Pred Rev ATI pt. 3

Valproic acid

* A/R: - hair loss -weight gain -Ataxia

Enalapril , lisinopril , captopril ACE INHIBITORS

* take same time daily * monitor: - hypotension - cough - edema - increased creatinine and blood urea nitrogen

Medroxyprogesterone

- **This med can cause irregular vaginal bleeding - weight gain can occur - this form of birth control does NOT protect against STIs - Antibiotics are not contraindicated use with this med

Propranolol

- A beta blocker - A/R * Bradycardia * lightheadedness * Dizziness - Can cause cold intolerance -Client should avoid driving or hazardous activities until the effects of the medication are known. -AVOID abrupt discontinuation of the medication bc it can cause life- threatening arrhythmias. -Take missed dose ASAP and prior to 4 hours before the next dose is scheduled.

Cefotetan

- A cephalosporin ( antibiotic that is structurally similar to penicillins.) Can cause severe allergic reaction.

Cephalexin

- A cephalosporin (chemical structure is similar to penicillin, can cause a cross-reactivity that can cause an allergic reaction. Nurse should notify the provider.

Omeprazole

- A proton pump inhibitor, blocks the secretion of gastric acid. - It is available in delayed release capsules and OTC in delayed release tablets, as well as suspensions and powders. -Take on an empty stomach, and not with food. -antacids does not interfere with absorption of omeprazole

Magnesium Sulfate

- An anticonvulsant medication. Used to depress the CNS and PREVENT SEIZURES

Nurse is collecting data from a client who is receiving digoxin for treatment of HR. The nurse should identify which of the following findings as adverse effects of this medication?

- Blurred vision (any visual changes: blurred vision, halos , or yellow or green tinge to vision is an A/R of digoxin -Nausea (N/V are A/R) -Dysrhythmia ( is an A/R)

Risk factors associated with abruptio placentae

- Client will HAVE PAIN with abruptio - Blunt abdominal trauma - Cocaine use - Cigarette smoking

Hydatidiform Mole

- Client with hydatidiform mole will exhibit: - INCREASE fundal height that is inconsistent with the week of gestation, excessive N/V due to ELEVATED hCG levels -Client will usually have DARK BROWN vaginal bleeding ( SCANT, dark discharge ) in the 2nd trimester that is NOT accompanied by abdominal pain.

Contraceptive patches

- Contraceptive patches are removed 1X / week.

Isotretinoin Therapy

- Do not take Vit. A bc it enhances the risk of isotretinoin toxicity bc isotretinoin is a derivative of Vitamin A. - Isotretinoin can cause severe birth defects; make sure that client is NOT pregnant ( need to have 2 negative preg test prior to starting this therapy). - This medication can cause depression that can lead to suicide. - The drying effects of this medication can cause nosebleeds. - Liver enzymes should be monitored after 1 month of therapy and periodically after bc this medication is metabolized in the liver.

What infections can be treated during labor or immediately following birth?

- Gonorrhea (ERYRHTROMYCIN is given to infant IMMEDIATELY after delivery to prevent Neisseria gonorrhea). - Chlamydia (ERYRHTROMYCIN is given to infant IMMEDIATELY after delivery to prevent Chlamydia trachomatis). - HIV ( ZIDOVUDINE is prescribed to a client in labor who is HIV +). - Group B streptococcus beta- hemolytic ( PENICILLIN G or AMPICILLIN may be prescribed to treat + GBS).

Probable signs of pregnancy

- Goodell's sign : softening of the cervical tip - Ballottement : Rebound of unengaged fetus - Chadwick's sign : deepened violet- bluish color of cervix and vaginal mucosa -Uterine enlargement - Hegar's sign: softening and compressibility of lower uterus - Braxton Hicks : false contractions that are painless, irregular and usually relieved by walking - Positive preg test - Fetal outline by PCP

Manifestations of PE ( Pulmonary embolism )

- Hypotension - tachycardia - tachypnea

IUD

- IUDs are replaced every 3- 5 years depending on the type of IUD being used - Clients do not have to have given birth to use an IUD - **REPORT abdominal pain to PCP bc it can indicate potential complications - REPORT changes of string length bc this can indicate expulsion

Manifestation of Parkinson's Disease

- Masklike expression - Stooped posture

Nurse is assisting with the care of a client who had cardiac catheterization via the right femoral artery. Which of the following actions should the nurse take to prevent post procedure complications?

- Monitor the insertion site for bleeding - Maintain the pressure dressing ( to prevent hemorrhaging and allow for the cannulation site to heal) - Check the client's peripheral pulses ( to help identify signs of arterial occlusion)

Manifestation of meningococcal meningitis

- Red macular rash

Adverse effect of epidural infusion:

- Urinary retention - Nausea - Pruritus

Manifestations of hyperthyroidism

- Weight loss - Tachycardia / increased HR - tachypnea - Amenorrhea

Presumptive signs of pregnancy

- amenorrhea - fatigue - N/V - Urinary Frequency - Breast changes - Quickening: slight fluttering movements of fetus , usually between 16 to 20 weeks of gestation - Abdominal enlargements

JP jackson pratt

- bulb manual suction drain - keep bulb compressed - wound suction device promotes drainage of fluid from the incisional site - decreases pressure on tissues - decreases abscess formation small to moderate drainage

Pregnancy test

- hCG can be detected 8 days after conception - Urine pregnancy test should be done on a FIRST void in the morning to provide the most accurate results.

Surgical Drains

- jackson - pratt ( JP ) - Hemovac - penrose - wound vacuum assisted closure ( wound vac)

Lovastatin , simvastatin , atorvastatin, niacin, questran , gemfibrozil (statins)

- lowers cholesterol by blocking enzymes that are essential to the production of cholesterol in the body

Bowel training

- offer hot drink or fruit juice before defecation time - assist client to toilet at the dedicated time - avoiding medications such as analgesics - providing privacy and setting a time limit for defecation ( 15 to 20 min) - instruct client to lean forward at the hips while sitting on toilet to apply manual pressure with hands over abdomen and to bear down but not to strain to stimulate colon emptying

Age appropriate response to death with a PREESCHOOLER

- preschooler might believe that his thoughts can cause another person's death which can make him or her feel guilty and responsible for their death. Preeschooler might believe that death is a sleep like state that is TEMPORARY and GRADUAL -Curiosity occurs after death -understanding death is irreversible occurs at age 9-10.

Preparing preschooler diagnostic procedure

- review the child's present understanding of procedure - prepare child shortly before procedure - describe any expected sensations experienced during the procedure - plan for 10-15 min teaching no more than 15 min - use concrete terms and visual aids

Hematoma

- swelling - bruising Can develop by NOT holding enough pressure after discontinuing an IV

Infiltration

- swelling - cool skin

Manifestations of ectopic pregnancy

-Abrupt, sharp right lower quandrant pain with bright vaginal bleeding. -unilateral lower quadrant pain with or without bleeding. * the use of an IUD IS A RISK factor associated with his condition

Tetracyclines

-Can cause fungal infections like candidiasis. -Do NOT take tetracyclines with foods high in CALCIUM like milk b/c it decreases the absorption of this med. - Affects kidney fxn test like BUN and creatinine

Oral Contraceptives

-Can reduce acne. **REPORT SHORTNESS OF BREATH IMMEDIATELY TO PCP bc it can indicate pulmonary embolism or an MI. *Common adverse effects: - Reduced menstrual flow but subsides after few months of use - Breast tenderness -Headaches are common and will subside after months of use

Positive signs of pregnancy

-Fetal heart sounds - Visualization of fetus by ultrasound - Fetal movement

Nitroglycerin

-Headaches are common adverse effect ( instruct client to use a mild analgesic to relieve the headache). - Onset 1 to 3 mins. - Duration 60 min. - Store at ROOM temp, not in the extreme heat. Do not store inside a car's glove box.

Budesonide and albuterol inhalers for asthma

-I never forget to rinse my mouth after using my budesonide inhaler ( to reduce the risk for fungal infection) - Between office visits, I keep a record of how many times I use my albuterol inhaler ( this info can assist the provider to determine the effectiveness of the medication ) - I use my albuterol inhaler before I go swimming ( use before exercise to prevent exercise- induced bronchospasms )

Neuroleptic Malignant Syndrome ( NMS )

-Muscle rigidity - hyperpyrexia - diaphoresis -sudden high fever -altered mental status -blood pressure -tachycardia -dysrhythmias -seizures -acute renal failure -coma - a potentially life threatening adverse effect of antipsychotic medications

Good source of calcium

-milk - calcium fortified soy milk - fortified orange juice - nuts - legumes - DARK LEAFY GREEN VEG ( artichoke, kale, turnip greens) Recommended 1, 000 mg/day for pregnant clients AND 19 to 50 yrs of age - 1,300 mg/ day for clients under 19 yrs of age

Infant experiencing pain

-open mouth in squarish shape - loud cry - lower and draw together their eyebrows -Rigid body

Nurse is preparing to administer phytonadione 7mg subcutaneously to a client who has an INR of 4. Available is phytonadione 10mg/ mL. How many mL should the nurse administer?

0.7 mL

Parenting styles / types of parenting

1. Authoritarian : parents try to control the child's behaviors and attitudes through unquestioned rules and expectations. 2. Permissive : parents exert little or no control over the child's behaviors and consult the child when making decisions 3. Authoritative : Parents direct the child's behavior by setting rules and explaining the reason for each rule setting.

Family theories

1. Family systems : family is viewed as a WHOLE, 1 change to one family member affects entire family. Too much or too little change can lead to dysfunction 2. Family stress : stress is inevitable , stressors can be expected or unexpected, explains the reaction of a family to stressful events, offers guidance for adapting to stress. 3. Developmental : views family as SMALL groups that interact with the larger social system . Uses Duvall's family life cycle stages.

NC of children Temperature

2 hrs old = 99 F 4 hrs old = 98.6 F (Same as adults) Axillary = 97.6 F Oral = 98.6 F Tympanic = 98.6 F Rectal = 99.6F Newborn temp / less than 1 month old = axillary route - NO rectal temp for newborns or infants less than 1 month old d/t mucosa is FRAGILE - NO ORAL temp for children under 5 y.o. - NO oral temp for children receiving O2, recent trauma to oral mucosa or altered LOC - axillary temp for 3 mins for newborns, axillary route is the preferred route for newborns

Recommended weight gain during pregnancy

25 to 35 lb 2.2 to 4.4 lb during 1st trimester, then 1 lb/ week on last 2 trimesters. - underweight clients should gain 28 to 40 lb -overweight clients should gain 15-25 lb.

