Nclex Vocabulary

A client diagnosed with systemic lupus erythematosus (SLE) is concerned about skin lesions on the face and neck. The client asks the nurse, "What should I do about these spots?" Which of the following responses would be appropriate by the nurse?

"Apply moisturizer after bathing the lesions with warm water." The nurse should instruct the client to clean, dry, and moisturize the skin using warm (not hot) water, and unscented lotion (scented lotion may contain alcohol, which dries the skin).

A nurse has given a client instructions regarding postoperative care of a cerclage. The nurse knows the client understands the instructions when she states,

"I have to go to the hospital at the first sign of labor." The cerclage procedure reinforces the weakened cervix by the use of sutures that go around the cervix to try to hold it closed, just like the tie around a drawstring purse. The provider will need to remove the suture so the cervix can dilate.

A client reports urinary frequency at 8 weeks of gestation. The client asks the nurse how long this will last. Which of the following is an appropriate nursing response?

"The urinary frequency usually lessens by the end of the first trimester." The majority of clients report the urinary frequency lessens once the uterus becomes an abdominal organ. This usually occurs by the end of the first trimester or 12 weeks. However, it is likely that the client will again experience urinary frequency late in the third trimester due to increasing uterus size and pressure on the bladder when the fetus drops.

Myxedema

(Hypothyroidism) Deficiency of thyroid hormone; causes non-pitting edema or myxedema. Puffy, edematous face, coarse facial features, dry skin, and dry, coarse hair and eyebrows..decrease temp. DECREASE in all body functions.

mastectomy precautions

(eg, no blood pressure measurements, venipuncture, or IV lines)

Tension Pneumothorax

- A life-threatening collection of air within the pleural space; the volume and pressure have both collasped the involved lung and caused a shift of the mediastinal structures to the opposite side. -emergency large bore needle decompression followed by chest tube placement

hydrotherapy tub

- limit to 30min. -Water used in the hydrotherapy tubs is hypotonic. Prolonged periods of immersion increase the client's risk of sodium loss.

Ventricular tachycardia

- pulse or pulseless - pulse = stable or instability - signs of unstable w/ pulse = hypotension, altered mental status, signs of shock, chest pain, acute heart failure = treat synchronized cardioversion - treat stable VT w/ pulse = antiarrythmic meds = amiodarone, procainamide, sotalol - VT w/ pulseless = CPR and Defibrillation

Raynaud's disease

- vasoconstriction or arterioles in fingers and toes causing pain and reduced blood flow from excessive sympathetic stimulation -Clients with Raynaud's disease are prone to more frequent attacks during cold weather. Extreme cold can lead to tissue damage. Therefore, the client needs to be protected with layers of clothing.

Dosing for acute exacerbation of asthma using Albuterol?

-2 to 4 puffs every 20 mins x 3

Pavlik harness

-A Pavlik harness, the most common tool used in treating early Developmental dysplasia of the hip (DDH), maintains the infant's hips in a slightly flexed and abducted position, allowing for proper hip development. -Worn for about 3-5 months or until the hip joint is stable. The straps are adjusted periodically by the health care provider to account for infant growth. Instructions on care for the infant wearing a Pavlik harness are as follows: -Regularly assess skin for redness or breakdown under the straps -Dress the child in a shirt and knee socks under the harness to protect the skin -Avoid lotions and powders to prevent irritation and excess moisture -Lightly massage the skin under the straps every day to promote circulation -Only apply 1 diaper at a time as wearing ≥2 diapers (previous treatment practice) increases risk of incorrect hip placement -Apply diapers underneath the straps to keep harness clean and dry

Cushing's syndrome

-A metabolic disorder resulting from the chronic and excessive production of cortisol by the adrenal cortex or by the administration of glucocorticoids in large doses for several weeks or longer (exogenous or iatrogenic) -weight gain, facial hair, amenorrhea, frequent bruising and acne. affects women ages 20 to 40. causes changes in fat distribution, adipose tissue accumulates in the trunk, face (moonfaace) and dorsocervical areas (buffalo hump)

Positive end-expiratory pressure (PEEP)

-A method of holding the alveoli open by increasing expiratory pressure. Some bag-valve units used in EMS have PEEP attachments. Also EMS personnel sometimes transport patients who are on ventilators with PEEP attachments. -High PEEP is commonly used to prevent small airway/alveolar collapse in clients with ARDS. PEEP helps to reduce oxygen toxicity. However, high levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause barotrauma to the lung, resulting in a pneumothorax, and decreased venous return causes hypotension.

pharmacologic nuclear stress

-A pharmacologic nuclear stress test utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. -These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. -A radioactive dye is injected so that a special camera can produce images of the heart. -Based on these images, the health care provider (HCP) can visualize if there is adequate coronary perfusion.

neutropenic caution

-A private room -Strict handwashing -Avoiding exposure to people who are sick -Avoiding all fresh fruits, vegetables, and flowers -Ensuring that all equipment used with the client has been disinfected

Supraventricular tachycardia

-A regular, narrow QRS complex tachycardia with a rate of around 150-220/min. -The best treatment is vagal maneuvers and adenosine IV push. -For adenosine, place IV line as close as possible to the heart= push rapidly 1-2 seconds w/ 20mL flush= transient asystole is common = feeling flushing and dizziness

Addison's disease

-Bronze pigmentation of exposed and unexposed skin -Addison's disease is a hormone deficiency caused by damage to the outer layer of the adrenal gland (adrenal cortex). The disease is characterized by darkening of the skin in both exposed and unexposed parts of the body. -disease requires a diet high in salt, carbohydrates and protein, and low in potassium. American cheese provides protein and salt. Saltine crackers provide carbohydrates and salt.

allergy desensitization

-Desensitization injections work by stimulating a mild, local response to the allergen. These repeated exposures then build the client's immunity to the allergen, thereby preventing a more serious systemic reaction. Epinephrine would only be administered to treat a systemic reaction. -Each desensitization injection uses an increased amount of allergen so the client can build up an immunity to the allergen by learning to tolerate larger amounts. Occasionally, a client's dose has to be reduced temporarily on a subsequent visit if the client has a severe reaction to a higher dose. -After the desensitization injection is administered, observation for a minimum of 30 min is required to monitor the client for any manifestations of an anaphylactic reaction.

Kaposi's sarcoma (KS)

-Expect Reddish-purple skin lesions -Kaposi sarcoma causes lesions to grow in the skin, lymph nodes, internal organs, and mucous membranes lining the mouth, nose, and throat. It often affects people with immune deficiencies, such as HIV or AIDS. -Purple, red, or brown skin blotches are a common sign. Tumors also may develop in other areas of the body. Treatment may include radiation or chemotherapy. Rarely, surgery may be needed. -KS is commonly associated with AIDS and manifests as hyperpigmented multicentric lesions that can be firm, flat, raised, or nodular. Following biopsy, the lesions are treated with radiation and/or chemotherapy.

SIADH treatment includes:

-Fluid restriction to <1000 mL/day -Oral salt tablets to increase serum sodium (Option 3) -Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations -Vasopressin receptor antagonists (eg, conivaptan) -Strict fluid I/O -Monitor neuro status

Third-spacing

-Fluid that shifts into the interstitial spaces and remains there. Sites for third-spacing: abdomen, pleural cavity, peritoneal cavity, and pericardial sac. - Third-space fluid is useless because it does not circulate to provide nutrients for the cells. -Risk factors are liver or kidney disease, diabetes, trauma, burns, sepsis, wound healing, major surgery, malabsorption syndrome, malnutrition, alcoholism and elderly -Third-spacing can lead to hypovolemia, decreased cardiac output, hypotension and tachycardia, and decreased urine output. -Monitoring vital signs and urine output, and maintaining IV fluids are appropriate interventions to prevent prerenal failure and hypovolemic shock.

Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes the following:

-IV antibiotic therapy - to cover the gram-negative and anaerobic organisms that reside in the colon and contribute to diverticulitis; these commonly include metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or Bactrim DS; Septra) or ciprofloxacin (Cipro) -NPO status - more acute cases require complete rest of the bowel (NPO status); less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet -NG suction - in severe cases of abdominal distention, nausea, or vomiting -IV fluids - prevent dehydration -Bed rest ****NO barium enema= increase peristalisis = perforation/rupture

Opioid agonist-antagonist medications commonly used in labor

-Opioid agonist-antagonist medications commonly used in labor are butorphanol tartrate and nalbuphine hydrochloride. -These medications can precipitate withdrawal in opioid-dependent clients and should not be used. -They are used in the active phase of stage 1 labor when labor contractions are well established (2-4 mins apart) and the cervix is dilated to at least 4 cm.

normal sinus rhythm

-P waves occurring at 0.16 seconds before each QRS complex 60-100 beats min

Characteristic manifestations of OA of the knee joint include:

-Pain, often described as aching, exacerbated by weight-bearing activities—results from synovial inflammation, muscle spasm, and nerve irritation -Crepitus, a grating noise or sensation with movement that can be heard or palpated—results from the presence of bone and cartilage fragments that float in the joint space -Morning stiffness that subsides within about 30 minutes of arising -Decreased joint mobility and range of motion -Atrophy of the muscles that support the joint (eg, quadriceps, hamstring)—due to disuse -noninflammatory = no temperature

acute pancreatitis

-Pancreatitis is the most common reason for marked elevations in serum amylase. -Serum amylase begins to increase about 3 to 6 hr following onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to normal in 2 to 3 days. -Lipase levels in pancreatitis increase after a rise in serum amylase and stay elevated for up to 14 days longer than amylase.

Peritonitis

-Peritonitis is a common but serious complication of peritoneal dialysis. -Manifestations include cloudy effluent, fever, abdominal pain, and rebound tenderness. Treatment is based on culture of the peritoneal fluid.

Pheochromocytoma

-Pheochromocytoma is a tumor of the adrenal gland that causes excess release of the catecholamines epinephrine and norepinephrine, hormones that regulate blood pressure and heart rate. A laboratory test used for diagnosis includes a urine test for VMA which measures the level of catecholamine metabolites in a 24-hr urine sample. -Vanillylmandelic acid (VMA)

Guillain-Barré syndrome.

-Respiratory distress is a potential complication of progressing paralysis in clients with Guillain-Barré syndrome. -The nurse should prioritize and monitor for the presence of this complication. Measurement of serial spirometry (FVC) is the gold standard for assessing ventilation.

SIADH

-SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). -Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions.

Pressure ulcers

-Skin assessment, proper skin care, repositioning every 2 hours, adequate nutrition, and proper support surfaces are effective in helping prevent pressure ulcers. -Massage over the bony prominences is not recommended for pressure ulcer prevention.

Depth of burn injury

-Superficial - damage to epidermis -Superficial partial thickness - damage to the entire epidermis and some parts of the dermis -Deep partial thickness - damage to entire epidermis and deep into the dermis -Full thickness - damage to the entire epidermis and dermis, and may extend into the subcutaneous tissue. Nerve damage also occurs. -Deep full thickness - damage to all layers of skin and extends to muscle, tendons and bones

Pulses

-The nurse should palpate and compare the characteristic and quality of the pulses on the right and left extremities simultaneously to determine symmetry. -The force of the pulse should be rated as 0, absent; 1+, weak; 2+, normal; and 3+, increased, full, bounding. These descriptions should be documented in the client's record.

toxic megacolon

-Toxic megacolon is a common, life-threatening complication of inflammatory bowel disease. -Clients present with abdominal pain/distension, bloody diarrhea, fever, and signs of shock (eg, hypotension, tachycardia).

