predominate

glucagon

given IM, SubQ, or IV for SEVERE hypoglycemia iv glucose is preferred due to its immediate effect; however if it is unavailable, glucagon can be given to stimulate glycogenolysis in the liver thereby raising blood glucose

client with drug overdose (OD)

highest priority as the actual amount taken and its effects are unknown in addition, clients who deliberately OD often consume other substances (eg, alcohol) that can potentiate the effect of the drug OD is especially concerning for a tricyclic antidepressant (TCA) due to the effect this can have on the cardiovascular and central nervous systems (eg, dysrhythmias, seizures) TCA use for depression is an uncommon second-line treatment, but the drug class is used for neuropathic pain and sometimes bed wetting (enuresis)

hypovolemic shock

hypotension, tachycardia, and low central venous pressure (normal: 2-8 mmHg) may indicate hypovolemic shock central venous pressure is a measurement of right ventricular preload (volume within the ventricle at the end of diastole) and reflects the client's fluid volume status do not elevate HOB because causes blood pressure to decrease and inadequate circulating vascular volume

air embolus

in the event of an air embolus, the HOB should be LOWERED (TRENDELENBURG) and client positioned on LEFT SIDE; this will cause the air to rise to the right atrium the HCP should be notified immediately and the nurse should remain with the client

crisis

individuals impacted by emergencies such as a natural disaster often experience severe emotional stress and are in need of mental health services clients may experience a wide range of emotions and reactions including confusion, fear, hopelessness grief, survivor guilt, and anxiety mental health professionals can provide support, crisis intervention, and promote resilience in coping with the effects of the disaster services may be provided in shelters, food distribution centers, churches, "pop up" disaster relief centers, schools, and/or in homes finding and reaching potential clients and family members in aftermath of a disaster can be challenging because: -clients may not know where or how to seek help -clients may be afraid or unable to leave their homes -telephone services and other lines of communication may be disrupted -potential clients may leave their homes and go to shelters or alternate housing -transportation may be severely limited it is essential to coordinate outreach efforts to maximize resources and avoid duplication of services and/or inefficiency in providing services the mobile crisis team's priority action is to check in with the local command center, then to assist in planning outreach strategies with other community agencies, and receive assignments

contact precautions

infections caused by MRSA, C. diff, VRE and scabies require contact precautions which include: 1. placing the client in private room (preferred) or cohorting clients with the same infection 2. using dedicated equipment (must be disinfected when removing from room) 3. wearing gloves when entering room 4. perform proper hand hygiene before exiting room (use soap and water or alcohol-based hand rubs for MRSA and VRE but only soap and water for c diff and scabies) 5. wearing gown with client contact and removing before leaving room 6. place door notice for visitors 7. having client leave room only for essential clinical reasons (ie, tests, procedures). if an x-ray is needed try to arrange for a portable one

isoniazid (INH)

interferes with the action of vitamin B6 (pyridoxine), resulting in peripheral neuropathy it manifests as ataxia and paresthesia individuals who are most predisposed to becoming neurotoxic from taking INH include older adults, those who are malnourished, diabetic clients, pregnant or breastfeeding clients, alcoholics, children, those with liver or renal disease and HIV+ individuals to prevent these complications, a vitamin B6 supplement at a dose of 25-50 mg/day is recommended for those at high risk

chronic heart failure

involves the inability of the heart to fill and pump blood effectively to meet the body's oxygen demands as a result, clients can develop dilutional hyponatremia (Na <135), an electrolyte disturbance caused by an excess of total body water in relation to total sodium content administering isotonic solution of 0.9% NS is contraindicated in these clients as it would increase the circulating extracellular fluid volume, worsen the symptoms, and exceed the <2 L/day fluid restriction -converting the running IV line to a lock for med administration would be appropriate fluid restriction is prescribed to correct dilutional hyponatremia (sodium <135) in a client with HF. in addition, al HF clients require a low salt diet excess salt causes retention of more water

levofloxacin (levaquin)

is a broad-spectrum ABX that may be used to treat respiratory tract infections, such as bacterial pneumonia

fibromyalgia

is a chronic, nonspecific pain disorder common sequelae include: -fatigue -sleep disturbances -emotional distress (eg, anxiety, depression) -mild cognitive impairments (eg, forgetfulness, difficulty concentrating) treatment is focused on symptom management and often includes: 1. muscle relaxers (eg, cyclobenzaprine) 2. narcotic analgesics (eg, tramadol, hydrocodone) 3. nonsteroidal anti-inflammatory drugs (eg, ibuprofen, naproxen, celecoxib) 4. neuropathic pain relievers (eg, pregabalin, gabapentin) 5. antidepressants such as selective serotonin reuptake inhibitors (eg, fluoxetine, duloxetine) and tricyclic antidepressants (eg, amitriptyline) antidepressants can cause suicidal ideation and behaviors, esp during the initial few weeks of therapy this risk is even higher for young adults (age 18-24). the nurse must assess for this adverse effect and alert the provider fibromyalgia is treated using a variety of medications nurses must be aware of the risks associated with medications, specifically antidepressants that may increase suicidal behaviors during the first few weeks of therapy. any indication of such effects requires immediate intervention by the nurse (eg, alert health care provider)

methadone

is a potent narcotic with a longer half-life than its duration of action due to its lipophilic properties the risk of overdose exists as clients can inadvertently take too many tablets for additional pain relief even though fat cells will continue to release high amounts of the drug into circulation early signs of toxicity: -nausea/vomiting -lethargy a client who falls asleep with stimulation (ie, is obtunded) requires additional observation/monitoring sedation precedes respiratory depression, a life-threatening complication of severe toxicity an acceptable pulse oximetry reading for a normal, healthy nonsmoking adult is considered 95-100%. a reading of 90% is low and indicates inadequate depth or rate of respiration with possible respiratory depression itching sensation (pruritus) is an expected finding with narcotic use, especially in opioid-naive clients. can be managed with antihistamine occasional premature ventricular contractions are a common, insignificant finding in most adults. the client should have cardiac monitoring in the setting of methadone use/overdose as there is a risk of QT interval prolongation (normal 0.34- 0.43 sec, or less than half the RR interval) which can lead to cardiac arrhythmias (eg, torsades de pointes) methadone is a potent narcotic with a long half-life. early signs of toxicity (nausea/vomiting & lethargy) the nurse should monitor the client's RR, pulse oximetry, and ECG. respiratory depression and QT interval prolongation can lead to life-threatening complications

percutaneous coronary intervention (PCI)

is a procedure used to restore coronary perfusion to prevent or treat ischemia or infarction clients having undergone a PCI would be expected to have no chest pain at rest chest pain at rest indicates myocardial ischemia clients should not have chest pain at rest after a percutaneous coronary intervention

anorexia nervosa

is a psychogenic eating disorder with potentially fatal physiological implications clients with anorexia exhibit preoccupation with body image and obsessive behaviors to lose weight (ie, excessive exercising/dieting) clients commonly have protein-energy malnutrition and may be extremely underweight acute care focuses on restoring physiological integrity through appropriate weight gain and nutritional intake nursing care includes: 1. determining minimum caloric intake for healthy weight gain and documentation of consumed calories and protein 2. establishing a weekly weight-gain goal : an appropriate goal for most clients is 2-3 lb/week 3. limiting physical activity initially and gradually increasing as oral intake improves 4. allowing client to make food choices, when possible, to give a sense of control 5. providing reflection with the client about behaviors, triggers, or situations that cause dysfunctional eating 6. weighing the client at the same time each day, after voiding, and wearing the same clothing to assess efficacy of nutritional support allowing the client with anorexia to continue exercising will cause further energy deficit, which can contribute to worsening malnutrition and end-organ damage (eg, renal failure) extensive focus on food intake (eg, food logs) should be avoided as it may increase the client's preoccupation with eating

somatic symptom disorder (SSD)

is a psychological disorder in response to stress that results in symptoms of physical disorders (eg, chest pain, syncope) for which there is no identifiable medical source (eg, myocardial infarction, hypotension) periods of increased stress (eg, work demands, family events) frequently precede the onset, or worsening, of physical symptoms and result in frequent requests for medical attention and treatment SSD and care-seeking behaviors may then be reinforced and perpetuated by secondary gains (eg, social affirmation, "sick role" avoidance of unpleasant activities when evaluating clients' responses to treatment for SSD, the nurse should monitor for the following indicators of positive progress: 1. identification of alternate support systems for stress (eg, spouse, friends) 2. identification of perceived strategies (eg, drawing, meditating) rather than fixation on symptoms 3. verbalization of factors causing or worsening symptoms when medical treatment does not support a diagnosis for the physical symptoms, the client may become frustrated and seek the opinion of additional health care providers. this indicates a lack of treatment progress SSD occurs when psychological stresses manifest as physical symptoms of illness without physiological cause treatment has been effective if the client with SSD is able to identify alternate support systems for stress, identify perceived benefits of behaviors, employ stress management strategies and verbalize factors associated with symptoms

malignant hyperthermia (MH)

is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a paralytic used adjunctively for intubation and general anesthesia) skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature early signs of MH include: -tachypnea -tachycardia -rigid jaw -generalized rigidity as the condition progresses, the client develops a high fever muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias and myoglobinuria MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism succinylcholine should be discontinued. other interventions include applying cooling blankets to reduce temperature and treating high potassium levels

malignant hyperthermia (MH)

is a rare, life-threatening inherited muscle abnormality that is triggered by certain drugs used to induce general anesthesia in susceptible clients the triggering agent leads to excessive release of calcium from the muscles, leading to sustained muscle contraction and rigidity. it can occur in the operating room or in the PACU the most specific characteristic signs and symptoms of MH include -hypercapnia (earliest sign) -generalized muscle rigidity (eg, jaw, trunk, extremities) -hyperthermia hyperthermia is a later sign and can confirm a suspicion of MH the nurse monitors the temp as it can rise 1 degree celsius every 5 minutes and can exceed 105F the nurse would notify the HCP indicating the need for immediate treatment (eg, dantrolene, cooling blanket, fluid resuscitation)

influenza

is a respiratory illness common during the cooler months of the year each year, a new influenza vaccine is created to help protect against specific viral strains the CDC and prevention and public health agency of canada recommend that all clients age >6 months receive the influenza vaccine annually unless the client has a life-threatening allergy to the vaccine or one of its ingredients special emphasis should be placed on vaccinating the following high-risk individuals: 1. clients with chronic conditions (eg, asthma, heart failure, cancer) may experience exacerbation of symptoms if infected 2. immunocompromised clients (eg, HIV) have decreased ability to fight infection 3. health care workers and caretakers are at greater risk for acquiring and transmitting infection to other clients 4. healthy children age 6-23 months and clients age >65 are at greatest risk for serious, flu-related complications (eg, pneumonia, dehydration) 5. pregnant clients are at increased risk for premature labor/delivery or influenza complications due to pregnancy-related physiologic changes annual vaccination during influenza season is recommended for all clients age >6 months without life-threatening allergy to the vaccine or its ingredients high-risk groups include clients who have chronic conditions, those who work in health care settings or as caretakers, those age 6-23 months or >65, and pregnant clients