Separation anxiety Play during hospitalization pg. 52-53

3 behavioral responses: pg. 51 1. Protest 2. Despair 3. Detachment

Nurse is caring for a client who is receiving 0.9% sodium chloride 1,000mL to infuse over 8 hr. The drop factor on the manual IV tubing is 15 gtts/mL. The nurse should ensure that the manual infusion is set to deliver how many gtt/min? Round to nearest whole number.

31 gtt/min

13 month old toddler + urinary catheter what french to use?

5 french 12 french = adolescent client 10 french = 8 yo child 14 french =adolescent

15 month old toddler Calcium intake?

500 mg of calcium to support adequate bone development. milk yogurt cheese green leafy veg all high in Ca+ calorie intake toddler= 1,000 to 1,400 for boys who are 2-3 y.o.

Neural tube defects

= HIGH levels of AFP ( alpha fetoprotein ) - AFP test assess for fetal neural tube defects or chromosome disorders. - amniotic fluid alpha fetoprotein screening = for clients who previously delivered a child with a neural tube defect. - screening for alpha fetoprotein is NOT indicated for the client who has been exposed to AIDS or for the client with mitral valve insufficiency, not for clients with history of preterm labor

Down syndrome

= Low levels of AFP

possible indicatos of physical abuse in infants

= burn with splash marks or that are symmetrical -an abrasion on the back of the infant's arm

WHEN is a Contraction stress test or CST needed?

A CST is needed when: - there's a DECREASE in FETAL MOVEMENT - INTRAUTERIN GROWTH RESTRICTION ( IUGR ) - POSTMATURITY Contraindications of a CST: -placenta previa Complication of CST: - amniotic fluid emboli

Nurse is preparing to administer a PRN medication to a group of clients. Which of the following clients should the nurse administer medication to first?

A client who is attending postoperative physical therapy and requests pain medication.

Paroxetine ( Paxil )

A/R = -Anorexia and decreased appetite - dry mouth - vasodilation and ORTHOstatic hypotension - Sexual dysfunction

Celiac disease FOODS to include in diet

AVOID GLUTEN ( even eating very small amounts can damage intestines) -TX is lifelong, strict gluten free diet AVOID: wheat, rye, barley and oats, graham crackers , french fries EAT: gluten free , milk, cheese rice corn, eggs, potatoes , fruits, vegetables, fresh poultry, meats, fish and dried beans.

Monoamine Oxidase Inhibitors ( MAOI )

AVOID: aged foods like - hard cheeses and meats, salami, air dried sausage while taking MAOI bc it can increase BP Can drink milk, shellfish, but not smoked or pickled fish, canned tuna is okay

Acarbose adverse effect

Abdominal cramps ( Acarbose affects GI system. Nurse should monitor client for GI distress - abdominal cramping - rumbling bowel tones -diarrhea - Long term and high dose of Acarbose can cause liver dysfunction

Manifestation of Scarlet fever

Abdominal pain

Nurse is reinforcing teaching with a client who has seizures and a new prescription for valproic acid . The nurse should instruct the client to report which of the following adverse effects of valproic acid immediately to the provider?

Abdominal pain. ( The greatest risk to the client while taking valproic acid is HEPATOTOXICITY and PANCREATITIS which can cause abdominal pain. Notify provider immediately if client is experiencing: - decrease appetite - nausea - abdominal pain - yellowing of the skin

Penicillin IM client begins exhibiting hives and has a severe difficulty breathing. After establishing patent airway, which of the following actions should the nurse take next?

Administer epinephrine ( to reduce bronchospasms and laryngeal edema) -Monitor VS during crisis to dectect a decrease in BP and an increase in respiratory effort. - Administer antihistamine to treat hives and reduce the histamine release

Adolescent has partial thickness burn on right hip, nurse assisting with sterile dressing change what action should nurse take?

Administer pain med to client before procedure Open sterile dressing tray before cleansing wound - Assist client into the left lateral position before removing soiled drssing - REMOVE previous dressing and inspect wound to identify infection

Implantable progestins

Adverse effects of implantable progestins: - irregular vaginal bleeding -weight gain -breast changes

Lumbar puncture , nursing actions to prevent complications

After lumbar position, child is to remain FLAT and SUPINE to prevent headaches. - Side lying is the optimal position to stabilize the client so that the spine is flexed during the procedure -Elbow restrains are used to prevent the child from reaching the head or face. Arms are secured with the holding positions - After lumbar puncture FLUIDS are ENCOURAGED to replace the fluids removed for sampling

Cystic fibrosis + taking PANCRELIPASE as a pancreatic enzyme replacement. What are the therapeutic effects of PANCRELIPASE ?

Amount and consistency of stools. ( Recording the amount and consistency of the child's stools will help determine the effectiveness of PANCRELIPASE, which is taken to DECREASE the BULK of feces - The chloride sweat test can determine if a client has cystic fibrosis or not.

Acyclovir ( Zovirax )

Antivirals. Uses: genital herpes, shingles, HIV. Precautions: administer with food, increase fluid intake, and begin therapy with first onset of symptoms. SIDE EFFECTS: - Nephrotoxicity - Thrombocytopenia -Reproductive toxicity * Use cautiously with renal and hepatic impairment and dehydration * Get CBC * advice women to AVOID getting pregnant

Administration of opthalmic drops to a child, nursing actions should the nurse take?

Apply pressure to the lacrimal punctum for 1 min following administration ( to prevent medication from entering the nasopharynx). -Have the child extend his head while administering the eye drops -hold dropper 1 to 2 cm ( 0.4 to 0.8 inch ) above the eye to administer the med - Nurse should wipe off excess medication from the inner canthus outward

Nurse is reinforcing discharge instructions with a client who is postoperative following a right hip arthroplasty. Which of the following statements should the nurse make?

Avoid bending your hips more than 90 degrees. ( to prevent dislocation of the replacement hip). - Nurse should instruct client to wait 90 days before crossing legs. Crossing legs early int heh postoperative period can result in dislocation of the replacement hip. -Nurse should inform the client that she ay lie on her operative side with a pillow between her legs. This will not injure the suture site or cause dislocation of the replacement hip. - Nurse should instruct the client to sleep on a firm mattress to avoid potential dislocation of the replacement hip.

Partial gastrectomy for ulcers patient teaching

Avoid liquids at mealtimes. ( Remind client to avoid drinking liquids at mealtimes to prevent the food from emptying into the small bowel too quickly.) -Include starchy vegs in the meal plan to SLOW gastric emptying -Eat high protein meals to slow gastric emptying - Do NOT eat sweetened fruits from diet to help slow gastric emptying.

Nurse is reinforcing teaching with a client who has Helicobacter pylori and a new prescription for tetracycline . Which of the following instructions should the nurse include in the teaching?

Avoid prolonged exposure to the sunlight. (while taking tetracycline , as this medication causes photosensitivity and increased severity of sunburn).

Lab levels to review before cardiac catheterization

BUN ( BUN levels indicate kidney fxn. Contrast media that's used during cardiac catheterization can cause RENAL FAILURE. Nurse should review this laboratory level to determine if he client can tolerate the IV contrast dye during the procedure.

Folate

Best source is peas Recommended amt is 600mcg of folate per day

HEART RATE HR Respirations

Birth - 2 days : 93 - 159 /min 3 days - 3 weeks : 91 - 182 /min 1 month - 2 months : 128 - 179/min 6 to 11 months : 109 -- 169/ min 1 year to 2 years : 89 - 161 /min 3 years to 4 years : 73 - 137/min 5 years to 7 years: 65 - 133/ min 8 years to 11 years : 62 - 130/min 12 to 15 years : 60 - 119 /min Respirations : 2 to 6 hrs : 20- 80/ min 6hrs to 12 months : 20-60/min 1 to 2 years: 25-30/min 3 to 9 years: 20 to 25 /min 10 to 18 years: 16-20/min

School age child testing for acute lymphoid leukemia ( ALL ) , what is this test for?

Bone marrow biopsy to confirm diagnosis of ALL.

three point gait

Both crutches and involved leg advance together Uninvolved leg follows Uses two canes/crutches or a walker

Client with chronic kidney disease with hyperkalemia . Expected finding related to hyperkalemia?

Bradycardia ( client who has hyperkalemia can have irregular, slow HR )

Initial treatment for depression

Bupropion mirtazapine both ssri

Gonorrhea treatment

Ceftriaxone IM and Azithromycin PO or Doxycycline PO for 7 DAYS Both are BROAD spectrum ANTIBIOTIC; bacterial action.

Undoing

Client tries to make amends for something she has done

Missed abortion

Client would report brownish discharge and NO PAIN.

Client in labor with HIV Contraindications to what interventions?

Clients with HIV in labor are contraindicated for the following interventions: - EPISIOTOMY bc there's a high risk of maternal blood exposure -FORECEPS should be avoided d/t fetal and maternal bleeding - INTERNAL FETAL MONITORING should be avoided bc of the risk of fetal bleeding.

Birth control for a client with history of breast cancer. What birth control is contraindicated with this client?

Combination of oral contraceptives. ( bc combo oral contraceptives INCREASES estrogen levels, which can stimulate the growth of any remaining cancerous breast cells. )

Condoms

Condoms are used with water soluble lubricants

Cerebral palsy and Nasogastric tube actions that the nurse should take?

Confirm the pH of the stomach contents is 5 or less ( before administering the tube feeding in order to confirm tube placement in the stomach. Ideal placement is pH of 5 or less indicates gastric placement). -flush tube with 1 to 15 mL of sterile water to maintain patency -formula should be at ROOM temp to avoid abdominal cramping - Nurse should NOT exceed 5mL every 5 to 10 min in PREMATURE or INFANTS who are small for gestational age and 10 mL/min in older infants and children. - Feeding should take 15 to 30 minutes to complete to PREVENT Nausea and regurgitation.

Latex condom

Contraindicated for clients with allergy to latex.

MMR to preschooler CONTRADICTIONS to receiving the MMR immunization?

Contraindications: If the child has received an immunoglobulin last month. Have parent resched the immunization in 3 months since the child received passive immunity via administration of an immunoglobulin. -An allergy to baker's yeast is a contraindication for receiving the HPV vaccine - Latex allergy is a contraindication for receiving the rotavirus or meningococcal vaccine.

