Test #10

Raynaud phenomenon:

- is a vasospastic disorder triggered by exposure to cold or stress. -Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened, and clients experience throbbing or aching pain, swelling, and tingling. -Acute vasospasms are treated by immersing the hands in warm water. -Client teaching regarding prevention of vasospasms includes: -Wear gloves when handling cold objects Dress in warm layers, particularly in cold weather. -Avoid extremes and abrupt changes in temperature. -Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). -Avoid excessive caffeine intake -Refrain from use of tobacco products -Implement stress-management strategies (eg, yoga, tai chi) -If conservative management is unsuccessful, calcium channel blockers may be prescribed to relax arteriole smooth muscle and prevent recurrent episodes.

Fifth disease

-("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. -The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. - Affected children typically recover quickly, within 7-10 days. -Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition.

Antiplatelet agents

-(clopidogrel, ticagrelor, prasugrel, aspirin) -prevent platelet aggregation and are given to clients to prevent stent re-occlusion. -They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. -Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. -Antiplatelet agents and Ginkgo biloba should not be taken together. -If this were to occur, this client would be at an increased risk for bleeding. -This information should be reported to the prescribing health care provider before the client is discharged.

The nurse reinforces teaching to a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis. Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include.

-A teaching plan for a client prescribed rifampin includes these additional instructions: -Rifampin changes the color of body fluids (eg, urine, sweat) due to its body-wide distribution. -Tears can turn red, making contact lenses appear discolored. Client should wear eyeglasses instead of soft contact lenses while taking this medication. -Women should use nonhormonal birth control methods while taking this drug as it can decrease the effectiveness of oral contraceptives.

The nurse is caring for a client with a history of headaches who has come to the clinic reporting a "bad migraine." The client was able to provide a full health history while waiting to be seen. Which finding is most concerning?

-Although a client may have a history of recurring headaches (eg, migraine, tension, cluster), the nurse should not assume a headache is benign, as it may be a sign of increased intracranial pressure (ICP). Level of consciousness (LOC) is the most important, sensitive, and reliable indicator of the client's neurological status. A change in LOC (eg, confusion, drowsiness, flat affect) is the earliest sign of increased ICP or reduced cerebral blood flow. Later signs of increased ICP include Cushing triad (eg, bradycardia, widening pulse pressure [increasing systolic/decreasing diastolic], altered respiratory pattern); fixed, dilated pupil(s); and decreased motor function.

Medical Battery

-Battery is the intentional touching of a person that is legally defined as unacceptable or occurs without the person's consent. Many routine actions that are permissible when proper consent is obtained would otherwise be considered medical battery. Furthermore, actions can be considered battery even if no physical injury results. Any health care provider (HCP) who performs a medical or surgical procedure without receiving the required informed consent from a competent client (or parent/legal guardian in the case of a child) is committing battery and could be legally charged. -Assault is the threat of battery.

The nurse is reinforcing discharge teaching for the parents of a 1-year-old with a newly diagnosed cow's milk allergy. Which nutrients normally provided by milk should be obtained from other sources:

-Calcium and vitamin D are nutrients in cow's milk that are essential for proper bone development in children and should be obtained from other sources for clients with a cow's milk allergy. -Alternate sources of calcium include beans, dark greens, and calcium-fortified cereal and juices. Vitamin D is synthesized in the skin when exposed to sunlight and can be obtained in foods such as fish, egg yolks, and vitamin D-fortified foods.

Tasks within the licensed practical nurse (LPN) scope of practice include:

-Collecting data (eg, pulse oximetry, urinary output). -Monitoring client status (eg, work of breathing, mental status). -Administering most medications (eg, albuterol [Proventil]) -Evaluating client response to interventions performed.