Pregnant client who is HIV positive

-Transmission of HIV infection from mother to baby can occur during antepartum, intrapartum, or postpartum periods. -Maternal antiretroviral therapy (ART) during pregnancy is imperative for decreasing the risk of perinatal transmission. Pregnant clients who are HIV positive should receive recommended inactivated vaccines. -Newborns born to HIV-positive clients should not breastfeed and should receive 4-6 weeks of ART after birth.

tracheostomy suctioning

-Use strict sterile technique throughout suctioning process. -Pre-oxygenate with 100% oxygen (hyperoxygenation) for 3-4 breaths. -Aspirate during withdrawal of catheter only, limiting each suction pass to 10 seconds. -Allow client 4-5 recovery breaths between suction passes to replenish oxygen.

Supine hypotensive syndrome

-Usually seen in the third trimester of pregnancy when the weight of the uterine contents compresses the inferior vena cava. -Best treated initially by turning the client to the right or left side to relieve pressure on the vena cava.

Uterine contractions

-Uterine contractions duration should not exceed 90 seconds or occur less than 2 minutes apart. -Excess resting tone, contraction duration, and frequency result in uteroplacental insufficiency.

adenoma

-a benign tumor that arises in, or resembles, glandular tissue -tumor of gland -most common cause of hypopituitarism -most common cause of primary hyperparathyroidism

electroencephalogram (EEG)

-a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. -The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parent includes the following: -Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. -Hair may need to be washed after the procedure to remove electrode gel. -Avoid caffeine, stimulants, and central nervous system depressants prior to the test. -The test is not painful, and no analgesia is required.

ventricular tachycardia

-a very rapid hearbeat that begins within the ventricles -Example =An irregular ventricular rate of 125, with a wide QRS pattern

Amenorrhea

-an abnormal absence of menstruation. -Amenorrhea is a presumptive sign of pregnancy.

Nephrotic syndrome?

-an autoimmune disease, affects children age 2-7 and is characterized by increased permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). -Loss of albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces. -Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (renin-angiontensin-aldosterone system). -Clients will have generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output. Loss of immunoglobulins makes children susceptible to infection. Treatment typically includes:

Management for lymphedema includes

-decongestive massage therapy -compression bandages or sleeves -elevation of the arm above heart level -isometric exercises -avoidance of venipuncture or blood pressure measurements on the affected limb.

dysphagia

-difficulty swallowing or eating -risk for aspiration and aspiration pneumonia. -Dietary modifications and swallowing rehabilitation measures can reduce the risk of aspiration in clients who can tolerate oral feedings. Specific techniques include the following: 1.Modification of food consistency (pureed, mechanically altered, soft) 2.Thickened liquids 3.Having the client sit upright at a 90-degree angle 4.Placing food on the stronger side of the mouth to aid in bolus formation 5.Tilting the neck slightly to assist with laryngeal elevation and closure of the epiglottis

exophthalmos

-hyperthyroidism/ grave's disease -an abnormal protrusion of the eyeball out of the orbit

What are albuterol common expected side effects?

-insomnia -nausea and vomiting -palpitations (tachy) -mild tremors *** no constipation, allergic reaction ***

Immune thrombocytopenic purpura (ITP)

-is an autoimmune condition in which clients have abnormal platelet destruction with a count <150,000/mm3 (150 x 109/L). -ITP is associated with an increased risk of bleeding. A common manifestation of ITP includes petechiae, which are pinpoint flat, red or brown microhemorrhages under the skin caused by leakage of red blood cells. *****Petechiae are an expected finding.

premature ventricular contractions.

-on EKG there is an early wide QRS complex with no associated P wave. after that beat there is a slight pause and then a normal rhythm continues. -Example = Ventricular rate of 82 with an atrial rate of 80

acute pancreatitis

-severe pain in upper left quadrant or midepigastric abdomen = radiates to back -pain improves leaning forward -pain increase lying down and high fat meal -nausea and vomiting due to severe pain

Separation anxiety

-starts around age 6 months -peaks at age 10-18 months, and can last until age 3 years. -separation anxiety is normal and resolves by age 3 years.

Functional disorders

-undiagnosable medical issues and should not be confused with psychosomatic illness, attention-seeking behavior, or malingering.

The normal serum creatinine for an adult

0.6 -1.3 mg/dL (53-115 mmol/L). Serum creatinine provides an estimation of the glomerular filtration rate and is an indicator of kidney function.

To perform postmortem care:

1) Maintain standard or isolation precautions in place at the time of death. 2) Gently close the client's eyes. 3) Remove tubes and dressings per policy, unless an autopsy or organ harvest is pending (Option 4). 4) Straighten and wash the body and change the linens. 5)Handle the body carefully, as tissue damage and bruising occur easily after circulation has ceased. 6)Replace dentures so the face maintains its shape. It is difficult to place dentures once rigor mortis sets in (Option 7)A towel folded under the chin may be needed to keep the jaw closed. 8)Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters (Option 3). 9)Raise the head of the bed to prevent blood from pooling and discoloring the face. 10)Remove equipment and soiled linens from the room. 11) Give client belongings to a family member or send with the body.

acute respiratory distress interventions

1. Place in high Fowler's position - quickly maximizes ability to expand lungs, promotes oxygenation, and helps to decrease risk of further aspiration 2. Perform oropharyngeal suctioning - the priority is clearing the airway after the client has been placed in a position that prevents further aspiration 3. Administer 100% oxygen by nonrebreather mask - corrects hypoxemia/hypoxia once the airway has been cleared to allow passage of oxygen. The nurse has already gathered focused assessment data and determined the need for emergent oxygen delivery (eg, tachycardia, tachypnea, hypoxia, cyanosis, decreased level of consciousness). 4. Assess lung sounds - determines air movement and presence of adventitious sounds (eg, crackles, wheezing, stridor) that can indicate obstruction, secretions, atelectasis, or fluid. This assessment is performed once emergency measures are in place (eg, oxygen) and the client has been stabilized. 5. Notify the primary HCP - to report the situation and assessment data

The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline):

1. Take on an empty stomach - for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals 2. Avoid antacids or dairy products - tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption 3. Take with a full glass of water - tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion 4. Photosensitivity - severe sunburn can occur with tetracycline. The client should use sunblock

activities that may increase intraocular pressure - cataract surgery

1. bending (eg, vacuuming floors, playing golf) 2. lifting more than 5 lb, sneezing 3. coughing 4. rubbing or placing pressure on the eye 5. straining during a bowel movement. (constipation)

Low CD4 counts are defined as

1. less than 750/mm3 for infants 12 months or younger 2. less than 500/mm3 for children between age 1-5 years 3. less than 200/mm3 for children age >5 years and adults.

Drugs commonly associated with orthostatic hypotension include:

1.Most antihypertensive medications, particularly sympathetic blockers such as beta blockers (eg, metoprolol) and alpha blockers (eg, terazosin) 2. Antipsychotic medications (eg, olanzapine, risperidone) and antidepressants (eg, selective serotonin reuptake inhibitors) 3. Volume-depleting medications such as diuretics (eg, furosemide, hydrochlorothiazide) 4. Vasodilator medications (eg, nitroglycerine, hydralazine) 5. Narcotics (eg, morphine)

What is the therapeutic level of magnesium?

4-7 mEq/L

gram to mL

= 1 g = 1 mL

Central venous catheter CVC

= 10 mL syringe

Uterine hyperstimulation

= 5 contractions in 10 mins/ 20 mmHg resting tone = If FHR is reassuring then placed/maintain side lying position and a bolus of IV fluid is given = If FHR is non reassuring.......... 1. Stop oxytocin immediately - this will stop uterine stimulation and should be the nurse's first action 2. Reposition or maintain the side-lying position - this is a simple and effective measure to decrease aortocaval compression and increase placental blood flow 3. Apply oxygen at 10 L/min via face mask - only if steps 1 and 2 do not reduce abnormalities. Administering oxygen will be more helpful if there is adequate placental perfusion of the oxygenated blood. Maternal repositioning should therefore be performed before oxygen administration. 4. Give IV fluid bolus 5. Consider giving terbutaline subcutaneously per unit protocol or standing prescriptions 6. Notify the health care provider 7. Document the findings

ACE inhibitors

= ACTION: prevent the conversion of angiotensin I to angiotensin II in the lungs USES: CHF, HTN , usually end in PRIL = side effect hyperkalemia = no salt substitutes, bananas, oranges, processes meats, cheese, frozen meals

Streptomycin = aminoglycoside antibiotic

= Difficulty hearing (tinnitus, subjective hearing loss)

Mantoux skin test using purified protein derivative (PPD)

= Identify clients who have been infected with mycobacterium tuberculosis.

somnolence/decrease level of conscious

= NPO status = prevent aspiration

Pneumocystis carinii pneumonia (PCP)

= The organism that causes PCP exists as part of the normal flora of the lungs. It becomes an aggressive pathogen when the immune system is compromised; the infection results from an impaired immune system.

Indications of a mole's potential malignancy

= Ulceration, bleeding, or exudation

Eosinophils

= allergy indicator = normal range = 1-2%

Terazosin

= alpha adrenergic blocker = treat benign prostatic hyperplasia (BPH) = relaxes smooth muscles in the bladder = causes orthostatic hypotension, syncope, falls = instruct client to take at bedtime

Benzodiazepines (eg, alprazolam [Xanax], lorazepam [Ativan], clonazepam, diazepam)

= are commonly used antianxiety drugs. = may cause sedation, which can interfere with daytime activities =Giving the dose at bedtime will help the client sleep.

Administer morphine

= assess in 30 mins

Cardiac catheter

= assessment q15 mins = report back or flank pains = retroperitoneal bleeding

Clients with acute pancreatitis

= at high risk for developing acute respiratory distress syndrome = inspiratory crackles

Client with chronic kidney injury

= below normal range hematocrit and hemogloblin

Following a prostatectomy,

= bleeding is a potential complication that requires a thorough assessment. -Any bleeding, passage of clots, decrease in urinary stream, urinary retention, or symptoms of urinary tract infection should be reported to the HCP. ***Do not bear down (Valsalva maneuver) = increase venous presssure = hematuria

PIV catheter sites

= change 72-96 hours

Narcan

= check respiratory status = 60

Thrombolytic agents (eg, alteplase, tenecteplase, reteplase)

= contraindicated in clients with............ - active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg). . -Administering alteplase in the presence of these conditions can cause hemorrhage, including life-threatening intracerebral hemorrhage

Erythropoietin

= contraindicated with hypertension

What is first priority in a client with AFIB

= control ventricular rate (goal = less than 100/min) with calcium channel blockers (diltiazem, metoprolol) or digoxin

Assessing well child

= correct order is auscultation, palpation and percussion in a head-to-toe direction, traumatic procedures, and elicitation of Moro reflex.

pancrelipase

= digestive enzymes

Enoxaparin

= do not rub after injection = do not expel air bubble

COPD exacerbation

= do not use morphine, benzodiapines = depress respiratory = worsen Co2 retention

meningococcal meningitis

= droplet precaution= continue for 24 hr after antibiotics = nurse wears mask = patient wears mask only on transportation = minimize stimuli

Trisomy 13 & 18

= early deaths in neonates

adenotonsillectomy

= expected ear pain

Grossly swollen upper thigh

= fractured femur w/ extensive bleeding

Phenytoin (Dilantin) side effects

= gingival hyperplasia, body hair, rash, folic acid depletion and decrease bone density (osteoporosis) = need for good oral care and dentist regularly

Positive TB test

= greater than 15mm

Somatotropin

= growth hormone = acromegaly

Bacterial conjunctivitis (pink eye)

= highly contagious

O2 SAT less than 90%

= hypoxemia

Complications of thoracentesis include

= iatrogenic pneumothorax = hemothorax = infection. Post-procedure, the nurse assesses for = pain and difficulty breathing = monitors vital signs and oxygen saturation = observes for changes in respiratory rate and depth = symmetry of chest expansion, and breath sounds.

glaucoma

= increase intraocular pressure = eye redness

No licorice roots with non potassium sparing diurectics

= increase potassium loss = hypokalemia = report to HCP

Developmental dysplasia of the hip (DDH)

= instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. =Nonsurgical treatment methods = harness or cast, are most successful when initiated during the first 6 months of life. After this time, surgery is frequently required.

