Semester 3 UNIT 1

Define Seizure

Uncontrolled electrical discharge of neurons in the brain that disrupts normal function.

Which clinical findings would the nurse expect when assessing a client with Cushing syndrome? Select all that apply. One, some, or all responses may be correct. a. Lability of mood b. Slow wound healing c. A decrease in the growth of hair d. Ectomorphism with a moon face e. An increased resistance to bruising

a. Lability of mood b. Slow wound healing Excess adrenocorticoids cause emotional lability, euphoria, and psychosis. Hypercortisolism impairs the inflammatory response, slowing wound healing. Increased secretion of androgens results in hirsutism (increase in growth of hair). Although a moon face is associated with corticosteroid therapy, ectomorphism is a term for a tall, thin, genetically determined body type and is unrelated to Cushing syndrome. There is increased bruising because capillary fragility results in multiple ecchymotic areas.

Which signs of Cushing syndrome would the nurse identify in a client with a pituitary tumor? a. Retention of sodium and water b. Hypotension and a rapid, thready pulse c. Increased fatty deposition in the extremities d. Hypoglycemic episodes in the early morning

a. Retention of sodium and water Increased levels of steroids and aldosterone cause sodium and water retention in clients with Cushing syndrome. Hypertension, not hypotension, is expected because of sodium and water retention. The extremities will be thin; subcutaneous fat deposits occur in the upper trunk, especially the back between the scapulae. Hyperglycemia, not hypoglycemia, occurs because of increased secretion of glucocorticoids. Hyperglycemia is sustained and not restricted to the morning hours.

Define meningitis.

acute inflammation of the meningeal tissue that covers the brain and spinal cord due to infection.

One week after beginning antithyroid medication for the treatment of hyperthyroidism, a client reports diarrhea, abdominal pain, and a fever. The client is admitted with a diagnosis of thyrotoxic crisis. Which intervention is appropriate to implement for this client? a. Limit fluid intake. b. Reduce body temperature and heart rate. c. Observe for an exaggerated response to sedatives. d. Treat the associated hyperglycemia and ketoacidosis.

b. Reduce body temperature and heart rate. Immediate treatment in this emergency focuses on reduction of oxygen demands and thus cardiac workload to prevent cardiac decompensation. The need is for an increase, not decrease, in fluid intake to compensate for that loss because of the high metabolic rate. A response to sedatives is not likely because medications are metabolized more rapidly with thyrotoxic crisis; there is a danger of exaggerated effects of the medication with hypothyroidism. Clients with thyrotoxic crisis are more apt to develop hypoglycemia from the high metabolic rate.

Which are neurological manifestations of hyperthyroidism? Select all that apply. One, some, or all responses may be correct. a. Fatigue b. Diaphoresis c. Blurred vision d. Exophthalmos e. Shallow respirations

c. Blurred vision d. Exophthalmos Blurred vision and exophthalmos are the neurological manifestations of hyperthyroidism. Fatigue is the metabolic manifestation of hyperthyroidism. Diaphoresis, or excessive sweating, is the skin manifestation of hyperthyroidism. Shallow respirations are the cardiopulmonary manifestation of hyperthyroidism.

A 13-month-old child is undergoing lumbar puncture for confirmation of a diagnosis of bacterial meningitis. During the procedure the nurse notes that the spinal fluid is cloudy. Which would this finding indicate? a. Healthy spinal fluid b. Increased glucose level c. Increased white blood cell (WBC) count d. Rising number of red blood cells (RBCs)

c. Increased white blood cell (WBC) count A high WBC count causes spinal fluid to appear cloudy and possibly milky white; it is a sign of infection. Healthy spinal fluid is clear. An increased glucose level does not affect the color or clarity of the spinal fluid. RBCs give the spinal fluid a sanguineous, not cloudy, appearance.

Which complication would the nurse recognize as the most serious in an infant with meningitis? a. Epilepsy b. Blindness c. Peripheral circulatory collapse d. Communicating hydrocephalus

c. Peripheral circulatory collapse Peripheral circulatory collapse (Waterhouse-Friderichsen syndrome) is a serious complication of meningococcal meningitis caused by bilateral adrenal hemorrhage. The resultant acute adrenocortical insufficiency causes profound shock, petechiae, ecchymotic lesions, vomiting, prostration, and hypotension. Although epilepsy or blindness may occur, neither condition is as serious a complication as peripheral circulatory collapse. Similarly, although hydrocephalus may occur, it is rare and not as serious as peripheral circulatory collapse.

Which clinical finding would the nurse expect to encounter during a physical assessment of an infant with meningococcal meningitis? a. Severe glossitis b. Low-grade fever c. Purpuric skin rash d. Tremors of the extremities

c. Purpuric skin rash Meningococcal meningitis is identified by its epidemic nature and purpuric skin rash. Glossitis and tremors are not characteristic of meningococcal meningitis, and the fever of meningitis is usually high.

A 28-month-old toddler is admitted to the pediatric unit with suspected meningitis. A few hours later the mother tells the nurse, "I have to leave now, but whenever I try to go my child gets upset and then I start to cry." Which is the best action by the nurse? a. Walking the mother to the elevator b. Encouraging the mother to spend the night c. Staying with the child while the mother leaves d. Telling the mother to wait until the child falls asleep

c. Staying with the child while the mother leaves Staying with the child enables the mother to leave and reassures her and the child that someone will be with and comfort the child. The mother has indicated that she is upset when the child is upset; walking the mother to the elevator meets neither the mother's nor the child's needs. The mother has said she must leave; trying to persuade her to stay will make her feel guilty about having to leave. Telling the mother to leave after the child is asleep is a dishonest solution; the child should be aware that the mother is leaving and reassured in terms that a toddler will understand that she will return.

Clinical manifestations of tonic phase of a seizure?

continuous muscle contraction/rigidity (hypertonic > 5-15sec)

An adolescent with leukemia is to be given a chemotherapeutic agent. Which time is best for the nurse to administer the prescribed antiemetic? a. As nausea occurs b. An hour before meals c. Just before each meal is eaten d. Before each dose of chemotherapy

d. Before each dose of chemotherapy The purpose of an antiemetic before chemotherapy is to prevent the child from experiencing nausea during and after the administration of the medication. Waiting until nausea has occurred is too late; the medication should be given before nausea occurs. The meals are not causing the nausea; the nausea is caused by the chemotherapy, and if nausea is not prevented, the child will not eat.

The nurse is caring for an infant with bacterial meningitis. Which etiology would the nurse consider as the most likely route of transmission to the central nervous system? a. Genitourinary tract b. Gastrointestinal tract c. Skin or mucous membranes d. Cranial apertures or sinuses

d. Cranial apertures or sinuses Infections of cranial structures, such as apertures or sinuses, can cause meningitis because bacteria travel by way of direct anatomical route to the meninges and cerebrospinal fluid (CSF). Skin, the genitourinary tract, and the gastrointestinal tract do not come into contact with CSF.

How long would the nurse maintain isolation of a child with bacterial meningitis? a. For 12 hours after admission b. Until the cultures are negative c. Until antibiotic therapy is completed d. For 48 hours after antibiotic therapy begins

d. For 48 hours after antibiotic therapy begins Most children are no longer contagious after 24 to 48 hours of intravenous antibiotics. Twelve hours after admission is inadequate, even if antibiotics are started immediately. Keeping the child isolated until cultures are negative or antibiotic therapy is complete is an excessively long period and is unnecessary.

Clinical manifestations of postictal phase of a seizure?

Altered LOC Lethargy HA Confusion

Define goiter.

Enlargement of the thyroid gland.

Decerebrate Posturing?

Hyperpronated and adduction of arms w/ extension of elbows (Indicates SERIOUS DAMAGE)

Clinical manifestations of aural phase of a seizure?

Incontinence Diaphoresis Change in LOC Pallor, flushing, cyanosis, warm skin Weird sensation Tachycardia

Decorticate Posturing?

Internal rotation and abduction of arms w/ flexion of elbows

Precursors of thyroid hormones?

