U

absence seizure

Occur age 4-12 disappear by poverty -loss less than 10 seconds - symptoms: Bres loss of consciousness, appearance of inattention or day dreaming (the absence attack) without loss of postural body tone

intussusception

When part of the bowel slides into another section occur in children<6

Myopia (nearsightedness)

a condition resulting from a refractive error in which light rays entering the eye are brought into focus in front of the retina. -reduced visual acuity when viewing objects at a distance ( holding objects near faces or sitting lose to something to see it) symptoms: -headache -dizziness -decrease school performance from eye strain

ventriculoperitoneal shunt

a tube used to drain fluid from brain (hydrocephalus) -look for symptoms of increase intercranial pressure (Vomiting, headache, vision changes and changes in mental status) wit shunt to catch shunt malfunctions

hypospadias

abnormal congenital opening of the male urethra on the underside of the penis instead of on the tip. circumcision is delayed so that foreskin can be used by surgery to reroute the urethra - urine output is closely monitored to ensure latency

nephrotic syndrome

autoimmune disease group of clinical signs and symptoms caused by excessive protein loss in urine symptoms: -edema (weight gain) -massive proteinuria -hypoalbuminemia -hyperlipemia -loss of appetite -decrease urine output treatment: -corticosteroids and other immunosuppressants(cyclosporin) -infection prevention (limit social interactions until child is in remission) -loss of appetite management (make foods fun and attractive) -low sodium -fluid restriction (input and output)

cystic fibrosis

autosomal recessive genetic disorder that affect respiratory an digestive tract with thick sputum and colonization of bacteria complications include: -diabetic mellitus -vitamin deficiency - chronic hypoxemia -nutritional deficiencies -abnormal growth(failure to thrive) -sodium loss

viral infections

cannot be treated by antibiotics

Acute Glomerulonephritis (AGN)

caused by streptococcal bacteria symptoms: -peri orbital and facial edema -hypertension -oliguria (decrease urine) tea color cloudy urine interventions: -monitor vital signs (especially blood pressure) -monitor intake and output -avoid salts -conserve energy

Atopic Dermatitis (Eczema)

chronic inflammation of the skin; rash occurs in face, neck , elbows, knees, and upper trunk of the body along with itching do not scratch skin

talipes equinovarus (clubfoot)

deformity of one or both feet being turned inward treatment: -manipulation and stretching of affected foot -serial cast soon after birth cast care teaching: -monitor circulation (toes pink and warm) -keep cast dry always

Immunization for children who are HIV positive

heamophilus influenza type B (HIB) -pneumococcal conjugate vaccine(PCV) MMR varicella hep A note: live vaccines (MMR, varicella) are contraindicated when one is immunocompramise

measles

highly contagious viral disease characterized by fever and rash covering the body intervention: -vaccine (MMR) -airborne precautions ( negative pressure room, n95 mask) - vitamin A

the most accurate indicator of fluid loss or gain in an acute ill client is

weight (intake and output losses maybe difficult enthuse patients)

Rotavirus

Contagious and leading cause of diarrhea , transmitted by fecal oral route symptoms: -foul smelling watery diarrhea 5-7 days -fever -vomiting

Electroencephalogram (EEG)

Diagnostic procedure used to evaluate presence of abnormal electrical discharge in the brain which can result in seizures. It can be done while asleep or awake with or without stimulation. Teaching: -wash hair -avoid caffeine stimulants and central nervous system depressant prior to test - the test is not painful and no anelgesia needed

scarlet fever

A complication of Streptococcal infection characteristics: -red rash that begin at neck to chest speed to extremity, resemble sunburn, blanch with pressure, has the bump like sandpaper -fever - swollen lymph node

cystic fibrosis

A genetic disorder that is present at birth and affects both the respiratory and digestive systems.

Pinworm

Anal itching, trouble sleeping

tape worm

Food eaten that is contaminated with feces or undercooked meat from an infected animal

How to hold a child during a lumbar puncture

Head and knees tucked in and back rounded out

Tetralogy of Fallot

Heart defect in which oxygenated and unoxygenated blood mixes

Hemophilia

Hereditary bleeding disorder Normal clotting factors are missing -at risk for permanent joint destruction Interventions: -avoid anticoagulants (aspirin -avoid intramuscular injection (in trader atl is better) - use soft toothbrush ( see dentist regularly to prevent gum from bleeding) -avoid contact sports -wear medical alert bracelet

Cystic fibrosis diet

High calorie, high protein, high fat

Pertussis (whooping cough)

Highly contagious communicable disease caused by bordetella pertussis disease. Has thick mucus nursing intervention: 1. droplet and airborne precautions 2. turn client on left side 3. Monitor for signs of airway obstruction 4.offer small amount of fluids frequently 5. Vaccination ( can still get it) treatment: -oral antibiotics -humidified oxygen -fluids

Scabies

Highly contagious skin infection pread by person to person (skin to skin) intervention: - apply permethrin creme - wash belongings in hotttttt water - treat persons in close proximity treatment: permithrin creme

febrile seizures treatment

Use antipyretic therapy (acetaminophen; ibuprofens ) -apply cool damp compress -increase room air circulation -wear loose fit clothing -apply seizure safety precautions

fetal alcohol syndrome (FAS)

In distinct filtrum, thin upper lip,

hydrocephalus

Increase in intercranial pressure resulting from Fluid in the cavity deep within the brain and spine ventriculoperitoneal is used to drain the fluids

Epiglottis

Inflammation obstruction above and arround the epiglottis. it Is a medical emergency. Can progress quickly from no symptoms to having a clogged airway in no time

Bronchiolitis/ (RSV virus)

Inflammation of the bronchioles that usually occurs in children younger than 2 years and is often caused by the respiratory syncytial virus. symptoms: -upper respiratory tract symptoms -wheezing -coughing

Bacterial Meningitis/ increase intercranial pressure(ICP)

Inflammation of the mennings and spinal cord cause by bacteria Can lead to: -hearing loss -visual impairment -paralysis -brain damage -herniation -death treatment: -antibiotics

Rhinitis (common cold)

Irritation and swelling of much membrane in nose - A common viral infection of the nose and throat

Hemolytic Uremic Syndrome

Is a life threatening emergency os escherichia coli bacteria results in red cell hemolysis,low platelet, acute kidney failure -result in anemia, low platelet, petechia/ purpura and low urine output

FLACC scale/pain scale (face leg activity cry insolability)

Use to assess pain in non verbal children signs: -facial grimace -leg movement, tension or bending up toward the chest -activities including squirming, arching and jerking -crying or moaning Difficultly consoling or comforting the child

Varicella Zoster Virus (chicken pox, shingles)

Leision that begins as rash progress to weeping vesicles -crust over within one week -pruritic (itching) and painful with fever treatment: -cool oatmeal bath and topical antihistamines (diphenhydramine) applies to elisions for itching) -acetaminophen as needed for cold and fever immunocompramise client needs antiviral therapy( acyclovir) -clients remains infective until lesions crust over

infant botulism/ food poisoning

Life threatening paralysis (Clostridium botulism) Found in soil and animal products ( ex: raw honey ,milk). Can lead to quick respiratory failure symptoms: -difficulty feeding - decreased head control -deminished deep tendon reflexes

Live vaccines

MMR, Varicella, rotavirus, yellow fever

Negative pressure room precautions

Measles, mumps reubella (MMR) -tubercolosis -varicella zoster (chicken pox)

Hookworm

Parasitic, blood sucking round worm infect the intestine and cause intestinal bleed and anemia

pyloric stenosis symptoms

Projectile vomiting, irritability, hunger, palpable abdominal mass in RUQ, nonbilious emesis, weight loss, dehydrated, sunken frontanelle, decrease skin turgor, delayed capillary refill, electrolyte imbalances (metabolic alkalosis

Appendicitis S/S

RLQ abdominal pain or cramping, nausea, vomiting, chills, low grade fever

Autism Spectrum Disorder (ASD)

Sensory problems (hypo or hyper sensitive) to sound, light, movement, touch, taste and smell -provide calm environment with minimal stimulation (private room away from nursing station) -interventions: Use quite monotone voice when speaking to the child, Use eye contact and gestures carefully, Move slowly, limit visual clutter, maintain minimal lighting, Provide child a single toy to focus on

Genu valgum (knock knees)

This is a condition in which the knees touch but the ankles do not. Can be normal in children up to age 3.

dental avulsion

Tooth separated from the mouth of a permanent tooth -dental emergency -rinse tooth and re-insert stablelize with fingers,you have 15 minutes to reinsert -if cannot reinsert then tooth should be kept moist

Retinoblastoma

Tumor of the eye, retina appears white, child won't have the normal red eye reflex treatment: radiation enucleation( renal of the eye, prosthesis)

Autism Spectrum Disorder (ASD)

Unknown cause with studies of strong genetic component who's at risk for gets it. children who has older siblings with ASD

acute otitis media

infection of the middle ear followed by respiratory track infection symptoms: -high fever -ear pain -irritability/restlessness -loss of appetite - pulling on the affected ear -red buldging tympanic membrane treatment: eliminate exposure to smoke -get immunization against influenza and pneumonia -illuminate pacifier -pull pinna down and backwards during examination -insert speculum to outer cartilaginous part of external auditory canal not the bony part -use otoscope at the end of the assessment

appendicitis

inflammation of the appendix

Duchenne muscular dystrophy gower sign (placing hands on the thighs to push up)

x linked recessive trait muscle weakness characterized by replacement of muscle tissues with connective tissues starting from lower extremities to pelvis, no cure, wheelchair bound by adolescent, die between ages 20-30 -carry by females affects male -due to a lack of protein called dystrophin needed for muscle stabilization -onset at ages 2-5 the gower sign involves the use of hands to rise from a squat or a chair symptoms: -gomer sign/maneuver -enlarge calves -walking on tiptoes -frequent tripping/falling

Selective Estrogen Receptor Modulators (SERMs)

, tamoxifen, Raloxifene (Evista) cause: endometrial cancer venousthromboembolism menopausal symptoms (vaginal dryness, hot flashes)

mononucleosis (caused from Epstein bar virus)

- Contacted through saliva (drink sharing, kisses etc). -viral infection so antibiotics won't work -symptoms: Fatigue, fever, soar throat, splenomegaly, hepatomegaly and swollen lymph nodes -treatment: hydration, rest, control of pain, reduce fever if necessary -complications: airway obstruction(ex. Strider Difficultly breathing), - swollen lymph nodes around the neck -severe abdominal pain (splenic rupture) -avoid contact sports to prevent injury to the spleen or liver

3- phases of Kawasaki disease

1. Acute= High fever that don't respond to treatment ( irritable, swollen red feet and hands, tongue becomes swollen red and cracked 2. subacute= skin of hand and feet peels 3. convalescence = symptoms disappear slowly, temperature returns to normal

Normal PT time

10-12 seconds therapeutic level is 1.5 -2 times higher than the normal level

Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral hepatitis B? Select all that apply. 1. Offer small, frequent meals to prevent nausea 2. Promote rest periods between periods of activity 3. Provide a diet high in fat and low in carbohydrates 4. Teach the client not to share razors or toothbrushes with others 5. Teach the client to abstain from drinking alcohol

1. Offer small, frequent meals to prevent nausea 2. Promote rest periods between periods of activity 4. Teach the client not to share razors or toothbrushes with others 5. Teach the client to abstain from drinking alcohol Explanation Hepatitis (inflammation of the liver) is often caused by infection, toxins, or trauma (eg, drug use, viral hepatitis, acute poisoning), resulting in impairment of liver function (eg, bile production, detoxification of blood, metabolism). Nursing interventions for clients with acute viral hepatitis include: Rest Alternate periods of rest and activity to reduce metabolic demands and avoid fatigue (Option 2). Avoid hepatotoxins (eg, alcohol, acetaminophen) as they worsen injury to liver cells (Option 5). Medications (eg, appetite stimulants, antipruritics, analgesics, sedatives) metabolized in the liver should be used cautiously to allow hepatocytes to heal. Nutrition Encourage low fat, small, frequent meals to decrease nausea and promote intake in clients with anorexia. Anorexia is lowest in the morning; promote eating a larger breakfast (Option 1). Provide oral care and avoid extremes in food temperature to increase appetite. Promote water consumption (2500-3000 mL/day) and diets adequate in carbohydrates and calories. Infection control Hepatitis B is transmitted through sexual contact and infected blood (eg, drug use, accidental needle stick, perinatal mother-to-child infection). A condom should be used during sexual intercourse. Clients should not share razors or toothbrushes (Option 4). (Option 3) Diets high in fat should be avoided as liver bile production, which is needed for fat digestion, may be impaired. Encourage protein and carbohydrate intake to assist with liver healing. Educational objective: Nursing interventions for clients with acute viral hepatitis include the promotion of rest alternated with activity, avoidance of hepatotoxic substances (eg, alcohol), and adequate nutrition (adequate carbohydrates and protein intake; low fat; small, frequent meals).

The nurse is teaching general skin care guidelines to a client receiving teletherapy (external beam radiation therapy). Which statements does the client make that indicate proper understanding of the teaching? Select all that apply. 1. "I may apply an ice pack to the treatment site if it begins to burn." 2. "I will rub baby oil after each treatment to prevent dry skin." 3. "I will use extra measures to protect my skin from sun exposure." 4. "I will wash the treatment site with lukewarm water and mild soap." 5. "I will wear soft, loose-fitting clothing."

3. "I will use extra measures to protect my skin from sun exposure." 4. "I will wash the treatment site with lukewarm water and mild soap." 5. "I will wear soft, loose-fitting clothing." Explanation Clients receiving teletherapy (external beam radiation therapy) often experience significant effects to the skin of the treatment area. Teaching essential skin care standards to these clients is focused on preventing infection and promoting healing of the affected skin. Key measures of skin care that clients receiving teletherapy should take include: Protect the skin from infection by not rubbing, scratching, or scrubbing (Option 2) Wear soft, loose-fitting clothing Use soft, cotton bed sheets 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) 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 Educational objective: The client receiving teletherapy is taught measures to implement to protect the skin from infection and promote healing. Recommended skin care measures include taking a lukewarm shower daily, avoiding rubbing or scratching the skin, using only approved lotions, shielding the skin from the effects of the sun, and avoiding extremes in temperature.

Reconstituting powdered medications

3. Perform hand hygiene and don clean gloves 5. Withdraw air from the vial 1. Inject diluent into the vial 4. Roll vial between the palms of the hands to mix 6. Withdraw reconstituted medication from the vial 2. Label syringe with medication name and dosage

A 25-year-old marathon runner is admitted for suspected rhabdomyolysis. The client has oliguria, dark amber urine, and muscle pain. The nurse should implement which prescription first? 1. ECG[22%] 2. IV morphine 2 mg[5%] 3. Normal saline bolus[50%] 4. Urine sample[21%]

3. Normal saline bolus[50%] Rhabdomyolysis occurs when muscle fibers are released into the blood, usually after an intense muscle injury from exercise, heat stroke, or physical trauma. Acute renal failure can occur when elevated myoglobin (protein found in muscle tissue) levels overwhelm the kidneys' filtration ability. The nurse's priority is to prevent kidney damage using rapid IV fluid resuscitation to flush the damaging myoglobin pigment from the body. Common signs of rhabdomyolysis are dark, oftentimes bloody urine, oliguria, and fatigue. (Option 1) With muscle injury, intracellular potassium is released into the circulation, potentially causing dangerous arrythmias. Therefore, ECG and cardiac monitoring are needed. However, with IV fluid administration, potassium levels decrease rapidly. In addition, clients with rhabdomyolysis have extensive third spacing of the fluids into the injured muscles. Therefore, aggressive fluid resucitation is a high priority. The general rule is that treatment/prevention of an underlying expected problem is a priority over testing to identify the problem. (Option 2) Pain and symptom management should be a high priority but should not take precedence over preserving the client's kidney function. (Option 4) Although obtaining a urine specimen to assess the characteristics is important, laboratory testing would not take priority over treatment to preserve kidney function. Educational objective: Rhabdomyolysis is a medical emergency caused by muscle injury that releases myoglobin into the bloodstream. The nurse's priority when treating the client is to preserve kidney function by administering large volumes of IV fluid.

The family practice clinic nurse is conducting client intake histories. Which client findings or histories indicate a need for heightened concern that the client may have cancer? Select all that apply. 1. The 60-year-old client was just diagnosed with benign prostatic hyperplasia (BPH) 2. The client reports a mobile, golf ball-sized lesion under the skin over the right thigh that feels doughy 3. The client reports a nagging cough with hoarseness for the past 3 months 4. The female client who weighed 150 lb (68.0 kg) has lost 15 lb (6.8 kg) in 3 months without dieting 5. The male client reports a skin change on the breast that looks like an orange peel

3. The client reports a nagging cough with hoarseness for the past 3 months 4. The female client who weighed 150 lb (68.0 kg) has lost 15 lb (6.8 kg) in 3 months without dieting 5. The male client reports a skin change on the breast that looks like an orange peel Explanation Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss (Option 4). The warning signs of cancer can be remembered with the acronym CAUTION: Change in bowel or bladder habits A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere Indigestion or difficulty in swallowing Obvious change in a wart or mole Nagging cough or hoarseness (Option 3) Although 99% of breast cancers are found in women, men can also develop breast cancer, especially if risk factors, such as past chest radiation, are present. Later signs of breast cancer include a newly retracted nipple or an orange-peel appearance of the breast tissue (peau d'orange) caused by the plugging of dermal lymph drainage (Option 5). (Option 1) BPH is caused by hormonal changes related to aging. Growth is not related to cancer. (Option 2) Lipomas are benign, fatty masses and rarely become malignant. They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic. Masses that are hard and fixed, not soft and mobile, usually indicate malignancy. Educational objective: Signs of potential cancer include unplanned weight loss, nagging cough/hoarseness, and dimpled skin (orange peel) on the breast. Hard, fixed masses, non-healing ulcers, and changing moles may also indicate malignancy and require further workup.

Glycoprotein IIb/IIIa inhibitors

Abciximab (ReoPro) Eptifibatide (Integrilin) Tirofiban (Aggrastat) risk for bleeding and thrombocytopenia monitor: blood count blood pressuse heart rate/rhythm signs of bleeding

Pulmonary edema signs

Acute-onset dyspnea and cough with frothy, pink-tinged sputum indicate pulmonary edema. Auscultation reveals crackles at the lung bases.