Polycythemia vera (true primary polycythemia)

= is a chronic myeloproliferative disease characterized by bone marrow overproduction of red blood cells, white blood cells, and platelets. = increased hematocrit (>53% [0.53]) and blood volume, enhanced blood viscosity, and abnormal clotting. *****A hematocrit of 66% (0.66) is an expected finding.

metformin side effects

= lactic acidosis, metallic taste in mouth

FLU infection

= last 1 week

Assess cerebellar functions

= maintenance of balance and posture ( watching normal gait then heel to toe gait (tandem) = cordination (finger tapping, rapid alternative movements, finger to nose, heel to shin

Tension pneumothorax

= mediastinal structures (tracheal deviation), including the heart and great vessels, resulting in reduced cardiac output and hypotension. -This is a life-threatening emergency. -The client should have emergency large-bore needle decompression, followed by chest tube placement, to relieve the compression on the mediastinal structures.

Immunizations w/ infants

= mild soreness and redness at injection site is common = notify provider when temp is higher than 100.4 = fussiness and anorexia should not last more than 24hrs = should not restrict activity of child

Trazodone

= modulates serotonin levels in the brain. = it blocks alpha and H1 receptors, leading to orthostatic hypotension and sedation, respectively. = Priapism (erection lasting several hours) is another serious side effect, though rare.

Blood drainage amount

= more than 250 mL in first 8 hours = excessive = check

rheumatoid arthritis

= morning stiffness of 60 mins = serum rheumatoid factor present

major adverse effects of statin drugs (atorvastatin)

= muscle cramps , liver injury

Grapefruit juice

= no calcium channel blockers or sildenafil

COPD

= no codiene

pertussis

= no cough suppressants

Corticosteroids use

= no eye exposure to ultraviolet lights = cataracts

Delegating UAP

= no sterile dressing changes or perform drain care

Vegans

= no vit-B12 = risk for megaloblastic anemia

impetigo

= not contagious after 24hr of antibiotics

Potassium infusion

= not exceed 10 mEq/hr

Transmission of Hep B

= not urine

varacity

= nurse's duty to tell the truth

Appendicitis pain

= periumbilical pain progressing to right lower quadrant

hallmark sign of fat emboli

= petechiae (pin-sized red/purple spots) that result from small-vessel clotting and appear across the chest, in the axillae, and in the soft palate.

antipsychotic / antidepressants

= photosensitivity

New onset of dependent edema

= potential HF

A client with polycythemia vera will require periodic therapeutic phlebotomy treatments to reduce the RBC count and risk of blood clotting associated with the increased blood viscosity that occurs with this disorder.

= potential blood clots

mitral valve regurgitation with fatique

= potential heart failure

TPN

= potential hyperglycemia

thyroidectomy

= potential hypocalcemia ( less than 8.6 mg/dL) = monitor signs tetany (tingling of hands, toes, and circumoral region; positive Trousseau or Chvostek sign) -confirm with serum calcium results, and administer calcium gluconate as prescribed. ******Untreated clients can develop life-threatening laryngeal spasm.

Babinski reflex

= present with children 1-2 years

epiglotitisis

= preventable with vaccinations = The majority of cases of epiglottitis are caused by Haemophilus influenza type B (HiB), which is covered under the standard vaccinations given during the 2- and 4-month visits. =Epiglottitis is rarely seen in vaccinated children.

Cardiac catetherization

= quiet activities for 24 hours

Ectopic pregnancy

= referred shoulder pain

Post OP clients with nausea

= risk for aspiration = placed on side = receive antimetics

Mother with gestational diabetes

= risk for neonate hypoglycemia

Abdominal surgery w/ vomiting and dry heaving

= risk for wound dehiscence evisceration

frail chest = multiple rib fractures

= see saw chest movement

Duloxetine (Cymbalta)

= serotonin-norepinephrine reuptake inhibitor = also treats chronic pain in Fibromyalgia (FM)

Kidney stone pain

= severe pain in flank, back, or lower abdomen = radiating to groin

Scabies

= spread easily via direct skin-to-skin contact. = all who have been in contact with the infested child must be treated. = one-time application of a scabicide (typically 1% topical permethrin). =The child's bedding and clothing should be placed in plastic bags (for a minimum of 3 days) or washed in hot water and dried on the hottest dryer cycle.

HIV + lung infection

= standard precaution

Cystic fibrosis (CF)

= sudden drop in O2 SAT is nurse priority

butterfly rash

= systemic lupus erythematosus

Acid-suppressing meds (proton pump inhibitors, H2 blockers)

= take 30 mins before meals

Levothyroxine

= take on empty stomach in the morning

NSAIDS

= take with food

heparin

= taken IV or subcutaneous = measured by aPTT (1.5-2 times normal range = 20-45 secs Max 112 secs) = antidote = protamine sulfate

warfarin (Coumadin)

= taken orally = measured by INR (1.5-2 times normal range = 10-14 secs) =

Hypothermia

= temp less than 95 degrees

Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers

= teratogenic

Heparin infusion for DVT

= therapeutic range of 46-70 secs

antipsychotic medications / metoclopramine w/ extrapyramidal side affects

= treat with Benztropine (Cogentin)

Phenytoin (Dilantin)

= use to treat generalized tonic-clonic seizures = therapeutic levels = 10-20 mcg/mL = signs of toxicity = central nervous system = ataxia, nystagmus, slurred speech, decreased mentation

Safe for using with PT with latex allergy

= vinyl gloves = mylar balloons = silicone catheters

Addison disease

= vitiligo = blotchy skin

systemic lupus erythematosus (SLE) nursing discharge teaching

="Monitor your body temperature and report any elevations promptly." SLE is a chronic autoimmune disorder that can affect virtually any organ of the body. With SLE, the body's immune system becomes hyperactive, forming antibodies that attack normal tissues and organs, including the skin, joints, kidneys, brain, heart, lungs, and blood. SLE is characterized by periods of exacerbation and remissions. The nurse should teach the client to monitor body temperature and report any elevations promptly as fever could suggest either exacerbation or a potentially life-threatening infection.

Rocky Mountain Spotted Fever

=A diffuse maculopapular rash

Common early manifestations of Lyme disease

=A progressive, circular rash Early Lyme disease is characterized by fever, influenza-like manifestations, and erythema migrans, a distinct progressive circular (or bulls-eye) rash that develops often at the bite site, and also at other sites such as the thighs and knees. Late symptoms = double vision, arthritis (stiff, swollen, painful joints)

A nurse caring for a client who is HIV-positive is teaching the client about the earliest manifestations of acquired immune deficiency syndrome (AIDS). The nurse explains that they include which of the following?

=Persistent fever, swollen glands, diarrhea, weight loss, and fatigue

Which of the following findings should alert the nurse to the possibility that a client who is 2 days postoperative is developing an infection?

=Redness (erythema) at the incision site is an initial sign of a wound infection. Note: A minor temperature elevation (100.2) in a postoperative client is expected due to the inflammatory process.

Herpes zoster. The nurse examines the client's skin for which of the following?

=Unilateral, localized, nodular skin lesions Herpes zoster (shingles) results from the reactivation of a dormant varicella virus. It is the acute, unilateral inflammation of the dorsal root ganglion. The infection typically develops in adults and produces localized vesicular lesions confined to a dermatome. It produces unilateral, localized, nodular skin lesions.

immune deficiency syndrome (AIDS)

=clean bodily fluid with bleach and wear gloves

Iron deficiency anemia

=most common nutritional disorder in children. -Risk factors include premature birth, cow's milk before age 1 year, and excessive milk intake in toddlers. -Prevention and treatment are achieved through proper nutrition (eg, meat, leafy green vegetables, fortified cereal) and supplementation.

Transient abnormal PMI (point of maximal impulse)

??

percutaneous transluminal coronary angioplasty (PTCA)

A PTCA dilates an obstructed coronary artery. A catheter with an inflatable balloon tip is inserted into the obstructed coronary artery. The balloon is inflated, compressing atherosclerotic plaque against the coronary artery wall, resulting in dilation of the artery.

Cleft Palate

A child with a cleft palate (CP) is at risk for aspiration and inadequate nutrition due to eating and feeding difficulties. This is due to the infant's inability to create suction and pull milk or formula from the nipple. Until CP can be repaired, the following feeding strategies increase oral intake and decrease aspiration risk: Hold the infant in an upright position, which promotes passage of formula into the stomach and decreases the risk of aspiration (Option 3). Tilt the bottle so that the nipple is always filled with formula. Point down and away from the cleft. Use special bottles and nipples, including cross-cut and preemie nipples and assisted delivery bottles. These devices allow formula to flow more freely, decreasing the need for the infant to create suction. Using a squeezable bottle allows the caregiver to apply pressure in rhythm with the infant's own sucking and swallowing (Option 5). These infants swallow large amounts of air during feeding and so need to be burped more often to avoid stomach distension and regurgitation (Option 2). Feeding slowly over 20-30 minutes reduces the risk of aspiration and promotes adequate intake of formula. Feeding every 3-4 hours; more frequent feedings may be tiring for the infant and the mother. Some infants may need to be fed more frequently if they are not consuming adequate amounts of formula.

placentae previa

A condition in which the placenta is formed in an abnormal location (low in the uterus and close to or over the cervical opening) that will not allow for a normal delivery of the fetus; a cause of excessive prebirth bleeding.

deep partial-thickness burn

A deep partial-thickness burn occurs when the first layer of skin, the epidermis, is burned all the way through, and some level of burning occurs in the underlying layer of skin, called the dermis. A deep partial-thickness burn can cause permanent scars, much like a full-thickness burn. Exposure to sun of the newly formed and healing skin in the year following a burn injury can cause more intense scarring.

mitral stenosis

A defect in the mitral valve will cause a backup of blood in the pulmonary vein, which returns oxygenated blood to the left atrium. This backup of blood leads to engorgement of the capillaries of the lung field and to an accumulation of fluid in the lungs.

A nurse is preparing a community education program about hepatitis B. Which of the following statements should be included in the nurse's discussion?

