NCLEX Questions Coordinated Care

PIE

Problem, intervention, and Evaluation format is used by the nurse to assess all the areas to compare the results with normal standards.

Hypovolemic shock

Resulting from hemorrhage a ministration of intravenous fluids is priority

Respite from the assignment

Talking with someone who faced the same problems may provide constructive help with situations

Preschool child language

Who cannot point to body parts and is only using one word would be classified as having global language delay. A child who used to speak but stops has language loss When a parent is the only one who understands the child, it is referred to as articulation disorder. Children who understand language but will only point to things they want to have expressive language delay.

Seizure disorders

Who exhibit sifting of the muscles and loss of consciousness, then rhythmic movement of the extremities, it is likely suffering a tonic clonic grand mail seizure. If there's seizure last 30 minutes or more the client is experiencing status epilepticus. This is a medical emergency as the continued seizure activity deplete the brain of oxygen and glucose and may cause permanent brai n damage. The immediate intervention the nurse would expect in this situation is to administer intravenous convulsion medication to the client.

Burned Client

Who is admitted with black soot on the cheeks has probably sustained an inhalation injury in addition to the burn. An inhalation injury, respiratory tissues swell, and the client is at risk for developing pulmonary edema and adult respiratory distress syndrome. Priority is to secure the client's airway before swelling develops.

The nurses priority for pregnant clients

Would be to violate a client reporting a large amount of lochia and a large peritoneal hematoma who is at risk for hemorrhage. A multi para patient with diabetes who needs morning insulin would be the next priority. 30 year old multi para who wants to shower and take pain medication before the healthcare provider comes to just discharge them. A 20 year old Primavera who doesn't know how to breast-feed

Bone density affective learning

instruct the client to be very careful to prevent injuries perform weight-bearing activities such as running

Guillan-Barre syndrome

is a rare neurological disorder in which the body's immune system mistakenly attacks part of its peripheral nervous system—the network of nerves located outside of the brain and spinal cord. Increased respiratory rate greater than 30 breaths per minute, Abnormal chest movements, and decreasing vital capacity are signs of ineffective breathing. A client who exhibit these signs would need to be prepared for mechanical ventilation to decrease the work of breathing and increase oxygenation. Turning the client every two hours would help in clearing adventitious breath sounds.

Ondansetron

is an anti-emetic agent used to treat nausea and vomiting induced by chemotherapy ages. Oral Ondansetron is often described as an orally this grading tablet and is dissolved in the mouth. Swallowing several times as the tablet dissolves enhances absorption. Hand should be clean and dry before moving the pill from the package to prevent infection and disintegration of the tablet with fluid. The tablet should not be removed from its package until the client is ready to take it. Ondansetron should be stored at room temperature,taking care not to expose the tablets to moisture, heat, or light sources.

Hypo parathyroidism

is characterized by urinary frequency rather than polyuria. The nurse will encourage the client to drink large amounts of fluids to prevent renal calculi formation. Sodium should be encouraged to replace losses in urine. You will not restrict fluid because that could put the client at even great risk for renal calculi.

Behavior objective

one that is considered to be observable and measurable. Behavior is generally construed to be an action of an individual that can be seen, felt, or heard by another person.

Spleen

plays a role in immunity. Initially this being in larges and becomes congested with accumulated single red blood cells; in time, fibrous material replaces the tissue in the spleen, and by the age of five the spleen is obliterated. Without a spleen the child is prone to infection, which came for precipitate a sickle cell crisis.

Severe headache

Is indicated of hypertension and preeclampsia and requires immediate nursing assessment and reporting to the health care provider. Nausea and constipation are common during the pre-and post natal period.

Universal clients bill of rights

Is party in a long-term care setting. Ethical issues occurring in long-term care that are important include guardianship, advance directives, power of attorney, and do not resuscitate orders.

Erythromycin

Is prescribed to treat syphilis for clients were allergic to penicillin

A hospital-based home agency

Is private and institution based; it may be a profit-based or nonprofit- based agency.

Severely anorexic individuals

Resuming eating after. Starvation is refeeding syndrome. This is an imbalance of fluids and electrolytes that can lead to say dysfunction and life-threatening complication such as heart failure and dysrhythmia.

Rehabilitation

Is required for a variety of conditions and stages of illness. Loss of vision after a head injury Balance problems after cerebellar stroke Difficulty speaking after traumatic brain injury Anterior wall myocardial infarction with deconditioning Inability to perform daily hygiene due to myasthenia gravis

Acute arterial occlusion

A food that is cool to the touch, spell, and has an absent pedal pulse. The client needs surgery immediately to restore blood flow to the foot. Anticoagulation should not be given before surgery to help prevent hemorrhage during the surgery. I love being in the flood and applying heat to the foot will not restore circulation and may be harmful

Ericksons developmental theory

A four month old infant is working to build trust. When an infant is hospitalized, the parents may not be present all the time. To assist with building trust, the nurse will assign the same mistake care for the infant each day. Older children such as 12 years old child would be comfortable with a nurse at the same sex. The nurse should avoid switching primary nursing assignments each day

Early post burn Period

12 to 48 hours after the injury, fluid shifts from the bloodstream to the interstitial tissues. The shift produces a decrease in blood volume that results in the decrease tissue perfusion. This decrease blood volume would cause the client to experience hypovolemic shock characterized by an extremely low blood pressure. Blood pressure is a better indicator of fluid status and the possibility of hypovolemic shock then the degree of edema that is present.

Autonomic dysreflexia

A spinal cord injury at the level of T6 or higher This is an emergency actuation trigger by noxious stimuli. When this condition occurs, the nurse will check for a bladder distention because this is often a treatment factor.

Dinoprostone (Cervidil)

A temperature of 100.6 is an expected finding for up to 6 hrs after administration. A sponge bath can aid in comfort and minimize symptoms of fever. Aspirin does not lower a dinoprostone induced fever, and administering a medication is not within a nursing assistant's scope of practice.

right total knee replacement

A total joint replacement would be to check circulation and sensation in the affected extremity to determine if adequate circulation is being maintained in the limb

Pneumothorax signs and symptoms

An individual with chest trauma experience dyspnea, tachycardia, restlessness, anxiety, decreased movements of chest wall, and absent breath sounds on the affected side. You will prepare for insertion of chest tube to restore negative pressure in the pleural cavity and to expand the lung.

Speech therapy for a child

By the age of two years a child should be able to form three word sentences. If a three year old child is unable to perform this task, the nurse to notify the healthcare provider of the possible need for a space therapist. A five-year-old child would be able to count 10 pennies correctly and name for colors. A four year old child would be able to tell a simple story.

Noncompliance

An informed decision was made by the client not to follow a prescribed treatment. When a client does not take a medication currently, it may be that he or she is not informed regarding how to take it properly or the possible consequences of incorrectly taking the medication. A healthcare provider who is not right in the correct dosage of a medication for a client and pharmacist not following drug manufacturers recommendations are not compliant.

Amitriptyline (Elavil)

Can be prescribed for clients with fibromyalgia to improve sleep, to decrease stress and fatigue, and as an adjuvant medication of pain control. It treats depression and fibromyalgia

Postobstructive diuresis

Can cause electrolyte imbalances. The laboratory values must be checked the electrolytes can be replaced as needed. Vital signs in initially be taken every 30 minutes for the first four hours and then every two hours.The clients weight would be taken daily to to assess fluid status more closely.Urine Output needs to be assessed hourly

School age children

6-12 years Requires time for play which allows for creativity and distraction during the illness.

Laryngeal spasms

Can occur abruptly; Patency of the airway is determined through continuous monitoring for signs of respiratory distress. Providing oxygen is important, but maintenance of respiration is the priority. The fever should be treated

Growth and development of a five year old

Can you copy simple shapes Knows the days of the week Uses 6 to 8 word sentences Vocabulary consists of 2000 words Has beginning awareness of the outside world

Postpartum temperature

Temperature is up to 100.4 in the first 24 hours after birth are often related to dehydrating affects of labor. Encouraging oral fluid intake to help the temperature return to normal. The clients temperature can be taken every four hours while they are awake, it is unnecessary to retake in 30 minutes.

cephalopelvic disproportion

A birth is indicated infusing oxytocin at this time could result in fetal compromise and uterine rupture. The NPO status is appropriate in anticipation of cesarean birth. A peripheral IV is needed not only for hydration but also for venous access if IV medications become necessary. The client will have an alectronic moitor recording the fetal heart rate and uterine contractions continuously and needs frequent assessment by the nurse.

Eczema Breakout

A break in the skin may allow the entry of pathogens. The nurse needs to assess the client to make sure there is no infection. An elevation in temperature will signal the development of a systemic infection. Taking the pulse rate, respiration rate, and blood pressure will give valuable client data, but the temperature will signal the development of an infection.

Before a scheduled hysterectomy proceeds

A catheter decompresses the bladder and limits trauma to the surgical site; it eliminates the need for repeated straight catheterization after surgery. The gastrointestinal tract does not need it to be decompressed for this type of surgery, so a nasogastric tube is not necessary. Vagina packing is use after a hysterectomy, 10 days is excessively long time. Drains are usually not necessary after a hysterectomy.

Transformational leader

A charismatic leader Motivational person Shows individualized consideration

By the age of two years

A child should be able to walk and run well including going up and down the stairs. Parallel play is it appropriate for a child of 2 years. Constructing three word sentences is appropriate development for a 2 year old child and would not require a speech therapy consult. Parallel play is age appropriate, so recreational therapy is not needed.Stacking cubes and using a spoon are developmentally appropriate for a child of 2 years and do not indicate a need for occupational therapy.

Dietitian 10 year child weight and height

A child who is 50 inches tall and weighs 50 pounds is underweight for his or her height and should be referred to a dietitian.

Best room assignments for children related to abuse

A child with different signs of abuse needs close supervision, especially with members of the family visit. The child would require close monitoring and should not be left alone.

Osteoarthritis

A chronic condition with no known cure. Goals for a client with osteoarthritis include maintaining mobility as much as possible, reducing pain to a manageable level although it will never be completely eliminated, and minimizing joint deformity. Reversing joint deformity is not possible.Another goal is to maintain muscle strength(not increase it).

Term gestation laboring that an RN needs to be notified

A client who is G2 P0 2 cm/100% of effacement /0 station, contracting every 2 to 3 minutes, 60 seconds in duration, moderate to palpation, spontaneous person membranes with Meconium-stained fluid, and a fetal rate of 158. Meconium - stain fluid is associated with fetal compromise during labor and infant distress after birth.

Sexual disorders

A decreased, not increased, level of estrogen and systemic diseases such as diabetes and hypertension can predispose a woman to vagina infection, resulting in vagina -itis. The risk for breast cancer increases, not decreases in win after age 40 years. Prostate enlargement is indeed increasingly common in men older than 40. Chronic problems such as diabetes mellitus and hypertension leads to importance in men. The American Cancer Society suggest an annual mammogram for women older than 40.

Partial placenta previa discharge home instructions for a strict bedrest

A dietitian can provide information regarding dietary requirements to support the pregnancy and growth of the fetus.

Transactional Leadership

A leader has a punitive behavior Act of rewarding for good performance

Informed consent

A life-threatening emergency, and if the client is unable to sign an informed consent it is the legal responsibility of the surgeon and the primary healthcare provider to sign the consent form so that further injury to the client and her fetus may be prevented. There's not enough time to obtain a verbal consent. It is illegal to perform the surgery without a signed consent. Lately and it's not allowed to how to sign and informed consent unless the client has signed it first

Fetal heart rate

A normal fetal heart rate is 120 to 160 bpm. In the event of fetal bradycardia of 100 bpm between contractions, that healthcare provider should be notified as immediate medical management may be necessary. After notifying the healthcare provider, the nurse can document and monitor. NEVER encouraged a client to push before if the client isn't fully dilated.

Myxedema coma

A nurse is aware that severe hypo thyroidism mirror result to mix edema, where, but life-threatening. This is accompanied by a drastic drop in the metabolic rate causing the crease vital signs, hyperventilation, possible respiratory acidosis, and non-pitting edema.

Early Stage of ASPGN

A reduced C3 level urinalysis is necessary to determine the presence of proteinuria and hematuria

What will require a cesarean birth

A shoulder presentation in a multiple para is indicated of a transverse line in this necessitates a cesarean birth. It is not uncommon for the fetus of the Multipara to be high floating at the beginning of labor; early engagement occurs more often with a prima gravida with an ocular posture position the baby may be longer, but usually the mother can give birth vaginally. If the first twin is in the vertical position a vagina birth maybe attempted with a double set up preparation for the vagina and cesarean birth if possible, the baby of the second twin also will be attempted vaginally.

Liver Bile

A small of bile colored spotting is expected Notify health care provider Large amount is excessive and not expected

heart failure (HF) treatment

A sodium restricted diet is prescribed

Mechanism that causes changes in behavior through group therapy

ALTRUISM Feedback Communication Experimentation Discovering similarities

Notify the healthcare provider

About the discovery of mass at the base of the repair laceration and the clients feelings of peroneal pressure, both of which may be indicated of the formation of a hematoma. The absence of voiding may be due to dehydration, postpartum hemorrhage, or peroneal trauma after delivery. The rise in fundal height may be due to a feeling bladder; therefore, the nurse will palpate the bladder and assist the client with voiding as needed. 25 g reflects 25 ML's blood loss, which is in expected finding associated with moderate rubra. The rubra may decrease after the client Has voided and is not considered a significant findings.

