NURSING COMPREHENSIVE 2
types of child abuse
-Physical -Emotional or mental -Sexual -Neglect: is most common type, physical, emotion or educational neglect, such as refuse/delay to seek healthcare, abandon, inadequate supervision, fail to enroll child in school
PET scan
-Pt either inhaled radioactive gas or injected with radioactive substance that have (+) changed particle → combined with (-) charged lectrone in body cells → result in gamma rays that can be detected by scanning device, producing 2D views - Used to measure blood flow, tissue composition, brain metabolism changes ( changes in glucose use) and thus function ( such as in Alzheimer disease ), locate lesions ( timor, epileptogenic lesions) and O2 metabolism in stroke pt - Isotopes have short half life and are expensive
CN VI
-abducens - motor - muscle that move the eye
multiple sclerosis patho
-autoimmune mediated , progressive demyelinated disease of CNS - destruction of myeline- result in impaired transmission of nerve impulse - can occur any age , but peak onset is 25-35 yo and affect women more freq than men
measures/education a nurse can provide for family/friends with caregiver role strain
-caregiver can face difficulty decision, : when pt should stop driving, when to assume pt's financial affairs - feeling guilt, nervous, worry - can feel unappreciated, frustrated and angry if pt exhibit aggression or hostility. - can lead to neglect or abuse --> which require report to local adult protective services agency. - participate in Alzheimer's association, community resource ( Area Agency on Aging) for family support group, respite ( relief) care, adult day care,
Explain the role of overstimulation and excess stimuli on a patient with delirium
-client with delirium can experience sensory overload - reduce stimulation because these pt easily distracted such as minimizing environmental noise including TV, - monitor pt respond to visitors or more than 1 person talking at once can increase confusion
bipolar disorder
-extreme mood swing from extreme of amnia to depression - mania is when mood abnormally and persisiteny elevated, expansive or irritable that last 1 wk or longer - During mania episode, pt have extreme euphoric[ intense happiness or excitement], excess in appearance or style [ grandiose] ,sleeplessness, excessive and pressured speech ( rapid, loud talking w/o pause), flight of ideas, distractibility, increased activity or psychomotor agitation, excessive involvement is risk taking behaviors. Mood can be excessively cheerful, enthusiastic, or very irritable. They denies problem, blame on other. Some also have delusions and hallucinations. - During the depressive phase, s/sx same with major depression.
CN VII
-facial - mixed - symmetry of facial expression and muscle movement in upper and lower face, salivation and tearing, taste and sensation in the ear
the population most at risk for rape, most common areas/locations of rape,
-highest incidence of rape is in girls and women age 16-24 with girl <20yo account fo 80% cases reported. - most occur in women's neighborhood, often inside or near her home - most rape is planned - stranger perpetrate 43% of rapes, husband na dbf commit 19% and other relative 38% - male rape is often underreported, most common in institution such as prison. - Date rape, occur on first date, on ride home, more prevalent near college and uni. campuses, esp when alcohol is consumed by victims or penetrators.
early sx of dementia / AD
-memory impairment is early sx - initially, recent or shortermnmemory impaied, repeat some stories, ask same questions repeatedly) and subtle memory loss, difficulty remember new learned info. - then eventually forget familiar faces, places, lost in familiar environment, or name of object, - can still function in daily life, social behavior intact - reasoning or use reality orientation with people with AD inly increase their anxiety w/o increase function -
the profile of the "usual" rapist.
-men who commit rape often between 25-44 yo - race: white account 52% -alcohol involve: 34% of cases - 75% of arrested rapist have prior criminal histories including rape, assaults, robberies, and homicides
pain in gastric ulcer
-right after eating -awake with pain at night (40%)
Carbamazepine (anticonvulsant) and health concern
-this med have great concern of deficiency of granulocytes in blood, risk for infection --> must have blood check freq for toxicity with therapeutic level is 4-12 µg/mL.
CN V
-trigeminal - mixed - facial sensation, corneal reflex, mastication
CT scan nursing interventions
- assess iodine,/ shellfish allergy , kidney function before and after procedure - require 4h fasting prior to study - educate pt to lie still throughout procedure - encourage fluid intake after procedure to clear out contrast
RA is
- autoimmune disorder - chronic inflammation of synovial joint - autoantibodies production against joint tissue
pt teaching prevention and limit severity of flare up SLE
- avoid sunlight + apply sunscreen - avoid stress - protect against cold water by layering warm socks, wearing gloves - if child with SLE outside for extended time during winter month --> inspect fingers and toes for discoloration - exercise when not flare up to remain joint, muscle function - supplement: glucosamines -diet low on salt - avoid crowded area - counsel risk of autoantibodies transmission to fetus of become pregnant - support services include Lupus Alliance of America and Lupus Foundation of America
psychotherapy in depressive clients
- best when combined with medication therapy 1. interpersonal therapy: focus in difficulties in relationship such as grief reactions, role dispute, role transitions ( such as person who as a child never learn how to trust person outside of family or how to make friends) 2. behavior therapy: increase freq of client positive interaction with environment and to decrease negative interaction, focus on improve social skill 3. cognitive therapy: focus on how pt think about self, others , future and how pt interpret their experiences - focus on person's distorted thinking, which intern influences feeling, behavior and functional abilities.
possible nursing dx for RA
- chronic pain - fatigue - activity intolerance r/t effects of inflammation
ALZHEIMER DISEASE
- common form of dementia - is a progressive, irreversible, degenerative neurologic disease - gradual loss of cognitive function - can affect people as young as 40, but uncommon before 65yo - cause is unknown but the "amyloid cascade hypothesis" is most widely discussed and hypothesis today.
Norepinephrine role in depression
- deficient in depression and increased in mania ( NE role is to energize body to mobilize during stress, and inhibit kinking, the process in which seizure activity in brain stimulated by reaching threshold of cumulative effects of stress, low electric impulse or chemical such as cocaine that sensitize nerve cells and pathway --> when these sensitized pathways no longer need stimulus to induce seizure, it occur spontaneously--> that why anticonvulsant, which inhibit kindling effective in tx boiler disorder
neurogenic shock
- develop as result of loss of ANS function below level of lesion - vital organs are affected --> cause decrease BP, slow HR< low CO, venous pooling in extremities and peripheral vasodilation - also not perspire in paralyzed portion of body because sympathetic activity is blocked - injury to cervical and upper thoracic affect resp. function --> reduce vital capacity, retention of secretion, increase PaCO2, decrease O2, resp. failure and pul. edema
hypovolemic shock
- emergency condition in which severe blood and fluid loos make the heart unable to pump enough blood to the body --> can cause many organ to stop working - cause : - lost about 20% or more blood - excessive diarrhea, sweating, burns or vomitting blood loss can due to - bleeding from cuts or wounds - bleeding from injury - internal bleeding : GI tract or ruptured ectopic pregnancy symptoms ? - anxiety - blue lips, finger nails - rapid heart rate - shallow breathing - low urine output
s/sx of cholelithiasis ( gallstones)
- epigastric distress - fullness, abdominal distention - vague pain in right upper abdominal quadrant *** - distress usually follow a meal rich in fried to fatty foods*** -jaundice with pruritus (itchy) - dark color urine - grayish color feces - vitamin deficiency (A, D, E, K)
SERs test - somatosensory evoked responses is used to
- evaluate pathway from nerves in extremities though spinal cord, to brainstem or cerebral cortex upon stimulation of peripheral axon - to detect defect in spinal cord, peripheral nerve conduction, also monitor spinal cord function during surgery procedure, help diagnose demyelinated disease such as MS, id. neuropathy problems.
the nurses role in support rape victims emotionally and physically (exam, collection of evidence, etc)
- exam before victims shower, brush her teeth, douched, changed her clothes or had anything to drink (unless no report of oral sex) to preserve evidence - use rape kit and rape protocol with instruction to collect evidence- physician responsible for this - victims must sign consent form before any photograph or hair and nails sample taken. - ask victim describe what happen, if cannot, may ask questions gently- let victim proceed at her own pace, not rushing thru interview or exam procedure - give victim as much control possible such as who to call, what would she like get done, its her decision to file charges or testify against penetrator or not, - prophylactic tx for STD is offered - encourage HIV testing at specific intervals because result may not occur immediately - encourage women engage in safe sex practice until result of HIV available - prophylaxis with ethinyl estradiol and norgestrel to prevent pregnancy - rape crisis centers, women's advocacy group and other local resources often provide counselor or volunteer to be with victim from ER to follow up to provide emotional support, be an advocate for them - use supportive therapy, restore victim sense of control, relieve feeling of helplessness, dependency, regain trust, obsession with assault that freq follow rape, improve daily function, find adequate social support, deal with feeling of guilts, shame and anger - refer to group therapy - it often take 1 yr or more for survivor of rap etc regain previous level of function , can have longterm effect such as PTSD -
compare the neuroanatomic and neurochemical theories of cause/etiologies of schizophrenia
- genetic factors ( partial inheritance) - neuroanatomic and neurochemical factor: less brain tissue in frontal and temporal region of brain and CSF, dopamine excess and serotonin modulation of dopamine or excess - drugs that increase activity in the dopaminergic system, such as amphetamine and levodopa, sometimes induce a paranoid psychotic reaction similar to schizophrenia. Second, drugs blocking postsynaptic dopamine receptors reduce psychotic symptoms; in fact, the greater the ability of the drug to block dopamine receptors, the more effective it is in decreasing symptoms of schizophrenia - theory regarding serotonin suggests that serotonin modulates and helps to control excess dopamine. Some believe that excess serotonin itself contributes to the development of schizophrenia. Newer atypical antipsychotics, such as clozapine (Clozaril), are both dopamine and serotonin antagonists. Drug studies have shown that clozapine can dramatically reduce psychotic symptoms and ameliorate the negative signs of schizophrenia
medical management of AD
- goal is too manage cognitive and behavioral s/sx - cholinesterase inhibitor DONEPEZIL HYDROCHLORIDE [ ARICEPT] and RIVASTIGMINE TARTRATE [ EXELON] --> enhance acetylcholine uptake ingrain, thus maintain memory skill, --> cognitive ability improve w/in 6 -12 months of therapy - behavioral such as agitation and psychosis --> managed with behavioral and psychosocial therapies - because sx changes over time --> nurse should reevaluate routinely--> document + and - response to meds
cause and factors of jaundice in newborn
- hemolysis is the primary cause - polycythemia - shorter RBC cycle (80 days compare to 120 in adults) - immature liver uptake
lab value indicate gallstone in common bile duct
- increased conjugated bilirubin level - ALK (alkaline phosphate )
Neuroleptic malignant syndrome (NMS) i
- is a serious and frequently fatal condition seen in those being treated with antipsychotic medications. - It is characterized by muscle rigidity, high fever, increased muscle enzymes (particularly creatine phosphokinase), and leukocytosis (increased leukocytes). - It is estimated that 0.1% to 1% of all clients taking antipsychotics develop NMS. - Any of the antipsychotic medications can cause NMS, which is treated by stopping the medication.
medical management of increased ICP
- is emergency - stat tx to decrease cerebral edema, lower volume of CSF, - give osmotic diuretic ( mannitol), restrict fluid, drain CSF, control fever, maintain BP, O2, reduce metabolic demand.
CT scan
- is quick, painless procedure use small amount of radiation to provide cross section view of brain - to distinguish density of tissue, skull, cortex from lesions ( which have different density), tumor, infarction, hemorrhage, cortical atrophy - may or may not use contrast, can be PO or barium IV - if combined with angiogram can allow viewing of blood vessels at same time
Test cerebellar function
- is testing of balance and coordination - note speed and symmetry of these - rapid alternating movement - touch thumb to finger in consecutive motion - point to point- have pt touch their finger to nurse's finger then to their nose several times - touch heel to shin
lumbar puncture (spinal tap)
- is used to withdraw CSF to exam, measure, reduce CSF pressure, determine presence of absence of blood - needle is inserted into subarachnoid space below 3rd lumbar vertebrae - pt lie on one side, at edge of bed with thigh and legs flexed. pt must relax because anxious increase pressure readings.
psycho-pharmacology for bipolar disorder
- lifetime use of med 1. antigenic agent - lithium 2. anticonvulsant used as mood stabilizer: gabapentin, lamotrigine, carbamazepine --> work by raising brain's threshold for dealing with stimulation, prevent pt from being bombarded with internal and external stimuli - psychotherapy - useful in mild or moderate depressed , but useful in acute mania stage
lower motor neuron lesion ( neuron from spinal cord) cause
- loss of voluntary control - decrease muscle tone - hypotonicity - flaccid muscle, paralysis - muscle atrophy - assent or decreased reflexes - negative Babinski: toe point down ( normal) - freq occur with compression of nerve roots by herniated intervertebral dics, trauma, infection, toxin , vascular disorder, degenerative process etc
upper motor neuron lesion ( neuron from brain) cause
- loss of voluntary control - increased muscle tone - hypertonicity - muscle spasticity - no muscle atrophy - if atrophy then because no nerve stimulation lead to non-using of muscle - hyperactive and abnormal reflex - positive Babinski ( abnormal) - meaning when stimulated, toe point up and fanning out - freq occur with stroke, spinal cord injury, MS, Parkinson
lithium concern
- maintain therapeutic level: 0.6-1.2 mEq/L - pt who take this med should drink 2L of water a day and consume normal salt intake - high sodium intake reduce availability of lithium receptor site - daily weight and monitor I & O - assess for sx of dehydration or fluid retention - pt who have diarrhea, flu, fever, vomiting should contact physician asap.--> risk for toxicity - thyroid function baseline and q6mth because first 6-18 months of taking lithium, increased thyroid stimulating hormone happen--> can cause anxiety, labile emotion, sleep difficulty - contraindicated in pt with impaired renal function, urinary retention or those taking low salt diet or diuresis, and people with brain or CV damange
valproic acid (anticonvulsant med)
- med used for simple absence and mixed seizure, migraine prophylaxis and mania - action unclear - therapeutic level is 50-125 µg/mL - require baseline and ongoing liver function test, including serum ammonia, pt and coagulants lab values
opioid abuse and treatment
- methadone - a potent synthetic opiate, given as substitute for heroin --> take one daily dose , which meet physical need but does not produce cravings anymore --> may addicted to methadone, but methadone is safer and is level, control by physician
RA complication
- musculoskeletal ( deformities, demineralization, stress - hematologic (anemia, splenomegaly) - Cardiac ( pericarditis, myocarditis , valve involvement) - pulmonary (fibrosis, pneumonitis, pleural disease)
medical management for seizure / epilepsy etc
- no cure, can only control - if in status epileptics, give benzodiazepin diazepam, lorazepam or fosphenytoin IV slowly to halt seizure asap. - anticonvulsant meds to control and prevent such as carbamazepine, clonazepam, gabapentin, phenobarbital, phenytoin, valproate , etc. * pt receive phenytoin should have good oral hygiene to prevent gingival hyperplasia - educate pt must take anticonvulsant med as prescribed on continuing bases and drug dependence or addiction does not occur. - require serum level monitor freq. - educate pt to avoid factor such as emotional, stressor, constipation, hypoglycemia, get rest ( enough sleep), moderate routine lifestyle, avoid stimulant such as alcohol, caffeine, wear dark glasses if bright , flickering light or TV cause seizure. - educate to report s/sx of toxicity such as drowsiness, lethargy, dizziness, difficulty walking, hyperactivity, confusion, visual disturbances
similarities of OA and RA
- pain - stiffness - weakness ( from decreased use of muscle bc of pain and stiffness - depression
palliative care vs hospice care
- palliative care is aimed at anyone who has been dx with life threatening illness --> help maintain quality of life and reduce illness sx --> recent research findings suggest pt who receive palliative care alongside with standard tx can live longer - hospice care is aimed at pt dx with terminal illness --> provide pt with dignified, pain free death --> most commonly provide at pt home
inter negational transmission process in violent family
- patterns of violence usually maintain from 1 generation to the next through role modeling and social learning - children who witness violence between parents learn that violence is a way to resolve conflict and is integral part of close relationship. - statistic show that ⅓ of abusive men likely to have come from violent home where they witness the wife being beaten or abused - women who grow up in violent home are 50% more likely to expect or accept violence in their own relationships - not all person expose to family violence become abusive or violent as adult -Adults who were victims of abuse as children frequently abuse their own children
spinal shock
- physiologic response that occurs between 30 and 60 minutes after trauma to the spinal cord and can last up to several weeks. - spinal shock presents with total flaccid paralysis and loss of all reflexes , no sensation below the level of injury. - can be tempo or permanent, if reflex come back but no sensation or motor function meaning it is complete - BP decreased and bradycardia --> low BP can further damage spinal cord --> maintain MAP >85 mm Hg - reflex of bladder and bowel also affected --> bladder and bowel distention, paralytic ileus [ often occurs within first 2-3 day after SCI and resolve within 3-7days] --> decompress by NG tube
nursing management after seizure
- post-ictal can last minute to hours - pt at risk for hypoxia, vomiting and pulmonary aspiration after seizure --> place in side lying position to facilitate drainage of oral secretion , have suction ready and suction PRN assess for - any obvious paralysis or weakness of extremities after seizure - inability to speak after seizure - if pt sleep afterward, they can be very fatigue and drowsy for hrs - cognitive status ( confused, or not) --> re-orientate pt if they awake --> if GCS decrease--> should concern about possible brain lesion/ injury. - support physical and psychologically ( anxiety, embarrassment, fatigue, depression), - ask for developmental history : event of pregnancy and childbirth trauma,a, pre-existing head injury or illness affected the brain - implement seizure precaution, document in chart and communicate that with other staff ( bed in low position, pad side rails, suction ready)
nursing assessment for pt with PD
- s/sx: tremor, rigidity, postural changes (forward posture) , and bradykinesia ( slowness of movement) - how disease affect ADL, functional abilities - response to medication, compliance. - observe quality of speech, loss of facial expression, swallowing deficit ( drooling, poor head control, coughing), mental slowness, confusion - how pt is coping, family support structure - fall risk assessment ( ask pt if they have irregular jerking, stiffness of extremities, any recent falls?) - ask and observe of their mouth have excessive saliva, if they notice they grimacing or have chewing, lip smacking movement ( dyskinesia)
alcohol and drug abuse in violent family
- substance abuse, esp alcoholism ass with family violence - alcohol is not cause of abuse, but it diminish inhibition and make violent behavior more intense and freq - abusive person likely to use alcohol and drugs - violent incidents , including acquaintance rape or date rape, usually have alcohol involved - women who have partner abuse alcohol more likely than other women to be assaulted by their partner
Alcohol withdrawal syndrome
- symptoms of withdrawal usually begin 4 to 12 hours after cessation or marked reduction of alcohol intake. - Symptoms include coarse hand tremors, sweating, elevated pulse and blood pressure, insomnia, anxiety, and nausea or vomiting. - Severe or untreated withdrawal may progress to transient hallucinations, seizures, or delirium—called delirium tremens (DTs). - Alcohol withdrawal usually peaks on the second day and is over in about 5 days. This can vary, however, and withdrawal may take 1 to 2 weeks.
RA stages
- synovitis ( thickened and inflammation of synovial membrane) - pannus ( cartilage destruction) - fibrous ankylosis (fibrous tissue evolves into scar tissue)
SLE is affect which population?
- systemic lupus erythematosus - not communicable - autoimmune connective tissue disorder - systemic --> affect multiple organs of body - M : F is 1 : 10 - more common is black African and Indian , asian , hispanics than Caucasians - strong genetic component - onset any age --> peak at 25-35yo and 50-60yo** - can have flare up and remission
abuse of power and control in violent family
- the abuser always hold control, power in physical, economic and social, is often the one who make decisions, spend money. - the abuser belittle, blames, manipulate victim - if abuser perceive independence or disobedience ( real or imagined), violence escalates
What can the nurse tell a client about antipyretic drugs during fever? "Antipyretics are ineffective in most cases." "They usually have little effect." "Antipyretics help to protect the body." "They are not recommended."