A hepatitis B immunization is given to infants and children. Hepatitis B immune globulin is given as part of the standard childhood immunizations. It may be administered as early as birth, especially in infants born to hepatitis B surface antigen (HBsAg)-negative mothers. The infants should then receive the second dose between 1 and 4 months of age.

macule

A macule is flat, variably shaped, discolored, and small, typically smaller than 10 mm in diameter. A macule is basically a change in the color of the skin. Freckles and the rash associated with fifth's disease are types of macules.

Memantine

A medication used in the treatment of moderate to severe Alzheimer disease (AD). It slows the progression of AD symptoms, and improvement may be seen in the client's behavior, cognitive functioning, and ability to perform activities of daily living. Clients with moderate to severe AD may experience improvement in: Cognition - memory, thinking, language Daily functioning - dressing, bathing, grooming, eating Behavioral problems - agitation, depression, hallucinations

Infant

A normal blood glucose range for an infant is 40-60 mg/dL (2.2-3.3 mmol/L) within the first 24 hours after delivery. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. A normal respiratory rate for an infant is 30-60/min. It is normal to auscultate crackles in an infant during the first hour of life. A normal temperature range for an infant is 97.7-99.7 F (36.5-37.6 C).

papule

A papule is a small, solid, elevated lesion with distinct borders. It is usually smaller than 10 mm in diameter. Papules are common lesions of acne, and warts can also be papules.

ectopic pregnancy

A pregnancy in which the fertilized ovum implants in a tissue other than the uterus, most commonly in the fallopian tubes

Trousseau's Sign

A sign of latent TETANY. A SPHYGMOMANOMETER cuff is applied to the upper arm and inflated. Within 4 minutes the forearm muscles go into spasm.

Meconium-stained amniotic fluid places the newborn at risk for meconium aspiration syndrome.

A skilled neonatal resuscitation team should be present at birth for immediate newborn evaluation and stabilization.

Transjugular intrahepatic portosystemic shunt

A transjugular intrahepatic portosystemic shunt is a surgical procedure used to treat esophageal varices through placement of a stent into the portal vein. The stent serves as a shunt between the portal circulation and the hepatic vein, thereby reducing portal hypertension.

vesicle

A vesicle is a circumscribed, elevated lesion containing serous fluid. Vesicles typically arise with herpes simplex, poison ivy, and chickenpox.

This postoperative client is at greatest risk due to the presence of the following 4 risk factors:

Abdominal cesarean section surgery (endothelial damage) Engorged pelvic vessels from pregnancy (venous stasis, hypercoagulability of blood) Inactivity/immobility ≥6 hours related to positioning during surgery and the immediate postoperative period and epidural anesthesia (venous stasis) Postpartum state (hypercoagulability of blood)

leukopenia

Abnormally low WBC count

hyperkalemia

Administration of IV 50% dextrose and regular insulin rapidly corrects an elevated serum potassium level by shifting potassium intracellularly. If the client has ECG changes from hyperkalemia, calcium gluconate should be given first to stabilize cardiac muscle.

Methotrexate (Rheumatrex) is a nonbiologic disease-modifying antirheumatic drug (DMARD) prescribed to treat RA.

Adverse effects associated with this medication include bone marrow suppression, hepatotoxicity, and gastrointestinal irritation (eg, nausea, vomiting, diarrhea). Nausea and vomiting are the most common side effects (25%-60%) associated with methotrexate. Stomatitis (inflammation of the mouth, oral ulcers) is a common side effect associated with methotrexate. It can be prevented with folic acid supplementation. Bone marrow suppression can lead to anemia, leukopenia, and thrombocytopenia. Anemia manifests as fatigue, dyspnea on exertion, and pallor. Leukopenia increases the risk for infection. Thrombocytopenia presents as petechiae, purpura, or bleeding. Petechiae are small, purplish hemorrhagic skin spots that occur when the platelet count is <150,000/mm3(Option 3). Bone marrow suppression is managed with dose reduction or discontinuation of the medication.

Calcium channel blockers are utilized to treat hypertension and chronic stable angina.

Adverse effects of these medications include dizziness, flushing, headache, peripheral edema, and constipation.

Tooth eruption is variable, but it starts with the lower central incisors usually between age 6-10 months.

Age of child (in months) - 6 = Expected number of teeth A 12-month-old should have approximately 6 teeth, and by age 30 months all primary teeth (20) should have erupted.

If acute otitis media (AOM) symptoms do not improve within 48-72 hours of starting antibiotics, a follow-up visit is required to determine if a different antibiotic is necessary.

Amoxicillin = diarrhea = expected side affect Fever + abdominal pain + diarrhea = C-Diff = call HCP

Gastric Bypass

An RYGB (anastomosis of a small gastric pouch to the Roux limb of the small intestine) has several potential complications, including dumping syndrome, iron deficiency anemia, and cobalamin deficiency. To prevent dumping syndrome, the client should consume small meals, eat a low-carbohydrate diet, and consume food and fluids 30 minutes apart.

S3 heart sound

An S3 sound can be an expected finding in young adults. However, a new S3 sound in older adults should be evaluated as it may be the first sign of heart failure or volume overload.

autopsy

An autopsy is often performed when a client dies by suicide, homicide, accident, or within 24 hours of admission to a health care facility. Consent from the family is not required. ********During postmortem care, all tubes and IV lines should be left in place.

24 hours after childbirth

An elevated WBC count and temperature are expected findings during the first 24 hours after childbirth. It is important to ambulate the client soon after childbirth, if possible. Otherwise, the client is at higher risk for DVT.

Angiomas

Angiomas (birthmarks) are benign vascular tumors involving the skin and the subcutaneous tissues. They can be flat, violet-red patches (port-wine angiomas) or raised, bright red, nodular lesions (strawberry angiomas).

immunogloblulin

Antibodies that bind with specific antigens in the antigen-antibody response.

The nurse should teach a client receiving a clonidine patch to:

Apply patch to a dry hairless area on the upper arm or chest **** Do not shave**** Wash hands before and after application Rotate sites with each new patch application Discard patch away from children or pets with sticky sides folded together Never wear more than 1 patch at a time Never stop using the patch abruptly

Arteriosclerosis obliterans

Arteriosclerosis obliterans is a disease of the blood vessels characterized by narrowing of the arteries in the legs and feet. This causes a decrease in blood flow to the distal extremities which can lead to tissue damage. Common symptoms are intermittent claudication (leg pain with exercise), cold or numb feet at rest, loss of hair on the lower legs, and weakened pulses.

RAI is the primary form of treatment for individuals with hyperthyroidism. It destroys or damages the thyroid gland (or a part of it). RAI has a delayed response and may take up to 3 months to have a maximum effect. For this reason, other medications should be maintained to lower thyroid hormone synthesis and treat symptoms of hyperthyroidism until RAI begins to have maximum effect Depending on dosage, clients who receive RAI should be taught to use the following precautions for up to 1 week:

Avoid close proximity to pregnant women or children Do not breastfeed as RAI may be excreted through breast milk and could harm the infant Do not share utensils with others or use bare hands to handle food that is to be served to others Isolate personal laundry (eg, bed linens, towels, daily clothes) and wash it separately Use a separate toilet from the rest of the family and flush 2-3 times after each use Wash hands frequently and thoroughly, especially after restroom use Drink plenty of fluids Sleep in a separate bed from others and do not sit near others in an enclosed area for a prolonged period of time (eg, train or flight travel)

Basal cell carcinomas

Basal cell carcinomas are the most common type of skin cancer and rarely metastasize. They arise from the basal cell layer of the epidermis or the hair follicles and generally appear on sun-exposed areas of the body.

A client with bipolar disorder, manic episode, is at risk for under-nutrition and dehydration due to high energy needs secondary to psychomotor agitation.

Because most clients with mania are unable to sit down long enough to consume a meal, foods and fluids that are easily consumed "on the run" must be provided.

Benztropine (Cogentin)

Benztropine (Cogentin) is an anticholinergic drug used to treat extrapyramidal symptoms, which are side effects of some antipsychotic medications.

Biological dressings

Biological dressings are temporary grafts used during the acute phase to increase the rate of epithelialization, act as a barrier to protect the wound from contamination, and reduce fluid and protein loss.

Cognitive Behavior Therapy

CBT involves 5 basic components: 1. Education about the client's specific disorder 2. Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity 3. Physical control strategies - deep breathing and muscle relaxation exercises 4. Cognitive restructuring - learning new ways to reframe thinking patterns, challenging negative thoughts 5. Behavioral strategies - focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events

Chadwick's sign

Chadwick's sign is a bluish discoloration in the cervix, vagina, and vulva and is associated with pregnancy. After a first pregnancy, this discoloration may remain, making it of little value in subsequent pregnancies. Therefore, this is considered a probable sign.

Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and sepsis.

Changes in vital signs (eg, decreased systolic pressure, tachycardia, tachypnea) and cool, pale skin can indicate decreased cardiac output and altered tissue perfusion.

Priority interventions for active or suspected air embolism are as follows:

Clamp the catheter to prevent more air from embolizing into the venous circulation. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium. Administer oxygen if necessary to relieve dyspnea. Notify the HCP or call an RRT to provide further resuscitation measures. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.

The pursed-lip breathing technique helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease.

Clients are taught to relax the shoulders and neck, inhale though the nose for 2 seconds with the mouth closed, and exhale through pursed lips for 4 seconds (or twice as long as inhalation).

The placenta is normally expelled from the uterus within 30 minutes of delivery. The most morbid cause of a retained placenta is placenta accreta, a condition of abnormal placentation that involves implantation in the myometrium (normal implantation is in the endometrium). A placenta accreta adheres very strongly to the myometrium, and attempted separation results in life-threatening hemorrhage.

Clients at risk for life-threatening hemorrhage should have a type and crossmatch and 2 large-bore patent IV sites for rapid resuscitation.

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear.

Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks).

RA

Clients with RA are taught symptom management techniques and lifestyle modifications to protect joints by preventing contracture with range of motion exercises, allowing for periods of rest, and using moist heat for stiffness and cold packs for joint pain.

The newborn with a myelomeningocele is at risk for infection.

Covering the myelomeningocele with a sterile, moist dressing is indicated to decrease the risk of infection at the site. The infant should be placed on the abdomen (prone) with the face turned to the side.

Pneumonia is an acute infection of the lungs. Findings in a client with pneumonia include:

Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus Fever, chills, productive cough, dyspnea, and pleuritic chest pain Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be an early sign of pneumonia. Unequal chest expansion - Decreased expansion of affected lung on palpation Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia)

Cryosurgery

Cryosurgery is a treatment method used for squamous cell or basal cell carcinomas. Cryosurgery destroys the tumor by deep-freezing it with liquid nitrogen. Malignant melanomas are often too deep (and widespread) for this therapy to be effective.

Pancytopenia

Deficiency of all blood cells = aplastic anemia

lithium toxicity.

Dehydration, decreased renal function, diet low in sodium, and drug-drug interactions (eg, NSAIDs and thiazide diuretics)

Blood transfusions cannot be run with any other IV fluid except normal saline (NS).

Dextrose can lyse the red blood cells, and other fluids can cause precipitation. If another fluid has been infused through an IV catheter, the nurse should discontinue the infusion(s) and tubing and flush with NS before administering blood.