Tx for myopia

Corrective biconcave lenses

Venous spasms

Cramping at or above insertion site and numbness

A nurse is reviewing the laboratory results of a client who is scheduled for a CT scan with an IV contrast agent Which of the following laboratory findings should the nurse report to the provider prior to the procedure?

Creatinine 1.9 mg/dL ( This value is not within the expected reference range)

A nurse is contributing to the plan of care for a client who has peripheral arterial disease ( PAD ) of the lower extremities. Which fo the following interventions should the nurse include?

Dangle the extremities off the side of the bed. ( To aid in reducing pain by increasing arterial blood flow. The client should NOT raise lower extremities above the level of the heart when resting in bed because it impairs arterial blood flow.) - Avoid applying heat to the client's extremities to prevent injury due to decreased sensation. - Nurse should avoid massaging the client's lower extremities if the client is having pain from ischemia. A warm environment and keeping the client warm will help with circulation to the extremities and decrease pain through vasodilation. - Avoid applying support stockings to the lower extremities bc stocking interfere with the arterial blood flow to the lower extremities.

A nurse is collecting data from a client who has Parkinson's disease and is taking levodopa/carbidopa . The nurse should identify which of the following findings as an adverse effect of this medication?

Dark Urine. ( Levodopa/Carbidopa can cause a darkening of the client's urine, sweat and saliva. ) - Can cause orthostatic hypotension -Can cause dry mouth -Can cause tachycardia

Digoxin Expected finding

Decrease shortness of breath. ( Digoxin increases contractility of the heart which decreases pulmonary congestion ). - Increase Urinary output ( bc digoxin improves Cardiac output and increases the client's renal blood flow through the kidneys which results in an increased excretion of urine). - Decrease in HR ( bc digoxin decreases the client's sympathetic nerve tone, which slows the heart down). -Clients weight to decrease ( bc of the increase excretion of fluid that is caused by improved cardiac output).

Appendicitis

Decreased bowel sounds

Nurse is caring for a client who has MS and has a new prescription for baclofen . Which of the following findings indicates to the nurse that the medication is having a therapeutic effect?

Decreased muscle spasticity. ( Baclofen is an antispasmodic that decreases muscles spasticity in a client who has MS. ) - Adverse effect of baclofen: urinary frequency * Causes: - Drowsiness - Fatigue -Confusion - Does not produce an increase in the client's metal alertness as a therapeutic effect. - Does NOT decrease clients HR.

Good source of Vitamin C and A

Deep red or orange vegf

Nurse is caring for a client who is scheduled for surgery and is experiencing anxiety. Which of the following interventions should the nurse identify as the priority?

Determine the client's understanding of the procedure. ( in order to provide the necessary teaching which can help manage his anxiety).

Situational crisis highest priority

Determining if client has psychotic thinking

Coombs test

Detets Rh antibodies in the mother's blood

Diaphragm

Diaphragm should be removed no sooner than 6 hrs and no later than 24 hours

Nurse is reinforcing teaching with a client who has a new prescription for etanercept to treat rheumatoid arthritis. Which of the following instructions about self- administering this medication should the nurse include?

Discard any solutions that are cloudy. ( discard any vials or pre filled syringes that contain solutions that are discolored, cloudy, or have any sediment in them. - Client should attach a 27 gauge needle to syringe for injecting the medication subQ - Self administer medication once per week. -Client should swirl the solution gently before self admin

A nurse is assisting the charge nurse with developing an in service about caring for clients who have internal sealed ration implants. Which of the following should the nurse include?

Dispose of radiation implants in a lead container. - Pregnant women and children should NOT be allowed to visit client who is receiving internal radiation therapy because of the risk for exposure to radiation emissions. - The nurse should use forceps to pick up a radiation implant if it becomes dislodged -Nurse should limit time spent in the client's room to 30 mins during an 8 hour shift.

Alcohol intolerance or sensitivity

Do not take sirolimus

Sterile gloves

During: - sterile dressing changes - tracheostomy

Nurse is caring for a client who is postoperative and has an epidural infusion. Which of the following findings should the nurse recognize as the priority?

Dyspnea. ( Dyspnea is a complication of epidural infusion)

Juvenile idiopathic arthritis

ENCOURAGE the child to take a warm bath daily. ( warm bath will help relieve discomfort in swollen joints ) the most efficient and practical method to relieve pain and stiffness is a warm bath) -Naps are discouraged bc inactivity can cause joints to stiffen ( have them play games or read a book) - Promote independence - encourage child to participate in physical activities as tolerated to maintain joint mobility - give time to exercise and rest throughout the day

Four-point gait pattern

Each leg is moved alternately with each opposing crutch so that 3 POINTS of support are on the floor at all times

Manifestations of anaphylactic reaction

Early Manifestation: -Hives Later Manifestation: -Wheezing - Angioedema - Hypotension

Infant exposed to pertussis Manifestations of pertussis

Early manifestation: -Dry cough

Nurse is caring for a client who is 24 hr postoperative following abdominal surgery and has an NG tube . Which of the following actions should the nurse plan to take to decrease the risk of postoperative complications?

Encourage the client to use an incentive spirometer every hour while awake. ( Add coughing and deep breathing every hour while awake for the first 24 hours postop and at least every 2 hr while awake thereafter. An incentive spirometer will inflate the client's alveoli and improve ventilation to prevent postoperative pneumonia. ) -Provide frequent oral care and the use of moistened toothette to alleviate dry mucous membranes. Oral fluids are contraindicated for a client who had abdominal surgery and has an NG tube. -Nurse should monitor the client's lower extremities for tenderness, warmth or redness. DO NOT massage client's lower extremities ( contraindicated) bc if there is a blood clot formation in the a lower extremity, it can loosen the clot and cause a pulmonary embolism). - Nurse should elevate the foot of the bed slightly and apply prescribed compression stockings or sequential compression devices to promote venous return. However pillow beneath the client's knees can create pressure and decrease venous return in the lower extremeties, which can ead to thrombosis.

Nurse is contributing to the plan of care for an older adult client who is at risk for osteoporosis. Which of the following interventions should the nurse include to prevent bone loss?

Encourage weight-bearing exercises. (Weight bearing exercises like walking can maintain bone mass by reducing bone demineralization). - Caffeine and alcohol intake can increase the client's risk of developing osteoporosis . -ROM Exercises is beneficial to maintain flexibility and prevent contractures

Client who has hypomania , findings to expect

Euphoria -Psychomotor activity increases during period of hypomania - inflated self of self importance

Anaphylactic reaction to eggs

Eval before getting influenza immunization

Nonstress test

Evaluation of FETAL WELLBEING performed during 3rd TRIMESTER

Hyperemesis gravidarum

Excessive vomiting/ nusea - will have 5% weight loss and manifestations of dehydration, electrolyte imbalance, aetonuria and ketosis -MOst important lab test is POSITIVE KETONURIA

Cerebral palsy

Expect ataxia

Apical heart rate of newborn

Expected finding 110-160/ minute

Pregnant women test positive for Hep B , what to do?

Explain to the client that she will receive the hepatitis B immune globulin immediately.

Toddler + strabismus Treatments?

Eye patch ( to cover the STRONG EYE to strengthen the muscles of the weak eye). - Strabismus surgery is performed to improve visual stimulation to the weak eye.

12 to 20 years old ( adolescents ) Expected growth and development , cognitive development , psychosocial development, sexual identity , moral development, self- concept development, body- image changes , social development pt. 35 Immunizations , nutrition, injury prevention pg. 36

FEMALES: sexual maturation in order: 1. breast development 2. pubic hair growth 3. axillary hair growth 4. Menstruation MALES: sexual maturation order : 1. testicular development 2. pubic hair growth 3. penile elargement 4. Growth of axillary hair 5. Facial hair growth 6. Vocal changes

Nurse is reviewing the laboratory results of a client who takes insulin for the management of diabetes mellitus. Which of the following findings should indicate tot he nurse the medication is effective.

Fasting blood glucose 100mg/dL. ( Expected reference range of fasting blood glucose is 70 to 110 mg/ dL. Nurse should identify that a fasting blood glucose of 100 is effectively managing diabetes mellitus. )

Metoprolol , atenolol , carvedilol , propranolol

For: mild to moderate HTN Slows HR and decrease BP - if pulse less than 60 , hold an notify PCP ADVERSE EFFECTS: - fatigue - lethargy - impotance - wheezing - dyspnea - heart failure CONTRAINDICATED in bronchial asthma

Nurse is reviewing medication prescriptions for a group of clients. The nurse should recognize that which of the following prescriptions can result in a medication administration error?

Furosemide 10.0 mg PO daily. ( Avoid trailing zeros after a whole number. ) - Polyuria is an A/R of furosemide

What does this mean: G3 T1 P0 A1 L1

G3= client has had 2 prior pregnancies and is pregnant now T1= Client has delivered 1 full term baby L1= Client has 1 living child

Nurse is collecting data from the parent of a toddler who is about to receive the varicella immunization. The nurse should identify that an anaphylactic reaction to which of the following substances is a contraindication for receiving this immunization?

Gelatin ( Nurse should identify that hypersensitivity reactions to either gelatin or neomycin are contraindications for receiving the varicella vaccine bc it contains both of these substances. ) -

Teaching about low sodium diet and recovering rom acute glomerulonephritis

Good food choices: - Apples ( Low sodium) NO canned veg, pretzels, canned corn, no peanut butter high in sodium.

penrose

Gravity drain uses capillary action. - promotes healing from inside out - decreased chance of abscess - safety pin prevents the exposed end from slipping back into the wound - apply precut gauze around drain and apply 4x4 with tape over the top of the drain for wound drainage and to protect the surrounding skin

iron deficiency anemia signs for adherence to ferrous sulfate therapy

Green tarry stools is the outcome of ferrous sulfate therapy. -occasional vomiting and nausea are ADVERSE EFFECTS of ferrous sulfate -take ferrous sulfate with OJ ( vit. C) -AVOID giving with milk or milk , tea or coffee products bc it will interfere with absorption of med

Crutches

Hand grips should be positioned so that the axillae are not supporting the client's body. -determine correct position of the hand grips with the client upright, supporting weight by the hand grips with elbows slightly flexed at 30 degrees *Basic crutch stance= - tripod position - crutches placed 6 inches in front and 6 inches to the side of each foot - head and neck should be erect, with vertebrae straight, and hips and knees extended - axillae should not bear any weight - tripod position should be assumed before crutch walking

Child with tonic clonic seizure nursing actions?