Iodine & tyrosine

Define hyperthyroidism.

Overactive thyroid gland resulting in increased production of thyroid hormones.

What diagnostic test is used to differentiate b/t different causes of hyperthyroidism?

Radioactive Iodine Uptake Test o Thyroid absorbs radioactive iodine and measurement of absorption is taken o Grave's Disease à 35 - 95% absorption o Thyroiditis à less than 2% o Nodular Goiter à normal range (3 - 25%)

Nursing intervention r/t difficulty breathing?

Raise the head of the bed to make it easier to breathe Administer O2

Clinical manifestation specific to Meningococcal meningitis?

Rash or Petechiae (Petechiae = pinpoint round spots caused by bleeding, non blanchable, red/purple/brown)

Diagnostic studies for hyperthyroidism?

TSH, free T4 (free T3) o ↓ TSH (< 0.4 mU/L) & ↑ free T4

List 4 phases of a tonic-clonic seizure.

1. Aural Phase 2. Tonic/Hypertonic Phase 3. Clonic Phase 4. Postictal Phase

Emergency management/Nursing Interventions for tonic-clonic seizure?

1. Maintain airway 2. Protect from injury 3. Lay pt. on their side 4. Remove restrictive clothing 5. IV access/anticipate antiseizure meds 6. Note time of onset (duration > 5min = S.E.) 7. Suction if needed

Diagnostic studies for meningitis?

1. blood culture 2. lumbar puncture & CSF culture 3. CT scan (R/O obstructions in foramen magnum & show ICP/hydrocephalus) 4. X-ray (show sign of infection) 5. PCR (if viral suspected)

Nursing goals r/t meningitis (3)?

1. maximal neurologic function 2. resolve infection 3. pain management

Radioactive Iodine 1. Drug Class 2. Mech of Action 3. Adverse Effects 4. Diag. / Teaching

1. radiation therapy 2. radioactive iodine gets transported to thyroid gland and slowly kills thyroid tissue 3. 4. Limit contact with body fluids, 2x flush toilet, don't touch babies

Clinical manifestations of hyperthyroidism (cardiac/respiratory/SNS)? (5)

1. ↑ Syst. BP 2. ↑ HR 3. ↑ Contractility 4. ↑ Respiratory rate 5. Dyspnea upon mild exertion

Clinical manifestations of hyperthyroidism (Metabolic/GI)? (8)

1. ↑Appetite/thirst 2. Weight loss 3. ↑ Peristalsis/bowel sounds/defecation 4. Proximal muscle wasting (catabolism) 5. Weakness (from muscle wasting)/Fatigue (initially more energy but not sustainable body has no chance to rest) 6. Hypoglycemia 7. Heat Intolerance/Inc. Temp 8. Diaphoresis

Drug Class used to treat symptoms of hyperthyroidism caused by overactive SNS?

Beta Adrenergic Blockers

Clinical manifestations of meningitis (Earlier)?

Fever Severe HA nausea/vomiting pain upon neck flexion

Nursing Interventions r/t meningitis?

Monitor temp. Administer pain meds Monitor s/s inc. ICP

Clinical manifestations of meningitis (Later)?

Photophobia Dec. LOC Inc. ICP Seizure

o Drug overdose or withdrawal o Head trauma o Infectious process (meningitis, encephalitis, sepsis) o Intracranial process (tumor, stroke, ↑ICP, o Other medical disorder (heart, liver, lung, kidney) o Metabolic imbalance (fluid/electrolyte, hypoglycemia) o High fever o Cardiac arrest All potential causes of what?

Seizures

Which is the most important need for a newly pregnant client receiving phenytoin for seizures? a. Discussing the need to increase protein requirements b. Providing a referral for immediate termination of the pregnancy c. Stressing the need to decrease phenytoin to prevent fetal phenytoin toxicity d. Explaining why it is extremely important to take the prescribed folic acid supplements

d. Explaining why it is extremely important to take the prescribed folic acid supplements Phenytoin therapy interferes with folate absorption, which increases the risk of neural tube deformities in the developing fetus; therefore, it is a priority for this client to take folic acid supplements. Although all pregnant clients have increased protein needs, phenytoin therapy does not cause a need for additional protein. Before termination of any pregnancy, it is important to ensure that the client receives appropriate counseling to make an informed decision. Fetal phenytoin toxicity is not an issue of concern; however, the effect of phenytoin on the fetus is, so rather than decreasing phenytoin, the more appropriate choice would be to discuss a different antiepileptic with the provider.

Clinical manifestations of clonic phase of a seizure?

muscle spams

S/S of increased ICP?

Δ LOC Cushing's Triad (brain stem) Δ Temp. (hypothalamus), Ocular Signs Dec. Motor Function Unexpected Vomiting

Clinical manifestations of hyperthyroidism (psychological)? (6)

1. Restlessness 2. Irritability/Agitation 4. Nervousness 5. Depression 6. Insomnia

Cushing's Triad?

1. Systemic Hypertension (w/ widening pulse pressure) 2. Bradycardia 3. Irregular Respirations Sign of brain stem compression & impending death

Diagnostic studies for seizures.

1. accurate description of seizure and health hx 2. EEG 3. CBC, serum chemistries, liver/kidney funct. (R/O metabolic cause)

Which finding from cerebral spinal fluid would lead the nurse to associate with a diagnosis of bacterial meningitis? a. Increased protein b. Increased glucose c. Decreased specific gravity d. Decreased white blood cell count

a. Increased protein Bacterial meningitis causes increased permeability of the blood-cerebrospinal fluid barrier, resulting in increased protein in cerebrospinal fluid. The glucose level will be within the expected range. The specific gravity will be increased, as will the white blood cell count.

Pharmacological treatment of meningitis?

1. Antibiotics 2. Codeine for HA 3. Tylenol for fever

List 5 treatment options for seizure disorders.

1. Anticonvulsive Medication 2. Surgical Resection 3. Vagal Nerve Stimulation 4. Responsive Neurostimulation 5. Keto Diet

phenobarbital 1. Drug Class 2. Mech of Action 3. Adverse Effects 4. Teaching/Diag. Studies

1. Barbiturate 2. Inhibition of CNS 3. Apnea, Hypotension, Somnolence 4. Many drug interactions, sedation!

List 4 drug classes used to treat seizures.

1. Barbiturates 2. Hydantoins 3. Iminostilbenes 4. Misc. anticonvulsants

propranolol (Inderal) atenolol 1. Drug Class 2. Mech of Action 3. Adverse Effects 4. Diag. / Teaching

1. Beta Blockers 2. Inhibits the SNS -- ↓HR, ↓ nervousness/irritability, ↓ Tremors 3. bradycardia, depression, impotence, constipation, fatigue 4.

List 4 phases of any seizure.

1. Prodromal Phase ----sensations or behavior changes that precede a seizure by hours or days 2. Aural Phase ----sensory warning that is similar each time a seizure occurs ----considered part of the seizure 3. Ictal Phase ----from first symptoms to the end of seizure activity 4. Postictal Phase ----recovery period after the seizure

A client who is to undergo a mastectomy for breast cancer says, "I am worried about what I'll look like after surgery." Which response would the nurse use? a. "I understand that you'd be concerned about appearance." b. "Try not to think about the surgery or the outcomes." c. "Anyone in your position would feel the same way." d. "Perhaps you should discuss this with your husband."

a. "I understand that you'd be concerned about appearance." The nurse reflects the client's concern: women facing breast surgery often have feelings relating to their sexuality and change in body image. Blocks to communication (don't think about surgery) are avoided. The focus should be on the client, not on others (anyone). Eventually, the client would be encouraged to have an open discussion with her husband, but first she needs the opportunity to express and clarify her own feelings.

A client is diagnosed with Cushing syndrome. The nurse would monitor the client for which cardiovascular complication? a. Chest pain b. Tachycardia c. Hypertension d. Atrial fibrillation

c. Hypertension Hypertension is a cardiovascular complication found in clients with Cushing syndrome due to increased metabolic demands and catecholamines. Chest pain is seen in clients with hyperthyroidism and hypothyroidism. Tachycardia and atrial fibrillation are manifestations of dysrhythmias, which are associated with hypothyroidism or hyperthyroidism, parathyroidism, and pheochromocytoma.