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

Apply patch to a dry hairless area on the upper arm or chest Wash hands before and after application Rotate sites with each new patch application Discard patch away from children or pets with sticky sides folded together Never wear more than 1 patch at a time Never stop using the patch abruptly

For cardiac temponade

Ascultate the heart sounds

Pediatric Asthma

Can often present as night coughing until the child vomits

Vericella vaccine

Chickenpox

PCA pump and IV fluids

Continuous IV fluids are often necessary with use of a patient-controlled analgesia (PCA) pump; the fluids maintain an open vein and provide a vehicle for PCA delivery.

after motor vehicle accident if pt becomes pale and hypotensive (88/50) it signifies uterine displacement so do the following

During stabilization of a pregnant client after trauma (eg, motor vehicle collision, fall), uterine displacement is the first step to address supine hypotension (due to aortocaval compression and decreased venous return to the heart) and promote blood circulation to the fetus. The client should be tilted laterally while strapped on the backboard to promote venous return and protect the client from further potential spinal injury (Option 4).

Fentanyl Patch

Fentanyl, a potent opioid analgesic, is administered IV to treat acute pain and as a transdermal patch (Duragesic) dosed in mcg/hr to treat chronic pain. When given via transdermal patch, fentanyl is absorbed systemically through the skin to provide continuous analgesia. Patches are replaced every 72 hours, and the used patch must be removed before applying a new one (Option 5). Used patches must be folded and discarded immediately, as some medication remains in a used patch. Opioid medications must be stored and disposed of securely (eg, flushed down the toilet, discarded in a sharps container) as accidental exposure is potentially fatal for children, pets, and caregivers (Option 3).

Treatment for symptomatic bradycardia

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

placenta previa

In placenta previa, the placenta is implanted over or very near the cervix. This causes placental blood vessels to be disrupted during cervical dilation and effacement, which may result in massive blood loss and maternal/fetal compromise. Because of the increased risk of hemorrhage if contractions result in cervical change, a cesarean birth is planned for after 36 weeks gestation and prior to the onset of labor (Option 4). A stable client with no active bleeding and reassuring fetal status may be discharged home and managed in an outpatient setting (Option 3). However, the client must be closely monitored and instructed to return to the hospital immediately if bleeding recurs.

Echolalia

Is a sign of autism spectrum disorder

hypertension risk factors

Key risk factors for developing hypertension include African American ethnicity, increasing age, positive family history, smoking, excessive sodium and alcohol use, diabetes mellitus, obesity, hyperlipidemia, chronic stress, and sedentary lifestyle. Untreated hypertension increases client risk for coronary artery disease, stroke, heart failure, and renal failure.

Cirrhosis of the liver

Laboratory abnormalities common in liver failure include low serum albumin (causes ascites), elevated INR (increases risk for bruising and bleeding), elevated serum ammonia (causes lethargy and confusion), and increased bilirubin (causes jaundice and itching).

Marfan syndrome and aortic root dilation

Marfan syndrome is a connective tissue disorder that causes visual and cardiac defects and a distinct long, slender body type. In Marfan syndrome with aortic vessel involvement, the root of the aorta is dilated or weakened, increasing the risk of aortic dissection and aortic rupture. Increases in blood volume and cardiac workload that occur during pregnancy may worsen aortic root dilation and further increase the risk of aortic dissection/rupture. Pregnancy in clients with Marfan syndrome, especially those with aortic root dilation, poses a high risk of maternal mortality. Clients should be instructed about the importance of consistently using reliable birth control methods to prevent pregnancy (Option 3)

Safe medication administration is conducted according to 6 rights:

Right client using 2 identifiers Right medication Right dose Right route Right time Right documentation Additionally, the NPSGs of improving the safety of using medications should be followed including : labeling all medications discarding medications found unlabeled, and taking extra care for clients taking anticoagulant drugs.

Reduce the risk for fat emboli

Minimizing movement of a fractured long bone and early stabilization of the injury with surgery reduce the risk for fat emboli.

morphine antidote

Naloxone (Narcan)

Myelomeningocele/ neural tube defect

Neural tube fail to fuse properly so protrusion of the membranes of the brain or spinal cord is seen

Ocular chemical burns

Ocular chemical burns require emergency care to prevent permanent vision loss. Alkali burns (eg, ammonia, cement, lye-containing drain cleanser) are particularly dangerous as they will quickly penetrate deep into the eye, causing severe, irreversible damage. For all types of ocular chemical burns, copious eye irrigation with sterile saline or water should begin immediately to flush the chemical irritant out of the eye (Option 3). Before transport to an emergency care facility, tap water can be used for eye irrigation. If transported by ambulance, emergency care personnel continue irrigation during transport with IV tubing or a Morgan lens. Irrigation is continued until the pH of the eye returns to normal (pH 6.5-7.5), which typically requires 30-60 minutes depending on the type of chemical.

Oropharyngeal candidiasis, or thrush (moniliasis)

Oropharyngeal candidiasis, or thrush (moniliasis), is an infection of the mucous membranes generally caused by the yeastlike fungus Candida albicans. The fungus causes pearly, "milk-curd" lesions on the oral or laryngeal mucosa that may bleed when removed. Immunosuppressed individuals such as those taking corticosteroid medications, clients undergoing chemotherapy or radiation, or clients with immune deficiency states (eg, AIDS) have an increased incidence. Clients receiving prolonged or high-dose antibiotic treatment are at increased risk as the normal microbial flora of the mouth is reduced, allowing other opportunistic infections to arise (Option 2). Individuals with dentures and infants also commonly experience monilial infections. Treatment is antifungal medications (eg, nystatin) and proper oral hygiene.

Positive signs of schizophrenia

Repeats statements of others State they are the president

Teach client the following steps for self-administration of ophthalmic ointments:

Perform hand hygiene Tilt the head back, pull the lower lid down, and look upward Squeeze a thin strip of ointment onto the lower eyelid, from the inner to the outer edge Close the eyes gently for 2-3 minutes after applying the ointment

Hypoalbuminemia cause

Pitting edema

pressure injuries

Pressure injuries are staged from 1 to 4 to classify the degree of tissue damage and determine the most effective wound treatment. Unstageable pressure injuries have full-thickness skin loss with slough and/or eschar, which prevents visualization of the wound base. Slough in a wound base appears as yellow or tan stringy tissue; eschar is dried, black or brown necrotic tissue. The wound cannot be staged until slough and eschar are debrided by a wound care nurse or health care provider and the base can be visualized (Option 4).

Rheumatic fever

RF is an acute inflammatory disease of the heart. It is a complication that occurs 2-3 weeks after a streptococcal pharyngitis. RF is caused by a delayed-onset autoimmune reaction involving anti-streptococcal antibodies that cross-react with the antigens in the heart and other organs. Recurrent, untreated streptococcal pharyngitis will lead to faster onset and increased severity of rheumatic heart disease due to increased autoimmune activity. RF affects the heart, skin, joints, and central nervous system. The presence of 2 major criteria or 1 major and 2 minor criteria and evidence of a preceding streptococcal infection indicate a high probability of RF.

Raynaud Phenomenon/Disease

Raynaud phenomenon can develop secondary to scleroderma. It is characterized by vasospasm-induced color changes in the fingers, toes, ears, and nose. This requires urgent treatment (eg, immersing hands in warm water) but is not life-threatening.

Right sided heart failure s/s

Right-sided heart failure results from pulmonary hypertension, right ventricular myocardial infarction, or left-sided heart failure. The right ventricle cannot effectively pump blood to the lungs, which results in incomplete emptying of the right ventricle. The resulting decrease in forward blood flow causes blood to back up into the right atrium and then into venous circulation, resulting in venous congestion and increased venous pressure throughout the systemic circulation. Clinical manifestations of right-sided heart failure include: -Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities (Option 4). -Jugular venous distension (Option 3). -Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation (Option 2). -Hepatomegaly due to hepatic venous congestion.

scleroderma

Scleroderma is an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. This is a progressive disease without a cure, and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal.

Failure to capture (pacemaker)

Signs and symptoms of a failing pacemaker include failure to capture (pacer spikes without associated QRS complexes) with bradycardia and hypotension. The nurse should use a transcutaneous pacemaker to stabilize the client until the internal pacemaker can be repaired or replaced.

Supraventricular Tachycardia (SVT) risk factors and treatment (inside down t wave)

Stimulants (eg, nicotine, caffeine, cocaine) and organic heart disease can cause SVT. Clinical significance depends on the client's symptoms. A prolonged episode of SVT with a heart rate >180/min will cause decreased cardiac output and hypotension. The client may also experience palpitations, dyspnea, and angina. Treatment includes vagal stimulation and drug therapy. Common vagal maneuvers include Valsalva, coughing, and carotid massage. IV adenosine is the drug of choice to convert SVT to a sinus rhythm. If vagal stimulation and drug therapy are ineffective and the client becomes hemodynamically unstable, synchronized cardioversion is used. Recurrent SVT may require radiofrequency catheter ablation.

Hypocolemic shock s/s

Tachycardia Hypotension

Testicular cancer

Testicular cancer is the most common form of cancer in men age 15-35. When diagnosed early, it is highly curable. Clients at high risk for developing a tumor (eg, history of undescended testis) are encouraged to perform a monthly TSE. Client instructions for a TSE include: Perform TSE monthly on the same day (easy to remember) Perform TSE while taking a warm shower or bath as warm temperatures will relax the scrotal tissue and make the testis hang lower in the scrotum Use both hands to feel each testis separately Palpate each testicle gently, using the thumb and first 2 fingers Check that the testicle is normally egg-shaped and movable with a smooth surface The clinical findings that should be reported to the health care provider include: Painless, hardened lump on testes Scrotal swelling or heaviness Dull ache in pelvis or scrotum

Hypertension (DASH) diet

The Dietary Approaches to Stop Hypertension (DASH) diet is often recommended to reduce blood pressure in clients with hypertension. The client is taught to limit intake of sugar, sodium, cholesterol, and trans or saturated fats, and instead choose healthier options (eg, fresh fruit and vegetables, low-fat dairy products).

Valsalva maneuver contraindications ( do not use in these people)

The Valsalva maneuver is contraindicated in the client diagnosed with increased intracranial pressure, stroke, head injury, heart disease, glaucoma, eye surgery, abdominal surgery, and liver cirrhosis.

potential malignant skin neoplasm (skin cancer)

The examination for skin cancer follows the ABCDE rule: Asymmetry (eg, one half unlike the other) (Option 2) Border irregularity (eg, edges are notched or irregular) Color changes and variation (eg, different brown or black pigmentation) (Option 5) Diameter of 6 mm or larger (about the size of a pencil eraser) (Option 4) Evolving (eg, appearance is changing in shape, size, color) (Option 1) Normal variations in skin will blanch with manual pressure. Failure to blanch is typically an indication that there is blood beneath the skin, as in petechiae and/or purpura. (Option 3) Pus or purulent drainage is usually indicative of an infectious process, not cancer. Educational objective: Examination of a skin lesion for malignancy should include ABCDE: Asymmetry, Border irregularity, Color change and variation, Diameter of 6 mm or more, and Evolving in appearance.

brain lobes

The frontal lobe controls executive function and personality. The temporal lobe receives auditory input. The parietal lobe receives sensory input. The occipital lobe receives visual images.

1. Confusion and restlessness 4. Petechiae over neck and chest 5. Pulse oximeter showing hypoxia

The health care provider (HCP) suspects a fat embolism syndrome (FES) in a client who has had multiple long bone fractures. Which findings does the nurse expect to assess to support this diagnosis? Select all that apply. 1. Confusion and restlessness 2. Increasing pain despite the opioid analgesia 3. Paresthesia of the affected extremity 4. Petechiae over neck and chest 5. Pulse oximeter showing hypoxia Explanation FES is a rare, but life-threatening complication that occurs in clients with long bone and pelvis fractures. It can also occur in nontrauma-related conditions, such as pancreatitis and liposuction. It usually develops 24-72 hours following the injury or surgical repair. There are no specific diagnostic tests to identify FES. However, the initial characteristic signs and symptoms include: Respiratory problems (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure. This pathophysiology is similar to that of a pulmonary embolus (Option 5). Neurologic changes (eg, altered mental status, confusion, restlessness), which occur due to cerebral embolism and hypoxia (Option 1). Petechial rash (eg, pin-sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion. This defining characteristic differentiates a fat embolus from a PE (Option 4). Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction. (Options 2 and 3) Increasing, severe pain unrelieved by opioid analgesia or pain that is disproportionate to the injury and paresthesia (eg, numbness, tingling, burning) of the affected extremity are assessment findings indicative of compartment syndrome. Educational objective: FES presents with a triad of respiratory distress, mental status changes, and petechial skin rash. Fever and thrombocytopenia can also be present.

Tb na roux test

The intradermal purified protein derivative (PPD) test, or Mantoux test, is administered to screen for tuberculosis (TB). The forearm is injected with 0.1 mL of the PPD, and the client returns in 48-72 hours to have the site assessed for induration (a raised area). Redness alone is not read as a positive response. An area of induration >15 mm is considered a positive response in any client (Option 1). However, a positive PPD test does not mean that the client has active TB infection but rather that the client has been exposed to TB and has developed an immune response. Positive sputum cultures, chest x-rays, and the presence of symptoms confirm that the client has active disease(Option 3).

Thoracic Aortic Aneurysm (TAA)

The nurse should report swallowing difficulty immediately in a client with a thoracic aortic aneurysm. This could indicate that the aneurysm has increased in size and may require treatment.

Stroke prevention

The single most important factor in preventing strokes is controlling hypertension.

signs of magnesium sulfate toxicity

The therapeutic level of magnesium for pre-eclampsia/eclampsia treatment is 4-7 mEq/L (2.0-3.5 mmol/L). Signs of magnesium toxicity may be noted with: ----serum levels >7 mEq/L (3.5 mmol/L) and include ---absent or decreased deep tendon reflexes, --------respiratory depression, and cardiac arrest. Calcium gluconate is the (antidote) for magnesium sulfate. should be readily available in the event of cardiorespiratory compromise.

signs & symptoms of hypocalemia (8.6 -10 mg/dl)

paresthesia, numbness, hyperactive deep tendon reflexes, positive trousseau and chvosteks sign, muscle cramps, increase neuromuscular excitability, muscle cramps, twitching, tetany, seizures, irritability, anxiety, hyperactive bowel sounds, abdominal cramps

cogent/benztropine

anticholinergenic use to treat extrpiramidal symptoms which are side effects of antipsychotic medications treat: muscle rigidity and shuffling gait

Clinical manifestations of pulmonary edema And treatment

-A history of orthopnea and/or paroxysmal nocturnal dyspnea -Anxiety and restlessness -Tachypnea (often >30/min), dyspnea, and use of accessory muscles -Frothy, blood-tinged sputum (pink frothy sputum) -Crackles on auscultation Treatment: 100% oxygen Diuretics

Hirschsprung disease

-A portion of the colon have no innervation and must be removed, -some children require temporary colostomy -stoma should remain beefy red -any paleness or graying of the stoma indicates decreased blood supply

Signs of increase intercranial pressure (ICP) in children are:

-Bulging frontanelle -increase head circumference - sunset eyes (setting sun sign) - sclera visible above the iris

intussusception symptoms

-Crampy abdominal pain - palpable sausage-shaped abdominal mass -red currant jelly stools - crying and knee drawn up to the chest -vomiting

Epstein-Barr virus (EBV)/ herpes virus 4

-Family of the herpes virus. spread commonly through body fluids, primarily saliva

Kawasaki disease (treatment)

-IVIG, high-dose aspirin IVG remains in the body for 11 months. - Dont give live vaccines (MMR, varicella) until after 11 months -monitor the heart for coronary artery disease

cleft palate

-Incomplete fusion of the palatine bonanza maxilla -difficultly in sucking and feeding -surgical repair happens between 6-24 mths

Signs of dehydration

-Increase capillary refill time -increase heart rate —increase respiratory rate -When severe hydration occur the treatment is intravenous rehydration especially in children

Pediculosis Capitis (Head Lice)

-Launder clothes, sheets, towels with hot water -place in hot dryer for 20 minutes

Tetralogy of fallot nurse Intervention to reduce hyper cyanosis spells

-Provide calm environment -sooth and quiet infant crying or distress -offer pacifier -swaddled or hold infant during procedures or times of stress -provide frequent small feedings

Tetralogy of Fallot 4 characteristics are

-Pulmonary stenosis -right ventricular hypertrophy -overriding aorta -ventricular septal defect

Left to right cardiac shunt ( patent ductus arteriosus, atrial septal defect, ventricular septal defect)

-Result in excess blood flow to the lungs manifestations include: - heart murmur -poor weight gain -diaphoresis -signs of heart failure

How to use a metered-dose inhaler:

-Shake metered dose inhaler(MDI) and attach it to spacer -exhale completely -place lips tightly around the mouthpiece -deliver one puff of medication into the spacer -take a slow deep breath and hold for 10 seconds - rinse mouth with water

Reye's syndrome

-Syndrome which is an acute encephalopathy (inflammation of the brain). -Usually follows a viral illness (Varicella, influenza) -risk increase if aspirin is used to treat fever acetaminophen (not aspirin) is used to reduce fever symptoms: -fever -acute encephalopathy ( alteration of brain function -altered hepatic function -elevated serum ammonia levels

tonic-clonic seizure

-Turn client on the side - provide oxygen —provide suction as needed -pad side rails -remove objects that are near the client to decrease the risk for injury during seizures -do not use restraints

TNF inhibitors

-eg. etanercept, infliximab, adalimumab -cause immunosuppression reduce manifestation of rheumatoid arthritis and slows progression of joint damage TB reactivation os a major concern therefore all clients must be a skin test

Cleft palate interventions

-encourage soothing for pain -place child in upright, supine position -utilize elbow restraints so child put nothing in the mouth - monitor skin and neurovascular status by removing elbow restraints per policy

pharyngitis (sore throat)

-highly contagious —Children may refuse to eat because of pain so a soft diet and cool liquids should be offered -complete full course antibiotic -replace toothbrush 24 hours after starting antibiotics

Laryngotracheitis (Croup) cause by parainfluenza virus

-hoarseness -barking cough -stridor -respiratory distress

Hypophosphatemia risk factors

-malnutrition or starvation (malnutrition is associated with alcoholism) -aluminum hydroxide base -magnesium based antacid

compartment syndrome 6 P`s

-pain increase (despite elevation or analgesics and ice) -pressure -paresthesia (tingling, numbness or burning) -pallor -pulselessness -paralysis (loss of function or inability to move extremities or digits)

The nurse is caring for a female client newly diagnosed with epilepsy who has been prescribed phenytoin. Which of the following should the nurse include in client teaching? Select all that apply. 1. "Avoid drinking alcoholic beverages." 2. "Do not abruptly stop taking your phenytoin." 3. "Go to the emergency department every time a seizure occurs." 4. "Wear an epilepsy medical identification bracelet." 5. "You may need to start using a nonhormonal birth control method."