Have a suction canister and tubing available in the child's room to keep the child's airway patent during a seizure. - keep bed at lowest position to reduce the risk of injury in case the child falls out of bed during a seizure - DO NOT place a padded tongue blade at the bedside bc placing an object between the child's teeth during a seizure can cause loose or broken teeth - DO NOT restrain the child during a seizure bc it can cause injury.

Nurse is reinforcing teaching about benzodiazepine withdrawal with an older adult client who discontinued taking lorazepam after taking it for 3 months. Which of the following instructions should the nurse include?

Have someone assist you with ADLs. (A client with lorazepam withdrawal can manifest tremors and dizziness, making ADLs difficult to perform.) - Client with lorazepam withdrawal can manifest insomnia and diaphoresis and should increase fluid intake to prevent dehydration.

Sickle cell anemia + school age child what to report

Hgb of 7 % . this is LOW. expected range is 9.5-14 g/dL School age child + specific gravity = 1.005 to 1.030 School age child + platelets = 150,000- 400,000/mm3 School age child + O2 stat = 95-100%

Butter and shortening

High in saturated fat which contributes to the development of cardiovascular disease. It should be used sparingly or avoided.

Coconut oil

High in saturated fat, which contributes to the development of cardiovascular disease. It should be used sparingly or avoided.

Spina bifida had a ventriculoperitoneal shunt placed for HYDROCEPHALUS Indication of INCREASED intracranial pressure

High pitched cry BULGING ANTERIOR FONTANEL

Lisinopril foods to avoid

High potassium foods , bc it increase the risk of hyperkalemia

A nurse is collecting data from a client who is asking about taking celecoxib for treatment of joint pain. The nurse should identify that which of the following findings is a contraindication to receiving CELECOXIB ?

History of MI. ( Celecoxib increases the risk of MI caused by INCREASED vasoconstriction and unimpeded platelet aggregation. ) -Contraindicated in clients with Hx of MI and hear disease. -Use with caution in clients who have peptic ulcer disease, but it is NOT contraindicated. - Causes hypersensitivity reactions in client who are allergic to sulfonamides or salicylates rather than penicillin. -NOT contraindicated for patients who has hyperglycemia.

Anaphylactic reaction after admin of IM antibiotic, what to observe?

Hives Early manifestation of anaphylactic reaction: - hives late manifestation of anaphylactic reaction: - hypotension - angioedema - wheezing

4 year old preschooler gross motor skills expect?

Hopping on one foot - 5 year old = skip on alternate feet, jump rope, roller skate

Adverse effect of methylergonovine

Hypertension

Risk factors for primary amenorrhea

Hypothyroidism Cannabis use Oral contraceptive use Emotional stress

A home health nurse is reinforcing teaching with a client about preventing complications of peripheral vascular disease PVD . Which of the following statements indicates that the client is adhering to the nurse's instructions?

I don't cross my legs anymore. ( Client who have peripheral vascular disease should NOT cross their legs bc it can impede circulation. ) -Clients with PVD have DECREASED sensation of the affected extremities Therefore, they are unable to detect the temperature of the water bottle, which increases the risk for burns. - Wool socks can result is perspiration, which puts the client risk for developing a fungal infection. The client should use light-weight socks to promote arterial blood flow. -Rubbing alcohol has a drying effect on skin and can increase cracking allowing an entry point for infection . The client should apply lotions that do not contain alcohol.

Borderline personality disorder , reviews days schedule

I don't like it when you address me with that tone of voice

Nurse is reinforcing teaching about GERD with a client. Which of the following statements by the client indicates an understanding of the teaching?

I should wait at least 2 hours after eating before going to bed. ( Wait 2 hours before lying down or going to bed to minimize reflux) - Eat 4 to 6 meals a day rather than 3 big meals to prevent bloating and abdominal distention - Client should avoid spicy foods ; including garlic to minimize reflux - Avoid using a straw which can promote belching and reflux

Nurse is reinforcing teaching with an adolescent client regarding testicular self examination Which of the following statements by the client demonstrates an understanding of the teaching?

I understand that testicular cancer is painless. ( Clients should report a lump that is NOT painful bc testicular cancer is typically painless). - Perform a testicular self examination after a WARM shower - Perform testicular self exam MONTHLY - Clients should report pea- sized lump in the testes to the provider.

Surgical repair of scoliosis

I will begin ROM exercises on the first postoperative day will be discharged within 5-7 days - ambulate within 2-3 days , discharge in 1 week

Nurse is reinforcing teaching with a client about the use of sublingual nitroglycerin for chest pain. Which of the following statements by the client indicates an understanding of the teaching?

I will call 911 if my chest pain is not relieved within 5 minutes of taking nitroglycerin. ( Chest pain not relieved by nitroglycerin can be an indication that the client is having a MI. The client should continue to take 2 more nitroglycerin tablets EVERY 5 minutes for continued chest pain, while waiting for emergency response to arrive. -Take nitroglycerin tablet prophylactically 5 to 10 min prior to exercise because sublingual nitroglycerin has an onset of 1 to 3 min with a duration of up to 60 min.

Child w/ juvenile idiopathic arthritis ( JIA ) which statements indicate understanding?

I will have my child sleep in knee , wrist, and hand splints. ( this will decrease pain and enhance joint function). - AVOID taking naps during the day bc this can increase joint stiffness and interfere with nighttime sleeping - Corticosteroids are admin orally , into joints, IV and intraocular for the child who has JIA . - Avoid longterm opioid use - if taking ibuprofen: longterm A/R is bloody stools Manifestation: stiff joints

DC of school age child with prescription of home oxygen therapy

I will make sure that electrical devices in the house are grounded ( to decrease risk of a fire caused by electric spark) -Make sure to have enough tubing to allow for easy moveement within the home environment can be up to 30 m ( 98 feet). - oxygen should be stored VERTICALLY NOT horizontally bc placing it at its side can cause the tank to rupture which can lead t serious injuries of individuals at home

Safety of a toddler

I will place a screen in front of the fireplace. - Place all batteries in an elevated and secure location to prevent injury. - Keep all medications in a locked medicine cabinet or high shelf that is not accessible to the child to prevent accidental poisoning. - Use a cool mist instead of steam vaporizer to prevent injury form the burns.

Nurse is reinforcing teaching with a client who has a new prescription for ethinyl estradiol/norethindrone , an oral contraceptive. Which fo the following client statements should indicate to the nurse an understanding of the teaching?

I will take the medication at the same time everyday. ( to maintain a consistent level to reduce fertility and the chance of pregnancy. Other Pt. teaching: -Client should monitor her BP for hypertension because the medication causes increased secretion of aldosterone and angiotensin. - This is a combo medication that contains both estrogen and progestin -Pt. teaching: volume fo menstrual flow will decrease as well as the number of days of period.

Nurse is reinforcing teaching with a client who has a prescription for alendronate . Which of the following client responses indicates to the nurse an understanding of the teaching?

I will take the medication with 8oz of water. (Take alendronate on an empty stomach with 240mL or 8 oz of water to ensure it does not lodge in the esophagus which can cause esophageal ulcerations. -Client should sit UPRIGHT for 30 mins after taking this medication bc alendronate can cause erosion of the esophagus - Do not take alendronate with anti-acids that contain calcium bc it DECREASES the the absorption of alendronate. -Client should take alendronate as soon as they get up and at least 30 mins before eating or drinking liquids other than water.

Sign of cognitive disortion

If i eat one piece of candy, i may as well eat ten. - displays all or nothing, which is a form of cognitive distortion

Nurse is reinforcing teaching with a client who has a new prescription for propranolol Which of the following information should the nurse include in the teaching ?

If your pulse rate is less than 50 beats per min , notify you PCP. (Nurse should instruct the client to check his pulse before taking the medication and to withhold the medication if his pulse is less than 50/ min. The client should also notify his provider. Bradycardia is common A/R for beta blockers.

Nurse is reinforcing about management fo constipation with a client who has hypothyroidism. Which fo the following should the nurse include in the teaching?

Increase intake of fiber rich foods ( Dried beans and brown rice are examples of fiber rich foods) -Take laxative in the evening to stimulate the evacuation of stool. Use laxatives sparingly. -Increase fluid intake 2,000mL per day to maintain soft stools. - Increase activity to stimulate the evacuation of stool

Ear drops admin otic

Infants and toddlers/ children under 3 years : pull pinna DOWN and back to visualize the tympanic membrane -children 3 years and older: pull PINNA UP and back to visualize

Adolescent client w/ HIV what to include in plan of care?

Inform the client regarding routes of transmissions ( and how to prevent its spread). - Use a room with NEGATIVE pressure air flow in care plan who is on airborne precautions - use disposable dishes who is on contact precaution d/t an illness that is easily transmitted by direct contact - Contact precaution: have visitors wear gowns when entering room of a client who is on contact precautions when there is a possibility of coming into contact with contaminated objects. Have visitors wear MASK when coming in contact 1m ( 3.3 ft) who is on DROPLET precaution.

Methylphenidate Adverse effect

Insomnia

Nurse is collecting data and notices several skin lesions. Which of the following findings should the nurse report as possible melanoma ?

Irregular borders. ( Nurse should report irregular borders of a skin to the provider because it can indicate malignant melanoma.) -Report scaly patches ( possible basal or squamous cell carcinoma) - Nurse should report silvery white plaques as possible psoriasis - Nurse should report raised edges of skin lesion (possible basal cell carcinoma).

head injuries school age children manifestations to report

Irritability = can indicate increased ICP - monitor for N/V after head injury - monitor for elevated temp - monitor for increased sleep

Indomethacin

Is prescribed for the client in PRETERM LABOR

Nifedipine

Is prescribed for the client in PRETERM LABOR -Nifedipine is an ANTIHYPERTENSIVE medication , avoid ACE inhibitors and angiotensin II r/c blockers with this med.

Hemophilia + experiencing acute HEMARTHROSIS . What should the nurse include in the teaching?

Keep the affected joints immobilize. ( to minimize bleeding. After the acute episode, the child should begin active ROM exercises). - Have parent administer acetaminophen for reports of pain. IBUPROFEN prolongs bleeding time by inhibiting platelet aggregation ( or clotting).

school age child w/ acute lymphocytic leukemia with an absolute neutrophil count of 450/mm3. What instructions should you include?

Keep your child away from crowds ( due decrease risk of infection) -Do not get varicella immunization bc varicella is a live virus vaccine and can cause an infection for the child who has neutropenia. - limit intake of fresh fruits and veg bc this increase the introduction to microorganisms. - DO NOT take rectal temps to decrease the risk of mucosal damage and infection

What is preterm labor?