use of corticosteroids

is a risk factor for cataract development so wear sunglasses to prevent exposure of eyes to ultraviolet rays

hyperemesis gravidarum

is a severe vomiting that can result in dehydration. despite being given some fluids, this client still needs additional fluids. minimal obligatory urine output is 30 mL/hr or 120 mL/4 hr . urine output is the best indicator of adequate rehydration. tachycardia with pulse of 120/min indicates dehydration unless there is another clear etiology

carotid endarterectomy

is a surgical procedure that removes atherosclerotic plaque from the carotid artery clients with carotid artery disease are at increased risk for transient ischemic attack and stroke post-surgical risks include cerebral ischemia and infarction as well as bleeding blood pressure is closely monitored during the first 24 hours post surgery hypertension may strain the surgical site and trigger hematoma formation which can cause hemorrhage or airway obstruction systolic blood pressure is maintained at 100-150 mmHg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain

phenazopyridine hydrochloride (pyridium)

is a urinary analgesic prescribed to relieve the pain and burning associated with a UTI the urine will turn bright red orange while on the medication other body fluids can be discolored as well because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication phenazopyridine hydrochloride provides symptomatic relief but not ABX action so it is important to take full course of ABX

iron

is absorbed better on an empty stomach ascorbic acid (vitamin C) such as found in citrus fruits and juices, increases the absorption of iron however, milk products decrease iron absorption and should be avoided

guillain-barre syndrome (GBS)

is an acute, immune mediated polyneuropathy that is most often accompanied by ascending muscle paralysis and absence of reflexes lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves (CNs) neuromuscular respiratory failure is the most life threatening complication the rate and depth of the respirations should be monitored measurement of serial bedside forced vital capacity (spirometry) is the gold standard for assessing early ventilation failure absence of knee reflexes is expected early in the course of GBS due to the ascending nature of the disease absence of gag reflex indicates GBS progression PERRLA evaluation assesses CNs II, III, IV, and VI CN abnormalities are expected after the thoracic muscles (respiratory) are involved due to the ascending nature of GBS

oxybutynin (ditropan)

is an anticholinergic medication that is frequently used to treat overactive bladder common side effects include: 1. new-onset constipation 2. dry mouth 3. flushing 4. heat intolerance 5. blurred vision 6. drowsiness decreased sweat production may lead to hyperthermia the nurse should instruct the client to be cautious in hot weather and during physical activity sedation is a common side effect of anticholinergic drugs. clients should be taught not to drive or operate heavy machinery until they know how the drug affects them anticholinergic medications are commonly associated with constipation, urinary retention, flushing, dry mouth, and heat intolerance clients should be taught to prevent these side effects by increasing intake of fluids and bulk-forming foods (prevents dry mouth and constipation) and by avoiding locations or activities that may lead to hyperthermia

levetiracetam (keppra)

is an anticonvulsant prescribed for seizure disorders as with other antiseizure medications, levetiracetam has a depressing effect on the CNS which may cause drowsiness, somnolence, and fatigue as clients adjust to the med clients should be assured that this is common and typically improves within 4-6 weeks however, the CNS-depressing effects of levetiracetam may be enhanced if taken with other CNS-depressing substances (eg, alcohol) or medications new or increased agitation, anxiety, and/or depression or mood changes should be reported immediately as levetiracetam is associated with suicidal ideation like other anticonvulsants, levetiracetam can trigger stevens-johnson syndrome, a rare but life-threatening blistering reaction of the skin rash, blistering, muscle/joint pain or conjunctivitis should be reported and assessed immediately clients with seizure disorders should avoid driving or operating heavy machinery until they have permission from their HCP and have met the requirements of their department of transportation typically the client must be free from seizures for an allotted time period levetiracetam is an anticonvulsant prescribed for seizure disorders it may have depressing effects on the CNS (eg, drowsiness) as the body adjusts to therapy serious adverse effects include suicidal ideation and stevens-johnson syndrome clients with seizure disorders must meet the guidelines of their department of transportation and receive permission from their HCP prior to legally operating a motor vehicle

clopidogrel (plavix)

is an antiplatelet medication that should be discontinued 5-7 days before surgery to decrease the risk for excessive bleeding

iv sodium bicarbonate

is an appropriate treatment for aspirin toxicity after the administration of activated charcoal it is given to make the blood and urine more alkaline, therefore promoting urinary excretion of salicylate

chemical burn to eye

is an emergency alkali burns (concrete, drain cleaners containing lye) are particularly concerning as they will denude the protein and continue to penetrate until the substance is completely removed copious irrigation with water (at home) or normal saline/lactated ringer's solution is started immediately if the client cannot open the eye, another person should help open the eyelid the irrigation should continue in the ambulance and in the ED with a special irrigating device that looks like a large contact lens the pH of the eye is obtained prior to irrigation and irrigations continue until the eye pH is 7-7.5 irrigation can last up to 60 minutes the priority with caustic substances (especially alkaline) in the eyes is copious eye irrigation with water or normal saline/lactated ringer's

activated charcoal

is an important treatment in early acetylsalicylic acid (ASA) toxicity; it is recommended for GI decontamination in clients with clinical signs of ASA poisoning (disorientation, vomiting, hyperpnea, diaphoresis, restlessness) as well as in those who are asymptomatic activated charcoal binds to available salicylates, thus limiting further absorption in the small intestine and enhancing elimination

furosemide (lasix)

is appropriate to administer in clients in order to decrease left ventricular preload in a client in cardiogenic shock with a PAWP of 24 mmHg (normal 6-12 mmHg) is a fast-acting loop diuretic prescribed to decrease preload in clients with HF who are fluid overloaded and experiencing manifestations of pulmonary congestion (eg, crackles, dyspnea). appropriate diuresis in this client would remove excess free water and corect dilutional hyponatremia potassium chloride is administered to clients receiving furosemide to prevent or treat diuretic-associated hypokalemia

unilateral extremity swelling

is concerning for DVT in a hospitalized client bilateral swelling indicates volume overload or venous stasis this client is started on enoxaparin (blood thinner) to prevent DVT

allen's test

is performed before cannulating the radial artery and determines the adequacy of ulnar artery blood flow, circulation to the extremity is monitored frequently

gastric lavage (GL)

is performed through an orogastric tube to remove ingested toxins and irrigate the stomach GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias) GL is only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol) intubation and suction supplies should always be available at bedside during GL in case the client develops aspiration or respiratory distress GL is usually performed through a large bore (36-42 french) orogastric tube so that a large volume of water or saline can be instilled in and out of the tube during GL, clients should be placed on their side or with the HOB elevated to minimize aspiration risk GL should be initiated within one hour of overdose ingestion to be effective. the client's stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards gastric lavage is used to remove ingested toxins and irrigate the stomach after a drug overdose the nurse should position the client to prevent aspiration and have emergency respiratory equipment at the bedside

thyroid stimulating hormone (TSH)

is released from the pituitary gland to stimulate the thyroid to secrete hormones (T3, T4) when sufficient thyroid hormone is circulating, negative feedback causes a normally functioning pituitary to slow or stop the release of TSH in primary hypothyroidism, the thyroid is unable to synthesize enough T3 or T4, slowing the metabolic rate in response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high TSH levels levothyroxine (Synthroid), a thyroid hormone replacement drug, is commonly used to treat hypothyroidism levothyroxine dosing is adjusted to regulate circulating thyroid hormone levels; this creates a euthyroid (normal) state and TSH levels are decreased decreasing the dose or discontinuing levothyroxine would lead to increased TSH and worsening hypothyroidism as the amount of circulating thyroid hormone decreases levothyroxine should be taken on a consistent morning schedule, at least 30 mins before a meal. foods containing certain ingredients (eg, walnuts, soy products, dietary fiber, calcium) can decrease drug absorption in primary hypothyroidsim, the thyroid does not produce enough hormones (T3, T4) in response to low circulating thyroid hormones, the pituitary continues to release TSH, resulting in high levels of circulating TSH levothyroxine is usually started or increased to lead to a euthyroid (normal) state

trigeminal neuralgia

is sudden, sharp pain along the distribution of the trigeminal nerve the symptoms are usually unilateral and primarily in the maxillary mandibular branches clients may experience chronic pain with periods of less severe pain, or "cluster attacks" of pain between long periods without pain triggers can include washing the face, chewing food, brushing teeth, yawning, or talking pain is severe, intense, burning, or electric shock-like the primary intervention for trigeminal neuralgia is consistent pain control with medications and lifestyle changes the drug of choice is carbamazepine -it is a seizure medication but is highly effective for neuropathic pain carbamezapine is associated with agranulocytosis (leukopenia) and infection risk. clients should be advised to report any fever or sore throat high fiber diet is not required for a client with trigeminal neuralgia and the additional chewing with higher fiber foods may serve as a pain trigger clients with trigeminal neuralgia are encouraged not to massage the face as this can trigger pain primary intervention for trigeminal neuralgia: 1. pain control 2. limiting pain triggers drug choice: carbamazepine triggers can include: -washing the face -chewing food -brushing teeth -yawning -talking

ineffective coping

is the inability to manage stressors and problems effectively depression can affect a client's cognitive ability (eg, poor concentration, lack of judgment) and ability to cope with feelings of despair

radioactive iodine (RAI)

is the primary treatment for nonpregnant adults with hyperthyroid disorders such as graves' disease (a type of autoimmune hyperthyroid disease) the use of RAI is contraindicated in pregnancy and could cause harm to a fetus pregnancy results should therefore be confirmed using a valid pregnancy test in all clients who still have menstrual cycles rather than using a subjective form of assessment such as asking when the last menstrual period occurred radiation thyroiditis and parotitis, which cause dryness and irritation to the mouth, may occur after RAI treatment a baseline assessment is helpful but is not the most important action listed the nurse can teach the client to take sips of water frequently or to use salt and soda gargle solution 3-4 times daily to relieve these symptoms RAI damages or destroys the thyroid tissue, thereby limiting thyroid secretion, and can result in hypothyroidism clients need to take thyroid supplementation (levothyroxine) for life -because these symptoms are delayed, this teaching can occur before or after the procedure. it is not as important as assessing pregnancy status RAI destroys the thyroid gland, making clients permanently hypothyroid and requiring life long thyroid supplements in female clients, a nonpregnant status should be confirmed with a valid pregnancy test prior to administering RAI. RAI may cause harm to fetus

suicide

is the second leading cause of death in people age 15-24 the risk for suicide is increased in individuals with psychiatric disorders, such as depression, and in those who have attempted suicide within the past 2 years based on the client's history and statements, the HCP must perform a suicide assessment and take action (ie, psychiatry referral) to provide for the client's safety this is imperative as the client is prescribed the antidepressant fluoxetine (prozac) and has no follow-up with the prescribing HCP

phenazopyridine (pyridium)