The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings:

-During pregnancy, the fetus stores large quantities of glycogen that are used during the transition to extrauterine life. As a result, glucose levels are decreased 1 hour after birth, then rise and stabilize within 2-3 hours. Optimal glucose levels are 70-100 mg/dL (3.9-5.6 mmol/L), but ≥40 mg/dl (2.2 mmol/L) is considered normal. -A hypoglycemic neonate (<40 mg/dl [2.2 mmol/L]) should be fed immediately. Infants of diabetic mothers are at increased risk for hypoglycemia due to excess intrauterine insulin produced in response to high maternal glucose levels. -Normal newborn respiratory rate is 30-60 breaths per minute. Breathing may be slightly irregular, diaphragmatic, and shallow. -Milia (white papules) form due to plugged sebaceous glands and are frequently found on the nose and chin. They resolve without treatment within several weeks. -A single transverse crease extending across the palm of the hand is a classic sign of Down syndrome. -A holosystolic murmur (heard during entire systole phase) at the left lower sternal border is a classic sign of a ventricular septal defect (VSD). Although abnormal, most small VSDs close spontaneously within the first 6 months of life.

Which are appropriate examples of cost-effective care?

-EX: -Removing a dressing that has been on the client's skin is not a sterile procedure (unlike applying a new dressing, when sterile technique is commonly used). The gloves need to be removed and changed prior to application of a new dressing. There is no need to use the more expensive sterile gloves. -The sterile glove wrapper is inside a paper package and is sterile. It can be used as a small sterile field if properly opened, with the other aspects of asepsis/sterile field observed (eg, do not get it wet, do not reach over it).

The nurse contacts the health care provider (HCP) for certain circumstances, regardless of the time of day. An emergent call is warranted if a client:

-Falls -Deteriorates significantly or dies -Has critical laboratory results -Needs a prescription that requires clarification -Leaves against medical advice or runs away -Refuses key treatments in a relevant period -The HCP should be called after the initiation of hospital protocols (eg, stroke, code blue) and after a concerning assessment finding (eg, significant change in vital signs, unilateral drift, change in level of consciousness, signs of trauma after a fall ).

A 12-month-old with Kawasaki disease received IV immunoglobulin (IVIG) 2 months ago. The child is in the clinic for follow-up and scheduled immunizations. Which vaccine should be delayed.

-Kawasaki disease is treated with aspirin and IVIG to prevent coronary artery aneurysms. Antibodies acquired from the IVIG therapy will remain in the body for up to 11 months and may interfere with the desired immune response to live vaccines. Therefore, live vaccines (eg, varicella, MMR) should be delayed for 11 months after IVIG administration as this therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity.

The nurse assesses a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which assessment technique should the nurse use to check for complications in this client?

-Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L). Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of parathyroidectomy because the parathyroids regulate calcium levels in the blood. When one or more parathyroids are removed, it may take some time for others that have been dormant during hyperparathyroidism (which causes an increase in serum calcium) to begin regulating serum calcium. -Trousseau's sign may indicate hypocalcemia before other signs and symptoms of hypocalcemia, such as tetany, occur. Trousseau's sign can be elicited by placing the BP cuff on the arm, inflating to a pressure > than systolic BP, and holding in place for 3 minutes. This will occlude the brachial artery and induce a spasm of the muscles of the hand and forearm when hypocalcemia is present. -Chevostek's sign another early indicator of hypocalcemia, should also be assessed. It may be elicited by tapping the face at the angle of the jaw and observing for contraction on the same side of the face.

The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately:

-Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. -Stridor and/or difficulty breathing (noisy breathing) in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated.

Teletherapy (external beam radiation therapy)

-Teaching essential skin care standards to these clients is focused on preventing infection and promoting healing of the affected skin. *Protect the skin from infection by not rubbing, scratching, or scrubbing -Wear soft, loose-fitting clothing -Use soft, cotton bedsheets and towels -Pat skin dry after bathing -Avoid applying bandages or tape to the treatment area. *Cleanse the skin daily by taking a lukewarm shower -Use mild soap without fragrance or deodorant -Do not wash off any radiation ink markings *Use only creams or lotions approved by the health care provider (HCP) (Option 2) -Avoid over-the-counter creams, oils, ointments, or powders unless specifically recommended by the HCP as they can worsen any irritation. *Shield the skin from the effects of the sun during and after treatment -Avoid tanning beds and sunbathing -Wear a broad-brimmed hat, long sleeves, and long pants when outside. -Use a sunscreen that is SPF 30 or higher *Avoid extremes in skin temperature -Avoid heating pads and ice packs (Option 1) -Maintain a cool, humid environment for comfort