"Antipyretics help to protect the body." Explanation: Antipyretic drugs are given to alleviate the discomfort of fever and protect vulnerable organs, such as the brain, from extreme elevations in body temperature. They are usually effective.
The nurse is teaching a client who will be undergoing heart open surgery about what to expect when waking up from anesthesia. The nurse explains the client will experience feeling cold, which is induced during surgery. The client asks the nurse why they induce cold. What is the best response by the nurse? "Inducing a cold environment will make the surgery go faster." "It will decrease the amount of bleeding during surgery." "It will reduce the demand for tissue oxygenation."? "It will decrease symptoms related to anesthesia."
"It will reduce the demand for tissue oxygenation."
grey-runner's sign
"turn her over" bluish, discoloration on the flank (side of abdomen )
nursing intervention for pt with SCI
(1) maintain adequate breathing and airway clearance (2) improve immobility - maintain proper body lalignment, turn safety and freq, use splint to prevent foot drop, trochanter tool to prevent hip external rotation, provide passive ROM prevent contracture 4-5 time daily. caution that hypotension occur with changing position (3) preventing injury, maintain skin integrity (4) maintain urinary and bowel elimination
MS- nursing goal and intervention
(1) promote physical mobility: exercise, assertive device use to ensure safety, minimize spasticity and contracture ( use warm pack, daily stretch). Allow resting time to avoid raising temp and cause exacerbation. Take muscle relaxant med as Rx( but can cause fatigue as SE) (2) nutrition: many MS pt are overweight, because of use of corticosteroid and mobility impairment --> health eating, wt reduction (3) preventing injury: walk with feet apart watch feet while walking, use assistive device, consult PT, OT for home modification with handrails, raised toilet seat, no loose rugs etc (4) enhancing bladder and bowel control to avoid use of catheter: have bedpan or urinal ready, set up voiding time ( q1.5-2hr) , instruct drink water q2h and void 30 min after drinking ( use timer or watch to help signal time for empty bladder) . For constipation, set bowel routine, increase fiber and fluid intake. (5) enhancing communication, manage swallowing difficulty --> have suction available , careful feeding, confirm correct fluid and food consistency, risk for aspiration is higher in later disease process, teach pt to tilt head down while swallowing, conscious thinking while eating (6) improv cognitive function: wear glass, free talking book, large print book, pt can be in denial, depression, withdrawal , hostility --> set meaningful and realistic goal, encourage family and friend support. (7) strengthen coping mechanism,: consult OT, PT, speech therapy, social service, homemaker services, remove stress ( physical, emotional) which can cause flare up, avoid extreme cold or heat, recommend air conditioner in house, consult with sexual counselor for sexual concern. (8) potential complication of MS: resp. failure, autonomic dysfunction, DVT, PE, urinary retention ( because detrusor muscle in bladder not receive signal) (9) resources: local national MS society for service, publication, support group
5 types of immunoglobulins (antibodies)
(GAMDE) IgG, IgA, IgM, IgD, IgE
agnostic
(n.) one who believes that nothing can be known about God; a skeptic; (adj.) without faith, skeptical
risk factor of gallstone
* women more than man : estrogen increase cholesterol formation --> oral contraceptive pills --> increase risk of cholesterol stones * obesity --> increase cholesterols --> increase risk of cholesterol gallstone * rapid weight loss --> decreased lipids --> imbalance in bile components --> increase chances of calcium-bilirubin precipitation --> bilirubin gallstones formation
s/sx of cholecystitis
** Pain (midepigastric ) --> radiate to Rigidity of the upper right abdomen → radiate to misdternal area of right shoulder Nausea vomitting Usual s/sx of inflammation
RA clinical manifestations
** deformities is the key characteristic clinical sign** - gradual onset - joints --> morning stiff lasting at least 1h after wakeup - systemic swelling of 3 or more joints --> mostly in wrist, hands - systemic effects = low grade fever = malaise and weakness = anorexia and wt loss = depression = fatigue by afternoon = vasculitis = chronic hand deformities - pain, inflammation, redness, joints are warm to touch - sx got worse in hot weather
osteoarthritis node
- Bouchard's nodes in proximal inter-phalangeal joint (PIP) --> second or last knuckle of finger - Heberden's node --> distal inter-phalangeal (DIP ) - closer to finger tip
lithium toxicity s/sx
- COARSE Hand Tremors - Confusion - Nausea - Muscle weakness
cultural or ages consideration with depression
- Children with depression often appear cranky, have school phobia, hyperactivity, learning disorder, failing grade, antisocial behaviors - Adolescent abuse substance, join gangs, engage in risky behaviors, drop out of school - In adult: substance abuse, eating disorder, compulsive behavior such as workaholism, gambling, - Older adults: cranky, argumentative - Asian who are anxious or depressed c/o headache, backache, etc - Latin culture c/o nerves or headache while Middle Eastern culture c/o heart problem
EEG - electroencephalography
- Electrodes are applied on scalp or microelectrode placed within brain tissue to assess cerebral electrical activity → result recorded on encephalogram ( paper) - Used to dx seizure disorder, coma, brain syndrome, brain death - Tumor, brain abscess, blood clot and infection can cause abnormal e- activity. - Baseline is recorded by having pt lie quietly with both eyes closed and asked to hyperventilate for 3-4 min or look at bright, flashing light for photic stimulation → to evolve abnormal e-discharge , such as seizure potential → standard EEG take 45-60min - Sleep EEG → EEG record after sedation because some abnormal brain waves only seen while pt asleep , → require 12hrs
neuro assessment
- Glasgow coma scale, VS, gait, handgrip, facial expression, finger to nose, Romberg test, balance test , walk straight line on tippy toe, any pre-existing brain trauma, BG, medication currently taking,Babinski, - pain: back pain, headache, numbness, tingling , how bad how often - seizure: can be blank stare, tonic clonic, can be induced by fiver, alcohol drug withdrawal, hypoglycemia. seizure is first obvious sign of brain lesion - dizziness, vertigo: + n/v, abnormal balance and movement, - visual disturbances: blurry vision, seeing flash of light, blind spot, double vision. - muscle weakness: compare to side - abnormal posture: (1) decortication is abnormal flexion of upper extremities and extension of lower ones, (2) decerebration( extreme extension of all extremities, or 3) flaccidity
food that reduce arthritis and inflammatory pain
- turmeric - cherry - ginger - omega 3 foods (flax seed, chia seed, hemp seed) - pineapple - raw apple cider vinegar
MRI scan
- use magnetic field - with or w/o contrast - can identify cerebral abnormalities earlier and clearer than other test, provide information about chemical changes within cells, tumor's response to treatment - useful in dx brain tumor, stroke, MS - may take an hour or longer, not use in emergency
bipolar disorder onset / risk factor
- usually in late teen 20-30s - Manic episodes begins suddenly, last few weeks to months - young men early on course of their illness at highest risk for suicide, esp. who with hx of attempt suicide or alcohol or drug abuse and those recently discharged from hospital - occur equally among men and women - more common in highly educated people - adolescent with bipolar disorder more likely to have psychotic sx ( delusion, hallucination)
CN X
- vagus - mixed - muscle pf pharynx, larynx and soft palate - sensation in external ear, pharynx , larynx, thoracic and abdominal viscera - parasympathetic innervation of thoracic and abdominal organs
non neurologic SE of antipsychotic meds
- weight gain - sedation - photosensitivity - anticholinergic sx ( dry mouth, blurred vision, constipation, urinary retention - orthostatic hypotension - agranulocytosis [ clozapine]
when gallstone stuck in common bile duct
--> block flow of bile from the liver --> backflow to liver --> pressure on bile duct in liver ---> get into blood vessels --> increase of conjugated bilirubin serum level (lab) --> jaundice - when bile backflip --> cause pressure in cells of liver and bile duct -->these cell lignin the ducts can die --> release ALK ( alkaline phosphate enzyme ) --> increase serum ALK
pain in duodenal ulcer
-2-3 hour after eating -awake with pain at night (80%) relief of pain after eating or after taking antacid
lethality assessment for suicide
-Does the client have a plan? If so, what is it? Is the plan specific? - Are the means available to carry out this plan? (e.g., If the person plans to shoot himself, does he have access to a gun and ammunition?) - If the client carries out the plan, is it likely to be lethal? (e.g., A plan to take 10 aspirins is not lethal, while a plan to take a 2-week supply of a tricyclic antidepressant is.) - Has the client made preparations for death, such as giving away prized possessions, writing a suicide note, or talking to friends one last time? - Where and when does the client intend to carry out the plan? - Is the intended time a special date or anniversary that has meaning for the client?
biological theories of anxiety disorder
-GABA is an amino acid neurotransmitter believed to be dysfunction in anxiety disorder - GABA is an inhibitory neurotransmitter function as body's natural anti anxiety agent by reducing cells excitability , decrease the rate of neuronal firing. - serotonin and NE increase anxiety - imbalance between these 2 occur in anxiety disorder - excess of NE is suspected in panic disorder , GADm and PTSD
how to assess for suicide (include order of questions) and the nurses responsibility in assessing suicide risk
- Ideation: "Are you thinking about killing yourself?" - Plan: "Do you have a plan to kill yourself?" - Method: "How do you plan to kill yourself?" - Access: "How would you carry out this plan? Do you have access to the means to carry out the plan?" - Where: "Where would you kill yourself?" - When: "When do you plan to kill yourself?" - Timing: "What day or time of day do you plan to kill yourself?"
pharmacology therapy for PD
- Levodopa is most effeective med and is maintay treatment of PD, most beneficial in 1st and 2nd year of treatment, - benefit decrease and AE more severe overtime. -Cardidopa often added to levodopa treatment to avoid metabolism of levodopa before it reaches the brain. Within 5-10 yrs, meds not effective anymore, pt develop AE dyskinesia including facial grimacing, rhythic jerking movement of hands, head bobbing ( quick movement up and down of head), chewing and smacking movement, - Other potential AE: neuroleptic maligment syndrome: involve severe muscle stiffness, rigidity, hyperthermia ( high fever 102-104F), sweat a lot, anxiety, fast or abnormal heart beat, quick breathing, more saliva than usual Anticholinergic meds to control tremor such as benztropine mesylate [ cogentin] Beta blocker ( propranolol) also used to help reduce tremor , off lable use is to calm pt ( by lower HR) , relieve anxiety.
basilar skull fracture (Battle's sign)
- Most dangerous type of head injury is Basilar ( or basal) skull fracture - Meaning the fracture is at the base of the skull - the fracture tend to transverse the paranasal sinus of frontal lobe or middle ear located in temporal lobe→ freq produce hemorrhage from nose, pharynx or ears and blood may appear under conjunctiva → an area of ecchymosis ( bruising) may be seen over mastoid ( behind the ears) ( Battle sign) - Basal skull fracture is suspected when CSF escape from ears ( CSF otorrhea) and the nose ( CSF rhinorrhea) → drainage of CSF is serious problem because meningeal infection can occur if organism gain access to cranial content via the nose, ear, or sinus through a tear in the dura.
RA treatment
- NSAIDs - cox1 and cox 2 inhibitor - corticosteroids, - disease-modifying drugs (MTX, sulfasalazine, TNF inhibitors) - methotrexate - heat/ cold application - deformities prevention devices - physical therapy - surgery - joint replacement
MRI nursing intervention
- Questions and assess for implant of any metal objects (aneurysm clips, orthopedic hardware, pacemakers, artificial heart valves, intrauterine device) → malfunction, dislodge or heat u, ask veteran if have bullets in their bodies - Remove any metal object, credit cards, medication patches that have metal backing (nicotine patch) , metallic lead wires, oxygen tanks, IV poles, ventilator and even stethoscopes. - pt Lies with head in a flat platform that moved into a tube containing magnets ( pt who cannot lie flat may not tolerate MRI) - Educate pt that Procedure is painless, pt will hear loud thumping noise and they able to talk to staff through a microphone inside scanner. - Assess if pt have claustrophobia, Give sedation PRN
warning signs to be alert for that could alert the nurse/provider that a child is a victim of abuse (physical, emotional, and mental signs)
- Serious injuries such as fractures, burns, or lacerations with no reported history of trauma - Delay in seeking treatment for a significant injury - Child or parent giving a history inconsistent with severity of injury, such as a baby with contrecoup injuries to the brain (shaken baby syndrome) that the parents claim happened when the infant rolled off the sofa - Inconsistencies or changes in the child's history during the evaluation by either the child or the adult - Unusual injuries for the child's age and level of development, such as a fractured femur in a 2-month-old or a dislocated shoulder in a 2-year-old - High incidence of urinary tract infections; bruised, red, or swollen genitalia; tears or bruising of rectum or vagina - Evidence of old injuries not reported, such as scars, fractures not treated, and multiple bruises that parent/caregiver cannot explain adequately - Sexually abused children often talk or behave in way indicate advanced knowledge of sexual issue expected for age - Child can be frighten, anxious, either cling to or reject adult entirely, refuse to eat or aggressive behavior.
EEG nursing interventions
- To increase chances of recording seizure activity, sometimes pt need to deprive of sleep the night before EEG - Withheld anticonvulsant, tranquilizers, stimulants and depressants 24-48hrs before EEG ( these med alter or mask wave patterns of seizure disorders) - Not allow coffee, tea, chocolate, cola - because have stimulating effect - However, pt can have meal normally because layered BG cause changes in wave pattern - Assure pt that procedure does not cause electric shock and it is a diagnostic test, no treatment performed - Routine EEG use water soluble lubricant for electrode contact, can wiped off and removed by shampoo - Sleep EEG use collodion glue for electron contact, which require acetone for removal
what to concern if pt use contrast for diagnostic testing
- allergy to iodine, shellfish - kidney function before and after - if pt take metformin, must hold it before procedure and at least 48h after because risk of lactic acidosis, esp. if pt have severe impaired kidney.
late sign of increased ICP
VS: increase in SBP, widening pulse pressure, slow HR, pulse fluctuate rapidly from bradycardia to tachycardia, temperature increase, altered resp. pattern such as cheyne-strokes breathing - projectile vomiting - Cushing triad: bradycardia, hypertension and bradypnea - LOC decrease till pt comatose, with decortication or decerebration or flaccidity of extremities. - if coma is profound and irreversible because too high ICP compress brainstem lead to brain death --> loss of brainstem reflexes such as apnea, no response to pain stimulus, loss of brainstem reflex ( pupil dilated and fixed, corneal reflex [ eye don't blink when rubbed with cotton ball] , no gag reflex)
cultural imposition
When one person imposes his or her beliefs, values, and practices on another because he or she believe his or her ideals are superior
Zollinger-Ellison syndrome (ZES)
ZES --> Peptic Ulcer Disease Pathophys = gastrin-secreting tumors (gastrinomas) within GI tract --> hypersecretion of gastric acid
Faith
a confident belief in something for which there is no proof or evidence can involve person, idea, or thing, followed by action related to the ideals or value of that belief
Delirium tremens
a disorder involving sudden and severe mental changes or seizures caused by abruptly stopping the use of alcohol
Delusional thinking:
a fixed, false belief not based in reality
flooding
a form of rapid desensitization in which a behavioral therapist confronts the client with the phobic object (either a picture or the actual object) until it no longer produces anxiety
psychosis
a psychological disorder in which a person loses contact with reality, experiencing irrational ideas and distorted perceptions, delusion, hallucination
dissociation
a subconscious defense mechanism that helps a person protect his or her emotional self from recognizing the full effects of some horrific or traumatic event by allowing the mind the forget or remove itself from the painful situation or memory
system theory
a system is composed of subsystems interconnected to the whole system and to each other by self regulating feedback mechanism, circular patterns of behaviors
Decatastrophizing
a technique that involve learning to assess situation realistically rather than always assuming a catastrophe will happen ex: what is the worst thing that can happen, is it likely to happen, could you survive it - use thought stoping, distraction technique, flashing face with cold water, snapping rubber band or shouting to break cycle of negative thoughts.
compassion fatique
a type of secondary trauma or stress resulting from helping others work through trauma stress; experience by those in the helping professions
s/sx of appendicitis
abdominal pain from umbilical radiate to right lower quadrant, , nausea, vomiting, loss of appetite
empathy
ability to perceive the meanings and feelings of another person and to communicate understanding to that person
stress ulcers
acute gastric mucosal lesions occuring after medical crisis or trauma ( burn, shock, sepsis ,
sx of delirium
altered LOC is early sx, , range from stupor ( hypo-alert, hypoactive) to excessive activity ( hyperactive- hyper-alert) or combination of both, disorganized thinking, short attention span, easily distract, hallucination, delusion, fear, anxiety and paranoia, speech less coherent , poor judgement, insomnia, daytime sleepiness
acute gastritis s/sx
anorexia rapid onset epigastric pain hematemesis = vomiting blood hiccups melena = black tarry stool hematochezia = bloody stool n/v
what is ANA
antinuclear antibodies - antibodies that target "normal" proteins w/in the nucleus of a cell
interferons function
antiviral and anti tumor proteins secreted by T cells; they also stimulate macrophages to ingest bacteria - used to tx multiple sclerosis and chronic hepatitis
Spirituality
anything that pertains to a person's relationship with a nonmaterial life force or higher power
Dystonic reactions
appear early in the course of treatment and are characterized by spasms in discrete muscle groups such as the neck muscles (torticollis) or eye muscles (oculogyric crisis). These spasms may also be accompanied by protrusion of the tongue, dysphagia, and laryngeal and pharyngeal spasms that can compromise the client's airway, causing a medical emergency. Dystonic reactions are extremely frightening and painful for the client. Acute treatment consists of diphenhydramine (Benadryl) given either intramuscularly or intravenously, or benztropine (Cogentin) given intramuscularly.
how to know there is a obstruction when pt have NGT
assess fluid aspirated --> if more than 400ml -->obstruction --> why???
stereotype
assigning characteristics to a group of people without considering specific individuality Maybe positive or negative
IgE
associate mainly with allergy / allergen found in lung, skin, mucous membrane - protect against parasitic worm
potential complication of SCI
autonomic dysreflexia DVT, PE orthostatic hypotension
Long term or high dose use of corticosteroids AD
avascular necrosis = lack of blood supply to joint, result in tissue damage --> teach pt to report new onset of joint pain, particularly with wt bearing, limited ROM
acceptance
avoiding judgments of the person, no matter what the behavior
treatment of acute gastritis
avoiding mucosal irritants and quit smoking antacids H2 blocker (famotidine, ranitidine) misoprostol PPIs (omeprazole , lansoprazole)
increased neutrophils means
bacterial infection
orientation phase
begin when the nurse and client meets and end when the client begins to id. problems to examine
systemic desensitization
behavioral technique used to help overcome irrational fears and anxiety associated with phobia - therapist progressively expose the client to the threatening object in a safe setting until client's anxiety decrease
A client experienced a stroke that damaged the hypothalamus. The nurse should anticipate that the client will have problems with? thinking and reasoning. balance and equilibrium. visual acuity. body temperature control.
body temperature control Explanation: The body's thermostat is located in the hypothalamus; therefore, injury to that area can cause problems with body temperature control. Balance and equilibrium problems are related to cerebellar damage. Visual acuity problems would occur following occipital or optic nerve injury. Thinking and reasoning problems are the result of injury to the cerebrum.