is used as a local anesthetic in the treatment of UTI azo dye turns the urine an orange-red color the client needs to be reassured that this is an expected result and could stain clothing

ethambutol (myambutol)

is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active TB the client must have baseline and periodic EYE EXAMS during therapy as optic neuritis is a potentially reversible adverse effect the client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination hepatotoxicity is not common

niacin (nicotinic acid or B3)

is used in large doses for lipid-lowering properties in large doses, it may produce cutaneous vessel vasodilation the resulting warm sensation within the first 2 hours after oral ingestion is uncomfortable but harmless it may last for several hours effects usually subside as therapy continues narcotic-induced pruritis is not a true allergy

warfarin (coumadin)

is used to prolong clotting so that the desired result is a "therapeutic" range rather than the client's "normal" control value when not on the drug therapeutic range is considered (1.5-2.5 times the controlled INR of 2-3) but up to 3-4 times (INR of 2.5-3.5) in high risk situations such as artificial heart valves

abdominal paracentesis

is used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis) the client should be positioned in HIGH FOWLER's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted the client SHOULD VOID PRIOR to the procedure to decrease the risk of bladder puncture

metronidazole (flagyl)

is used to treat trichomoniasis and amebiasis consuming alcohol while taking the mediation may elicit a disulfiram (antabuse)-like reaction alcohol should be avoided for at least 48 hours after treatment is completed

isotonic fluid

isotonic iv fluids expand only the extracellular fluid and are used as fluid replacement for fluid volume deficit common examples are normal saline and lactated ringer's capillary refill indicates adequate circulation and perfusion normal capillary refill time is less than 3 seconds and a delay can be an indication of dehydration mottling is characterized by patches of pink, pale, and cyanotic skin and can be indicative of poor perfusion clients in labor usually receive 500-1000 mL of isotonic fluids prior to an epidural anesthesia as vasodilation below the epidural site can occur and result in hypotension up to 40% of these clients experience hypotension after an epidural anesthesia. the preadministration of IV fluids can lessen hypotension

bowel surgery

it can take 24-48 hours for peristalsis to return after bowel surgery due to manipulation of the bowels and anesthesia client should be monitored for return of bowel function and should be assessed last

bed bugs

it is a common misconception that bed bugs are drawn only to dirty environments they can inhabit any environment and can travel and spread easily in clothing, bags, furniture, and bedding although they do not pose significant harm, bed bugs can cause an itchy red rash that can be uncomfortable and affect sleep bed bugs should be exterminated, especially in a home with children it is important to treat the entire house for bed bugs. washing a single pillowcase or blanket will not stop the infestation. bed bugs multiply quickly and can hide in any crevice. once pest control is complete, the home will need to be monitored for signs of lingering bugs bed bug bites can cause a rash that clients, esp children will be inclined to scratch. precautions should be taken to help alleviate the rash as itching can cause complications such as secondary skin infections once a home is infested, the bugs can travel quickly and occupy spaces and crevices. all household members and pets will be afllicted

borderline personality disorder (BPD)

live in fear of rejection and abdonment to avoid abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving the manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person an individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving for this client, the nursing care plan must include the assignment of different staff members this will help diminish the client's dependence on a particular individual and help the client learn to relate to more than one person

alcohol withdrawal syndrome

manifestations: -mild withdrawal -seizures -alcoholic hallucinosis -delirium tremens s/s: -mild withdrawal: anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation -onset: 6-24 hrs -seizures: single or multiple generalized tonic-clonic -onset: 12-48 hrs -alcoholic hallucinosis: visual, auditory, or tactile; intact orientation; stable vital signs -onset: 12-48 hrs -delirium tremens: confusion, agitation, fever, tachycardia, hypertension, diaphoresis, hallucinations -onset: 48-96 hrs one of every 6 clients undergoing an emergency surgical procedure will show some signs of alcohol withdrawal during the hospital stay screening for heavy use of drugs and alcohol should occur at several points during hospitalization to avoid complications of withdrawal delirium tremens and other withdrawal symptoms can be prevented with benzodiazepine administration during hospitalization the stages of alcohol withdrawal do not always occur as a progressive sequence decreased RR is not a sign of alcohol WITHDRAWAL. it is more commonly seen in alcohol & opiate overdose clients experiencing alcohol withdrawal symptoms will be agitated and have tremors and hyperreflexia alcohol dependency is frequently missed during admission process clients should always be screened for heavy use of alcohol or benzos as withdrawal is potentially life-threatening and avoidable s/s of delirium tremens: agitation, fever, tachycardia, hypertension, diaphoresis

anticholinergics

many antihistamines also have anticholinergic effects anticholinergics have an antimuscarinic effect that can increase intraocular pressure and are therefore contraindicated in closed-angle glaucoma other contraindications include urinary retention (benign prostatic hyperplasia) and bowel obstruction related to the anticholinergic drug's effect on the smooth muscle in the urinary and GI tract

acetylcysteine (mucomyst)

may be given via nebulizer to help loosen and liquefy respiratory secretions to more easily clear them from the airway inhaled acetylcysteine may be used for clients with cystic fibrosis or other respiratory conditions with thick bronchial mucus acetylcysteine has no therapeutic effect on airway smooth muscle as it works primarily on secretions and has been shown to cause and/or worsen bronchospasm nurses caring for clients with reactive airway diseases (eg, asthma) prescribed acetylcysteine should clarify the prescription with the HCP

abdominal aneurysms

may be present with a pulsatile mass in the periumbilical area slightly to the left of the midline a bruit may be auscultated over the site back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). rupture of an abdominal aneurysm can quickly cause exsanguination and death. this client may need emergency surgery to repair the aneurysm

hypovolemic (hemorrhagic) shock

may occur after abdominal trauma or surgery as mesenteric edema resolves and previously compressed sites of bleeding reopen the shock continuum is staged in severity from initial (I) to irreversible (IV). during the initial stage, there is inadequate oxygen to supply the demand at the cellular level and anaerobic metabolism develops at this point, there may be no recognizable signs or symptoms as shock progresses to the compensatory stage, sympathetic compensatory mechanisms are activated to maintain homeostasis (eg, oxygenation, cardiac output) cold, clammy skin indicates failing compensatory mechanisms (ie, progressive stage), and immediate intervention is necessary to prevent irreversible shock and death cold, clammy skin in a client with shock indicates that compensatory mechanisms are failing and that hypoperfusion is occurring this should be reported promptly to the HCP as immediate intervention is necessary to prevent irreversible shock

PTSD

may occur in people who have seen or experienced a terrifying, traumatic event (eg, war, tornado, rape, plane crash) 3 categories of PTSD symptoms: 1. reexperiencing the traumatic event -examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (eg, rapid, pounding heart; gastrointestinal distress; diaphoresis) 2. avoiding reminders of the trauma: -examples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the event 3. increased anxiety and emotional arousal -examples include insomnia, irritability, outbursts of rage, persistent anger and/or fear, difficulty concentrating, hypervigilance, and exaggerated startle response persons with PTSD are typically restless and hypervigilant and have trouble falling or staying asleep

trochlear IV)

motor assessment: extraocular movements - inferior adduction

hypoglossal XII

motor assessment: stick tongue out

spinal accessory XI

motor assessment: turn head and lift shoulders to resistance

case manager (the nurse)

needs to assure that the client has the essential equipment/supplies for a smooth discharge into the home environment. the safest option is to delay discharge until that can be accomplished a client should not be allowed to leave until essential home supplies and equipment have been made available for a safe discharge

instilling eardrops (in adults)

otic medications are used to treat infection, soften cerumen for later removal, and facilitate removal of an insect trapped in the ear canal they are contraindicated in a client with a perforated eardrum general procedure for instilling ear drops include: 1. perform hand hygiene and don clean gloves. the ear canal is not sterile, but aseptic technique is used 2. position the client side-lying with the affected ear up (if not contraindicated) . this facilitates administration and prevents drops from leaking out of the ear 3. warm ear drops to room temp (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremes 4. pull the pinna up and back to straighten the ear canal in clients >4 years old and adults. pull the pinna down and back in clients <3 years old 5. support hand on the client's head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the ear canal. this avoids damaging the ear canal with the dropper 6. apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain, which facilitates the flow of medication into the ear canal 7. instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage 8. place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication. perform this with caution and avoid in infants or very young clients as it is a choking hazard

Al-Anon

provides help for spouses, significant others, family, and friends of alcoholics to share their personal experiences and coping strategies.

tubal myringotomy (tympanostomy)

purulent drainage is expected in a 1 day post-tubal myringotomy client the drainage shows the procedure was successful

MRI

radio waves and a magnetic field are used to view soft tissue during MRI this test is esp useful in diagnosing tumors, disc disease, avascular necrosis, ligament tears, cartilage tears, and osteomyelitis MRIs can have open or closed chambers the client should be advised that the procedure is painless but the machine will make loud tapping noises and may cause claustrophobia in some clients inside a closed chamber MRI is contraindicated in clients with 1. aneurysm clips 2. metallic implants such as ICDs (implantable cardioverter defibrillator) 3. pacemakers 4. electronic devices 5. hearing aids 6. shrapnel the large magnet of the MRI can damage the ICD or interfere with its function MRI is a noninvasive test that does not require anesthesia the client is not required to have NPO and can take medications as normally indicated no povidone-iodine (betadine) is used during MRI; gadolinium contrast is used

alzheimer disease

related to a combination of genetic, lifestyle and environmental factors clients with AD are usually diagnosed at age >65 early onset AD is a rare form of the disease that develops before age 60 and is strongly related to genetics children of clients with early onset AD have a 50% chance of developing the disease for late-onset AD, the strongest known risk factor is advancing age having a first-degree relative (eg, parent, sibling) with late-onset AD also increases the risk of developing AD trauma to the brain has been associated with the development of AD in the future brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls research suggests that healthy lifestyle choices (eg, smoking cessation avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk of developing AD research has failed to confirm that exposure to aluminum products (eg, cans cookware, antiperspirant deodorant) is related to the development of AD

blood transfusion reaction

s/s of a blood transfusion reaction typically will occur within the first 15 minutes after initiation of the transfusion these include: SOB, chest tightness, fever, back pain, anxiety, tachycardia, and hypotension when a transfusion reaction is suspected the first step is to STOP the infusion an infusion of normal saline is typically started it is important that normal saline be administered through a different port of the CVC using a new tubing or at the closest access point to the client flushing the blood in the IV tubing into the client will expose the client to more of the causative agent and increase complications from the transfusion reaction . notify HCP because the client has SOB and chest tightness an assessment of breath sounds is appropriate adventitious sounds could indicate bronchospasm or excess fluid in the lungs if an adverse blood transfusion is suspected, the first action is to stop the infusion an infusion of NS through a diff port for the cvc is typically started a client assessment and notification of the HCP are also required

trigeminal V

sensory & motor assessment: clench teeth & light touch

glossopharyngeal IX

sensory and motor assessment: gag reflex

history of penicillin hypersensitivity

should be determined prior to administration clients who are truly allergic to penicillins (eg, anaphylaxis) have an increased risk of allergy to other beta-lactam abx the incidence of cross-reactivity is 1-4% penicillins and cephalosporins can have a cross sensitivity response

chest tube insertion

should be performed with the client's ARM RAISED ABOVE the HEAD on the AFFECTED SIDE if possible, the HOB should be raised 30-60 degrees to reduce the risk of injury to the diaphragm

fall risk precautions

standard: -Orientation to room & call light -Call light within reach -Bed in lowest position -Uncluttered room -Nonslip socks or shoes -Well-lit room -Belongings within reach high fall risk: Bed alarm High fall risk signs Room close to nurses' station Color-coded socks & wristbands