The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first:

-The child with a recent tonsillectomy is at highest safety risk. Postoperative hemorrhage from tonsillectomy is uncommon but may occur up to 14 days after surgery. -Caregivers should be taught to observe for signs of bleeding (eg, frequent swallowing, throat clearing). -The child may also experience increased pain. -The nurse should instruct the parent that the child should not resume strenuous activity or contact sports for at least 7-14 days post surgery.

The nurse inserts a urinary catheter into a female client who has not voided for 6 hours. No urine is returned. What action should the nurse take next?

-The most common explanation is that the catheter was unintentionally inserted into the vagina. The nurse should leave that catheter as a landmark and insert a new sterile catheter into the urethra which is located above the vagina. - A urinary catheter should never be reused as it is no longer sterile and may introduce bacteria in the urinary tract; a new one should always be obtained. By removing the first catheter, the nurse will be more likely to re-insert it into the same (wrong) opening.

The nurse has received report on the following clients. Which client should be seen first?

-The nurse should first see the client who had bowel surgery, as hypotension can be a manifestation of bleeding, hypovolemia, and early septic shock. The nurse should check vital signs and perform a cardiovascular exam, comparing findings with those documented in the immediate postoperative period from the post-anesthesia care unit (PACU).

Parents of an infant or child with a repaired congenital heart should be able to recognize and report signs and symptoms of heart failure:

-These may include rapid breathing rate; rapid heart rate at rest; dyspnea; activity intolerance; pale, cool extremities; weight gain; reduction in wet diapers; and puffiness around the eyes.

The nurse is reinforcing teaching about symptom management with a client newly diagnosed with trigeminal neuralgia. Which of the following instructions should the nurse include?

-Trigeminal neuralgia (TN) is a disorder of cranial nerve V resulting in attacks of intense facial pain that may impair the client's ability to perform activities of daily living (eg, hygiene, feeding, drinking). The pain of TN is often triggered by tactile or thermal stimulation. -The nurse should educate clients with TN to avoid pain triggers during daily activities by: -Using a small, soft-bristled toothbrush and lukewarm mouthwash during oral care. -Chewing food on the unaffected side of the mouth to reduce tactile stimulation of the nerve. -Avoiding consumption of food or drink that is very hot or cold. -Facial stimulation (eg, massage) may trigger or worsen pain in clients with TN.

Incisions may take 4-6 weeks to heal. The nurse should teach clients how to care for their incisions by providing the following instructions:

-Wash incisions daily with soap and water in the shower. Gently pat dry. -Itching, tingling, and numbness around the incisions may be present for several weeks due to damage to the local nerves. -Avoid tub baths due to the risk of infection. -Do not apply powders or lotions on incisions as these trap bacteria at the incision site. -Report any redness, swelling, drainage increase, or if the incision has opened. -Wear a supportive elastic hose on the legs and elevate them when sitting to decrease swelling.

Self-care strategies for heart failure:

-focus on preserving cardiac function and improving quality of life. -Important self-care strategies for heart failure include: -Restriction of sodium intake (ie, low-sodium diet). -Taking medications exactly as prescribed; medications should not be skipped or missed. -Monitoring fluid intake and output (eg, daily weights, fluid restrictions.

Irritable bowel syndrome

-is a chronic condition characterized by altered intestinal motility, causing abdominal discomfort with diarrhea and/or constipation. -Clients can manage symptoms by avoiding gas-producing foods (eg, broccoli, beans), caffeine, alcohol, and gastrointestinal irritants (eg, high-fructose corn syrup, spices, dairy products) and by increasing fiber. -Foods that are generally well tolerated include proteins, breads, and bland foods.