PD manifestations
cardiac signs: tremor, rigidity , bradykinesia and postural changes - tremor: slow, unilateral resting tremor which disappear with purposeful movement and during sleep - rigidity: resistant to movement, mostly in arm, legs, face and posture. Early in disease , pt ℅ of should pain due to rigidity - bradykinesia: overall slowing of active movement, take longer to complete activity to difficulty initiating movement such as rising from sitting position, turning in bed - postural instability: head bend forward, forward flexion of hip, knee and elbow, loss of balance, walk with body bend forward. - late s/sx: dementia, change in mental status, dysphasia ( begin to drool), depression, dysphonia ( voice impairment),
Early s/sx of increased ICP
changes in LOC, disorientation, restlessness, agitation, confusion, drowsiness - delayed verbal response. - increased resp. effort, purposeless movement, - pupillary changes and impaired extra-ocular movement occur as increased pressure displaced brain against the oculomotor and optic nerve (CN II, III, IV, VI), which arise from midbrain and brainstem - weakness in one side of body - instant headache, increasing in intensity, and aggravated by movement or straining ( increased ICP stretching vessels)
gallstone = cholelithiasis types
cholesterol stones bilirubin stones
Cholelithiasis (gallstones) types / forms ( 2)
cholesterol stones = precipitated cholesterol bilirubin stones = pigmented
medication used for dementia
cholinesterase inhibitor 1. donepezil - 5-10mg PO q day - monitor for nausea, diarrhea, and insomnia - test stool periodically for GI bleeding 2. rivastigmine - monitor for n/v, abd. pain and loss of appetiite 3. galantamine - monitor for n/v, loss appetite, dizziness and syncope NMDA receptor agonist - slow progression of moderate to severe stage of Alzheimer 4. memantine - monitor for hypertension, pain, headache, vomiting, constipation, and fatigue.
ideas of reference
client's inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message has personal meaning
Opsonization
coating antigen with antibody to enhances phagocytosis
treatment of H.pylori gastritis
combo of - PPI antibiotics bismuth salts
elements of internal structure of family
composition, gender and gender roles, rank order, subsystems, boundaries, power structure
Korsakoff's syndrome/ dementia
dementia result from longterm use of alcohol
ETHICAL KNOWING
derived from moral knowledge of nursing
aesthetic knowing
derived from the art of nursing
empirical knowing
derived from the science of nursing
role of the DSM V how it is used and the purpose
describes all mental disorders and outlines specific diagnostic criteria for each based on clinical experience and research purpose - standardize nomenclature, language - identify defining characteristics or symptoms - assist in identifying underlying causes
factor affecting spirituality
developmental considerations family ethnic background formal religion life events
inappropriate affect
displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances
broad affect
displaying a full range of emotional expressions
restricted affect
displaying one type of emotional expression, usually serious or somber
cultural diversity
diverse groups in society, with varying racial classifications and national origins, religious affiliations, languages, physical size, gender, sexual orientation, age, disability, socioeconomic status, occupational status, and geographic location
diverticulosis vs diverticulitis
diverticulosis = many diverticula esp at sigmoid colon; causes a focal weakness in colonic wall; ass with low fiber diets; asymptomatic or slight discomfort; diverticulitis = inflammation causing LLQ pain, fever, leukocytosis; can lead to peritonitis, abscess formation or bowel stenosis
Tx of SLE
drugs: - corticosteroid (prednisone, solumedrol) - immunosuppressant drugs - NSAIDs for musculoskeletal complaints - Antimalarials (hydroxychloroquine or quinacrine) --> ( slow joint degeneration)
life affirming
enhance life, give meaning and purpose to existence, strengthen self, are health giving and life sustaining
IgA
found in mucous membrane , esp those lining the respiratory and GI tract as well as saliva, tears protect against pathogen high concentration in breast milk
increased monocytes means which type of infection
fungal / vial infection
attitudes
general feelings or a frame of reference around which a person organizes knowledge about the world
hormones that raise glucose level
glucagon, epinephrine, adrenalcorticosteroids, growth hormones, thyroid hormone
alpha cell of pancreas produce
glucagon: raise blood glucose by converting glycogen to glucose in the liver. glucagon is secreted in response decreased level of blood glucose
most-common cause of increased ICP
head injury, brain tumor, subarachnoid hemorrhage, toxic or viral encephalopathies
RA risk factors
higher incidence in women - any age, peak in 40 to 50 yo - smoker, stress, infection
CN XII
hypoglossal - motor - movement of tongue
beliefs
ideas that one holds to be true
Apraxia:
impaired ability to execute motor functions despite intact motor abilities
Lock-in syndrome
inability to move or respond except for eye movement due to lesions affecting the pons
Agnosia:
inability to recognize or name objects despite intact sensory abilities
Mental Illness definition
includes disorders that affect mood, behavior, and thinking, such as depression, schizophrenia, anxiety disorders, and addictive disorders.
substance dependence
includes problems associated with addiction, such as tolerance, withdrawal, and unsuccessful attempts to stop using the substance
function of bradykinin
increased blood flow increase capillary permeability increase pain
how NSAIDs effect GI tract
inhibit prostaglandin --> disrupt normal protective mucosal barrier. --> decrease resistant to bacteria --> h. pylori infection
family function include
instrumental (ADLs) affective and socialization expressive healthcare
hormone produced by beta cells of pancreas
insulin
Hypomania
is a period of abnormally and persistently elevated, expansive, or irritable mood and some other milder symptoms of mania. The difference is that hypomanic episodes do not impair the person's ability to function (in fact, he or she may be quite productive), and there are no psychotic features (delusions and hallucinations).
Mental health definition
is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability.
spiritual needs
lack of anything necessary for spiritual health (e.g., meaning and purpose, love and relatedness, forgiveness)
Herpes simplex virus
lifelong viral infection --> can't be cured --> tx is to relieve sx cause lesion - blister on external genitalia, occasional vagina and cervix initial infection usually very painful --> take 2-4 w to heal usually killed at room temp by drying --> diminished and tay in nerve ganglia --> outbreak when stress, sunburn, dental work, inadequate rest, poor nutrition. spread though close contact: mouth, oropharynx, mucusal surface, vagina, cervix can spread though labor to infant --> c section
risk factors of diverticula
low fiber diet smoking NSAIDS family history
thrombocytopenia
low platelet count -most common cause of bleeding in pt with cancer - usually defined as platelets count less than 100,000 /mm3
Waxy flexibility:
maintenance of posture or position over time even when it is awkward or uncomfortable
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication? fluid volume excess malignant hyperthermia hypothermia infection
malignant hyperthermia Explanation: Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Hypothermia is a lower than expected body temperature. Signs of infection would not present during the procedure. Increased body temperature would not indicate fluid volume excess.
spirituality concepts
meaning, presencing, empathy/compassion, giving hope, love, religion/transcendence, and touch and healing.
social isolation of violent family
members of families keep to themselves, not usually invite other into their home or tell anything about family, abuser threaten victims with greater harm ( such as a parent, sibling, pet will die if others know b' the abuse)
Methadone and opioid recovery
methadone may not produce significant withdrawal symptoms for 2 to 4 days, and the symptoms may take 2 weeks to subside. Methadone can be used as a replacement for the opioid, and the dosage is then decreased over 2 weeks. Substitution of methadone during detoxification reduces symptoms to no worse than a mild case of flu
pupil that is fixed and dilated indicate?
midbrain lesion/ injury
Pseudoparkinsonism,
neuroleptic-induced parkinsonism, includes a shuffling gait, masklike facies, muscle stiffness (continuous) or cogwheeling rigidity (ratchet-like movements of joints), drooling, and akinesia (slowness and difficulty initiating movement). These symptoms usually appear in the first few days after starting or increasing the dosage of an antipsychotic medication.
Religion
organized system of beliefs about a higher power; often includes set forms of worship, spiritual practices, and codes of conduct influence patients' responses to illness and suffering, self-care practices such as diet and hygiene, birth and death rituals, gender roles, spiritual practices, and moral codes.
Psychomotor retardation:
overall slowed movements
o'brien spiritual assessment distress guide
pain alienation anxiety guilt anger loss despair
RA nursing interventions
pain control self esteem client education maintain joint function
increased eosinophils means which type of infection
parasite or allergy reaction
problem identification
part of working phase of nurse client relationship when the client identifies the issues or concerns causing problems
schizophrenia onset
peak incidence is 15-25yo for men and 25-35yo for women - onset- can be abrupt or slow and insidious, most with slow, gradual development of s/sx - diagnosed usually with more actively positive sx of psychosis
flashbacks
person feels or acts as though the traumatic events were recurring
function of histamine in inflammation
present in many tissue of body but concentrated in mast cell. Released when injury occur and is responsible for early changes in vasodilation and vascular permeability
social relationship
primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task
Cultural assimilation (acculturation)
process that occurs when a minority group, living as part of a dominant group within a culture, loses the cultural characteristics that made it different
s/sx of CSF leak
pt ℅ salty taste , clear nasal drip, CSF dripping down on throat
family context include
race and ethnicity, social class, religion and environment
cholescintigraphy (HIDA scan)
radioactive tracer attach to HIDA (hepatic iminodiacetic acid --> injects to patient --> taken up by hepatocytes (liver cells) --> excrete in bile --> drained down hepatic ducts --> if no block --> tracer get to small bowel --> or block and can not see small intestine to detect gallstone block in common bile duct
Labile mood:
rapidly changing or fluctuating, such as someone's mood or emotions
labile
rapidly changing or fluctuating, such as someone's mood or emotions
Peritonitis s/s:
rebound tenderness muscular rigidity laying still w/fast shallow breaths distended abd ascites fever leukocytosis (elevate WBC) decreased hemoglobin and hematocrit if blood loss
Echolalia:
repetition or imitation of what someone else says; echoing what is heard
confidentiality
respecting the client right to keep private any information about his or her mental and physical health and related care
life denying
restrict or enclose life patterns, limit experiences and associations, place burdens of guilt of guilt on individuals, are health denying and life inhibiting
self disclosure
revealing intimate aspects of oneself to others
the priorities in planning/providing care for a schizophrenic patient:
safety always comes first 1. Watch for increasing agitation, violence, escalating behavior and protect patient, family and staff from pt - kicking/throwing items - Frantically pacing - yelling 2. Help them maintain adequate nutrition and drink enough water
Romberg test
screening test for balance - pt can with or stand with feet together, arms at sides, first with eyes open and then close for 20sec --> observe pt have slight swaying , which is normal but if loss of balance that require open of eye to can cause threat to safety is abnormal
5 types of inflammatory exudates
serous : clear , watery --> skin blister fibrinous: increased fibrinogen --> adhesion post catarrhal: cloudy, mucus --> runny nose with common cold purulent: yellow, green opaque --> absesses hemorrhagic: RBC --> hematoma
perforated peptic ulcer s/sx
severe, sharp and consistent upper abdominal pain --> *** pain referred to shoulder (right) ** boardlike abdomen --> shock (hypotension, tachycardia)
blunt affect mean
showing little or a slow-to-respond facial expression; few observable facial expressions
flat affect
showing no facial expression
Race
specific physical characteristics such as skin pigmentation, body stature, facial features, and hair texture. categories including American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, and White,
CN XI
spinal accessory - motor -sternocleidomastoid and trapezius muscles
function of prostaglandins
stimulate local nocioceptors, pain, increased vascular permeability, increased edema
Immunomodulators
stimulating the immune system to fight against disease include interferons, colony stimulating factors, monoclonal antibodies - usually used in immune therapy
thought blocking
stopping abruptly in the middle of a sentence or train of thought; sometimes client is unable to continue the idea
theories of family function
system theory Bowen's family system theory communication
grounding techniques
technique remind the client that she/she is in the present, as an adult and is safe, helpful to use with pt who is dissociating or experiencing flashback Decrease the dissociative expeirnece by focus on current sense ( can you see me and room we are in, can you feel watch on your wrist , feel the blanket wrap aroud them)
circumstantial thinking
term used when a client eventually answers a question but only after giving excessive, unnecessary detail
tolerance
the need for increased amount of a substance to produce the same effect
withdrawal syndrome
the negative psychologic and physical reactions that occur when use of a substance ceases or dramatically decreases
Bowen's Family Systems Theory
the nuclear family is a part of a multigenerational extended family with patterns of relating that tend to repeat over generation when the pattern continues across generations, it is called multigenerational transmission process focus on differentiation of self and triangles
self awareness
the process by which a person gains recognition of his or her own feelings, beliefs, and attitudes; the process of developing an understanding of one's own values, beliefs, thoughts, feelings, attitudes, motivations, prejudices, strengths, and limitations and how these qualities affect others
advocacy
the process of acting on the client behalf when he or she cannot do so a
cultural blindness
the process of ignoring differences in people and proceeding as though the differences do not exist
preconception
the way one person expects another to behave or speak; often the roadblock to the formation of an authentic relationship
Loose association/disorganized thinking:
thinking that jumps from one idea to another with little or no evident relation between the thoughts
CN IV
trochlear - motor - muscle that move the eye
genuine interest
truly paying attention to the client, caring about what he or she is saying only possible when the nurse is comfortable with himself or herself and aware his or her strength and limitations
Intoxication
use of a substance that results in maladaptive behavior.
A nurse plans to measure the temperature of a client with mild diarrhea, but the client has just had hot soup. Which action should the nurse perform in order to obtain the accurate temperature of the client? ask the client to drink a glass of cold water before measuring the oral temperature wait for 15 to 20 minutes before measuring the oral temperature obtain the client's temperature rectally after lubricating the rectum use the axillary site for measurement once the client's body has been sponged with cold water
wait for 15 to 20 minutes before measuring the oral temperature EXPLANATION: The nurse should wait for 15 to 20 minutes and then measure the oral temperature of the client, since hot and cold liquids cause slight variations in temperature. Giving the client a glassful of cold water to drink will not help, because the thermometer will still show temperature variation, not the accurate body temperature. The rectal route is contraindicated in clients with diarrhea, because it can cause mucosal tearing or perforation. Hence, the nurse should not lubricate the client's rectum or measure the rectal temperature. The axillary route is the least accurate and least reliable site, because temperature may reflect the temperature of the water used during sponging. Friction used to dry the skin may also influence the temperature.
Positive Murphy's sign
when press on right upper quadrant --> pt take deep breathing --> pain--> because diagram pressed on gallbladder indicate cholecystitis
exploitation
when the nurse guide the client to examine feelings and response to develop better coping skills and more positive self imaging encourage behavior change and develops independence part of the working phase
2 major factor place elderly at risk for hematoma after fall are
1- dura layer is more adhere to skull 2- longterm anticoagulant - blood thinner use.
antidepressant meds
1. SSRI - fluoxetine 2. SNRI - duloxetine 3. TCA - imipramine 4. MAOIs - phenelzine - cause hypertensive crisis if take with tyramine containing food 5. antipsychotics used if pt show psychotic sx ( delusion, hallucinations)
three major element of PTSD are
1. reexperiencing the trauma thru dreams or recurrent and intrusive thoughts 2. showing emotional numbing such as feeling detached from others 3. being on guard, irritable or experiencing hyperarousal ( sx that arise from high level of anxiety, including insomnia, irritability, anger outburst, watchfulness, suspiciousness and distrustfulness) other sx: - feel upset, have physical reaction ( heart pounding, trouble breathing , sweating) when soneone or something remind them of stressful experience) , avoid thinking or activites or situation that remind of events, have trouble remebr importan oart of the events, loss interest in activies previosuly enjoyed,
common characteristic of violent families
1. social isolation : 2. abuse of power and control: 3. alcohol and other drug abuse 4. inter-generational transmission process
medication for schizophrenia
1.conventional antipsychotic ( dopamine antagonist) - target positive sx - no observable effects on negative sx 2. atypical antipsychotics ( dopamine ,serotonin antagonist) - diminish or lessen positive and negative sx 3. 2 antipsychotic available in depot inj form - fluphenazine[ prolix] in decanoate and enanthate - haloperidol [ halloo[ in decanoate - effect last 2-4 wks , eliminate need for daily PO med
normal WBC count
4500-11,000
Automatisms
: repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot
Rovsing sign
: when palpate left lower quadrant → pain felt on right lower quadrant --> appendicitis
atheist
A person who denies the existence of God
schizophrenia
A psychotic disorder involving distortions in thoughts, perceptions, and/or emotions.
Ethnicity
A sense of identification with a collective cultural group, bases on the group common heritage he sharing of common and unique cultural and social beliefs and behavior patterns, including language and dialect, religious practices, literature, folklore, music, political interests, food preferences, and employment patterns develop thru day to day life with family and friends within the community
Culture
A shared system of beliefs , values and behavioral expectations provide social and structure for daily living Influence role and interaction with others as well as within family and communities Apparent in the attitudes and institution unique to that prticular group
Which intervention is an appropriate action by a nurse to take in attempting to decrease a client's temperature through conduction? Apply cooling blanket Give client a warm bath Lower the room temeprature Remove the client's blankets
Apply cooling blanket
common characteristics of religions
Basis of authority or source of power Portion of scripture or sacred word Ethical code defining right or wrong A psychology and identity Aspirations or expectations Some ideas about what follows death
Place the four successive stages of fever in correct order. Prodromal Flush Chill defervescence
Correct response: Prodromal Chill Flush Defervescence
A surgeon is explaining the anatomical structures of the penis during grand rounds. During his explanation the surgeon states that the cremaster muscles work in concert with the pampiniform plexus that surrounds the testicular artery to: empty fluid from the seminal vesicles into the genital ducts. maintain testicular temperature. move the testes into the scrotum. move sperm from the ampulla to the penis.
Correct response: maintain testicular temperature. Explanation: The location of the testes in the scrotum is important for sperm production, which is optimal at 2°C to 3°C below body temperature. Two systems maintain the temperature of the testes at a level consistent with sperm production. One is the pampiniform plexus of testicular veins that surround the testicular artery. This plexus absorbs heat from the arterial blood, cooling it as it enters the testes. The other is the cremaster muscles. These muscles respond to decrease in testicular temperature by moving the testes closer to the body.
A nurse is teaching newborn care to students. The nurse correctly identifies which mechanism as the predominant form of heat loss in the newborn? nonshivering thermogenesis lack of brown adipose tissue sweating and peripheral vasoconstriction radiation, convection, and conduction
Correct response: radiation, convection, and conduction
differences between dementia and delirium
Delirium is short term and has a sudden onset , secondary to another cause. If treat underlying cause, delirium disappear--> if not recognized and treat underlying cause can progress to change LOC, irreversible brain damage and sometimes death. Dementia have subtle onset of sx and progress slowly and irreversible
personal knowing
Derived from life experiences
A 6-month-old infant is admitted to the hospital because of a fever. When the nurse obtains a health history, what data would be obtained first? Review of systems History of past illnesses Details about the fever Family profile
Details about the fever
nurse's role in maintaining reality when a patient is experiencing delusions
Do not confront pt about delusion Make simple statements:"Tell me more about that" "what are they saying" Do not reinforce delusion by "playing along" or agreeing that you are experiencing the delusion as well
The newborn has been placed in skin-to-skin contact with his mother. A blanket covers all of his body except his head. His hair is still wet with amniotic fluid, etc. What is the most likely type of heat loss this baby may experience? Conductive Convective Evaporative Radiating
EVAPORATIVE
PET scan nursing intervention
Educate technique of inhalation and the sensation might occur (dizziness, lightheadedness and headache)
Extrapyramidal Side Effects.