Normal range of... 1. TSH 2. T4 (thyroxine) 3. T3 (triiodothyronine)

1. 0.40 - 4.50 mIU/mL 2. 5.0 - 11.0 ug/dL 3. 100 - 200 ng/dL

cefuroxime (Ceftin) cefotaxime ceftriaxone ceftizoxime ceftazidime 1. Drug Class 2. Mech of Action 3. Adverse Effects 4. Teaching/Diag. Studies

1. Cephalosporins 2. 3. 4. Take full course of antibiotics

Ocular signs of inc. ICP (5)?

1. Dilation of one pupil (on effected side - Fixed unilateral dilated pupil) 2. Poor response to light 3. Inability to move eye upward & adduct 4. Ptosis of eyelid (drooping) 5. Blurred vision, diplopia (2x vision), Δ extraocular eye movement (cardinal directions)

Clinical manifestations of hyperthyroidism (change in appearance)? (6)

1. Exothalmos 2. Brittle hair/nails 3. Vitiligo (Loss of skin pigment) 4. Acropachy (Clubbed fingers/toes) 5. Goiter 6. Fine tremors

propylthiouracil methimazole 1. Mech of Action 2. Adverse Effect 3. Diag. Studies

1. Inhibits the production of thyroid hormones (T3 & T4) by blocking conversion of iodine into iodine ion. 2. liver & bone marrow toxicity 3. TSH, T4 free, T3 free Liver enzymes, CBC

vancomycin 1. Drug Class 2. Mech of Action 3. Adverse Effects 4. Teaching/Diag. Studies

1. Glycopeptide 2. inhibits bacterial cell wall synthesis 3. 4. Take full course of antibiotics

Which education would the nurse provide about the occurrence of febrile seizures? a. They may occur in minor illnesses b. The cause is usually readily identified. c. They usually do not occur during the toddler years. d. The frequency of occurrence is greater in females than males.

a. They may occur in minor illnesses Febrile seizures are usually not associated with major neurological problems; they may occur during minor illnesses. Between 95% and 98% of these children do not experience epilepsy or other neurological problems. The cause of febrile seizures is still uncertain. Most febrile seizures occur after 6 months of age and before age 3 years, with the average age of onset between 18 and 22 months. Boys are affected about twice as frequently as girls.

A child undergoing prolonged steroid therapy takes on a cushingoid appearance. The nurse would expect to find which of these manifestations during further assessment? Select all that apply. One, some, or all responses may be correct. a. Truncal obesity b. Thin extremities c. Increased linear growth d. Loss of hair on the body e. Decreased blood pressure

a. Truncal obesity b. Thin extremities An increase in appetite results in deposition of fat on the abdomen and trunk. Muscle wasting results in thin extremities. Increased excretion of calcium causes retardation of linear growth and a resulting short stature. Because of the excess production of androgens, virilization and hirsutism occur. Increased salt and water retention cause hypertension and hypernatremia.

A client who has undergone a mastectomy because of breast cancer is now undergoing chemotherapy, which has caused hair loss. The client states, "I feel like I've lost my sense of power." Which response would the nurse give? a. "Hair does not empower a person." b. "Losing power seems important to you." c. "Knowledge is power; I'll give you some pamphlets to read." d. "Hair loss is common; it will grow back, so you should not worry."

b. "Losing power seems important to you." Stating that the loss of power seems important to the client provides an opportunity for the client to discuss her feelings. Stating that hair does not empower a person is confrontational and may cut off further communication. Offering to get the client some pamphlets dismisses the client's concern and does not promote the client's further verbalization of feelings. Stating that hair loss is common and the client should not worry dismisses the client's concerns and cuts off further communication.

Which cause of Cushing syndrome would the nurse consider before assessing a client for physiological responses? a. Pituitary hypoplasia b. Hyperplasia of the adrenal cortex c. Deprivation of adrenocortical hormones d. Insufficient adrenocorticotropic hormone (ACTH) production

b. Hyperplasia of the adrenal cortex Hyperplasia of the adrenal cortex leads to increased secretion of cortical hormones, which causes signs of Cushing syndrome. Pituitary hypoplasia is a malfunction of the pituitary that will result in Simmonds disease (panhypopituitarism), which has clinical manifestations similar to those for Addison disease. Cushing syndrome results from excessive cortical hormones. ACTH stimulates production of adrenal hormones. Inadequate ACTH will result in Addisonian signs and symptoms.

phenytoin (Dilantin) 1. Drug Class 2. Mech of Action 3. Adverse Effects 4. Teaching/Diag. Studies

1. Hydantoin 2. decreasing abnormal nerve signaling in the brain (regulate sodium ion channels) 3. dipoplia, nystagmus, ataxia, drowsiness, mental slowness, swollen gums 4. Abruptly stopping this medication may cause seizure

gabapentin (Neurontin) 1. Drug Class 2. Mech of Action 3. Adverse Effects 4. Teaching/Diag. Studies

1. Misc. Antiepileptic 2. Analogue of GABA neurotransmitter, inhibit CNS 3. Dizziness, drowsiness, visual & speech changes 4. also treats neuropathic pain

A client with severe abdominal pain is on meperidine treatment and later develops seizures. Which intervention is given highest priority? a. Stop administration of meperidine b. Administer transdermal scopolamine. c. Administer oxygen (O 2) through facial mask. d. Monitor respiratory status and sedation level.

a. Stop administration of meperidine Opioids such as meperidine are associated with neurotoxicity and seizures, which are caused by accumulation of its metabolite, normeperidine. The administration of the medication must be stopped immediately. Transdermal scopolamine helps reduce nausea and vomiting associated with administration of the meperidine. O 2 is administered when the client has oversedation and respiratory distress because of meperidine. Frequent monitoring of both the sedation level and respiratory rate is essential in clients receiving opioid analgesics but is of moderate priority in this situation.

Which metabolic manifestations are likely to be observed in a client with hypothyroidism? Select all that apply. One, some, or all responses may be correct. a. Impaired memory b. Intolerance to cold c. Difficulty breathing d. Decreased blood pressure e. Decreased body temperature

b. Intolerance to cold e. Decreased body temperature Cold intolerance and decreased body temperature are the metabolic manifestations observed in a client with hypothyroidism. Impaired memory is the neuromuscular manifestation of hypothyroidism. Difficulty in breathing is the pulmonary manifestation observed in the client with hypothyroidism. Decreased blood pressure is the cardiovascular manifestation observed in the client with hypothyroidism.

Which prescribed medication would the nurse anticipate administering to a client who tested positive for human epidermal growth factor (HER) and has a diagnosis of advanced breast cancer? a. Erlotinib b. Lapatinib c. Rituximab d. Tositumomab

b. Lapatinib Clients with advanced breast cancer have an overexpressed HER-2. Lapatinib inhibits epidermal growth factor-r (EGFR)-tyrosine kinase (TK) and binds HER-2. Erlotinib is an EFGR-TK inhibitor prescribed to treat non-small cell lung cancer and advanced pancreatic cancer. Treatment of non-Hodgkin lymphoma includes administration of rituximab and tositumomab.

A client is being treated for pituitary Cushing syndrome. The nurse anticipates that which medication will be prescribed? a. Mitotane b. Cabergoline c. Cyproheptadine d. Bromocriptine mesylate

c. Cyproheptadine Cyproheptadine is effective for the treatment of pituitary Cushing syndrome. Mitotane is prescribed for the treatment of adrenal Cushing syndrome. Cabergoline and bromocriptine mesylate are effective for the treatment of hyperpituitarism.