1. "Avoid drinking alcoholic beverages." 2. "Do not abruptly stop taking your phenytoin." 4. "Wear an epilepsy medical identification bracelet." 5. "You may need to start using a nonhormonal birth control method." Explanation Epilepsy is characterized by chronic seizure activity. Clients typically require lifelong anticonvulsant medication. The nurse should provide education about identifying and avoiding seizure triggers, such as excessive alcohol intake, sleep deprivation, and stress (Option 1). Practicing relaxation techniques (eg, biofeedback) may help reduce the number of episodes. The client should also be encouraged to wear an epilepsy medical identification bracelet in case of emergency (Option 4). Phenytoin (Dilantin), a hydantoin anticonvulsant, may decrease the effectiveness of some medications (eg, oral contraceptives, warfarin) due to stimulation of hepatic metabolism. An alternate, nonhormonal birth control method (eg, condoms, copper intrauterine device) should be used in addition to or instead of oral contraceptives (Option 5). Clients should discuss pregnancy plans with their health care provider, as phenytoin can cause fetal abnormalities (eg, cleft palate, heart malformations, bleeding disorders). Clients taking phenytoin should also receive education about practicing good oral hygiene as gingival hyperplasia is a potential complication. Anticonvulsants should not be stopped abruptly, as this increases the risk of seizure (Option 2).

The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, "I guess I can anticipate getting this disease myself at some point." What is an appropriate response by the nurse? 1. "Engaging in regular exercise decreases the risk of AD."[52%] 2. "Having a family history of AD is not a risk factor."[29%] 3. "Try not to worry about this now as you can't do anything to prevent AD."[11%] 4. "You should avoid aluminum cans and cookware to prevent AD."[6%]

1. "Engaging in regular exercise decreases the risk of AD."[52%] Explanation The development of Alzheimer disease (AD) is related to a combination of genetic, lifestyle, and environmental factors. Clients with AD are usually diagnosed at age ≥65. Early-onset AD is a rare form of the disease that develops before age 60 and is strongly related to genetics. Children of clients with early-onset AD have a 50% chance of developing the disease. For late-onset AD, the strongest known risk factor is advancing age. Having a first-degree relative (eg, parent, sibling) with late-onset AD also increases the risk of developing AD (Option 2). Trauma to the brain has been associated with the development of AD in the future. Brain trauma may be prevented by wearing seat belts and sports helmets and taking measures to prevent falls. Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing AD (Options 1 and 3). (Option 4) Research has failed to confirm that exposure to aluminum products (eg, cans, cookware, antiperspirant deodorant) is related to the development of AD. Educational objective: Research suggests that healthy lifestyle choices (eg, smoking cessation, avoiding excessive alcohol intake, exercising regularly, participating in mentally challenging activities) reduce the risk for developing Alzheimer disease.

Meningococcal meningitis nurse intervention

1. Nurse wears mask 2. elevate head of bed 3. prepare for seizure precaution 4. Minimize environmental stimuli

The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond? 1. "Genetic counseling is recommended. You will receive a referral before you leave."[49%] 2. "Huntington disease inheritance requires both biological parents to carry the gene."[42%] 3. "There are other ways to grow your family. You should consider adoption."[0%] 4. "This disease occurs spontaneously and is not likely to affect your children."[7%]

1. "Genetic counseling is recommended. You will receive a referral before you leave."[49%] Educational objective: Huntington disease is an incurable autosomal dominant disease that causes progressive nerve degeneration, which impairs movement, swallowing, speech, and cognitive abilities. Death typically occurs within 20 years. Clients who have a parent with this disease should receive genetic counseling, especially when planning to start a family.

The nurse is assessing a client in the outpatient clinic who has a cast on for a distal humerus fracture. Which statements made by the client would be the priority to assess further? 1. "I am having problems extending my fingers since this morning."[37%] 2. "I can't take any of the pain medicine because it makes me feel sick."[0%] 3. "I have to scratch under the cast with a nail file because of the itching."[8%] 4. "I noticed a warm spot on my cast, and a bad smell is coming from it."[53%]

1. "I am having problems extending my fingers since this morning."[37%] Volkmann contracture occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive dressing should be removed immediately, and the health care provider (HCP) must be notified for possible surgical intervention (eg, fasciotomy). (Option 2) The nurse should educate the client about ways to prevent medication-related nausea, or the HCP may consider switching pain medications. This would be addressed last. (Option 3) The client must be instructed to never stick anything inside the cast; this can lead to altered skin integrity and infection. This would be addressed third. (Option 4) A warm spot on the cast with a foul odor can indicate infection under the cast, especially if the client has been sticking objects inside to scratch the skin. This would be addressed second. Educational objective: Volkmann contracture (wrist contracture, inability to extend the fingers) occurs as a result of ischemia from compartment syndrome after a distal humerus fracture. It is a medical emergency that requires immediate intervention.

The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching? 1. "I have to remember to raise my chin slightly upward when I swallow."[56%] 2. "I have to remember to swallow 2 times before taking another bite of food."[13%] 3. "I should avoid taking over-the-counter cold medications when I'm sick."[22%] 4. "I should sit upright for at least 30-40 minutes after I eat."[7%]

1. "I have to remember to raise my chin slightly upward when I swallow."[56%] Explanation Dysphagia increases the risk for aspiration of oropharyngeal secretions, gastric content, food, and/or fluid into the lungs. Aspiration of foreign material into the lungs increases the risk for developing aspiration pneumonia. Interventions to help decrease aspiration and resulting aspiration pneumonia in susceptible clients (eg, elderly, neurologic dysfunction, decreased cough or gag reflexes, decreased immunity, chronic disease), include the following: Swallowing 2 times before taking another bite of food. This clears food from the pharynx. Thickening liquids to assist swallowing Avoiding over-the-counter cold medications. Antihistamine cold preparation medications also have some anticholinergic properties, such as causing drowsiness, decreasing saliva (xerostomia) production, and making the mouth dry. Saliva is a lubricant, and it helps bind food together to facilitate swallowing. Sitting upright for at least 30-40 minutes after meals. This uses gravity to move food or fluid through the alimentary tract, decreases gastroesophageal reflux, and helps decrease risk for aspiration. Brushing teeth and using antiseptic mouthwash before and after meals. This reduces the bacterial count before eating because bacteria as well as food can be aspirated. After-meal use removes particles of food that can be aspirated later. Smoking cessation. Smoking decreases mucociliary clearance and increases bacterial count in the mouth.

A client newly diagnosed with osteomalacia is reviewing home care instructions with the nurse. Which statements indicate the need for further instruction? Select all that apply. 1. "I will avoid foods high in calcium and phosphorus." 2. "I will avoid going outside on sunny days." 3. "I will decrease activity to prevent bone injury." 4. "I will eat foods that are fortified with vitamin D." 5. "I will use a cane to help me get around better."

1. "I will avoid foods high in calcium and phosphorus." 2. "I will avoid going outside on sunny days." 3. "I will decrease activity to prevent bone injury." Osteomalacia is a reversible bone disorder caused by vitamin D deficiency and is characterized by weak, soft, and painful bones that can easily fracture or become deformed. In vitamin D deficiency, calcium and phosphorus cannot be absorbed from the gastrointestinal tract and are unavailable for calcification of bone tissue. Vitamin D deficiency is also associated with increased risk of falls, especially in elderly clients, due to muscle weakness. Nursing management focuses on: Implementing safety measures such as canes or walkers to prevent falls and injury (Option 5) Encouraging light to moderate activity, which can help promote bone strength and health (Option 3) Increasing dietary intake of: Calcium (eg, leafy green vegetables, dairy) (Option 1) Phosphorus (eg, milk, organ meats, nuts, fish, poultry, whole grains) Vitamin D (eg, vitamin D-fortified milk and cereal, egg yolks, saltwater fish, liver); exposure to sunlight is also recommended as it synthesizes vitamin D (Options 2 and 4) Taking over-the-counter or prescription supplemental vitamin D Educational objective: Osteomalacia occurs when the body is unable to use calcium and phosphorus for bone calcification due to a vitamin D deficiency. Nursing management focuses on implementing safety measures, encouraging activity, and increasing intake of vitamin D, calcium, and phosphorus.

Which client is at greatest risk for pulmonary embolism? 1. A client 6 hours postoperative cesarean section[44%] 2. A client in atrial fibrillation[35%] 3. A client with a subdural hematoma[10%] 4. A client with pneumonia[9%]

1. A client 6 hours postoperative cesarean section[44%] Explanation Death from pulmonary embolism is often attributed to a missed diagnosis. Early identification of risk factors (eg, venous stasis, hypercoagulability of blood, endothelial damage) can have a positive effect on client outcome. This postoperative client is at greatest risk due to the presence of the following 4 risk factors: Abdominal cesarean section surgery (endothelial damage) Engorged pelvic vessels from pregnancy (venous stasis, hypercoagulability of blood) Inactivity/immobility ≥6 hours related to positioning during surgery and the immediate postoperative period and epidural anesthesia (venous stasis) Postpartum state (hypercoagulability of blood) (Option 2) In atrial fibrillation, stasis and turbulence of blood increases risk of thrombus formation. Once mobilized, emboli can get trapped in blood vessels causing ischemia. Smaller vasculature and increased blood flow in the brain increases the probability of a stroke, rather than PE. This client has 1 risk factor and is not at greatest risk for PE. (Option 3) The presence of a subdural hematoma does not pose a significant risk for PE unless the client has been immobile. Many clients with subdural hematomas are asymptomatic and walking. This client is not at greatest risk for PE. (Option 4) Any acute medical illness (eg, pneumonia) can predispose a client to PE from inflammation and the client's relative immobility. However, this risk is lower than the risk for PE from major surgery. Educational objective: Death from pulmonary embolism (PE) is often attributed to a missed diagnosis. Nurses must recognize any condition or situation that predisposes a client to venous stasis, hypercoagulability of blood, and endothelial damage, as these factors increase the risk for PE.

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? Select all that apply. 1. Add a thickening agent to the fluids 2. Avoid administering sedating medications before meals 3. Place the client in an upright position during meals 4. Restrict visitors who show signs of illness 5. Teach the client to flex the neck while swallowing

1. Add a thickening agent to the fluids 2. Avoid administering sedating medications before meals 3. Place the client in an upright position during meals 5. Teach the client to flex the neck while swallowing Explanation Aspiration pneumonia develops when aspirated material (eg, food, emesis, gastric reflux) causes an inflammatory response and provides a medium for bacterial growth. At-risk conditions include cognitive changes (eg, dementia, head injury, stroke, sedation), difficulty swallowing, compromised gag reflex, and tube feeding. Aspiration-prevention measures include: Thicken liquids (eg, to nectar or honey consistency) for clients with dysphagia; thin liquids are more difficult to control when swallowing (Option 1). Ensure that the client is fully awake before eating. The nurse should time the administration of sedating medications (eg, opioids, benzodiazepines) to avoid sedation during meals (Option 2). Elevate the head of the bed to 90 degrees during and for 30 minutes after meals, and never place the head of the bed lower than 30 degrees (Option 3). Encourage clients to facilitate swallowing by flexing the neck (chin to chest) (Option 5). Administer prescribed antiemetics (eg, ondansetron) as needed to prevent vomiting. Monitor for coughing, gagging, and pocketing food. (Option 4) Performing strict handwashing and limiting sick visitors are important infection-control measures; however, they do not prevent noninfectious aspiration pneumonia. Educational objective: Measures for preventing aspiration pneumonia include administering medications to prevent vomiting, avoiding mealtime sedation, maintaining head-of-bed elevation at 30 degrees or more (90 degrees during and 30 minutes after meals), and encouraging neck flexion while swallowing. Clients with dysphagia should receive thickened liquids and be monitored for coughing, gagging, and pocketing food.

A client is admitted to the hospital with an exacerbation of myasthenia gravis. What are the appropriate nursing actions? Select all that apply. 1. Administer an anticholinesterase drug AC 2. Anticipate a need for an anticholinergic drug 3. Develop a bladder training schedule 4. Encourage semi-solid food consumption 5. Teach the necessity for annual flu vaccination

1. Administer an anticholinesterase drug AC 4. Encourage semi-solid food consumption 5. Teach the necessity for annual flu vaccination Explanation Myasthenia gravis is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs (difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted. Treatment includes anticholinesterase drugs (pyridostigmine [Mestinon]) that are administered before meals so that the client's ability to swallow is strongest during the meal (Option 1). Semi-solid foods (easily-chewed foods) are preferred over solid foods (to avoid stressing muscles involved in chewing and swallowing) or liquids (aspiration risk) (Option 4). All clients with a serious chronic co-morbidity should receive the annual flu vaccine (also the pneumonia vaccine if appropriate) as they are more likely to have a negative outcome if the illness is contracted. It is especially important in clients with myasthenia gravis as the flu (or pneumonia) would tax the already compromised respiratory muscles (Option 5). (Option 2) An anticholinergic drug, such as atropine, is used for treatment in a cholinergic crisis (eg, the medication is too high or there is excess acetylcholine). The need would not be anticipated during a myasthenic crisis (eg, exacerbation of myasthenia gravis), which is usually a result of too little medication related to noncompliance, illness, or surgery. (Option 3) The skeletal muscles are involved in myasthenia gravis; dysfunction of the reflexes or central nervous system affects bowel and bladder control. This issue is classic with multiple sclerosis. Educational objective: Myasthenia gravis involves reduction of acetylcholine receptors in the skeletal muscles; this decreases the strength of muscles used for eye and eyelid movements, speaking, swallowing, and breathing. Treatment includes administration of anticholinesterase drugs before meals, easily-chewed foods, and appropriate vaccinations.

A is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? Select all that apply. 1. Apply a patch to the right eye at night 2. Avoid driving 3. Chew on the left side 4. Maintain meticulous oral hygiene 5. Use a cane on the left side

1. Apply a patch to the right eye at night 3. Chew on the left side 4. Maintain meticulous oral hygiene Bell's palsy is an inflammation of cranial nerve VII (facial) that causes motor and sensory alterations. Clients are usually managed as outpatients, with corticosteroids to reduce inflammation, and taught eye/oral care. In Bell's palsy, the eyelids do not close properly. This may result in eye dryness and risk of corneal abrasions. However, weakness of the lower eyelid may cause excessive tearing due to overflow in some clients. Facial muscle weakness results in poor chewing and food retention. Client teaching should include the following: Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea (Option 1). Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries) (Options 3 and 4)

A client with a hip fracture is placed in Buck traction. Which activities are appropriate for the nurse to include in the client's plan of care? Select all that apply. 1. Assess for skin breakdown of the limb in traction 2. Ensure adequate pain relief 3. Keep the limb in a neutral position 4. Perform frequent neurovascular checks on the limb in traction 5. Reposition the client and use a wedge pillow

1. Assess for skin breakdown of the limb in traction 2. Ensure adequate pain relief 3. Keep the limb in a neutral position 4. Perform frequent neurovascular checks on the limb in traction Explanation Buck traction is a type of skin traction used to immobilize hip fractures and reduce pain and spasm until the client can undergo surgical repair of the fracture. A traction boot is applied to the leg, below the fracture site. A weight gently and continuously pulls on the leg and hip, helping maintain alignment of the limb. The nurse should ensure that the traction boot is fitted properly and that the limb remains straight in a neutral position (Option 3). Skin traction exerts pressure on nerves, blood vessels, and soft tissue. The nurse should frequently assess neurovascular status (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin integrity in the limb to which the boot is applied (Options 1 and 4). Overall pain level and efficacy of administered pain medications should be monitored closely, as increasing pain in the limb in traction may indicate neurovascular compromise (Option 2). (Option 5) Side-to-side repositioning of the client in Buck traction can cause injury. Side-to-side position changes cause the affected leg to be adducted or abducted, which, when paired with the force of traction, can increase spasm and pain and contribute to neurovascular and orthopedic compromise. Educational objective: Buck traction is used to immobilize hip fractures and reduce pain and spasm until the fracture can be repaired surgically. The nurse caring for a client in Buck traction should frequently assess the neurovascular status and skin integrity of the affected limb and maintain it in a straight, neutral position

The nurse reviews discharge teaching about residual limb care for a client who had a lower limb amputation. Which of the following instructions should the nurse include? Select all that apply. 1. Assess the residual limb daily for redness or irritation 2. Keep limb socks and elastic wraps clean and dry 3. Lie on your stomach three times a day for 30 minutes 4. Massage the residual limb with lotion each day 5. Wash the residual limb daily with soap and water

1. Assess the residual limb daily for redness or irritation 2. Keep limb socks and elastic wraps clean and dry 3. Lie on your stomach three times a day for 30 minutes 5. Wash the residual limb daily with soap and water Explanation Residual limb care following an above-knee amputation (AKA) or a below-knee amputation (BKA) is an important component of rehabilitation and focuses on maintaining skin integrity, controlling pain, preventing infection, and restoring mobility. It is also important for the nurse to consider that the client may experience grief due to disturbed body image. The nurse should include the following residual limb care instructions when discharging a client after an AKA or BKA: Clean the limb by washing it daily with soap and warm water. Thoroughly dry after washing to prevent skin maceration (Option 5). Thoroughly inspect the limb for signs of infection (eg, redness) and areas that may be at risk for infection (eg, irritation, skin breakdown) (Option 1). Keep limb socks, wraps, and appliances/prostheses clean and dry (Option 2). Perform daily range-of-motion exercises to improve muscle strength and mobility. Hip flexion contractures are a common complication during the recovery process. Nurses should teach clients to lie prone several times each day and to avoid sitting in a chair for ≥1 hour (Option 3). (Option 4) Clients should be taught to avoid applying potential irritants (eg, alcohol, lotion, powder) to the residual limb, unless prescribed by the health care provider. This reduces the risk of skin breakdown and infection. Educational objective: Clients who have undergone lower limb amputation should be taught to wash the residual limb daily with warm water and soap; inspect the limb for redness or irritation; keep limb socks, wraps, and appliances clean and dry; and lie prone several times daily to prevent hip contractures.