Extrapyramidal side effects are reversible movement disorders induced by neuroleptic medication. They include dystonic reactions, parkinsonism, and akathisia.
common side effects of antipsychotics and interventions/patient education to alleviate then to improve medication compliance
Extrapyramidal symptoms-acute dystonic reactions, akathisia, parkinsonism Tardive dyskinesia Seizures Neuroleptic malignant syndrome Sedation Dry mouth Constipation Weight gain Blurred vision Sexual dysfunction Photosensitivity-sunburn easily
CN IX
Glossopharyngeal - mixed - taste, sensation in pharynx and tongue,, pharyngeal muscle, swallowing
Food to avoid when have ostomy bag
Hard to digest-- block stom --> CORN, PEAS, POCORN, NUT, SEED, RASIN, SKIN OF Fruit, RAW MUSHROOM gas causing foods: beans, onions, eggs, broccoli, cabbage, garlic, alcoholic beverage ,fish, high fiber food
barriers to medication compliance for schizophrenic patients
Horrible side effects Lack planning/May forget to take medication access-do they remember to use their resources appropriately May not be able to afford medications-may not have a job
echopraxia
Imitation of the movements and gestures of another person whom the client is observing
signs/symptoms of schizophrenia relapse
Impaired cause-and-effect reasoning Impaired information processing Poor nutrition Lack of sleep Lack of exercise Fatigue Poor social skills, social isolation, loneliness Interpersonal difficulties Lack of control, irritability Mood swings Ineffective medication management Low self-concept Looks and acts different Hopeless feelings Loss of motivation Anxiety and worry Disinhibition Increased negativity Neglecting appearance Forgetfulness NOTE: relapse is typically apparent early on and if intervention is implemented soon enough, psychosis can be delayed or prevented.
general warning signs of substance abuse that a nurse should be alert for in coworkers
Incorrect drug counts Excessive controlled substances listed as wasted or contaminated Reports by clients of ineffective pain relief from medications, especially if relief had been adequate previously Damaged or torn packaging on controlled substances Increased reports of "pharmacy error" Consistent offers to obtain controlled substances from pharmacy Unexplained absences from the unit Trips to the bathroom after contact with controlled substances Consistent early arrivals or late departures from work for no apparent reason
healthy people objectives/goal in relation to mental illness
Increase number of people identified, diagnosed, treated, helped to live healthier lives Decrease rates of suicide, homelessness Increase employment for those with serious mental illness Provide more services for incarcerated persons with mental health problems - Reduce the suicide rate - Reduce suicide attempts by adolescents - Reduce the proportion of adolescents who engage in disordered eating behaviors in an attempt to control their weight - Reduce the proportion of persons who experience major depressive episode - Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral - Increase the proportion of juvenile residential facilities that screen admissions for mental health problems - Increase the proportion of persons with SMI who are employed - Increase the proportion of adults with mental health disorders who receive treatment - Increase the proportions of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders - Increase depression screening by primary care providers - Increase the number of homeless adults with mental health problems who receive mental health services
Review risk factors for delirium
Increased severity of physical illness Older age Hearing impairment, decreased food and fluid intake Medications Baseline cognitive impairment such as seen dementia Children- when related to febrile illness, certain medication such as anticholinergics.
antidepressant med that lethal when overdose
MAOI and cyclic antidepressants - depressed or impulsive pt who take these antidepressant med need to have prescriptions and refills in limited amount
duty to warn
Mental health professional's responsibility to break confidentiality and notify the potential victim whom a client has specifically threatened.
Review common causes of delirium
Occur secondary to lots of cause: physical illness, surgery, meds or alcohol toxicity, dehydration, fecal impaction, malnutrition, infection, head trauma, sensory deprivation or overload.
PREPARE mnemonics for griefing and coping
P - protect , provide needs / safety R - role model / coping strategies ( who, where to find suppport system) E - establishing coping behavior P - pull support system ( family, religion, clergy man, spiritual groups, people with the same diagnosis,) A - allow expression of feelings R - refer to self help group E - expand coping behavior --> empower other people
Perseveration
Persistent adherence to a single idea or topic; verbal repetition of a sentence, word, or phrase; resisting attempts to change the topic
McBurney point/sign
Point located one third of the distance from the anterior superior iliac spine to the umbilicus on the right. (Tenderness at the site is associated with acute appendicitis)
Trichomonas
Protozoal infection in vagina. dc that is thin, bubbly, yellow to green and smell very baddd vaginal inspection reveal erythema with strawberry spots. Treat with metronidazole. (metallic taste)
What is a priority nursing intervention for a nurse caring for a premature infant born at 32 weeks gestation? Provide a neutral thermal environment. Promote bonding between infant and parents.? Teach parents regarding newborn care. Administer immunizations to the newborn.
Provide a neutral thermal environment.
catatonia
Psychologically induced immobility occasionally marked by periods of agitation or excitement; the client seems motionless, as if in a trance
differences in treatment of RA and OA
RA: control / decrease inflammation - DMARDs (decrease joint damage ) - steroids (anti-inflammatory)( SE --> decrease immune system) - NSAIDs (anti-inflammatory) - pain control SURGERY FOR BOTH --> last tx in severe case because require long recovery. OA: pain control - lifestyle (diet, wt loss ) - PT (muscle training) ( because people tend to stop using that muscle because of pain) - NSAIDs (GI effect) - injections into specific affected joint (steroid, or analgesic)
s/s of sepsis
S -slurred speech E - extremely painful muscle P - passing no urine in a day S - severe breathlessness I - I feel like I might die S - skin mottled or discolored
Alcohol withdrawal treatment
Safe withdrawal is usually accomplished with the administration of benzodiazepines such as lorazepam (Ativan), chlordiazepoxide (Librium), or diazepam (Valium) to suppress the withdrawal symptoms.
While obtaining the admission history for an 80-year-old client admitted to the medical unit, the nurse learns that the client keeps the thermostat in the home at 64° in order to cut the cost of the monthly heating bill. What should the nurse include in the teaching plan for this client? Importance of always keeping the thermostat set on 74°F. Referral to social services for assistance with resources. Assessment for hypothermia. Strategies to reduce the risk of hypothermia?
Strategies to reduce the risk of hypothermia
RA dx criteria
+ serum rheumatoid factor elevated ESR elevated C reactive protein (CRP) positive antinuclear antibody (ANA) - X-ray looks for nodules, soft tissue swelling, deformities, erosion
how to prevent headache post- lumbar puncture (spinal tap)
Can be mild to severe, occur a few hours or several days after procedure Throbbing frontal or occipital headache, dull and deep, severe on sitting or standing but lessen or disappear when lies down Caused by leakage of CSF at puncture site → deplete CSF till it is insufficient to maintain proper mechanical stabilization of brain → tension and stretching of venous sinuses and pain sensitive structure occur when pt in upright position Pt should be in supine position for 4-8 hrs post-procedure and bed rest, analgesic and hydration help prevent headaches.
Aphasia
Can not express with language or speech
possible complications of alcoholism on the body
Cardiac myopathy Wernicke's encephalopathy Korsakoff's psychosis Pancreatitis Esophagitis Hepatitis Cirrhosis Leukopenia Thrombocytopenia Ascites
Subtance abuse risk factor - family dynamics
Children of alcoholics are four times as likely to develop alcoholism compared with the general population
A Child's Perceptions of God
God works through intimacy and the interconnectedness of lives. God is involved in self-change and growth and transformation that make the world fresh, alive, and meaningful. God has tremendous power, and children show considerable anxiety in face of it. God is an image of light.
Neologisms:
Inventing words that only the patient understands
culture shock
The feelings a person may experience when placed in a different culture perceived as strange
CN I
Olfactory (smell)
how to decrease cerebral edema in pt with increased ICP
Osmotic diuretic such as mannitol and hypertonic saline 3% given or restrict fluid to dehydrate brain tissue, reduce edema → urine output monitor by urinary catheter → serum osmolality an electrolyte monitor to eval hydration status If brain tumor cause increased ICP → corticosteroid ( dexamethasone) reduce edema
stages of inflammation
1) Vascular & cellular responses, 2) exudate production, 3) tissue repair
transference
occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships; it is common for the client to unconsciously transfer to the nurse feelings he or she has for significant others
countertransference
occurs when the therapist displaces onto the client attitudes or feelings from his or her past process that can occur when the nurse responds to the client based on personal, unconscious needs and conflict
congruence
occurs when words and actions match
CN III
oculomotor - motor - muscle that move the eye and lid, pupillary constriction , lens accomodation
CN II
optic sensory visual acuity and visual fields
increased basophils indicate
allergy reaction or hypothyroid
complication of chronic gastritis
anemia = not able to absorb vitamin B12 --> fatigue
Diverticula occur where?
can occur anywhere in GI tract most common if sigmoid colon
colony-stimulating factors function
play key role in the growth and differentiation of bone marrow cells
complication of acute gastritis
possible signs of shock (sepsis) if perforate --> if have obstruction in pylori or narrowing of pylori orifice.--> surgery --> gastrojejunostomy
Cultural Conflict
situation that occurs when people become aware of cultural differences, feel threatened, and respond by ridiculing the beliefs and traditions of others to make themselves feel more secure about their own values
delta cells in pancreas produce
somatostatin --> raise blood glucose level
linguistic competence
the ability of caregivers and organization to understand and effectively response to the linguistic needs of patients and their families and a health care encounter
insight
the ability to understand the true nature of one's situation and accept some personal responsibility for that situation
Ethnocentrism
the belief that the ideas, beliefs, and practices of one's own culture are superior to those of another's culture.
hypo-proliferative anemia means
the bone marrow does not produce adequate number of erythrocytes. - result from marrow damage due to medication (chloramphenicol), chemical (benzene) , lack of factors ( iron, vitamin B12 , folic acid, erythropoietin)
common dx of gallstone
ultrasounds - detect stone, mucous building and how thick the gallbladder wall is if see nothing cholescinti-graphy (hida scan)
positive regard
unconditional, nonjudgemental attitude that implies respect for the person regardless their behavior, background ỏ liétyle
patterns of knowing
empirical knowing personal knowing aesthetic knowing ethical knowing
function of serotonin in inflammation
vasoconstrictor helps decreased blood flow
how to dx peptic ulcer
endoscopy
Zollinger-Ellison syndrome manifestation
epigastric pain pyrosis (heartburn) diarrhea steatorrhea (fatty stool)
flight of ideas
excessive amount and rate of speech composed of fragmented or unrelated ideas; racing, often unconnected, thoughts
Function of kinins in inflammation
vasodilation, increased permeability of blood vessels, attract neutrophils to area
Function of bradykinin
vasodilation, pain
increased lymphocyte means which type of infection
viral infection
hallucinations
false sensory perceptions or perceptual experiences that do not really exist
sympathy
feelings of concern and compassion
s/sx of rupture appendicitis or peritonitis
fever, leukocytosis, board-like abdomen, rebound tenderness, pain may subside when ruptured but increased when peritonitis.
IgM
first antibody produced - attach to surface of B cells or secreted into blood - responsible for early stage of immunity - first to be produce in immune response
word salad
flow of unconnected words that convey no meaning to the listener
monocolonal antibodies function
growth and production of targeted antibodies for specific pathologic organisms
religious beliefs
guide to daily living habits source of support source of strength and healing source of conflict
assertiveness training
learn to negotiate interpersonal situation, make more control of their life's situation, use "I" statements to identify feeling and communicate concerns.
unlearning
learning new stuff causes unlearning of old stuff
treatment of chronic gastritis
modify diet rest, reduce stress avoid alcohol, NSAIDs, antacids, H2 blocker and PPI
IgG
most abundant , secreted by plasma cell in the blood can cross placenta to fetus
regression
move back to previous developmental stage to feel safe or have needs met - 5 yo ask for a bottle when new baby brother is being fed - man pouts like a 4yo if he is not the center of his gf attention
when not to give laxative, no enema for abdominal pain
nausea, fever, abdominal pain
RA hand s/sx
z thumbs buttoniere's? swan necking? muscle wasting - carpal tunnel syndrome - decreased hand function (knife and forks doing buttons) nodule are common
component of therapeutic relationship
trust genuine interest empathy acceptance positive regard
positive reframing
turning negative messages into positive messages
2 major categories of sx
1. positive ( hard) - delusions , hallucinations, grossly disorganized thinking, speech , behaviors 2. negative - soft - flat affect, lack of volition, social withdrawal or discomfort
CN VIII
- acoustic - sensory - hearing and equilibrium
IgD
Part of the B cell receptor. Activates basophils and mast cells
akinetic mutism is
unresponsiveness to environment, make no movement or sounds but sometimes open eyes
consequences of increased ICP
1. decreased cerebral perfusion 2. stimulate swelling/ edema 3. shift brain tissue result in herniation.
tangential thinking
wandering off the topic and never providing the information requested
MS s/sx and nursing assessment
→ PT usually have sx long time ago without seeking care- check up due to vague, nonspecific s/sx ( fatigue) Most common sx are (1) fatigue, weakness: affect most people: most disabling sx. heat, depression, anemia and med can contribute to fatigue --> have pt avoid hot temp, effective tx of depression , anemia, etc can help with fatigue. (2) visual disturbance: blurred vision, diplopia, scotoma ( patchy blindness) , or total blindness (3): pain, paresthesia, numbness, tingling : due to lesion in nerve pathway, discomfort to touch, proprioception loss, --> need analgesics meds daily, sometimes opioids, anticonvulsant meds. women are more likely to have pain with osteoporosis - bone density testing recommended for this group (4) spasticity ( occur in 90% pt, most often in lower extremities) , difficulty in coordination, loss of balance (5) cognitive and psycho problems - may reflect frontal or parietal lobe involvement - such as memory loss, decreased concentration (in 50% pt) LATE SIGNS as disease progresses→ contracture and cognitive changes, speech difficulty, dysphasia, depression - asses for weakness,spasticity, visual impairment, incontinence, swallowing and speech problem, neuro deficit , muscle coordination, blur vision, pain, urinary hesitancy, - assess how pt coping, how family coping, if they adhere to med regimen - assess for 2nd complication: URI, constipation, pressure ulcers, contracture, dependent edema, pneumonia and posteoporosis - assess for concern about depression, medication cost, immobility, functional loss, family burden, marital concern, sexual concern.
client statement suggesting suicide
"I just want to go to sleep and not think anymore." "I want it to be all over." "It will just be the end of the story." "You have been a good friend." "Remember me." "Here is my chess set that you have always admired." "If there is ever any need for anyone to know this, my will and insurance papers are in the top drawer of my dresser." "I can't stand the pain anymore." "Everyone will feel bad soon." "I just can't bear it anymore." "Everyone would be better off without me." Nonverbal change in behavior from agitated to calm, anxious to relaxed, depressed to smiling, hostile to benign, from being without direction to appearing to be goal directed
Seizure types
(1) partial ( =focal seizure, involve one are of brain and do not spread throughout organ ) : include (a) simple partial seizure: consciousness remains intact, involve single muscle movement or sensory alteration and (b) complex partial seizure: impairment of consciousness, involve series of reaction or emotional or sensory changes such as hallucination, mental distortion, etc (2) generalized: seizure begin in one area of brain and rapidly spread to both hemisphere. Include (a) tonic-clonic seizure : involuntary muscle contraction and relaxation with aggressive spasm, loss of consciousness, little memory and extreme exhaustion when awake, (b) absence seizure = petit Mal: abrupt, brief 3-5 sec of loss of consciousness with no muscle movement, occur common ins children,
SLE symptoms
- *photosensitivity* --> erythematous rash to areas exposed to sunlight - *butterfly rash over cheek = malar rash* - *mouth, nose sore, ulcers* - lung = tachypnea = cough = pleural inflammation, effusion - systemic = wt loss / anorexia = fatigue = *fever*, infection = *arthritis*--> symmetrical , small joint like RA but changes to not cause loss of function like RA = emotional lability = hematologic disorders = neurologic disorders *(seizures)* - heart : = Raynaud's phenomenon ? = pericarditis = vascular inflammation **- kidney** = lupus nephritis = proteinuria = hematuria
immigrant women and domestic violence
- Battered immigrant women face legal, social, and economic problems different from U.S. citizens who are battered and from people of other cultural, racial, and ethnic origins who are not battered. - the battered woman may come from a culture that accepts domestic violence. - She may believe she has less access to legal and social services than do U.S. citizens. - If she is not a citizen, she may be forced to leave the United States if she seeks legal sanctions against her husband or attempts to leave him. - She is isolated by cultural dynamics that do not permit her to leave her husband; economically, she may be unable to gather the resources to leave, work, or go to school. - Language barriers may interfere with her ability to call 911; learn about her rights or legal options; and obtain shelter, financial assistance, or food.
what to check with peptic ulcer
- CBC if have bleeding peptic ulcer --> determine extend of blood loss -check stool periodically until negative for blood
depression assessment
- History: Ask about behavior changes: when it started, what was happening, duration, what pt tried to do about it, history of episode of depression, tx and pt's response to treatment. - Family history of mood disorder, suicide or attempted suicide - General appearance and motor behavior → look sad or ill, head down posture, make minimal eye contact, psychomotor retardation ( low body movement, slow cognitive processing and verbal interaction), latency of response ( take up to 30s to respond), reply with only 1-2 words,may answer " I don't know" because too fatigue to think of an answer, anxiety , difficulty sitting still, psychomotor agitation ( increased body movement and thoughts include pacing, accelerated thinking, argumentativeness) - Mood and affect: describe themselves hopeless, help;ess, down, anxious, feel like burden or failure of life, easily frustrated and angry with them self or others, anhedonia ( lost pleasure from any activity previously enjoyed). They sit alone, stare into space, overwhelmed by noise, withdraw. - Thoughts process and content: slow thinking process. -Focus on failure or negative things, ruminate ( repeatedly go over same thoughts) - Poor judgement, intact or limited insight - Self concept: poor, feel good for nothing, worthlessness, feel responsible for things they have no control, believe other better off without them - Role and relationships: impaired, withdraw - Physiologic and self care: weight loss, sleep distubrances, feel unrefleshes, lost interest in sex, poor hygiene, constipation, dehydrated. - Depression rating scale: self rating scale of depression include the Zung Self Rating Depression Scale and the Beck Depression Inventory. Clinician-rated depression is the Hamilton Rating Scale for Depression
bipolar disorder assessment
- History: may be difficulty, use short session, talk to family members - General appearance and motor behavior: pt with mania is irrigation, hard to sit still, continual movement, wear close that reflect elevated mood ( bright color, attention seeking, or sexual suggestive clothes, lots of jewelry, heavy makeup, male wear muscle revealing shirt, or bare chest) → think, move, talk fast, loud speech without pauses, interrupted and cannot listen to others, turn to one listener to other or speak to no one at all. - Mood and affect:euphoria, may be angry, verbally aggressive, sarcastic, irritable, labile mood, may alternate period of loud laugh with episode of tears - Thought process and content → flight of ideas, start activities as they occur in thought process such as shopping , use money excessively mile unemployed, start several business at once, having unprotected sex, gambling, take impulsive trips, risky investment, etc.. if they are psychosis s.sx, may claim to be rich, famous, or importance. - Sensorium and intellectual process: may oriented to person and place but rare to time, impaied concentration Judgment and insight → impulsive, rarely think before acting or speaking, insight is impaired as thinking self is fine and having no problem, blame difficulties on other - Self concept: exaggerated self esteem, believe they can accomplish anything. - Role and relationships: impaired have great need to socialize but no understanding of other, invade intimate space , can be hostile to whom they think against them. - Physiologic and self care consideration: can go days without sleep or food and not realize hungry or tired, ignore personal hygiene as boring, consider self have more important things to do
intimate partner violence (IPV)
- Is the mistreatment or misuse of one person by another in the context of an emotionally intimate relationship, can be spouse, partners, boyfriends, gf, - Involve 4 types of violence : = physical violence (shoving, pushing, sever bartering, choking, even homicide) , = sexual violence ( any assault during sexual relation, slapping and hitting, and rape) , = stalking = and psychological abuse ( name-calling, belittling, screaming, yelling, destroyed property, making threats)
nursing management for pt with AD
- Provide cue and guidance increasingly overtime as disease progress, be patient/ unhurried with these pt, repeat instruction PRN; use clear, simple sentences; break task into simple , achievable step to promote self care activities; use post-it note to remind daily activities - Provide safe, hazard free, calm, noise-free predictable, familiar environment with adequate lighting [ esp hall, stair and bathroom], use nightlight, - Excitement and confusion can upset pt, cause combative agitated state known as catastrophic reaction ( overreactive to excessive stimulation) → pt respond with screaming, crying, abusive verbally or physically → is their way to express inability to cope with environment → don't force pt to proceed with activities , postpone it → move to familiar environment, listen to music, help calm pt down. - Set regular routine - Display clock, calendar to help orient to time - Promote active participation in social interaction , physical activity, communication with visitor, phone calls, encourage spouse to talk about sexual concern about refer to sexual counseling - Have pt wear identification tag all times incase separation from caregiver - Have consistent display location of plate, fork etc, cut food in small piece and thicken fluid if dysphasia, keep food warm to prevent burning, allow pt to eat with finger PRN or feed pt to promote adequate nutrition - Promote sleeping and rest with warm milk at night, music, back rubbing, encourage daytime physical activities and avoid daytime sleeping.