Diabetes insipidus

Diabetes insipidus is characterized by increased thirst (polydipsia) and increased urination (polyuria). The large quantity of urine that is excreted will have a very low specific gravity.

large wound healing by secondary intention

Diets high in protein and vitamin C are recommended because these nutrients promote wound healing. A wound with little or no tissue loss (a surgical wound) heals by primary intention. Wounds involving loss of tissue (severe lacerations or pressure ulcers) are left open until filled with scar tissue. This healing by secondary intention takes longer.

hypoglycemia

Drowsiness is an early manifestation of hypoglycemia. Other early manifestations include fatigue, headache, shakiness, and nausea.

The shock continuum progresses in severity from the initial (I) to the irreversible (IV) stage.

During the initial stage, there is an imbalance of oxygen supply and demand at the tissue and metabolic levels and anaerobic metabolism develops; there may be no recognizable signs and symptoms. As shock progresses to the compensatory (II) stage, the neural, hormonal, and biochemical compensatory mechanisms are activated to maintain homeostasis (oxygenation, cardiac output). Cold and clammy skin indicates failing sympathetic nervous system compensation. The client is moving along the continuum to the progressive (III) stage, which begins when compensatory mechanisms fail. Immediate intervention is necessary to prevent further progression.

Naegele's rule

EDB = (LMP minus 3 months) + 7 days. If the LMP occurs in January, February, or March, the EDB will be in the current year. If the LMP occurs after March, the EDB will be in the next year.

Heart Attacks in women

Early recognition and treatment of heart attack are critical. Women, the elderly, and clients with a history of diabetes may not have the classic heart attack symptoms of dull chest pain with radiation down the left arm. Instead, they can present with "atypical" symptoms such as nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue.

The normal therapeutic level of vancomycin is 10-20 mg/L (6.9-13.8 µmol/L).

Elevated vancomycin trough levels (>20 mg/L [>13.8 µmol/L]), creatinine (>1.3 mg/dL [>115 µmol/L]), and blood urea nitrogen (>20 mg/dL [>7.1 mmol/L]) are associated with nephrotoxicity and should be reported to the health care provider.

Epoetin alfa

Epoetin alfa is a synthetic version of human erythropoietin. Epoetin alfa is used to treat anemia associated with kidney disease or medication therapy. It increases and maintains the red blood cell level so that blood transfusions are not needed. It takes about 2 to 4 weeks for epoetin alfa to cause an increased level of Hgb and HCT.

Esophagoscopy

Esophagoscopy is useful in determining the incompetence of the lower esophageal sphincter and the extent of inflammation, potential scarring, and strictures.

Iron toxicity

Excess storage of iron in the body is known as hemosiderosis. The excessive iron may come from overuse of supplements or from receiving frequent blood transfusions, as in sickle cell anemia. Clients who have a long history of repeated, frequent transfusions are at risk for development of hemosiderosis.

FHR

FHR of 110-160/min, occasional accelerations, and early decelerations are components of a reassuring FHR pattern. Minimal variability usually indicates fetal sleep or the effects of CNS depressants. Late decelerations with minimal variability indicate utero-placental insufficiency and require further assessment and intervention.

Failure to Thrive

FTT is generally defined as weight less than 80% of ideal for age and/or depressed weight for length, correcting for gestational age, sex, and special medical conditions. Observation of the child while being fed may provide information related to the cause of inadequate dietary intake, including disturbances in feeding behavior and psychosocial factors.

One of the most common benign breast disorders is fibrocystic breast changes.

Fibrocystic changes correlate to estrogen/progesterone hormone fluctuations during the menstrual cycle. Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. The condition typically resolves after menopause.

The proper method of delivering a dose via MDI includes the following steps:

First shake MDI and attach it to the spacer. Exhale completely to optimize inhalation of the medication. Place lips tightly around the mouth piece. Deliver a single puff of medication into spacer. Take a slow, deep breath and hold it for 10 seconds to allow for effective medication distribution. After the dose, rinse mouth with water to remove any left-over medication from oral mucous membranes. Spit out the water to ensure no medication is swallowed. Educational objective: Any child under age 12 should use a spacer with the MDI to ensure the entire dose is inhaled appropriately.

Surgery involving the urinary system.

Fluid intake of 3,000 mL per day should be encouraged in clients

Midazolam (Versed) benzodiazepine antidote

Flumazenil (Romazicon)

Botulism is a result of ingesting improperly canned or stored food.

Food in a can with a bulging end should not be used. Children under age 1 year should not be given honey as their immature gut system makes them prone to developing infant botulism.

Women who are planning to become pregnant should consume 400-800 mcg of folic acid daily to prevent neural tube defects (eg, spina bifida, anencephaly).

Food options that are rich in folic acid include fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables.

Necrotizing enterocolitis is a life-threatening complication in premature infants due to underdeveloped intestine and gut immunity.

Frequent abdominal girth measurements are essential to assess for worsening distension. Clients are placed supine and undiapered. Rectal temperatures should be avoided due to the risk of perforation.

Stage 4 Pressure Ulcers

Full-thickness tissue loss is involved with a stage IV ulcer, with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, and undermining. There may be eschar (black scab-like material) or slough (tan, yellow, or green scab-like material).

fulminant hepatic failure

Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion, and corticosteroids. Consequently, liver transplantation has become the treatment of choice for these clients

Common causes of metabolic acidosis include:

GI bicarbonate losses (eg, diarrhea) Ketoacidosis (eg, diabetes, alcoholism, starvation) Lactic acidosis (eg, sepsis, hypoperfusion) Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) Salicylate toxicity

Signs and symptoms of digoxin toxicity include the following:

Gastrointestinal symptoms (eg, anorexia, nausea, vomiting, abdominal pain) are frequently the earliest symptoms Neurologic manifestations (eg, lethargy, fatigue, weakness, confusion) Visual symptoms are characteristic and include alterations in color vision, scotomas, or blindness Cardiac arrhythmias - most dangerous (eg heart skips a beat)

Glycosylated hemoglobin levels

Glycosylated hemoglobin levels, or hemoglobin A1C, is an accurate method to determine if the client is routinely compliant. Glycosylated hemoglobin refers to hemoglobin that is connected to glucose. Since the life span of a red blood cell is approximately 4 months, this value will not be affected by recent changes in diet or medication.

Graves' disease

Graves' disease is a common cause of hyperthyroidism, an imbalance of metabolism caused by overproduction of the thyroid hormone. Thyroid storm, an exaggerated condition of hyperthyroidism is associated with the development of fever, hypertension, abdominal pain, and tachycardia.

A peak flow meter uses traffic signal colors to categorize degrees of asthma symptoms.

Green zone indicates asthma is under control. Yellow zone indicates caution, symptoms are getting worse, PEF is 50%-80% of personal best, and there is a need for further medication. Red zone indicates the need for emergency treatment if the level does not immediately return to yellow after taking rescue medications.

Live vaccines (eg, varicella, MMR) should be delayed for up to 11 months after IVIG administration as IVIG therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity.

Hib vaccine is not a live vaccine, and final dose (fourth) is recommended between age 12-15 months, according to the Centers for Disease Control and Prevention (CDC). Hep B vaccine is not a live vaccine; the CDC recommends that the final dose (third) be administered between age 6-18 months. PCV is also not a live vaccine, and the final dose (fourth) is recommended between age 12-15 months, according to the CDC.

During a weather-related emergency, home care visits are classified as:

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

The assessment data that support a deficit in oxygenation and gas exchange include:

High-pitched wheezing on inspiration and expiration. Wheezing is usually heard on expiration; when heard on inspiration as well, it indicates an even greater degree of bronchospasm, airway resistance, and hypoxemia. Diminished breath sounds during an asthma attack indicate reduced delivery of inspired oxygen due to hyperinflation, air trapping, and alveolar hypoventilation. Decreased oxygen saturation (pulse oximeter of 87% on room air) in the presence of tachycardia and tachypnea indicates significant impaired gas exchange and hypoxemia.

Tamoxifen has mixed agonist and antagonist activity on estrogen receptors in various tissues.

However, it is associated with increased risk of endometrial cancer and venous thromboembolism. Menopausal symptoms (eg, vaginal dryness, hot flashes) are the most common side effect. Due to its estrogen-agonist actions, tamoxifen also poses a risk for thromboembolic events (eg, stroke, pulmonary embolism, deep vein thrombosis).

Kawasaki Disease

IVIG along with aspirin is the recommended initial treatment for Kawasaki disease, with the primary goal of coronary disease prevention.

The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway. (Option 1)

If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties. Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain the airway. The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to prevent excessive pressure and mucosal tissue damage.

A woman's uterus should be firm, midline, and between the symphysis pubis and umbilicus. Massaging the uterus is the priority nursing action for a midline, boggy uterus after the placenta is delivered.

If massage fundus doesnt work = administer Oxytocin

Accidental dislodgement of the tube in a fresh (immature, < 1 week) tracheostomy is a medical emergency.

Immediate nursing actions include pulling the retention sutures apart if present, or inserting a curved hemostat to hold the stoma open if sutures are absent. If desaturation progresses, the nurse should apply a sterile occlusive dressing over the stoma and ventilate the client with a bag-valve mask over the nose and mouth.

A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features:

Immobility—the client remains in a fixed stupor or position for long periods Refuses to move about or engage in activities of daily living May have brief spurts of excitement or hyperactivity Remaining mute Bizarre postures—the client holds the body rigidly in one position Extreme negativism—the client resists instructions or attempts to be moved Waxy flexibility—the client's limbs stay in the same position in which they are placed by another person Staring Stereotyped movements, prominent mannerisms, or grimacing

Agnosia

Impairment of the ability to recognize, or comprehend the meaning of, various sensory stimuli, not attributable to disorders of the primary receptors or general intellect

Anxiety is common in clients with COPD and can contribute to difficulty breathing.

In the client with acute shortness of breath and normal assessment findings, appropriate interventions are controlled breathing and relaxation.

Parent teaching for administration of digoxin includes the following:

Inform parents of the pulse rate at which to hold the medication based on HCP prescription. In general, digoxin is held if pulse <90-110/min for infants and young children or <70/min for an older child. Administer oral liquid in the side and back of the mouth Do not mix the drug with food or liquids as the refusal to take these would result in inaccurate intake of medication If a dose is missed, do not give an extra dose or increase the dose. Stay on the same schedule. If more than 2 doses are missed, notify the HCP If the child vomits, do not give a second dose. Nausea, vomiting, or slow pulse rate could indicate toxicity. Notify the HCP. Give water or brush the client's teeth after administration to remove the sweetened liquid

Isotretinoin = Accutane

Isotretinoin is a pregnancy category X drug and will cause birth defects if taken during pregnancy. The client must use 2 forms of birth control for 1 month prior to taking the medication as well as during treatment and 1 month afterward. The client must also be enrolled in a risk management program prior to receiving refills.

Adenosine is the drug of choice for the treatment of paroxysmal supraventricular tachycardia.

It has a short half-life and should be administered rapidly over 1-2 seconds, followed with a 20-mL saline bolus. A brief period of asystole can be common. Flushing from vasodilation is seen frequently.

Sodium nitroprusside is given as an infusion for the short-term treatment of acute decompensated heart failure, especially in clients with markedly elevated blood pressure.