The nurse assessing a client with an upper gastrointestinal bleed would expect the client's stool to have which appearance? 1. Black tarry[84%] 2. Bright red bloody[11%] 3. Light gray "clay-colored"[2%] 4. Small, dry, rocky-hard masses[1%]

1. Black tarry[84%] The nurse would expect a client experiencing an upper gastrointestinal (GI) bleed to have black tarry stools (melena). As blood passes through the GI tract, digestion of the blood ensues, producing the black tarry appearance. (Option 2) Bright red bloody stool (hematochezia) would indicate a lower GI hemorrhage. (Option 3) Decreased bile flow into the intestine due to biliary obstruction would produce a light gray "clay-colored" stool. (Option 4) Small, dry, rocky-hard masses are an indication of constipation. Inactivity, slow peristalsis, low intake of fiber in the diet, decreased fluid intake, and some medications (eg, anticholinergics) may contribute to constipation. Educational objective: Clients with upper gastrointestinal (GI) bleed tend to have black tarry stools (melena). Lower GI bleeding will have bright red bloody stool. Blood present on surface of stool indicates hemorrhoids.

A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture? Select all that apply. 1. Calcium supplements 2. Encourage bed rest 3. Use of full bed rails during the night 4. Vitamin D supplements 5. Weight-bearing exercises

1. Calcium supplements 4. Vitamin D supplements 5. Weight-bearing exercises Explanation The primary treatment goal for elderly clients with osteoporosis is to prevent bone fracture, especially hip fracture. Teaching to increase bone mineral density and prevent bone loss (resorption) includes: Bisphosphonate medication (eg, alendronate [Fosamax], risedronate [Actonel], zoledronic [Reclast]) Calcium and Vitamin D supplementation (Options 1 & 4) Smoking cessation and alcohol avoidance, as these increase bone resorption and contribute to falls Weight-bearing exercise (eg, walking, dancing) and resistance training (eg, weights) ≥3 times a week for 30 minutes, as increasing mechanical stress on bone increases bone density (Option 5) Interventions to prevent falls and resulting hip fracture include: Maintain bed in low and locked position Ensure that call light and personal belongings are within reach Orient client and ensure use of non-skid footwear, eyeglasses and hearing aids, and assist devices if needed Keep environment well-lit and free of clutter (Option 2) A client should not be placed on bed rest solely for the prevention of falls. Immobilization actually increases fracture risk due to bone resorption, a condition called disuse osteoporosis. The nurse should encourage and assist with mobility and weight-bearing exercises to prevent muscle atrophy and bone resorption. (Option 3) The client may actually incur more injury from a fall if trying to climb over side rails to get out of bed. The nurse should utilize bed alarms if the client is prone to getting out of bed without assistance. Educational objective: An osteoporosis-related fall is the most common cause of hip fracture in the elderly. Interventions to reduce the risk of fall and hip fracture include bisphosphonate medication, calcium and vitamin D supplements, mobility and weight-bearing exercise, smoking cessation, and avoiding excessive use of alcohol.

The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? Select all that apply. 1. Change in lacrimation on the affected side 2. Electric shock-like pain in the lips and gums 3. Flattening of the nasolabial fold 4. Inability to smile symmetrically 5. Severe pain along the cheekbone Bell's Palsy

1. Change in lacrimation on the affected side 3. Flattening of the nasolabial fold 4. Inability to smile symmetrically Bell palsy is peripheral, unilateral facial paralysis characterized by inflammation of the facial nerve (cranial nerve VII) in the absence of a stroke or other causative agent/disease. Paralysis of the motor fibers innervating the facial muscles results in flaccidity on the affected side. Manifestations of Bell palsy include: Inability to completely close the eye on the affected side Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to weakness of the lower eyelid muscle (Option 1) Flattening of the nasolabial fold on the side of the paralysis (Option 3) Inability to smile or frown symmetrically (Option 4)

The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply. 1. Cleans around the pin sites using sterile water 2. Gently tightens the device screws if they become loose 3. Holds the frame of the device when logrolling the client 4. Places a small pillow under the head when client is supine 5. Uses a blow-dryer on the cool setting to dry the vest when wet

1. Cleans around the pin sites using sterile water 4. Places a small pillow under the head when client is supine 5. Uses a blow-dryer on the cool setting to dry the vest when wet Explanation A halo external fixation device stabilizes a cervical or high thoracic fracture when there is insignificant damage to the ligaments or spinal cord. Sensory and muscle function should be monitored to determine any new deficits, and pin sites should be regularly assessed for loose pins or infection. Care for the client with a halo device includes: Cleaning pin sites with sterile solution (eg, chlorhexidine, water) to prevent infection (Option 1) Keeping the vest liner clean and dry (eg, changing weekly or when soiled, using a cool blow-dryer to dry) to protect the skin (Option 5) Placing foam inserts under pressure points to prevent pressure injury Placing a small pillow under the client's head when supine to reduce pressure on the device (Option 4) Keeping the correct-sized wrench available at all times in case of emergency (Option 2) Only the health care provider can adjust the pins. (Option 3) The nurse should avoid grabbing the device frame when moving or positioning the client, as this may cause the screws to loosen or alter device alignment. Educational objective: A halo external fixation device stabilizes a cervical or high thoracic fracture. The nurse should clean the pin sites with sterile solution to prevent infection, reduce pressure on the halo device (eg, pillow under the head), keep the vest clean and dry, and avoid holding the device frame while moving the client. Pins can be adjusted only by the health care provider.

myelomeningocele/ neural tube defect intervention

1. Cover with a sterile moist gauze 2. place on abdomen (prone) with face turn to the side

A with advanced osteoarthritis is admitted for right total knee arthroplasty. Which characteristic manifestations does the nurse expect to assess in this client? Select all that apply. 1. Crepitus with joint movement 2. Low-grade fever 3. Morning stiffness lasting 10 to 15 minutes 4. Pain exacerbated by weight-bearing activities 5. Positive serum rheumatoid factor

1. Crepitus with joint movement 3. Morning stiffness lasting 10 to 15 minutes 4. Pain exacerbated by weight-bearing activities Osteoarthritis (OA) is a degenerative disorder of the synovial joints (eg, knee, hip, fingers) that causes progressive erosion of the articular (joint) cartilage and bone beneath the cartilage. As the degenerative process continues, bone spurs (osteophytes), calcifications, and ulcerations develop within the joint space, and the "cushion" between the ends of the bones breaks down. Clinical manifestations of OA of the knee include: Pain exacerbated by weight-bearing activities: Results from synovial inflammation, muscle spasm, and nerve irritation (Option 4) Crepitus, a grating noise or sensation with movement that can be heard or palpated: Results from the presence of bone and cartilage fragments that float in the joint space (Option 1) Morning stiffness that subsides within 30 minutes of arising (Option 3) Decreased joint mobility and range of motion Atrophy of the muscles that support the joint (eg, quadriceps, hamstring) due to disuse (Option 2) Low-grade fever develops as part of systemic inflammation. OA is typically a noninflammatory, nonsystemic disorder. Occasional OA inflammation is limited to affected joints. (Option 5) Serum rheumatoid factor is positive in clients with systemic rheumatoid arthritis. No diagnostic laboratory tests or biomarkers exist for OA. Educational objective: Osteoarthritis is a degenerative disorder of the synovial joints that leads to progressive erosion of the articular (joint) cartilage. Clinical manifestations include pain exacerbated by weight-bearing, crepitus, morning stiffness subsiding within 30 minutes, decreased joint mobility and range of motion, and atrophy of supporting muscles.

The emergency department nurse assesses an elderly client who was just admitted with a fractured hip after a fall. Which assessment findings would the nurse most likely expect? Select all that apply. 1. Ecchymosis over the thigh and hip 2. Groin and hip pain with weight bearing 3. Internal rotation of the affected extremity 4. Muscle spasm around the affected area 5. Shortening of the affected extremity

1. Ecchymosis over the thigh and hip 2. Groin and hip pain with weight bearing 4. Muscle spasm around the affected area 5. Shortening of the affected extremity Explanation The most common clinical manifestations of hip fractures include: Ecchymosis and tenderness over the thigh and hip - occur from bleeding into the surrounding tissue as the femur is very vascular and a fracture can result in significant blood loss (>1000 mL) (Option 1) Groin and hip pain with weight bearing (Option 2) Muscle spasm in the injured area - occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area (Option 4) Shortening of the affected extremity - occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward (Option 5) Abduction or adduction of the affected extremity depending on location and mechanism of injury. (Option 3) The affected extremity is usually externally rotated. Educational objective: The characteristic clinical manifestations of most hip fractures include external rotation, abduction, muscle spasm, and shortening of the affected extremity.

tonsilitis

1. Fever 2. soar throat (difficultly swallowing) 3. Trismus ( cannot open the mouth) 4. Muffled hot potato voice 5. Deviation of the uvula to one side 6. pooling of saliva

Clinical manifestations of bacterial meningitis in children <2

1. Fever possible hypothermia 2. Irritability frequent seizures 3high pitch crying 4. poor feeding and vomiting 5. Neutral rigidity (stiff neck) 6. Bulging frontanelle ( not always present)

The nurse is caring for a client in the medical-surgical unit who has delirium according to the Confusion Assessment Method assessment tool. Which of the following assessment findings are likely contributing to the client's delirium? Select all that apply. 1. Multiple doses of IV hydromorphone administered in the past 12 hours 2. Serum sodium of 123 mEq/L (123 mmol/L) 3. SpO2 of 82% on room air 4. Temperature of 103.1 F (39.5 C) 5. Urine culture positive for gram-positive cocci in chains

1. Multiple doses of IV hydromorphone administered in the past 12 hours 2. Serum sodium of 123 mEq/L (123 mmol/L) 3. SpO2 of 82% on room air 4. Temperature of 103.1 F (39.5 C) 5. Urine culture positive for gram-positive cocci in chains Explanation NCLEX® CHANGE AS OF 2017 - Please note that select-all-that-apply (SATA) questions on NCLEX can now include any number of correct responses. Only ONE option or up to ALL options may be correct. UWorld questions now reflect this change. Visit NCSBN® NCLEX FAQs for more information. Delirium is characterized by an acute or fluctuating change in mental status that is often reversible and related to an underlying medical condition. Evidence-based assessment tools, such as the Confusion Assessment Method (CAM), help clinicians quickly recognize delirium. Criteria of the CAM tool include an acute or fluctuating change in mentation, inattention, disorganized thinking, and altered level of consciousness. Precipitating factors of delirium are numerous and include: Medications (eg, opioids, anticholinergics) (Option 1) Electrolyte imbalances (eg, hyponatremia) (Option 2) Hypoxia (Option 3) Acute infection (eg, fever, positive culture) (Options 4 and 5) Sleep deprivation Dehydration or malnutrition Metabolic disorders (eg, hypoglycemia) Nursing interventions include treating the underlying cause as prescribed to resolve delirium (eg, antibiotics, supplemental oxygen), maintaining a safe environment (eg, continuous monitoring, room near the nurses' station, bed alarm), reorienting the client frequently, promoting a regular sleep cycle, providing familiar items from home, and encouraging family and friends to stay with the client. Educational objective: The Confusion Assessment Method is an assessment tool that helps clinicians quickly recognize delirium, which is characterized by an acute or fluctuating change in mental status and is often caused by medications (eg, opioids) or an underlying medical condition (eg, hypoxia, electrolyte imbalances, infection).

The nurse has provided education for a client with newly diagnosed ankylosing spondylitis. Which client statements indicate a correct understanding of teaching? Select all that apply. 1. "I should continue strenuous exercise during flare-ups." 2. "I should include spine-stretching activities such as swimming." 3. "I should quit smoking and perform breathing exercises." 4. "I will sleep on a soft mattress to decrease my morning stiffness." 5. "I will take the prescribed ibuprofen on an empty stomach."

2. "I should include spine-stretching activities such as swimming." 3. "I should quit smoking and perform breathing exercises." Ankylosing spondylitis (AS), an inflammatory disease affecting the spine, has no known cause or cure. AS is characterized by stiffness and fusion of the axial joints (eg, spine, sacroiliac), leading to restricted spinal mobility. Low back pain and morning stiffness that improve with activity are the classic findings. Involvement of the thoracic spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation. The client with AS should: Promote extension of the spine with proper posture, daily stretching, and spine-stretching exercises (eg, swimming, racquet sports) (Option 2). Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications (Option 3). Manage pain with moist heat and NSAIDs. Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility. (Option 1) It is best to rest during flare-ups. The client should delay exercise until the pain and inflammation are under control. (Option 4) Clients with AS are encouraged to sleep on their backs on a firm mattress to prevent spinal flexion and the resulting deformity. (Option 5) Ibuprofen and other NSAIDs should be taken with a meal or snack to avoid gastric upset. Educational objective: Ankylosing spondylitis is an inflammatory spinal disease characterized by back pain and morning stiffness that improve with exercise/activity. Chest wall restriction is a serious complication. Treatment is targeted at reducing pain (eg, moist heat, NSAIDs) and maintaining skeletal mobility (eg, proper posture, stretching, breathing exercises) to promote activities of daily living.

The registered nurse (RN) is supervising a graduate nurse (GN) providing postoperative teaching for a male client after an inguinal hernia repair. Which statement by the GN would cause the RN to intervene? 1. "Elevate your scrotum and apply an ice bag to reduce swelling."[18%] 2. "Practice coughing to clear secretions and prevent pneumonia."[47%] 3. "Stand up to use the urinal if you have difficulty voiding."[27%] 4. "Turn in bed and perform deep breathing every 2 hours."[5%]

2. "Practice coughing to clear secretions and prevent pneumonia."[47%] After inguinal hernia repair surgery, clients should avoid coughing and heavy lifting, ambulate early, turn and deep breathe every 2 hours, and stand when voiding. Scrotal elevation and ice packs help decrease pain and swelling.

A client tells the nurse of wanting to lose 20 lb (9 kg) in time for the client's daughter's wedding, which is 16 weeks away. How many calories (kcal) will the client have to eliminate from the diet each day to meet this goal? 1. 450 kcal/day[27%] 2. 625 kcal/day[46%] 3. 860 kcal/day[17%] 4. 1,000 kcal/day[8%]

2. 625 kcal/day[46%] A reduction or energy expenditure of 3,500 calories (kcal) will result in a weight loss of 1 lb (0.45 kg). To lose 20 lb (9 kg), the client needs to reduce intake by a total of 70,000 kcal (3500 kcal x 20 lb [9 kg] = 70,000 kcal). Over a period of 16 weeks, this would require a daily reduction of: 625 kcal (70,000 kcal / [16 weeks x 7 days] = 625 kcal/day) Adding an exercise regimen to the client's daily routine would facilitate additional weight loss and/or reduce the need for severe caloric restriction. (Option 1) Reducing intake by 450 kcal/day over 16 weeks would result in a weight loss of 14.5 lb (6.5 kg). (Option 3) Reducing intake by 860 kcal/day over 16 weeks would result in a weight loss of 27.5 lb (12.4 kg). (Option 4) Reducing intake by 1000 kcal/day over 16 weeks would result in a weight loss of 32 lb (14.5 kg). Educational objective: A reduction or energy expenditure of 3500 calories (kcal) will result in a weight loss of 1 lb.

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply. 1. Albumin 2. Ammonia 3. Bilirubin 4. Prothrombin time 5. Sodium

2. Ammonia 3. Bilirubin 4. Prothrombin time Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes alter blood flow through the liver and decrease the liver's functionality. Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin (Option 3). Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated partial thromboplastin time [aPTT]) are usually elevated (Option 4). Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy (Option 2). (Options 1 and 5) Albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of vascular spaces into interstitial spaces (eg, edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb (conserve) both sodium and water. The large amount of water in the body results in a dilutional effect (low sodium). Educational objective: The chronic, progressive destruction characteristic of cirrhosis causes bilirubin, ammonia, and coagulation studies (PT/INR and aPTT) to become elevated. Hyponatremia and hypoalbuminemia are to be expected.