nurse's priority for a patient during an anxiety attack
- The nurse's goal must be to lower the person's anxiety level to moderate or mild before proceeding with anything else. - It is also essential to remain with the person because anxiety is likely to worsen if he or she is left alone. - Talking to the client in a low, calm, and soothing voice can help. If the person cannot sit still, walking with him or her while talking can be effective. During panic-level anxiety, the person's safety is the primary concern.The nurse must keep talking to the person in a comforting manner, even though the client cannot process what the nurse is saying. Going to a small, quiet, and nonstimulating environment may help to reduce anxiety. The nurse can reassure the person that this is anxiety, that it will pass, and that he or she is in a safe place. - The nurse should remain with the client until the panic recedes.
warning signs of relationship violence
- When women state her partner has hurt her but promised to changes → important because violence is rarely one time occurence, usually continue and escalate in severity. - s/sx of abuse, maltreatment and neglect may include suicide attempt, drug and alcohol use, freq ED visit, vague pelvic pain, depression ( possible due to stress or fear of impending abuse) - Women anxious about pelvic exam, breast exam, or any tx require hand-on or removal of clothing - Abuser thinking victim as their property and become increasingly violent and abusive if victim show sx of independence ( get a job or threaten to leave) - Abuser usually have strong feelings of inadequacy, low self esteem, poor problem solving skills and social skills, emotionally immature, needy, jealous [ can even jealous with their children] and possessive - Personal and financial dependency are most common reason abused women find it hard to leave the abuser. Fear that the abuser will kill them if try to leave!
progressive s/sx of dementia/ Alheizmer disease
- aphasia - difficulty finding words or can't name familiar object, echolalia ( echoing what is heard) or palilalia ( repeat words or sounds over again) -apraxia: impaired ability to execute motor function despite intact motor abilities, cause pt loos ability to perform ADL - gnosis: inability to recognize name object despite intact sensory abilities, --> frustrating for pt, can't name table or chair for example - executive function lost- cannot learn new material, solve problem, can't think abstractly lost abstract thinking, impulsive behavior, - personality changes ( disengage in activity, relationships, depressed, suspicious, paranoid, hostile, combative) - speaking skill deteriorate to nonsense , poor judgement - cannot perform purposeful movement, -wander at night - assistant with ALD is needed eventually such as eating and toileting because dysphasia and incontinence develop - terminal stage : immobile, loss all voluntary activity, require total care ( last month or years) --> death result from complication of pneumonia, malnutrition or dehydration.
neuro structure and physiologic changes in older adults
- as brain age, neuron lost, leading to decreased number of synapses and neurotransmitter , cerebral blood flow decreased--> slow nerve conduction --> take longer to response , to process information and to recall memory --> BUT MEMORY , LANGUAGE AND JUDGEMENT ARE STILL INTACT --> CONFUSION, CHANGE IN MENTAL STATUS IS NOT NORMAL OF OLDER ADULT ( can be caused by infection, med AE, dehydration, drug toxicity, depression etc) - temperature regulation less efficient: feel cold more readily than heat, require extra blanket, caution with hot or ice pack, can be burned or have frostbite, esp. if pt have diabetes. - visual and auditory nerve degenerative, loss visual acuity and hearing - taste bud atrophy + ability to smell less effective ( dangerous if cannot smell gas leak or fire) - vestibular system's nerve and proprioceptive pathway also degenerate + decreased strength --> gait is slow, balance difficulty, less sensation of position --> risk for fall and skin integrity impairment -
nursing assessment - abuse
- ask everyone if they are safe at home and in their relationship - not only "likely victim" - SAFE QUESTIONS 1. Stress/ safety: what stress do you experience in your relationship? do you feel safe in your relationship? should I be concern for your safety? 2. afraid / abused : Have there been situations in your relationships where you have felt afraid? Has your partner ever threatened or abused you or your children? Are you in a relationship like that now? Has your partner ever forced you to engage in sexual intercourse that you did not want? People in relationships/marriages often fight; what happens when you and your partner disagree? 3. Friends / Family: Are your friends aware that you have been hurt? Do your parents or siblings know about this abuse? Do you think you could tell them, and would they be able to give you support? 4. Emergency plan: Do you have a safe place to go and the resources you (and your children) need in an emergency? If you are in danger now, would you like help in locating a shelter? Would you like to talk to a social worker/a counselor/me to develop an emergency plan?
Parkinson disease pathology
- destruction of dopaminergic cells cause depletion of dopamine stores --> decrease dopamine level - imbalance of excitatory ( acetylcholine) and inhibiting (dopamine) neurotransmitter - lead to impairment of nerve pathway to control complex body movement --> lead to tremor, rigidity, bradykinesia and postural changes.
Electroconvulsive therapy
- for pt not respond to antidepressant or cannot tolerate SE, pregnant women, suicidal pt if concern about their safety while waiting for full effect of meds → very effective → pt given antidepressant after ECT to prevent relapse - Involve application of electrode on head, deliver an electrical impulse to the brain and cause seizure → stimulate brain chemistry to correct chemical imbalance of depression → brain activity is monitored by EEG - Usually receive series of 6-15 treatment 3 times a week, minimum of 6 treatments needed to see improvement and maximum is 15 treatment - Pt is NPO after midnight, remove any finger nail polish, void before procedure, inserted IV line - Pt receive short acting anesthetic ( not awake during procedure) → receive muscle relaxants / paralytic ( usually succinylcholine, which relax a muscle to reduce outward sx of seizure) - Also receive O2, assisted breath with ambu bag → usually awaken after few mins and monitor VS, return of gag reflex → CAN MILDLY CONFUSED and disoriented , short term memory loss→ very tired and often has headache → pt may eat if hungry and sleep → treat headache PRN
automatic dysreflexia
- is emergency situation occur as result of exaggerated autonomic response to stimuli - occur in pt with SCI above level L6, after spinal shock subside, can occur years after injury s/sx: severe funding headache, sudden sharp increased BP, profuse diaphoresis above injury level, nausea, nasal congestion, bradycardia and piloerection - sudden increase in BP can also cause retinal hemorrhage, hemorrhagic stroke, MI or seizures - trigger include: distended bladder, fecal impaction, stimulation of skin ( tactile, pain, thermal, pressure ulcers) --> prevent and remove it pt have AD - rapid assessment to id. cause /trigger --> straight Cath, irrigate catheter, remove fecal impaction ( with lots of lube and double gloves), remove skin irritation ( ted hose, SCD, etc) - administer hydralazine or nitroglycerin for vasodilation effect - educate other staff, document event and label pt at risk for AD< as well as educate pt and family about triggers, s/sx
risk factor for suicide
- men, young men, whites and separated and divorced people are at increased risk for suicide - adults older than 65yo account for 25% of suicide - people 15-24yo - pt with psychiatric disorder, esp depression, bipolar disorder, drug and alcohol abuse, ) - pt with chronic medical illness ( cancer, HIV, cerebrovascular , head and spinal injury) - environmental factor : isolation, resent loss, family hx - history of previously attempted suicide, first 2 yrs represent high risk period, esp. first 3months - those with relative who committed suicide, the closer the relationship, the greater the risk. - family in which parents/ couple fights a lot, lots of conflict, alcohol/ drug use, hx of fight. access to weapon in home.
serotonin syndrome and antidepressant meds
- occur when in adequate washout period between taking MAOIs and SSRIs or when MAOIs combined with meperidine ( opioid). - sx include 1. changes in mental status: confusion and agitation 2. Neuromuscular excitement: muscle rigidity, weakness, sluggish pupils, shivering, tremors, myoclonic jerks, collapse, and muscle paralysis 3. Autonomic abnormalities: hyperthermia, tachycardia, tachypnea, hypersalivation, and diaphoresis
nursing management during seizure
- provide privacy- start timing seizure - PROTECT FROM INJURY--> ease to floor if possible, push aside any furniture, protect head with pad, loose constrictive clothing, remove eyeglasses, remove pillow and raise padded side rails. if possible, place pt on side with head flex forward ( allow tongue fall forward, help drain saliva and mucus) - do not attempt to open jaw, or insert anything in mouth and do not restrain - nurse should observe and record initial pattern ( which help indicate origin of seizure, where movement or stiffness begins such as only finger, hand shakiness, mouth jerk uncontrollably, dizziness, (pt report) unusual sight ( flashing light), odors, taste, sound , tactile stimuli, emotional or psychological disturbance ( stress) , position of head begin of seizure --> if not observed since beginning, should document so as well. - document time, duration, type , part of body involve, size of pupil, if eye were open, presence or absence of automatism ( involuntary motor activity such as lips smacking or reported swallowing) - did pt have incontinence of urine and stool?
nursing management for pt following abuse, maltreatment and neglect (women)
- reassure that she is not alone - express that no one should be hurt, abuse is fault of the batterer and is against the law, not her fault, - reassure her info is confidential, although become part of medical record, because concern about safety. - document statement of abuse, take pics of any visible injuries if inform consent obtained - provide options for shelter safe for her and children ( length vary but often up to 2 myths), assists with housing, jobs, emotional distress - educate women that violence get worse, not better - if women choose to go to shelter, let her make the call - if women choose to return to abuser, remain nonjudgemental and still provide shelter, hotline number info incase she needs it and - develop safety plan if decide to return home ( packed bags and important paper hidden in safe spot) - provide or refer to psychotherapy, group therapy, support group
DSM-5 dx criteria for bipolar disorder - manic episode
- requires at least 1 week of unusual and incessantly heightened, grandiose, or agitated mood in addition to three or more of the following symptoms: - exaggerated - self-esteem; - sleeplessness; - - pressured speech; - flight of ideas; - reduced ability to filter extraneous stimuli; - distractibility; - increased activities with increased energy; - multiple, grandiose ( excessive in style or appearance, heavy makeup, loud color clothing) - high-risk activities involving poor judgment and severe consequences, such as spending sprees, sex with strangers, and impulsive investments
schizophrenia clinical course
1. immediate courses: 2 pattens: - ongoing psychosis, never fully recovering - episodes of psychosis sx alternating with episodes of relatively complete recovery 2. longterm course: intensity of psychosis diminishes with age, most with difficulty function, few with ability to live fully independent lives
medical management for MS
- there is no cure- individualized regimen to relive sx, provide support with goal is to delay progression of disease, manage chronic sx ( ataxia, bladder dysfunction, depression, fatigue, spasticity) and treat acute exacerbation MS is managed with: (1) interferon beta 1a (Rebif) and interferon beta 1b ( Betaseron) --> give SQ every other day, while interferon beta 1a ( Avonex) give IM once a week --> SE of interferon beta meds are flu like sx ( in50% pt) that can result in discontinue of med!!! (2) glatiramer acetate [ copaxone] - can reduce rate of relapse in Relapse-remitting -- give SW daily -- may take 6months to show effectiveness (3) FORE FLARES!!!IV METHYLPREDNISOLONE used to tx acute relapse RR course -- exert anti-inflammatory , acting on T cells and cytokines -- give 1g IV daily for 3-5 days -- follow by taper to PO med prednisone -- SE: mood swing, weight gain, and electrolyte imbalance (4) FOR SPASTICITY: baclofen, benzodiazepines such as diazepam [valium]m tizanidine , dantrolene [ dantrium] (5) FOR FATIGUE interfere with ADL --> amantadine [ symmetrel], pemoline [cylert], or dalfampridine [ ampyra] (6) FOR ATAXIA: beta blocker, anticonvulsant meds ( gabapentin), benzodiazepine ( clonazepam) (7) FOR BLADDER AND BOWEL PROGRAM: anticholinergic , alpha-adrenergic blockers, antispasmodic agent, and program training (8) for UTI - ascorbic acid, acidify urine, which make bacteria growth less or antibiotic
depression incidence or risk factor
- twice as common in women - 1.5-3 times greater incidence in 1st degree relative than general population - incidence decreases with age in women and increases in age with men - highest in single, divorced people - people who had previous depression episodes family hx of depression or mental disorder.
SLE diagnostic test
- urine dipstick --> for renal impairment --> red cell casts and proteinuria - blood --> *elevated ESR + elevated CRP* - ANA testing (sensitive but not specific --> can be due to RA< meds such as anti-TNFs) - anti- double stranded DNA --> present in 60% of cases - watch for BP (hypertension) , serum BUN, creatinine , urine output , hematuria or proteinuria --> indicate renal involvement.
alcohol withdrawal treatment
- vitamin B1 thiamine for wernicke-worsakoff syndrome, - vitamin B12 and folic acid for nutritional deficiency - benzodiazepine - anxiolytic agent tp suppress withdrawal sx --> lorazepam, chlordiazepoxide, and diazepam - disulfiram given to help deter pt from drinking --> do not drink alcohol or any alcohol containing product such as cough syrup, locations, mouthwash while taking disulfiram because severe AE occur with flushing, throbbing headache, eating, n/v --> if severe, lead to severe hypotension, confusion, coma and even death - acamprosate - given for client recovering from alcohol abuse or dependence to help reduce cravings of alcohol and reduce physical and emotional discomfort that usually occur first few months. [ sweating, anxiety, sleep disturbances] --> c/I in renal impairment . SE are mild, include diarrhea, nausea, flatulence, and pruritis
three stages of reaction to stress
1. ALARM REACTION STAGE: stress stimulate body to send message from hypothalamus to gland ( adrenal gland to send out adrenaline [ epi] and NE for fuel ) and to organs ( liver to concert glycogen to glucose) to prepare for potential defense needs 2. RESISTANCE STAGE: the digestive system reduces function to shunt blood to areas needed for defense. the lungs take in more air, heart beat faster and harder so it can circulate this highly oxygenated and highly nourished blood to muscles to defend the body by fight or flight or freeze behaviors. if the person adapt to stress, the body response by relax, and gland, organs and systemic response subside 3. EXHAUSTION STAGE: occur when the person has responded negatively to anxiety and stress, body stores of fuel depleted, or the emotional components are not resolved, resulting in continual spousal of the physiologic responses and little reserve capacity.
different type of schizophrenia delusion
1. Referential-delusions of reference. Usually involves media, books, radio, TV. : The client may report that the president was speaking directly to him on a news broadcast or that special messages are sent through newspaper articles. 2. Grandiose- think they are superior, famous, or have accomplished something great 3. Nihilistic delusions are the client's belief that his or her organs aren't functioning or are rotting away, or that some body part or feature is horribly disfigured or misshapen. 4. Persecutory/paranoid delusions involve the client's belief that "others" are planning to harm the client or are spying, following, ridiculing, or belittling the client in some way. Sometimes, the client cannot define who these "others" are. 5. Religious delusions often center around the second coming of Christ or another significant religious figure or prophet. Examples: The client claims to be the Messiah or some prophet sent from God and believes that God communicates directly to him or her or that he or she has a "special" religious mission in life or special religious powers. 6. Somatic delusions are generally vague and unrealistic beliefs about the client's health or bodily functions. Factual information or diagnostic testing does not change these beliefs. Examples: A male client may say that he is pregnant, or a client may report decaying intestines or worms in the brain. 7. Sexual delusions involve the client's belief that his or her sexual behavior is known to others; that the client is a rapist, prostitute, or pedophile or is pregnant; or that his or her excessive masturbation has led to insanity. 8.
cycle/pattern of violence
1. Violent behavior 2. → honeymoon period / period of remorse or contrition ( express regret, apologize, promise it will never happen again, engage in romantic behavior such as buying gifts, flowers → the abused person continuously believe and hope that the abuser will change. 3. → tension building phase ( arguments, stony silence, complaints of each other →lead to another violence episode. - honeymoon period can last weeks to months initially causing victim to believe the abuser has changed → over time, violent episode more often, remorse period disappear, severity of injury worsen → violence become routine
clozapine concern
1. agranulocytosis : - failure of the bone marrow to produce adequate white blood cells). - develops suddenly and is characterized by fever, malaise, ulcerative sore throat, and leukopenia. - This side effect may not be manifested immediately but can occur as long as 18 to 24 weeks after the initiation of therapy. - The drug must be discontinued immediately. - Clients taking this antipsychotic must have weekly white blood cell counts for the first 6 months of clozapine therapy and every 2 weeks thereafter. - Clozapine is dispensed every 7 or 14 days only, and evidence of a white blood cell count above 3500 cells/mm3 is required before a refill is furnished. 2. 5% of pt taking clozapine have seizure incidence , compare to 1% in other meds.
complication of increased ICP
1. brainstem herniation--> brain tissue press down on brain stem lead to irreversible brain anoxia and brain death 1. diabetes insipidus: result of decreased secretion of ADH --> pt have excessive urine output, --> tx with fluid, electrolyte replacement, vasopressin ( desmopressin) 3. SIADH - result of increased secretion of ADH --> pt become fluid overload, urine output diminished, resumé's Na diluted --> tx with fluid restriction (<800ml/day) with no free water --> if severe five 3% NS with rate <1.3mEq/L/hr.
neurologic SE of antipsychotic med
1. extrapyramidal SE - acute dystonic reactions - akathisia - Parkinsonism 2. tardive dyskinesia 3. seizures 4. neuroleptic malignant syndrome
biologic theories of mood disorders
1. genetics: 1st degree relative, twins 2. neurochemical theories: - serotonin deficient in depression - norepinephrine deficient in depression and increased in mania - acetylcholine and dopamine might also involve 3. neuroendocrine influences - elevated glucocorticoid activity ass w stress response, --> increased cortisol apparent in 40% pt with depression, highest in older clients - elevated thyroid hormone also happen in 5-10% of people with depression.
schizophrenia assess
1. history : previous hx of schizophrenia, previous suicicde ideation, current support system, pt' perception of current situation 2. general appearance: motor behaviors, speech ( odd, bizarre, catatonia, echopraxia, psychomotor retardation, word salad, echolalia, latency of response 3. mood affect ( flat, blunted, anhedonia 4. thought process, content : thought blocking, broadcasting, withdrawal or insertion 5. delusions 6. sensorium interlectual process ( hallucinations of auditory, visual, olfactory, tactile ,gustatory, kinesthetic, kinesthetic, command] depersonalization 7. judgement, insight: usually imaired 8. self concept: loss of ego boundaries, ideas of references 9. role and relationship: social isolation 10. physiologic, self care: inattention to hygiene and grooming, failure to recognize sensations, polydipsia
goal and intervention for PD
1. improve mobility with exercise, stretching 2. enhancing self care activity while ensuring safety : assistive device, environmental modification, consult with OT, PT 3. constipation: consume lots of fiber and water, set routine bowel elimination time, avoid laxatives 4. improve nutrition and preventing aspiration: weight weekly maintain healthy wt, conscious eating ( think while place food in tongue, close lips, chew and swallow), use warm food tray, non-spill cup 5. improve communication: face listener, speak in short sentence, take deep breaths before talking, consult speech therapist 6. support coping ability: set realistic goals, psychotherapy, support group, encourage pt carry out talk, plan program activity, provide resources from Parkinson Disease Foundation and American Parkinson's disease Association 7. avoid complication: skin breakdown, pneumonia ( deep breathing, movement), contracture ( exercise , ROM)
psychosocial tx for schizophrenia pt
1. individual , groups therapies - supportive, me management, use of community support 2. social skill training - cognitive adaptation training - cognitive enhancement therapy (CET) 3. family therapy 4. family education
nursing management for pt with increased ICP
1. patent airway , adequate breathing pattern: suction, lung sounds, avoid coughing, elevate HOB, increased pressure on frontal lobe or deep midline structure cause cheyne-stoke respiration while pressure in midbrain cause hyperventilation. , if lower portion of brain stem ( pons and medulla) involve, resp is irregular and eventually ceases. maintain PaO2 >60 and PaCO2 <30 2. adequate cerebral tissue perfusion , reducing ICP : HOB 30-45 defray, head in neutral position, avoid extreme rotation of neck, flexion of neck, avoid extreme hip flexion, reduce intrathoracic and abdominal pressure), avoid straining, avoid emotional stress, reduce environmental stimuli 3. restore fluid balance: Check skin turgor, mucous membrane, urine output, serum and urine osmolality, VS, BP, catheter output , renal function I&O, observe for possible HF or pulm edema if given mannitol, if urine output >200ml per hr for 2 consecutive hrs indicate diabetes insipidus 4. absence of infection: use of strict aseptic technique when manage ICP monitoring system such as change ventricular drainage bag, → check for connection, leaks, Observe drainage of CSF, report if cloudy or bloody, Monitor for s/sx of meningitis: fever, chills, nuchal ( neck ) rigidity, increasing per persistent headache
The nurse is assessing a three week old infant, and recognizes which finding as an early sign of hypothermia? 1.The infant is shivering. 2. Rectal temperature is 33° celsius. 3. Skin is cool to touch and pale. 4. Rapid and slightly labored respirations.