Labor prior to 37 WEEKS of gestation, with PINK- STAINED vaginal discharge + Uterine contractions that become more regular.

Toddler + well child visit indications of child maltreatment

Laceration of the side of the torso ( a laceration on the side of the torso is NOT an injury that occurs due to the typical clumsiness of a toddler. The findings indicates the need to further investigate for suspected child maltreatment. ) -bruising is expected d/t frequent falls -diaper dermatitis is expected

Nurse is monitoring a client who recently had a cast placed on the right lower extremity for a bone fracture . Which fo the following findings should the nurse recognize as abnormal?

Lack of sensation on between the firs and second toes. ( Lack of sensation between the toes indicates peripheral nerve impairment and is an abnormal finding that can indicate the client has compartment syndrome. Nurse should report to the PCP immediately). **Casts expected finding: - capillary refill of 3 seconds in the nail beds of the toes is slowed but still within the expected reference range after application of cast. - Cool bilateral extremities are an indication of the client's overall body temperature and general circulatory status and are an expected finding. - Dull throbbing pain is expected finding for a client with bone fracture

Lab result of preschooler what to report to Provider

Lead 14 mcg/dL. this is ABOVE expected range

What test determines lung fetal maturity?

Lecithin / sphingomyelin or L/S ratio -This is done with an amniocentesis

Nurse is reinforcing teaching with a client who is on a low sodium diet and asks about how to improve the taste of bland food . Which fo the following should the nurse recommend?

Lemon juice. ( Lemon juice is LOW on sodium) - NO ketchup, mayonnaise or soy sauce they are all high in sodium.

Pain management birth to 5 months 6 to 12 months toddler school age child adolescent A traumatic measures Pg. 45 FLACC , FACES , numeric scale pain assessment pg. 46

Lidocaine Transdermal Fentanyl NC of children pg. 47

Systemic lupus erythematosus ( SLE ) Pt. teaching when taking methylprednisolone orally

Limit contact with large groups of people. ( Glucocorticoids cause immunosuppresion and may risk infection. The client should limit contact with sources of possible infections like us large groups of people). - Take glucocorticoids with food to prevent GI upset and bleeding - Clients taking glucocorticoids are at risk for osteoporosis, they should take an additional Vit. D and calcium supplements.

Valproate for bipolar disorder

Liver fxn tests must be monitored regularly - used as a mood stabilizer

Nurse is reinforcing teaching with a client who has bipolar disorder and a new prescription for lithium. Which fo the following instructions should the nurse include in the teaching?

Maintain a consistent sodium intake. (Decreased serum sodium cause lithium excretion to decline, which can lead to toxicity). *Lithium: can cause -polyuria - hypothyroidism can occur while taking lithium - Take lithium with meals or milk to reduce GI upset. * hypothyroidism may occur in clients taking lithium over an extended period of time

A nurse is caring for a client who is 3 days postoperative following a total right hip arthroplasty . Which fo the following actions should the nurse take?

Maintain abduction of the client's right leg while in bed. ( To prevent dislocation of the affected hip by placing an abductor pillow between the client's legs when resting in bed.) -Nurse should encourage the client to stand at the bedside on the day of surgery and if prescribed by the provider to walk using a walker. Passive ROM exercises require flexion and extension of the joints and are not recommended 3 days post surgery. -Nurse should provide a chair that does not allow the client to recline because a reclining chair increases the risk of the client flexing at the hips beyond 90 degrees when moving to a standing position. -Nurse should not apply any type of traction boot or allow the client's leg to rotate internally or externally bc it can cause a dislocation of the affected hip.

Nurse is caring for a client who has meningococcal pneumonia. Which fo the following personal protective equipment should the nurse use?

Mask ( droplet precaution ) (Nurse should identify that a client who has meningococcal pneumonia requires DROPLET precaution -Mask when providing care within 3 feet of client.

Nagele's Rule

Minus 3 moths Add 7 days Add 1 year

Manifestation of poliomyelitis

Muscle stiffness

Immunization for a newborn

My baby will receive his next immunization when he is 2 months after birth. -All newborns start receiving immunizations at birth, before discharge from the hospital . - Children should receive the first varicella vaccine between 12 to 18 months. -All newborns should receive a hepatitis B vaccine at birth, regardless of the parents immunization status.

Contraindication of MMR immunization ( measles, mumps, rubella)

Neomycin sensitivity -Egg allergy -gelatin - if child has just received an immunoglobulin

Sinus rhythm

Nurse should auscultate heart sounds at the apical impulse, located left midclavicular line and fifth intercostal space. The expected heart sound include S1, which is the closure of the atrioventricular valves, and S2 is the closure of the semilunar valves.

Nurse is assisting with discharge planning for a client who is postoperative following a total hip arthroplasty . Which of the following instructions should the nurse include in the discharge plan ?

Obtain a raised toilet seat. ( to avoid flexing the hip more than 90 % which increases the risk for dislocation ). -Nurse should instruct client to report decreased sensation in the affected foot or leg because this can indicate neurovascular compromise. -Nurse should inform client that lying on the operative side is allowed BUT the client should place pillow between the legs to prevent dislocation of the hip. - Nurse should instruct client to avoid crossing her legs to prevent dislocation of the hip.

Nurse is reinforcing teaching about dietary changes with a client who has cardiovascular disease. Which of the following images indicates the type of cooking fat the nurse should recommend the client use when preparing meals?

Olive oil (Nurse should instruct client who has cardiovascular disease to consume foods which contain primarily monosaturated and polyunsatruated fats, such as olive oil or other vegetable oils rather than foods that are high in saturated fat. The nurse should reinforce the oils high in monosaturated fats help decrease the client's cardiovascular risk by lowering LDL cholesterol and triglyceride levels.

two point gait

One crutch and opposite extremity move together followed by opposite crutch and extremity

A nurse is reinforcing teaching with a client who has heart failure and a new prescription for hydrochlorothiazide . Which of the following findings should the nurse instruct the client to report to the provider?

Onset of nausea. ( which can be an indication of hyponatremia or hypokalemia resulting from the diuretic effects of the hydrochlorothiazide. -Nurse should remind client that an increase in urinary output is desired effect of hydrochlorothiazide. -Nurse should remind client to report a weight gain of 0.9kg ( 2lb) or more per week - Nurse should instruct client to take a missed dose of the medication as soon as the client remembers. But client should not take a double dose of the medication.

A nurse is reviewing the medical record of a client who has a new prescription for cephalexin to treat pneumonia . Which of the following data should the nurse report to the provider before the client receives this medication?

Penicillin allergy.

Nurse is reviewing the history of a client who is to start taking cefotetan to treat a bacterial infection. Which of the following information from the client's medical record should the nurse report to the provider before the client begins receiving this medication?

Penicillin allergy.

Nurse is caring for client who has a compound fracture of the femur and was placed in balanced suspension skeletal traction 4 days ago. Which of the following actions should the nurse take?

Perform pin site care daily. ( Nurse should perform pin site care daily with chlorhexidine solution or use a solution according to facility protocol. The nurse should also monitor the pin sites for manifestations of infection.) - Nurse should ensure the client has an overbed trapeze to aid in lifting upper body off the bed when necessary and to help prevent skin breakdown of the heels and elbows with client repositioning. - Nurse should identify that balanced suspension skeletal traction is managed through the use of pins, pulleys, weights and frame and that the client does NOT wear a boot. - Nurse should ensure the weights hang freely at all times.

Nurse is preparing to remove a client's NG tube . Which of the following interventions should the nurse take to decrease the risk of aspiration ?

Pinch the NG tube ( to prevent secretions from draining into the client's throat which can cause aspiration. ) - Nurse should instill 50 mL of air through the NG tube to REMOVE mucus and gastric secretions from the tube and to prevent aspiration of these secretions. - Nurse should place client in a sitting position to prevent the risk of aspiration. - Nurse should identify that irrigating the NG tube before removal can put the client at risk for aspiration and should be avoided.

Nasogastric enteral feeding w/ infant

Place the infant in semi-fowler position for 1 hr AFTER feeding ( nurse should elevate infant's bed by 30 to 40 degrees for 30 min for 1 hour AFTER feeding - DO NOT flush the tube BEFORE feeding, when flushing tube before Medication admin, nurse should use STERILE water rather than normal saline - Admin feeding at room temp to decrease GI discomfort - Auscultating over infant's epigastric area does NOT ensure proper tube placement.

Preschooler w/ Wilms' Tumor + Tx w/ antineoplastic medication regimen What to REPORT TO PROVIDER?

Platelet count of 70,000 /mm3 ( this is BELOW the expected range) and increases the risk for spontaneous bleeding. Nurse should HOLD the medication and report finding to PCP.

Obtain BP reading from school age child

Position child's arm at the level of the heart

Nurse is caring for client who is at risk for developing pressure ulcers. Which of the following actions should the nurse take?

Position pillows between the bony prominences. ( Nurse should use positioning devices to keep bony prominences from being in direct contact with each other, which will prevent skin breakdown and pressure ulcer development.) - Check client for incontinence at least every 2hours to prevent skin breakdown. - Do not massage over reddened areas of the skin, bc it can lead to the formation of a pressure ulcer by damaging underlying tissue. - Do not elevate head of bed to an angle greater than 30 degrees. An angle over 30 degrees can cause shearing of the skin, which leads to tissue injury and pressure ulcer development.)

Fontanels

Posterior fontanel closes by 6-8 weeks Anterior fontanel closes between 12 - 18 months.

Nurse is reviewing the lab results of a client who has type 2 diabetes mellitus . The nurse should identify that which of the following laboratory values indicates the client is at risk for delayed wound healing ?

Prealbumin 12 mg/dL ( this lab value is BELOW the expected reference range, indicating that client's protein status is inadequate and that he is at risk for delayed wound healing due to malnutrition ). - Elevated HbA1C can increase the risk for delayed wound healing. - Elevated WBC count increases risk for delayed wound healing - Client who is diabetic is at increased risk for development of renal failure, which can increase the risk for infection and delayed wound healing.

Sickle cell anemia experiencing vaso-occlusive crisi

Promote oxygenation utilization ( to prevent further sickling of the the red blood cells and promote adequate oxygenation of the tissue). - Apply warm compress to the joints to reduce pain and inflammation.