Toxoplasmosis

-is a disease due to Toxoplasma gondii, a parasite that infects humans via cat feces or ingestion of undercooked meat. - toxoplasmosis is acquired during pregnancy, it can cause stillbirth or serious fetal malformations. The nurse must instruct pregnant clients to avoid handling litter box or cat feces to decrease the risk of contracting this disease.

Measles, or rubeola

-is a highly contagious disease that can affect people of all ages. The disease starts with fever, cough, runny nose, and conjunctivitis, soon after which a rash appears on the face and slowly spreads downward. -Measles is spread through the air when infected persons cough and sneeze, and the virus remains in the air for up to 2 hours. Clients with measles are placed on airborne precautions in a negative-pressure single occupant room: Nursing care includes the following: -Administering antipyretics -Placing the child with high fevers on seizure precautions -Providing a quiet, dimly lit atmosphere -The measles vaccine drastically decreased the disease incidence in the United States; however, with increased foreign travel and greater numbers of nonvaccinated children, there has been a resurgence of cases. -Postexposure vaccination is recommended in exposed persons who have not been vaccinated or had the disease previously.

Magnetic resonance cholangiopancreatography

-is a noninvasive diagnostic test used to visualize the biliary, hepatic, and pancreatic ducts via MRI. -The nurse must assess for contraindications before the procedure, including the presence of certain metal and/or electrical implants (eg, aneurysm clip, pacemaker, cochlear implant) or any previous allergy or reaction to gadolinium. -A client with a history of rash following prior IV contrast administration should be assessed to determine the type of contrast that caused the reaction. Although allergies to iodine-based contrast material are more common, the nurse must rule out a gadolinium allergy. -Pregnancy also is a contraindication for MRCP as gadolinium crosses the placenta and may adversely affect the fetus. -Smoking does not affect MRI visualization and is not a contraindication.

Hypothyroidism

-is a thyroid disorder characterized by thyroid hormone deficit (low T3 and T4). -Hypothyroidism affects almost every body system and is predominately associated with a slow metabolic rate. -Some common manifestations include the following: -Decreased gut motility leading to constipation -Cool and pale skin due to decreased blood flow; hyperkeratosis results in dry and rough skin -Brittle nails and hair; hair loss due to poor blood supply -Bradycardia from low metabolic state Joint pains and muscle aches are common -Clients can develop dementia and depression due to mental slowing -Cold intolerance characteristic -Modest weight gain

The point of maximal impulse (PMI)

-is also called the apical pulse. It reflects the pulsation of the apex of the heart and should be felt medial to the midclavicular line at the 4th or 5th intercostal space. When the PMI is below the 5th intercostal space or left of the midclavicular line, the heart may be enlarged.

Methotrexate (Rheumatrex)

-is classified as an antineoplastic immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying antirheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. - Eye examinations every 6 months are not indicated for clients on methotrexate. -Clients are at risk for infection and should avoid crowded places and contact with individuals who have known infections. Clients on methotrexate should receive the recommended killed (inactivated) vaccines (eg, influenza, pneumococcal), but live vaccines (eg, herpes zoster) are contraindicated. - Methotrexate is teratogenic and can cause congenital abnormalities and fetal death; therefore, clients should not become pregnant while taking this drug and wait at least 3 months after it is discontinued to conceive. -Methotrexate is hepatotoxic; clients on this medication should avoid drinking alcohol as alcohol use increases the risk for hepatotoxicity.