ACE inhibitors

such as lisinopril are teratogenic lisinopril can cause embryonic/fetal developmental abnormalities (cardiovascular and central nervous system) if taken during pregnancy, especially during the first 13 weeks of gestation during the 2nd and 3rd trimesters, ACE inhibitors interfere with fetal renal hemodynamics, resulting in low fetal urine output (oligohydramnios) and fetal growth restriction

precontemplation

the client does not believe a problem exists, although others may point it out (eg, encouraging healthy eating)

termination

the client has achieved the desired change this stage may be theoretical, as relapse to former behaviors is always possible

preparation

the client has decided to change, explores emotions related to the decision, and begins establishing goals (eg, fitting into a dress)

action

the client has firmly committed to changing, has developed a plan (eg, dietary modifications, exercise plans), and actively takes steps toward new behavior (eg, choosing activity over television)

during lumbar puncture

the client is positioned SIDE-LYING, with the head, back and knees flexed a small pillow may be placed between the legs ad under the head for comfort and to maintain the spine in a horizontal position following the procedure, the client will be positioned according to the HCP's prescription (usually supine or with HOB elevated 30 degrees)

contemplation

the client recognizes a change is needed but is undecided whether it would be possible or worthwhile

after a liver biopsy

the client should lie on the right side for a minimum of 2 HOURS (to apply pressure and splint the puncture site) and THEN SUPINE for additional 12-14 HOURS. the risk of bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk

Home visit priority

the high-priority clients are those who are at risk for harm if a scheduled visit cannot be made in 24 hours or more

preparing client for bronchoscopy

the nurse must be able to perform basic assessment skills, such as assessing vital signs, lung sounds, ability to swallow, and gag reflex; maintain NPO status, prepare a checklist before the procedure; and monitor for respiratory difficulty after the procedure

risk for fall clients who are confused

the nurse should ensure that multiple interventions are put in place for the client at high risk for falls these include placing the bed in the lowest position with 2-3 side rails up, identifying the client with a fall risk ID band, using bed alarms, and making frequent rounds on the client

measuring weight of diaper

to measure the urinary output of an infant in diapers, subtract the weight of the diaper when dry from its weight when wet 1 g of weight = 1 mL of fluid adequate urinary output for an infant is 2 mL/kg/hr

client falling

to prevent injury to the nurse and the client if the client is falling, the nurse uses good body mechanics to try to break the fall and guide the client to the floor if necessary actions include: -step slightly behind the client and place the arms under the axillae or around the client's waist -place feet wide apart with knees bent - creates a broad base of support, provides stability, and reduces the risk for back injury to the nurse -place one foot behind the other and extend the front leg: allows the nurse to bring the client backward by using the leg muscles to rock backward while supporting the client's weight -let the client slide down the extended leg to the floor: lowers the client gently to the floor while keeping the client's head protected from injury

normal findings in infant

urinary output of 2 mL/kg/hr and flat fontanel

st john's wort

used for treatment of depression has many interactions with other prescription medications

ginseng

used to promote mental alertness and enhance the immune system

administering subcutaneous anticoagulant injections

when administering subQ anticoagulant injections (eg, heparin, enoxaparin) the nurse must select the appropriate needle length and angle to avoid accidental IM injection esp in clients with insufficient adipose tissue (eg, cachexia) IM injection of heparin would cause rapid absorption, resulting in a hematoma and painful muscle irritation the nurse should administer subcutaneous injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped, or at 45 degrees if only 1 in (2.5 cm) can be grasped anticoagulants are best absorbed if administered in the abd at least 2 in (5 cm) away from the umbilicus a 45 degree angle is used for clients with minimal adipose tissue to avoid accidental IM injection which would cause rapid absorption and result in hematoma and painful muscle irritation

new graduate nurse assignment

when assigning clients to the appropriate staff member, the RN must consider the individual client needs and the skills of the staff member the more experienced RN is assigned to the client with the more complex physiologic and psychologic needs,m who requires a more advanced level of nursing skill the new graduate nurse is assigned to the client with less complex needs, who requires basic nursing skills such as measurement of vital signs and basic physical assessment

tracheostomy suctioning

when performing the suctioning procedure, the nurse follows institution policy and observes principles of infection control and client safety strict aseptic technique is maintained because suctioning can introduce bacteria into the lower airway and lungs 1. place the client in semi-fowler's position, if not contraindicated, to promote lung expansion and oxygenation 2. preoxygenate with 100% oxygen (hyper-oxygenate) to prevent hypoxemia and microatelectasis. alternately if the client is breathing room air independently, ask the client to take 3-4 deepbreaths 3. insert the catheter gently the length of the airway without applying suction to prevent mucosal tissue damage. the distance can be premeasured (0.4-0.8 inches) (1-2 cm) past the distal end of the tube 4. withdraw the catheter slightly (0.4-0.8 in) (1-2 cm) if resistance is felt at the carina (bifurcation of the left and right mainstem) to prevent mucosal tissue damage 5. apply intermittent suction while rotating the suction catheter during withdrawal to prevent mucosal tissue damage. limit suction time to 5-10 seconds with each suction pass to prevent mucosal tissue damage and limit hypoxia suctioning removes secretions from the airway the nurse should minimize risks associated with suctioning by using correct aspiration technique and client positioning semi-fowler's position promotes lung expansion preoxygenation and limit of suction time to 5-10 secs reduces hypoxia and trauma

tactile hallucination

which gives the client the sensation of being touched -ex: "I need for you to get rid of these bugs that are crawling under my skin"

scabies

will be placed in contact isolation

pseudohyperkalemia

with the exception of clients in end-stage renal disease, a serum potassium value >6.5 in any client who is walking and talking should raise the suspicion of an erroneously elevated serum potassium (pseudohyperkalemia) from poor hematology technique, hemolysis, or clotting a serum potassium level of 7 would normally constitute a life-threatening electrolyte imbalance that would cause severe weakness or paralysis, unstable arrhythmias, and eventual cardiac arrest an assessment would focus on evaluating cardiac symptoms and muscle strength and be reported to the HCP pseudohyperkalemia can be avoided on the repeat blood draw by using heparin-impregnated hematology vials to prevent clotting, minimal use of a tourniquet and fist clenching and use of a larger gauge needle for the sample high serum potassium levels could be due to hemolysis or clotting during the blood draw if a clinical assessment does not correlate with the lab values, repeat testing is needed

normal BUN (children)

5-18 BUN is elevated with dehydration or a need for fluids

central venous access device (CVAD) (eg, peripherally inserted central catheter, central venous catheter)

A central venous access device (CVAD) (eg, peripherally inserted central catheter, central venous catheter) is a catheter inserted into a large vein (eg, internal jugular, femoral) to administer medications, collect blood samples, or monitor central venous pressure. Sterile technique during insertion reduces the risk of central line-associated bloodstream infections. When assisting with CVAD placement, the nurse: Limits traffic in and out of the room (Option 2) Completes a safety checklist (eg, verifies consent and client identifiers) prior to the procedure (Option 5) Assists the health care provider (HCP) in establishing a sterile field with maximal barrier precautions (eg, head-to-toe sterile drape, sterile gowns). All individuals in the room, including the nurse and HCP, must wear face masks (Option 3). Maintains a sterile environment, monitors the client, and assists the HCP as needed Places a sterile, occlusive dressing as soon as the CVAD is in place (Option 1) (Option 4) After insertion, the nurse should not inject or infuse anything through the CVAD until appropriate placement (ie, catheter tip in the superior vena cava) is confirmed via chest x-ray. Educational objective: When assisting with central venous access device (CVAD) placement, the nurse verifies consent and client identifiers, uses maximal barrier precautions (eg, face masks, sterile drape), and limits room traffic. The nurse applies a sterile dressing immediately after CVAD insertion and obtains a chest x-ray to verify placement before use.

craniotomy

A craniotomy involves incision into the cranium and is indicated for elevated intracranial pressure or removal of tumors, blood, or abscesses. Postoperatively, clients are at risk for developing a cerebrospinal fluid (CSF) leak from an intraoperative dural injury, which increases the risk for meningitis. Excessive drainage from a craniotomy incision (eg, saturated dressing, >50 mL per shift into the drain) or from the nose or ear suggests a possible CSF leak requiring immediate notification of the health care provider (HCP) (Option 3). Interventions focus on decreasing strain on the dural tear to encourage closure and include bedrest, lumbar drain placement, and surgical intervention. (Option 1) The incision should not be re-dressed until the HCP can evaluate the wound and drainage. (Option 2) The nurse should mark the drainage edges at least once per shift for comparison. However, a saturated dressing indicates a possible CSF leak. (Option 4) Specific client positioning postcraniotomy is usually prescribed by the HCP. The head of the bed is elevated approximately 30 degrees to facilitate venous drainage from the head and prevent increased intracranial pressure; if the bed is flat, the client should not lie on the operative side. Repositioning may be indicated but is not the most appropriate action at this time. Educational objective: Clients postcraniotomy are at risk for developing a cerebrospinal fluid leak. Incisional edema or clear drainage from the incision, nose, or ear is reported immediately to the health care provider for evaluation and intervention to decrease the risk of meningitis.

schizophrenia with catatonia

A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features: Immobility—the client remains in a fixed stupor or position for long periods Refuses to move about or engage in activities of daily living May have brief spurts of excitement or hyperactivity Remaining mute Bizarre postures—the client holds the body rigidly in one position Extreme negativism—the client resists instructions or attempts to be moved Waxy flexibility—the client's limbs stay in the same position in which they are placed by another person Staring Stereotyped movements, prominent mannerisms, or grimacing Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition. The priority nursing action is to anticipate the client's needs, and to ensure that the client is well hydrated and has adequate nourishment. Some clients will need total care. (Option 1) Impaired social interaction is also an appropriate nursing diagnosis in a client with catatonic schizophrenia. However, it is not a priority, especially during the early phases of the disease. (Option 2) The client's mutism makes the diagnosis of impaired verbal communication appropriate, and the nurse should gently encourage this client to talk without undue expectations or pressure. This is not the priority nursing diagnosis. (Option 4) If this client is in a bizarre or fixed posture, there may be a risk for decreased circulation and pressure ulcers. The nurse needs to encourage ambulation and/or provide range-of-motion exercises. Educational objective: Clients with catatonic schizophrenia are unable to meet their own needs for fluids, food, movement, and elimination and need assistance in performing basic activities of daily living. However, a priority diagnosis is deficient fluid volume.