It is a potent vasodilator and reduces preload and afterload. The main adverse effect is symptomatic hypotension, necessitating close monitoring of blood pressure.

Allopurinol

It is important for the nurse to educate the client taking allopurinol about drinking a full glass of water with each dose and increasing overall fluid intake. Increased fluids help to prevent renal stones and promote diuresis and uric acid excretion.

A child with a mild traumatic brain injury (TBI) must be discharged with a responsible adult who can monitor the child's responsiveness.

It is normal for a child with TBI to have a headache, trouble thinking, and irritability for up to 6 weeks. Children who were unconscious for ≥5 minutes or had amnesia for the event are usually admitted for observation.

Mononucleosis is caused by the Epstein-Barr virus.

It is typically seen in adolescence from the sharing of drinks, kissing, or other direct exposure to saliva. Symptoms may include fatigue, fever, sore throat, splenomegaly, hepatomegaly, and swollen lymph nodes. Antibiotic treatment is inappropriate for a viral infection. Inadvertent intake of antibiotics (amoxicillin) can cause a rash. Treatment for mononucleosis is management of symptoms and includes hydration, rest, control of pain, and reducing fever as necessary. Sore throat is treated with saline gargles or anesthetic troches. Complications include airway obstruction (eg, stridor, difficult breathing) from swollen lymph nodes around the neck and severe abdominal pain (splenic rupture). These should be reported to the health care provider (HCP) immediately.

Reye syndrome is characterized by fever, acute encephalopathy, and altered hepatic function.

It often develops following a viral infection, especially varicella or influenza. The risk of developing Reye syndrome increases if aspirin therapy is used to treat fever.

Separation anxiety, also known as anaclitic depression, particularly affects children age 6-30 months. There are 3 stages of separation anxiety: protest, when the child refuses attention from others, screams for the parent to return, and cries inconsolably; despair, when the child is withdrawn, quiet, uninterested in activities or meals, and displays younger behavior (eg, use of pacifier, wetting the bed); and detachment, when the child suddenly appears happy and interested in building relationships.

Key interventions include: Encouraging the parents to leave favorite toys, books, and pictures from home Establishing a daily schedule that is similar to the child's home routine Maintaining a close, calming presence when the child is visibly upset Facilitating phone or video calls when parents are available Providing opportunities for the child to play and participate in activities

Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow.

Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: Tachypnea Tachycardia, even at rest Diaphoresis during feeding or exertion (Option 3) Heart murmur or extra heart sounds (Option 4) Signs of congestive heart failure Increased metabolic rate with poor weight gain (Option 5)

insomnia

Long-term treatment with medication alone is not necessarily the best approach to treat insomnia. Nonpharmacological strategies for improving sleep hygiene include: 1. Avoiding naps throughout the day 2. Engaging in physical activity or exercise, preferably at least 5 hours before bedtime 3. Receiving at least 20 minutes of natural sunlight each day, ideally in the morning, to improve sleep patterns 4. Avoiding caffeinated beverages after noon 5. Avoiding alcohol and/or smoking at bedtime 6. Participating in a relaxing activity before bedtime (eg, warm bath, reading, listening to soft music) 7. Decreasing environmental stimuli; making sure the bedroom is dark, cool, and quiet 8. Avoiding heavy meals or large amounts of fluids at bedtime 9. Drinking a cup of warm milk or eating a small amount of carbohydrates before bedtime, which promotes comfort and relaxation to aid sleepiness

PPIs

Long-term use of PPIs (Prazoles - omeprazole, lansoprazole, pantoprazole, rebeprazole) has been associated with decreased bone density (calcium malabsorption) and increased risk for C difficile-associated diarrhea and pneumonia.

airborne precaution

MTV (measles, TB, varicella)

Acute pancreatitis, a potentially life-threatening complication, can occur following an endoscopic retrograde cholangiopancreatography.

Manifestations include acute abdominal pain, often radiating to the back, and a rise in pancreatic enzymes (eg, amylase, lipase).

Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome:

Massive proteinuria - caused by increased glomerular permeability Hypoalbuminemia - resulting from excess protein loss in the urine Edema - specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities Hyperlipidemia - related to increased compensatory protein and lipid production by the liver Additional symptoms include decreased urine output, fatigue, pallor, and weight gain.

Clients with severe preeclampsia may need magnesium sulfate therapy for seizure prevention.

Maternal magnesium therapy can cause newborn respiratory depression at birth. Mild preeclampsia = no magnesium

Megaloblastic anemia

Megaloblastic anemia is a decrease in the red blood cells caused by folate (folic acid) deficiency. -caused by vitamin B12 or folic acid deficiency. -Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts

Melanomas

Melanomas are malignant neoplasms with atypical melanocytes in both the epidermis and the dermis (and sometimes the subcutaneous cells). It is the most lethal type of skin cancer, often causing metastases in bone, liver, lungs, spleen, the central nervous system, and lymph nodes.

Common misperceptions of contraindications to immunization:

Mild illness (with or without an elevated temperature) Currently taking antibiotics Mild site reactions (eg, swelling, erythema, soreness) Recent infection exposure Penicillin allergy

Non-modifiable breast cancer risk factors include: Female sex and age ≥50 First-degree relative (mother or sister) with history of breast cancer BRCA1 and BRCA2 genetic mutations (Option 2) Personal history of endometrial or ovarian cancer Menarche before age 12 or menopause after age 55

Modifiable breast cancer risk factors include: Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause) (Option 5) Postmenopausal weight gain and obesity as fat cells store estrogen (Option 4) History of smoking and alcohol consumption Dietary fat intake Sedentary lifestyle

penicillin derivates and preganancy

Most penicillin derivates (eg, ampicillin, amoxicillin) and cephalosporins (eg, cephalexin, ceftriaxone) = generally considered safe for use by women who are pregnant or lactating.

Pregnancy and NSAIDs

NSAIDs must be avoided starting at 30 weeks gestation due to the risk of causing premature closure of the ductus arteriosus in the fetus and prolonged labor for the client. Prior to 30 weeks gestation, they should be taken only under the close supervision of an HCP.

myopia

Nearsightedness

Fasting blood glucose

Normal serum fasting blood glucose is 70-99 mg/dL (3.9-5.5 mmol/L).

ICP

Notify the HCP of signs/symptoms of increased ICP, including unexpected vomiting. The vomiting is often projectile, associated with headache, and gets worse with lowering the head position.

PVC

Occasional premature ventricular contractions (PVCs) in the normal heart are not significant. PVCs in the client with coronary artery disease or myocardial infarction indicate ventricular irritability and may lead to life-threatening dysrhythmia such as ventricular tachycardia.

Parathyroid hormone

Parathyroid hormone regulates calcium, phosphorus, and magnesium balance within the blood and bone by maintaining a balance between the mineral levels in the blood and the bone. Hyperparathyroidism is associated with hypercalcemia; therefore, a decrease in the calcium level indicates an improvement in the client's condition.

pertussis infection.

Paroxysms of rapid coughing that lead to vomiting are a key feature of pertussis infection. Pertussis is a highly contagious disease = droplet precautions. It can be deadly if contracted in infancy before vaccination is started. This client should be placed in isolation immediately to prevent the spread of disease.

pernicious anemia

Pernicious anemia is caused by a lack of intrinsic factor needed to absorb vitamin B12 from the gastrointestinal tract. Monthly vitamin B12 injections are the definitive treatment to correct the vitamin B12 deficiency.

A pessary is a vaginal support device recommended for pelvic organ prolapse.

Pessaries are fitted by an HCP; many clients can then remove, clean, and replace these themselves. Clients can remain sexually active with a pessary in place.

Asthma

Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: -Oxygen to maintain saturation >90% -High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes -Systemic corticosteroids (Solu-Medrol)

Polyhydramnios

Polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Polyhydramnios is associated with gastrointestinal fetal malformations and neurologic disorders. Two examples of these are tracheoesophageal fistula and anencephaly.

Pre procedure for pharmacologic nuclear stress

Pre-procedure client instructions include the following: 1. Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications 2. Avoid caffeine products 24 hours before the test 3. Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine (Option 1). 4. Do not take theophylline 24-48 hours prior to the test (if tolerated). 5. If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. 6. Hypoglycemia can result if the medicine is taken without food (Option 5). 7. Some medications can interfere with the test results by masking angina. 8. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: -Nitrates (nitroglycerine or isosorbide) -Dipyridamole -Beta blockers

A nurse is caring for a client after having a splenectomy following a motor vehicle crash. Which of the following client care measures has the highest priority?

Promoting lung aeration Postoperative pain causes splinting, shallow breathing, and under-aeration of the lung's left lower lobe because of close proximity of the spleen to the diaphragm. Slow, deep, and relaxed breaths will facilitate greater lung expansion and oxygen use; therefore, preventing atelectasis from developing.

Sleep needs of school-age children are dependent on health status, activity level, and age.

Required sleep averages 11 hours (for 5-year-olds) to 9 hours (for 12-year-olds). It is important to establish bedtime hours and bedtime rituals. These children usually do not need daytime naps if they have slept well at night.

Treatment for a sprained joint consists of

Rest, Ice, Compression, and Elevation (RICE) for the first 24-48 hours following the injury, mild analgesia with a nonsteroidal anti-inflammatory drug, and an exercise rehabilitation program when pain subsides.

A nurse is caring for a client who is scheduled to have an esophagogastroduodenoscopy (EGD). The nurse should recognize that this procedure is used to do which of the following?

Sclérose esophageal varices. EGD is the direct visualization of mucus in the upper gastrointestinal tract using a flexible fiberoptic endoscope. The endoscope used for EGD can be positioned to cauterize the bleeding varices to prevent extensive blood loss.

Seizure phases

Seizure manifestations generally are classified into 4 phases: The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. The ictal phase is the period of active seizure activity. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.

Correct use of the MDI is necessary to receive the full benefit from inhaled medication. The steps are as follows:

Shake canister well for about 3-5 seconds. Tilt head back slightly and exhale slowly for 3-5 seconds. Hold canister mouthpiece about 1½ inches in front of open mouth; as an alternative, place the mouthpiece in the mouth with lips sealed around it. Holding it in front of the open mouth prevents impaction of the particles into the tongue and sides of mouth. Compress canister while inhaling slowly for about 3-5 seconds. Hold breath for 10 seconds, if possible, before exhaling. Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff.

endometrial infection

Signs of endometrial infection include elevated temperature, chills, malaise, excessive pain, and foul-smelling lochia. During the first 24 hours postpartum, temperature and WBC count are normally elevated. Fever and leukocyte counts that do not decrease require further evaluation.

Squamous cell carcinomas

Squamous cell carcinomas arise from the epidermis and can metastasize, but they are not the most lethal type of skin cancer.

Insulin injections

Subcutaneous injection is the indicated route for NPH insulin administration; it should never be administered IV push. Regular insulin is the only insulin that can be administered IV push.

Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures.

Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive dressing should be removed immediately, and the health care provider (HCP) must be notified for possible surgical intervention (eg, fasciotomy).