4. Rapid and slightly labored respirations.
acute stress disorder vs PTSD
Acute stress disorder - 3 days to 3 month PTSD - sx for longer than >3 month , onset can be delayed for months /yrs. sx can fluctuate in intensity and severity, worse during stressful periods. can lead to depression, anxiety and substance abuse disorder. sx are similar
A pregnant woman enjoys exercising at a local health spa once a week. Which comment would lead the nurse to believe she needs additional health teaching? "I'm learning to play table tennis." "The gym gets hot and stuffy by midmorning." "Nothing feels nicer than a hot sauna after exercise." "I limit exercising to low-impact aerobics."
Correct response: "Nothing feels nicer than a hot sauna after exercise." Explanation: Hyperthermia may be associated with fetal anomalies and should be avoided during pregnancy. Exercise should be limited to low-impact activities.
The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement? "Late preterm infant complications are considered minor compared to the preterm newborn." "A late preterm newborn may have more clinical problems compared with full-term newborns." "The late preterm infant is more mature and able to cope as well as a full-term infant." "Late preterm newborns have fewer clinical problems leading to shorter hospital stays."
Correct response: "A late preterm newborn may have more clinical problems compared with full-term newborns." Explanation: The most common complications for late preterm infants are cold stress, respiratory distress, hypoglycemia, sepsis, cognitive delays, hyperbilirubinemia, and feeding difficulties. These are similar to those facing the preterm newborn and require similar management. Late preterm newborns have more clinical problems, longer lengths of stay, higher costs when compared with full-term newborns, and increased mortalities.
The nurse is caring for a 3-year-old child who experienced a febrile seizure for the first time. What statements by the parents of the child should the nurse address further? Select all that apply. "I am afraid that our 10-year-old will start having febrile seizures." "I am thankful that our child won't have to be on anti-seizure medication." "It's important to manage fevers in the future in order to decrease the risk of febrile seizures." "We have never had anyone in our family have a febrile seizure so I was so surprised when this happened." "It is so scary to think that our child will likely develop epilepsy now."
Correct response: "I am afraid that our 10-year-old will start having febrile seizures." "It is so scary to think that our child will likely develop epilepsy now." Explanation: It is very unlikely that the parents' 10-year-old child will develop febrile seizures. Febrile seizures usually affect children who are younger than 5 years of age, with the peak incidence occurring in children between 12 and 18 months old; it is rare to see febrile seizures in children younger than 6 months and older than 5 years of age. Children who experience one or more simple febrile seizures have a slightly greater risk of developing epilepsy than the general population, so it is not "likely" that the child will develop epilepsy.
The nurse has just measured an adult client's oral temperature and obtained a result of 102.4ºF (39.1ºC). The client states, "I just finished my coffee right before you came in. Can I have another cup?" Which response by the nurse is most appropriate? "I'll be right back with your coffee and a different thermometer. I'm not sure this one measured your temperature correctly." "You will need to remain NPO until I notify your primary health care provider about your increased temperature." "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." "Before you drink another hot beverage, drink some cool water so I can obtain an accurate oral temperature."
Correct response: "I will bring you another cup when I return in 30 minutes to reassess your temperature. Please do not drink any other beverages until I return." Explanation: Although an inaccurate thermometer may have caused a falsely elevated temperature, the more likely reason is consumption of a hot beverage; drinking another hot beverage would make any other oral thermometer's result inaccurate. The nurse does not need to tell the client to remain NPO until talking to the physician. The nurse needs to evaluate the temperature, as it may have been falsely elevated. Drinking cool water after hot water will not reverse the action of the hot beverage. The nurse does not need to bring another thermometer but reevaluate the temperature.
The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? "I must wait 15 minutes between applications of cold therapy." "I can let this stay on my ankle an hour at a time." "I should keep this on my ankle until it is numb." "I will put a layer of cloth between my skin and the ice pack."
Correct response: "I will put a layer of cloth between my skin and the ice pack." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.
The nurse has completed an education session with parents of children diagnosed with food allergies. Which statement by a parent would indicate a need for additional education? "I will make sure my daughter always has her EpiPen® with her all the time." "If we need to use the EpiPen® we will need to notify her physician's office the next business day." "I have found a website that makes medical alert bracelets in my daughter's favorite color." "The grey part of the EpiPen® should never be removed until right before we use it."
Correct response: "If we need to use the EpiPen® we will need to notify her physician's office the next business day." Explanation: If an EpiPen® is used, the child still needs immediate medical attention. EpiPens should be carried with the patient at all times. When administering an EpiPen, the grey safety cap should not be removed until immediately prior to using. Medical alert bracelets or necklaces should be worn by all children with severe allergies.
The father of a toddler tells the nurse that his child had a fever the previous night. During the assessment, which statement by the father indicates further discussion is necessary regarding temperature measurement? "My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better." "I used one of those thermometers that goes in the ear, but I don't think it was accurate." "We have an electronic oral thermometer. It seemed to match our child's symptoms of fever better." "I know rectal temperature is pretty accurate but I didn't see that it was necessary to cause the discomfort of that route."
Correct response: "My mother said she always used a glass thermometer when I was a kid and it was very accurate. Maybe that would be better." Explanation: The nurse should address the comment about use of a glass thermometer. These thermometers should be avoided since they contain mercury, which is toxic if the thermometer would break. Tympanic temperature measurement is dependent on several factors, so accuracy is sometimes questionable. Oral electronic thermometers are generally very accurate. Rectal temperatures are usually not necessary due to being invasive.
A health educator is teaching a group of colleagues about the physiology of thermoregulation. Which statement is most accurate? "Arachidonic acid induces cytokines to act on the temperature regulation center." "Prostaglandin E2 (PGE2) exerts a direct fever-producing effect on the hypothalamus." "PGE2 induces Kupffer cells to initiate a fever response via hepatic sinusoids." "Endogenous pyrogens induce host cells to produce exogenous pyrogens."
Correct response: "Prostaglandin E2 (PGE2) exerts a direct fever-producing effect on the hypothalamus." Explanation: PGE2 is the protein that exerts control on the hypothalamus and induces fever. Exogenous pyrogens induce host cells to produce endogenous pyrogens, and Kuppfer cells produce PGE2. Cytokines do not act directly on the hypothalamus.
A nurse is teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed? "If she needs dental surgery, we might need additional medication." "To prevent another episode, she'll need preventive antibiotic therapy for at least 5 years." "We can stop the penicillin when her symptoms disappear." "She needs to take the drug for the full 14 days."
Correct response: "We can stop the penicillin when her symptoms disappear." Explanation: For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.
On the third day postpartum, which temperature is internationally defined as a postpartal infection? 104.2° F (40.1° C) 102.4° F (39.1° C) 100.4° F (38° C) 99.6° F (37.5° C)
Correct response: 100.4° F (38° C) Explanation: A temperature over 100.4° F (38° C) past the first day postpartum is suggestive of infection.
Based upon circadian rhythms, when would the nurse note the highest temperature during a 24-hour period? 0300 1500 1700 1100
Correct response: 1700 Explanation: Body temperature fluctuates throughout the day. Temperature is usually lowest around 0300 and highest from 1700 to1900.
Which temperature readings indicate to the nurse that the clients have fever? Select all that apply. 2-year-old with axillary reading of 35.8ºC (96.4ºF) 35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) 19-year-old with oral reading of 38.4ºC (101.1ºF) 3-day-old with rectal reading of 38ºC (100.4ºF) 77-year-old with tympanic reading of 36.3ºC (97.3ºF)
Correct response: 35-year-old with pulmonary artery reading of 37.9ºC (100.2ºF) 19-year-old with oral reading of 38.4ºC (101.1ºF) 3-day-old with rectal reading of 38ºC (100.4ºF) Explanation: A core body temperature reading can be obtained from the esophagus, pulmonary artery catheter, a urinary catheter probe, or the rectum. For rapidly fluctuating temperatures, the pulmonary artery is most accurate. An oral temperature is generally lower than core by about 0.5ºC (1ºF). Axillary temperatures are approximately 0.5ºC (1ºF) lower than oral. A fever is temperature elevation above the body's normal set point which is usually between 36ºC (97ºF) and 37.5ºC (99.5ºF).
A parent has sought care from the nurse practitioner to treat a child's fever. The nurse practitioner is most likely to recommend what nonsalicylate drug? Naproxen Ibuprofen Indomethacin Acetaminophen
Correct response: Acetaminophen
What pharmacologic therapy does the nurse anticipate administering when the patient is experiencing thyroid storm? (Select all that apply.) Propylthiouracil Acetaminophen Iodine Dexamethasone (Decadron) Synthetic levothyroxine
Correct response: Acetaminophen Iodine Propylthiouracil Explanation: Treatments for thyroid storm include the following: a hypothermia mattress or blanket, ice packs, a cool environment, hydrocortisone, and acetaminophen (Tylenol); propylthiouracil (PTU) or methimazole to impede formation of thyroid hormone and block conversion of T4 to T3, the more active form of thyroid hormone; and iodine, to decrease output of T4 from the thyroid gland.
Which nursing diagnosis would best apply to a child with rheumatic fever? Disturbed sleep pattern related to hyperexcitability Ineffective breathing pattern related to cardiomegaly Risk for self-directed violence related to development of cerebral anoxia Activity intolerance related to inability of heart to sustain extra workload
Correct response: Activity intolerance related to inability of heart to sustain extra workload Explanation: Acute rheumatic fever affects the joints, central nervous system, skin and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness. Rheumatic fever does not produce cardiomegaly nor does it interfer with respirations or the ability to oxygenate the body. Children with rheumatic fever may develop chorea. These movements are involuntary and are not related to hyperexcitability.
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? Massage the extremities. Elevate the legs. Administer an analgesic as ordered. Apply a heat lamp.
Correct response: Administer an analgesic as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
The nurse is preparing to administer a scheduled dose of baclofen and notes that the client's most recent oral temperature was 100.9° (38.3°C). What is the nurse's best action? Administer the medication as prescribed and monitor the client Report this assessment finding promptly to the care provider Hold the baclofen, administer antipyretics as prescribed and reassess the client in one hour Perform a focused respiratory assessment
Correct response: Administer the medication as prescribed and monitor the client Explanation: A fever is not necessarily an indication that the client's baclofen should be held. Administering the drug as prescribed does not pose any clear safety risk in the presence of a fever. The nurse will need to follow up the client's fever, but there is no obvious need to report it.
The perioperative nurse is caring for a client who is undergoing abdominal surgery with the inclusion of succinylcholine in the client's anesthesia. The anesthesiologist tells the team that the client is exhibiting signs and symptoms suggestive of malignant hyperthermia. What is the nurse's best action? Prepare to administer acetylcysteine IV Administer naloxone IV as per facility protocol Initiate resuscitation Anticipate IV administration of dantrolene
Correct response: Anticipate IV administration of dantrolene Explanation: Dantrolene is the treatment for malignant hyperthermia. Naloxone treats opioid overdoses and acetylcysteine treats acetaminophen overdoses. Resuscitation efforts would be based on the client's current cardiopulmonary status and would not necessarily be required.
Which of the following measures can be used to cool a burn? Application of cool water Wrapping the person in ice Application of ice directly to burn Using cold soaks or dressings for at least 1 hour
Correct response: Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.
The camp nurse is caring for a child who was bitten on the leg by a dangerous spider. The child is being taken to a care provider. What is the most appropriate action for the nurse to do with this child? Splint the leg. Administer pain medication. Apply ice to the affected area. Briskly scrub the site.
Correct response: Apply ice to the affected area. Explanation: Spider bites can cause serious illness if untreated. Bites of black widow spiders, brown recluse spiders, and scorpions demand medical attention. Applying ice to the affected area until medical care is obtained can slow absorption of the poison.
Which structure would likely be present in a hair follicle in a man's groin but not in a follicle on his face? Sebaceous gland Arrector pili muscle Hair papilla Aprocrine gland
Correct response: Aprocrine gland Explanation: Aprocrine glands are only found in hair follicles in the underarms and groin. All hair follicles contain an erector pili muscle, sebaceous gland, and blood supply in the form of the hair papilla.
Which statement concerning blood flow to the skin is true? The skin contains only arteries. The skin contains only veins. Veins carry oxygenated blood to the skin. Arteriovenous anastomoses in the skin regulate temperature.
Correct response: Arteriovenous anastomoses in the skin regulate temperature. Explanation: The skin is supplied with arteriovenous anastomoses in which blood flows directly between an artery and a vein, bypassing the capillary circulation. These anastomoses are important for temperature regulation.
The nurse is working in collaboration with a nurse anesthetist to assess a preoperative client. When addressing the client's risk for malignant hyperthermia as a result of neuromuscular junction blockers, what assessment should be prioritized? Assessing for a history of febrile seizures in childhood Assessing for any history of cytochrome P450 dysfunction Assessing the client's allergy status Assessing for a family history of malignant hyperthermia
Correct response: Assessing for a family history of malignant hyperthermia Explanation: Family history is the most salient risk factor for malignant hyperthermia. This adverse effect is physiologically unrelated to childhood febrile seizures and does not result from cytochrome P450 dysfunction. Malignant hyperthermia is not a hypersensitivity response.
A homeless client presents to the ED. Upon assessment, the client is experiencing hypothermia. The nurse will plan to complete which priority intervention during the rewarming process? Insert a Foley urinary catheter Attach a cardiac monitor Assist with endotracheal intubation Administer inotropic drugs
Correct response: Attach a cardiac monitor Explanation: Continuous electrocardiograph (ECG) monitoring is performed during the rewarming process because cold-induced myocardial irritability leads to conduction disturbances, especially ventricular fibrillation. A urinary catheter should be inserted to monitor urinary output; however, ECG monitoring is the priority. There is no indication for endotracheal intubation. Inotropic medications are contraindicated because they can stimulate the heart and increase the risk for fatal dysrhythmias, such as ventricular fibrillation.
A nurse is performing a physical examination on a newborn. Which assessment should she include? Oral temperature, blood pressure, head circumference Temporal temperature, blood pressure, reflexes Rectal temperature, femoral pulse, head circumference Axillary temperature, femoral pulse, head circumference
Correct response: Axillary temperature, femoral pulse, head circumference Explanation: When examining newborns, take axillary or temporal temperatures to prevent rupture of rectal mucosa. Be certain to take femoral pulses in newborns to rule out coarctation of the aorta. Include newborn reflexes, head circumference, and an assessment of gestational age as routine parts of the examination. Taking blood pressure is not necessary because this value is unreliable in newborns.
Which intervention would be the best way for the nurse to prevent heat loss in a newborn while bathing? Bathe the baby in water between 90 and 93 degrees. Postpone breastfeeding until after the initial bath. Limit the bathing time to 5 minutes. Bathe the baby under a radiant warmer.
Correct response: Bathe the baby under a radiant warmer. Explanation: Bathing a newborn under a radiant warmer helps to prevent heat loss. To minimize the effects of cold stress during the bath, the nurse should also prewarm blankets, dry the child completely to prevent heat loss from evaporation, encourage skin-to-skin contact with the mother, promote early breastfeeding, used heated and humidified oxygen, and defer bathing until the newborn is medically stable. Limiting the length of time spent bathing the baby is secondary to maintaining the baby's body temperature. Having warm water is also important but is irrelevant if the baby is not kept warm under a warmer.
A client with a rising temperature is pale and has begun to shiver. The nurse reports that the client is in which phase of fever development? Chill Flush Defervescence Prodrome
Correct response: Chill Explanation: During the second phase or chill phase of fever development, the client's skin is pale; there is an onset of shivering, a rising temperature, and the sensation of being chilled. Therefore, the nurse should report that the client is in the second or chill phase of fever development.
When an infection is bloodborne, the manifestations include which symptom? Bradycardia Hyperactivity Chills Hypothermia
Correct response: Chills Explanation: Manifestations of bloodborne infection include chills, high fever, rapid pulse, and generalized malaise.
Which client would be diagnosed with wasting syndrome? Client with HIV, fever, diarrhea, and significant involuntary weight loss Client with AIDS with pneumonia, chronic fever, and chronic fatigue Client with chronic fatigue syndrome, no fever and herpes simplex, and candidiasis around the oral mucosa Client with HIV a CD4+ T-cell count of 1000 cells/μL, Kaposi sarcoma, and nausea and vomiting for more than 2 weeks
Correct response: Client with HIV, fever, diarrhea, and significant involuntary weight loss Explanation: A client diagnosed with wasting syndrome (an AIDS-defining illness) would have chronic fever, diarrhea, and a significant involuntary weight loss (usually more than 10%) without an opportunistic infection. Pneumonia, Kaposi sarcoma, and herpes simplex and candidiasis are all opportunistic infection.
Which client would be diagnosed with wasting syndrome? Client with HIV a CD4+ T-cell count of 1000 cells/μL, Kaposi sarcoma, and nausea and vomiting for more than 2 weeks Client with chronic fatigue syndrome, no fever and herpes simplex, and candidiasis around the oral mucosa Client with HIV, fever, diarrhea, and significant involuntary weight loss Client with AIDS with pneumonia, chronic fever, and chronic fatigue
Correct response: Client with HIV, fever, diarrhea, and significant involuntary weight loss Explanation: A client diagnosed with wasting syndrome (an AIDS-defining illness) would have chronic fever, diarrhea, and a significant involuntary weight loss (usually more than 10%) without an opportunistic infection. Pneumonia, Kaposi sarcoma, and herpes simplex and candidiasis are all opportunistic infection.