Nephrotic syndrome has prescriptions for CORTICOSTERIODS

Provide low sodium diet to decrease edema - do not encourage to increase fluid intake - monitor albumin levels DAILY to eval effectiveness of treatment - admin diuretics and immunosuppressants

Nurse is caring for a client who is 1 day postoperative following a hip arthroplasty . The client is exhibiting hypotension, tachycardia and tachypnea. The nurse should recognize that these finding indicate which fo the following complications?

Pulmonary embolism. (

A nurse is collecting data from a female client who has been taking propylthiouracil ( PTU ) for 2 months to treat Grave's disease. Which of the following findings should the nurse recognize as an indication that the medication is effective?

Pulse 82 / min . ( Tachycardia is a manifestation of hyperthyroidism. The nurse should identify that a pulse of 82/min is within the expected reference range of 60 to 100/min indicating that the medication is effective. -

Toddler age appropriate activity

Puzzle with large pieces

Indication of Appendicitis

Rebound tenderness

Nurse is caring for a client who has bacterial meningitis. Upon monitoring the client, which of the following findings should the nurse expect?

Red macular rash ( sometimes called petechial rash).

Nurse is providing discharge teaching for the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

Remind the client to avoid watching her feet when walking. ( Nurse should instruct client's family to frequently remind the client to maintain correct posture and prevent falls by not watching her feet when walking. ) - Nurse should instruct family to provide client with extra calories and protein to prevent unintentional weight loss from expenditures of energy due to tremors, dyskinesia, and difficulty swallowing. - Nurse should instruct family to avoid using area rugs in the client's home bc her foot may drag or be soft and catch on the area rug which can cause a fall. - Nurse should instruct family to encourage the client to take walk in , sit down showers bc skeletal muscle rigidity can cause difficulty in moving coordination and balance. which increases the risk of a fall.

A nurse is providing pin site care to a client in skeletal traction . Which of the following actions should prompt the charge nurse to intervene?

Removing the crust around pin sites during cleaning . ( Skeletal traction involves the use of a pulling force applied to the bone by weights attached by rope directly to a rod or screw placed through the bone. Examples include skeletal tongs ( Gardner - Wells) and femoral or tibia pins ( Steinmann pin ). Weights up to 25 lb can be applied as needed. One of the complications of this type of traction is infection, which can progress to osteomyelitis. Osteomyelitis in an inflammation within the bone secondary to penetration by infectious organisms. Prophylactic antibiotics are used to prevent infection, typically with a broad- spectrum IV antibio

Nurse is reinforcing discharge teaching with a client who has hearing loss. Which of the following actions should the nurse take when communicating with the client?

Rephrase client instructions when not understood. (When communicating with a client who has hearing loss the nurse should rephrase rather than to repeat, discharge instructions when they are not understood. ) -Keep hands away from your mouth when communicating with a client who has hearing loss so they can see your mouth. - Speak in a lower tone of voice. Higher sounds can impede hearing by accentuating vowel sounds and concealing consonants. - Nurse should sit or stand facing the client on the same level so that the nurse's mouth and lips can be seen for lip reading.

Nurse is reinforcing teaching about comfort measures with the parent of a 10 yo child who has a viral infection. The nurse plan to tell the parent that aspirin is contraindicated of the risk for which of the following conditions?

Reye's syndrome. ( Aspirin is contraindicated for children and adolescents who have a viral illness bc it is associated with the development of Reye's syndrome. There is a risk for children and adolescents to develop Reyes' syndrome if they take aspirin following a viral illness.

Manifestation of ruptured ectopic pregnancy

SEVERE SHOULDER PAIN d/t the presence of blood in the abdominal cavity which irritates the abdominal diaphragm and phrenic nerve. -LOW serum progesterone level - would show an EMPTY UTERUS via transvaginal ultrasound - has delayed, scant, irregular menses.

Infant w/ severe dehydration

SEVERE dehydration = - cap refil GREATER than 4 seconds - INCREASED HR - weight loss of 10% or greater - sunken anterior fontanel

Nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client's temp increases to 102.4 F (39.1). Which of the following actions should the nurse take first?

STOP the transfusion. ( Greatest risk to this client is injury from an elevated temperature). This is the priority action - Obtain a urine specimen to determine the extent of the reaction. - Nurse might need to administer antihistamine (like diphenhydramine , as an emergency mediation) - Nurse should notify the charge nurse of a possible transfusion reaction bc it is an emergent situation

PTSD + SERTRALINE

Sertraline is an SSRI that can cause serotonin syndrome ( agitation, anxiety , hallucinations, hyperactive reflexes, excessive diaphoresis, hyperthermia. this condition can cause death - sertraline can affect vision and balance, anorexia and weight changes - can cause palpitations and chest pain

Amniocentesis Test

Should be done with an EMPTY BLADDER. -This test tests for fetal genetic defects

A nurse in the long term care facility is collecting data from a client who reports fullness in the rectum and abdominal cramping. Which of the following findings should indicate to the nurse that the client might have a fecal impaction?

Small liquid stools. ( Small liquid stools can be the result of fecal material being expelled around an impaction). Manifestations of fecal impaction: * abdominal cramping and distention - Halitosis is associated with the ingestion of certain foods and medication and it can also be an indication of infection - Hemorrhoids indicate that the client is straining when defecating. But presence of hemorrhoids is not an indication of fecal impaction)

Contraceptive sponge

Sponge can increase the risk for toxic shock syndrome.

Assessment of a toddler, expected finding

Stands on one foot for several seconds. walking backwards with heel to toe = 5 yr old -Using scissors to cut out shapes = 4 y.o -Printing letters withe a pencil = 5 y o

Heparin sodium

Sub Q every 12 hr, continuous or intermittent IV infusion - Enoxaparin , dalteparin sodium , tinzaparin = subq Q 12 hrs for 2-8 days - Fondaparinux sodium = SubQ every 12 hr for 5-9 days

Terbutaline

Subcutaneous Q 4 hours

Nurse is reinforcing teaching with a client who has a new prescription for omeprazole oral capsule. Which of the following instructions should the nurse include?

Swallow the medication whole. ( Swallow capsules or tablets whole. Do not crush or chew.

Manifestation of bacterial conjuctivitis

Swollen eyelids

TORCH INFECTIONS

T= toxoplasmosis O= Other infections like hepatitis R= Rubella virus C= Cytomegalovirus H= Herpes Simplex Virus Expected findings for TORCH infections: FLU LIKE SYMPTOMS - Joint pain - Malaise - Rash -Tender lymph node **TORCH infections can be treated DURING PREGNANCY depending on the infection.

SSRIs vs. tricyclic antidepressants ( TCA s)

TCAs can cause and increased risk of cardiovascular side effects. TCAs can cause cardiac dysrhythmia and can be lethal to the client in the event of overdose. The nurse should include that clients should undergo cardiac screening before beginning therapy and have periodic ECG analysis while taking this medication TCA = sedation is common A/R

TSH level

TSH level determine thyroid function. Contrast media doesn't interfere with TSH levels.

11 year old immuniations

Tdap, for 11 -12 yo Hib = children between 6 weeks and 4 years of age IPV = children between 6 weeks and 6 Years of age , 4th dose given at 4 to 6 years of age RV = between 6- 32 weeks of age

Nurse is reinforcing teaching about home care with a client who had a knee arthroplasty. Which of the following factors should the nurse identify as an indication that a barrier to learning might be present?

The client stops the nurse and asks for pain medication. (Nurse should identify that a client who is in pain will not be able to concentrate which can interfere with his ability to learn.) -Nurse should identify that asking questions indicate active listening by the client and enhances learning. - Nurse should identify that clients learn . in different ways. Using multiple methods of teaching, including hands on practice and providing written materials enhances learning. - Nurse should identify that family members who are actively engaged in the teaching session and ask questions can enhance learning.

Agoraphobia

The fear of being in places where help might not be available like being outside alone.

Child w/ scabies and prescription for PERMETHRIN 5% cream. What info to tell ?

This medication will eliminate your child's itching within 2 to 3 weeks . This med will kill mites but itching can continue for 2 to 3 weeks after application. Topical adverse effects: burning or stinging - wash off Cream 8 to 14 hours AFTER application to ensure the treatment is effective - this is a ONE TIME DOSE and is applied to ALL SKIN SURFACES , not only the affected areas.

BPP Biophysical profile what does this test include?

This test include info on: - Fetal breathing movement - Fetal tone - Amniotic Fluid volume

What is a Kleihauer- Betke test ?

This test is used to verify that fetal blood is present during a percutaneous umbilical blood sampling procedure.

Nurse is reinforcing teaching with a client who is taking insulin glargine . Which of the following information should then nurse include in the teaching?

This type of insulin should be given at the same time everyday. Insulin glargine is released in the body over a 24 hr period. Nurse should instruct client to admin insulin glargine at the same time each day to maintain consistent serum levels for optimal therapeutic effect. - Insulin glargine should NOT be mixed with any other insulin - Insulin glargine is long acting insulin , administered daily at the same time and it NOT to be admin via IV - Insulin glargine has a LOW risk for hypoglycemia bc serum levels of the insulin do NOT peak and remain consistent over time.

Nurse is examining a client's IV site and notes a red line up his arm. The client reports a throbbing, burning pain at the IV site. The nurse should identify that the client's manifestations indicate which fo the following complications of IV therapy?

Thrombophlebitis Indications of thrombophlebitis - pain - warmth - red streak

School age child with skeletal traction to right lower let to repair a femur fracture, findings that are PRIORITY for the nurse to report to the PCP?

Tingling of the right foot ( this could be an indication of a nerve injury) . Nerve damage or compartment syndrome. -decrease appetite is expected due to pain an immobility. nurse should report inadequate nutritional intake -Crusting at pin site can possible indicate infection and should be reported to the provider and monitored closely

Zidovudine

Treatment for HIV/ AIDS

Metrodinazole

Treatment for bacterial vaginosis and trichomoniasis

Fluconazole

Treatment for candidiasis

A nurse is caring for a client who has a new prescription for SUMATRIPTAN. The nurse notes that the client takes FLUOXETINE . The nurse should notify the provider that the combination of the se medications will place the client at risk for which of the following adverse effects?

Tremors. ( Concurrent use of SUMATRIPTAN and FLUOXETINE can lead to excessive stimulation of serotonin receptors, placing the client at risk for serotonin syndrome. The client can experience: -tremors -confusion -hallucination

Dx of enterobiasis , what should the nurse advise the guardian of the child?