Schizophrenic

Absences of gag reflex may occur

Improvement findings of COPD medically managed with corticosteroids and bronchodilators

Absent cough Lungs clear bilaterally Tolerating ambulation Decreased resting respiratory rate Pulse oximetry greater than 92% on room air

Psychophysical problems key intervention

Acknowledge the clients as a responsible adult while indirectly addressing dependency needs. Secondary games should be minimize, maximize, once acute phase illness is resolved. The clients level of anxiety, not family, should be used as a gauge to determine the amount and type of health teaching. Clients should be encouraged, not discouraged, talk about feelings. The client and family should be assisted in enlarging, not knowing, their social networks.

In-home caregiver of a client with middle stage Alzheimer's disease

Adapt a home for client safety and convenience Designated caregiver is responsible for legal and financial decisions Caregivers will need to provide hygiene, elimination, feeding, and exercise assistance Coping is difficult with changing personality and behavior is. Support groups are helpful. Develop a medication schedule so that you are consistent with medication administration.

Celiac disease

Adherence to dietary restrictions can prevent future complications and celiac crisis. Celiac crisis usually develops as a result of not adherence to the diet. Celiac disease is forever

Safe and effective psychotherapeutic drug administration

Administer the medication to the client Assess the client prior to administering the medication Coordinate the clients care needs a medication schedule I'll find a way to track a fitness in monitor for adverse affects Monitor and I'm fine with the clients response to medication

Developmental needs

Adolescents value time with their friends and peers Video games would be more appropriate for school age and early adolescents children Arts and crafts are more appropriate for preschool and early school age children

Illness

Affects a clients health and can result in an inability to function sexually. The chronic lack of blaming control is associated with damage to vessels that serve the sex organs and may result in an ability to achieve or maintain an orgasm. Medication, stress, depression, and fatigue all affect sexual function. Changes in libido, desire, or ability all occur with aging. A lack of sexual desire may occur when a client is preoccupied with illness is such as spinal cord injury, depression, or diabetes

Postmenopausal woman with occurrence of stress incontinence

After menopause the vagina becomes dryer, dinner, and smoother, which increases the chance of vagina infection. The combination of this fat with the presence of urine places the woman and even higher possibility of infection, so the nurse should discuss good hygienic practices with the client reduce the likelihood of infection.

informed consent information

Alternative treatment options Risks and benefits of the treatment Risks involved by refusing the treatment The nature of the problem requiring the treatment

Nurse who is on the first day out of orientation

Always give a stable client to a new nurse

Deep vein thrombosis

Ambulation and exercise are contra indicated that healthcare provider will be notified so that appropriate tests and treatments can be implemented. Ambulation and exercise may precipitate an embolism, which is life-threatening. Unexpected pain must be a valid by the healthcare provider before medication is asked ministered. An energy list equal mass pain, making it difficult to assess; once the client has been examined by the healthcare provider, the client can be medicated. Although pain in the operative area and sometimes extending into the leg is common after this type of surgery, severe tenderness must be elevated.

Burns

An first 48 hours after a burn injury,capillary permeability is increased so that fluids and electrolytes leak out of the vasculature and into the tissues, which results in tissue swelling. This in turn causes in hypovolemia, which results in decreased urine output, decreased cardiac output, and decreased potassium levels. Eighteen to 36 hours after the injury, capillary permeability normalizes, and fluids shift back into the vasculature, resulting in a decrease in tissue swelling, an increase in urine output, normal cardiac output,and normal potassium levels.

Rectocele

Anticipate finding hemorrhoids in a client with a rectal sale. A rectocele is herniation of the rectum into the vagina. As a reduced to enlarges, the client will become constipated. Hemorrhoids result from straining to have a bowel movement. Tarry stools would occur with a Gastro intestinal bleeding at a site remote from the rectum. A rectocele does not affect the urinary tract. Difficulty urinating and stress incontinence do not occur as a result of a rectocele.

Oliguria after kidney transplant

Anticipates that diuretics and osmotic agents will be prescribed to increase urinary output. The client should be monitored closely because fluid overload can cause hypertension, congestive heart failure, and pulmonary Edema. Fluid intake would not be forced or restricted. Irrigation of the urinary catheter will not assist in alleviating this oliguria.

Informed consent

Apples to permission for procedures and treatments to be performed

Transdermal nitroglycerin Patch

Are apply patch for 10 to 12 hours then remove it, creating a nitrate-free interval.Do not

Transdermal nitroglycerin Patch

Are apply patch for 10 to 12 hours then remove it, creating a nitrate-free interval.Do not apply the patch to shaved areas as irritation to the skin may alter drug absorption. Donning sterile gloves is not necessary. The nurse should don clean gloves to apply the patch. Historic vital signs should always be reviewed, but the vital signs should be taken and recorded right before the patch is applied for safety. Sublingual nitroglycerin may be necessary as the patch dosage is adjusted.

ANA specific objections to PAS

Are based on the principles of beneficence, the duty to protect life, and nonmaleficence, to do no harm. The ethical principle of justice is about the concept of what is fair. In the context of nursing, this means that all clients have the same right to nursing interventions.

Oral contraceptives and type one diabetes

Are both associated with an increased risk for Candida infection, which requires treatment. There are specific characteristics of the vagina discharge associated with a candida infection. Headaches and breakthrough bleeding are common side effects related to the use of oral contraceptives. It slight increase in blood glucose is calling associated with the use of oral contraceptives

The three test increase PT/PTT, FDPS, and D-dimers

Are diagnostic test for disseminated intravascular Coagulation. DIC can occur secondary to trauma such as a car accident and results in the depletion of clotting factors in the body. Massive hemorrhage occurs as a result of clotting factor depletion.

Annual mammograms for

Are done once a year they are recommended for 48 year old females. A Pap test and HPV testing are recommended every five years. Fecal occult blood screening is recommended for clients 50 years or older will have no risk factors. Women or 65 and older should receive bone density testing.

orthostatic hypotension (postural hypotension)

As the blood pressure drops in position changes, when the client is bradycardic. This could be dangerous if the client were to try to do this. Therefore, the nurse would contact the physical therapist to hold the session. The clients oxygen saturation is 94% on room air and with a history of COPD this is an acceptable reading and does not want oxygen administration. The client reports pain but also has low BP readings. The nurse would try and reposition the client and use other pain management techniques prior to administering an opiate analgesic.

Rooming a vaso-occlusive sickle cell crisis

Thalassemia is a hemolytic anemia that is not communicable Roommates with infectious diseases should be avoided a client with sickle cell anemia is susceptible to infection

orthostatic hypotension

As the bp drops with positions changes, and the client is bradycardic. This could be dangerous of the client were to try to do exercises. Therefore, the nurse would contact the physical therapist to hold this session. The client's oxygen saturation is 94% on room air and with a history COPD this is an acceptable reading and does not warrant oxygen administration. The client reports pain but also has low BP readings. The nurse would try and reposition the client and use other pain many techniques prior to administering an opioid analgesic. The nurse did not document any signs of fluid overload, so the nurse would not initiate a fluid restriction unless prescribed by the health care provider.

Piaget preschool period

As the preoperational phase children are in this phase from ages 2 to 7. During this stage, children experience differing phases of cognition, including animism, which associates real life to inanimate objects such as dolls, blocks, and cars.

COPD prescription for 02

At sevenL/min would be a concern. The normal respiratory drive is triggered by high PA CO2 levels. Clients with COPD, however, have chronically high PAC O2 levels; the respiratory drive is hypoxia low PAO2. Therefore, these clients should not be provided with supplemental oxygen at high levels because the stimulus to breathe may be lost. A pulmonary rehabilitation program may help the COPD clients tolerate exercise better. Chest psychotherapy may be ordered to mobilize situations in a client with COPD. It is recommended that clients with COPD receive both the influenza and pneumococcal vaccine to prevent additional pulmonary conditions.

Respiratory complications for patients who are a mobile for several weeks

Atelectasis Hypoxemia Hypoventilation Hypostatic pneumonia Respiratory tract infections

Proper body mechanics

Avoid twisting to protect the back. The back, neck, pelvis, and fees are to be kept in line. This prevents back injury use arms and legs during lifting, not back titan gluteal muscles and a domino muscles in preparation to move a client.

Tonsillectomy teaching

Avoiding strenuous activity after a tonsillectomy will give the tissues a chance to heal and will decrease the possibility of bleeding. After a tonsillectomy, client to consume a soft diet that is high in protein and calories to facilitate healing. Citrus juice should be avoided because they irritate tissue in the throat. Ibuprofen and aspirin should be avoided because they interfere with blood clotting. Ear Ache are common after tonsillectomy and are not cause for alarm.

Fetal heart rate bradycardia

Baseline fetal heart rate slower than 110 bpm) indicates that the fetus may be compromised, requiring medical intervention. Resuming fetal heart rate monitoring may be dangerous; defeatist may be compromise, and time should not be spent on monitoring. The expected fetal heart rate is 110 to 1 60 bpm between contractions.

Partial and full thickness burns of the lower extremities

Because of the location and the gate of the ends, an IV for fluid restoration an access for pain medication is the priority. IV infusion for flood restoration to prevent hypovolemic shock is the priority.

Intimacy vs isolation

Beginning a new relationship with only one partner is behavior reflective of a young adult Beginning college and deciding on a professional career also falls

Schizophrenia

Bizarre behavior, impaired communication, delusions, illusions, and hallucinations Establishing a therapeutic relationship, you should use simple and clear statements, be available, and listen actively.

Children with bruises

Bruises could be related to a health problem, therefore, further information (data collection) is required before developing a plan with interventions. If the nurse suspects abuse after collecting more information, the nurse should document the findings and contact the healthcare provider and child ware fare services.

Type one diabetes mellitus Hypoglycemia nutrition

By ingesting 15 to 20 g of simple carbohydrates such as 6 to 7 pieces of hard candy, 2 to 3 packets of sugar(4 to 6tsp, 4 ounces of fruit juice.

Severe anxiety interventions

By staying physically close, the nurse conveys the message that someone cares enough to be there and that the client is a person worthy of care

Infants birthweight

By the age of six months the weight should be doubled by the age of a year the weight should be tripled And the infants name should increase by about 1 inch every month for the first six months, and increased by 50% by the age of a year. If a child's weight and height have followed this pattern, the nurse would document the finding and continue to monitor the infant.

confrontational response

That may make the health care provider look and feel incompetent and jeopardize the collegial relationship.

renal failure, chronic

Carbohydrates are needed to prevent protein catabolism Unrestricted intake of protein, sodium, potassium, influence may lead to dangerous accumulation of electrolytes and protein metabolism products such as amino acids and ammonia. Meat is higher in sodium and protein and may require restriction. Bananas are high in potassium and are restricted. Some substitutes are high in potassium and should be avoided, and fluid is restricted because the filling kidneys do not produce adequate urine.

Digoxin (Lanoxin)

Cardiac glycoside used to slow and straighten myocardial contraction and improve cardiac output.

End-stage heart failure and cardiomyopathy treatment

Cardiac transplantation is utilized

Raynard disease

Causes intermittent constriction of the arterials of the hands and toes. To obtain the best pulse oximetry reading, the nurse would place the pulse oximetry probe on the clients earlobe.

Myocardial infarction

Chest pain and pressure along with nausea and weakness or classic symptoms Further medical evaluation and intervention are needed immediately. Place the client in a semi Fowlers position not supine

Adolescents between 17 and 20 years of age

Child in when determining goals for the IEP Child should be able to verbalize what his or her post high school goals are

Falls two year old

Children of preschool age is for injuries from falls. Children of this age tend to hurry up and downstairs and make my dreams of trying to stand up on swings. They play with hard with toys, particularly those they can mount. Parents are advised to keep stairways free of clutter. The child shoes should have rubber soles, and new ones should be purchased when the tread of older shoes becomes smooth. Preschool children need to be taught about the dangers of talking to or accepting rides from strangers. When buying toys, parents must be sure they are sturdy and age appropriate.

chores, housework

Children who are at least 10 years old are typically able to mop the kitchen floor, keep their bedroom clean, take trash cans to the curb, and make a simple breakfast such as scramble eggs and toast. Five year olds should be able to start clothes for laundry and set the table Seven year olds should be able to vacuum and bathe them selves. Nine year olds should be able to do their own laundry and water plants

Self Concept in adolescents

Children whose parents are divorced and those who have long- standing chronic illnesses will have difficulty developing self- concept Self- concept reflects how an adolescent evaluates himself. or herself in domains (or areas) in which he or she. considers success important.2 An adolescent can have. a positive self-concept in some domains and a negatives

Clients with cardiac disease

Class II cardiac disease Should be taught the signs and symptoms of cardiac decomposition; if they occur, the client should stop activity that precipitated them and notify the primary healthcare provider. Participating in desired activities is acceptable behavior for a client with class one cardiac disease. Maintaining bed rest is the treatment for a client with class three cardiac disease. Considering a therapeutic abortion is the recommendation for a client with class four cardiac disease.

Benzodiazepines

Clients generally respond to therapy with benzodiazepines within 1 week. Clients may complain of morning hangover, blurred vision, and transient hypotension on arising. The dosage may need to reduced if the hangover becomes troublesome.Long term benzodiazepine use may result in physical dependence. Clients should be taught to stand slowly in the morning because of the risk for hypotension.

psychiatric advance directives beneficial for

Clients who aren't in contact with reality and aren't able to make reasonable decisions

Being Admitted to health care facility

Clients who have a short stay in a health care facility may not receive teaching until the day of discharge. A formal teaching plan should not begin until the assessment is complete and a care plan has been developed. The nurse should provide instruction when the client is attentive. The nurse should begin teaching early when the client is admitted to the facility. The nurse should instruct the client about medications on the day of discharge.