After rolling the ankle outwards when jogging, a client develops ankle pain and swelling. The health care provider diagnoses a lateral ankle sprain. Which interventions does the nurse include in the discharge instructions? Select all that apply. 1. Apply heat to reduce swelling during the first 24 hours 2. Begin an exercise rehabilitation program when the pain subsides 3. Elevate the leg above the heart level on 2 pillows 4. Flex and dorsiflex the foot to prevent stiffness during the first 24 hours 5. Take ibuprofen every 6 hours as needed 6. Wrap the ankle with an elastic compression bandage

2. Begin an exercise rehabilitation program when the pain subsides 3. Elevate the leg above the heart level on 2 pillows 5. Take ibuprofen every 6 hours as needed 6. Wrap the ankle with an elastic compression bandage Explanation A sprain is a stretch and/or tear of a ligament. Treatment for a sprained ankle includes: Rest - Activity should be stopped and movement limited for 24-48 hours to promote healing. The health care provider may prescribe no weight-bearing on the joint for 48 hours, and crutches may be required. Ice (cold, cryotherapy) - Cold therapy or an ice pack should be applied for 10-15 minutes every hour for the first 24-48 hours. Vasoconstriction helps to reduce pain, inflammation, and swelling. Ice should not be applied directly to the skin. Compression (eg, ACE wrap, splint) - Pressure/compression can help prevent edema and promote fluid return (Option 6). Elevation - The extremity should be kept elevated above the heart on pillows for 24-48 hours to help reduce swelling by promoting fluid return (Option 3). Analgesia - Mild analgesia with a nonsteroidal anti-inflammatory drug (eg, ibuprofen) can be taken every 6 hours as needed to relieve pain and reduce swelling (Option 5). Exercise rehabilitation program - This should be initiated as soon as possible after the injury (ie, when pain subsides) to restore range of motion, flexibility, and strength and prevent reinjury (Option 2). (Option 1) Cold therapy or ice should be used initially; after the first 24-48 hours, moist heat can be applied for 20-30 minutes at a time to reduce swelling, with a cooldown between applications. (Option 4) Rest is indicated during the acute injury phase (24-48 hours). After this acute phase, the client is encouraged to use the extremity and move the joint to improve circulation and reduce swelling as long as the joint is protected with some type of immobilizer (eg, brace, tape, splint). Educational objective: Treatment for a sprained joint consists of Rest, Ice, Compression, and Elevation (RICE) for the first 24-48 hours following the injury, mild analgesia with a nonsteroidal anti-inflammatory drug, and an exercise rehabilitation program when pain subsides.

he nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which of the following as expected neurological changes for the client with a concussion? Select all that apply. 1. Asymmetrical pupillary constriction 2. Brief loss of consciousness 3. Headache 4. Loss of vision 5. Retrograde amnesia Concussion

2. Brief loss of consciousness 3. Headache 5. Retrograde amnesia Explanation A concussion is considered a minor traumatic brain injury and results from blunt force or an acceleration/deceleration head injury. Typical signs of concussion include: A brief disruption in level of consciousness Amnesia regarding the event (retrograde amnesia) Headache These clients should be observed closely by family members and not participate in strenuous or athletic activities for 1-2 days. Rest and a light diet are encouraged during this time.

A client receiving total parenteral nutrition complains of nausea, abdominal pain, and excessive thirst. What is the best action for the nurse to take? 1. Assess the client's vital signs[10%] 2. Check the client's blood glucose[67%] 3. Report the findings to the health care provider[1%] 4. Slow down the rate of infusion[20%]

2. Check the client's blood glucose[67%] A complication of total parenteral nutrition (TPN) is hyperglycemia, as evidenced by excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision. The development of hyperglycemia is related to the following: Excessive dextrose infusion A low tolerance for dextrose in critically ill clients due to the inflammatory response and the resulting production of counterregulatory hormones High infusion rate Administration of medications such as steroids Infection Interventions to resolve TPN-associated hyperglycemia include reducing the amount of carbohydrate in the TPN solution, slowing down the infusion rate, and administering subcutaneous insulin.

The nurse is caring for a client with a balloon tamponade tube in place due to bleeding esophageal varices. The client suddenly develops respiratory distress, and the nurse finds that the tube has been partially pulled out. Which intervention should be the nurse's priority? 1. Contact the health care provider[7%] 2. Cut the tube with scissors[46%] 3. Increase gastric suction level[1%] 4. Place the client in high Fowler position[44%]

2. Cut the tube with scissors[46%] A balloon tamponade tube (eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal (Option 2). (Option 1) If airway obstruction occurs, the nurse should first clear the airway and then ensure that the client is stable before contacting the health care provider. (Option 3) Low intermittent suction to the gastric lumen of a balloon tamponade tube is used to drain stomach contents. Increasing the suction would not be indicated if the tube has become displaced. (Option 4) If the balloon tamponade tube is displaced and obstructing the airway, changing the client's position will not help until the client's airway is cleared by removing the tube. Educational objective: A balloon tamponade tube is used to compress bleeding esophageal varices. Tube displacement may result in airway obstruction. The nurse should keep scissors at the bedside so that the tube can be emergently cut and removed if respiratory distress develops due to tube displacement

The nurse provides education for caregivers of a client with Alzheimer disease. Which instructions should the nurse include? Select all that apply. 1. Complete activities such as bathing and dressing as quickly as possible 2. Decrease the client's anxiety by limiting the number of choices offered 3. Redirect the client if agitated by asking for help with a task or going for a walk 4. Remember to interact with the client as an adult, regardless of childlike affect 5. Use open-ended questions when communicating with the client

2. Decrease the client's anxiety by limiting the number of choices offered 3. Redirect the client if agitated by asking for help with a task or going for a walk 4. Remember to interact with the client as an adult, regardless of childlike affect Strategies for caring for clients with Alzheimer disease address progressive memory loss and declining ability to communicate, think clearly, and perform activities of daily living. Caregivers should also learn to manage clients' problematic behavior and mood swings. Therapeutic guidelines include: Use distraction and redirection (eg, going for a walk) to manage agitation (Option 3). Speak slowly and use simple words and yes-or-no questions. Do not try to rationalize with the client. Use visual cues when giving directions. Interact with the client as an adult, even as the client regresses to childlike affect and behavior; respect client dignity by avoiding use of pet names (eg, "honey," "sweetie," "darling") (Option 4). Break down complex activities into steps with simple instructions. Decrease the client's anxiety by limiting the number of choices (Option 2).

A client with a T4 spinal cord injury has a severe throbbing headache and appears flushed and diaphoretic. Which priority interventions should the nurse perform? Select all that apply. 1. Administer an analgesic as needed 2. Determine if there is bladder distention 3. Measure the client's blood pressure 4. Place the client in the Sims' position 5. Remove constrictive clothing Autonomic dysresflexia

2. Determine if there is bladder distention 3. Measure the client's blood pressure 5. Remove constrictive clothing Educational objective: Autonomic dysreflexia is a life-threatening condition in a client with high spinal cord injury. Classic signs/symptoms include severe hypertension, throbbing headache, diaphoresis, bradycardia, flushing, and piloerection. Emergency treatment includes correcting the cause (check bowel or bladder distention), removing tight clothing, and raising the head of the bed.

The nurse is assessing a client with advanced amyotrophic lateral sclerosis. Which of the following assessment findings does the nurse expect? Select all that apply. 1. Diarrhea 2. Difficulty breathing 3. Difficulty swallowing 4. Muscle weakness 5. Resting tremor

2. Difficulty breathing 3. Difficulty swallowing 4. Muscle weakness Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease) is a debilitating neurodegenerative disease with no cure. ALS causes progressive degeneration of motor neurons in the brain and spinal cord. Physical symptoms include fatigue, progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure (Options 2, 3, and 4). Most clients survive only 3-5 years after the diagnosis as there is no cure. Treatment focuses on symptom management. Interventions include: Respiratory support with noninvasive positive pressure (eg, bilevel positive airway pressure [BiPAP]) or invasive mechanical ventilation (eg, via tracheostomy) Feeding tube for enteral nutrition Medications to decrease symptoms (eg, spasms, uncontrolled secretions, dyspnea) Mobility assistive devices (eg, walker, wheelchair) Communication assistive devices (eg, alphabet boards, specialized computers) (Option 1) Constipation due to decreased mobility is more common in ALS. Diarrhea is not seen. (Option 5) Resting tremor is characteristic of parkinsonism. Educational objective: Amyotrophic lateral sclerosis causes motor neuron degeneration that leads to progressive muscle weakness, twitching and muscle spasms, difficulty swallowing, difficulty speaking, and respiratory failure. There is no cure. Treatment focuses on symptom management.

The nurse is caring for a client following a transsphenoidal hypophysectomy. Which clinical findings would the nurse recognize as signs that the client may be developing diabetes insipidus? Select all that apply. 1. Decreased serum sodium 2. Excess oral water intake 3. High urine output 4. Increased serum osmolality 5. Increased urine specific gravity

2. Excess oral water intake 3. High urine output 4. Increased serum osmolality Explanation Transsphenoidal hypophysectomy is the surgical removal of the pituitary gland, an endocrine gland that produces, stores, and excretes hormones (eg, antidiuretic hormone [ADH], growth hormone, adrenocorticotropic hormone). Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus (DI), a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys. Therefore, loss of circulating ADH results in massive diuresis of dilute urine. Clinical manifestations associated with DI include: Decreased urine specific gravity (<1.003) (Option 5) Elevated serum osmolality (>295 mOsm/kg [295 mmol/kg]) (Option 4) Hypernatremia (>145 mEq/L [145 mmol/L]) (Option 1) Hypovolemia and potential hypotension Polydipsia (Option 2) Polyuria (2-20 L/day) (Option 3) Educational objective: Diabetes insipidus (DI) is a metabolic disorder of decreased antidiuretic hormone, which is responsible for water retention in the kidneys. DI is often related to a preceding trauma, pituitary tumors, or neurosurgery (eg, hypophysectomy). Clinical manifestations of DI include polyuria, polydipsia, hypernatremia, hypovolemia, increased serum osmolality, and decreased urine specific gravity.

The nurse cares for a client admitted to the hospital due to confusion. The client has a nonmetastatic lung mass and a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which action(s) should the nurse expect to implement? Select all that apply. 1. Fluid bolus (normal saline) 2. Fluid restriction 3. Salt restriction in the diet 4. Seizure precautions 5. Strict record of fluid intake and output

2. Fluid restriction 4. Seizure precautions 5. Strict record of fluid intake and output Explanation SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions. SIADH treatment includes: Fluid restriction to <1000 mL/day Oral salt tablets to increase serum sodium (Option 3) Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations Vasopressin receptor antagonists (eg, conivaptan) The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration. (Option 1) Normal saline fluid bolus would worsen the hyponatremia as the client already has excess fluid volume. Symptoms are caused by a low sodium level. If the sodium level must be raised, the client will need hypertonic (3%) saline or salt tablets as these contain mainly sodium and little free fluid. Educational objective: SIADH can occur due to lung cancer and is characterized by water retention, increased total body water, and dilutional hyponatremia. Hyponatremia may cause neurologic complications (eg, confusion, seizures). SIADH treatment includes fluid restriction, oral salt tablets, and administration of 3% saline IV and/or vasopressin receptor antagonists.

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the client's symptoms? 1. Brain natriuretic peptide 70 pg/mL (70 pmol/L)[19%] 2. Hematocrit 21% (0.21)[62%] 3. Leukocytes 3,500/mm3 (3.5 x 109/L)[5%] 4. Platelets 105,000/mm3 (105 x 109/L)[12%]

2. Hematocrit 21% (0.21)[62%] Explanation Hematocrit (Hct) is the percentage of red blood cells (RBCs) in a volume of whole blood. Hct and hemoglobin (Hgb) values are related (approximately 3 x Hgb = Hct); when one value is decreased, the other is also. This client likely has hemoglobin of 7 g/dL (70 g/L) (normal, 13.2-17.3 g/dL [132-173 g/L] for males and 11.7-15.5 g/dL [117-155 g/L] for females). Hgb is a component of the RBC that carries oxygen to the body's tissues. A decrease in Hgb decreases oxygen-carrying capacity and transport to tissues. RBCs may be 100% saturated with oxygen at rest, but desaturation may occur with increased activity and oxygen demand in the presence of decreased Hct and Hgb. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia. (Option 1) Brain natriuretic peptide (BNP) >100 pg/mL (100 pmol/L) is considered elevated and indicates ventricular stretch (heart failure) as the cause of the dyspnea. This client has normal BNP levels, making heart failure an unlikely cause. (Option 3) The leukocyte count is decreased (normal, 4,000-11,000/mm3 [4.0-11.0 x 109/L]). Leukocytes play a role in protecting the body from disease. (Option 4) The platelet count is decreased (normal, 150,000-400,000/mm3 [150-400 x 109/L]). Platelets play a role in blood clotting. Educational objective: Hemoglobin is a component of red blood cells that carries oxygen to the body's tissues. In the presence of decreased hematocrit and hemoglobin, decreased oxygen-carrying capacity and transport occur. Manifestations associated with decreased oxygen transport include shortness of breath with activity, tachypnea, and tachycardia.

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next? 1. Check vital signs[38%] 2. Maintain IV access with normal saline[54%] 3. Notify the health care provider[6%] 4. Recheck identification labels and numbers[0%]

2. Maintain IV access with normal saline[54%] Explanation Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include: Stop transfusion immediately and disconnect tubing at the catheter hub. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse (Option 2). Notify health care provider (HCP) and blood bank. Monitor vital signs. Recheck labels, numbers, and the client's blood type. Treat client's symptoms according to the HCP's prescription. Collect blood and urine specimens to evaluate for hemolysis. Return blood and tubing set to the blood bank for additional testing. Complete necessary facility paperwork to document the reaction. (Option 1) Monitoring vital signs would be the step after ensuring IV access, administering normal saline, and notifying the HCP. (Option 3) The nurse should ensure continued IV access before notifying the HCP. The HCP will likely prescribe IV medications (eg, vasopressors, antihistamines, corticosteroids) to treat the transfusion reaction, so a patent IV is critical. (Option 4) Mislabeling blood and administering the wrong blood type are the most common causes of a transfusion reaction. However, maintaining IV access takes priority over investigating a potential clinical error. Educational objective: During a blood transfusion reaction, the nurse should immediately stop the transfusion and initiate normal saline to maintain IV access and prevent hypotension and vascular collapse.

The registered nurse is developing a nursing care plan for a client who has just undergone surgery for treatment of ulcerative colitis with the creation of a permanent ileostomy. What is the priority outcome for this client? 1. The client will contact the United Ostomy Association of America[1%] 2. The client will look at and touch the stoma[70%] 3. The client will read the materials provided on ostomy care[10%] 4. The client will verbalize methods to control gas and odor[18%]

2. The client will look at and touch the stoma[70%] A client who has undergone ostomy surgery must become independent in self-care. This requires adaptation to a significant alteration in body image and dealing with a number of psychosocial issues that are associated with a change in appearance and the loss of bowel control. It is not uncommon for a client to cope with this loss by refusing to look at or participate in the care of the stoma. Nursing interventions for this client will include: Supportive counseling and assistance in psychosocial adjustment Teaching and facilitating self-care Providing information about the reason for the surgery, prognosis, potential complications, and community resources The priority outcome of nursing care is that the client will look at and touch the stoma; this is an indication that the client has accepted or begun to accept the change in body image and functioning and can begin participating in self-care. (Option 1) This is an appropriate outcome; community organizations can offer support and educational materials to the client; however, it is not the priority. (Option 3) This is an appropriate outcome, but as a passive activity, it is not a strong indicator that the client is ready for self-care. (Option 4) This is an appropriate outcome as it indicates effective ostomy teaching; however, it is not the priority. Teaching will be more effective once the client has accepted the ostomy. Educational objective: A client with a change in body image and functioning, such as the creation of an ostomy, will need to adapt to and cope with the significant changes. Support and teaching will assist the client in overcoming psychosocial barriers to self-care; performance of a desired action is the strongest indicator of learning and acceptance.

Normal serum amylase level

25-151 units/L (will rise in pancreatitis) this level rise in chronic pancreatitis but not pass 3 times its normal level -in acute pancreatitis the levels will rise over 5 times its normal value

The nurse is educating a client newly diagnosed with rheumatoid arthritis about the disease process and home management. Which statement by the client indicates comprehension of teaching? 1. "Even with appropriate treatment joint damage and disability are inevitable."[16%] 2. "My arthritis can be resolved if I can improve my diet and lose weight."[7%] 3. "My methotrexate should be taken even when my joints aren't hurting."[61%] 4. "When my joints hurt, I should rest frequently and try not to move them."[14%]

3. "My methotrexate should be taken even when my joints aren't hurting."[61%] Rheumatoid arthritis (RA) is a chronic, relapsing autoimmune disorder causing painful inflammation of synovial joints and fibrosis and stiffening of synovial membranes. Contracture of ligaments and joint remodeling may occur, resulting in weakness and deformity. Clients with RA require education on prevention of disease progression, including: Joint protection - Fibrosis from RA can shorten tendons and ligaments when joints are flexed for prolonged periods. Body aligners or immobilizers should be used when resting to keep extremities straight (especially with advanced disease). Medications - RA is often treated using a regimen of disease-modifying antirheumatic drugs (eg, methotrexate), and clients should take their medication as prescribed regardless of symptoms (Option 3). (Option 1) Joint deformity can be prevented with appropriate treatment, including use of disease-modifying antirheumatic drugs and joint protection. (Option 2) Obesity is a risk factor for osteoarthritis, in which mechanical erosion of joint cartilage occurs. However, obesity is unrelated to RA, and clients with RA experience chronic fatigue and pain that may limit oral intake and cause weight loss. The nurse should ensure that clients with RA have access to adequate nutrition. (Option 4) During painful episodes, periods of rest are encouraged; however, clients should frequently perform range of motion exercises to prevent loss of function. Educational objective: Rheumatoid arthritis (RA) is a chronic autoimmune disorder that causes pain and joint deformity. Clients with RA should be taught to remain active to prevent contracture, take immunosuppressant medications consistently, use body aligners to prevent joint contracture, and eat a balanced diet

An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse? 1. "I will refer you to the dietitian."[3%] 2. "It should take about 6-8 weeks before you see improvement in your symptoms."[23%] 3. "Tell me what you had to eat yesterday."[71%] 4. "You must not be following your diet."[0%]

3. "Tell me what you had to eat yesterday."[71%] This client with celiac disease continues to have symptoms. An assessment of the client's food intake must be obtained to determine if it includes foods that contain gluten, a protein in barley, rye, oats, and wheat (mnemonic: BROW). The most common reason for non-responsiveness to a gluten-free diet in clients with celiac disease is that gluten has not been entirely eliminated from their food intake. (Option 1) Referral to a dietitian is an appropriate intervention. However, the nurse must first explore why the client is not responding to therapy. This is not the first or best response by the nurse. (Option 2) Most people experience dramatic relief of gastrointestinal symptoms within a few days of eliminating gluten from their diet. (Option 4) This is a non-therapeutic response that "blames" the client for symptoms. In addition, this conclusion cannot be made without an assessment of the client's intake. Educational objective: When a client with celiac disease does not experience symptom relief after being on a gluten-free diet, it is most important for the nurse to assess the underlying cause. The most common reason for refractory symptoms is failure to follow the strict gluten-free diet.