The nurse has admitted a small for gestational age infant (SGA) to the observation nursery from the birth room. Which action would the nurse prioritize in the newborn's care plan? Closely monitor temperature. Assess for hyperglycemia. Monitor intake and output. Observe feeding tolerance.
Correct response: Closely monitor temperature. Explanation: Difficulty with thermoregulation in SGA newborns is common due to less muscle mass, less brown fat, less heat-preserving subcutaneous fat, and limited ability to control skin capillaries. The priority would be to closely monitor the newborn's temperature. It is also is associated with depleted glycogen stores; therefore, this is hypoglycemia not hyperglycemia. Immaturity of CNS (temperature-regulating center) interferes with ability to regulate body temperature. Intake and output monitoring and observing feeding are not the priority.
The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism? Conduction Convection Radiation Evaporation
Correct response: Convection
A client taking the typical antipsychotic agent haloperidol experiences neuroleptic malignant syndrome. What nursing intervention is highest priority after stopping the medication? Diazepam Cooling blanket Bromocriptine IV fluid hydration
Correct response: Cooling blanket Explanation: Neuroleptic malignant syndrome (NMS) is a life-threatening condition most often triggered by typical antipsychotic agents such as haloperidol and chlorpromazine. The condition usually has sudden onset of hyperthermia, muscle rigidity, change in mental status, and autonomic dysfunction seen in labile blood pressure, dyspnea, and tachycardia. The priority interventions are to stop the medication and reduce the temperature using a cooling blanket or ice packs in the axillae and groin. Subsequent interventions of IV fluids and ventilator support are directed at controlling symptoms and supporting body systems. Dopamine agonists such as bromocriptine have been used to reduce the effect of the triggering neuroleptic agent. Benzodiazepines such as diazepam can be used to reduce anxiety.
A client with a history of malignant hyperthermia is scheduled for surgery. Which agent would the nurse most likely expect to administer? Baclofen Botulinum toxin type B Methocarbamol Dantrolene
Correct response: Dantrolene Explanation: Dantrolene is the drug that would be used as prevention and treatment of malignant hyperthermia.
What medication should the nurse prepare to administer in the event the client has malignant hyperthermia? Naloxone Dantrolene sodium Thiopental sodium Fentanyl citrate
Correct response: Dantrolene sodium Explanation: Anesthesia and surgery should be postponed. However, if end-tidal carbon dioxide (CO2) monitoring and dantrolene sodium (Dantrium) are available and the anesthesiologist is experienced in managing malignant hyperthermia, the surgery may continue using a different anesthetic agent.
The nurse in the NICU is caring for preterm newborns. Which guidelines are recommended for care of these newborns? Select all that apply. Discourage contact with parents to maintain asepsis. Take the newborn's temperature often. Give the newborn a warm bath immediately. Handle the newborn as much as possible. Supply oxygen for the newborn, if necessary. Dress the newborn in ways to preserve warmth.
Correct response: Dress the newborn in ways to preserve warmth. Take the newborn's temperature often. Supply oxygen for the newborn, if necessary. Explanation: Controlling the temperature of preterm newborns is often difficult; therefore, special care should be taken to keep these babies warm. Nurses should dress them in a stockinette cap, take their temperature often, and supply oxygen, if necessary. To conserve the energy of small newborns, the nurse should handle them as little as possible. Usually, they will not give them a bath immediately. Parents should be encouraged to bond with their infants.
A specific type of gram-negative bacteria contains endotoxin in the bacterial cell envelope. What is the likely clinical manifestation if these bacteria become pathogenic? Constipation Leukopenia Fever Vomiting
Correct response: Fever Explanation: A small amount of endotoxin in the circulatory system (endotoxemia) can induce clotting, bleeding, inflammation, hypotension, and fever.
The nurse is assessing a client diagnosed with varicella. The nurse is aware that nonspecific manifestations may include: Sores with crustations Pruritic rash Fever Liquid-filled blisters
Correct response: Fever Explanation: Symptoms such as fever, myalgia, headache, and lethargy are nonspecific manifestations of varicella. Liquid-filled blisters, sores with crustations, and pruritic rash are specifically related to this disease process.
A 28-year-old patient has a history of malignant hyperthermia following anesthesia. Today, this patient is on the operating room schedule for a D&C;. Which method of anesthesia would not be acceptable for this patient? General anesthesia with an inhalation agent Epidural anesthesia Local anesthesia Spinal anesthesia
Correct response: General anesthesia with an inhalation agent Explanation: Because this patient has a history of malignant hyperthermia, general anesthesia with an inhalation agent should not be given because it highly likely to trigger another event.
Which assessment and laboratory findings would be most closely associated with acute leukemia? Increased serum potassium and sodium levels Increased blood urea nitrogen and bone pain Decreased oxygen partial pressure and weight loss High blast cell counts and fever
Correct response: High blast cell counts and fever Explanation: Acute leukemia is often marked by a fever as well as leukostasis. Changes in oxygen saturation, electrolytes and BUN would be less closely associated with ALL and AML.
Neurogenic fevers begin in the central nervous system. By what characteristics are neurogenic fevers known? High temperatures that are not associated with sweating Temperatures that go up and down for no apparent reason High temperatures that respond quickly to antipyretic therapy Variable temperatures that are associated with sweating
Correct response: High temperatures that are not associated with sweating Explanation: A fever that has its origin in the central nervous system is sometimes referred to as a neurogenic fever. Neurogenic fevers are characterized by a high temperature that is resistant to antipyretic therapy and is not associated with sweating.
A nurse instructing unlicensed assistive personnel (UAP) on temperature regulation includes as part of her teaching that core body and skin temperatures are sensed by which part of the brain? Cerebellum Cerebral cortex Hypothalmus Medulla
Correct response: Hypothalmus Explanation: Core body and skin temperatures are sensed and integrated by the thermoregulatory regions in the hypothalmus.
A client was stranded when his automobile broke down while traveling in the mountains. The client had to walk 15 miles to the nearest gas station, and the outside temperature was 20°F (-7°C). The client was at risk for: Decreased blood viscosity and vasoconstriction Increased blood viscosity and vasoconstriction Increased blood viscosity and vasodilatation Decreased blood viscosity and vasodilatation
Correct response: Increased blood viscosity and vasoconstriction Explanation: Exposure to cold increases blood viscosity and induces vasoconstriction by direct action on blood vessels and through reflex activity of the sympathetic nervous system. The resultant decrease in blood flow may lead to hypoxic tissue injury, depending on the degree and duration of cold exposure. Injury from freezing probably results from a combination of ice crystal formation and vasoconstriction.
A nurse notes that a client with a fever has begun to shiver. The nurse should assess for which event? Hypothermia Hyperthermia Increased temperature Decreased temperature
Correct response: Increased temperature Explanation: The nurse should assess for increased temperature elevation. This is because although shivering is an attempt by the body to decrease temperature, it actually increases it along with oxygen consumption.
A client's temperature readings are as follows: 99.6°F (37.5°C) at 4 pm; 102°F (38.9°C) at 8 pm; and 97.9°F (36.6°C) at 12 am. The nurse's hand-off should include which note? Prodermal phase Remittent fever Defervescence Intermittent fever
Correct response: Intermittent fever Explanation: The nurse's hand-off report should include the presence of intermittent fever—a temperature that returns to normal at least once every 24 hours.
The nurse knows to assess a patient with hyperthyroidism for the primary indicator of: Constipation Fatigue Weight gain Intolerance to heat
Correct response: Intolerance to heat Explanation: With hypothyroidism, the individual is sensitive to cold because the core body temperature is usually below 98.6°F. Intolerance to heat is seen with hyperthyroidism.
A normal response to fever is an elevated heart rate. A client with a fever who is not exhibiting an elevated heart rate would indicate to the nurse that the cause of the fever might be: Hyperthyroidism Legionnaires' disease Flu Pulmonary emboli
Correct response: Legionnaires' disease Explanation: The observation that a rise in temperature is not accompanied by the anticipated change in heart rate can provide useful information about the cause of the fever. For example, a heart rate that is slower than would be anticipated can occur with Legionnaires' disease and drug fever, and a heart rate that is more rapid than anticipated can be symptomatic of hyperthyroidism and pulmonary emboli
After teaching a class about agents commonly associated with the development of malignant hyperthermia, the instructor determines that additional teaching is needed when the students identify which drug as a possible cause? Epinephrine Morphine Halothane Succinylcholine
Correct response: Morphine Explanation: Morphine is not associated with malignant hyperthermia. Agents such as halothan, succinylcholine, and epinephrine can induce malignant hyperthermia.
A nurse is caring for a client with fever of unknown origin (FUO). The nurse anticipates that the client may have which underlying condition? Select all that apply. Urinary tract infection Non-Hodgkin lymphoma Abscessed infection Pneumonia
Correct response: Non-Hodgkin lymphoma Abscessed infection Explanation: Underlying causes of FUO include malignancies, infections such as human immunodeficiency virus, tuberculosis, abscessed infections, and drug fever.
The nurse is caring for an 85-year-old client hospitalized for dehydration. The nurse notices that the client is shivering and takes the client's temperature. The nurse notes an oral temperature of 97.8°F (36.6°C). The client also reports being "chilly." Which nursing action is most appropriate? Increase the client's oral fluid intake. Assess the client's respiratory rate. Notify the physician. Offer the client an extra blanket.
Correct response: Offer the client an extra blanket. Explanation: Thermoregulation is a physiological need. The human body functions within a narrow temperature range with an oral temperature of 97.5 to 99.5°F (36 to 38°C). Homeostatic mechanisms and adaptive responses, such as shivering (to increase body temperature) or sweating (to reduce body temperature), help to maintain body temperature. Offering the client a blanket is appropriate because the external body covering will increase the client's low body temperature. Notifying the physician is not necessary because the temperature is within normal range. A normal or low temperature is not an indicator of dehydration, so increasing the intake of oral fluids is not necessary. A normal or low temperature is not an indication of respiratory distress, so an assessment of the client's respiratory rate is not necessary.
The nurse in the newborn nursery is placing a 30-minute-old newborn on a radiant warmer for thermoregulation. Where should she apply the temperature probe to be most accurate? Over the liver on the abdomen On the upper thigh Over the upper chest On the scalp
Correct response: Over the liver on the abdomen Explanation: Temperature probes are placed over the liver on the abdomen. The probe is never placed on bony prominences or over areas of brown fat because those areas tend to be warmer than the rest of the body.
A nurse is caring for a child with Kawasaki disease. Which assessment finding would the nurse expect to see? Peeling hands and feet and fever Irritability and dry mucous membranes Decreased heart rate and impalpable pulse Low blood pressure and decreased heart rate
Correct response: Peeling hands and feet and fever Explanation: Kawasaki disease is an acute sytemic vasculitis. Symptoms begin with very high fevers. One of the signs of Kawasaki disease is the peeling hands and feet and in perineal region.The child is usually tachycardic and laboratory values would indicate increased platelets and decreased hemoglobin. Another classic sign of Kawasaki is the strawberry tongue. The other symptoms are not necessarily characteristic of Kawasaki disease.The child should be evaluated if there are impalpable pulses because this could indicate a heart defect or some other serious illness.
When the health care provider looks in a child's mouth during a sick-visit examinaiton, the parent exclaims: "The tongue is bright red! It was not like that yesterday." The health care provider would most likely prescribe which medication based on the probable diagnosis? Acetaminophen to decrease the throat pain Erythromycin to prevent the spread to siblings Penicillin to prevent acute glomerulonephritis Steroids to decrease the inflammation
Correct response: Penicillin to prevent acute glomerulonephritis Explanation: A "strawberry tongue" is a classic sign of scarlet fever. Penicillin is prescribed to treat the beta-hemolytic group A strococcal infection and to prevent the complication of developing acute glomerulonephritis and rheumatic fever. Erythromycin can be used to treat the disease if the child is allergic to penicillin. Antibiotics are not give prophylactally to siblings. The disease is spread via droplets, so keeping the siblings away from the infected child and handwashing are the best preventative measures. Acetaminophen can be administered for fever control. It works systemically and has very little, if any, affect locally. Antibiotics are the mainstay of treatment. Steroids are used infrequently.
A child is brought into the emergency department experiencing significant hypothermia. Core rewarming techniques have been ordered. The nurse would most likely assist with administration of which of the following? Select all that apply. Warmed blankets Heated, humidified oxygen Warmed IV fluids Extracorporeal circulation Pleural lavage
Correct response: Pleural lavage Warmed IV fluids Heated, humidified oxygen Extracorporeal circulation Explanation: Core rewarming techniques include heated, humidified oxygen; warmed IV fluids; pleural lavage; and extracorporeal circulation.
A client complains of general malaise and fatigue and has a mild fever. The nurse would evaluate this stage of disease as the: Convalescent stage Incubation stage Prodromal stage Resolution stage
Correct response: Prodromal stage Explanation: The hallmark of the prodromal stage is the initial appearance of symptoms in the host that are mild and nonspecific. The other stages/symptoms would not be present.
A client has a mild headache and fatigue. He also states he has some aches and pains. Which stage of fever does the nurse determine the client is experiencing? Flush Prodrome Defervescence Chill
Correct response: Prodrome Explanation: During the first or prodromal period there are nonspecific complaints such as mild headache and fatigue, general malaise, and fleeting aches and pains.
Which hormone is responsible for breast development and the increase in body temperature that occurs with ovulation? Androgen Testosterone Prolactin Progesterone
Correct response: Progesterone Explanation: Progesterone is the hormone responsible for breast development and increase in body temperature during ovulation. The other options are not involved in either of these processes.
The nurse needs to assess a 1-year-old child for fever. Which approach will produce the mostaccurate reading? Oral Forehead Rectal Axillary
Correct response: Rectal Explanation: Measurement of core body temperature is important when evaluating fever. The rectal route is considered the most accurate. In adults and older children, the oral route is lower, but still accurate; however, in young children the oral route may be unreliable. Forehead thermometers can predict trends, but are not as accurate as other routes. The axillary route requires up to 10 minutes for the temperature to register appropriately.
A nurse is caring for an adult with fever. The nurse determines that which site is most ideal for obtaining the client's core body temperature? Ear Axilla Mouth Rectum
Correct response: Rectum
The nurse is taking a rectal temperature on a client who reports feeling lightheaded during the procedure. What would be the nurse's priority action in this situation? Call for assistance and anticipate the need for CPR. Leave the thermometer in and notify the physician. Remove the thermometer and assess the blood pressure and heart rate. Remove the thermometer and assess the temperature via another method.
Correct response: Remove the thermometer and assess the blood pressure and heart rate. Explanation: Vagal nerve stimulation may occur when obtaining a rectal temperature. Vagal nerve stimulation can cause the pulse and blood pressure to drop significantly, causing the client to feel lightheaded; therefore, the thermometer should be removed immediately and the pulse and blood pressure assessed. The physician can be called after assessing the client. The temperature is not the priority at this time. Assistance for CPR would be determined if the client's condition worsens.
A 6-year-old child is brought to the clinic by his parents. The parents state, "He had a sore throat for a couple of days and now his temperature is over 102°F (38.9°C). He has this rash on his face and chest that looks like sunburn but feels really rough." What would the nurse suspect? Pertussis Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) Scarlet fever Diphtheria
Correct response: Scarlet fever Explanation: Scarlet fever typically is associated with a sore throat, fever greater than 101° F (38.9° C), and the characteristic rash on the face, trunk, and extremities that looks like sunburn but feels like sandpaper. CAMRSA is typically manifested by skin and tissue infections. Diphtheria is characterized by a sore throat and difficulty swallowing but fever is usually below 102°F . Airway obstruction is apparent. Pertussis is characterized by cough and cold symptoms that progress to paroxysmal coughing spells along with copious secretions.
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Capillary refill of 2 seconds Shivering Cool, dry skin Urine output of 100 mL/hr
Correct response: Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
Which clinical manifestation is often the earliest sign of malignant hyperthermia? Tachycardia (heart rate >150 beats per minute) Hypotension Elevated temperature Oliguria
Correct response: Tachycardia (heart rate >150 beats per minute) Explanation: Tachycardia is often the earliest sign of malignant hyperthermia. Hypotension is a later sign of malignant hyperthermia. The rise in temperature is actually a late sign that develops quickly. Scant urinary output is a later sign of malignant hyperthermia.
A 30-year-old client would like to try using basal body temperature (BBT) as a fertility awareness method. Which instruction should the nurse provide the client? Avoid unprotected intercourse until BBT has been elevated for 6 days. Avoid using other fertility awareness methods along with BBT. Use the axillary method of taking the temperature. Take temperature before rising, and record it on a chart.
Correct response: Take temperature before rising, and record it on a chart. Explanation: The client should be instructed to take her temperature before rising and record it on a chart. If using this method by itself, the client should avoid unprotected intercourse until the BBT has been elevated for 3 days. The client should be informed that other fertility awareness methods should be used along with BBT for better results. The oral method is better suited than the axillary method for taking the temperature in this case.
A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for: Temperature Hypothermia Urinary output Respirations
Correct response: Temperature Explanation: Common clinical manifestations of fever include anorexia, myalgia, arthralgia, headaches, and fatigue; thus, the nurse should assess the client's temperature.
A client is experiencing anorexia, myalgia, arthralgia, headache, and fatigue. The nurse should assess for: Urinary output Respirations Hypothermia Temperature
Correct response: Temperature Explanation: Common clinical manifestations of fever include anorexia, myalgia, arthralgia, headaches, and fatigue; thus, the nurse should assess the client's temperature.
The nurse is teaching the parents of a 15-year-old boy who is being treated for acute myelogenous leukemia about the side effects of chemotherapy. For which symptoms should the parents seek medical care immediately? Blisters, ulcers, or a rash appear Temperature of 101° F (38.3° C) or greater Earache, stiff neck, or sore throat Difficulty or pain when swallowing
Correct response: Temperature of 101° F (38.3° C) or greater Explanation: The parents should seek medical care immediately if the child has a temperature of 101°F (38.3° C) or greater. This is because many chemotherapeutic drugs cause bone marrow suppression; the parents must be directed to take action at the first sign of infection in order to prevent overwhelming sepsis. The appearance of earache, stiff neck, sore throat, blisters, ulcers, or rashes, or difficulty or pain when swallowing are reasons to seek medical care, but are not as grave as the risk of infection.
Which client manifestation indicates signs of drug fever? Temperature reaches 39°C (102.2°F) following aerobic activity, pulse 125 beats/minute, sweating Temperature reaches 41°C (105.8°F) after a sauna, pulse 76 beats/minute, skin hot and dry Temperature reaches 38°C (100.4°F) for 3 days, pulse 106 beats/minute, purulent drainage Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis
Correct response: Temperature reaches 40°C (104°F) every afternoon, pulse 76 beats/minute, pruritis Explanation: Clients with drug fever often show signs of hypersensitivity such as joint pain, itching, rashes, muscle pains, and gastrointestinal distress. The fever has a diurnal pattern with the highest point in the afternoon or early evening. The clients in the other options are exhibiting signs of infection, heat exhaustion, and heatstroke.
The nurse is applying a heating pad to a client experiencing neck pain. Which nursing action is performed correctly? The nurse covers the heating pad with a heavy blanket. The nurse places the heating pad under the client's neck. The nurse uses a safety pin to attach the pad to the bedding. The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly.