Roflumilast

Clients with liver impairment should not take roflumilast because they will be unable to metabolize it and toxic levels may result. Does not cure bronchitis rather it reduces exacerbations in clients with chronic pulmonary disease. Is not a bronchodilator and has no value in acute treatment of brochospasms. Can be taken in conjunction with bronchodilators and corticosteroids for overall management. Is not helpful during an acute attack of bronchitis.

Complete physical assessment

Clothing is removed

What would the nurse do

Common in the newborn Although acrocyanosis( cyanotic hands and feet Circumoral pallor causes cardiac pathology

Dementia related to Alzheimer's Disease

Constant reassurance because forgetfulness blocks previous explanations Frequent presence of staff serves as continual reminder Unable to explain to explain the reasons for concerns Need simple , structured, routine environments and activities.

Colostomy

Contact games may be restricted, but other physical activities should be encouraged. The stoma should be inspected more often than once daily to insure adequate circulation. Increased fluid intake is needed to compensate for fecal fluid loss. The diet should not be restricted at the time of discharge. Both the parents and the child will learn which foods are poorly tolerated, and they will adjust the diet accordingly.

Adolescent is a harm to others

Contact the healthcare provider Would need immediate treatment

laparoscopic tubal ligation surgery

Contraceptives must be use for three months with history of hysteriascopic sterilization until tubal fibrosis occurs. A hysterosalpingogram can confirm closure of the tubes. Tubal ligation is effective immediately. The client should report any signs of bleeding or infection. Even though this is not major surgery, the client may require one or two days to recuperate. It is normal to feel some nausea from the anesthesia.

newborn Converting ounces into Pounds

Convert 4lb 4oz t pounds=4.25 convert lb to kg: 4.25/2.2+ 1.93=1.9kg 1.9kg*140 kcal per day=266 kcal per day

Pharyngitis/Tonsillitis

Is most likely caused by a Beta -hemolytic strep infection. It is important for clients to take all prescribe antibiotics to avoid the complication of rheumatic fever and not to stop them once they feel better. Food intake should be encouraged 2000 to 3000 animals/day, not limited. If necessary, A cool mist humidifier can be use in the bedroom to facilitate breathing.

Oxytocin

Is not administered when a woman has an active genital herpes infection . In this case, the baby would be delivered by means of cesarean section to prevent it from being infected during birth. CHORIOAMNIONITIS, hypertension associated with pregnancy, and postpartum pregnancy are all indications for the use of oxytocin induction.

Types of decelerations

Late delebration begin during the peak of a contraction and continues after the contraction has ended. Bradycardia is a fetal heart rate slower than 110 bpm for 10 minutes. Early deceleration mirrors the contraction, beginning at the start of a contraction and ending with a contraction is over. Variable decelerations fall and rise abruptly and do not have a uniform appears noted if early and late deceleration.

Anorexia nervosa clients

May use manipulation to defy the nursing staff; sharing this knowledge will be of benefit to the other health team members.

Intercostal nerve block

Maybe perform to relieve the pain of rib fractures.

IV infusion running

First determine whether the IV fluid contains vesicant. Local Adema and skin blanching are signs and symptoms of infiltration, the most common problem encountered with IV therapy. Signs and symptoms of extravasation may initially be similar to those with infiltration. If the food contains a vesicant, The nurse will determine whether an antidote is available before removing the IV catheter. If extravasation does occur, the nurse should not discontinue the IV catheter because the antidote must be delivered directly to the problem area. If infiltration has occurred, the infusion should be discontinued and the catheter Removed unless the IV infusion contains a drug that has vesicant properties. Application of a warm compress to the site is done for phlebitis caused by irritation of the vein by the needle. Signs of the virus or erythemia, warmth, swelling, and tenderness. If the IVs discontinued, then the nurse will need to stop is another IV line at a different site.

Deep partial thickness burns involving the face and chest plan of care

First impaired gas exchange Second presence of pain Third disturbed fluid balance Fourth potential for infection Fifth compromise body image

Application of nasal oxygen

For pulse oximetry reading of less then 90% require assessment. Assessing the oxygen need is the role of the nurse. The UAP is permitted to apply SCDs, obtain and record vital signs, and measure uncomplicated intake and output.

Respired care services that are offered at adult day care centers

Meals Crafts Counseling Social services Transportations In addition, adult daycare centers may also include limited nursing care, personal care, therapeutic activities, rehabitation therapies, and recreational activities.

Medication administration

For safety reasons a second nurse must check all computed dosages; this dose may be incorrect because it was calculated incorrectly. While the healthcare provider is responsible for prescribing drugs in the correct dosage, the nurse must understand the safe dosage of medication being admitted to children. When a prescribed dose is outside the unusual range or some question exists regarding the preparation or the route of administration, always check with the prescribing healthcare provider before proceeding with the ministration of the drug.

Bisphosphonates

Fosamax must be taken in the morning on a empty stomach at least 1 hour before breakfast with a full glass of water

Normal ranges for the maternal mother

Full-time for maternal hemoglobin is 11 to 13 G/DL In the third trimester of pregnancy and white blood cell counts between 12,000 and 18,000 is considered normal. The maternal pulse of 86 is normal.

Revision

Means these changes are documented in the original plan of care

Food and drug interactions

Furosemide do sometimes need potassium supplements. Individuals on warfarin should keep their intake of foods rich in vitamin K such as solid consistent with out any sudden increases or decreases.Atovastatin Interacts with grapefruit and grapefruit juice and should be avoided. Eating high potassium foods such as bananas and cantaloupe are good for individuals on furosemide and do not interact negatively with atovastatin and warfarin. The potassium in spinach and broccoli is good for individuals on furosemide, but Increase consumption of these fools would be avoided in this case because the client is also on warfarin, and these vegetables are rich sources of vitamin K.

Actual measurement of the anterior fontanelle

Measurements of both the transverse and anteroposterior diameter of the fontanelle are added together and then divided by two 3.0+4.4=7.4 7.4/2=3.7cm

Treatment of hypotension

In post operative clients should always begin with oxygen therapy to promote oxygenation of hypo perfusion organs. The surgical incision should be inspected later to determine if excessive bleeding is the cause of hypotension. Administration of IV fluid bolus to normalize the BP and administration of vasoconstrictive agents to increase systemic vascular resistance or the ongoing treatment.

Referral to the antepartum unit for further evaluation

Incline performing cake Counce should feel at least three fetal kids within 30 minutes. An AFI 16 cm is an acceptable finding. The service is very vascular and therefore it is not uncommon for a client experience spotting after a vagina examination. A client G1 PO 39 weeks stating she has felt six contractions over the past hour requires reinforcement of teaching about the signs of labor. Braxton Hicks contractions do not require a referral to the antepartum unit.

hyperthyroidism/ grave's disease

Include an weight loss, nervousness, increased appetite, tremors, and thyroid gland enlargement(goiter).

Discharge teaching for severe asthma exacerbation

Include directions for taking medication How to assess available community resources Prescribe dietary and activity measures Side and adverse effects of prescribe medications The schedule for home care services and medical equipment

The funds provided by local, state, and federal governments for personal health services

Includes public health research, nursing, immunization, maternal and child health, and other categorical environmental and general health activities.

CUS technique

Includes the nurse stating the concern, why he or she is concerned, and what safety issue is involved. As part of the two-challenge rule, a nurse must communicate any concerns at least twice. Information can be communicated in different ways, including written documentation, face to face, by way of text or a page, and over the telephone

Performing a head to toe assessment

Including vital signs, would indicate symptoms, such as juggler distention with right sided heart failure, or pulmonary issues such as crackles, which are complications of heart failure that the nurse would want to additionally assess for.

Morphine Sulfate

Increase fluid intake when taking pain medication

Sequence of events that occurs in a respiratory response to acidosis

Increase pH Hyperventilation Increased carbon dioxide elimination Decrease blood H plus ions

Combination of sulfur type loop diuretics and aminoglycosides

Increases the potential for the development of ototoxicity. Administering sulfa type loop diuretics with metolazone may result in excessive diuresis, opposing a risk for development of dehydration. Hypokalemia may occur in combination with diuretics and corticosteroids. Orthostatic hypotension not hypertension is a possible outcome from diuretics; dizziness is a possible side effect of aminoglycosides.

Contraction Stress Test

Indicates there are late fetal heart rate decelerations, which indicates there is a uteroplacental insufficiency compromising the oxygenation to the fetus. The L/S ratio of 2:1 indicates the fetal lungs are mature. A biophysical profile score of 8/10 is considered normal. A positive vibroacoustic stimulation after an equivocal NST is not an indication the fetus is compromised.

Diabetes mellitus

Ingrown toenails often who easily and those complications exist. The priority is to see the healthcare provider because diabetes may interfere with peripheral circulation that will cause complications for those with ingrown toenails.

Hypotension

Initiate IV fluids to restore the fluid volume The applications of oxygen, administering of an antibiotic, and application of a cooling blanket can be implemented after attempting to correct the clients hypotension

Informed consent

Inserting an indwelling catheter is considered a routine procedure to meet basic physiologic needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. Insertion of an indwelling catheter is covered by the consent signed at the time of admission, regardless of whether the client is aphasic. This treatment does not require special consent. This intervention is not an invasion of rights because of the consent signed at admission

Centering

Involved intuitive thinking

Artificialism

Involves associating how people take place in the creation of the world.

Right supervision

Involves conducting the appropriate monitoring, evaluation,intervention, and feedback.

Right task

Involves delegating care for a specific client and ensuring that the delegated task is within the delegated task is within the delegate's scope of practice Right direction involves giving a clear, concise description of the task. Right circumstances involve considering the setting, available resources, and other resources, and other relevant factors.

The manifestations of when a hospice client may be approaching death are

Irregular breathing pattern with 10 to 30 second periods of absence of breathing apnea. The blood pressure will fall with impending death. Oral secretion often increases, producing the death rattle near the end of life. The body temperature usually drops when the client is nearing death.

Major depressive disorder

Irritable mood, indications of poor academic performance, and complains of stomachache, Which is often defined as anger and hostility turned inward, does producing such symptoms.

Clonidine (Catapres)

Is a central-acting alpha-2 agonist often used for hypertension in adults;however, it also can treat attention deficit hyperactivity disorder(ADHD) in children. Acts by stimulating the alpha-adrenergic receptors in the brain stem, resulting in reduced sympathetic outflow from the central nervous system. It decreases heart rate and peripheral vascular resistance and causes a sharp drop in blood pressure. For a child, the nurse promptly notifies the health care provider of a pulse rate of 90 beats per minute or less because the prescriber may hold the dose.

Hashimoto's thyroiditis

Is a chronic inflammatory disease of the thyroid gland in which auto immune factors play a prominent role.

catatonic schizophrenia

Posturing is one position for hours to days occurs

Promethazine (Phenergan)

Is a dopamine antagonist and acts by inhibiting dopamine receptors that are part of the pathway to the vomiting center. The drug also blocks other dopamine receptors in the central nervous system, resulting in extrapyramidal symptoms of dystonia, parkinsonism, and tardive dyskinesia, as well as orthostatic hypotension and seizures.

Delusions of Grandor

Is a fix false belief that the person is a powerful, important person.

cretinism (congenital hypothyroidism)

Is a form of hypothyroidism that occurs in infants

Toddlers in preschool age children

Prefer being read to they view their bed as safe, so procedure should not be performed there. Finger foods is more appropriate for toddlers and preschool age children than older children

ventricular fibrillation

Is a lethal dysthymia and, once identified, must be terminated immediately by defibrillation so the sinus node can act again as the heart's pacemaker. Oxygen is administered to correct hypoxia, but if the heart is not pumping, oxygen will not be delivered to the tissues; it does not take priority over defibrillation. Cardio version is not effective in ventricular fibrillation. Bicarbonate is administered to correct acidosis; it does not take priority over defibrillation.

Herbal supplements during pregnancy

Is not regulated by the food and drug administration. Therefore, they may be unsafe and could cover up concerning pregnancy symptoms. It is the healthcare providers responsibility to counsel the client regarding all prescriptions, over-the-counter medication, and supplements. Continuing or increasing the dose of the supplement is potentially unsafe. It is the healthcare responsibility to counsel the client regarding all prescriptions, over-the-counter medication's, and supplements.

Torsemide

Is a loop diuretic used to treat fluid volume overload caused by Reno efficiency and/or heart failure. It should not be given later than mid afternoon to avoid nocturnal diuresis. It should be given with food to decrease gastrointestinal irritation. Combining this drug with a 0.9% sodium chloride infusion when hypercalcemia is present helps decrease serum calcium levels. A combination of tapwater and hydrogen peroxide or ice chips is used to manage dry mouth. Commercial mouthwashes should be avoided, as they contain alcohol and could further dry the oral cavity. Diuretics are often used in conjunction with other antihypertensive drugs to achieve acceptable blood pressure readings

Dating Clients

Is a no no it is an professional relationship; I will not see you socially sets clear limits on their relationship and maintains a professional rather than social role.

SBAR

Is a part of documentation and the method of communication among the healthcare workers that includes situation, background, assessment, and recommendation but not revision. Helps in preventing errors from poor communication during hand off or handover interactions.

CIWA-Ar

Is a rating scale used for symptom checker in treatment of alcohol withdrawal . Protocol calls for a ministration of a benzodiazepine like diazepam a.k.a. Valium when a client shows in symptoms. Disulfiram is given before alcohol ingestion to produce an unpleasant reaction. Is a symptom triggered protocol, not a fixed schedule regimen

Frequent swallowing

Is a sign of nasal or throw bleeding. The nurse will inspect the back of the throat for evidence of bleeding.