Which electrolyte imbalance response would the nurse assess for in a client with a diagnosis of Cushing syndrome? a. Hypovolemia b. Hyperkalemia c. Hypoglycemia d. Hypernatremia

d. Hypernatremia A client with Cushing syndrome secretes excess amounts of cortisol, a corticosteroid that acts to retain sodium and water, resulting in hypernatremia and edema. Hypervolemia, not hypovolemia, is caused by fluid retention. Hypokalemia, not hyperkalemia, occurs because potassium is lost when there is sodium retention. Hyperglycemia, not hypoglycemia, results from cortisol-induced glucose intolerance.

carbamazepine (Tegretol) oxcarbazepine (Trileptal) 1. Drug Class 2. Mech of Action 3. Adverse Effects 4. Teaching/Diag. Studies

1. Iminostilbenes 2. decreasing abnormal nerve signaling in the brain (regulate sodium ion channels) 3. dipoplia, nystagmus, ataxia, drowsiness, mental slowness 4. Abruptly stopping this medication may cause seizure, NO grapefruit

The nurse is admitting an 8-month-old infant with suspected bacterial meningitis to the hospital. List in order of priority the nursing actions that would be taken. - Assist with a lumbar puncture. - Monitor for signs of increased intracranial pressure (ICP). - Insert an intravenous access device. - Institute respiratory isolation. - Administer the prescribed antibiotics.

1. Institute respiratory isolation. 2. Insert an intravenous access device. 3. Assist with a lumbar puncture. 4. Administer the prescribed antibiotics. 5. Monitor for signs of increased intracranial pressure (ICP). Bacterial meningitis is transmitted through respiratory droplets. The nurse would first ensure that all who come in contact with the child are appropriately gowned, gloved, and masked. An intravenous access device provides an avenue to administer prescribed fluids and medications; also, it provides a circulatory access in case of an emergency. The next priority is to obtain a sample of cerebrospinal fluid (CSF). This will help determine whether the cause is viral or bacterial, which will guide pharmacologic treatment by the health care provider. An antibiotic is usually not administered until the lumbar puncture is completed and CSF specimen is sent for culture. Complications, such as increased intracranial pressure and seizures, should be monitored for after the infant is admitted, placed on isolation, and antibiotics are started.

ampicillin & penicillin 1. Drug Class 2. Mech of Action 3. Adverse Effects 4. Teaching/Diag. Studies

1. Penicillins 2. inhibits bacterial cell wall synthesis 3. 4. Take full course of antibiotics

When teaching the client about when to call the primary health care provider if they are showing signs of hypothyroidism after a thyroidectomy, which statement made by the client shows that teaching was effective? a. "I will call if I get dry hair and can't tolerate the cold." b. "I would call if I have muscle cramps and feel sluggish." c. "I will call if I am feeling fatigued and my pulse rate goes up." d. "I should call if my heart is beating really fast and I gain a lot of weight."

a. "I will call if I get dry hair and can't tolerate the cold." Dry, sparse hair and cold intolerance are characteristic responses to low serum thyroxine. Muscle cramping is associated with hypocalcemia. Low thyroxine levels reduce the metabolic rate, resulting in fatigue, but do not increase the pulse rate. Low thyroxine levels reduce the metabolic rate, resulting in weight gain and bradycardia, not tachycardia.

Which information about infection prevention would the nurse include when planning discharge teaching for a client being treated with chemotherapy for leukemia? a. "Wash hands before eating and after using the toilet." b. "Avoid use of antimicrobial soaps when showering or bathing. c. "Clean your toothbrush daily by running it through the dishwasher." d. "Read food labels to avoid added sodium in your diet."

a. "Wash hands before eating and after using the toilet." Hand washing is essential to infection prevention and will be performed by the client and all caregivers and visitors. Toothbrushes should be cleaned daily in the dishwasher or with a bleach solution to reduce risk for infection. Antimicrobial soaps are recommended for immunocompromised clients, especially when cleaning the axillary and genital areas. No salt or sodium restriction is needed for these clients.

A platelet transfusion is to be administered to a child with acute lymphocytic leukemia. Which step would the nurse do first? a. Administer the platelets rapidly through the intravenous (IV) line. b. Set the intravenous (IV) pump to run for 8 hours. c. Flush the intravenous (IV) line with a dextrose solution. d. Check the vital signs every 2 hours during the transfusion.

a. Administer the platelets rapidly through the intravenous (IV) line. Platelets are fragile and should be administered as quickly as possible, within 1 hour, or as fast as the child can tolerate the infusion. There are minimal numbers of red blood cells (RBCs) and white blood cells contained within the infusion, which reduces the risk of a severe reaction. Platelets must be infused within 1 hour. They may be infused as rapidly as the child's cardiovascular status will tolerate. A dextrose solution is not appropriate for flushing a blood derivative line because it may cause hemolysis of RBCs. Two hours is too long an interval between checks of the child's vital signs. Vital signs should be obtained before the infusion, 15 minutes after initiation of the infusion, and at the end of the infusion.

Which is the most important action the nurse would take in preparation for a lumbar puncture for a child with a tentative diagnosis of bacterial meningitis? a. Asking the parents what they were told about the test b. Using a doll to demonstrate the procedure to the child c. Obtaining a pacifier for the child to suck on during the procedure d. Telling the parents that they may stay with their child during the test

a. Asking the parents what they were told about the test Informed consent is required. The procedure should be explained to the parents by the health care practitioner, and the nurse would confirm the parents' comprehension and have them sign the consent form. The child is too young to comprehend a demonstration of the procedure. Although staying with the child may be important to the parents, it is not the priority. Although a pacifier may keep the child calm, this is not the priority either.

The nurse is caring for a child with an exacerbation of leukemia. The nurse would plan to administer the prescribed analgesic for bone pain at which time? a. At scheduled intervals b. When the child asks for it c. When pain becomes severe d. Before the pain becomes severe

a. At scheduled intervals For maximal benefit, the analgesic should be administered at scheduled intervals that are individualized for the child; routine administration manages the pain before it becomes too intense. The goal is to keep the child pain free; by the time the child asks for the analgesic, the pain has returned. It is insensitive to allow the child to be in pain; there should be no pain.

A client with the diagnosis of Cushing syndrome has the following laboratory results: Na + (sodium) 149 mEq/L (149 mmol/L); K + (potassium) 3.2 mEq/L (3.2 mmol/L); Hb (hemoglobin) 17 g/dL (170 mmol/L); and glucose 90 mg/dL (5 mmol/L). Based on these lab results, which instructions would the nurse include in the teaching plan for this client? Select all that apply. One, some, or all responses may be correct. a. Avoid foods high in salt. b. Restrict your fluid intake. c. Eat foods high in potassium. d. Limit your carbohydrate intake. e. Continue your regular diet as before.

a. Avoid foods high in salt. c. Eat foods high in potassium. Based on the laboratory results and not directly related to the client's chronic medical condition, dietary recommendations are as follows: A sodium level of more than 145 mEq (145 mmol/L) is considered hypernatremia; the client should be taught to avoid foods high in sodium (e.g., processed foods, specific condiments). A potassium level less than 3.5 mEq/L (3.5 mmol/L) is considered hypokalemia. The client should be encouraged to eat foods high in potassium. Restricting fluid intake will increase the serum sodium level and is contraindicated. A glucose level of 90 mg/dL (5 mmol/L) is within the expected range of less than 110 mg/dL (6 mmol/L) and is not a concern. The laboratory results for serum sodium and serum potassium are not within the expected values, and the client should be taught how to alter the diet.

A child is recovering from a diagnosis of meningococcal meningitis and appears sad and cries frequently. How would the nurse help the child verbalize her thoughts and feelings? a. By telling the child that she seems sad and upset b. By encouraging the parents to speak with their child c. By showing the child some photos of hospitalized children and having the child tell stories about them d. By having the child watch videotapes about sick children and answering any questions that the child might have

a. By telling the child that she seems sad and upset The child is old enough to respond when a direct question is asked or an open-ended statement of assessment is made. The parents may be too emotionally involved to effectively help their child communicate feelings. Younger children benefit from the projective technique of being shown photos of children in a similar situation and then constructing stories about them. Younger children benefit from the projective technique of watching videos of other sick children and asking questions about them.