Trim the child's fingernails SHORT. ( to reduce the collection of eggs under her nails and prevent reinfection) - Have child wear one-piece sleeping outfits to minimize scratching of the perianal area. - have child take showers , instead of tub baths to INCREASE the incidence of reinfection - Nurse should instruct guardian that treatment with antiparasitic medication should be repeated in 2 weeks to prevent reinfection.

confabulation

Unconscious filling of gaps in memory by imagining experiences or events that have no basis in fact - unconsciously telling untrue stories to protect self esteem

Nurse is reviewing the medical record of a client who has a prescription for morphine . Which of the following findings should the nurse report to the provider?

Urinary retention ( The nurse should recognize that administering morphine to the client can cause urinary retention. Therefore, the nurse should report this finding to the provider. )

Gentamicin , tobramycin , streptomycin

Use: - E. coli , pseudomonas, pneumona SIDE EFFECTS: - nephrotoxicity - Neurotoxicity - Ototoxicity - Hypersensitivity - Elderly at greater risk - N/V , diarrhea - Rash - tinnitus - pruritus - cramps *monitor UA, WBC, peak and trough , superinfections , fever, INTERACTION: - coumadin - penicillin CONTRAINDICATIONS: - myasthenia gravis - kidney disease - hearing loss

Erythromycin , Azithromycin , Clindamycin (macrolides)

Use: -clients allergic to penicillin -Strep & chlamydia SIDE EFFECTS: - GI discomfort - N/V - Epigastric pain - Thrombophlebitis * take on empty stomach with full glass of water * CONTRAINDICATED in anyone w/ LIVER DISEASE * monitor WBC, fever INTERACTIONS: - Antihistamines - Theophyline - Carbamazepin - Coumadin * complete entire dose of meds * notify PCP if GI upset or allergic reactions

Vancomycin

Use: MRSA, colitis, staph enterocolitis SIDE EFFECTS: - N/V/ - taste alterations - rare side effects - ototoxicity - nephrotoxicity - red neck syndrome : flushed chills, itching * OTOTOXICITY

Metoprolol , atenolol , carvedilol , propranolol , Beta blockers

Use: mild to moderate HTN , moderate to severe angina, postmyocardial infarction Beta blockers slow HR and decrease BP * if pulse less than 60 hold and notify PCP A/R beta blockers= - fatigue - lethargy - impotence - wheezing - dyspnea - heart failure CONTRAINDICATIONS: bronchial asthma

Sub Q = Subcutaneous route

Used = heparin, insulin , lovenox Rotate sites with each injections

Amphotericin B deoxychloate anti fungal

Uses: - Candidiasis - Tinea pedis - Tinea cruris SIDE EFFECTS: - Nephrotoxicity - Thrombophlebitis - Hypokalemia - bone marrow suppression - hepatotoxicity - irregular menstrual flow - gynecomastia * use with caution in pt.s w/ renal /hepatic impairment INTERACTION: - Aminoglycosides - Amphotericin B

Tetracycline , doxycycline

Uses: - H. pylori, mycoplams, pneumonia, acne, anthrax , UTIs, bronchitis SIDE EFFECTS: - N/V/ diarrhea - Photosensitivity - Stomatitis - Nephrotoxicity - Hepatotoxicity - superinfection - YELLOW BROWN tooth discoloration INTERACTIONS -Antacids - milk and calcium ( tetracyline) - oral contraceptives * drink w/ full glass of water

Trimethoprim/Sulfamethoxazole Sulfasalazine

Uses: - UTI , bronchitis, E. coli SIDE EFFECTS: - hypersensitivity - photosensitivity - blood disorders, anorexia - N/V diarrhea - dizziness headaches - crystalluria * monitor CBC, force fluids to prevent crystalluria INTERACTIONS: - antacid - dilantin - coumadin - oral hypoglycemics * Take with full glass of water * increase fluids to 8-10 glasses a day * avoid long exposure to sun * wear sunscreen * watch for allergies like skin rashes and itching

Abdominal CT with contrast dye Allergic reaction to contrast dye

Uticaria Itching Flushing of the skin possible anaphylaxis Respiratory distress, cyanotic appearance

Nurse is preparing to suction a client who has a tracheostomy . Which fo the following actions should the nurse take first?

Ventilate 100% oxygen ( Nurse should ventilate the client with 100% oxygen before suctioning to prevent hypoxemia when removing air and debris from the upper airway. ) -Nurse should insert catheter tip into the tracheostomy during inspiration until it meets resistance, then pull back 2.5cm (1 inch). But this is NOT the priority action. -Nurse should rinse or flush the catheter with 0.9% sodium chloride to clear the catheter of secretions before repeating the suctioning procedure. But this is NOT the priority action -Nurse should occlude the vent on the catheter for 10 to 15 seconds while removing the catheter during suctioning.

Nurse is preparing to suction a client who has a tracheostomy . Which of the following actions should the nurse take first?

Ventilate with 100% oxygen ( to prevent hypoxemia when removing air and debris from the upper airway). -Nurse should insert the catheter tip into the tracheostomy during inspiration until it meets resistance , then pull back 1 inch. -Nurse should rinse or flush the catheter with 0.9% sodium chloride to clear the catheter of secretions before repeating the suctioning procedure. - Nurse should occlude the vent on the catheter for 10 to 15 secs while removing the catheter during suctioning.

A nurse is caring for a client who has methicillin resistant staphylococcus aureus MRSA infection in a surgical wound. Which of the following information should the nurse plan to share with visitors?

Visitors must don a gown and gloves before entering client's room. ( This patient will be on a client on contact isolation precautions. Contact precautions requires visitors to put on a gown and gloves prior to entering the client's room to prevent MRSA from spreading) - Nurse should identify visitors of clients who are on airborne or droplet precautions should wear a mask within 3 feet of the client. -MRSA does not spread through the respiratory tract and does not need airborne or droplet precaution. -NO FRESH FLOWERS for patient on neutropenic precaution .

Home safety instructions for parents of toddler

We will turn the pot handles toward the back of the stoves ( to prevent toddler from pulling a pot off the stove) - keep toddler in crib until he has reached a height of 89 cm (35 inch) - keep toddler out of direct sun exposure between 1000 and 1400 when the sun rays are the strongest - Avoid providing snacks like peanuts or other hard foods bc this increases the risk for aspiration

A nurse is planning to administer metoprolol to a client who has heart failure and a heart rate of 48/min . Which of the following actions should the nurse take?

Withhold the client's medication. ( Withhold Med if client's HR is 50/min or less. Notify provider. So that dosage can be adjusted. -Administer with meals or immediately after meals. This medication can mask manifestations of hypoglycemia if client has diabetes.

Adolescent female client w/ acne vulgaris and ISOTRETINOIN

You will need 2 negative pregnancy tests prior to starting this medication. ( ISOTRETINOIN is TERATOGENIC. pregnancy must be ruled out PRIOR TO admin. and before each refill. Client should use 2 effective forms of contraception while taking this medication. ) - Need to regular monitoring of LIVER FXN and glycemic control while taking isotretinoin. - AVOID vit. A supplements while taking this med bc it INCREASES the risk for ADVERSE EFFECTS and medication toxicity.

A nurse is reinforcing teaching with a female client who has a new prescription for isotretinoin . Which of the following instructions should the nurse include in the teaching? Select all that apply

You will need to have your liver enzymes monitored after 1 month. -You can have nosebleeds while taking this medication. - you should report any thoughts of harming yourself. - You will need to have two negative pregnancy tests prior to starting the medication

Nurse is caring for a client who has a prescription for an IM injection of penicillin G benzathine . The client asks why the injection must be given IM instead of through the IV line. Which of the following responses should the nurse make?

Your medication can't be given IV because it is NOT water soluble. (This type of penicillin has poor water solubility and is NEVER administered intravenous). - This type of penicillin is absorbed SLOWLY for several weeks, Maintaining a continuous low blood level. Medications given IV are absorbed faster than IM medications. - IM injections of this medication can cause discomfort at the injection site. -IV injections are more precise than IM

Regression

a common reaction to stress when toddlers are hospitalized. temporary Stressful situations like hospitalizations/illness can result in regressive behaviors like bed wetting in a toddler who has been previously toilet trained. Nurse should provide assurance to the parent that his child will regain control of her bladder once she is feeling better and the stress of hospitalization is decreased.

Erotomania

a disorder involving the fixed (but incorrect) belief that one is loved by another, which persists in the face of strong evidence to the contrary - behavior in which client believes another individual desires him romantically

Status asthmaticus

a severe, life-threatening asthma attack that is refractory to usual treatment and places the patient at risk for developing respiratory failure. - admin albuterol via nebulizer promotes bronchodialation status asthmaticus is a medical emergency and can result in respiratory failure

IPV immunization RV immunization Hib Immunization

administered by 6 years of age Administred by 6 MONTHS of age Administered by 18 MONTHS of age.

Acute asthma attacks what to admin?

albuterol = short acting beta2 antagonist good for ACUTE asthma - admin FLUTICASONE for LONG TERM management of asthma -Admin CROMOLYN SODIUM for LONG TERM management of asthma - MONTELUKAST , a leukotriene modifier for long term management of asthma

15 month old toddler to receive MMR , any CONTRAINDICATIONS

allergies to neomycin

Contraindications to HPV vaccine

allergy to baker's yeast

Contraindication for ROTAVIRUS or meningococcal vaccine

allergy to latex

Diabetes insipidus DI

antidiuretic hormone (ADH) is not secreted, or there is a resistance of the kidney to ADH - clients with DI will have COLORLESS urine with a specific gravity of 1.005 or LESS * monitor: weight and report weight loss - do not limit fluids - report polyuria and polydipsia - avoid caffeine - wear medical alert bracelet if condition is chronic

cardiac catheterization

ask if client is allergic to iodine

Sputum collection

ask the child to cough deeply

Granduer

behavior in which client believes he is extremely important or powerful

Hemangioma

birthmark characterized by a bright red, rubbery nodule with a rough surface

NORTRIPTYLINE

can cause orthostatic hypotension, client should rise slowly in the morning - can drink caffeinated beverages A/R: - sexual dysfunction ( decreased libido) * clients taking MAOI can't eat aged meas ( pepperoni)

GERD toddler expected finding

chronic cough

Order burn wound care

clean burn with mild soap and tepid water remove any embedded debris apply an antimicrobial ointment wrap the hand with a gauze dressing inform the parent of dressing change schedule

Introjection

client incorporates the external environment into her own view of herself

Swing through gait

crutches forward, lift both feet and swing forward

Denial

defensive coping mechanism that protects the client from increasing anxiety levels. The client consciously disowns intolerable thoughts and ideas. This is a common response of victims of violent crimes.