Pheochromocytoma

Is a tumor of the adrenal medulla does the prefix excessive catecholamine.The nurse is likely to detect hypertension, tachycardia, hyperglycemia, hypermetabolism, and weight loss in a client with pneumo-chromocytoma.

HPV vaccine

Is administered to females through age 26. A 21 year old client who has not received an HPV vaccine will receive three separate doses of the vaccine: the initial dose and two additional doses administer at specific intervals. The vaccine dosage is not doubled. There are many different strains of HPV; therefore, it is recommended that clients receive the HPV vaccine if they test positive and are within the appropriate age group.

Codeine

Is an antitussive medication that acts by suppressing the cough center in the brain. Codeine should not be used after a tonsillectomy or adenoids to my, by those with genetic factors ultrarapid metabolism leading to respiratory depression, or by those who have conditions that increase the risk for serious breathing problems, such as obstructive sleep apnea or severe lung disease. Is useful in managing coughs associated with acute bronchitis, upper respiratory infections, acute viral infections, and other acute conditions that produce a dry, hacking, nonproductive cough.

celiac disease

Is an auto immune disorder that causes an allergy to gluten, which is found in wheat, rye, oats, and barley. Brow diet Cerebral palsy can benefit from physical and occupational Therapy. Children with seizure disorders may need education on safety. A child with bronchitis may need respiratory therapy treatments.

Anorexia nervosa

Is an eating disorder characterized by extreme weight loss and unrealistic perceptions of body image.

Autocratic leader

Is an expert in handling crisis conditions such as natural disasters and is often repeated for being able to skillfully handle difficult assignments. The leader is firm, insistent, dominating, and quick and making decisions and taking necessary actions. This leader clearly assigns define task to the working group to complete the work on time.

Idea of reference

Is an incorrect interpretation of an external event as having a special meaning to the person

Flight of ideas

Is an increase in the speed of thinking causing a person to shift from one idea to another without completing the previous idea; it is often expressed with pressured speech

Abnormal signs in active labor

Presence of pitting edema Contraction lasting more than 90 seconds Fetal heart rate of 80 bpm Temperature of 100.8 Fahrenheit Temperature should be monitored every two hours there after Maternal blood pressure of 140/98 MM Hg

Triage officer

Prioritizing treatment is the duty

Thromboangiitis

Is an inflammatory thrombotic Disorders of arteries and veins in the legs and feet that occurs in smokers. The most important instruction the nurse can give the client is to stop smoking. 40% of client to continue to smoke with this disorder will face amputation of the lower extremities. Sing a dentist to treat periodontitis, Protecting the feet against cold by wearing socks, and taking analgesic For pain can also be advised.

A public nonprofit freestanding agency

Is an official health agency

Fexofenadine

Is an over-the-counter antihistamine, which can interfere with accuracy of a circle mucus assessment. Antihistamine are intended to dry out mucus; therefore, they will interfere with the consistency of cervical mucus.

toxic shock syndrome (TSS)

Is associate with Dyer from use. It is associate with women who use tampons especially super absorbent tampons and those who use barrier types of contraceptives. It is crucial that anyone who has already experienced an episode of TSSB warrant against using those items. TSS is not associated with intrauterine devices, birth control pills, or medrooxyprogesterone acetate.

Disseminated intravascular coagulation

Is associated with any any fluid embolism also known as anaphylactoid syndrome pregnancy both problems may occur after premature separation of the center. Hypertension not hypertension expected. Thrombophlebitis And uterine atony is not a complication of amniotic fluid embolism but

A grand multipara(five or more births)

Is at greater risk for a precipitous labor and should be monitored more closely than a client with fewer deliveries(P0 or P1) and no other major risk factors.

Nephrotic Syndrome

Is at risk for infection. The child with thalassemia is noninfectious and therefore an appropriate roommate. The closeness of their ages will encourage preschool socialization. Impetigo, pneumonia, and conjunctivitis are all caused by pathogens; exposure of the child with nephrotic syndrome to infection should be avoided.

Malignant mesothelioma

Is caused by asbestosis exposure. The primary symptoms are dyspnea on exertion. Chest pain and Hemoptysis are symptoms of lung cancer. Wheezing over a lung fields is a sign of asthma.

Lithium

Is commonly prescribed for bipolar disorder. Signs and symptoms of lithium toxicity are vomiting ,extreme hand tremors ,sedation ,muscle weakness and dizziness.

Nurse practice act

Defines noticing it does not provide detail standard is for practice. Nurses are not protected by the good Samaritan legislation.

Children Injection

Deltoid should be is if it is well developed. I needle should point at a slight angle toward the shoulder. Vastus lateralis is the choice for infants younger than 12 months and Children older than 13 months of age for intramuscular injections. A child may need a 45° angle for the injection because the angle is vary depending on the child size and anatomy. It is preferable To find another way to give medication to children because IM injections are painful traumatic for child

Acamprosate (Campral)

Is contraindicated in clients with severe renal failure as indicated by a creatinine clearance lower than 30 ML's per minute. It is used when naltrexone is contraindicated, such as for clients with liver disease. A history of heart disease is not a contraindication for acamprosate. OTC products containing alcohol are contraindicated with disulfiram, not with acamprosate.

INR

Desired therapeutic level for an INR is 2 to 3.5. It is prudent to maintain bedrest to prevent injury until the healthcare provider evaluates the clients INR results. The next action would be to keep the client on bedrest, not preparing to administer phytonadione. A partial thromboplastin time is performed to evaluate a clients response to the administration of heparin, not warfarin sodium. Vitamin K is the antidote for Warthen sodium. You should limit intakes of food high in vitamin K

Accountability

Determines whether the actions were appropriate and provides a detailed explanation of the task performed

Suicidal precaution Teaching session with a client and family members

Develop a no suicide contract with the client Discuss with the family possible warning signs or please for help the client may use When will dangerous items from the clients room that could be used for self harm teach the client and family about signs, symptoms, and basic physiology of depression. Inform family that suicidal this increases for severely depressed clients as they begin to feel better.

Treatment of ADHD

Dextroamphetamine is a stimulant Dextroamphetamine should not be combined with caffeinated products as it can lead to palpitations and nervousness

Pyelonephritis

Is diagnosed by the presence of pyuria, leukocytosis, hematuria, and bacteria. The client exhibited fever, chills, and flank pain. Ketonuria Indicates a diabetic state. Myoglobinuria describes a condition in which a proteins known as myoglobin is present in the urine, which does not occur in pyelonephritis. The white blood cell count is more likely to be high in pyelonephritis instead of low.

Proprietary health agency

Is governed by a paid board of directors appointed by the owner; it is considered a private for- profit freestanding agency.

Diarrhea fluid and electrolyte imbalances that are expected

Diarrhea for 4 to 5 days can cause a fluid deficit leading to dehydration due to a loss of fluids that may not be replaced if the client is feeling nauseous and does not drink the normal amount of fluids. Diarrhea often develop a potassium deficient because of the large amounts of loss of this ion in the frequent stools. Hypernatremia can result from excessive diarrhea because there can be a net loss of fluid with a resulting excess of sodium left in the body fat is greater that the poor portion normally found in extra cellular fluid and in the blood. During frequent bouts of diarrhea, a large amount of bicarbonate may be lost in the stool. If the kidneys have decrease blood flow due to dehydration, then bass deficient and acidosis rapidly develop. When metabolic acidosis develops because of a loss of bicarbonate in freaking diarrhea, result is a reduce arterial pH. This leads to deep in rapid breathing, which helps raise the arterial pH by causing a compensating respiratory alkalosis.

Four month old infant knowing how the infant is eating enough

The infant was six diapers per day But if it gains 4 to 7 ounces per week The infant sleep somewhere hours after feedings The infant does not need to be cool horse to feed The infant feeds on flexible but a regular schedule. Force feedings are never appropriate

Coxsackievirus

Is one of the most common enteroviruses. Also known as hand foot mouth disease, it is most often caused by Coxsackievirus and 16 and is most common in children younger than 10 years. The signs and symptoms of hand foot mouth disease include a fever and small but painful sores on the throat gums and tongue and inside the cheeks. It may also cause a rash, often with blisters, on the hands, soles, and diaper area, As well as headache and a poor appetite.

Tardive dyskinesia

Is grimacing involuntary, sticking out the tongue, and making sucking movements with the lips Is an irreversible side effect of long term treatment with antipsychotic drugs such as chlorpromazine. Increasing the dose of chlorpromazine requires additional healthcare providers prescription and will worsen the clients condition. Increasing water intake is done for lithium toxicity, not for fluphenazone. Benztropine is administered in conjunction with antipsychotic medications to decrease the incidence of TD.

Discharge planning for Paul cesarean section diagnosed with endometriosis dietitian

Is helpful in discussing with clients foods high in protein and vitamin C to promote healing.

Amphotericin B

Is highly toxic to the kidneys. Monitoring urine output will provide information about kidney function. Breath sounds, blood pressure, and peripheral pulses are not affected by amphotericin given IV.

Mechanical ventilation

Is ordered for the clients in respiratory distress or failure.

Accidental overdose

The priority includes monitoring by all signs, assessing mental status, and initiating CPR if needed.

The Hospice Medicare benefits

Covers all expenses for acute care, including acute care to control the symptoms of illness and professional staff visits. Benefits provide bereavement follow up care for up to 1 year after the client's death. To receive hospice care and hospice Medicare benefits, a client requires verification from two primary health care providers that the client is dying.

Asset of the nurse as a licensed health care professional helps in planning effective nursing care

Critical thinking Diagnostic reasoning Ability to synthesize information

Anxiety or depression

Crying frequently/repetitive cutting may occur

Acute renal failure

Decreasing urinary output found in acute renal failure is associated with hyperkalemia, which can trigger a cardiac dysrhythmia. Hyperkalemia does not cause paresthesia sensation of numbness and tingling. Dehydration does not occur during the oliguric phase of acute renal failure but usually does arise during the diuretic phase. Pruritus results from Increase phosphates in acute renal failure and is not associate with hyperkalemia.

Transurethral resection syndrome

Disorientation and hypertension Is caused by increased absorption of irrigating fluid use during surgery. The nurse observes for signs of cerebral edema and increased intracranial pressure such as disorientation, increase blood pressure, bradycardia, confusion, muscle twitching, visual disturbances, and nausea and vomiting.

Understanding of Continuity of Care During Transfer Of a Client

Document the Client's Condition Before and During The Transfer Communicate with the nursing staff of the receiving unit regarding the client's condition

Documentation the information before discussing it

Documentation should include both the missed time and the effect on client care.

Circumcision concerns

Each health care provider has a protocol for relieving the pain caused by circumcision, and the parent has the right to be informed before signing the consent form. Newborns do feel pain, although their nervous systems are not yet mature enough to localize pain

Normal growth and development in a three year old

Egocentric Can participate in all the care with simple tasks

Antidepressants

Elevated serotonin level may occur with medications that increase serum serotonin

Assessments for a woman who missed their last three menstrual cycles

Endocrine testing Pregnancy testing Height and weight Medication history Pelvic examination

Verbal Prescription Orders

Ensure the clients medical record is open Enter the prescription Word for Word as it is given Make an entry in the nurses notes Describe the situation The nurse would read back the prescription after entering it in the client record

Assessments of the airway in cervical spine

Establishment of a patent airway by positioning

Oncology data collection method

Evaluate activity tolerance Observe for a compromise integrity Monitor condition of the oral cavity Assess for presence of pain or nausea Encourage small amounts of favorite food

Liver damage

Evidenced by jaundice is well documented toxic side effects of antipsychotics. Dosing of the antipsychotic should be stopped

Statements that encourage a client to view failure positivity

Expect to succeed next time Give yourself permission to fail Consider failure as a learning experience Recognize that for your is part of growth Discover new options in opportunities created by failure

Auditory hallucination

Experience when a person hears voices without external stimuli

Help to make a successful referral process for a client who has been referred to rehabilitative care

Explain the need for referral to the client and family Provide the referral with adequate client information Determine what the referral recommends for client care

Informed consent includes

Explanation of available alternative treatments Answers to questions and concerns about the procedure Complete description of the possible dangers and discomfort ms

Gastrointestinal disorder would indicate to the nurse a risk for suicide

Family history of suicide History of major depression Lack of family or social support History of chronic Crohn's disease Recently released from federal prison

Triage tags

Ferritin Normal of 3 ng/ml is 10 to 150 NG/ML Hemoglobin of five MG/DL normal 13.5 to 17.5 G/DL Indicates severe iron deficiency anemia. A client with severe anemia has to undergo rapid treatment to replenish the stores of iron and, therefore, a yellow tag is given to the client. A red tag is indicated for a client with life-threatening complications who needs immediate treatment. A black tag is given to a client who is expected to die. A green tag is appropriate for a minor conditions that do not require immediate treatment.