Which client's prescribed medication places him or her at risk for developing aseptic meningitis? a. Client A: Muromonab-CD b. Client B: Antithymocyte globulin-rabbit c. Client C: Rapamycin d. Client D: Cyclosporine

a. Client A: Muromonab-CD Muromonab-CD3 is effective for lessening transplant rejection, and prolonged administration may lead to aseptic meningitis in a client. Client A is at risk for developing aseptic meningitis. Antithymocyte globulin-rabbit is effective for reducing transplant rejection, and prolonged administration may cause thrombocytopenia and leukopenia. Rapamycin reduces transplant rejection, and prolonged administration may cause conditions such as thrombocytopenia and hypercholesterolemia. Cyclosporine reduces transplant rejection, and prolonged administration may lead to nephrotoxicity. Clients on antithymocyte globulin-rabbit, rapamycin, or cyclosporine are not at risk for developing aseptic meningitis.

A client is admitted with cellulitis of the left leg and a temperature of 103°F (39.4°C). The primary health care provider prescribes intravenous (IV) antibiotics. Which action is the priority before administering the antibiotics? a. Determine the client's allergies. b. Apply a warm, moist dressing over the cellulitis. c. Measure the amount of swelling in the client's left leg. d. Obtain the results of the culture and sensitivity tests.

a. Determine the client's allergies. Allergies are important. Medication hypersensitivity and anaphylaxis are most common with antimicrobial agents. Applying a warm, moist dressing over the area is a dependent function; it is not crucial to starting antibiotic therapy. Measuring the amount of swelling in the client's leg is an important assessment, but it is not crucial to starting antibiotic therapy. Withholding treatment until culture results are available may extend the infection.

Which clinical indicators are consistent with the diagnosis of hyperthyroidism? Select all that apply. One, some, or all responses may be correct. a. Emotional lability b. Dyspnea on exertion c. Abdominal distentio d. Decreased bowel sound e. Hyperactive deep tendon reflexes

a. Emotional lability b. Dyspnea on exertion e. Hyperactive deep tendon reflexes Lability of mood is a psychological/emotional manifestation related to excess thyroid hormones. Dyspnea with or without exertion can occur as the body attempts to meet oxygen demands related to the increased metabolic rate associated with hyperthyroidism. Hyperactive reflexes are a neurological manifestation related to excessive production of thyroid hormones. Abdominal distention is associated with hypothyroidism; it is related to constipation and weight gain. Bowel sounds increase, not decrease, as a result of hyperperistalsis associated with the elevated metabolic rate. Hypoactive bowel sounds are related to hypothyroidism.

Which action would the nurse perform immediately according to priority of care for a client with tonic-clonic seizures? a. Ensuring patent airway b. Administering intravenous (IV) fluids c. Monitoring level of consciousness d. Protecting the client from injury during seizures

a. Ensuring patent airway Ensuring a patent airway is the priority of the nurse because a client may lose consciousness during a seizure. IV fluids should be administered when the condition of the client is stable. Level of consciousness should be monitored during ongoing treatment. Continuous muscle contractions are observed in a client with tonic-clonic seizures, which may cause injury. The client should be protected from injury during seizures.

The client has had 2 weeks of radiation therapy for breast cancer and is experiencing some erythema over the area being irradiated and notes the area to be sensitive but not painful. The client states that she has been using tepid water and a soft washcloth when cleansing the area and applying an ice pack three times a day. Which conclusion would the nurse reach based on this information? a. Further teaching on skin care is necessary. b. No other intervention is needed at this time. c. The radiation team should be notified of this problem. d. Health teaching on the side effects of radiation is needed.

a. Further teaching on skin care is necessary. Further teaching is needed because extremes of temperature should be avoided; ice constricts blood vessels, interfering with circulation. Continued application of cold is contraindicated because it may cause tissue damage. Erythema is an expected reaction; however, pain, vesicle formation, or sloughing of tissue requires intervention. The knowledge deficit is related to skin care, not the side effects of radiation therapy.

A blood transfusion is prescribed for a child with acute lymphocytic leukemia (ALL). Which intervention will the nurse implement during the administration of the blood product? a. Infuse the blood over no more than 4 hours. b. Take the vital signs 3 hours after the transfusion. c. Check the vital signs 15 minutes after starting the transfusion. d. Have the blood warm at room temperature for 1 hour before administration.

a. Infuse the blood over no more than 4 hours. Blood should be administered within 4 hours; the risk for bacterial proliferation increases over time and exposure to room temperature. Taking the vital signs 3 hours after the transfusion is too long to wait; the vital signs should be checked every 5 minutes during the absorption of the first 50 mL of blood and then routinely thereafter (every 15 minutes to 1 hour, depending on hospital policy). Vital signs must be checked every 5 minutes during the administration of the first 50 mL of blood to detect a transfusion reaction. Blood should be used within 30 minutes after its arrival from the blood bank; the risk for bacterial proliferation increases over time and exposure to room temperature.

The nurse is caring for a child with a diagnosis of meningitis. Which clinical findings indicate an increase in intracranial pressure? Select all that apply. One, some, or all responses may be correct. a. Irritability b. Bradycardia c. Hyperalertness d. Decreased pulse pressure e. Decreased systolic blood pressure

a. Irritability b. Bradycardia Irritability is a classic sign of increased intracranial pressure, because it signals disruption of the central nervous system. Bradycardia is a classic late sign of increased intracranial pressure. With increased intracranial pressure there is decreased alertness or loss of consciousness. The pulse pressure increases with increased intracranial pressure. The systolic blood pressure increases with increased intracranial pressure.

Which clinical manifestation is associated with cellulitis? a. Lymphadenopathy b. Occasional papules c. Vesicles that evolve into pustules d. Isolated erythematous pustules

a. Lymphadenopathy Cellulitis is accompanied by lymphadenopathy. Occasional papules are present in folliculitis. Herpes simplex viral infections evolve the vesicles into pustules. Isolated erythematous pustules occur in folliculitis bacterial infections.

Which clinical findings would the nurse anticipate when assessing a child with newly diagnosed acute lymphoblastic leukemia? Select all that apply. One, some, or all responses may be correct. a. Pallor b. Fatigue c. Jaundice d. Multiple bruises e. Generalized edema

a. Pallor b. Fatigue d. Multiple bruises Pallor is the result of anemia associated with leukemia. Fatigue is the result of anemia associated with leukemia. Multiple bruises are the result of thrombocytopenia associated with leukemia. Jaundice usually indicates liver damage or excessive hemolysis and is not an early sign of leukemia. Edema is not a manifestation of the disease because the pathophysiology does not involve the transport of fluids.

Which interventions would the nurse implement to prevent infection in a preschool child with acute nonlymphoid leukemia who is admitted with a fever and neutropenia? a. Placing the child in a private room, restricting ill visitors, and using strict hand-washing techniques b. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion c. Avoiding taking rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture d. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes

a. Placing the child in a private room, restricting ill visitors, and using strict hand-washing techniques Children with leukemia most often die of infection; a low neutrophil count is associated with myelosuppressant therapy. Placing the child in a private room, restricting ill visitors, and using strict hand-washing techniques are the best ways to minimize complications. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion are not appropriate measures to prevent infection resulting from neutropenia; they are appropriate for treating the anemia. Avoiding taking rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture are not appropriate measures to prevent infection resulting from neutropenia; they are more appropriate for preventing bleeding. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes are not appropriate measures to prevent infection resulting from neutropenia; they are used to ease and treat stomatitis.

Which assessment findings are associated with Cushing disease? Select all that apply. One, some, or all responses may be correct. a. Round face b. Dependent edema in the feet and ankles c. Increased fatty deposition in the extremities d. Thin, translucent skin with bruising e. Increased fatty deposition in the neck and back

a. Round face b. Dependent edema in the feet and ankles d. Thin, translucent skin with bruising e. Increased fatty deposition in the neck and back Changes in fat distribution may result in a round face and fat pads on the neck, back, and shoulders. There are increased levels of steroids and aldosterone, causing sodium and water retention in clients with Cushing syndrome. This increased fluid retention results in dependent peripheral edema. Skin changes result from increased blood vessel fragility and include bruises and thin or translucent skin. The extremities appear thinner from muscle wasting and weakness, not thicker from fatty deposition.