Chovostek's Sign

The Chvostek sign is a clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve. When the facial nerve is tapped at the angle of the jaw (i.e. masseter muscle), the facial muscles on the same side of the face will contract momentarily (typically a twitch of the nose or lips) because of hypocalcemia (i.e. from hypoparathyroidism, pseudohypoparathyroidism, hypovitaminosis D) with resultant hyperexcitability of nerves

Delirium

The Confusion Assessment Method (CAM) is used to determine delirium. The signs are acute mental status changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness. The disorganized thinking includes hallucinations. Risk factors for delirium include older age, prior cognitive impairment, presence of infection, severe illness or multiple comorbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and pain.

Dash Diet

The DASH diet is often suggested for clients to reduce hypertension as this diet: Emphasizes intake of vegetables, fruits, and fat-free or low-fat dairy products Includes whole grains, fish, poultry, beans, seeds, nuts, and vegetable oils Limits ingestion of sodium, sweets, sugary beverages, and red meat

Somogyi effect

The Somogyi effect refers to a swing to a high blood glucose in the morning after an extremely low level occurring after an untreated insulin reaction during the night. The swing is caused by the release of stress hormones to counter low glucose levels. Monitoring of night time blood glucose levels over time may provide an accurate diagnosis of the Somogyi effect.

Compartment syndrome is a serious complication due to neurovascular compromise from swelling and increased pressure in a confined space.

The characteristics (6 Ps) of compartment syndrome include: pain, pressure, paresthesia, pallor, pulselessness, and paralysis.

Cirrhosis

The chronic, progressive destruction characteristic of cirrhosis causes bilirubin, ammonia, and coagulation studies (PT/INR and aPTT) to become elevated. Hyponatremia and hypoalbuminemia are to be expected.

Hemorrhagic cystitis (eg, bladder inflammation) is a well-known complication of cyclophosphamide (immunosuppressant and chemotherapy agent).

The client is instructed to drink plenty of fluids. Bleeding is usually minimal and occasionally requires a blood transfusion, but is rarely life threatening.

Ethambutol (Myambutol) is used in combination with other antitubercular drugs (eg, isoniazid, rifampin, pyrazinamide) to treat active tuberculosis.

The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color (red-green) discrimination.

Central venous pressure (CVP) and Pulmonary artery wedge pressure (PAWP)

The client's central venous pressure (CVP) is elevated (normal value 2-8 mm Hg), indicating increased systemic circulation volume and increased right ventricular preload. Pulmonary artery wedge pressure (PAWP) is also elevated (normal value 6-12 mm Hg), indicating increased left ventricular preload. In the presence of increased CVP and PAWP, coarse crackles indicate left-sided failure. The treatment goal is to decrease fluid volume and preload. Furosemide is a loop diuretic that will decrease both left- and right-sided preload.

Alzheimer disease (AD)

The development of Alzheimer disease (AD) is influenced by a combination of genetic, lifestyle, and environmental factors. The most significant and strongest risk factor for late-onset AD is advancing age.

There are 2 forms of heparin-induced thrombocytopenia.

The first form (platelets >100,000/mm3 [100 x 109/L]) normalizes within a few days. The second form (platelets <40,000/mm3 [40 x 109/L]) is a life-threatening autoimmune process that requires immediate heparin discontinuation.

Homonymous hemianopsia

The loss of the right or left half of the field of vision in both eyes.

arteriovenous fistula

The major complications of an AVF are infection (especially in end-stage kidney disease and diabetes), stenosis, thrombosis, and hemorrhage. Clients are taught the following preventive interventions: Report numbness or tingling of the extremity to the HCP to prevent neuromuscular damage Do not allow anyone (other than dialysis personnel) to draw blood or take blood pressure measurements on the extremity to prevent thrombosis Avoid wearing restrictive clothing or jewelry to prevent thrombosis Do not use the arm with vascular access to carry heavy objects (more than 5 lb [2.26 kg]); however, exercises to increase strength could include squeezing a soft ball or sponge several times a day Check the function of the vascular access several times a day by feeling for vibration to assess for patency, stenosis, and clotting Do not sleep on the arm with vascular access or use creams or lotions on the site Monitor for signs of infection and bleeding after dialysis and report immediately Keep the site clean to help prevent infection ***AVF takes 2-4 months to mature

MMR vaccine during pregnancy

The measles-mumps-rubella vaccine is a live attenuated vaccine and is contraindicated in pregnancy due to the risk of teratogenic effects to the fetus. Clients who are nonimmune to rubella should receive the vaccine in the postpartum period. Pregnancy should be avoided for at least 1-3 months after immunization.

A trial of labor for vaginal birth after cesarean is a major risk factor for uterine rupture.

The most common sign of uterine rupture is a nonreassuring fetal heart pattern (ie, variable or late decelerations, minimal or absent variability). Maternal manifestations include a change in uterine shape, abdominal pain, cessation of uterine contractions, and possible hemorrhage.

Gamma-glutamyl transferase (GGT)

The most sensitive enzymatic indicator for liver damage from ethanol intake

post-tonsillectomy

The risk of post-tonsillectomy hemorrhage persists for up to 14 days after surgery, and resuming strenuous activity too early increases this risk. The potential for bleeding is higher 7-10 days postoperatively while sloughing occurs.

Nitroglycerin and other nitrates increase cardiac blood flow and provide relief from the pain of ischemia in acute coronary syndrome by causing vasodilation.

Their infusion should not cause systolic blood pressure to fall to <90 mm Hg or to drop >30 mm Hg below baseline.

Low-pitched wheezing (rhonchi) and cough can indicate the presence of excessive secretions in the airway.

These symptoms are expected findings in asthmatic clients.

If a chest tube is dislodged from the client and the nurse hears air leaking from the site, the immediate action should be to apply an occlusive sterile dressing taped on 3 sides.

This action decreases the risk for a tension pneumothorax by inhibiting air intake on inspiration and allowing air to escape on expiration.

What is respiratory distress syndrome?

This condition is due to atelectasis (collapse of lungs) caused by insufficient surfactant in premature lungs, which may lead to acute respiratory failure and death

Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect.

This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect.

Kernig's Sign

This is a positive sign of meningitis that is when there is pain in the lower back or posterior(Back of) thigh that occurs when knee is extended while pt is lying in supine position and the hip is flexed at a right angle (pt can not straighten leg out if bent at knee when raised)

Trichomoniasis

Trichomoniasis is an STI. Expected symptoms include yellow-green, frothy discharge with a fishy odor and an accompanying itch. Metronidazole is the initial drug of choice. Clients should avoid alcohol while on metronidazole, which can make the urine darker and cause a metallic taste. Partners must be treated simultaneously.

Signs that a parent or friend of someone with this disorder might notice include the following:

Trips to the bathroom after meals Disappearance of large amounts of food Finding hidden wrappers and empty containers of food, especially foods that are sweet and easily consumed Smells of vomit; finding packages of laxatives or enemas Getting up in the middle of the night followed by a trip to the bathroom some time later Engaging in intense physical exercise despite fatigue or pain Swelling of the cheeks due to parotid gland damage and enlargement; staining of the teeth Periods of starvation Preoccupation with weight, food, and dieting

Hypospadias, a condition in which the urethral opening is on the underside of the penis, is surgically corrected by rerouting the urethra and inserting a temporary stent to aid healing.

Urinary output is closely monitored postoperatively to ensure patency.

Residual urine volume of >100 mL on bladder scan may indicate urinary retention.

Urine culture showing values >10,000 organisms/mL can suggest UTI. Burning sensation is common after cystoscopy. Renal arteriogram is performed with a contrast agent; excretion of the dye with oral and intravenous hydration is recommended to prevent kidney injury.

A nurse is caring for a client with bleeding esophageal varices who was treated with a double balloon tamponade (Sengstaken Blakemore tube). Several hours after the gastric and esophageal balloons were inflated, the nurse notes that the client has become increasingly agitated, and respirations are 36/min and shallow. Which of the following is an appropriate nursing action?

Use scissors to cut the tubing in front of the nose guard or sponge. The client's breathing problems are likely caused by an obstruction due to a displaced esophageal balloon. Using scissors to cut the tubing in front of the nose guard or sponge relieves the obstruction.

paralytic ileus

Usually temporary paralysis of intestinal wall that may occur after abdominal surgery or peritoneal injury and that causes cessation of peristalsis; leads to abdominal distention and symptoms of obstruction

sildenafil

Viagra

Lateral violence in the workplace (acts of aggression by an employee toward another employee) should not be tolerated or ignored.

Victims can take action against bullying, including documenting and reporting incidents, standing up to the bully in a professional way, and seeking support.

A client with reactive airway disease is tested and found to have an allergy to dust mites. The nurse determines that the client understands how to reduce her exposure to this allergen when she states which of the following?

Washing all the bed linens in hot water every week will be time-consuming."

Venipuncture is contraindicated in upper extremities affected by:

Weakness Paralysis Infection Arteriovenous fistula or graft (used for hemodialysis) Impaired lymphatic drainage (prior mastectomy)

Gout

Weight loss and dietary modifications may reduce the frequency of acute episodes of gout. These strategies include increasing fluids, avoidance of carbonated beverages with high fructose corn syrup, limiting daily alcohol consumption, and avoiding red meat and seafood to reduce purine load.

Wheals

Wheals, also known as hives, are transient, elevated lesions caused by localized edema. Wheals are a common manifestation of an allergic reaction.

Epiglottitis

When assessing a client with symptoms suggestive of epiglottitis (eg, acutely ill, high fever, drooling, leaning forward, dyspnea), the nurse should prepare for an emergency airway.

Stage 1 Pressure Ulcers

With a stage I ulcer, the skin is intact with an area usually over a bony prominence of persistent, non-blanchable redness that may feel warm or cool when touched. The tissue is swollen and congested, and the client may report discomfort at the site. With darker skin tones, the ulcer may appear blue or purple.

Stage 2 Pressure Ulcers

With a stage II ulcer, there is partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected. The client may report pain, and there may be a small amount of drainage.

Stage 3 Pressure Ulcers

With a stage III ulcer, there is full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common.

theophylline

a bronchodilator used to treat asthma and bronchitis and emphysema

percutaneous endoscopic gastrostomy (PEG) tube

a feeding tube inserted endoscopically into the stomach

abrupto placentae

abnormal condition when placenta seperates from uterine wall prematurely

The 2 core symptoms of autism spectrum disorder are

abnormalities in social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more significantly than other developmental functioning.

Atropine

administered to clients with symptomatic bradycardia

glucose tolerance test

aids in the diagnosis of diabetes mellitus. 2 hours after injection or ingestion of glucose, a level higher than 200 mg/dL confirms the diagnosis of diabetes mellitus.

nystagmus

an involuntary, constant, rhythmic movement of the eyeball that can be congenital or caused by a neurological injury or drug use

Nursing education about transdermal nitroglycerin includes

application of the patch to the upper arms or body, rotating the sites daily, removing the patch at night, taking no erectile dysfunction medications, and informing clients that headaches are common. Patches do not need to be removed for bathing.

Two common advance directives

are a living will (dealing with specific events/issues) and a durable power of attorney for health care (eg, an individual who can make decisions on the circumstances in light of the client's wishes).

Lipomas

are benign, fatty masses and rarely become malignant. They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic. Masses that are hard and fixed, not soft and mobile, usually indicate malignancy.

Catheters placed in the kidney pelvis

are irrigated using gentle pressure and small amounts of sterile saline solution (≤5 mL at one time) to avoid damaging renal tissues.