Involuntary commitment to behavioral health unit in order A client doing dangerous to self or others and cannot function in a reasonable matter

Filing a formal petition Assessed one or two healthcare providers who make a determination to release or omit the client Determination is made to hospitalized the clients Length of stay is based on clients response to therapy Conservator or a guardian is provided to protect the clients rights

Lorazepam (Ativan)

Is indicated for anxiety in the hospice care setting. Because this drug may cause orthostatic hypotension, the client should rise slowly from a supine to a sitting or standing position. A client does not need to wait to take pain medication

selective attention in a preschool age child

Has the ability to attend to important stimuli and ignore distractions but has difficulty finding multi step instructions, completing assignments, and behaving well. A child with long-term memory problems will have to leave mastery of alphabet parentheses reading and writing letters), so my handwriting, and an inability to progress beyond basic mathematics. A child with problems relating to sequencing ability may not remember things in order, which can lead to challenges with prioritizing and organizing assignments, planning, spelling, and telling time.

licensed practical nurse and the unlicensed nursing personnel

Have not been provided the knowledge and skills to care for a critically ill client

Leader of A Unit Possess

Having adaptability to hospital rules Encouraging the newly appointed nurses Being aware about the events of organization Collaborating with the staff for decision making Penalizing the nurses for poor performance is the duty of the nurse manager. Incredulity or doubting the staff performance may reduce job satisfaction instead of motivating nurses to improve their performance.

Auditory hallucinations

Hearing voices

Substance abuse adolescent peer groups

Help to loosen family ties Help to define Present and future roles Provide stability during times of change Establish behavioral and dress standards Learn to make and stand by their commitments

Haloperidol (Haldol)

Hey serious and potentially fatal side effects of haloperidol, along with other antipsychotics, is the development of neuroleptic malignant syndrome. Signs and symptoms of NMS include unstable vital signs, fever, confusion, muscle rigidity, tremor, and incontinence. A client experiencing the signs and symptoms should seek emergency medical attention. The inability to sit still is called AKATHISIA and is a side effect associated with haloperidol and other antipsychotic medication's. Haloperidol and other antipsychotic medications can cause impaired muscle tone or dyspnea. Tardive dyskinesia is a irreversible side effects associated with haloperidol and other antipsychotic medications. Signs of tardive dyskinesia include involuntary, repeated movement of muscles in the face, trunk, arms, and legs.

HYPER THYROIDISM GRAVES DISEASE

Highest priority for a client with hypothyroidism is imbalance nutrition in calorie deficiency because excessive thyroid hormone production needs to hypermetabolism and increase nutrient metabolism. These conditions result in a negative nitrogen balance, increase protein synthesis and breakdown, decrease glucose tolerance, and fats Mobilization and depletion. Hyperthyroidism is associated with an increase in metabolism and heart rate. Compromise in person skin integrity and body image disturbance are more appropriate for a clients with hypothyroidism, which slows the metabolic rate.

Type one diabetes mellitus information a nurse should prioritize

Hypoglycemia has a rapid onset, to the point the child may not know is occurring

Grandiose delusions

I am the king of England

Umbilical cord protruding a.k.a. prolapsed cord

If cord prolapse occurs, the client should be immediately placed Trends Dalenberg position to relieve cord compression and increase fetal oxygenation. In this position the clients hips are higher than their head, which shifts to fetal presenting part towards the diaphragm. After the client is positioned , the nurse can use the call button to summon help.

Beta-adrenergic blockers agent

If the client blood pressure is less than 100 mm Hg. The respiratory rate of 12 breaths per minute is normal. A pulse oximetry reading greater than 92% is not clinically significant. A beta- adrenergic blocking agent would be held for a heart rate less than 60 beats per minute.

Halo device

Immobilizes and aligns the cervical vertebrae but allows the client to be ambulatory. The device restricts movement of the head

ADHD (Attention-Deficit Hyperactivity Disorder)

In attention, lack of focus, and impulsively

Magnesium sulfate toxicity

Is suspected by the nurse because of the disappearance of the knee-jerk reflex and depressed respirations fewer than 12 breaths per minute. This is a life-threatening situation; the magnesium sulfate infusion must be stopped, and the primary healthcare provider must be notified immediately. Calcium gluconate will be given as an antidote, but the infusion a magnesium sulfate must be stopped first. Magnesium sulfate is not an antihypertensive. Waiting may put the client in danger of respiratory arrest; signs of toxicity require immediate intervention.

legal authority

Is the ability to transfer selected nursing activities in a given situation to a competent individual

Social worker

Is the best team member and she's fine financial resources for treatment and medication for the client. The healthcare provider would be notified if the social worker cannot find any resources for the best for medication; perhaps a more Affordable medication can be described

SOAPE

Is the documentation format that includes subjective and objective information, assessment, plan of care, and evaluation.

Battery

Is the intentional touching of one person by another without permission of the person being touched

Hyperparathyroidism

Is the most common an older woman and is characterized by bone pain and weakness from excess parathyroid hormone. Clients also exhibit hypercalciuria- causing polyuria. Clients with diabetes mellitus and diabetes insipidus also have polyuria, but they do not have bone pain.

Supervision

Is the provision of guidance and oversight of delegated nursing task

What's the priority intervention for a dying hospital client with following blood pressure and increasing pulse

Is to inform the family that these changes are normal and expected and are not uncomfortable for the client. Unconscious with irregular breathing,has a blood pressure of 70/40mmHg, and a pulse rate of 120 beats per minute

Pneumonia

Is to maintain oxygenation as the airways are compromised. This is done by administration of oxygen to the client. The nurse would assess the sputum for color and amount, but oxygenation is a higher priority. The flu vaccine will be administered closer to discharge. You will need to isolate unless the client has drug- resistant bacteria.

Magnesium sulfate level

Is too high; the therapeutic level is 4 to 8 mg/dl. Calcium gluconate is an antagonist to magnesium and must be available immediately with this therapy; this medication needs to be at the bedside, not in the pharmacy. Maintaining the client on the left side not the right side m with minimal stimuli would decrease the chance of a seizure and thus is a nursing concern.

NPASS (Neonatal pain, agitation, and sedation scale)

Is used for neonates who receive sedation

electroconvulsive therapy (ECT)

Is used only in clients is severe, long lasting depression after attempts to stabilize the depression with various medications and therapies have failed. It is not prescribed for clients with recent myocardial infarction, her disease, high or low blood pressure, stroke, or congestive heart failure.

Aminocentesis

Is usually done between 15 and 20 weeks gestation a pregnancy and carries the last race of injury to the fetus. Self free DNA is performed using a maternal blood sample and is a screening tool to identify the risk of chromosomal anomalies, not a dynastic tool. Chronic villus sampling is performed between 11 and 14 weeks gestation. Percutaneous umbilical sampling is perform at ATVs to station or later and carries the highest risk for injury or death the fetus

Joint commission

It has developed a brochure about rights and responsibilities of clients It is responsible for accrediting and certifying health facilities in the United States

IV medication administration

It is distributed almost immediately to tissues, and prompt physiologic action occurs.

False Imprisonment

It is example of an intentional tort It involves restraining a person unjustly without any legal warrant The client should be aware of his or her confinement

Criteria for hospice admissions

It is mandatory that the client desires to have hospice services. It must be determined and documented by the two healthcare providers that the client is terminal and has six months or less to live. The client and caregiver must agree to palliative of care services only, be willing to participate in planning care, and agree that no life saving treatment will be administered.

Clients with firm fundus and excessive bleeding

It may be caused by a laceration to the cervix or birth canal. The nurse will notify the healthcare provider of the need for assessment. The nurse needs to address the clients bleeding by notifying the healthcare provider before completing documentation. Massaging a firm funders will not address excessive postpartum bleeding. Trendelenburg position should be avoided, as it can affect the clients cardiac function.

Prior to administrating Cilostazol

It's a Playlist aggregation inhibitor used to manage intermittent claudication. You should assess the client for the presence of dizziness or headache. You should obtain and record baseline of vital signs and degree of pain the client is experiencing. It is imperative for the nurse to ask the client about the presence of any cardiac symptoms, history of peptic ulcer disease, and heart failure as these problems may be exacerbated by cilostazol.

Advocating for a client with heart disease

Join grassroots tobacco coalitions Promoting healthier cafeteria choices Advocating for the national institution of health and other organizations to maintain an increase research Creating safe places to promote physical activity in the community Providing free screenings and education are all excellent ways to promote the well-being of the population

Lithium level

Level of 1.5 to 2.5 would experience nausea, vomiting, ataxia, ringing in the ears, lethargy, apathy, drowsiness, severe diarrhea, slurred speech, blurred vision, moderate sluggishness, muscle weakness, irregular tremors, frank muscle twitching, and increased tonicity. A client with a serum lithium level of 0.5 meq/L would have a recommended maintenance level. A client with a serum lithium level of up to 1.2 meq would experience apathy

School age children

Like to be creative and enjoy group activities

Bulimia electrolytes

Loss of electrolytes such as potassium can occur in addition to signs and symptoms of starvation and dehydration. Serum glucose and sodium would be decreased

Iron deficiency anemia

Low RBC, HGB, and HCT counts accompanied by reports of poor eating habits point to the diagnosis of iron deficiency anemia. Treatment for iron deficiency anemia is the ministration of ferrous sulfate. Opiates are used to treat the pain that accompanies sickle cell anemia. Vitamin B12 is used to treat pernicious anemia. Fresh frozen plasma is given in treatment of hemophilia.

Diabetes mellitus avoid amputation

Low carbohydrate Diet

Sleep hygiene strategy

Maintain a cool temperature in the bedroom Set a consistent time to go to bed and wake up Do not eat, read, work,or watch television in bed Avoid excessive alcohol in the evening and before bed. Get out of bed and engage in other activities if unable to fall asleep

The economic factor increases the cost of health care

Malpractice insurance Advances in technology Increasing number of aging individuals

Ruled out physical and emotional causes

Many children who experience bedwetting me sleep soundly and not wake up to urinate . Therefore the nurse just adjust the parents initiate time voiding and wake up with a child to use the bathroom.

Elevating serum ammonia levels

May be a complication of bleeding esophageal varices in a client with cirrhosis. This is important for the nurse to monitor, as it is neurotoxic and would require management. Bilirubin level and potassium level do not indicate bleeding in clients with cirrhosis. Prothrombin time indicates the clotting tendency of the blood, not the increased risk for bleeding from varices in clients with cirrhosis.

Atomoxetine

May cause liver disfunction ALT is an enzyme found primarily in the liver. ALT normal range 7 to 77 U/L is increased with liver damage from medications and other toxins. ACT is a laboratory test that is used to monitor high doses of unfractionated heparin therapy; normal range for a person not on anticoagulant therapy is 70 to 1/22. Heparin is a drug that inhibits blood clotting and maybe use for Klein sustaining myocardial infarction. NC is a blood test that measures the number of neutrophils granulates in the blood and is commonly used to check for infection, information, or leukemia or to monitor the effect of chemotherapy on the body. The normal range for ANC is 1500 to 8000. The ANA test is used primarily to elevate a person for autoimmune disorders such as lupus erythermatosus (SLE). Normal value for ANA is less than 1:40 depending on the testing used, and is reported as positive or negative.

Neurodevelopment me or motor impaired children

May need to be taught how to play. Compared with non-handicapped children, children within parents may not have experience preschool playing. Repetition of play experiences is necessary for children with sensory or motor disorders. In addition to being age-appropriate, equipment and toys must be altered to accommodate the child size. Children can be encouraged to play with others; however, the play must be supervised. Children with impairments often have poor judgment, which can affect her safety and may create safety concerns.

Extrapyramidal side effects

May occur with antipsychotics such as haloperidol

method of contraception

Medroxyprogesterone Contains synthetic progesterone, which will help reduce the pain from endometriosis. A diaphragm has a higher Pregnancy failure rate then Medroxyprogesterone and does not contain the ***** moans that can help reduce symptoms associated with endometriosis. The basal body temperature method of contraception is one of the least effective contraceptive methods and does not contain the hormones that can help reduce the symptoms associated with endometriosis. A non-hormonal intrauterine device is not recommended for clients with endometriosis. It is also not an ideal choice of birth control for a client who has recently been treated for a sexually transmitted infection.

Sexual changes in older man

Men do not experience a major rapid change infertility as they age. Changes occur gradually during a process known as andropause. Sperm production slows down but does not cease in old age. Sexual interest often continues later in life, and the ability to procreate may continue into the 18th decade. Testosterone production decreases in old age but not dramatically. Prostate enlargement is increasingly common after forty years of age and may lead to cancer.

Methylergonovine maleate (Methergine)

Mild a domino cramping is expected

Prolonging vomiting severity of complications

Mobility Skin turgor Lung sounds Temperature Blood chemistry

Lithium

Must be taken on a regular basis at the same time daily. If the client misses a dose, he or she should wait until the next scheduled time to take the lithium. Starting a new diet require an adjustment in the dose of lithium and is to be discussed with the healthcare provider. Clients may experience mild side effects when lithium is started, including a fine hand tremor. Most side effects will pass with time. Vomiting is a potentially serious side effect of lithium and can indicate lithium toxicity. The client should notify healthcare provider immediately.

In a dying client the hospice aid delegations are

Nail care, oral care, Washington clients hair, light housekeeping task, and applying lotion to intact skin.

Alzheimer disease drugs

Naproxen sodium

Peripheral Vascular Disease Avoid Amputation

Nicotine causes vasoconstriction, which decreases the blood and oxygen supply to body tissues

Before a cleft palate surgery

No tap water enema The lower gastrointestinal tract is not involved with this procedure. IV fluid is needed because the child is on NPO status. The child is kept NPO to minimize the risk of aspiration associated with anesthesia administration. Obtaining blood for typing and crossmatching is an important routine pre operative instruction in the event that a transfusion might be needed.

Lab values

Normal platelet counts are 150,000 to 450,000. Hemoglobin range is 12.0 to 15.5 G/DL. If it were low the client could be bleeding due to the hybrid. The INR is monitored for clients receiving warfarin . The a PTT is monitor for intravenous infusion not into meters injections of subcutaneous containers heparin. Platelets should be monitored during heparin therapy for this reaction. An adverse reaction to occur with this drug is heparin-induced thrombocytopenia.