Metoclopramide (Reglan)

-is prescribed for the treatment of delayed gastric emptying, gastroesophageal reflux (GERD), and as an antiemetic. -Similar to antipsychotic drugs, metoclopramide use is associated with extrapyramidal adverse effects, including tardive dyskinesia (TD). -The client should call the health care provider immediately if TD symptoms develop, including uncontrollable movements such as: -Protruding and twisting of the tongue -Lip smacking -Puffing of cheeks -Chewing movements -Frowning or blinking of eyes -Twisting fingers -Twisted or rotated neck (torticollis)

Iron deficiency anemia:

-is the most common chronic nutritional disorder in children. There are many risk factors for iron deficiency, including insufficient dietary intake, premature birth, delayed introduction of solid food, and consumption of cow's milk before age 1 year. -One common cause in toddlers is excessive milk intake, over 24 oz/day. In addition to becoming overweight, toddlers who consume too much milk develop iron deficiency due to the likely exclusion of iron-rich foods in favor of milk, a poor source of available iron. -Treatment of iron deficiency anemia includes oral iron supplementation and increased consumption of iron-rich foods (eg, leafy green vegetables, red meats, poultry, dried fruit, fortified cereal). It is also important to limit milk intake (16-24 oz/day) in toddlers to ensure a balanced diet.

Acute diverticulitis

-occurs when diverticula become inflamed, typically from impacted fecal material or bacterial infection. -In diverticulitis, the diverticula are fragile and create weak areas of the colon wall, which increases the risk of bowel perforation. -Nurses caring for clients with acute diverticulitis should avoid actions that increase the intraluminal pressure and peristaltic movement of the colon, such as administering laxatives (eg, magnesium citrate, bisacodyl) or enemas, which may strain and rupture fragile diverticula

Mitral valve stenosis

-often produces a diastolic murmur best heard at the apex of the heart (5th intercostal space, midclavicular line) with a stethoscope.

Measles

-or rubeola is a highly contagious disease. -disease starts with fever, cough, runny nose, and conjunctivitis, soon after which a rash appears on the face and slowly spreads downward. -it is spread through the air. -clients are placed on airborne precautions in negative air pressure single occupant room. -Nurse care includes: -administering antipyretics -placing the child with high fevers on seizure precautions -provide a quite lim atmosphere -gowns, gloves, and face shield are required only if substantial spraying of respiratory fluids is anticipated.

Initial teaching of the parents of a child with newly diagnosed type 1 diabetes

-should focus on basic safety and survival skills, including proper insulin administration and adequate monitoring of blood sugars. -Information should be introduced slowly, repeated often, and given based on the child's developmental age.

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

1.Shake canister well for about 3-5 seconds. 2.Tilt head back and exhale slowly for 3-5 seconds. 3.Hold canister mouthpiece about 1½ inches in front of open mouth; as an alternative, place the mouthpiece in the mouth with lips sealed around it. Holding it in front of an open mouth prevents impaction of the particles into the tongue and sides of mouth. 4.Compress canister while inhaling slowly through the mouth for about 3-5 seconds. 5.Hold breath for 10 seconds, if possible, before exhaling. 6.Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if prescribed. The first puff of medication dilates the bronchioles and allows easy passage of the second puff.

Oxytocin is the most commonly used medication for inducing labor; however, it is also a high-alert medication. While infusing oxytocin, the nurse must assess the following:

Fetal heart rate (FHR) pattern - Before induction, the registered nurse determines whether the FHR and patterns are reassuring. The FHR is charted in the labor record at least every 15 minutes during the first stage of labor and every 5 minutes during the second stage. -Contraction pattern - The nurse also monitors for contraction patterns that may lead to decreased placental perfusion. More than 5 contractions in 10 minutes or a series of single contractions lasting more than 2 minutes (tachysystole) may lead to reduced placental exchange and nonreassuring FHR patterns. -Vital signs - The client's blood pressure, pulse, and respirations are taken every 30 minutes or with each oxytocin dose change to identify changes from baseline. Oxytocin infusion can cause hypotension. -Intake and output - Oxytocin infusion has an antidiuretic effect and can cause water intoxication, resulting in dilutional hyponatremia and seizure risk. Urine output should be at least 120 mL every 4 hours. -Recording intake and output identifies fluid retention, which precedes water intoxication . -Cervical dilation - The rate of oxytocin infusion may be gradually reduced when the client is in the active phase of labor, about 5-6 cm of cervical dilation. Oxytocin may be stopped or reduced after the client's membranes rupture.