The nurse is caring for several clients in a women's health clinic. Based on the data collected, which client's history is most concerning for an increased risk of endometrial cancer? 1. 40-year-old client who has been taking hormonal birth control pills for the past 10 years[8%] 2. 45-year-old client who reports a history of an ectopic pregnancy with a ruptured ovary and two preterm births[10%] 3. 47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments[42%] 4. 60-year-old client who recently had a colposcopy after testing positive for a high-risk type of human papillomavirus[38%]

3. 47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments[42%] Endometrial cancer arises from the inner lining of the uterus and forms after the development of unregulated endometrial overgrowth (ie, hyperplasia). Although typically slow growing, it can metastasize to the myometrium (ie, uterine muscle tissue), cervix, and nearby lymph nodes and eventually beyond the pelvis. Many signs of endometrial cancer are nonspecific (eg, lower back or abdominal pain), but the hallmark symptom is abnormal uterine bleeding (eg, heavy, prolonged, intermenstrual, and/or postmenopausal bleeding). As with many cancers, the client's family and genetic history (eg, BRCA mutation carrier) are significant risk factors; however, prolonged estrogen exposure without adequate progesterone is the greatest risk factor for developing endometrial cancer. Factors increasing estrogen exposure and endometrial cancer risk include: Conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility, late menopause, early menarche) (Option 3) Obesity Tamoxifen (a medication given for breast cancer) (Option 1) Progestin-containing contraceptives (ie, birth control pills) are associated with a decreased endometrial cancer risk because progestins thin the uterine lining, therefore preventing endometrial hyperplasia. (Option 2) Ectopic pregnancy with a ruptured ovary or preterm birth is not associated with endometrial cancer, although never giving birth at term gestation may increase ovarian cancer risk. (Option 4) Infection with a high-risk type of human papillomavirus increases cervical (not endometrial) cancer risk. Educational objective: Endometrial cancer is a slow-growing malignancy that arises from the inner lining of the uterus. Major risk factors include conditions associated with infrequent or anovulatory menstrual cycles (eg, polycystic ovary syndrome, infertility), obesity, and tamoxifen therapy.

An elderly client with osteoporosis falls onto an out-stretched hand and injures the wrist. The client has severe wrist edema, deformity, and pain rated a 10 on a pain scale of 0-10. What should be the nurse's first action? 1. Administer analgesia[12%] 2. Apply an ice pack to the wrist[10%] 3. Assess capillary refill and sensation[64%] 4. Elevate the wrist above heart level[12%]

3. Assess capillary refill and sensation[64%] A Colles' fracture is a type of wrist fracture (distal radius fracture) that causes a characteristic dinner fork deformity of the wrist. It usually occurs when the client tries to break a fall with an outstretched arm or hand, and lands on the heel of the hand. It is one of the most common fractures in women age >50 and is related to osteopenia or osteoporosis. While the client is undergoing evaluation by the health care provider (HCP) in the emergency department (ED), nursing interventions should include: Performing a neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement). This is the priority nursing action as neurovascular insufficiency related to swelling (eg, compartment syndrome) or arterial/nerve damage by the bone fragments is associated with a Colles' fracture. If neurovascular status is compromised, urgent reduction of the fracture is indicated. Administering analgesia to promote comfort (Option 1). Applying an ice pack to the wrist to help reduce edema and inflammation (Option 2). Elevating the extremity on a pillow above heart level to reduce edema (Option 4). Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of motion. Educational objective: While a client with a traumatic wrist fracture is undergoing evaluation by the HCP in the ED to determine appropriate treatment, the nurse assesses circulation, sensation, and movement of the affected hand, and then performs nursing interventions to reduce pain and edema.

The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse's initial action? 1. Encourage intake of over-the-counter iron pills[18%] 2. Encourage intake of red meat and egg yolks[29%] 3. Facilitate a screening colonoscopy[43%] 4. Facilitate another blood test in 6 months[8%]

3. Facilitate a screening colonoscopy[43%] Explanation Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment. (Options 1 and 2) The cause of anemia must be determined before recommendations can be provided for iron deficiency. There are many causes of anemia (including pernicious anemia) in older adults that involve deficiencies in vitamin B12, not iron. (Option 4) Waiting for 6 months will delay care. Educational objective: The etiology of new-onset anemia in an adult should be determined prior to treatment. Clients age ≥50 should be screened for colorectal cancer. Early signs include anemia.

The nurse teaching a group of clients about celiac disease will include which meal in the teaching plan? 1. Baked salmon with rice, steamed vegetables, and dinner roll[13%] 2. Breaded pork chops, corn on the cob, and steamed snow peas[7%] 3. Grilled chicken, green beans, and mashed potatoes[75%] 4. Spaghetti with Italian tomato sauce and meatballs[3%]

3. Grilled chicken, green beans, and mashed potatoes[75%] No breads or pastas, macaroni, spaghetti Celiac disease is an autoimmune disorder in which chronic inflammation caused by gluten damages the small intestine. The following are important dietary principles to teach clients with celiac disease: All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. Rice, corn, and potatoes are gluten free and are allowed on the diet (Option 3). Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten, such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from their diet reduces the risk for nutritional deficiencies and intestinal cancer (lymphoma). Eating even small amounts of gluten will damage the intestinal villi, although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet. (Option 1) Baked salmon, rice, and steamed vegetables are all permitted on a gluten-free diet. The dinner roll contains gluten and should be avoided. Baked goods and breads (including white and wheat) contain gluten unless the package is labeled "gluten free" or the products are made from nongluten sources (eg, rice flour). (Option 2) Although meat, fish, and poultry are permitted, marinated and breaded protein sources should be avoided. Corn and snow peas are appropriate selections for a gluten-free diet. (Option 4) Pasta contains gluten and should be avoided. Gluten-free pastas are available and are safe to consume. Educational objective: All sources of gluten must be eliminated from the diet of a client with celiac disease. Consuming small amounts, even in the absence of clinical symptoms, will increase the risk for damage to the intestinal villi. Clients can have foods containing rice, corn, and potatoes. They should read food labels and follow the diet for the rest of their lives.

The nurse is caring for a client diagnosed with Guillain-Barré syndrome (GBS) after a recent gastrointestinal (GI) illness. Monitoring for which of the following is a nursing care priority for this client? 1. Diaphoresis with facial flushing[8%] 2. Hypoactive or absent bowel sounds[16%] 3. Inability to cough or lift the head[65%] 4. Warm, tender, and swollen leg[9%]

3. Inability to cough or lift the head[65%] GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep-tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include: Inability to cough Shallow respirations Dyspnea and hypoxia Inability to lift the head or eye brows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation. (Option 1) Severe autonomic dysfunction can present as diaphoresis and facial flushing. (Option 2) The client with GBS is also at risk for paralytic ileus, which is related to either immobility or nerve damage. As a result, the nurse should monitor for the presence hypoactive/absent bowel sounds. (Option 4) Clients with GBS are at risk of developing deep venous thrombosis due to lack of ambulation and should receive pharmacologic prophylaxis (heparin) and support stockings. Although symptoms in options 1, 2, and 4 represent a progressive illness and are important to communicate to the health care provider promptly, they are not the highest priority compared to impending respiratory failure. Educational objective: Respiratory distress is a potential complication of progressing paralysis in clients with Guillain-Barré syndrome. The nurse should prioritize and monitor for the presence of this complication. Measurement of serial spirometry (FVC) is the gold standard for assessing ventilation.

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination? Select all that apply. 1. Bitter almond smell on breath 2. Fever and raised skin pustules 3. Low blood cell counts 4. Oral mucosal ulcerations 5. Vomiting and diarrhea

3. Low blood cell counts 4. Oral mucosal ulcerations 5. Vomiting and diarrhea Explanation Radiation damages the DNA, which causes cell destruction. Radiation (and chemotherapy) usually affects tissues with rapidly proliferating cells (eg, oral mucosa, gastrointestinal tract, bone marrow) first, followed by tissues with slowly proliferating cells (eg, cartilage, bone, kidney). As a result, early manifestations of radiation damage include oral mucosal ulcerations, vomiting/diarrhea, and low blood cell counts. The extent of radiation exposure can be monitored indirectly by measuring blood cell counts. (Option 1) A bitter almond smell on the client's breath is a classic sign of cyanide poisoning. (Option 2) Fever and raised skin pustules are signs/symptoms of smallpox, which is transmitted from person to person via respiratory droplets. Infection starts with fever, followed by a rash and then sharply raised pustules. Educational objective: Radiation contamination (and chemotherapy) affects rapidly proliferating (dividing) cells first, such as those of the oral mucosa, gastrointestinal tract, and bone marrow.

Thrombotic thrombocytopenic purpura is suspected due to the client's current platelet count of 2,000/mm3 (2 x 109/L). Which client sign or symptom is the most concerning and requires immediate further nursing action? 1. Current oozing epistaxis[17%] 2. Ecchymosis on leg since yesterday[4%] 3. New-onset confusion[76%] 4. Reported history of hematuria[2%]

3. New-onset confusion[76%] Explanation Thrombotic thrombocytopenic purpura (TTP) consists of hemolytic anemia with fragmentation of erythrocytes, signs of intravascular hemolysis, thrombocytopenia, decreased renal function, and fever. Regardless of the cause of the low platelets, the concern in this case is the critically low (below 10,000/mm3 (10 x 109/L) platelet count, which puts this client at risk for internal bleeding, especially within the brain. Change in level of consciousness is the most clinically significant finding requiring an emergency response. (Option 1) The head is very vascular, and a nosebleed can occur with low platelets. A nosebleed is treated with direct pressure and application of cold. In this client, potential intracranial bleeding is the priority. (Option 2) Easy bruising can occur as a result of low platelets. However, the bruise is "old," and potential intracranial bleeding is the priority. (Option 4) Blood in the urine can be a symptom of low platelets due to lack of clotting ability. Although this is concerning, alterations in level of consciousness is the priority. Educational objective: A priority assessment in a client with low platelets is any change in level of consciousness (eg, disorientation, lethargy, restlessness). This can indicate intracranial bleeding and increased intracranial pressure.

Steps for performing the z tract technique

4. Pull the skin 1-1 ½" (2.5-3.5 cm) laterally and away from the injection site 3. Hold the skin taut with non-dominant hand and insert needle at a 90-degree angle 2. Inject medication slowly with dominant hand while maintaining traction 6. Wait 10 seconds after injecting the medication and withdraw the needle 5. Release the hold on the skin, allowing the layers to slide back to their original position 1. Apply gentle pressure at the injection site but do not massage

The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider? 1. "I got short of breath this morning when I worked out."[7%] 2. "I have cut down on smoking to 1/2 pack per day."[12%] 3. "I haven't been feeling well, so I have been sleeping a lot."[27%] 4. "I took an acetaminophen in the waiting room for this bad headache."[51%]

4. "I took an acetaminophen in the waiting room for this bad headache."[51%] Explanation An arteriovenous malformation (AVM) is a tangle of veins and arteries that is believed to form during embryonic development. The tangled vessels do not have a capillary bed, causing them to become weak and dilated. AVMs are usually found in the brain and can cause seizures, headaches, and neurologic deficits. Treatment depends on the location of the AVM, but blood pressure control is crucial. Clients with AVMs are at high risk for having an intracranial bleed as the veins can easily rupture because they lack a muscular layer around their lumen. Any neurologic changes, sudden severe headache, nausea, and vomiting should be evaluated immediately as these are usually the first symptoms of a hemorrhage (Option 4). (Option 1) The report of dyspnea may prompt further evaluation depending on the type of exercise performed, but it is not the priority. Clients with AVMs should be discouraged from engaging in heavy exercise as it increases blood pressure. (Option 2) Clients with AVMs should avoid smoking to prevent hypertension. This client needs education on smoking cessation, but it is not the priority. (Option 3) Reports of not feeling well and sleeping a lot may be related to the headache and possible hemorrhage, but this alone would not prompt a call to the health care provider. Educational objective: An arteriovenous malformation is a congenital deformity of tangled blood vessels often occurring in the brain. These vessels may weaken and rupture, causing an intracranial hemorrhage. Any neurologic changes and severe headache need to be addressed immediately as these may indicate hemorrhage.

The nurse assesses a client who has followed a vegan diet for several years. Which client statement indicates a potential nutritional deficiency? 1. "I have had some visual disturbances while driving at night."[13%] 2. "I have had trouble falling asleep over the past few months."[1%] 3. "Scaly patches of skin are developing on my elbows and knees."[20%] 4. "Sometimes my hands and feet get a tingling sensation."[64%]

4. "Sometimes my hands and feet get a tingling sensation."[64%] Explanation Clients who follow a vegan diet eat only plant-based foods, omitting animal proteins (eg, meat, poultry, fish) and products (eg, dairy, eggs). Clients who are vegan are at risk for deficiency of vitamin B12 (cobalamin), which is primarily supplied by animal products. Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain. Manifestations of chronic deficiency include: Peripheral neuropathy (eg, tingling, numbness) (Option 4) Neuromuscular impairment (eg, gait problems, poor balance) Memory loss/dementia (in cases of severe/prolonged deficiencies) Clients who follow a vegan diet are encouraged to take supplemental vitamin B12 to prevent severe neurological complications. In addition, clients are taught to incorporate vitamin B12-fortified foods (eg, cereals, grain products, soy and nut milks, meat substitutes). (Options 1, 2, and 3) Visual disturbances, difficulty sleeping, and scaly patches of skin are likely not complications of a nutritional deficiency related to a vegan diet. Educational objective: Clients following a vegan diet should be educated about vitamin B12 deficiency and the importance of supplementation and eating B12-fortified foods. Chronic vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms (eg, peripheral neuropathy, neuromotor impairment, memory loss).

The nurse is caring for a client diagnosed with Broca aphasia due to a stroke. Which of the following deficits would the nurse correctly attribute to Broca aphasia? Select all that apply. 1. Client coughs and gasps when swallowing food and liquids 2. Client is easily frustrated while attempting to speak 3. Client is unable to understand speech and is completely nonverbal 4. Client misunderstands and inappropriately responds to verbal instruction 5. Client's speech is limited to short phrases that require effort Broca (expressive) aphasia

4. Client misunderstands and inappropriately responds to verbal instruction 5. Client's speech is limited to short phrases that require effort Explanation Broca (expressive) aphasia is a nonfluent aphasia resulting from damage to the frontal lobe. Clients with Broca aphasia can comprehend speech but demonstrate speech difficulties. The speech pattern often consists of short, limited phrases that make sense but display great effort and frequent omission of smaller words (eg, "and," "is," "the") (Option 5). Clients with Broca aphasia are aware of their deficits and can become frustrated easily (Option 2). In comparison, clients with Wernicke (receptive) aphasia are unaware of their speech impairment. (Option 1) Trouble swallowing, often identified by coughing and gasping when eating and drinking, is dysphagia, which is not related to Broca aphasia. (Option 3) Clients with damage to multiple language areas of the brain may develop global aphasia, resulting in the inability to read, write, or understand speech. This is the most severe form of aphasia. (Option 4) Clients with damage to the temporal portion of the brain may develop Wernicke (fluent) aphasia (ie, the inability to comprehend the spoken and/or written word) and exhibit a long, but meaningless, speech pattern. Educational objective: Damage to the frontal lobe of the brain may cause Broca (expressive) aphasia. Clients with this condition demonstrate effortful and sensible speech characterized by short, limited sentences, with retained ability to comprehend speech. This impairment often causes clients with Broca aphasia to be frustrated when speaking

A nurse is caring for a client diagnosed with rheumatoid arthritis (RA). Which assessment finding does the nurse expect to assess? 1. Asymmetrical pain in the large weight bearing joints[11%] 2. Low back pain and stiffness that is worse in the morning[18%] 3. Pain, swelling, and redness of the great toe[3%] 4. Symmetrical pain and swelling in the small joints of the hands[67%]

4. Symmetrical pain and swelling in the small joints of the hands[67%] Explanation Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory, autoimmune condition of unknown origin that has periods of exacerbation and remission. The body's immune system attacks the lining of the joints, leading to bone erosion and joint deformity. Although there is no cure for the disease, early diagnosis and appropriate treatment can help limit localized joint destruction and systemic organ damage. Characteristic features of RA include the following: Symmetrical pain and swelling that initially affects the small joints of the hands and feet Morning joint stiffness that lasts from 60 minutes to several hours Elevated ESR and rheumatoid factor levels (Option 1) Asymmetrical pain in the weight bearing joints is characteristic of osteoarthritis. Crepitus, especially over the knee joints, is also present in osteoarthritis. (Option 2) Low back pain and stiffness, worse in the morning and improving as the day progresses, is characteristic of ankylosing spondylitis. RA typically does not involve the spine, except the cervical spine. (Option 3) Pain, swelling, and redness of one or more extremity joints (typically the great toe) are characteristic of acute gout attack. Educational objective: RA is a chronic, systemic, inflammatory, autoimmune disease of unknown origin. Early localized articular symptoms include bilateral, symmetrical pain and swelling that initially affects the small joints of the wrists, hands, and feet and morning joint stiffness that lasts at least an hour.

The nurse is assessing a client who had an esophagogastroduodenoscopy 3 hours ago. The client is reporting increasing abdominal pain. Which clinical finding requires an immediate report to the health care provider? Click the exhibit button for additional information. 1. Blood pressure 108/72 mm Hg[20%] 2. Gag reflex has not returned[26%] 3. Sore throat when swallowing[4%] 4. Temperature 100.6 F (38.1 C)[47%]

4. Temperature 100.6 F (38.1 C)[47%] Explanation An esophagogastroduodenoscopy (EGD) involves passing an endoscope down the esophagus to visualize the upper gastrointestinal structures (eg, esophagus, stomach, duodenum). Perforation of the gastrointestinal tract is a life-threatening complication of EGD that can lead to peritonitis and sepsis. Signs of perforation include a sudden temperature spike, increasing pain/tenderness, restlessness, tachycardia, and tachypnea. The nurse should notify the health care provider immediately if the client develops a fever (Option 4). (Option 1) Post-procedure changes in blood pressure can be caused by sedation, blood loss, or sepsis. Although the client had a slight decrease in blood pressure, it has remained relatively consistent with the other blood pressure readings and does not require immediate notification of the health care provider. (Option 2) An EGD involves applying a topical anesthetic to the throat to pass the endoscope. It may take a few hours for the gag reflex to return. Absent gag reflex after a prolonged period (eg, 6 hours) should be reported to the health care provider. (Option 3) A sore throat is expected after certain procedures (eg, EGD, intubation) due to local irritation. Warm saline gargles can provide some relief. Educational objective: Perforation of the gastrointestinal tract is a life-threatening complication of esophagogastroduodenoscopy that can lead to peritonitis and sepsis. Signs of perforation (eg, fever, increasing pain/tenderness, tachycardia, tachypnea) require immediate notification of the health care provider.