A neonate with abnormal hemoglobin can be ?

Notify the health care provider Hypoxic even when the pulse oximeter displays a normal reading. Based on the laboratory results, the neonate requires a higher level care. Cyanosis REMEMBER IS A LATE SIGN OF HYPOXIA

Family centered care

Now supported by hospitals, does not support policies requiring parents to leave at night. Telling parents to go home does not support family-centered care or increase their child's feelings of security. Most hospitals no longer consider parents" visitors" and welcome their presence throughout the child's hospitalization. Although parents are encouraged to visit, it is never to take the place of a nurse due to short staffing. It is not true that a parent's presence will cause a child anxiety; the parent's presence helps increase the child's feelings of security.

The education and scope of practice of the charge nurse and the newly hired registered

Nurse allows them knowledge and skills to manage the nursing care of critically ill client

Community Volunteering performed by a Nurse

Nurses provide unique leadership in community volunteer opportunities. Organizing individuals in the community to develop health care delivery is an example of the nurse's role as community volunteer. Recording vaccinations, attending a city commission meeting, and writing letters to the editor of a newspaper are tasks performed by a nurse as a community opinion leader.

Charting

Nursing care must be done after providing the care to the client, not before The nurse should not chart retaliatory comments about the client it represents unprofessional behavior Information is too generalized, the specific information about the client's status may be overlooked. It's done in black ink to avoid illegibility. Correct time of an event occurrence indicates appropriate documentation

Priority assessments while evaluating breathing

Observe for chest wall trauma Assess breath sounds and respiratory effort

Understanding the nature of clients pain

Observe where the client locates the pain Note whether the pain radiates to any other part of the body

Hemorrhage

Observing the amount of lochia is a priority during the 4 hours after delivery Which normally occurs during the fourth stage of labor, and the increased risk of low platelets because of blood clotting issues that accompany preeclampsia. Monitoring blood pressure is important to help assess. Do not be breastfeeding while receiving magnesium therapy.

Uric acid stones

Occurs from too much purine in the diet. This is found in organ meats, gravies, red wines, and sardines. Strawberries, spinach, and peanuts are sources of oxalate that would be avoided in clients with calcium oxalate stones.

Deviated septum

Occurs when the cartilaginous wall between the nares is off center. Headaches, sinusitis, and epistaxis(nosebleed) are signs of a deviated septum. Chest pain, congestion, and blurred vision are not usually seen with a deviated septum.

Lice infestation

Occurs with contact with others who have them. The best advice is to avoid reinfestation is to never share hat or comes. Unsanitary living does not cause lies.

Blood alcohol content

Of 0.30% to 0.39% will experience confusion, stupor, or responsiveness to most external stimuli, and ability to control involuntary response, bradycardia, hypotension, and increased respiratory rate. Blood alcohol contact of 0.05% to 0.09% what experience lol judgment, be more socially at ease, slow reaction time, inability to perform complicated tasks, hypertension, and tachycardia. Blood alcohol content of 0.10% to 0.90% will experience clumsy voluntary motor actions, alter death perception, slow reaction time, affected focus, and decreased judgment and control. Blood alcohol content of 0.20% to 0.29% would experience depression of the entire motor area of the brain, staggering, loss of conscious control of reason, being easily angered, and potential ability to weep, shout, and fight

Serosanguineous drainage

Of 80 to 120 ML's is expected during the first 24 hours; more than this amount of drainage should be reported. Turn the client onto the right side will have no effect on the portable wound drainage system; it functions your negative pressure, not gravity.

Total bilirubin

Of more than 5mh/dl in 24 hours or a level greater than 12.9 mg/dl warrants further investigation. Hemoglobin of 18.5 mg is an acceptable findings. An infant weighing 3000 g converted to kg per hour, 3000 g converted to kg is 3 kg, and 1 ml multiplied by 3 kg results in a minimum urine output of 3ml per hour. Anticipated blood glucose is above 40 mg/dl.

Normal growth and development in a five year old

Often struggle to accept losing

Septic patient

Priority is to draw blood cultures so the antibiotic can be initiated as soon as possible. Administering the antibiotic before teen black coaches good mass infection, delaying appropriate treatment. Taking the client to x-ray before obtaining the blood cultures will delay antibiotic initiation. What cultures should be drawn before administration of latte ringer solution.

Which type of agency is governed by a hospital board of directors, provide limited community health care, and receive fees from all sources

Private for profit institution based Private nonprofit institution based

Win a client is experiencing eclampsia

Oxygen and suction must be immediately available. If you don't mind I will eventually be used but it's not unusual criminals apply to a pregnant eclamptic client. Padding is used as a seizure precautions to prevent injury should seizure occur. The nurse will protect the client from injury during a seizure by protecting her from striking human services.

Undertreatment of pain in children

Pain assessment, especially for children who have limited cognitive and language skills, continues to be a challenge for health care providers. One can rely on physiologic variables and behavioral variables, such as vocalization, facial expressions, and body movements. Nothing indicates that children are at any increased risk for physiologic or psychologic dependence from the use of opioids for pain management. Although respiratory depression is a possible side effect with opioids in children older than 3 months of age and possibly younger, opioids cause no greater respiratory depression than in adults.

Hospice Medicare

Pays benefits for bereavement for up to 1 year after a clients death Is provided only to clients with terminal illnesses who require palliative care. Covers all palliative treatment expenses Dying adults often achieve a higher level of control and dignity within a hospice than with other types of health care

Pericarditis treatment

Pericardiocentesis is performed

Stress

Physiologic response to stress as the body is trying to improve vision as a protective mechanism. Another indicator of stress is tachycardia with a pulse of 120 bpm.

On drugs

Pinpoint pupils Response to drugs such as coding, hydrocodone, morphine, or heroin

Pyloric stenosis

Place in the infant in a sideline position helps protects the airway and prevents aspiration of gastric contents. Keep the affected infant on an NPO status to eliminate vomiting.

Taking home the placenta

Placenta is part of the body and therefore contains body fluids. It must first be obsessed by the healthcare provider to be sure that it is not infected and to be sure that all parts of the placenta have been accounted for. The nurse must follow hospital policy regarding the release of the placenta to the family. All necessary documentation must be signed, and the policy must be followed before the release of the placenta to the family

Metabolic syndrome

Places the client at high risk cardiovascular disease. Notify the health care provider immediately regarding the client's complaint of chest discomfort at rest. Clubbed nail beds are indicators of chronic hypoxia usually associated with right sided heart failure. Lentigo senilis on the arms are called age spots and occur due to exposure to ultraviolet light over time. Shortness of breath may be attributed to obesity as seen with metabolic syndrome

The nurses primary focus for a client with a fractured femur

Possibility of inability to tolerate activity Fractured femur is acute pain

Postpartum Hemoglobin levels

Postpartum client at risk for hemorrhage, therefore, the healthcare provider typically orders a hemoglobin level one to two days after delivery to assess risk. A level of 9.9 G/DL is lower than normal for a postpartum client but is not necessarily low enough to warrant a blood transfusion. You would notify the healthcare provider of the findings and ask about follow up labs on rounds. Only the healthcare provider can decide if the test should be repeated.

Phonologic

Processing causes delayed receptive language skills, as well as attention and behavior problems secondary to understanding directions. Persistent letter confusion between (b,d, and g), difficulty with basic reading and writing, and limited "sight" vocabulary are issues related to visual analysis. Proprioception and motor control problems manifest as poor handwriting requiring inordinate effort, often with an overly tight pencil grasp, as well as special difficulty with timed tasks.

ARDS (acute respiratory distress syndrome)

Prone positioning has been shown to improve oxygenation Are usually intubated and placed on mechanical ventilation with positive end expiratory pressure.

lansoprazole

Protein pump inhibitor used to decrease incidence of stress or service

Tardive Dyskinesia

Protrusion of the tongue(flycatcher sign) and puffing of cheeks or tongue in cheek (bonbon sign).

Home Health Care

Provides skilled services such as nurses, aides, and speech therapy. If your being discharged home than you will not need a skilled nursing facility

Factors that contribute to homelessness in the United States

Public assistance eligibility requirements Difficulty maintaining steady employment Lack of low income housing in communities Lack of support systems in families and communities Movement of chronically mentally ill people into communities

Strategies for reducing the number of sickle cell crisis

Quitting smoking, identifying stressors, avoiding alcoholic beverages, drinking 4 to 6 L of fluid daily, and avoiding high altitudes.

Spasmodic croup immediate intervention

Rapid respirations may be a sign of impending airway obstruction. Unless irritability is accompanied by severe restlessness, symptomatic care should be given. Unless accompanied by signs of respiratory embarrassment, hoarseness needs no immediate intervention. A barking cough may sound ominous, but it is not a sign of respiratory compromise, as is rapid respiration.

Speech and language development in a preschool child

Recall ability Hearing testing Visual assessment Testing oral motor skills Confirmation of understanding Observation of social interactions

Immune compromise for induction chemotherapy

Recommend as a parent to five technology such as the laptop in theory for a big child to stay in contact with friends and family members. Other children would not be allowed because of high risk for infection.

Acute blastic leukemia referrals

Referring the parent back to the healthcare provider with a suggestion that addresses the need for more information is an appropriate initial intervention. The healthcare provider can coordinate the referral to the appropriate specialist examples oncologist or hematologist.

Assessment

Refers to an analysis or potential diagnosis of the cause of clients problem or need

responsibility

Refers to the reliability, dependability,and obligation to accomplish the task

Intracranial hemorrhage

Reports of headache, vomiting, and loss of consciousness, the nurse should notify EMS for further treatment. Once EMS has been contacted The nurse can elevate the lower extremities, obtain vital signs, and apply cold washcloth to the forehead

stroke (aka cerebrovascular accident, CVA)

Requires immediate medical attention. A potentially life-threatening medical emergency. Damage to the brain from interruption of its blood supply.

Crutches

Resting the armpit on the crutch would cause pressure in the axillary area and could damage nerves and result in temporary or permanent numbness in the hands. Before beginning to walk with crutches, the client should assume the tripod position where the client stands on the good foot and places the crutch tips 4 to 6 inches to the side and in front of each foot. When standing with crutches, the elbows should be slightly flexed to allow for full extension when taking a step. When climbing the stairs, the good leg is placed up on the step first, while the crutches support the body. Full body weight is then transferred to the good leg, and the crutches and affected leg are then swung up on the step

Intervention

Specific care given to a client

If the mother and the baby has two different blood types The mother is negative and the baby is positive

Rho(D) Immune globulin will prevent sensitization from recess incompatibility that may arise between an Rh negative mother any Rh positive infant and needs to be given within 72 hours after delivery. This is a mother's first birth so the RH for Rh incompatibility is minimal. Only the mothers and the newborns our age factors are relevant at this time.

Documentation of findings crackles and bronchi in the left lower lung

Rhonchi are coarse sounds heard over the large airways; including bronchi in the record makes documentation inaccurate. Crackles and rhonchi or chemical indicator not a nursing diagnosis. It is incorrect to use the term bronchi to refer to crackling sounds in the lower lung. Crepitus, which indicates subcutaneous emphysema, is unrelated to auscultated breath sounds.

COMFORT

Scale requires the measurement of two physiological systems, which are not a standard procedure for the assessment of neonatal pain after circumcision

Fluticasone

Seasonal allergies with sneezing and nasal congestion. The desloratadine cannot be taken with monoamine oxidase inhibitors (MAOIs), and the client is taking selegiline, which is an MAOI. Pseudoephedrine should not be used in clients with hypertension.

Secondary syphilis

Specifically the rash with brown spots on the palms of the hands and soles of the feet. The use of tampons, diarrhea or vomiting, and exposure to a viral infection associated with toxic shock syndrome. Symptoms of toxic shock syndrome include skin peeling from the palm and souls one to two weeks after the illness and a sudden spike in fever.

Larynotracheobronchitis (viral croup)

Tapani and tachycardia, intercostal and subscribe attractions, and increase versus Ness are signs of increasing hypoxia cycle and intubation may be necessary to maintain an open airway. The signs are not indicated of increased accretions; suctioning could precipitate sudden laryngeal spasms. Striking the bag would not be affected against the windshield spasms. The information is preventing the oxygen from reaching the lungs; increasing the amount of oxygen will not be affected until the information is reduced.

Community Relations Officer

Serves as a liaison between the health care facility and the media

The medical command health care provider

Serves to determine the resource needs of the client as well as the acuity and number of the clients. In addition to these responsibilities, this health care provider is also expected to determine which clients need to be moved to larger medical centers and who can be retained for treatment.

Most therapeutic parental actions

Setting clear limits, explaining the consequences of disregarding them, and firmly and consistently applying them

Hypertensive crises

Severe headache, blurred vision, nausea, restlessness, and confusion with an extremely high BP indicate Treatment is aimed at reducing the BP as quickly as possible by giving potent vasodilation and diuretics. Continuously monitored with an arterial.Blood cultures are obtained of sepsis is suspected.