fast flush of arterial line

A fast flush of the arterial line system (square wave test) should be performed after the nurse has ruled out a physiological cause of the low pressure alarm. This test helps to verify if the arterial line is functioning correctly.

hypoglycemic baby

A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24 hours after delivery. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline-low glucose level is symptomatic and should be assessed first. (Option 1) A normal respiratory rate for an infant is 30-60/min. This infant is currently stable. (Option 3) It is normal to auscultate crackles in an infant during the first hour of life. This is because fluid is still being pushed out of and absorbed by the lungs. This infant is currently stable. (Option 4) A normal temperature range for an infant is 97.7-99.7 F (36.5-37.6 C). This infant is currently stable. Educational objective: The nurse should monitor infants for hypoglycemia by assessing for symptoms and monitoring the blood glucose level. A blood glucose level <40 mg/dL (2.2 mmol/L) indicates hypoglycemia and should be treated immediately by feeding or administering a glucose bolus.

peripheral angiogram

A peripheral angiogram is used to assess for occlusions (eg, embolism), injuries, aneurysms, or abnormalities in the vasculature of an extremity. During an arterial angiogram (arteriography), a catheter is inserted into the femoral artery and contrast dye is injected to make the blood vessels visible by x-ray. The nurse should assess for complications (eg, hemorrhage, hematoma) at the catheter insertion site and the affected extremity. The nurse should perform frequent neurovascular checks (eg, temperature, distal pulses, color, capillary refill, sensation, movement) of the affected extremity. Coolness and inability to palpate pedal pulses are signs of decreased perfusion that must be further investigated by comparing the affected extremity to the unaffected extremity, comparing the current assessment to the pre-intervention assessment, and using a Doppler ultrasound to reassess pedal pulses (Option 4). (Option 1) A heating pad is contraindicated for clients with decreased perfusion as a loss of sensation increases the risk for burns. (Options 2 and 3) Further assessment is needed before calling the health care provider or documenting the findings. Educational objective: After a peripheral angiogram, frequent neurovascular checks (eg, temperature, distal pulses, color, capillary refill, sensation, movement) are required to assess peripheral circulation. Signs of decreased perfusion (eg, inability to palpate pedal pulses) must be investigated (eg, Doppler ultrasound to reassess pulses) prior to further interventions.

spine immobilization

1. cervical collar application 2. logroll technique (moving client as a unit) 3. immobilization on spine board The initial priorities for a client with a suspected cervical spine injury are to ensure a patent airway and immobilize the spine to prevent further injury. This includes applying a rigid hard collar, placing the client on a firm surface (eg, a backboard), and moving the client as a unit (logrolling) if required (Options 1, 4, and 5). A soft foam cervical collar does not provide immobilization. Further stabilization is achieved by taping down the client's head and using straps to immobilize the arms, especially if the client is not cooperating. After immobilizing the client, the nurse should obtain a baseline set of vital signs to monitor for neurogenic shock (eg, hypotension, bradycardia, poikilothermia [ie, inability to regulate body temperature]), a potential complication of spinal cord injury. The nurse should also assess the client's respiratory rate, pattern, and effort. Presence of abdominal breathing or increased work of breathing may indicate impending loss of airway and require prompt rapid-sequence intubation (Option 3). (Option 2) Movement of the neck/upper extremities should be avoided until cervical spine injury is ruled out with imaging, which is done after the spine is immobilized with a hard collar. Educational objective: The priorities for a client with a suspected cervical spine injury are maintaining a patent airway and spinal immobilization. Interventions include application of a rigid hard collar, placing the client on a firm surface, logrolling the client during movement and transfers, and continued assessment of need for an advanced airway.

nursing priorities when implementing chemical contamination

1. restricting other clients, staff, and bystanders from the victims' vicinity to protect non-affected individuals and the health care facility from the contaminant 2. donning personal protective equipment to protect the nurse when providing care 3. decontaminating the clients outside the facility before initiating treatment. if the chemical is not removed, it will continue to cause respiratory distress; contaminated clothing is left outside the facility to reduce the risk of contaminating staff and other clients 4. assessing and providing treatment of symptoms. initial treatment is for the symptoms (eg, wheezing), regardless of specific cause the nurse should always protect other clients, staff, and the health care facility first in a chemical contamination PPE should be put on before decontamination victims should be decontaminated outside the facility before care is administered

UAP

A client with a casted extremity requires frequent neurovascular assessment to monitor for compartment syndrome. Unlicensed assistive personnel (UAP) are delegated tasks for stable clients by the nurse. Tasks requiring clinical judgment cannot be delegated to UAP; these include parts of the nursing process (eg, assessment, planning, evaluation) and teaching. Appropriate tasks for UAP include: Elevating the casted extremity above heart level to promote venous blood return (Option 4) Alerting the nurse of client reports of tingling, decreased sensation, and pain as these may indicate impaired circulation and nerve compression (Option 1) Assisting the client in performing active and passive range-of-motion exercises to prevent muscle atrophy and disuse syndrome (Option 2) (Option 3) Neurovascular checks are important for monitoring for compartment syndrome but must be done by the nurse. (Option 5) The routine skin assessment should be done by the nurse. Educational objective: A client with a cast requires frequent neurovascular assessment to monitor for compartment syndrome. Appropriate tasks for unlicensed assistive personnel for a client with a cast include elevating the casted extremity, assisting with range-of-motion exercises, and alerting the nurse of client reports of tingling, pain, or decreased sensation.

disturbed sleep pattern

A disturbance in sleep pattern refers to time-limited interruptions of the amount and quality of a client's sleep due to external factors (eg, noise, lighting, noxious odors, interruptions due to medical and nursing care). Evidence shows that excessive noise and sleep disturbances in critically ill clients can affect outcomes as they can lead to significant psychologic (eg, delirium, post-traumatic stress disorder, anxiety) and physiologic (eg, circadian rhythm disturbance, decreased REM sleep, increased heart rate, impaired immunity) consequences. Sleep disturbance pattern can lead to anxiety, powerlessness, and acute confusion. Therefore, disturbed sleep pattern related to environmental factors such as excessive noise and changes in daylight-darkness exposure (circadian rhythm disturbance) is the priority ND. Disturbed sleep pattern related to environmental factors, such as excessive noise and circadian rhythm disturbance, is an important ND for a critically ill client. Lack of adequate uninterrupted sleep can lead to negative physiologic (eg, decreased REM sleep, increased heart rate) and psychologic (eg, delirium, anxiety, powerlessness, acute confusion) consequences that can affect client outcomes.

atypical presentation of MI

Atypical presentation of a myocardial infarction (MI) refers to a client who is having characteristic symptoms (eg, sweating, nausea, dyspnea) with no chest pain. Although any client may have atypical symptoms during an MI, certain factors increase the risk of atypical presentation. Clients with advanced age or female gender have a greater risk for atypical presentation during an MI (Option 1). Clients with diabetes or neuropathy may have impaired pain perception due to nerve dysfunction, which makes them more likely to have an atypical presentation, or a silent MI (ie, asymptomatic). (Options 2, 3, and 4) Hyperlipidemia, hypertension, and smoking increase the risk of MI, but these factors do not specifically increase the risk of atypical presentation. Educational objective: Atypical presentation of a myocardial infarction involves associated symptoms (eg, sweating, nausea, dyspnea) with no chest pain. Women, older adults, and clients with diabetes or neuropathy are more likely to have an atypical presentation.

prevent transmission of infection while drawing blood specimen from client's central line

Blood and bodily fluids are considered hazardous materials and must be placed in containers identifying them as biohazards (eg, biohazard bag) (Option 4). This alerts staff to take the necessary precautions to prevent infection transmission when handling the specimen. Other procedures to prevent transmission of infection include: Meticulous hand hygiene (Option 3) Use of disposable gloves during collection and handling of specimen Cleaning the specimen bag with a disinfecting wipe Proper and immediate transport of specimen to the lab Avoiding placing specimen in clean areas (eg, nursing station) An appropriate antiseptic (eg, 70% alcohol) scrub of the catheter hub prior to use inhibits microorganism entry and prevents transmission of infection to the client (Option 5). (Option 1) When drawing a blood specimen from a central line, the nurse should discard the first blood drawn to prevent an inaccurate lab result, but this will not prevent the transmission of infection. (Option 2) Flushing the line prior to specimen collection will clear any previous infusions and assist in checking patency. It is important to flush the line after collection to remove blood and prevent clotting. Neither action prevents infection transmission. Educational objective: When handling blood or body fluid specimens, the nurse should adhere strictly to protocols that will prevent the transmission of infection, including meticulous hand hygiene and use of gloves. All body fluid specimens should be transported immediately in a container labeled with the biohazard symbol.

6 months

By 6 months of age, infants are able to roll over and sit up for short periods. Development of eye-hand coordination allows them to locate and grasp objects, and they have an oral fixation and tend to put small objects in their mouth. Caregivers of infants at this stage should employ the following safety strategies: Keep small objects off the floor Avoid toys with small, removable parts (eg, stuffed animals with hard plastic eyes glued or sewn on) Lock all cabinets in which toxic substances are stored (eg, under kitchen sink) (Option 3) Place sharp or fragile items on high shelves (Option 5) (Option 1) Infants and toddlers should sit in a rear-facing car seat until 2 years of age or the child exceeds the car seat's maximum allowable height/weight. (Option 2) Although they are not yet ambulatory, infants can roll and easily fall from heights if inadequately guarded. Childproof gates should be in place once the infant is able to roll over. (Option 4) The infant should never be left alone on a changing table, even with a restraining belt. One hand should be maintained on the infant at all times if the caregiver must turn away. Educational objective: Safety strategies for caregivers of 6-month-old infants include preventing falls (eg, childproof gate at the top of stairs, hand placed on the child on a changing table), aspiration (eg, no small objects on the floor), and poisoning (eg, locking of cabinets with toxic substances) as well as using a rear-facing car seat until 2 years of age.

cardiac glycosides (digoxin, lanoxin)

Cardiac glycosides (digoxin [Lanoxin]) improve cardiac output and efficiency in clients with heart failure by increasing cardiac contractility and decreasing heart rate. A client experiencing weight gain and orthopnea is likely experiencing a heart failure exacerbation. The nurse should assess the client's entire medication regimen to determine why digoxin may not be working effectively (eg, possible drug interactions). Sucralfate (Carafate) is used to coat and protect the mucosal lining in clients with ulcers; therefore, drug absorption will be altered. Sucralfate should be taken at least 2 hours after digoxin administration, as taking these medications at the same time can result in decreased digoxin absorption (Option 3). (Option 1) Exercise is an important part of maintaining cardiac health. A client with heart failure should exercise as tolerated with frequent periods of rest. However, this is not the priority assessment for a client with a heart failure exacerbation. (Option 2) Checking the heart rate prior to taking digoxin is recommended to assess for signs of digoxin toxicity (eg, bradycardia). However, this is not the priority teaching for a client with a heart failure exacerbation. (Option 4) Information about the client's last visit to the primary care clinic might be helpful but would not be beneficial to the assessment of symptoms. Educational objective: Cardiac glycosides (digoxin [Lanoxin]) improve cardiac output and efficiency in clients with heart failure. Sucralfate (Carafate) taken at the same time as digoxin can decrease absorption of the latter, thereby increasing symptoms of heart failure. Clients should take sucralfate at least 2 hours after digoxin.