The nurse prepares to assess a newly admitted client diagnosed with chronic alcohol abuse whose laboratory report shows a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which assessment finding does the nurse anticipate? 1. Constipation and polyuria[2%] 2. Increased thirst and dry mucous membranes[2%] 3. Leg weakness and soft, flabby muscles[28%] 4. Tremors and brisk deep-tendon reflexes[66%] Explanation

4. Tremors and brisk deep-tendon reflexes[66%] Explanation Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]), is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority). Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures. (Option 1) Constipation and polyuria indicate hypercalcemia. Calcium has a diuretic effect. (Option 2) Increased thirst with dry mucous membranes indicates hypernatremia. (Option 3) Hypokalemia results in muscle weakness/paralysis and soft, flabby muscles. Paralytic ileus (abdominal distension, decreased bowel sounds) is also common with hypokalemia. However, the most serious complication is cardiac arrhythmias. Educational objective: Clients who abuse alcohol often have low magnesium levels that manifest as ventricular arrhythmias and/or neuromuscular excitability (similar to hypocalcemia), which includes tremors, positive Chvostek and Trousseau signs, hyperactive reflexes, and seizures.

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective? 1. Abdominal circumference reduced from admission recording[45%] 2. Flapping tremor no longer visible with arm extension[20%] 3. Shortness of breath no longer experienced in supine position[14%] 4. Vital signs remain within the client's normal parameters[18%]

4. Vital signs remain within the client's normal parameters[18%] Explanation Ascites is the accumulation of fluid in the peritoneal space that often occurs in clients with liver cirrhosis. Ascitic fluid increases abdominal pressure, resulting in weight gain, abdominal distension and discomfort, and shortness of breath. Paracentesis (ie, needle insertion through the abdomen into the peritoneum to remove ascitic fluid) is often performed to reduce symptoms of ascites. However, clients undergoing paracentesis must be monitored closely for hypotension as changes in abdominal pressure often result in systemic vasodilation. Clients may receive IV albumin (a colloid) after paracentesis, which increases intravascular oncotic pressure resulting in increased intravascular fluid volume. Albumin administration prevents hypotension and tachycardia by mitigating hemodynamic changes associated with paracentesis (Option 4). (Options 1 and 3) Decreased abdominal circumference and improved respiratory effort occur in clients with ascites after ascitic fluid is removed via paracentesis. Albumin does not directly reduce ascitic fluid volume. (Option 2) Asterixis (ie, flapping hand tremors during arm extension) occurs due to elevated blood ammonia levels. Lactulose is commonly used to treat asterixis as it promotes ammonia excretion. Albumin does not affect ammonia excretion. Educational objective: Clients undergoing paracentesis to alleviate symptoms related to ascites are at risk for hypotension due to changes in abdominal pressure. IV albumin increases intravascular fluid volume and may be used to prevent hypotension associated with paracentesis.

Holter monitor

A Holter monitor continuously records a client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's chest and a portable recording unit is kept with the client. At the end of the prescribed period, the client returns the unit to the health care provider's (HCP) office. The data can then be recalled, printed, and analyzed for any abnormalities. Client instructions include the following: Keep a diary of activities and any symptoms experienced while wearing the monitor so that these may later be correlated with any recorded rhythm disturbances Do not bathe or shower during the test period (Option 4) Engage in normal activities to simulate conditions that may produce symptoms that the monitor can record (Option 3)

PEG tube (percutaneous endoscopic gastrostomy)

A PEG is a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The tube's tract begins to mature in 1-2 weeks and is not fully established until 4-6 weeks. It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement (Option 3). (Options 1 and 4) The insertion of a Foley catheter or immediate reinsertion of the PEG tube should not be attempted because the tube's tract is only 3 days old (immature). A reinserted tube could be placed inadvertently into the peritoneal cavity, leading to serious consequences such as peritonitis and sepsis. Therefore, these are not the most appropriate interventions. (Option 2) Small-bore nasointestinal tubes are used for short-term rather than long-term administration of enteral feedings. They are prone to clogging from enteral feedings, undissolved medications, and inadequate tube flushes. They can also kink, coil, and become dislodged by coughing and may require frequent reinsertion. Therefore, they are not the most appropriate intervention. Educational objective: A PEG tube's tract begins to mature in 1-2 weeks and is fully established in 4-6 weeks. Tube dislodgement <7 days from placement requires surgical or endoscopic replacement. Attempting to reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis.

STAT order

A STAT order indicates that a medication is to be given immediately and only once.

A ampule is a single-dose medication container with a scored area on the neck that must be broken to withdraw the medication. When preparing medication from a glass ampule, the nurse ensures safety and prevents contamination during medication administration by:

A ampule is a single-dose medication container with a scored area on the neck that must be broken to withdraw the medication. When preparing medication from a glass ampule, the nurse ensures safety and prevents contamination during medication administration by: Flicking the upper stem of the ampule with a fingernail several times to ensure removal of medication from the ampule neck Using sterile gauze to break the ampule neck away from the nurse's body to prevent injury from glass shards (Option 2) Setting the ampule on a flat surface or inverting it to withdraw the medication Disposing of the ampule in a sharps container (Option 3)

Coronary artery angiogram

A coronary arteriogram (angiogram) is an invasive diagnostic study of the coronary arteries, heart chambers, and function of the heart. It requires that the client have an intravenous (IV) line started for sedating medications; the femoral or radial artery will be accessed during the procedure. The client should be instructed: -Not to eat or drink anything for 6-12 hours prior to the procedure (depending on the particular health care provider performing the procedure) (Option 4) -The client may feel warm or flushed while the contrast dye is being injected (Option 2) -Hemostasis must be obtained in the artery that was cannulated for the procedure. Most commonly, this is the femoral artery. Compression is applied to the puncture site and the client may have to lie flat for several hours to ensure hemostasis (Option 1)

1. Administer rectal diazepam[30%]

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first? 1. Administer rectal diazepam[30%] 2. Assess for neck stiffness and Brudzinski sign[48%] 3. Draw blood for laboratory studies[1%] 4. Transport the client to CT for assessment of shunt malfunction[19%] Explanation This client is in status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer. Grunting and a dazed appearance are 2 common signs. A client with hydrocephalus (abnormal collection of cerebrospinal fluid in the head) and a ventriculoperitoneal (VP) shunt is at a higher risk for seizures. Stopping seizure activity is the first nursing priority. IV benzodiazepines (diazepam or lorazepam) are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department. (Option 2) Stopping the status epilepticus is a priority over determining its cause through a neurologic assessment. Quickly obtaining the oxygen saturation level and managing the airway are priority assessments. (Option 3) Blood draw is needed for laboratory studies but is not a priority over stopping the seizure. (Option 4) A VP shunt drains excess fluid in the brain down to the abdomen, where it is absorbed by the body. A CT scan can accurately assess shunt malfunction. Any malfunction would need to be treated promptly to prevent future seizures and damage. Finding the cause of the seizure is important and should be done as soon as seizing has stopped. Educational objective: Status epilepticus is a serious condition that could result in brain damage and death. Quickly stopping the seizure is the first nursing priority as long as there is an adequate airway and the client is breathing. IV or rectal benzodiazepines (lorazepam or diazepam) are used to rapidly control seizures.

cirrhosis

A client with cirrhosis may experience pruritus (itching) due to buildup of bile salts beneath the skin. Clients with cirrhosis are also at an increased risk for skin breakdown due to the development of edema, which increases skin fragility and impedes wound healing, and the loss of muscle and fat tissue from pressure points (eg, heels, sacrum). The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to the skin from scratching (Options 2 and 5). Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated skin (Options 1 and 4). Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in feces, thereby decreasing pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given 1 hour after all other medications. (Option 3) Temperature extremes (eg, hot baths/showers) may intensify pruritus. The nurse should instruct the client to bathe with tepid water until the pruritus has subsided. Educational objective: A client with cirrhosis may experience pruritus (itching) due to the buildup of bile salts beneath the skin. Comfort measures include encouraging the client to cut nails short and wear long-sleeved cotton shirts and cotton gloves. Baking soda baths, calamine lotion, and cool, wet cloths also help. Cholestyramine increases the excretion of bile salts through feces, thereby decreasing itching.

closed-wound drainage system device (eg, Jackson-Pratt, Hemovac)

A closed-wound drainage system device (eg, Jackson-Pratt, Hemovac) consists of fenestrated drainage tubing connected to a flexible, vacuum (self-suction) reservoir unit. The distal end lies within the wound and can be sutured to the skin. It is usually inserted near the surgical site through a small puncture wound rather than in the surgical incision. The purpose of the drain is to prevent fluid buildup (eg, blood, serous fluid) in a closed space. Although it depends on the client and type of surgical procedure, about 80-120 mL of serosanguineous or sanguineous drainage per hour during the first 24 hours after surgery can be expected. The priority action is to notify the HCP due to the change in type and amount of drainage after the first 24 hours following surgery. Excessive bleeding and fluid collection into the closed space following breast reconstruction can greatly affect the integrity of the surgical incision, the tissue reconstruction, and wound healing (Option 1). Although it depends on the type of surgical procedure performed, about 80-120 mL of serosanguineous or sanguineous drainage per hour for the first 24 hours following surgery can be expected. The nurse should notify the HCP if the drainage in the Jackson-Pratt closed-wound drainage device changes from serosanguineous to sanguineous and if the amount increases significantly after the first 24 hours following surgery.

colostomy irrigation

A colostomy is a surgical procedure that creates an opening (stoma) in the abdominal wall for the passage of stool to bypass an obstructed or diseased portion of the colon. Stool drains through the intestinal stoma into a pouch device secured to the skin. Clients with a descending or sigmoid colostomy drain stool that is more formed and similar to a normal bowel movement. Although less common, some clients choose to irrigate their colostomy in order to create a bowel regimen that allows them to wear a smaller pouch or a dressing over the stoma. When irrigated daily, the client gains increased control over the passage of stool. The procedure for bowel irrigation is as follows: Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on a hook or intravenous pole (Option 2) Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma (Option 3) Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes Clamp the tubing if cramping occurs, until it subsides (Option 4) Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet (Option 1) A cone-tip applicator is used to instill the irrigation solution into the stoma. An enema set should never be used to irrigate a colostomy. A cone-tip applicator is specifically made to avoid damage to the sensitive colostomy opening. Educational objective: Colostomy irrigation allows the client to create a bowel regimen and to apply a dressing or smaller pouch device over the stoma. To properly irrigate the stoma, use 500-1000 mL of lukewarm water, hang the bag 18-24 inches above the stoma, use the cone-tipped irrigator to slowly infuse the solution, and allow stool to drain through the sleeve into the toilet.

Gastroduodenostomy (Billroth I)

A gastroduodenostomy (Billroth I) involves removing the distal two-thirds of the stomach with anastomosis of the remaining stomach to the duodenum. Following partial gastrectomy, clients should remain NPO until bowel sounds return (Option 3). Once tolerated, consumption of small, frequent meals will help prevent the occurrence of dumping syndrome (ie, rapid emptying of stomach contents into the small intestine). Postoperative clients are at risk for developing venous thromboembolism (VTE) due to reduced mobility levels and require VTE prophylaxis (eg, sequential compression devices, compression hose) (Option 1). Clients are also at risk for hypoventilation and respiratory compromise due to sedation, pain, and immobility. Encourage clients to turn, cough, and deep breathe while splinting the surgical site to prevent development of atelectasis (Option 2). (Option 4) In the postoperative period, the nurse should elevate the head of the bed to improve ventilation and reduce the risk of aspiration. Only clients who experience dumping syndrome should lay supine for a short period after eating. (Option 5) Clients may have a nasogastric tube postoperatively for gastric decompression. Clogged nasogastric tubes should be reported to the surgeon. Attempting to manipulate or flush the device may disrupt the surgical site, causing hemorrhage or gastric perforation. Educational objective: Postoperative care of a client with gastroduodenostomy includes initiation of thromboembolism prophylaxis; turning, coughing, and deep breathing; and aspiration precautions (eg, elevating the head of the bed). The nurse should keep clients NPO until bowel sounds return and should not manipulate clogged nasogastric tubes.

cystic fibrosis

A genetic disorder that is present at birth and affects both the respiratory and digestive systems. thick sputum

laparoscopic cholecystectomy

A laparoscopic cholecystectomy is the safest and most commonly used procedure for gallbladder removal. A laparoscope and grasping forceps are inserted through small punctures made in the abdomen. The procedure is associated with decreased postoperative pain, better cosmetic results, shorter hospital stays, and fewer days for recovery versus the open technique. Postoperative teaching includes: Diet - a low-fat diet is recommended postoperatively as it is well tolerated. A regular diet can be resumed after a few weeks although weight loss may be recommended (Option 1). Activity and work - resume normal activity slowly, as tolerated. Most individuals can return to work within a week (Option 2). Incision care and hygiene - dressings can be removed the day after surgery, and showering is permitted at this time. Signs and symptoms of infection (redness, edema, pus, severe pain, nausea, fever, chills) should be reported immediately (Option 3). (Option 4) Surgical bandages can be removed the day after surgery, and the client may shower at this time. Baths are not permitted as they may introduce infection into the surgical sites. Once the incisions are healed, baths may be resumed. Educational objective: A laparoscopic cholecystectomy enables clients to recover and resume normal activities more quickly than an open surgical technique. Clients should be taught to remove surgical bandages the day after surgery; showering may be resumed at this time. Clients should increase activity slowly and eat a low-fat diet.

brachytherapy( radiation)

A permanent or temporary implantation of small, sealed containers (seeds) of radioactive material directly into the cancerous tumor or in a cavity of the tumor. (used to treat cervical and endometrial cancer). intervention/implementation: 1-limit time spent in the room to 30 minutes per shift (time spent toner radiation source is restricted) -cluster nursing care, rotate daily staff responsibilities to limit time spent in client room, all staff must wear dosimeter film badge in client room tp monitor radiation exposure, no one pregnant or under the age go 18 should be in room 2-everyone must keep maximum distance of 6 feet. assign client to private room, keep room door closed, post caution sign mark radioactive material is fixed to the door, instruct client to remain on bedrest to prevent dislodgment of the implant 3- shielding with lead (diminishes exposure to radiation) all staff providing care must wear lead

Pharmacologic nuclear stress test

A pharmacologic nuclear stress test utilizes vasodilators (eg, adenosine, dipyridamole) to simulate exercise when clients are unable to tolerate continuous physical activity or when their target heart rate is not achieved through exercise alone. These drugs produce vasodilation of the coronary arteries in clients with suspected coronary heart disease. A radioactive dye is injected so that a special camera can produce images of the heart. Based on these images, the health care provider (HCP) can visualize if there is adequate coronary perfusion. Pre-procedure client instructions include the following: Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications (Option 3). Avoid caffeine products 24 hours before the test (Option 2). Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine (Option 1). Do not take theophylline 24-48 hours prior to the test (if tolerated). If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food (Option 5). Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: Nitrates (nitroglycerine or isosorbide) Dipyridamole Beta blockers (Option 4) Educational objective: Clients scheduled for cardiac nuclear pharmacologic stress testing should not eat, drink, or smoke on the day of the test; avoid both caffeinated and decaffeinated products for 24 hours before the test; and avoid taking theophylline or antianginal medications unless otherwise instructed by the health care provider.

colonoscopy

A risk of a colonoscopy (or any procedure in which a firm scope is inserted into a "hollow tube" organ) is perforation. Signs of perforation include abdominal pain (with shoulder tip pain), positive rebound tenderness, guarding, abdominal distension, tenesmus, and/or boardlike (rigid) abdomen. Another potential complication is rectal bleeding.

vasectomy (permanent male sterilization)

A vasectomy is a surgical procedure performed for permanent male sterilization. During the procedure, the vasa deferentia (ie, ducts that carry sperm from the testicles to the urethra) are cut and sealed, preventing sperm from entering the ejaculate. The vasa deferentia are severed in the scrotum at the site before the seminal vesicles and prostate. As a result, the procedure should not affect the ability to ejaculate, amount and consistency of ejaculatory fluid, or other physiological mechanisms (eg, hormone production, erection, orgasm). Following a vasectomy, sperm continue to be produced but are absorbed by the body. Following the procedure, it can take several months for the remaining sperm to be ejaculated or absorbed. Alternative birth control should be used until the health care provider confirms that semen samples taken at a follow-up appointment are free of sperm; otherwise, pregnancy can occur (Option 4).

alanine aminotransferase /aspartate aminotransferase (ALT/AST)

ALT and AST are the enzymes released when hepatic cells are injured (hepatitis). There are smaller amounts in the cardiac, renal, and skeletal tissues, but ALT/AST are used to diagnose hepatic disorders. Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake (Option 3), some over-the-counter medications (eg, acetaminophen), and certain herbal and dietary supplements (Option 5). IV illicit drug use increases the risk for hepatitis B and C infection (Option 2). (Option 1) Black tarry stool (melena) is an expected finding from a gastrointestinal bleed (from the digested blood). Melena can be seen in clients with gastric or esophageal varices, which are often complications of hepatic disease (eg, cirrhosis). However, melena is not an etiology of liver injury. (Option 4) Immunizations do not cause liver damage. It is possible to get a small elevation with an intramuscular injection, but not values this high. Educational objective: ALT/AST are enzymes indicating liver injury. Besides the obvious viral hepatitis, it can result from excess chronic alcohol intake or some over-the-counter drugs, including acetaminophen.