Which assessment findings would indicate the need for atenolol in a client diagnosed with hyperthyroidism? Select all that apply. One, some, or all responses may be correct. a. Tachycardia b. Atrial fibrillation c. Distant heart sounds d. Systolic hypertension e. Decreased cardiac output

a. Tachycardia b. Atrial fibrillation d. Systolic hypertension In hyperthyroidism, atenolol is prescribed to reduce cardiac manifestations. Tachycardia, atrial fibrillation, and systolic hypertension are cardiac manifestations associated with hyperthyroidism. Distant heart sounds are associated with hypothyroidism. The cardiac output is increased in hyperthyroidism.

An infant with congenital hypothyroidism receives levothyroxine for 3 months. Which finding would indicate to the nurse that the medication is effective? a. The infant is alert and interactive. b. The skin is cool to the touch. c. The baby's fine tremor has ceased. d. The baby's thyroid stimulating hormone level has increased.

a. The infant is alert and interactive. Infants with congenital hypothyroidism are lethargic, and may even need to be awakened and stimulated to nurse; therefore an infant who is alert and interacts appropriately for its age would demonstrate improvement. Cool skin is a clinical sign of hypothyroidism related to a slow basal metabolic rate. Fine hand tremor is related to hyperthyroidism and is not present in an infant with hypothyroidism, even one whose condition is being stabilized with levothyroxine. An increased thyroid stimulating hormone level would indicate inadequate treatment.

A client has been taking levothyroxine for hypothyroidism for 3 months. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply. One, some, or all responses may be correct. a. Tremors b. Bradycardia c. Somnolence d. Heat intolerance e. Decreased blood pressure

a. Tremors d. Heat intolerance Excessive levothyroxine produces adaptations similar to hyperthyroidism, including tremors, tachycardia, hypertension, heat intolerance, and insomnia. These adaptations are related to the increase in the metabolic rate associated with hyperthyroidism. Bradycardia is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Somnolence is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Hypotension is a sign of hypothyroidism and a need to increase the dose of levothyroxine.

Which measures would the nurse include when teaching a client with hyperthyroidism how to manage the discomfort associated with exophthalmia? Select all that apply. One, some, or all responses may be correct. a. Use tinted glasses. b. Use warm, moist compresses. c. Elevate the head of the bed 45 degrees. d. Tape eyelids shut at night if they do not close. e. Apply a petroleum-based jelly along the lower eyelid.

a. Use tinted glasses. c. Elevate the head of the bed 45 degrees. d. Tape eyelids shut at night if they do not close. Tinted glasses decrease light on the eyes and protect eyes that are photosensitive. Elevating the head of the bed 45 degrees will promote a decrease in periorbital fluid. Taping the eyelids shut at night if they do not close reduces the risk of corneal dryness, which can lead to infection or injury. Cool, moist compresses are used to relieve irritation; warm compresses cause vasodilation, which may aggravate tissue congestion. Artificial tears are used to moisten the eyes, not a petroleum-based jelly.

The nurse is performing a breast assessment. Which statement made by the client indicates a risk of breast cancer? Select all that apply. One, some, or all responses may be correct. a. "I had a late onset of menarche." b. "My first child was born when I was 32." c. "I noticed a slight discharge from a nipple." d. "I perform breast self-examinations frequently." e. "I consume two to four glasses of alcohol a day."

b. "My first child was born when I was 32." c. "I noticed a slight discharge from a nipple." e. "I consume two to four glasses of alcohol a day." Clients who gave birth to a first child after the age of 30 are at a risk of breast cancer. Discharge from the nipple may indicate an early symptom of breast cancer. Consuming two to four glasses of alcohol daily may also increase the risk of breast cancer. An early onset of menarche is a risk factor for breast cancer. Performing breast self-examinations frequently may help identify the early stages of breast cancer.

A 7-year-old child who is taking medication to prevent seizures has been seizure free for 2 years. The child's parents ask the nurse, "How much longer will my child need to take the medication?" Which answer will the nurse provide? a. "Medications are continued for 3 years after the last seizure." b. "This is usually attempted after 2 years, but medications must be gradually decreased." c. "Children are usually able to stop seizure medication after puberty." d. "Seizure disorders are lifelong problems that require ongoing medications."

b. "This is usually attempted after 2 years, but medications must be gradually decreased." A predesigned protocol is used to wean a child off anticonvulsants gradually because abrupt removal of the drug can result in a seizure. Anticonvulsants are discontinued gradually after a child is seizure free for 2, not 3, years and has an EEG within expected limits. Anticonvulsants cannot be stopped abruptly at the 2-year follow-up visit, but the discontinuation process may be started. The statement that seizure disorders are lifelong problems that require ongoing medications may or may not be true; this is determined on an individual basis.

A client is admitted to the hospital with a tonic-clonic seizure after his seizures had been well controlled by phenytoin for 6 months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which response would the nurse make? a. "Did you forget to take your medication?" b. "You are worried about having more seizures?" c. "You must be under a lot of stress right now." d. "Don't be concerned; your medication can be increased."

b. "You are worried about having more seizures?" The response "You are worried about having more seizures?" addresses the client's feelings and encourages communication. The question "Did you forget to take your medication?" sounds accusatory; it ignores the client's feelings and discourages communication. Although the statement "You must be under a lot of stress right now" may be true, it does not encourage further communication concerning the seizure. The statement "Don't be concerned, your medication can be increased" negates the client's feelings and discourages communication.

Propylthiouracil and potassium iodide are prescribed for the client with hyperthyroidism. Which statement would the nurse include in the client's plan of care? a. Administer propylthiouracil and potassium iodide on an empty stomach. b. Assess the client for signs of infection and bleeding every shift. c. Stop the medications 2 weeks before thyroid surgery. d. Discontinue the medications if the heart rate is maintained within the expected range for 48 hours.

b. Assess the client for signs of infection and bleeding every shift. Propylthiouracil can cause depression of leukocytes and platelets. This creates an increased bleeding risk. Propylthiouracil and potassium iodide should be given with milk, juice, or food to prevent gastric irritation. Medication therapy decreases the risk of postoperative hemorrhage because this medication regimen decreases the size and vascularity of the thyroid gland. Medication therapy is continued for at least 6 to 8 weeks, even if the client's temperature and pulse return to the expected range.

Which instructions would be included when teaching a client with hyperthyroidism who just had radioactive iodine to ablate thyroid tissue? a. Remain in the house. b. Avoid holding an infant. c. Save urine in a lead-lined container. d. Refrain from using a bathroom used by others.

b. Avoid holding an infant. Infants are particularly sensitive to radioactivity; even the small amount emitted after treatment may affect infants. It is not necessary to avoid leaving the house as long as close proximity to others is avoided. Saving urine in a lead-lined container is not necessary; the same bathroom may be used by all members of the family, but the toilet should be flushed twice after use by the client. Refraining from using a bathroom used by others is not necessary.

A child is admitted to the pediatric intensive care unit with acute bacterial meningitis. Which intervention would the nurse include in the plan of care? a. Offering clear fluids whenever the child is awake b. Checking the child's level of consciousness hourly c. Assessing the child's blood pressure every 4 hours d. Administering the prescribed oral antibiotic medication

b. Checking the child's level of consciousness hourly Checking the level of consciousness is part of a total neurological check. It can reveal increasing intracranial pressure, which may occur as a result of cerebral inflammation. The child is too ill to ingest anything by mouth; also, vomiting is likely. Hydration is maintained intravenously. Taking the blood pressure and other vital signs every 4 hours is insufficient monitoring; many changes can occur in this timespan. Intravenous antibiotics have a rapid systemic effect and are preferable to those administered by way of the oral route.