catheter occlusion

Catheter occlusion is the most common complication of central venous access devices. Kinked tubing, catheter malposition, medication precipitate, or thrombus can occlude the lumen, preventing the ability to flush or aspirate blood. The nurse should first assess for mechanical, nonthrombotic problems by: Repositioning the client (eg, head, arm) as the catheter tip may be resting against a vessel wall (Option 4) Assessing IV tubing for clamps, kinks, and precipitate The nurse should then attempt to flush the device again. If the occlusion remains, the nurse should not flush against resistance as applying force may damage the catheter or dislodge a thrombus. Instead, the nurse should contact the health care provider (HCP), who may prescribe medication (ie, alteplase) to dissolve a thrombus or fibrin sheath. (Option 1) Most needleless connector manufacturers recommend flushing with normal saline. Some facilities may use heparinized saline flushes; the nurse should follow HCP prescriptions and institution guidelines. Heparin flushes should be at the lowest acceptable dose (eg, 10 units/mL) to prevent heparin-induced thrombocytopenia. (Option 2) Flushing with a syringe smaller than 10 mL causes increased intraluminal pressure and may damage the catheter. (Option 3) The nurse should rule out a mechanical problem before notifying the HCP. Educational objective: Occlusion of a central venous access device can be related to mechanical, medication precipitate, or thrombotic causes. The nurse should first attempt to remove the occlusion by eliminating a possible mechanical obstruction (eg, reposition client to adjust catheter tip location) before notifying the health care provider.

phlebostatic axis

The transducer should be leveled to the client's phlebostatic axis to measure arterial pressure correctly. However, this should be done after the client has been checked for a physiological cause of the alarm.

tricuspid atresia

Tricuspid atresia is a congenital heart defect in which the tricuspid valve does not develop; therefore, blood is unable to flow from the right atrium to the right ventricle and on to the lungs. Cyanosis would be a normal finding as deoxygenated blood from the right atrium flows through a patent foramen ovale and mixes with oxygenated blood in the left ventricle before being pumped throughout the body.

varicella (chickenpox)

airborne precautions PPE: -N95 particle respirator -As needed for procedures with risk of splash or body fluid contact: Nitrile gloves, disposable gown, goggles/shield Rooms: -Negative air pressurization -High-efficiency particulate air filters

clinical features of cardiac tamponade

assessment findings: 1. narrowed pulse pressure 2. muffled heart sounds 3. distended neck veins distended neck veins distended superior vena cava pericardium interventricular septum deviation reduced left ventricular cavity space pericardial effusion

auditory hallucination

clients experiencing auditory hallucinations hear sounds and voices others do not ex: "hear that? she told me to kill my father"

heparin

clients receiving iv heparin should maintain therapeutic clotting times, avoid developing embolic events, and remain free from signs of heparin-induced thrombocytopenia (eg, petechiae, purpura)

airborne precautions

common applications of airborne precautions: 1. TB 2. varicella (chickenpox) (also contact precautions) 3. rubeola (measles) equipment used for airborne precautions: -Personal: 1. N95 particle respirator 2. as needed for procedures with risk of splash or body fluid contact: Nitrile gloves, disposable gown, goggles/shield -Rooms: 1. negative air pressurization 2. high-efficiency particulate air filters

folic acid deficiency

does not cause peripheral neuropathy it is associated with macrocytic anemia and neural tube defects in children

acute hemolytic reaction

during a blood transfusion usually develops within the first 15 minutes s/s: chills, fever, lower back pain (from damaged cells in the kidneys) tachycardia tachypnea hypotension acute hemolytic reaction is an emergency that requires the nurse to stop the transfusion and treat shock

site for immunization for children (vastus lateralis)

for children age < 7 months, the site for immunizations is the anterolateral thigh (vastus lateralis) the gluteus medius muscle (muscle injected with a ventrogluteal injection) is developed through crawling and walking. the muscles are not developed enough at this age to be used as an acceptable site IM injections are given in the vastus lateralis to children age <7 months

cystic fibrosis

is a genetic condition that causes dehydration and thickening of mucus in the respiratory, gastrointestinal, and GU systems thick mucus within the pancreas impairs the release of digestive enzymes (eg, lipase) requiring supplementation to improve digestion and prevent malnutrition in clients with CF

gingival hyperplasia (hypertrophy)

is a known side effect of phenytoin (Dilantin) vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome (fever, skin rash, and lymphadenopathy)

norepinephrine (Levophed)

is a vasopressor used to increase stroke volume, cardiac output, and MAP titrating a norepinephrine infusion upward to maintain the MAP within normal limits >65 mmHg is an appropriate nursing action for a client in anaphylactic shock

epinephrine

is administered for cardiac arrest, anaphylactic reations, or severe asthma attacks

facial VII

motor and sensory assessment: facial movement - close eyes, smile

general procedure for administration of ophthalmic medications

1. remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the INNER to OUTER CANTHUS to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct 2. place the client in supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa 3. rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination 4. pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac 5. instruct client to look upward and then instill drops of medication into the conjunctival sac. this minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea 6. instruct client to close the eyelid and move the eye around (if able). then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate) this will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption 7. remove excess medication from each eye with a new tissue or gauze pad to prevent cross contamination 8. wait 5 minutes before instilling a different medication into the same eye

inexperienced med surg nurse floats to ICU

A medical-surgical nurse inexperienced in the intensive care unit (ICU) setting would have the knowledge and experience to care for clients with lower-acuity needs (eg, stable, predictable). A medical-surgical nurse can safely care for a client 3 days after a femoral-popliteal bypass. This client requires neurovascular checks at regular intervals (eg, pulses, color, temperature, capillary refills, pain, movement) (Option 1). A client with diabetic ketoacidosis who has been weaned from IV insulin and is receiving preprandial subcutaneous insulin requires blood glucose monitoring and possible administration of IV fluids and electrolytes. This medical-surgical nurse should have the knowledge to manage this client's treatment (Option 5). (Option 2) Mechanically ventilated clients require specialized critical care nursing knowledge and should be assigned to an ICU nurse. (Option 3) Norepinephrine (Levophed) is an IV vasopressor used to treat hypotension and hypoperfusion in clients with shock. Norepinephrine administration requires careful titration and hemodynamic monitoring. (Option 4) Tissue plasminogen activator (tPA) is given during an ischemic stroke to reestablish cerebral perfusion. Due to the high risk of complications (eg, intracranial hemorrhage), this client should be cared for by an ICU nurse with experience in tPA infusions (eg, frequent neurologic assessment and vital signs). Educational objective: When creating nursing assignments, the nurse's area of expertise and level of experience must be considered. Clients with lower-acuity needs who are more stable or predictable (eg, stable femoral-popliteal bypass graft, stabilized diabetic ketoacidosis) should be given to a medical-surgical nurse floating to the intensive care unit.

bronchiolitis

Bronchiolitis is a lower respiratory tract infection most commonly caused by respiratory syncytial virus. It causes inflammation and obstruction of the lower respiratory tract. Depending on the severity of the infection, infants with bronchiolitis can experience mild cold symptoms or respiratory distress. The infant will have difficulty feeding and can become dehydrated. Medical care is supportive and includes suctioning, oxygen, and hydration. The infant with irritability may be exhibiting signs of hypoxia. The nurse should see this client first. (Option 1) Intussusception can be reduced with hydrostatic enema (nonoperative approach). This is important but is not a priority over a child with bronchiolitis and respiratory distress. (Option 2) Chemotherapy can result in neutropenia and immunosuppression. Even a low-grade fever should be taken seriously as it can result in lethal sepsis. The client needs cultures and empiric antibiotics. However, the client with bronchiolitis is the priority. (Option 3) Increased intracranial pressure will occur with shunt malfunction. The nurse should routinely measure the head circumference, but it is not a priority over a client with respiratory distress. Educational objective: A client with bronchiolitis will require frequent suctioning, especially before feeding. The nurse should use the ABC (airway, breathing, circulation) guidelines and see this client first.

clonidine patch

Clonidine is a potent antihypertensive agent and is available as a transdermal patch. The patches should be replaced every 7 days and can be left in place during bathing. Instructions for using the clonidine (transdermal) patch: Apply the patch to a dry hairless area on the upper outer arm or chest once every 7 days (Option 1). Do not shave the area before applying the patch. The skin should be free from cuts, scrapes, calluses, or scars (Option 5). Wash hands with soap and water before and after applying the patch as some medication may remain on the hands after application. Wash the area with soap and water, then rinse and wipe with a clean, dry tissue. Remove the patch from the package. Do not touch the sticky side. Rotate sites of patch application with each new patch (Option 4). Remove the old patch only when applying a new one. Do not wear more than 1 patch at a time unless directed by your health care provider (HCP). When removing the patch, fold it in half with the sticky sides together. Discard the patch out of the reach of children and pets. Even after it has been used, the patch contains active medicine that may be harmful if accidentally applied or ingested (Option 2). Notify the HCP if you are experiencing side effects such as dizziness or slow pulse rate. Do not remove the patch without discussing this with the HCP as rebound hypertension can occur (Option 3). Educational objective: The nurse should teach a client receiving a clonidine patch to: Apply patch to a dry hairless area on the upper arm or chest Wash hands before and after application Rotate sites with each new patch application Discard patch away from children or pets with sticky sides folded together Never wear more than 1 patch at a time Never stop using the patch abruptly

cardiac arrest in pregnant client

Common causes of sudden cardiac arrest in pregnant clients include embolism, eclampsia, magnesium overdoses, and uterine rupture. If cardiopulmonary resuscitation (CPR) is required, several modifications must be made to ensure efficacy of the rescue efforts. During pregnancy, the heart is displaced toward the left because the growing uterus pushes upward on the diaphragm, particularly in the third trimester. To accommodate this displacement, the hands should be placed on the sternum slightly higher than usual for chest compressions during CPR (Option 2). In addition, a gravid uterus can significantly compress the client's vena cava and aorta, thereby hindering effective blood flow during CPR. The uterus should be manually displaced to the client's left to reduce this pressure. The nurse can also place a rolled blanket or wedge under the right hip to displace the uterus. If return of spontaneous circulation (ROSC) does not occur after 4 minutes of CPR, emergency cesarean section is usually initiated. Delivery should occur within 5 minutes of initiating CPR. (Option 1) Compressions to the right sternal border will lack effectiveness as the heart is displaced to the left side during pregnancy. (Option 3) Chest compressions given below the diaphragm are not effective for ROSC and greatly increase the risk of injury to the client's uterus, spleen, or liver. (Option 4) In the supine position, the vena cava and aorta are compressed by the uterus, hindering effective blood flow during CPR. The uterus should be displaced to the left to reduce pressure. Educational objective: Two important modifications for cardiopulmonary resuscitation of a pregnant client include performing chest compressions slightly higher on the sternum and displacing the uterus to the client's left side.