A Term Neonate Weight

Should not experience a weight loss greater that 10%

Industry vs. Inferiority

Showing an interest in having good grades

Response is appropriate

Significant sign that wife is depressed and in need of immediate intervention

Cystic fibrosis

Signs and symptoms hypothyroidism and current findings of hypothermia, hyperventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area.Is a disorder of the exocrine glands, which are those that secrete mucus, sweat, saliva, and digestive enzymes. And having cystic fibrosis the airway obstruction and decreases resistance lead to chronic back to your infections. Individuals with cystic fibrosis lose more sodium and chloride in sweat then is normal so they are at risk for hyponatremia. Cystic fibrosis also abstracts pancreatic ducts so that pancreatic enzymes are not delivered to the intestine, resulting in the inability to absorb proteins, fats, and fat-soluble vitamins. Therefore, stools are bulky and foul - and smelling. Cystic fibrosis causes the production of thick, tenacious mucus, which is then expelled in a cough. Cough, increased sputum production, and fatigue leads to a decrease in exercise tolerance.

Increasing intracranial pressure

Signs of restlessness, agitation, and lethargy has sustained a head injury in this prompt the nurse to notify the health care provider

Before administering a beta blocker to a hypertension client

Simulation of beta receptors stimulate the heart and relax bronchial smooth muscle. Beta blockers will not stop stimulation the heart and relaxation of bronchial smooth muscles. Beta blockers may be taken with or without food. Cardiac rhythm problems and muscle weaknesses are signs of hypokalemia; this is a side effect of diuretics clients with asthma who take beta blocker would be at risk for asthmatic attack as bronchial smooth muscles may spasm.

Visual hallucinations

Sing spider in the eye and aliens coming into the room

First activities of daily living ADLs

So feeding is an early step in the progression of growth and building skills. Dressing is a more advanced skill; It requires mastery of gross and fine motor skills and hand eye coordination. Toileting is a more advanced skill it requires control of the anal and urethral sprinters, readiness of pschophysiologic factors, and motivation. Combing the hair is more advanced skill it requires control of gross and fine motor skills and muscle coordination.

Placement of an ileostomy

Stoma excreting liquid stool, the aroma being bright red and moist, and mucoid drainage from the anus are all expected findings that require no immediate action.

Hypervolemia

Such as cool skin, sensation of impending doom, and restlessness. A healthcare provider must be notified immediately, as severe hypovolemia and delayed fluid therapy can lead to ischemic injury an irreversible shock with multi organ system failure. The most appropriate position for a client in shock is supine with the legs elevated. You cannot deliver auction and without an order from the healthcare provider.

RN responsibility

Supervise the delegated task

Cleft lip When will it be repaired

Surgeries perform as soon as possible; if the infant is in good health, it may be done right after birth or by the age of 6 to 12 weeks. Babies begin to have teeth at 7 to 8 months. surgeries perform much earlier than 18 months. Cleft palette not cleft lip may be repaired at this time healthy newborns lose weight during the first week of life.

Ectopic pregnancy

Symptoms of cramping and bleeding.

Laparoscopic tubal ligation

Takes about 20 minutes to perform. The client is admitted as an outpatient and goes home the same day after she recovers from anesthesia. AdMinistration will continue because there is no trauma to the ovaries or the endocrine glands involved with reproduction. Sterility is immediate and a waiting period is not required as it is with a vasectomy. Microsurgery to reverse the procedure is not guaranteed or easily accomplish.

Ways to cope

Talking with nurses who cope with similar issues allows the nurse to share feelings and obtain constructive emotional support. Avoidance by taking several personal days off from work may provide an immediate solution, but it works only for a short time. Limiting emotional involvement with the clients avoids personal feelings about death and dying and is an unacceptable attitude when caring of dying clients. Emotional withdrawal may be perceived by the clients as rejection. Avoidance by requesting a transfer to another area of the hospital may provide an immediate solution, but it works only for a short time. The nurse will eventually have to work through feelings.

Vision screening: children

The USPSTF recommends vision screening at least once in all children ages 3 to 5 years to detect amblyopia or its risk factors. Children who need to be screened for visual abnormalities Move their seats closer to the board or squint to read the board. Having difficulties sitting still in class may indicate ADHD. Asking the teacher to repeat and instruction may indicate hearing impairment. Displaying involuntary neck movements are tics that may occur during stress

Bath oil

The addition of oils to bathwater is used as treatment for itchy skin. However, this creates an unsafe condition in a tub as they made the tub very slippery the addition of handrails to prevent falling is recommended

Action should the nurse take first

The assessment that the medication had been ineffective in relieving the adolescent's pain for the duration that it was prescribed to cover

Involuntary admission

The behavioral health unit is warranted if the client is address for harming the self or others.

Chemical dependency

The body reliance on certain drugs. Common features of chemical dependency include anxiety, itching, sweating, tachycardia, and skin disturbances.

Accidentally stick from a needle used on a client with HIV

The care is post exposure prophylaxis of combination antiviral therapy can significantly decrease the risk for infection.

Anti-depressants

The child and family should be taught to drink plenty of fluids, especially water. The child should be provided with high foods in fiber prevent constipation. The child should be reminded to rise slowly for me sitting or laying position to avoid dizziness. Children usually do not outgrow depression and end up taking antidepressant medication's for a lifetime. exercise should be encouraged to prevent constipation. Most antidepressant medication do not cause tachycardia

Eight month old

The child shows signs of male carries, which can develop if the child goes to bed with milk in a bottle. The sugar in the milk sits in the mouth and can result into decay. Black spots on the child's front teeth indicate cavities, so the nurse would refer the parents to a dentist. A soft diet is not necessary unless the child is having difficulty chewing food. The family should be educated on the use of fluoridated toothpaste in amounts about the size of a grain of rice as fluoride promotes healthy teeth.

A home alone child

The child to stay inside if the parents are not home.

Acute kidney injury setting theory to glomerulonephritis highest priority

The client has an elevated potassium level, which can lead to life-threatening dysthymias, so the nurse would need to promptly initiate continuous telemetry monitoring. The glucose level is slightly elevated, but this would be the highest priority. The nurse can administer IV fluids after initiating the telemetry monitoring. The transfusion would be administered after the other measures.

Percutaneous lithotripsy for Renal calculi

The client needs to report the presence of foul smelling or cloudy urine. The nurse told the client to drink large quantities of food each day to post to kidneys in this contraindicated. Hematuria is common after lithotripsy decline would not be told to report urine within 24 hours after the procedure. Sandlike the debris is normal due to the residue stone products, so it does not need to be reported.

Ileostomy discharge teaching

The client should know that there is help available even though direct supervision is no longer provided. Ileostomies are not irrigated because the stool is liquid.

HPV vaccine

The client will still carry the virus after treatment with laser vaporization. The clients partner should be treated for HPV. Although general wards may clear up on their own, the client still carries the virus. The vaccine is only recommended for a woman up to 26 years of age.

The individuals that are a core interdisciplinary team member in hospice care are

The client/family, social worker, medical Director, nurse coordinator, and spiritual coordinator.

Evaluation

The clients response to the prescribe plan

Hormone replacement therapy

The contraindications include seizure disorders like epilepsy It can lower the level of seizure preventing medication in the blood and increase the rest for seizures. Menopausal woman need 1200 MG's of calcium daily to prevent osteoporosis vagina cream should be inserted in the evening when the client Will be lying down for an extended period to maximize disruption. The creams are prescribed for vaginal dryness. Those ginseng may interact with some medication such as blood thinners, Anti-depressants, and anti diabetics

Cardiac catheterization

The diagnostic test that would provide the most information for clients suffering from unstable angina is a Kia catheterization. A Holter monitor provides information about the cardiac rhythm over an extended period. Arterial blood gases provide information about oxygenation status of the blood. A CBC provides information on overall health by looking at the cells of the blood.

Fractures of long bones

The femur are at risk for developing a fat embolism. Signs of fat embolism include respiratory distress, tachycardia, Tamia, fever, and confusion. Treatment of a fat embolism includes the application of oxygen, bedrest, and then a little support. Fat embolism causes confusion which is due to hypoxia. Find embolism does not normally result in pain.

Heparin

The heparin would be withheld because 98 seconds is almost 3 times the normal time it takes a fibrin clot to form 25 to 36 seconds, and prolonged bleeding may result; the therapeutic range for heparin is 1 1/2 to 2 times the normal range. The primary healthcare provider will be notified. The doses of the heparin must be increased because the client already has Received too much. Documenting the results on the medical record and recheck in the APTT in four hours is unsafe option continue in the fusion could result in hemorrhage. The medication does not have to be changed; it would be stop temporary until the a PTT is within the therapeutic range

hypospadias

The infant will have normal reproductive function. After surgery to correct hypospadias, the infant will have normal urinary function and will not require catheterization. In hypospadias, the urethral opening is located along the ventral anterior portion of the penile shaft. Hypospadias will not spontaneously resolve; surgical correction is needed.

Infectious diseases

The instance of previously common childhood infectious diseases such as measles, chickenpox, and moms has been most effectively reduced by immunizations of all school age children.

Compartment syndrome

The intervention is to elevate the fractured arm to cardiac level to stop further swelling. Next, the nurse would call the health care provider regarding the client's condition. Medicating the client for pain then informing the nursing supervisor are the next actions to take. This client likely is experiencing compartment syndrome, which likely will require emergent surgical intervention.

Hypothermia for Anorexic Patient

The loss of subcutaneous fat as the result of weight loss. It's unrelated to getting sick, the weather,or the clothing worn.

Maslow's Hierarchy of Needs

The love and belongingness need involves the nurse lending support to a client and his or her loved ones when the client is diagnosed with a life threatening disease. Self esteem needs are addressed when dignity and recognition are taken into consideration in health care. Self actualization needs involve personal growth and maturity. Safety and security needs are associated with protection from physical harm.

Body basal temperature

The most accurate BBT is taken before a woman gets out of bed and begins any type of activity that could increase the body's temperature even slightly. Should be charted daily on a calendar to permit interpretation of temperature fluctuations. Taken in the evening may be increased after a day of activity. Daily assessment and recording of BBT during the first half of the menstrual cycle is also crucial, because a woman's BBT is lower then than during the second half of her cycle. May rise slightly with ovulation.

Spica cast delayed capillary refill and toes that are now cool to the touch

The nurse must immediately report this finding to the health care provider as it indicates compromised circulation in the infants lower extremities, and emergency intervention is required. Documenting this finding in the medical record is important because it is abnormal; however, this is not the nurse's priority intervention.

Hyperaldosteronism

The nurse recognizes that the clients hypertension is most likely caused by an excessive creation of other strength in the adrenal cortex. This one will ask on the renal tubule where it from was reabsorption of Sodium and excretion of potassium and hydrogen ions. The pancreas many secretes hormones involved in glucose metabolism. The parathyroid secretes parathyroid hormone. The adrenal medulla secretes catecholamines epinephrine and norepinephrine.

Initial response that's most appropriate

The nurse should discuss alternatives in terms of funding, such as Medicaid, research projects, and special aid.

Boggy uterus that is displaced

The nurse should have the client empty their bladder, as a uterus placed above to the right of indicates bladder distention, which can lead to a body uterus. If the uterus was at midline and below the umbilicus, the nurse would massage the fundus. If the fundus is not firmly contracted after the client empties the bladder then you will massage the fundus until it's firm to help express any accumulated clots. If the uterus is under contract in, the nurse will not push on it as this can cause the uterus to invert

Boggy uterus

The nurse should initially massage the fundus until firm. Boggy uterus indicates uterine atony which would be confirmed by perfuse lochia and the passage of clots larger than 1 cm. Once the fundus massage has been started, the healthcare providers should be notified. Administering Merthergine may also be necessary if the fundus does not become firm with massage.

Incident report

The nurse should monitor the vitals of the client constantly until the condition stabilizes. It is the responsibility of the nurse to report the incident to the primary healthcare provider. Enter reports can be found against the nurse as a charge of negligence. The nurse should not admit to liabilities of the cause of the incident because it may lead to further legal complications. The details of the primary healthcare provider, who is providing the polls incidental care, should be included in the report.

Nursing process

The nurse uses it to plan, deliver, and evaluate nursing care in the scientific manner.

Normal Ranges

The nurse will notify the healthcare provider of low platelet count of 52×10 square root 3/ML because the normal range is 150 to 400 times 10 square root 3/ML. Low platelets, or thrombocytopenia is a serious adverse reaction that can occur with oxycarbazepine is 3 to 40 mg/L , so the value is within normal range. The normal sodium level range for a child is 135 to 155mEq/ML, and the child's value is within the normal range. Sodium and albumin levels are not affected by oxycarbazepine therapy.

Atopic Dermatitis (Eczema)

The nurse would ask about the risk factors for eczema, which include a personal or family history of asthma or hayfever while diabetes mellitus, emotional stress, or industrial cleaners as an irritant may cause itching, they are not causes of atopic dermatitis.

Subtotal thyroidectomy

The nurse would monitor for signs of a thyroid crisis, which usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyper thyroidism that the client is experiencing. Symptoms of thyroid crisis include diarrhea, vomiting, confusion, hypertension, and extreme agitation.

Children dentist visits

The presence of multiple carries is hesitates referral of the child to a dentist as soon as possible. Third molars do not irrupt until age is 17 to 21. Nausea and vomiting can be treated by a healthcare provider. Use of fluoridated toothpaste is appropriate for all school age children.

Pica

The primary concern for a pregnant woman who practices pica is that her diet is nutritionally inadequate. Nutritional guidelines may be necessary, depending on the findings of this assessment. If the substance is not toxic to the mother, it is generally not fetotoxic. Iron has nothing to do with pica

Acute phase of a stroke

The priority is to maintain the client's airway as airway obstruction can occur for many reasons. The nurse would maintain body alignment and elevate the head of bed 25 to 30 degrees to maintain the airway. Instilling artificial tears in the eyes of a stroke client will help keep the eyes moist. Responding promptly to calls for assistance will reduce the chance the client will try to get up by themselves and cause injury.