Sterile warm saline soaks three times a day are prescribed for a client with cellulitis from a puncture wound. The primary nurse places a clean basin, washcloth, and protective pad at the bedside in preparation for the soak but is unable to continue the procedure. Which step would the new nurse assigned to complete the soak do? a. Continue the procedure as started. b. Collect new supplies before starting. c. Discuss the type of soak with the primary health care provider. d. Report the primary nurse to the unit's nurse manager.

b. Collect new supplies before starting. The supplies at the bedside are not sterile, and the primary health care provider prescribed sterile soaks; new supplies must be gathered. Continuing the procedure as started is unsafe; a clean basin and washcloth are not sterile. It is unnecessary to discuss the type of soak with the primary health care provider; the primary health care provider has already indicated the type of soak desired. Reporting the primary nurse to the unit's nurse manager is not the priority; client safety is the priority at this time.

Which discharge instructions would the nurse include for a woman who has undergone breast-conserving surgery (lumpectomy) for breast cancer? a. Assuring her that a supportive brassiere is unnecessary b. Emphasizing the importance of breast self-examination c. Instructing her to return the next day for removal of the drain d. Explaining why it is unnecessary to exercise the arm on the unaffected side

b. Emphasizing the importance of breast self-examination A client who has cancer of one breast is at risk for the development of cancer in the remaining breast; therefore, breast self-examination is important. Wearing a supportive brassiere limits incisional discomfort. There may or may not be a wound drainage system in place, and the timing of its removal is individualized. With the removal of breast tissue, specific exercises are needed to prevent muscle atrophy and contractures; the right and left arms should be exercised at the same time.

Which intervention would the nurse include in the plan of care for a client with breast cancer who received doxorubicin and cyclophosphamide 12 days ago and now has a white blood cell (WBC) count of 1.4 cells/mm 3 and reports shortness of breath and activity intolerance? Select all that apply. One, some, or all responses may be correct. a. Use an electric razor when shaving. b. Institute neutropenic precautions. c. Place client on airborne precautions. d. Transfuse two units of packed red blood cells (RBCs). e. Instruct nursing staff to wear a dosimeter badge.

b. Institute neutropenic precautions. Doxorubicin and cyclophosphamide can lower the client's blood cell counts. Clients with low WBC counts need interventions to prevent infection, which include instituting neutropenic precautions. The nurse would instruct the client to use an electric razor if the platelet count was less than 50,000 cells/µL. Airborne precautions would be indicated if the client was ill with an infectious disease. The nurse would transfuse RBCs for a client with anemia (if prescribed by the health care provider). Nursing staff would wear dosimeter badges when caring for a client receiving internal radiation (brachytherapy).

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply. One, some, or all responses may be correct. a. These seizures are associated with amnesia. b. These seizures increase the risk for injuries from a fall. c. These seizures are most resistant to medication therapy. d. These seizures are preceded by perception of an offensive smell. e. These seizures cause one-sided movement of extremities in the client.

b. These seizures increase the risk for injuries from a fall. c. These seizures are most resistant to medication therapy. Atonic (akinetic) seizures are characterized by a sudden loss of muscle tone lasting for seconds followed by postictal confusion. These seizures cause the client to fall because of the decreased muscle tone, which may result in injury. This type of seizure tends to be most resistant to medication therapy. Amnesia is associated with complex partial seizures. In simple partial seizures, the client reports an aura and perception of unusual sensations, such as an offensive smell and sudden onset of pain. Simple partial seizures are also associated with one-sided movement of the extremities.

A client with hyperthyroidism asks the nurse about the tests that will be ordered. Which diagnostic tests would the nurse include in a discussion with this client? a. Thyroxine (T 4) and x-ray films b. Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T 3) c. Thyroglobulin level and Po 2 d. Protein-bound iodine and sequential multichannel autoanalyzer (SMA)

b. Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T 3) A decreased TSH assay together with an elevated T 3 level may indicate hyperthyroidism. X-ray films will not indicate thyroid disease, and elevation of T 4 level might indicate hyperthyroidism. However, this may be a false reading because of the presence of thyroid-binding globulin (TBG) and is inadequate for diagnosis when used alone. Po 2 is not specific to thyroid disease, and the thyroglobulin level is most useful to monitor for recurrence of thyroid carcinoma or response to therapy. The results with the SMA are not specific to thyroid disease; the protein-bound iodine test is not definitive because it is influenced by the intake of exogenous iodine.

Why is a lumbar puncture performed when meningitis is suspected? a. To identify the presence of blood b. To determine the causative agent c. To reduce the intracranial pressure d. To measure the spinal fluid glucose level

b. To determine the causative agent Organisms that cause meningitis are often harbored in the spinal fluid. The lumbar puncture helps determine whether meningitis is present and whether the causative agent is bacterial or viral. Although some blood may be found in the spinal fluid, its presence is not a confirmation of the diagnosis of meningitis. More conservative measures, such as medications or positioning, are used to reduce intracranial pressure. Although testing for spinal fluid glucose level may be done, it will not reveal the causative agent.

The mother of an infant recently prescribed phenobarbital for seizures calls the pediatric clinic and states that the infant is lethargic and sleeps for long periods. Which response by the nurse is most appropriate? a. "There's a medication that will prevent this problem." b. "This means that your baby's dosage needs to be adjusted." c. "This is a temporary response to the medication; it usually stops after a few weeks." d. "Many infants experience the same problem, but your baby needs the medication."

c. "This is a temporary response to the medication; it usually stops after a few weeks." Drowsiness is frequently a side effect of barbiturate therapy because it depresses the central nervous system; the infant will adapt to this over time. Stimulants are not routinely administered because they counteract the desired effect of seizure reduction. The dosage does not need adjustment; this response demonstrates little understanding of barbiturate therapy. The mother's concern is with her own baby; the medication's side effects should be explained.

A 26-year-old woman whose sister recently had a lumpectomy for breast cancer calls the local women's health center and asks for an appointment for a mammogram. Which guidance would the nurse provide the client? a. Mammograms are not done before age 40. b. Genetic testing is required before evaluation when there is a family history of breast cancer. c. An appointment should be given for history, assessment, and indicated imaging. d. A magnetic resonance imaging (MRI) scan would be the recommended imaging for a client with this history.

c. An appointment should be given for history, assessment, and indicated imaging. The client would be advised to have an appointment that ideally would include detailed family history including any genetic testing that may have been done on the client's sister, examination, and counseling regarding her options in genetic testing and imaging as indicated. The American Cancer Society (ACS), The American College of Obstetricians and Gynecologists (ACOG), and the United States Preventative Task Force (USPTF) all have differing recommendations for breast cancer screening. The approach of shared decision-making is advocated, which is where the known information is presented to the client and she shares in the decision-making regarding screening for breast cancer. It would be incorrect to say that mammograms are not done before age 40. It would also be incorrect to say that genetic testing is required. Genetic testing is always voluntary, and the client may decline after being counseled. An MRI scan is an option for women at higher risk of breast cancer, but it is generally used in conjunction with another imaging mode such as a mammogram.

During a home visit, the nurse discovers that a child in the household who has a disability has been experiencing seizures. The child's parent appears indifferent to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. Where would the nurse direct a referral? a. Outpatient clinic b. Hospital pediatric unit c. Child Protective Services d. Bureau of the Handicapped

c. Child Protective Services All states have laws about obligatory reporting of child abuse to local authorities. This responsibility is delegated by the state to an appropriate local agency such as Child Protective Services. A staff member of the agency investigates allegations of child abuse, and recommendations are made to protect the child's welfare. The clinic treats the client medically, but other agencies handle child abuse and other social problems. The hospital probably will not admit the child unless an immediate medical incident requires it. The Bureau of the Handicapped is concerned with equipment and supplies required for the individual with a disability.