cranial nerves

Each of the 12 cranial nerves has a sensory function, a motor function, or both. Cranial nerve II, the optic nerve, allows the brain to sense what the eye sees. The client with an impaired cranial nerve II may have altered visual acuity or visual fields. To ensure that the client understands interventions, the nurse should verbally explain all procedures in detail (Option 4). (Option 1) Chewing is affected by cranial nerve V (trigeminal). (Option 2) Although raising the head of the client's bed to prevent aspiration is an appropriate nursing action, it is not necessary with an alteration with cranial nerve II. Swallowing is affected by cranial nerves IX (glossopharyngeal) and X (vagus). (Option 3) Using a pen and paper to ask the client questions would be appropriate if cranial nerve VIII (vestibulocochlear or acoustic) were impaired, causing a hearing deficit. Educational objective: Clients with impairment of cranial nerve II have altered visual acuity or visual fields. To ensure that the client understands interventions, the nurse should verbally explain all procedures in detail. "On Old Olympus Towering Tops A Finn And German Viewed Some Hops" "Some Say Marry Money But My Brother Says Bad Business Marry Money"

ectopic pregnancy

Ectopic pregnancy can be life-threatening if diagnosis and treatment are delayed. A growing embryo implanting anywhere outside the uterus (eg, fallopian tube, abdominal cavity) results in an ectopic pregnancy. Rupture of an ectopic pregnancy can occur if the embryo outgrows its environment, resulting in hemorrhage. Any woman with amenorrhea (ie, delayed or absent menstrual period), pelvic or abdominal pain, and/or subsequent vaginal bleeding/spotting should be evaluated promptly for the possibility of ectopic pregnancy. (Option 1) Severe, intractable nausea, and vomiting can result in dehydration and electrolyte imbalances (ie, hyperemesis gravidarum). Although this client should be assessed for hyperemesis gravidarum, the condition is not immediately life-threatening. (Option 2) Irregular Braxton Hicks contractions (ie, false labor) are not uncommon for a client at 37 weeks gestation (ie, term gestation). These contractions are more common in multiparous women or women with an overdistended uterus (eg, twin gestation, polyhydramnios). True labor is indicated by cervical change resulting from regular contractions over time. (Option 4) Quickening, or a woman's first perception of fetal movement, usually occurs at 18-20 weeks gestation in primigravida clients. However, this timeframe may be influenced by increased maternal BMI or an anteriorly placed placenta. Educational objective: Ectopic pregnancy can result in rupture and life-threatening hemorrhage if not promptly identified. Any woman with amenorrhea, pelvic or abdominal pain, and/or subsequent vaginal bleeding/spotting should be evaluated promptly for the possibility of ectopic pregnancy.

failure to sense

Failure to sense occurs when a pacemaker fails to recognize the intrinsic electrical activity of the heart and fires at inappropriate times during the cardiac cycle. If the pacemaker fires during myocardial repolarization (eg, within the T wave), life-threatening arrhythmias (eg, ventricular tachycardia, ventricular fibrillation) may occur (Option 3). Failure to sense is treated by increasing or lowering the sensitivity setting until the pacer senses appropriately. (Option 1) Pacer spikes occurring before every P wave indicate an atrial paced rhythm. The P wave may appear normal or abnormal; the QRS complex appears normal. (Option 2) Ventricular paced rhythms have a pacer spike before the QRS complex. The QRS complexes are often wide and distorted as the electrical impulse is generated in the ventricle (instead of the atrioventricular node) and does not follow the normal conduction pathway of the heart. (Option 4) Pacer spikes before every P wave and QRS complex indicate an atrioventricular (dual-chamber) paced rhythm. Educational objective: Failure to sense occurs when the pacemaker fails to recognize the intrinsic electrical activity of the heart and fires at inappropriate times during the cardiac cycle. If the pacemaker fires during myocardial repolarization (eg, within the T wave), life-threatening arrhythmias (eg, ventricular tachycardia, ventricular fibrillation) may occur.

medical procedures, nurse should ensure that the client:

For medical procedures, the nurse should ensure that the client: 1. Has an empty bladder and is in high Fowler's or a sitting position for paracentesis 2. Is Trendelenburg on the left side for suspected air embolism 3. Has the arm raised above the head on the affected side for chest tube insertion 4. Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy 5. Is side-lying with the head, back, and knees flexed for lumbar puncture

frostbite

Frostbite occurs when vasoconstriction restricts blood flow, intracellular fluid freezes, and cell membranes rupture; tissue may appear pale, waxy, blue, or mottled. Clients with peripheral vascular problems (eg, advanced age, diabetes, smoking) are at a higher risk for developing frostbite. A warm water bath (eg, 98.6-102.2 F [37-39 C]) is administered to thaw and reestablish as much circulation to viable tissue as possible. Subsequent edema and/or superficial blistering may develop as the damaged tissue is rewarmed. Blisters are opened to reduce pressure and sterile dressings are applied. The client will need analgesics as the rewarming process is very painful. (Options 1 and 3) Manual friction (eg, massage, ambulation) applied to tissues affected by frostbite is contraindicated as it may further damage the tissues. (Option 2) Comfort care (eg, warm blankets) may be provided after emergent interventions to salvage the client's lower extremities. However, the nurse should consult with the health care provider before providing food or drink to the client. Educational objective: Tissue damaged by frostbite may appear pale, waxy, blue, or mottled due to frozen intracellular fluid. Affected extremities are thawed in a warm water bath (98.6-102.2 F [37-39 C]), and analgesics are administered. Manual friction (eg, massage, ambulation) is contraindicated as it may further damage the tissue.

magnetic resonance cholangiopancreatography (MRCP)

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less-invasive alternative to endoscopic retrograde cholangiopancreatography to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to gadolinium (Option 4). A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy (Option 2). Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. Delayed/irregular menses may be a normal variation in some clients; however, delayed menses may indicate pregnancy and should be reported for further investigation prior to MRCP (Option 3). (Option 1) Many clients should be NPO for 4 hours prior to the procedure to allow better visualization of the anatomical features. (Option 5) Smoking does not affect MRI visualization and is not a contraindication. Educational objective: Magnetic resonance cholangiopancreatography uses MRI to visualize the biliary and hepatic ductal system. Contraindications, including pregnancy, the presence of certain metal implants, and an allergy to gadolinium (ie, noniodine contrast agent), should be assessed before the procedure.

manipulative behaviors

Manipulative behaviors, such as attempts at staff splitting, are common in clients with borderline and antisocial personality disorders, substance abuse problems, somatic symptom disorder, and bipolar disorder (during the manic phase). The manipulative behavior is aimed at gaining control/power over a person/situation or for material gratification. Clients manipulate by flattery or by pitting staff members against each other. They may "tell" on a staff member or act in a way to give the impression of sincerity and caring. Nursing interventions for manipulative behaviors include: Setting limits that are realistic, nonpunitive, and enforceable Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors Enforcing all unit, hospital, or center rules (Option 4) Ensuring consistency from all staff members in enforcing set limits (Option 1) Telling the client the gift shop is closed does not address the client's manipulative behavior. (Option 2) Believing the client's statement is not appropriate as it will only reinforce the client's manipulative behavior. (Option 3) Asking the client the reason for going to the gift shop ignores the fact that the client is trying to break the rules. Educational objective: Clients who want to gain power or control over a situation or desire material gratification may use manipulative behaviors (eg, staff splitting). Nursing interventions include setting behavioral limits; using a neutral, matter-of-fact tone when discussing rules and consequences of unacceptable behavior; and ensuring consistency from staff members in enforcing limits.

child <1 with fever, lethargy, and vomiting

This child age <1 with fever, lethargy, and vomiting likely has sepsis or meningitis. Clients with suspected meningitis need to be seen immediately and require close monitoring (eg, level of consciousness, vital signs), isolation, spinal fluid cultures, and antibiotics (Option 1). Signs of meningitis in an infant include: Fever or hypothermia Poor feeding, vomiting Altered level of consciousness (eg, restlessness, irritability, lethargy) Increased intracranial pressure (bulging fontanelle [late sign], opisthotonic positioning [arching of the back with hyperextension of the neck]) (Option 2) Occasional barking cough without stridor is a sign of mild viral laryngotracheobronchitis (ie, croup). This client is stable and lower priority than a client with meningitis; however, the nurse should monitor for signs of deterioration (eg, stridor, lethargy, tachypnea) and have oxygen and emergency respiratory equipment available. (Option 3) Generalized edema and cola- or tea-colored urine (hematuria) indicates acute postinfectious glomerulonephritis, which occurs after infection with group A beta-hemolytic Streptococcus and is not emergent. Treatment is supportive (eg, bed rest, sodium restriction, diuretics) and may be delayed. (Option 4) Painful urination could signify a urinary tract infection and has less risk of becoming emergent than the other clients' conditions. The teenager's withdrawn behavior warrants further assessment (eg, for suspected abuse or depression), but this can be delayed. Educational objective: Bacterial meningitis is inflammation of the meninges, which causes cerebral edema and may be fatal. Clients with fever and signs of increased intracranial pressure need close monitoring, isolation, spinal fluid cultures, and antibiotics.

timed urine collection tests

Timed urine collection tests are usually done to assess kidney function and measure substances excreted in the urine (eg, creatinine, protein, uric acid, hormones). These tests require the collection of all urine produced in a specified time period (a crucial step) to ensure accurate test results. The proper container (with or without preservative) for any specific test is obtained from the laboratory. The collection container must be kept cool (eg, on ice, refrigerated) to prevent bacterial decomposition of the urine. Not all of the client's urine was saved during the collection period. Therefore, the nurse or UAP must discard the urine and container and restart the specimen collection procedure. Although a 24-hour urine collection can begin at any time of the day after the client empties the bladder, it is common practice to start the collection in the morning after the client's first morning voiding and to end it at the same hour the next morning after the morning voiding (Option 2). (Option 1) Adding 250 mL to the total output when the test is completed is not an appropriate action as the actual urine output from the 24-hour period is needed for accurate results. (Option 3) To start the collection period, the nurse asks the client to void and discards this specimen (it is not added to the collection container). The 24-hour period starts at the time of the client's first voiding. (Option 4) Relabeling the same container and changing the start time from 6:00 AM to 10:00 AM is not an appropriate action. The container would include part of the urine produced in a 28-hour period, and the test results would be inaccurate. Educational objective: It is common practice to start a 24-hour urine collection test at the time of the client's first voiding in the morning. If any urine is discarded by accident during the test period, the procedure must be restarted. All produced urine should be placed in the same container and kept cool (on ice).