Developmental delay in 7 yo

does not know the difference between right and left

deficient fluid volume

dry mucous membranes

Tracheostomy care what to include in the teaching?

ensure one finger fits between the ties and the neck ( to ensure the tube is held securely in place). - Instruct parent to clean around the stoma with SOAP and WARM water. parent should also use HYDROGEN peroxide to remove secretions that have adhered to the tube. - instruct parent to perform necessary tube changes before meals or 2 hrs AFTER meals - instruct parents to change the tracheotomy tube once each week

Hirschsprung disease

expected finding : - constipation - Abdominal distention

Nephrotic syndrome why it's important to check child's nephrotic syndrome

explantions: - A decrease in urine protein indicates that treatment is effective. ( desired outcome is a reduction of proteinuria) -

Psychomotor seizure

findings: amnesia

Extrusion reflex

force tongue outward when it is touched , should dissapear by 4 months of age.

Manifestations of dysfunctional grieving

grieving becomes dysfunctional when a client is unable to resume regular activities of daily living or experience emotions other than sadness or depression.

Client with schizophrenia jumps and runs out yelling, you're all making fun of me

ideas of reference

12 month old infant well-child visit expected growth and development

identify 3 to 5 words Babinski reflex DISSAPEARS roughly around 12 months. Birth weight should TRIPLE by 12 months of age Attempting to build 2 block tower but fails -REPORT BP 115/70 bc its ABOVE the expected reference range -Resp rate of 30 /min =normal -HR 130/min = Normal -Temp 99.5 = normal

child on chemo + platelet count 100,000/mm3

inspect inside of mouth for sores everyday

Physical findings of sexual abuse

irritation to the external genitalia

Rubella Immunization

is CONTRAINDICATED in pregnant women bc it is a LIVE VIRUS and rubella infection can develop. ( women should avoid crowds of young children ) Women should receive immunizations AFTER giving birth

TOXOPLASMOSIS

is a type of TORCH infection that is contracted by consuming UNDERCOOKED meat.

Methylergonovine

is prescribed for the client experiencing POSTPARTUM HEMORRHAGE

CRIES pain rating scale

is used to determine the level of pain experienced by infant at 32 weeks to 60 weeks of gestational age. This scale is used by nurses who are caring for premature and full term infants in the neonatal intensive care unit. The nurse uses a scale from 0 to 10. 0 indicating no pian and 10 indicating highest pain level . Crying Requires increased oxygen Increase VS Expression Sleepless

Bacterial upper respiratory infection

keep towels separate from the rest of the family. use separate towels, utensils, cups to prevent infection from spreading - fever: drink cold liquids to reduce core body temp and prevent dehydration. do not force to drink fluids= can induce n/v - place humidifier in room to provide moisture and improve the child's ability to breathe

crutch walking on stairs

lead with the good foot going up and lead with the crutches going down

Dull sound percuss

liver right side under breast

Injury prevention of an infant

make sure to dress infant clothes WITHOUT buttons ( to reduce the risk of choking and aspiration) -crib should have slats less than 6cm (2.4 inch) apart to reduce the risk of suffocation -AVOID using talcum powder to reduce the risk of aspiration pneumonia if inhaled -AVOID using drop side crib to reduce the risk of suffocation and falls

Domestic violence

men and women who are abusers come from all socioeconomic levels - typical vicimizer has: - low self esteem, - jealous and possessive - gains power and control by intimidating

alcohol withdrawal delirium

mental confusion that occurs in severe alcoholism in the absence of alcohol *Expected finding: - Visual hallucination - Paranoid delusions - Tremors - elevated blood pressure

mild dehydration

moist mucus membranes, slight thirst decreased urine output weight loss of 6% to 8%

Amphetamine capsules

monitor weight twice per week, this med can reduce child's appetite

IM = intradermal route injections

most often used for = tuberculin skin testing , allergy testing - given under the epidermal layer of the skin - monitor presence of wheal after administering to indicate correct technique * Landmark ID= 3 finger widths below acromion process and draw line across arm at axilla. * Ventroluteal = heel of nondominant hand over lateral aspect of greater trochanter, index finger toward the anterosuperior iliac spine, middle finger towards the iliac crest. and thumb toward the groin. - recommended site for adults when deltoid is not used.

School age treat for frequent UTIs , possible cause of UTI

my daughter has bowel movements every 4 to 5 days ( this frequency indicates the child is CONSTIPATED. therefore large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection - frequent emptying of bladder PREVENTS urinary stasis and infection - child should wear COTTON underwear to help prevent UTIs bc NYLON underwear is more likely to trap bacteria in the genital area

Bacterial meningitis

nuchal rigidity

Colic

offer pacifier to soothe and comfort him - caused by swallowing excessive air responding immediately can eliminate excessive air intake from crying

Introduce solid food

over 4-7 days to observe for allergies give 1-2 tsp initially of solid food when introducing each new food

6 months old + sickle cell disease WHERE should you monitor for manifestations of splenic sequestration?

over the spleen (left side of the abdomen) - Splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood. - greatest risks to the child with sickle cell crisis are from inadequate rest and pain management. The nurse should NOT place another client in the room of a child with sickle cell crisis due to the frequent assessments and interventions required when caring for the client with an appendectomy.

Albuterol A/R

palpitations or tachycardia N/V

amblyopia

patch the unaffected eye during the day

Infant reflexes Cranial nerves

pg. 11 pg. 12

1 - 3 years Toddler expected growth and development Age appropriate activities pg. 22 Immunizations , nutrition , sleep and rest , dental health, injury prevention , Pg. 22

pg. 21

Injections

pg. 42 -43 -IM injections 22 to 25 gauge needle. - IM meds vastus lateralis in supine position -Deltoid muscle : up to 1 mL of medication -Ventrogluteal & vastus lateralis for IM injections for up to 2 mL fluid -dorsogluteal - vastus lateralis is recommened for infants and toddlers , after age 2 = ventral gluteal

Type 1 DM

place child's finger under warm water to promote blood flow - do not stead finger against hard surface

Good Samaritan law

provide civil immunity when actions performed in an emergency are within the nurse's abilities and expertise. IF the nurse is certified in CPR and basic life support, the nurse has the expertise and ability to perform CPR in this emergency situation.

nystagmus

rapid eye movement of eyes , normal after seizure

Tdap vaccine

recommended between ages 11 and 12 years

Preservation

repeating of words of behaviors that worsens with stress

School aged child receiving PREDNISONE

report SODIUM 150 mEq/L = hypernatremia is ADVERSE effect of PREDNISONE Adverse effect of prednisone: - HYPERGLYCEMIA -HYPERNATREMIA - HYPOKALEMIA - DECREASE of WBC

Intrauterine device ( contraceptive )

requires client to check the placement monthly

Stoma

should be red or pink and moist , above skin level and can have a bloody discharge at first

Meds that contain sulfonamide

should not be given to clients with hypersensitivity reaction to sulfa. - In other words if they are allergic to sulfa, don't take sulfonamide.

8 month old infant growth and development

sits unsupported for up to 10 min

Child w/ hearing loss what to recommend to facilitate with communication?

speak at the child's eye level. ( to ensure that theres adequate lighting on the speakers face to facilitate lip reading and communication). - should use facial expression when speaking , use hand gestures too to promote understanding, -AVOID exaggerating the pronunciation of words bc this decreases comprehension.

7 year old

spends a lot of time by herself This age group prefers to socialize with other children of the same sex and age.

Toddler developmental assessment

stands on one foot for several seconds 4 yo= cuts with scissors 5 yo= heel toe walk, printing letters with pencil

Diltiazem , Verapamil , Nifedipine (calcium channel blockers)

stops influx of Ca through cardiac, vascular smooth muscles For: angina, mild to moderate HTN , dysrhythmias NOT FOR MI * MONITOR - HR and rhythm, BP

Finding of physical neglect

the toddler is inadequately dressed for the weather

suggestive behavior of physical abuse

toddler does not react when the nurse administers an injection

Physical findings of physical abuse

toddler has symmetrical burns to both legs

Mongolian spot

type of birthmark usually dissapears by school age - large irregular brownish- blue area on the infants buttock

Manifestations of conjuctivitis

unilateral inflamed conjuctiva -caused by a foreign body

Car safety + 15 month old

use a rear facing car seat until age 2. or until they reach the highest weight or height allowed by the car seats manufacturer

Heel stick on infant

use an automated lancet device to puncture the heel.

hemovac

used after mastectomy, empty when full or q8hr, remove plug, empty contents, place on flat surface, cleanse opening and plug with alcohol sponge, compress evacuator completely to remove air, release plug, check system for operation. - decrease abcess formation -decrease pressure on tissues - portable closed system that applies negative pressure to the wound

Comfort pain rating sale

used in the critical care setting to determine the level of pain in infants, children and adolescents who are UNCONSCIOUS and require a VENTILATOR for breathing - uses 8 indicators : alertness agitation/calmness respiratory response physical movement BP HR muscle tone facial tension Goal is to score between 17-26 bc this indicates infant , child or adolescent's pain is under control

FACES pain scale

used to determine the level of pain in children beginning at 3 years of age. - scale contains a total of 6 cartoon faces to help the child demonstrate the level of pain they are feeling. The faces range from a smiling face identifying no pain or hurt to a sad tearful face, identifying tremendous pain or hurt the child is asked to point to the face that best describes how she is feeling.

FLACC pain rating scale

used to eval infant's pain level . - used for children ranging from 2 months to 7 years old Face Legs Activity Cry Consolability Scoring ranges from 0= no pain behaviors to 10= most possible pain behaviors

Digoxin toxicity s/sx

vomiting Bradycardia dysrhythmias

Somatic delusion

when a client believes that his body is changing in an unusual way

Rationalization

when client creates reasonable and acceptable explanations for unacceptable behavior

Reaction formation

when client is overcompensating or demonstrating the opposite behavior of what he feels

Displacement

when he shifts feelings about an object , person, or situation to another less threatening object, person, or situation. Client transferred his emotional reaction about the injury and inability to play to the provider to the chair. - when client transfers emotions from one situation to another

Betamethasone

will be given to client with placenta previa and is actively bleeding , betamethasone is given to PROMOTE LUNG MATURITY if delivery is anticipated.