A client who is receiving methotrexate for acute lymphocytic leukemia (ALL) develops a temperature of 101°F (38.3°C), and the health care provider prescribes aspirin 650 mg every 4 hours as needed. Which action would the nurse take regarding this new prescription? a. Express concern about the dosage prescribed. b. Request a prescription for an antacid. c. Express concern about the type of antipyretic prescribed. d. Ask if the frequency should be every 6 hours instead.

c. Express concern about the type of antipyretic prescribed. Both ALL and methotrexate may cause thrombocytopenia, with resulting bleeding risk. Aspirin is contraindicated with thrombocytopenia because of its inhibitory effect on platelet aggregation, so the nurse should express concern about the type of antipyretic prescribed. The dosage of aspirin prescribed is within the normal range for a client with a normal platelet count. In clients who need to take nonsteroidal anti-inflammatory drugs like aspirin, an antacid may be appropriate, but aspirin should not be administered to this client. Although the frequency is within acceptable limits, aspirin is contraindicated.

The parents of a young man suspected of having Cushing syndrome express anxiety about their son's condition. Which would the nurse tell the parents to help them better understand the illness? a. He will need to take exogenous steroids for several months. b. His condition will indicate improvement when he gains weight. c. He may have mood swings or depression as a result of his illness. d. His physical changes are permanent but may improve with therapy.

c. He may have mood swings or depression as a result of his illness. High levels of steroids result in emotional changes; the actual cause is unknown, but knowing the response may help the parents better cope with their son's behavior. The need to receive exogenous steroids for several months is unnecessary. Cushing syndrome is related to an excessive production of steroids. Weight loss, not weight gain, indicates an improving condition. The changes may not be permanent with adequate therapy.

Which result will the nurse expect diagnostic studies of a client with Cushing syndrome to indicate? a. Moderately increased serum potassium levels b. Increased numbers of eosinophils in the blood c. High levels of 17-ketosteroids in a 24-hour urine test d. Normal to low levels of adrenocorticotropic hormone (ACTH)

c. High levels of 17-ketosteroids in a 24-hour urine test High levels of 17-ketosteroids in a 24-hour urine test is a urinary metabolite of steroid hormones that are excreted in large amounts in hyperaldosteronism. With aldosterone hypersecretion, sodium is retained and potassium is excreted, resulting in hypernatremia and hypokalemia. With Cushing syndrome, the eosinophil count is decreased, not increased. ACTH levels usually are high in Cushing syndrome.

Which situation in a client with hyperthyroidism may precipitate thyroid crisis (thyroid storm)? a. Increased iodine in the blood b. Removal of the parathyroid glands c. High levels of the hormone triiodothyronine d. Rebound increase in metabolism after anesthesia

c. High levels of the hormone triiodothyronine Thyroid trauma, thyroid surgery, or physiological stress in a client with hyperthyroidism may lead to a release of abnormally high levels of thyroid hormones. High levels of the hormone triiodothyronine (T 3) intensify all the signs and symptoms of hyperthyroidism (thyroid storm or crisis), such as increased temperature, pulse, and respirations, restlessness, vomiting, and often death. Iodine binds with thyroxine, thus decreasing the potential for crisis. Tetany, not thyroid crisis, occurs from surgical excision of the parathyroid glands. Anesthesia will depress metabolism, not increase it.

An infant is being admitted to a pediatric unit with bacterial meningitis. Which is the priority nursing action? a. Assessing the infant's neurological status b. Beginning intravenous fluids and antibiotics c. Implementing respiratory isolation precautions d. Teaching the parents the importance of maintaining a quiet environment

c. Implementing respiratory isolation precautions The infant's illness, bacterial meningitis, is contagious, and the nurse, as well as other clients, must first be protected with the implementation of respiratory isolation precautions. Assessment of neurological status would be performed after implementing isolation. Parental teaching and implementation of prescribed fluids and antibiotics may be done after assessment. Also, antibiotics are usually not administered until after all cultures have been obtained.

A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. Which would the nurse consider when formulating a response? a. Hypothyroidism is a gradual slowing of the body's function. b. A decrease in pituitary thyroid-stimulating hormone (TSH) will occur. c. Less thyroid tissue is available to supply thyroid hormone after surgery. d. Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones.

c. Less thyroid tissue is available to supply thyroid hormone after surgery. After a thyroidectomy, thyroxine output usually is inadequate to maintain an appropriate metabolic rate. Hypothyroidism is decreased thyroid functioning, not a slowing of functions of the entire body. With hypothyroidism, the level of TSH from the pituitary usually is increased. Thyroid tissue remaining after surgery does not atrophy.

A 2-year-old child is admitted to the pediatric unit with a diagnosis of bacterial meningitis. Which is the most important safety measure for the nurse to institute immediately after the child has a seizure? a. Monitoring the child's vital signs b. Padding the side rails of the toddler's crib c. Placing the child in the side-lying position d. Bringing suction equipment to the bedside

c. Placing the child in the side-lying position The side-lying position promotes a patent airway; the tongue can move away from the back of the pharynx, and saliva can flow out of the mouth by gravity. Although monitoring vital signs is important, a patent airway is the priority. The crib sides should have been padded as a part of seizure precautions before the seizure. If the seizure was unexpected and seizure precautions were not previously instituted, they should be instituted after the immediate respiratory and safety needs of the toddler have been met. Suctioning may be unnecessary; the child should not be left alone while equipment is obtained.

In an ongoing research study, the nurse asks participants, who are breast cancer survivors, to briefly share information about their lives after surviving cancer. The nurse then compiles the views to determine the cancer survivors' quality of life. Which type of study is being conducted? a. Historical research b. Descriptive research c. Qualitative research d. Correlational research

c. Qualitative research Qualitative research involves inductive reasoning to develop an overview from specific observations or interviews. In this type of study, the nurse interviews the participants and then summarizes the common themes from all the interviews to develop generalizations or theories based on the observations. Historical research establishes facts and relationships concerning past events. Descriptive research measures characteristics of persons, situations, or groups and the frequency with which certain events or characteristics occur. Correlational research explores the interrelationships among variables of interest without any active intervention by the researcher.

A client with cellulitis of the leg asks why bed rest has been prescribed to prevent sepsis. Which response by the nurse would be the best explanation to give to the client? a. "Bed rest will decrease catabolism to promote healing at the site of injury." b. "Bed rest will lower your metabolic rate in an attempt to help reduce the fever." c. "Bed rest will reduce the energy demands on your body in the presence of infection." d. "Bed rest limits muscle contractions that may force bacteria into the bloodstream."

d. "Bed rest limits muscle contractions that may force bacteria into the bloodstream." Exercise will promote extension of the local infection from the leg into the circulation, causing septicemia (sepsis). Although bed rest does decrease catabolism to promote healing at the site of injury, it is not the purpose for bed rest in this situation. Although bed rest does reduce the energy demands on the body in the presence of infection and lowers metabolic rate, it is not the purpose for bed rest in this situation.

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. Which client statement indicates the nurse needs to follow up? a. "I will leave the skin markings intact." b. "I will protect the skin from sources of heat." c. "I will wear soft clothing over the upper body." d. "I will use an oatmeal-based lotion after each treatment."

d. "I will use an oatmeal-based lotion after each treatment." While undergoing radiation therapy, lotions, powders, and ointments should not be applied to the area. The other options are all correct statements. The skin markings should not be removed because they form the parameters for the delivery of radiation. To protect the irradiated skin, sunlight and heat should be avoided. Nonirritating clothing should be worn over the area to prevent trauma to the delicate irradiated skin.

The parents of a child with recently diagnosed leukemia ask the nurse why their child has too many white blood cells. Which is the nurse's best response? a. "The health care provider is the best one to answer that question for you." b. "You seem to be focusing on your child's white blood cells." c. "You don't seem to understand what occurs in this disease." d. "The bone marrow is not controlling your child's white blood cell production as it should."

d. "The bone marrow is not controlling your child's white blood cell production as it should." An accurate description of the malfunctioning bone marrow is a helpful response to the parents' question that reinforces what they were told. Referral to the health care provider abdicates the nurse's teaching responsibility. Accusing the parents of focusing on the disease is an insensitive response that will put them on the defensive. Accusing the parents of misunderstanding their child's illness is insensitive and demeaning; it reinforces parental insecurity about the information they have recently received.