to relieve choking in a responsive infant

To relieve choking in a responsive infant, the rescuer should: Hold the infant face down on the forearm with the infant's head slightly lower than the body. The rescuer's forearm is supported on the thigh to avoid compressing the infant's soft throat tissue and fontanelles. Forcefully perform 5 back slaps between the infant's shoulder blades with the heel of the hand. Using both forearms, turn the infant face up on the forearm with the head slightly lower than the body. Forcefully provide 5 chest thrusts in a downward motion over the lower half of the breastbone using 2-3 fingers. Repeat the cycle until the object is expelled or the infant becomes unresponsive. (Option 1) Cardiopulmonary resuscitation is not initiated until the infant is unresponsive. Priority for a responsive infant is to attempt to dislodge the object obstructing the airway. (Option 3) Finger sweeps are avoided unless the object is visualized and the rescuer is able to retrieve it with the fingers. Performing a blind finger sweep can push a foreign object farther into the airway. (Option 4) Abdominal thrusts are used in children over age 1 and adults but are not recommended in infants (ie, age <1 year). Educational objective: To relieve choking in a responsive infant (age <1 year), perform cycles of 5 back slaps and 5 chest thrusts to expel the obstruction. If the infant becomes unresponsive, cardiopulmonary resuscitation is initiated.

when a situation is out of control, SAFETY is the primary concern

When a situation is out of control, safety is the primary concern. The nurse and everyone else should leave the area, and security should be called immediately. (Option 2) The situation is no longer diffusible. Quoting authoritative rules will not likely have the desired effect as the client has lost control (and may not be in touch with reality). The nurse's priority is to move out of harm's way. (Option 3) Staff members should call security immediately and/or institute a back-up staff/takedown protocol. The fire alarm will activate a call to a fire department, which is not the type of help needed. However, when security arrives, the "best-trained brain" remains in control and the nurse should direct the actions of the team. (Option 4) When violence (eg, throwing a fire extinguisher) occurs, trying to defuse the situation verbally is no longer the priority. Educational objective: Safety is the priority when violence occurs. People should leave the area and call security immediately.

Catheter size for blood transfusion

When selecting catheter size, the need for rapid fluid administration and the type of fluid administered versus client discomfort should be assessed. A lower IV catheter gauge number corresponds to a larger bore IV catheter. A 14-gauge (large-bore) catheter may be used for administering fluids and drugs in an emergency or prehospital setting, or for hypovolemic shock (Option 1). In somewhat stable adult clients who require large amounts of fluids or blood, an 18-gauge catheter is preferred. (Options 3 and 4) A 20-22-gauge catheter is sufficient for administering general IV fluids and medications to adult clients; a 20-gauge is acceptable for blood transfusion. However, 20-22-gauge is not preferred for blood administration. A 24-gauge catheter is recommended for children and some older adults with small, fragile veins. Educational objective: A 14-gauge (large-bore) catheter is used to administer fluids and drugs in a prehospital or emergency setting, or for hypovolemic shock. An 18-gauge catheter is typically indicated for infusing blood or large amounts of fluid in adults.

macrolide antibiotics

all macrolide antibiotics (eg, azithromycin, erythromycin, clarithromycin) can cause a prolonged QT interval, which may lead to sudden cardiac death due to torsades de pointes therefore, an ECG should be monitored concurrent use of macrolide ABX with other drugs that prolong QT interval (eg, amiodarone, sotalol, haloperidol, ziprasidone, azole antifungals) will further increase this risk macrolides can also cause hepatotoxicity when taken in high doses or in combination with other hepatotoxic medications such as acetaminophen phenothiazines, and sulfonamides elevation of asparte transaminase and alanine transaminase levels (liver enzymes) may indicate that hepatotoxicity is occurring and the nurse should report these results to the HCP nausea and vomiting can be side effects of azithromycin decrease in wbc count would be expected as infection is resolving fever may be present with infection. nurse should use as-needed acetaminophen cautiously in a client also receiving azithromycin due to the risk of hepatoxicity

panic attack

client experiencing the symptoms of a panic attack. should not be left alone the priority nursing action is to stay with the client to offer support and reassurrance that the client is safe and secure additional nursing actions while the client is experiencing panic symptoms include: 1. maintaining a calm, matter of fact approach 2. speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures 3. placing the client in a room with as little stimuli as possible 4. administering an anti-anxiety medication such as benzodiazepine (per health care provider prescription) 5. having the client breathe into a paper bag if hyperventilation is a problem the priority nursing action for the client experiencing symptoms of a panic attack is for the nurse to stay with the client in a calm environment and offer support and reassurance that the client is safe and secure

atrial fibrillation

clients with a. fib may experience tachycardia and irregular heart rhythm even with treatment

power of attorney (POA)

designates a representative to act on a person's behalf in the event that the individual becomes incapacitated there are diff types of POAs, including medical and financial an advanced directive or living will describes the client's health care decisions (eg, do not resuscitate) as part of an advance directive, the client may designate a representative to make health care decisions for the client - a durable POA for health care or POA for health care (canada) although it is correct that the POA makes decisions for a client only when the client is no longer able to make them, the nurse first needs to determine what type of POA is in place

administering medications through feeding tubes

failure to correctly administer medications through feeding tubes (eg, nasogastric, gastrostomy) can result in obstruction of the tube, reduced medication absorption or efficacy and medication toxicity before administering medications through feeding tube, the nurse should determine if any of the medications are available in LIQUID form as liquid mediacations are less likely to clog the tube medications should be crushed, dissolved, and administered separately to prevent interactions (chemical reactions) between medications or interference with absorption a feeding tube should be flushed with STERILE water to avoid drug interactions and eliminate contaminants found in tap water the feeding tube should be flushed before and after each medication is given when using a feeding tube, each medication should be ADMINISTERED INDIVIDUALLY to prevent interactions between medications do not mix medications with enteral feedings bc of thick consistency and can clog the tube

hydromorphone

hydromorphone IV push, given undiluted or diluted with 5 mL of sterile water or normal saline should be administered slowly over 2-3 minutes; rapid infusion increases the risk of opioid -induced adverse reactions (eg, nausea, itching)

electroconvulsive therapy (ECT)

induces a generalized seizure by passing an electrical current through electrodes applied to the scalp although the exact mechanism is unknown, 15-20 second seizures are proven effective in treating mood disorders (eg, major depression, bipolar disorder) and schizophrenia client teaching: 1. NPO status is required for 6-8 hours prior to treatment except for sips of water with medications 2. anesthesia (eg, methohexital, propofol) and a muscle relaxant (eg, succinylcholine) will be administered; clients are unconscious and feel no pain during the procedure 3. driving is not permitted during the course of ECT treatment 4. temporary memory loss and confusion in the immediate recovery period are common side effects of ECT post-treatment nursing care include: -monitoring vital signs -ensuring a patent airway -assessing mental status -providing frequent reorientation during periods of postictal confusion

ketorolac

is a NSAID analgesic administered (orally, IV, or IM) for short term relief of mild to moderate pain usage should not exceed 5 days due to adverse effects (eg, kidney injury, GI ulcers, bleeding) ketorolac IM should be administered into a large muscle using the z-track method to mitigate burning and discomfort a 1- 1 1/2 inch (2.5 - 3.8 cm) needle is recommended to inject medication into the proper muscular space in average weight individuals

valproic acid (Depakote)

is an anticonvulsant that is also prescribed for bipolar disorder therefore, it would prevent the therapeutic effect of ECT any prescribed anticonvulsants should be discontinued prior to ECT ECT uses an electrical current applied to the scalp to induce a generalized seizure in an anesthetized client prior to the procedure, the client should be NPO and not take anticonvulsant medications temporary confusion and memory loss are common after the procedure clients should be instructed not to drive during the course of ECT treatment

anorexia nervosa

is disturbed body image/low self esteem there is often a large disparity between actual weight and the client's perceived weight clients with anorexia nervosa think of themselves as overweight and fat the nursing care plan should include helping the client develop a realistic perception of weight and body image the nurse can confront the client about the misinterpretation of body weight by presenting reality without challenging the client's illogical thinking the client's weight should be discussed in the context of overall health the nurse also needs to be aware of his/her own reaction to the client's behaviors and statement it is not uncommon for caregivers and care providers to feel frustrated or even angry when caring for a client with an eating disorder the nurse must maintain a neutral attitude and approach, avoiding arguing or disagreeing with the client's statements the nurse can help the client develop a more realistic self image by presenting the situation realistically and discussing weight in terms of the client's health

warfarin (coumadin)

is generally contraindicated in pregnancy warfarin is a teratogen and exposure during early pregnancy can result in fetal malformations (warfarin embryopathy) it crosses the placenta, resulting in fetal anticoagulation; dangerous fetal bleeding, including intracranial hemorrhage can occur as a result, a client on warfarin is taught to use effective contraception DO NOT ADMINISTER WARFARIN IF CLIENT IS PREGNANT

bisphosphonates (eg, risedronate, alendronate)

is necessary to prevent esophagitis and need to drink extra water and being upright for 30 minutes after taking it

hopelessness

is the belief that a situation or problem is intolerable, inescapable, or unending, and the individual is unable to find a solution

emergency/trauma assessment

primary survey: 1. airway: clear airway, stabilize cervical spine 2. breathing: give oxygen, prepare to intubate 3. circulation: check pulse and heart rate, control bleeding 4. disability: check level of consciousness, assess using glasgow coma scale 5. exposure: remove clothing, prevent heat loss secondary survey: 1. f: full set of vital signs/focused interventions: monitor ECG, place tubes & drains 2. G- give comfort: assess & treat pain 3. H- head to toe assessment/history: use SAMPLE - Signs/Symptoms, Allergies, Medications, Past health history, last meal, events preceding 4. I - inspect posterior: logroll & palpate The emergency department nurse follows the alphabetical primary and secondary assessments with trauma clients to ensure that injuries or life-threatening conditions are not overlooked. In this client, Airway and Breathing have been addressed via intubation, which protects the airway and allows for manual (eg, Ambu bag) or mechanical (eg, ventilator) ventilation. Circulation should be addressed next by assessing apical and peripheral pulses; assessing the extremities for color, temperature, and capillary refill; and obtaining large-bore IV access (eg, two 18- to 20-gauge peripheral IV lines, central line) for fluid/blood replacement (Option 2). (Option 1) The client's pain should be addressed during the secondary survey (ie, Give comfort). Maintaining circulation with a central line takes priority. (Option 3) After circulation is addressed, the final segments of the primary survey are Disability (eg, checking mental status) and Exposure, the latter of which includes removing all clothing and jewelry to assess for other injuries and then covering the client with warm blankets to maintain appropriate body temperature. (Option 4) X-rays and other imaging should be performed during the first segment of the secondary survey (ie, Focused assessment); Airway, Breathing, Circulation, Disability, and Exposure should be assessed prior to obtaining x-rays so that life-saving interventions can be initiated. Educational objective: The systematic, alphabetical primary and secondary surveys are necessary to ensure that injuries or life-threatening conditions are not overlooked in trauma clients. The primary survey includes Airway, Breathing, Circulation, Disability, and Exposure.