Potassium-sparing diuretics (eg, spironolactone, amiloride, triamterene, eplerenone)

are often combined with thiazide diuretics to reduce potassium loss during hypertension treatment.

Sjogren syndrome

autoimmune with dry eyes and mouth; lymphocytic infiltrations of salivary and lacrimal glands; can't cry

Macrolide antibiotics (eg, erythromycin, azithromycin, clarithromycin)

can cause QT prolongation, which can lead to life-threatening arrhythmias (eg, torsades de pointes). They can also be hepatotoxic; therefore, the nurse should monitor liver function tests and an ECG and report significant results to the HCP.

A low pressure alarm for an arterial line

can indicate the presence of hypotension or disconnected tubing. Hemorrhage can rapidly occur with a disconnected arterial catheter line. The nurse should check the client for the presence of hypotension and its causes before troubleshooting the system.

Retinal detachment

can result from trauma and aging. Classic symptoms include lightning flashes, floaters, a curtain across the vision, and "gnats/cobweb/hairnet" throughout the vision. Retinal detachment requires emergent consultation and treatment to prevent loss of vision.

Late decelerations

caused by uteroplacental insufficiency. The client with late decelerations should be given oxygen by facemask and placed on the right or left side, oxytocin stopped if being administered, and an IV fluid bolus provided.

Umbilical cord prolapse

causes cord compression, fetal heart rate deceleration, and disruption of fetal oxygen supply. The priority with fetal bradycardia after suspected rupture of membranes is to assess for a prolapsed cord. The nurse should then manually elevate the presenting fetal part off the cord, leave the hand in place, and call for help.

atelectasis

collapsed lung; incomplete expansion of alveoli

Recovery of mental illness

components necessary for recovery are self-direction and responsibility, holistic care, and hope. When all the components are reasonably represented, recovery is demonstrated by the client's ability to function in all aspects of living to the highest level of capacity.

After transurethral resection of the prostate

continuous bladder irrigation for 24-36 hours flushes out small clots and prevents obstruction. Reddish-pink drainage is expected in the immediate postoperative period.

Portacaval anastomosis

creates an anastomosis between the portal vein and the inferior vena cava, is used to treat esophageal varices and to minimize bleeding.

When preparing a client for surgery, the nurse needs to

ensure that operative permits are signed and on the chart, an allergy band is placed if allergies are present, the operative site is marked on a limb, and IV prophylactic antibiotics are infused within 1 hour prior to surgery.

Assessment findings of a 12-month-old infant should include

equal head and chest circumference. Motor skills include being able to sit from a standing position without assistance.

hyperglycemia symptoms

extreme thirst, frequent urination, dry skin, hunger, blurred vision, drowsiness, nausea

Brain natriuretic peptide (BNP)

greater than 100 pg/mL (100 pmol/L) is considered elevated and indicates ventricular stretch (heart failure) as the cause of the dyspnea.

thoracic aortic aneurysm

if difficulty swallowing = call HCP immediately

abdominal aortic aneurysm

if low back pain = call HCP immediately

Common causes of fetal tachycardia (heart rate >160/min)

include infection, early hypoxemia, maternal fever, and stimulant drugs. Persistent tachycardia without other indicators (eg, absent variability, late decelerations) has not been proven to affect neonatal outcomes. Moderate variability is a reassuring fetal heart rate pattern indicating the health of the fetal nervous system.

When obtaining blood from a client

insert the needle at 15-degree angle, limit attempts to 2, and avoid the side of a mastectomy. A capillary specimen should be obtained at the side of the finger pad. Never draw a specimen above an IV infusion = distal port

Myasthenia gravis

involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations.

Myasthenia gravis (MG)

is a chronic, neurologic autoimmune disorder that involves damage to acetylcholine receptors at the neuromuscular junctions, which results in skeletal muscle weakness. The ocular (ptosis) and facial muscles, along with those responsible for chewing and swallowing, are affected initially; however, weakness can progress to the respiratory muscles (eg, intercostal, diaphragm).

Pyridostigmine (Mestinon)

is a first-line drug that inhibits acetylcholine breakdown and is prescribed to temporarily increase muscle strength in clients with MG. It is the priority medication as difficulty swallowing indicates weakness of the muscles involved in swallowing and increases aspiration risk.

Inflammatory breast disease

is an aggressive breast cancer with symptoms of red, warm, peau d'orange breast tissue. A breast mass may or may not be present.

BIPAP therapy

is an effective treatment to decrease CO2 levels in clients with hypercapnic respiratory failure.

Dopamine

is an inotrope used to treat hypotension due to bradycardia.

Pleurisy

is characterized by stabbing pleuritic chest pain that increases on inspiration. It is a complication of pneumonia caused by inflamed parietal and visceral pleurae rubbing together.

Pericarditis

is characterized by typical pleuritic chest pain that is sharp. It is aggravated during inspiration and coughing. Pain is typically relieved by sitting up and leaning forward. Treatment includes a combination of NSAIDs or aspirin plus colchicine.

A nurse is caring for a client who has returned to the unit following a laparoscopic cholecystectomy and reports severe pain in the left shoulder. The nurse should recognize that the client's pain

is due to carbon dioxide instilled into the abdomen during surgery. Gas (carbon dioxide) injected into the abdominal cavity during laparoscopic procedures can irritate the diaphragm and cause referred pain in the shoulder area. The pain disappears in 1 to 2 days. Mild analgesics and a recumbent position may be helpful.

pediculosis capitis (head lice)

items that can not be washed = placed in a seal plastic bag for 14 days

chicken pox infection

lesions crusted and dried (3 weeks) = not contagious

Signs of severe dehydration include

lethargy, sunken fontanel, poor feeding, increased heart rate, and increased respiratory rate.

Hepatitis A symptoms

loss of appetite, fatigue, nausea, vomiting, abdominal pain, fever, light-colored stool, dark-colored urine, and yellow skin (jaundice)

dissecting aortic aneurysm

manifestations of a dissecting aortic aneurysm -hypotension -tachycardia -back pain (cardinal sign)

Clinical manifestations of serotonin syndrome include

mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia).

splenectomy

minor infection = life threatening

Toxic epidermal necrolysis (TEN) is an acute skin disorder

most commonly associated with a medication reaction, that results in widespread erythema, large blistering lesions, epidermal shedding, keratoconjunctivitis, and skin erosion (ie, denuded skin). It is a more severe form of Stevens-Johnson syndrome. The major cause of death related to TEN is sepsis, so infection prevention is critical.

Enteral feed residual volume

must be less than 250 mL= high risk for aspiration

nuchal rigidity

neck stiffness

aplastic anemia.

need blood transfusion

Serious adverse reactions to aminoglycosides (eg, gentamicin, tobramycin, amikacin) include

ototoxicity and nephrotoxicity. Age, renal function, and drug dose affect the occurrence of these adverse reactions. Tinnitus and vertigo are early signs of ototoxicity. The nurse should carefully assess for changes in the client's hearing, balance, and urinary output.

Manifestations of phlebitis associated with a peripheral IV catheter include

pain, swelling, warmth at the site, and redness extending along the vein. If phlebitis is present, immediate removal of the catheter is necessary as the condition can lead to a serious bloodstream infection or thrombophlebitis.

Common symptoms of small-bowel obstruction include

rapid onset of nausea and vomiting, colicky intermittent abdominal pain, and abdominal distension. Absolute constipation and lack of flatus are usually seen with large-bowel obstruction. Initial treatment of an obstruction includes placing the client on NPO status, inserting a nasogastric tube, administering IV fluids, and instituting pain control measures.

Babinski's Sign

reflex response, when sole of the foot is stroked, the big toe turns up instead of down (normal in newborn, but pathologic later on)

transsphenoidal hypophysectomy

removal of the anterior lobe of the pituitary gland or tumor through an opening into the upper gum margin; inferior nasal cavity and sphenoid sinus to the floor of the sella turcica; no postop scar; indications such as cushings syndrome acromegaly or hypopituitarism from intrasellar tumors

Clients with cystic fibrosis

require bronchodilators prior to chest physiotherapy a diet high in fat, calories, and proteins pancreatic enzyme supplements with all meals and snacks; and physical activity. Clients should also be monitored for atypical signs of respiratory infection (eg, anorexia, weight loss, decreased activity level

atrial flutter

saw tooth shaped flutter waves on EKG - artrial rate 250 - 300 - AV node selectively conducts impulse to ventricles - ventricular rate can be regular or variable

The client with symptomatic bradycardia

should be treated initially with IV atropine. Transcutaneous pacing or infusion of dopamine or epinephrine may be considered if atropine is ineffective.

Clients recovering from bariatric surgery are given

small, frequent meals to prevent nausea, vomiting, and regurgitation related to overstretching of the stomach. The bariatric postoperative diet is restricted to foods that are high in nutrients (eg, protein, fiber) and low in simple carbohydrates to prevent dumping syndrome.

Iron deficiency anemia

take ferrous sulfate = iron

With the complete removal of the lung in a pneumonectomy,

the client should be positioned on the surgical side to promote adequate expansion and ventilation of the remaining lung.

gluconeogenesis

the formation of glucose from noncarbohydrate sources, such as amino acids

When a medication prescription is outside the safety range

the nurse must question/clarify the prescription with the prescriber and not administer the drug automatically.

To reduce the incidence of catheter-related infections from peripheral IV catheters

the nurse should clip excessive hair if needed, -clean the site with chlorhexidine in a back-and-forth motion using friction, and allow it to dry completely. -The catheter hub should be secured with sterile tape, - access ports should be cleaned with 70% alcohol prior to use.

tooth avulsion

there is a limited amount of time (≤1 hour) before death of the affected tooth. These clients need prompt treatment to save a permanent tooth.

Allen's Test

to ensure collateral circulation to a hand. compress ulnar and radial artery at the wrist while a client makes a fist until blanching occurs. then release pressure while keeping press on the radial artery. color should return in 15 seconds indicating it can be used to obtain blood

Signs of potential cancer include

unplanned weight loss, nagging cough/hoarseness, and dimpled skin (orange peel) on the breast. Hard, fixed masses, non-healing ulcers, and changing moles may also indicate malignancy and require further workup.

Ventricular bigeminy in a client following a myocardial infarction indicates risk for developing

ventricular tachycardia or ventricular fibrillation, both potentially life-threatening dysrhythmias. The nurse should assess the client's vital signs, electrolytes, and apical-radial pulse, and notify the health care provider.

ABCDE of skin lesions

■■ A - Asymmetry: One side does not match the other ■■ B - Borders: Ragged, notched, irregular, or blurred edges ■■ C - Color: Lack of uniformity in pigmentation (shades of tan, brown, or black) ■■ D - Diameter: Width greater than 6 mm, or about the size of a pencil eraser or a pea ■■ E - Evolving: Or change in appearance (shape, size, color, height, texture) or condition (bleeding, itching)

Three Phases of Burn Care

◯◯ Emergent (resuscitative phase) ■■ First 24 to 48 hr after the burn occurs ◯◯ Acute ■■ Begins when fluid resuscitation is finished ■■ Ends when the wound is covered by tissue ◯◯ Rehabilitative ■■ Begins when most of the burn area is healed ■■ Ends when reconstructive and corrective procedures are complete (may last for years)