Correct response: The nurse keeps the pad in place for 20 to 30 minutes, assessing it regularly. Explanation: The nurse would keep the heating pad in place for 20 to 30 minutes, assessing it regularly. The nurse would not use a safety pin to attach the pad to the bedding. The pin could create problems with this electric device. The nurse would not place the heating pad directly under the client's neck. The nurse would not cover the heating pad with a heavy blanket.
Which role does adipose tissue play in the body? Balance electrolytes Make collagen Thermal insulation Manufacture energy
Correct response: Thermal insulation
A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin? They have no effect. They cause wide fluctuations in the need for insulin. They decrease the need for insulin. They increase the need for insulin.
Correct response: They increase the need for insulin. Explanation: Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications. Insulin requirements are decreased by hypothyroidism, decreased food intake, exercise, and some medications.
A 33-year-old client is brought into the emergency room with a core temperature of 39°C (102.2°F). The client is red in the face, chest, and back due to significant cutaneous vasodilation. The client is likely in which stage of fever? Third First Fourth Second
Correct response: Third Explanation: The first stage of a fever is marked by headache and body aches, the second stage is marked by the chills, and the third stage is the flush state. The fourth stage is defervescence.
A nurse is performing an admission assessment on a client who is scheduled for an elective surgery the next morning. When taking vital signs, the nurse finds that the client's temperature is 39.4°C (103°F). What should be the nurse's priority action? Inform the unlicensed assistive personnel to document the finding. Verbally report the finding to the charge nurse at the change of shift. Verbally report the finding immediately to the client's physician. Reassess the client's temperature in 2 hours and chart this data.
Correct response: Verbally report the finding immediately to the client's physician.
A man presents to the emergency department after being out in below-zero weather all night. He asks the nurse why the health care team is concerned about his toes and feet. How would the nurse respond? 1.After being out in the cold all night your toes and feet are frozen and it will be very painful to warm them again, and the health care team is concerned he might be a drug addict. 2. The staff is concerned that you might be a homeless person, and we were wondering how often this has happened to you before and when it will happen again. 3. Cold causes injury to the cells in the body by injuring the blood vessels, making them leak into the surrounding tissue. 4. Your toes and feet are frozen, and there is a concern about how decreased blood flow may lead to the formation of blood clots as we warm them again.
Correct response: Your toes and feet are frozen, and there is a concern about how decreased blood flow may lead to the formation of blood clots as we warm them again. Explanation: Injury from freezing probably results from a combination of ice crystal formation and vasoconstriction. The decreased blood flow leads to capillary stasis and arteriolar and capillary thrombosis. Edema results from increased capillary permeability. Exposure to low-intensity heat (43°C to 46°C [109.4°F to 114.8°F]), such as occurs with partial-thickness burns and severe heat stroke, causes cell injury by inducing vascular injury. The process of warming tissue that has been frozen or partially frozen causes pain. If the pain is bad enough, then medication to control the pain is given. Health team members are always concerned about giving pain medication to someone who might be an addict. Asking if this is the first time this person has had an injury induced by the cold is appropriate when taking a health history. However, pointing out that "it is obvious you are a homeless person" is not an appropriate remark for the nurse to make. Also not appropriate is wondering when it will happen again.
A chief danger of scarlet fever is that children may develop: acute glomerulonephritis. respiratory obstruction. local areas of skin necrosis. liver destruction.
Correct response: acute glomerulonephritis. Explanation: Scarlet fever infection is the result of group A streptococci. It generally starts with a throat infection (strep throat). The bacteria produce a toxin that causes the rash over the body. Because this is a streptococci-based infection, the child will need to be monitored for the development of rheumatic fever or glomerulonephritis following the illness. Scarlet fever does not cause respiratory symptoms, attack the liver, or have open lesions.
A pregnant client is undergoing a fetal biophysical profile. Which parameter of the profile helps measure long-term adequacy of the placental function? amniotic fluid volume fetal breathing record fetal reactivity fetal heart rate
Correct response: amniotic fluid volume Explanation: A biophysical profile combines five parameters (fetal reactivity, fetal breathing movements, fetal body movement, fetal tone, and amniotic fluid volume) into one assessment. The fetal heart and breathing record measures short-term central nervous system function; the amniotic fluid volume helps measure long-term adequacy of placental function.
Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia? a young adult with a fractured leg an adolescent having arthroscopic surgery a woman experiencing a cesarean birth an older adult man with a fractured hip
Correct response: an older adult man with a fractured hip Explanation: The risk of hypothermia increases in the very young and the very old.
The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold? tachycardia apnea crying sleepiness
Correct response: apnea Explanation: A premature infant has thin skin, an immature central nervous system (CNS), lack of brown fat stores, and an increased weight-to-surface area ratio. These are predisposing thermoregulation problems that can lead to hypothermia. As a result, the infant may become apneic, have respiratory distress, increase his or her oxygen need, or be cyanotic. The other choices are not specific to increased oxygen demand or respiratory distress.
A nurse is assessing a newborn during the first 24 hours after birth. Which findings would the nurse recognize as normal? rounded, symmetrical abdomen heart rate of 90 to 100 bpm enlarged labia with pseudomenstruation positive Ortolani sign body temperature of 97.9° to 99.7° F (36.5° to 37.5° C)
Correct response: body temperature of 97.9° to 99.7° F (36.5° to 37.5° C) Explanation: On average, a newborn's temperature ranges from 97.9° to 99.7° F (36.5° to 37.5° C).
A newborn's axillary temperature is 97.6° F (36.4° C). He has a cap on his head. His T-shirt is damp with spit-up milk. His blanket is laid over him, and several children are in the room running around his bassinet. The room is comfortably warm, and the bassinet is beside the mother's bed away from the window and doors. What are the most likely mechanisms of heat loss for this newborn? conduction and radiation conduction and evaporation convection and evaporation convection and radiation
Correct response: convection and evaporation
The nurse is preparing to assess a client's oral temperature. The nurse should plan to place the thermometer probe in which area of the client's mouth? superior to the tongue, with the tip touching the hard palate along either upper gum line, adjacent to an incisor in the inferior buccal space on either side of the tongue deep in the posterior sublingual pocket
Correct response: deep in the posterior sublingual pocket Explanation: When the probe rests deep in the posterior sublingual pocket, it is in contact with blood vessels lying close to the surface. None of the other areas provides as much contact with blood vessels and therefore is not an appropriate location to place the thermometer probe.
Many clients experience a slight fever after birth especially during the first 24 hours. To what should the nurse attribute this elevated temperature? change in the temperature from the birth room infection fluid volume overload dehydration
Correct response: dehydration Explanation: Many women experience a slight fever (100.4° F [38° C]) during the first 24 hours after birth. This results from dehydration because of fluid loss during labor. With the replacement of fluids the temperature should return to normal after 24 hours.
The LVN/LPN will be assessing a postpartum client for danger signs after a vaginal birth. What assessment finding would the nurse assess as a danger sign for this client? fundus is above the umbilicus presence of lochia rubra fever more than 100.4° F (38° C) fundus is firm
Correct response: fever more than 100.4° F (38° C) Explanation: A fever more than 100.4° F (38° C) is a danger sign that the client may be developing a postpartum infection. Lochia rubra is a normal finding as is a firm uterine fundus. A uterine fundus above the umbilicus may indicate that the client has a full bladder but does not indicate a postpartum infection.
A nurse is assessing a 1-hour-old neonate in the special care nursery. Which assessment finding indicates a metabolic response to cold stress? hypoglycemia hypertension hyperglycemia arrhythmia
Correct response: hypoglycemia Explanation: Hypoglycemia, not hyperglycemia, occurs as a result of cold stress. When a neonate is exposed to a cold environment his metabolic rate increases as the neonate's body attempts to warm itself. The increase in metabolic rate causes glucose consumption resulting in hypoglycemia. Arrhythmia and hypertension are associated with cardiopulmonary problems.
A nurse is asked to teach a woman to take her basal body temperature daily to assess the time of ovulation. She can detect her day of ovulation, following ovulation, because her temperature will: decrease a degree. fluctuate a degree daily. no longer reflect basal body temperature. increase a degree.
Correct response: increase a degree. Explanation: The effect of progesterone, released with ovulation, is to increase body temperature.
A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? lethargy and hypotonia increased appetite increase in the body temperature hyperglycemia
Correct response: lethargy and hypotonia Explanation: The nurse should look for signs of lethargy and hypotonia in the newborn in order to confirm the occurrence of cold stress. Cold stress leads to a decrease, not increase, in the newborn's body temperature, blood glucose, and appetite.
A client with schizophrenia started risperidone 2 weeks ago. Today, the client reports feeling flu-like symptoms. The nurse's assessment reveals the following: temperature 104.4° F (40.2° C), respirations 24 breaths/minute, blood pressure 130/102 mm Hg, pulse rate 120 beats/minute. The nurse also notes muscle stiffness and pain, excessive sweating and salivation, and changes in mental status. The nurse suspects the client is experiencing: septicemia. neuroleptic malignant syndrome. malignant hyperthermia. the flu.
Correct response: neuroleptic malignant syndrome. Explanation: Neuroleptic malignant syndrome is a rare but potentially life-threatening reaction to an antipsychotic or neuroleptic. The cardinal symptom is a high temperature. Other commonly observed symptoms include altered mental status and autonomic dysfunction. Although fever may be present with the flu, it doesn't normally cause altered mental status or autonomic dysfunction. Malignant hyperthermia is a complication associated with general anesthesia. These findings don't suggest the client has septicemia. Findings in septicemia include severe hypotension, fever, tachycardia, and a history of a recent infection.
A nurse is assigned to a client with a cardiac disorder. The nurse should question an order to monitor the client's body temperature by which route? tympanic axillary rectal oral
Correct response: rectal Explanation: When caring for a client with a cardiac disorder, the nurse should avoid using the rectal route to take temperature. Using this route could stimulate the vagus nerve, possibly leading to vasodilation and bradycardia. The other options are appropriate routes for measuring the temperature of a client with a cardiac disorder.
The skin is richly supplied with arteriovenous anastomoses in which blood flows directly between an artery and a vein, bypassing the capillary circulation. This particular vascular structure allows a client to: form "goose bumps" when cold. prevent localized hypoxia. regulate body temperature. maximize skin perfusion.
Correct response: regulate body temperature. Explanation: Anastomoses are important for temperature regulation. They can open up, letting blood flow through the skin vessels when there is a need to dissipate body heat, or close off, conserving body heat if the environmental temperature is cold. Although goose bumps are a reaction to cold, they are actually caused by the contraction of the arrector pili muscles. They are not involved specifically in oxygenation.
A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to take a hot bath. increase the dose of muscle relaxants. avoid naps during the day. rest in an air-conditioned room.
Correct response: rest in an air-conditioned room. Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.
A woman has been assessing her basal body temperature for 4 months. Upon reviewing her temperature history log, the nurse notes no change in her daily temperatures. Which should the nurse expect the health care provider to prescribe first? endometrial biopsy clomiphene serum progesterone level vaginal discharge culture
Correct response: serum progesterone level Explanation: There should be a significant increase in temperature, usually 0.5° to 1° F, within a day or two after ovulation has occurred. The temperature remains elevated for 12 to 16 days, until menstruation begins. The cause of this rise in temperature is the hormone progesterone. If there is no change in the woman's monthly temperature, the progesterone level should be assessed.
predictor or risk factor of PTSD
Direct involve in traumatic event Experience of physcia injury Loss of love ones Lack of soxial support Previous psychiatric history or personalitty factors ( despressiom, anxiety, personality disorder) Adolescent more likely to develop PTSD than adults : adolecent suffer PTSD have increased risk for suiccide, substance abuse, poor social support, acedemic proboem, health cncerns
culture of poverty
Feelings of despair, resignation, and fatalism Day-to-day attitude toward life; no hope for future Unemployment and need for financial or government aid Unstable family structure; possibly characterized by abusiveness and abandonment Decline in self-respect and retreat from community involvement
The nurse is conducting a physical assessment of a homeless man during a night when the wind chill factor is -10°F (-23°C). When assessing the man's fingers and toes for frostbite, the nurse looks for which type of cellular injury? Mechanical Hypoxic Chemical Endogenous
Hypoxic Explanation: Exposure to cold increases blood viscosity and induces vasoconstriction by direct action on blood vessels and through reflex activity of the sympathetic nervous system. The resultant decrease in blood flow may lead to hypoxic tissue injury, depending on the degree and duration of cold exposure.
measures to maintain safety for a patient with delirium
Reorien pt, control pain PRN, minimize use of psychoactive drugs, prevent sleep deprivation, use eye glassess, hearing aid, maintain O2 , fluid and electrolyte balance, monitor nutrition and fluid intake, provide calm, quiet environment, encourage family to touch and talk to pt, ongoing mental assessment - room is well lit to avoid illusion - if pt is agitated, psychosis, insomnia that can pose risk to safety --> sedation, antipsychotic meds ( haloperidol, 0.5-1mg, can decrease agitation, psychosis sx and promote sleep) - short-and intermediate acting benzodiazepines ( lorazepam) - helpful for sleep and tx delirium induced by alcohol withdrawal, but sedative and long-acting bento are avoided because worsen delirium
mnemonics for SLE --> SOAP, BRAIN, MD
S: serositis--> serous tissue around the heart and lung O: oral ulcer --> affect nutrition A: Arthritis P: photosensitivity B: blood disorders --> neutropenia, leukopenia --> CBC, BMP weekly R: neural involvement --> creatinine test A: antinuclear antibodies --> ANA test I: immunologic phenomenon N : neurologic disorders (seizure, psychosis) M: malar (butterfly rash) D : discoid rash--> red, thick, scaly rash --> impaired tissue integrity
For which assessment finding will the nurse intervene first when providing postoperative care to a patient who returned to the nursing unit 2 hours after receiving succinylcholine? Generalized muscle pain Pulse 90 beats per minute Temperature 40 degrees C (104 degrees F) Muscle weakness
Temperature 40 degrees C (104 degrees F) --> Malignant hyperthermia is a life-threatening condition that may occur after use of a nondepolarizing neuromuscular junction blocker. When prioritizing care, safety issues should be treated first, followed by the ABCs as outlined by Maslow.
tardive dyskinesia
a late-appearing side effect of antipsychotic medications, - is characterized by abnormal, involuntary movements such as lip smacking, tongue protrusion, chewing, blinking, grimacing, and choreiform movements of the limbs and feet. - These involuntary movements are embarrassing for clients and may cause them to become more socially isolated. - Tardive dyskinesia is irreversible once it appears, but decreasing or discontinuing the medication can arrest the progression. - Clozapine (Clozaril), an atypical antipsychotic drug, has not been found to cause this side effect, so it is often recommended for clients who have experienced tardive dyskinesia while taking conventional antipsychotic drugs.
seizure causes
cerebral vascular disease, CNS infection, hypoxemia, fever ( childhood), head injury, hypertension, brain tumor, metabolic and toxic condition ( kidney injury, hyponatremia, hypocalcemia, hypoglycemia), drug and alcohol withdrawal , allergy
Akathisia
characterized by restless movement, pacing, inability to remain still, and the client's report of inner restlessness. Akathisia usually develops when the antipsychotic is started or when the dose is increased. Clients are very uncomfortable with these sensations and may stop taking the antipsychotic medication to avoid these side effects. -blockers such as propranolol have been most effective in treating akathisia, whereas benzodiazepines have provided some success as well.
Values
abstract standards that give a person a sense of right and wrong and establish a code of conduct for living what you think is important to you and what you want to live by and for ẽx : hardworking, honesty, sincerity, cleanliness, orderliness
most common cause of abdominal pain resulting in surgery
appendicitis
s/s of appendicitis
begin with vague pain in periumbilical area --> progress over 4-6 hour to right lower quadrant low grade facer nausea, anorexia sudden pain relief may rupture --> indicate peritonitis\ rebound tenderness at mcburney point
chronic gastritis s/sx
belching = burp early satiety intolerance of spicy or fatty food n/v pyrosis (heartburn) sour taste in mouth vague epigastric discomfort relieved by eating
function of prostaglandins in inflammatory process
broad in function - vasodialation - increase vascular permeability - platelet aggrevation -pain
Cullen's sign
bruising (bluish) in the skin around the umbilicus --> indicate peritoneum bleeding --> indicate severe acute pancreatitis
diferences in the sx of RA and OA
cause + RA : autoimmune --> inflammation of synovial --> symmetrical + OA : over use of joint , not symmetrically --> depend on which joints are overused pain: + RA - pain is symmetry + OA : not symmetry, depends which joints are overused node location + RA: DIP not affected, affect PIP on both hands + OA: both DIP and PIP , randomly, not on both hands time: + RA: worst in morning + OA : good in morning, worse as day proceeds warmth, redness +RA : yes +OA : no , cool Shape : + RA: twitching of joint + OA : enlargement of joint - systemic sx: + RA: fever, malaise, vasculitis, cyst (fluid filled sac) in joints + OA: nothing specific
link between genetics and schizophrenia
identical twins have a 50% risk of schizophrenia; that is, if one twin has schizophrenia, the other has a 50% chance of developing it as well. Fraternal twins have only a 15% risk. This finding indicates a genetic vulnerability or risk of schizophrenia. - children with one biologic parent with schizophrenia have a 15% risk; the risk rises to 35% if both biologic parents have schizophrenia.
Parkinson disease (PD) is
is a slowly progressive neuro disorder that eventually lead to disability - affect men more than women , usually in their 50s - is diagnosed by history, presence of 2 /4 cardiac sx ( tremor, rigidity, bradykinesia and postural changes) - often confirmed by positive response to levodopa trial
Wernicke-Korsakoff syndrome
is a type of brain disorder caused by a lack of vitamin B-1, or thiamine. The syndrome is actually two separate conditions that can occur at the same time, Wernicke's disease (WD) and Korsakoff syndrome. Usually, people get the symptoms of WD first. WD is also known as Wernicke's encephalopathy. - Alcoholism, or chronic alcohol misuse, is the most common cause of WKS. WKS can also be linked to diet deficiencies or other medical conditions that impair the absorption of vitamin B-1. - Prominent symptoms of WD are: double vision a drooping upper eyelid, also known as ptosis up-and-down or side-to-side eye movements loss of muscle coordination, or ataxia, which may interfere with walking a confused mental state, which frequently leads to combativeness or violent behavior WD can later develop into Korsakoff's syndrome. People who have WKS have a variety of issues relating to memory. You may experience memory loss or be unable to form new memories. You may also have the following symptoms if you have WKS: amnesia for events that happen after the onset of the disorder difficulty understanding the meaning of information difficulty putting words into context hallucinations exaggerated storytelling, or confabulation --> vitamin B1 - thiamine and vitamin B12, folic acid tx
the 12-step program model for recovery
is based on the philosophy that total abstinence is essential and that alcoholics need the help and support of others to maintain sobriety. Key slogans reflect the ideas in the 12 steps, such as "one day at a time" (approach sobriety one day at a time), "easy does it" (don't get frenzied about daily life and problems), and "let go and let God" (turn your life over to a higher power) We admitted we were powerless over alcohol, that our lives had become unmanageable. Came to believe that a Power greater than ourselves could restore us to sanity. Made a decision to turn our wills and lives over to the care of God as we understood Him. Made a searching and fearless moral inventory of ourselves. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. Were entirely ready to have God remove all these defects of character. Humbly asked Him to remove our shortcomings. Made a list of all persons we had harmed, and became willing to make amends to them all. Made direct amends to such people whenever possible, except when to do so would injure them or others. Continued to take personal inventory and when we were wrong promptly admitted it. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out. Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.