Informed consent

The procedure should be explained to the parents by the practitioner, and the nurse should confirm the parents comprehension and have them sign the consent form.

Prospective payment system

The prospective payment system provided incentives to home health providers to deliver home health services more efficiently.

Conforms to request a new information via give me regarding the clients condition or presents in the hospital

The response we have no record of the client on our unit. Thank you for calling. HIPAA laws do not prohibit the provision of information to others as long as the client contents.

Pancreatic cancer helping clients plan for the future

The stage and grade of the clients cancer

Abdominal aortic aneurysm

The surgical repair requires that they are out of the clamp for a period of time. This creates a rest for kidney damage and renal failure. Decreased or an output must be reported immediately to the healthcare provider. We're attention and make hospital if your demo. Absent bowel sounds immediately after surgery would not overly concerned a nurse as peristalsis normally ceases temporary. A decreased pedal pulse can occur from impaired blood flow, but it is common after femoral or popliteal aneurysm repair

Percentage of body surface area burns

The trunk is 18 so key word if you see burns over chest and abdomen that's a truck which is 18. The anterior and posterior aspect of the arm 4.5% The anterior and posterior of the leg is nine 9% The head anterior and posterior is a 4.5

Periodic decelerations

They are normal. Variability in fetal heart rate during labor indicates the fetus well-being and activity and can include slight accelerations and decelerations. If late decelerations were noted, the nurse would administer oxygen via nasal cannula and position the client lying on her left side, as these actions help increase oxygen supply.

PRN prescriptions for restraints

They are unacceptable. A complete doctors order is needed to initiate the use of restraints except under extreme emergency situations when a RN can initiate the emergency use of restraint using an establish protocol until the doctors order is obtained and/or the dangerous behavior is no longer exist. Restraints without a valid and complete order are considered false imprisonment. The minimal components of orders for restraints include the reason for and rationale for the use of the restraint, the type of restraint to be use, how long the restraint can be used, the client behaviors that necessitated the use of the restraints, And any special instructions beyond and above those required by the facilities policies and procedures. Asking for the provider to indicate the type of restraint is insufficient. Less restrictive interventions are use when the client begins to add out; restraints are used as a last resort.

Anthralin

This drug is used for psoriasis Will cause straining of hair, skin, fingernails, furniture, bathroom fixtures, the client should be instructed to use gloves and to carefully apply it. Anthralin Is to be applied only to lesions. The action of Anthralin may be enhanced by ultraviolet B(UVB). UVA is used in combination with psoralen or methotrexate, not Anthralin.

Assault

Threat or an intentional act without touching that makes a person fearful or produces reasonable apprehension of bodily harm

NIPS pain scale

To be used for a neonate before and after circumcision

Fundal height measurements

To measure frontal height, a pregnant client is placed in a supine position. This can cause supine hypotension as a result of uterine compression of the vena cava and abdominal you are. If a pregnant client becomes dizzy and lightheaded during an exam, the nurse will first turn the client on her left side. Turning to the left side removes the compression and restores cardiac output and blood pressure.

Hypothyroidism

To report facial puffiness, extremely edema, and weight gain.

Child life specialist

Trained professional who plans therapeutic activities for hospitalized children. Is a healthcare professional with expertise in growth and development.

Infective Endocarditis (IE)

Treatment for IE includes IV antibiotics to treat the infection. This is done after dental surgery

Continuous heparin infusion

Treatment for a pulmonary embolus

COPD clients

Use more calories because of the extra work it takes for breathing. The client is underweight for height and has a low albumin level. The nurse would consult with the dietician to develop a plan to meet nutritional needs. Oxygen must be given all the time with patient with an oxygen saturation between 88% to 92%. Their drive to breathe is based on the high CO2 levels, and raising the oxygen saturation would diminish their breathing.

Greenfield filters

Used in clients at risk for a pulmonary embolus; they placed in the inferior vena cava to prevent emboli from reaching the lungs.

Levothyroxine (Synthroid)

Used to treat an under active thyroid gland hypothyroidism

Medicare home care services

Uses a medical model of practice. The services that are reimbursed by the home care limited by Medicare. The qualifications for providing home care services are changed by Medicare. The payment sources of home care services are changed by Medicare.

Factors Contributes to Anorexia and Would be analyzed

Usual diet Pain level Emotional status Gastrointestinal symptoms Presence of dental problems

Log rolling with a turning sheet correct sequence

Verify the turning sheet extends from above the shoulders to below the hips Instruct the client to cross arms over the chest Position two nurses on the same side of bed facing the client Place a pillow between the clients knees. One nurse grasp top and middle edges of training sheet and the other nurse grasp middle and bottom edges of turning sheet. Count one, two, three and turn the client using the turning sheet.

Normal growth and development in a 4 year old

Vocabulary of 1500 words and be able to count to five

hematesis

Vomiting large amounts of bright red blood Severely no hemoglobin and hematocrit, and then I was gonna take blood type and cross much for two units PRBCS. The nurse will schedule the ETD after the client is stabilized. The client is alert and oriented times four and vital signs are stable. After the blood is obtain the nurse can administer the IV fluids.

Prescribe medication

Wait at least two hours to take an antacid because antacids prevents the absorption of Chlorpromazine, and antipsychotic. Phenelzine is a monoamine oxidase inhibitor; it is correct for the client to avoid decongestants while taking this medication. Lorazepam we're not be taken with alcohol because it is an antianxiety medication and a central nervous system depressant. Be careful to get enough salt in their diet because hyponatremia may cause lithium toxicity.

Omnibus Budget Reconciliation Act

Was a landmark law that affected long-term care facilities

Manifestation managing a brain injury

Weakness Diaphoresis Tachycardia Cold extremities

Postoperative Care for Stomach Cancer

Weigh the client daily Provide oral care frequently Monitor nutritional intake Maintain nasogastric suction Stress the importance of ongoing vitamin B12 injection

Therapeutic communication Gender Identify Intervention

When asking the client what is right and what is wrong. Questions will help establish why the adolescent is troubled and help determine choices.

Egocentrism

Where the child cannot see any perspective other than his or her own

Severe preeclampsia

Which can develop suddenly with a blood pressure of 160/110 mm Hg or higher and proteinuria of 2+ to 3+ or more. Severe headache and blurred vision are typical symptoms. The client needs immediate treatment to prevent eclampsia.

Severe preeclampsia

Which develops suddenly with a blood pressure of 160/1 MMHG's or higher and proteinuris of +2 to or +3 or more. Severe headache and blood vision are typical symptoms. The client needs immediate treatment to prevent eclampsia. Having acetaminophen prescribed to relieve the headache is unsafe and would place both the client and fetus in jeopardy.

Abruptio placentas

Which is characterized by dark red bleeding. Pain is an important symptom associated with abruptio placentae. The client will receive row D immunoglobulin after suspected trauma regardless of whether she delivers or not.

Polycythemia Vera (PV)

Which occurs when too many red blood cells are produced and causes the blood to be more viscous than normal. Treatment includes removing 1 unit of blood so that the clients hematocrit returns to normal. This client does not have an infection, and administering an antibiotic is not necessary. Oxygen therapy is not indicated for this client.

Forgetting to take oral contraceptives for the past three days during having sexual intercourse

Will be instructed to take the most recent pill that was missed and include today's pill, disregard the other meds pills, and continue taking the pills using a back up method of contraception for seven days.

Erickson's theory of psychosocial development for adolescents

Will begin to establish their own identity and will ponder the question of who they are. Examples of adolescent wearing makeup and brand name clothes, participating in activities, and developing a group of friends to develop their own unique identity.

Acute exacerbation of Asthma (or asthmatic attack)

Will exhibit dyspnea or a productive cough and may use the accessory muscles of respiration. The client may also have an expiratory wheeze. The nurse would be most concerned by the absence of wheezing which indicates that the airways have become so narrow that the client is unable to move any air. At this point, respiratory arrest is imminent.

Antimicrobial therapy

With emphasis on the need to finish the medication completely even though the child feels better. Encourage the child to drink cool liquids until the throat feels better. To relieve throat discomfort in bacterial infections, administer saline gargles, lozenges, warm compresses to the neck, and acetaminophen. Emphasize follow up care after streptococcal pharyngitis to ensure eradication of the causative organism.

Ulcerative Colitis

With this disease you want to avoid diarrhea,bloating ,gas, and stomach cramping The food produce the diarrhea, the gas, and abdominal cramping Decrease alcohol consumption as much as possible Follow the low residue diet that limits high fiber foods Avoid concentrated sweets such as juices, candy, and soda Try incorporating more fish such as salmon, mackerel, and herring Consider eating smaller, more frequent meals rather than three large meals

Client receiving intravenous heparin for DVT

Would have the aPTT at 2.0 to 2.5 times the normal range. The desired range would be 75 to 100 seconds. The client's aPTT is 125 seconds, which exceeds the desired range, so the nurse would anticipate the health care provider to have the nurse stop the heparin infusion. The Antidote for Heparin is protamjne sulfate, and the antidote for warfarin is vitamin K. The PT and INR are within the expected range for a client taking warfarin, so the nurse would administer the dose but hold the heparin first. The platelet count is decreased but not life threatening, so the nurse would transfuse the platelets after holding the heparin.

Administering incorrect dose

Would it be an act of negligence that could endanger the clients or fears, and the nurse would be liable. If the dosage is not changed after the primary healthcare provider is question, the nurse should contact the nurse manager. The nurse should follow hospital protocol and first notify the nurse manager

The chief nursing officer

Would not be suitable to take on the task due to other responsibilities within the role

New onset type 2 diabetes mellitus

Would require a lot of education The nurse would instruct the client and parents about blood glucose monitoring because of starting a new medication, metformin. The nurse would also educate the client and parents about the medication metformin and a diet and exercise program to lose weight as the client is obese with a BMI of 29.1. The nurse would also educate about the disease process and possible complications and to increase fluid intake to 2000ml per day

Bulimia Patient

You accompany them when they will like to use the restroom

Anything that is new for the clients

You notify the primary healthcare provider. The client should be monitored continually to prevent falling or injuring.

delrium tremens

You want to determine the timing the patient consumed the last alcohol intake Blood alcohol levels of 200-399 mg% are associated with nausea, vomiting, marked ataxia and hypothermia. Signs and Symptoms Tremors or shaking hands and feet. Chest pain. Confusion. Deep sleep that lasts for a day or longer. Dehydration. Excitability or anger.

Triage emergency department

You want to treat the client with a life-threatening illness first

Discharge instructions for a Cocaine/crack Addicted Client Referral For the mother and infant

You will provide a home health nurse. A nurse ,by going into home, will be able to monitor both the mother's and the infant's health, as well as the mother's parenting skills, and will be able to gather evidence of drug abuse or rehabilitation.

Ringworm

You will report to the healthcare provider if the client develops a fever which could indicate a secondary bacterial infection, probably from scratching That breaks the skin. Prudence normally occurs with a tinea infection ringworm. Joint pain or stiffness may be a complication of psoriasis. Ringworm presents a scaly skin patches with raised borders

Hypoparathyroidism

You would expect to report face and puffiness, extremity edema, and weight gain. Signs and symptoms of hyperthyroidism Graves' disease include in weight loss, nervousness, grease appetite, tremors, and they recommend enlargement(goiter)

When the umbilical cord has prolapsed

Your place the client in the trendelenburg position it may prevent further prolapse and should relieve pressure on the umbilical cord. The fetal heart rate will be taken later. Turn the client on her side will not relieve pressure on the umbilical cord, although it will promote placental perfusion. Covering the cord with a sterile saline salt cloth will not relieve pressure on the umbilical cord

Munchausen syndrome

a condition in which the "patient" repeatedly makes up clinically convincing simulations of disease for the purpose of gaining medical attention

Spina bifida

a congenital defect of the spine in which part of the spinal cord and its meninges are exposed through a gap in the backbone. It often causes paralysis of the lower limbs, and sometimes mental handicap. Preventing infection and trauma is The priority rupture of the sac may lead to meningitis. The Apgar score or nine and 10 at one in five minutes. The infant should be dried off after the sack has been protected. The child will placed on a radiant warmer bed and will not need to be swaddled. Placement of the name bracelets on both mother and infant may be done before the infinite leaves the birthing room. The infant sac must be protected before the infant is transferred to the neonatal intensive care unit.

ischemic stroke

a type of stroke that occurs when the flow of blood to the brain is blocked Symptoms develop within the previous three hours in a candidate for treatment with tissue plasminogen activator. TPA acts to dissolve the clots and clients have an excellent job chance for a full recovery.

Certificates of Need

approval for major new services and construction or renovation of hospitals or related facilities, as issued by states

Clients receiving TPN

are at risk for hypoglycemia and the nurse would determine that monitoring of blood glucose levels is necessary Is administered intravenously through a central line( not through a nasogastric tube).

Self advocacy for clients

the ability to speak up for yourself, and have your needs considered and met by those around you.

in order to assess the accuracy of the pulse oximeter reading what should the lpn do?

the lpn will compare the heart rate reading on the monitor to the infant's heart rate. If both rates match, the saturation level reading is accurate.

Apnea Monitor

vital signs documented from the newborn monitor and the temperature with a skin probe. Newborn vital signs Respiration rate 40 to 60 times per minute Heart rate/ Pulse Rate 120-160 Temperature Average is 98.6F Pulse Oximetry 95 to 100 percent Newborn Hgb 14-24 or 140-240 infant Hgb 9.5 to 13g/dl or 95 to 130g/dl Hct Newborn 45% to 61% Hct Infant 32% to 42%