Absence seizures

Absence seizures typically occur in children. The presentation is classic and includes the following: Daydreaming episodes or brief (<10 seconds) staring spells Absence of warning and postictal phases Absence of other forms of epileptic activity (no myoclonus or tonic-clonic activity) Unresponsiveness during the seizure No memory of the seizure The most helpful response by the nurse is one that corrects while educating the UAP (Option 1). The UAP may be present when a client has a seizure, and understanding of what to expect will aid client care. (Options 2 and 4) Although it is not the responsibility of the UAP to monitor the client, the UAP may witness a seizure and call for help if needed. (Option 3) Seizures may include tonic (body stiffening), clonic (muscle jerking), atonic (loss of muscle tone or "drop attack"), myoclonic (brief muscle jerk), or tonic-clonic (alternating stiffening and jerking) body motions. Absence seizures do not typically involve these body motions. Educational objective: Absence seizures are brief periods of staring; there is no evidence of tonic-clonic activity or postictal confusion. The UAP should be educated about absence seizures when involved in the care of such clients.

acute angle closure glaucoma

Acute angle-closure glaucoma is a form of glaucoma that requires immediate medical intervention. Glaucoma disorders are characterized by increased intraocular pressure (IOP) due to decreased outflow of the aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness. In acute angle-closure glaucoma, IOP increases rapidly and drastically, which can lead to the following manifestations: Sudden onset of severe eye pain Reduced central vision Blurred vision Ocular redness Report of seeing halos around lights

Reasons for giving different types of IV gluids

Acute gastroenteritis is associated with nausea, vomiting, and diarrhea, placing the client at risk for dehydration and sodium loss. Clients with gastroenteritis are encouraged to increase fluid intake but may require IV fluid therapy. Isotonic crystalloid fluids (eg, 0.9% sodium chloride, lactated Ringer solution) are the treatment of choice due to the similarity in concentration with plasma and ability to increase extracellular fluid (ECF) without moving into the intracellular space. In addition, isotonic fluids may increase sodium levels in clients experiencing excess sodium loss (eg, vomiting, diarrhea) (Option 2). (Option 1) Hypertonic solutions (eg, 3% sodium chloride) are administered to clients with increased intracranial pressure (ICP) to raise the osmolality of ECF, which decreases cellular swelling by drawing water from the cells. Isotonic fluids are avoided because an increase in circulating isotonic fluid promotes additional fluid shifting into the cells, which further increases ICP. (Option 3) The client with a serum sodium of 112 mEq/L (112 mmol/L) is dangerously hyponatremic and at risk for further neurological decline. A hypertonic solution (eg, 3% sodium chloride) is the most appropriate choice to rapidly correct sodium deficits. (Option 4) Isotonic solutions can exacerbate fluid overload in clients with chronic renal failure and cause increased blood pressure.

Juvenile Idiopathic Arthritis (JIA)

Affects children (onset before age 10). Persistent joint swelling (synovial thickening, accumulation of synovial fluid) - exercise and physical activities are important to prevent joint deformity and maintain muscle strength and endurance -low impact activities weight bearing and non weight bearing are best -swiming -riding a stationary bike -throwing -kicking a ball -yoga

What to avoid when you have an implantable cardioverter defibrillator/ pacemaker

After placement of an implantable cardioverter defibrillator, clients are instructed to avoid lifting the arm on the side of the ICD above the shoulder (until cleared by the health care provider) to avoid dislodging the lead wire system.

central venous catheter dislodgement

Air embolism is a rare but life-threatening complication of central venous catheter (CVC) placement in which air enters the bloodstream. This air displaces blood in the pulmonary vessels, which prevents oxygenation of blood by the lungs. Air embolism may occur after CVC removal, as air can enter the bloodstream via the open, large-bore insertion site. Clients with air embolism can rapidly develop respiratory distress leading to cardiopulmonary collapse. Nurses caring for clients with symptoms of air embolism (eg, hypoxemia, dyspnea, sense of impending doom) after CVC removal or dislodgement should perform these actions: Apply an occlusive dressing to the insertion site to prevent entry of additional air into the bloodstream (Option 2) Administer 100% oxygen via non-rebreather mask to improve oxygenation (Option 1) Position the client in left lateral Trendelenburg position to promote venous air pooling in the heart apex rather than the lung capillary beds Continuously monitor vital signs and client respiratory effort to identify changes in client status (Option 4)

Cardiac Cathetherization complication

Allergic reaction: Clients with a previous allergic reaction to IV contrast may require premedication (eg, corticosteroids, antihistamines) or another contrast medium (Option 2). Clients with shellfish allergies were once believed to be at higher risk, but this has been disproved. Contrast nephropathy: Iodine-containing contrast can cause kidney injury, although this risk can be reduced with adequate hydration. However, clients with renal impairment (eg, serum creatinine >1.3 mg/dL [115 µmol/L]) should not receive IV contrast unless absolutely necessary (Option 4). Lactic acidosis: Metformin (Glucophage) with IV iodine contrast increases the risk for lactic acidosis. Metformin is usually discontinued 24-48 hours before exposure and restarted after 48 hours, when stable renal function is confirmed (Option 5).

anaphylactic shock treatment

Anaphylactic shock has an acute onset (20-30 minutes) caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs (eg, antibiotics), foods (eg, shellfish, peanuts), diagnostic agents (eg, contrast), biologic agents (eg, blood, vaccines), and venom (eg, bees, snakes) and results in circulatory failure, laryngeal edema, and severe bronchoconstriction. Management of anaphylactic shock includes: Stop the infusion that is causing the reaction and call for help (eg, rapid response team) (Option 5). Ensure patent airway, then administer oxygen via a high-flow nonrebreather mask and prepare for intubation if needed (Option 2). Give epinephrine intramuscularly. Epinephrine counteracts the effect of the histamines released, dilating bronchial smooth muscles and providing vasoconstriction. Most deaths from anaphylaxis are due to delaying epinephrine. Maintain blood pressure with normal saline IV fluid (Option 3). Administer adjunctive therapies: Bronchodilators (eg, albuterol) to dilate the small airways and reverse bronchoconstriction, antihistamines (eg, diphenhydramine) to modify the hypersensitivity reaction, and corticosteroids (eg, methylprednisolone) to decrease airway inflammation and swelling associated with the allergic reaction (Option 1). Continue to reassess vital signs for any changes (Option 4).

Alzheimer disease (AD)

Alzheimer disease (AD) is a form of dementia that causes progressive decline of cognitive and physical abilities. The nurse should educate the client/caregiver to prepare for current and future safety needs. Interventions evolve to meet client needs at each stage of disease progression. Safety promotion for the client with moderate AD includes: Keyed deadbolts (with keys removed) and close supervision to provide a controlled environment for wandering (Option 3) Medical identification/location devices (eg, bracelets, shoe inserts) in case the client wanders outside the designated area (Option 2) Decreased water heater temperature and "hot" and "cold" labels on faucets to prevent burns Household hazards (eg, gas appliances, rugs, toxic chemicals) removed to prevent injury (Option 5) Grab bars installed in showers and tubs (Option 1) (Option 4) All medications should be out of the client's reach or locked away. A confused person may not remember the day of the week and take more or less medication than prescribed. Educational objective: For clients with moderate Alzheimer disease, caregivers should provide a controlled environment for safe wandering (eg, throw rugs and clutter removed, exterior doors secured), and the client should wear an identification/location device (eg, bracelet). All medications should be out of reach or locked away. Hazards (eg, gas appliances, rugs, toxic chemicals) should be removed. Grab bars should be installed in showers and tubs.

RYGB procedure/ Roux-en-Y gastric bypass (RYGB)

An RYGB procedure uses a small proximal portion of the stomach to create a gastric pouch that is anastomosed to the Roux limb of the small intestine, bypassing most of the stomach and a portion of the duodenum. Dumping syndrome, the rapid emptying of gastric contents into the small intestine, is a potential complication. The presence of a large quantity of hyperosmolar intestinal contents causes fluids to shift out of the vascular system into the intestines, leading to symptoms such as nausea, vomiting, diarrhea, weakness, and hypotension. To prevent dumping syndrome, clients should eat multiple small meals, eat a low-carbohydrate diet, and separate their consumption of food and fluids (Option 1). (Option 2) Clients should be taught to consume food and fluids at least 30 minutes apart, and the health care provider may limit total daily fluid consumption. Limiting fluids decreases distension and feelings of fullness. (Option 3) Iron-deficiency anemia is a common side effect after an RYGB as iron is absorbed in the duodenum and proximal jejunum. Taking supplements of iron and calcium can help with this problem but does not prevent dumping syndrome. (Option 4) The smaller gastric pouch decreases the amount of intrinsic factor made by the parietal cells in the stomach, which may cause cobalamin deficiency. The client will need parenteral or intranasal cobalamin replacement; however, this will not prevent dumping syndrome. Educational objective: An RYGB (anastomosis of a small gastric pouch to the Roux limb of the small intestine) has several potential complications, including dumping syndrome, iron deficiency anemia, and cobalamin deficiency. To prevent dumping syndrome, the client should consume small meals, eat a low-carbohydrate diet, and consume food and fluids 30 minutes apart.

small bowel follow-through (SBFT)

An SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine (Option 2). Using this technique, decreased motility (eg, ileus), increased motility (eg, malabsorption syndromes), fistulas, or obstructions are identified. Clients should be instructed as follows: Fast 8 hours prior to the examination. The test usually takes 60-120 minutes, but if obstruction or decreased motility is present, it can take longer. Drink plenty of fluids after the examination to facilitate barium removal. Chalky stools may be present 24-72 hours after the examination. If brown stools do not return after 72 hours or abdominal pain or fullness is present, contact the HCP. (Option 1) Black, tarry stools (melena) are not an expected symptom of an SBFT; melena is indicative of gastrointestinal bleeding and should be reported immediately to an HCP. (Option 3) An endoscope is not used to complete an SBFT. (Option 4) Clients should refrain from eating 8 hours prior to the examination. Polyethylene glycol (Nu-LYTELY) is prescribed as a bowel preparation for a colonoscopy, not an SBFT. Educational objective: An SBFT uses sequential x-ray images to visualize the structure and function of the small intestine. The client should fast for 8 hours prior to the examination. Stools may be chalky for up to 72 hours. Black, tarry stools indicate a potential gastrointestinal bleed and should be reported immediately.

acute hemolytic transfusion reaction

An acute hemolytic transfusion reaction is a life-threatening reaction caused primarily by blood incompatibility. If it occurs, the transfusion should be stopped and a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion.

Where to listen for a bruit

An aneurysm is an outpouching or dilation of a vessel wall. An abdominal aneurysm occurs on the aorta. A bruit, a swishing or buzzing sound that indicates turbulent blood flow in the aneurysm, is best heard with the bell of the stethoscope. It may be auscultated over the aortic aneurysm in the periumbilical or epigastric area slightly left of the midline. Educational objective: The nurse should listen for a bruit with the bell of the stethoscope over the periumbilical or epigastric area.

Asthma action plan

An asthma action plan is an individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department. The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction (peak flow meter readings): Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing (Option 1). Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a change in treatment is needed (Option 2). Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to yellow immediately after taking rescue medications (Option 4). Educational objective: A peak flow meter uses traffic signal colors to categorize degrees of asthma symptoms. Green zone indicates asthma is under control. Yellow zone indicates caution, symptoms are getting worse, PEF is 50%-80% of personal best, and there is a need for further medication. Red zone indicates the need for emergency treatment if the level does not immediately return to yellow after taking rescue medications.

ileostomy/colostomy/stoma

An ileostomy is a surgically created opening (stoma) in the abdominal wall that connects the small intestine to the external abdomen. Stool from the small intestine bypasses the colon and exits through the ileostomy. Functions of the colon (eg, fluid and electrolyte absorption, vitamin K production) do not occur, resulting in liquid stool that drains into an external ostomy appliance attached to the skin. In the immediate postoperative period of an ileostomy, a low-residue diet (low-fiber) is prescribed to prevent obstruction of the narrow lumen of the small intestine and stoma (1-in [2.54-cm] diameter or less). After the ileostomy heals, the client reintroduces fibrous foods one at a time. The client is instructed to thoroughly chew food and monitor for changes in stool output. Foods to be avoided include: High fiber: popcorn, coconut, brown rice, multigrain bread (Options 3 and 4) Stringy vegetables: celery, broccoli, asparagus (Option 2) Seeds or pits: strawberries, raspberries, olives Edible peels: apple slices, cucumber, dried fruit (Option 1) After an ileostomy, a client may consume fruits and vegetables that are pitted, peeled, and/or cooked (eg, peaches, bananas, potatoes). (Option 5) Low-fiber carbohydrate options include white rice, refined grains, and pasta. Educational objective: The low-residue diet of a client with a new ileostomy helps prevent obstruction of the narrow lumen of the stoma. During the immediate postoperative period, the client should avoid foods that are high in fiber; stringy vegetables; and fruits and vegetables with pits, seeds, or edible peels.

An implantable cardioverter defibrillator (ICD) is a device used to sense life-threatening arrhythmia and discharge electrical shocks to correct the arrhythmia. If a client experiences repeated ICD shocks without dysrhythmia resolution, the nurse should obtain a manual external defibrillator and initiate cardiac life support.

An implantable cardioverter defibrillator (ICD) is a device used to sense life-threatening arrhythmia and discharge electrical shocks to correct the arrhythmia. If a client experiences repeated ICD shocks without dysrhythmia resolution, the nurse should obtain a manual external defibrillator and initiate cardiac life support.

inferior vena cava filter

An inferior vena cava filter traps thrombi migrating from the lower extremities to the lungs. Discharge teaching includes promotion of physical exercise, reporting of symptoms of pulmonary embolism (eg, chest pain, shortness of breath) and impaired lower extremity circulation (eg, pain, numbness), and notification of the health care team prior to MRI.

inferior vena cava filter

An inferior vena cava filter traps thrombi migrating from the lower extremities to the lungs. Discharge teaching includes promotion of physical exercise, reporting of symptoms of pulmonary embolism (eg, chest pain, shortness of breath) and impaired lower extremity circulation (eg, pain, numbness), and notification of the health care team prior to MRI.

Meningococcal meningitis

An inflammation of the meningeal coverings of the brain and spinal cord; can be highly contagious.

Epitaxis (nosebleed)

Caused by dry mucus membrane, local injury (nose picking) , insertion of a foreign body or rhinitis -treatment: apply direct pressure to the sides of the nose for 5-15 minutes, place a cold rag or ice on the bridge of the nose, Keep child quiet and calm

Osteogenesis Imperfecta (OI)

inherited condition of deformed and abnormally brittle bones treatment: -check blood pressure manually tighteningavoid cuff over to -lifting infant at a broad area (back, bottom, chunk) -reposition infant frequently using supportive devices -padding infant to avoid molding of the soft bones of the skull

Antiretroviral therapy (ART)

Antiretroviral therapy (ART) is a medication regimen consisting of multiple drugs for managing and preventing progression of HIV infections. ART impairs viral replication at multiple points, which leads to decreased viral loads and increased CD4+ (ie, helper T) cell counts. When educating clients about ART, it is critical to explain that treatment is lifelong and requires strict adherence (Option 1). Even clients with undetectable viral loads remain infected with HIV. The discontinuation of, or poor adherence to, ART results in the progression of HIV (which may lead to AIDS) and promotes viral drug resistance. (Option 2) Clients with HIV who are sexually active are at increased risk for sexually transmitted infections (STIs). Regular testing (≥1 time annually) and treatment for STIs are recommended. (Option 3) Latex or polyurethane barriers should be used during sex to prevent STI transmission, as nonbarrier contraception and natural skin condoms (eg, lambskin) offer poor protection against HIV and STI transmission. (Option 4) IV drug use is a common source of HIV infection. Although abstinence from IV drugs is preferred, clients who continue to use them should be instructed to avoid sharing needles and receive information about needle and syringe exchange programs. Educational objective: Clients with HIV must be educated to strictly adhere to prescribed antiretroviral therapy to prevent disease progression. Clients with HIV who are sexually active should seek testing for sexually transmitted infections and use latex condoms/barriers during sex. Clients with HIV should use a needle exchange program if using IV drugs.

Aortic Stenosis (AS)

Aortic stenosis is the narrowing of the orifice between the left ventricle and aorta. Many clients with aortic stenosis are asymptomatic. Symptoms usually develop with exertion as the left ventricle cannot pump enough blood to meet the body's demands due to aortic obstruction (stenosis). These include dyspnea, angina, and, in severe cases, syncope (reduced blood flow to the brain). Clients usually do not experience symptoms at rest. (Options 2 and 4) This client already developed syncope and angina (exertional chest pain) and is at high risk for sudden death with exertion. (Option 3) The client should restrict activity. The incidence of sudden death is high in this population, and it is therefore prudent to decrease the strain on the heart while awaiting surgery. Educational objective: Clients with severe aortic stenosis are at risk for developing syncope and sudden death with exertion. The left ventricle cannot push enough blood into the aorta to meet the body's demands due to the valve stenosis.

appendicitis

Appendicitis is inflammation of the appendix and often results from obstruction by fecal matter. Appendiceal obstruction traps fluid and mucus typically secreted into the colon, causing increased intraluminal pressure and inflammation. As appendiceal intraluminal pressure and inflammation increase, blood circulation to the appendix is impaired, resulting in swelling and ischemia. These factors increase the risk for appendiceal perforation, a medical emergency, which may lead to peritonitis and sepsis. When prioritizing care of the client with appendicitis, the nurse should utilize the ABCs (ie, airway, breathing, circulation). Fluid resuscitation with IV crystalloids (eg, normal saline, lactated Ringer solution) is an important intervention aimed at preventing circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status (Option 3). (Option 1) Pain medications may be administered to promote comfort, but should be administered via IV route to maintain NPO status in case of emergency surgery. However, circulation takes priority over pain medication. (Options 2 and 4) Blood and urine samples often are prescribed to assist with treatment and care decisions. However, the nurse should prioritize circulatory status over obtaining laboratory specimens. Educational objective: Nurses caring for clients with appendicitis should prioritize client care according to the ABCs (ie, airway, breathing, circulation). Initiating IV crystalloids (eg, normal saline) is a priority action that prevents circulatory collapse resulting from fluid losses (eg, vomiting, diarrhea) and NPO status.

Basic steps for suppository administration include the following:

Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent) (Option 4). Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption. Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years (Option 5). Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years. Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption (Option 2). Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion (Option 3). If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository.

Trisomy 21 (Down syndrome) Is associated with

Atrioventricular (AV) canal deficit a loud murmur that requires no action when vital signs are stable. can be corrected by surgery

The proper positioning and administration of nasal sprays allow the medication to reach the nasal passages. When educating a client on how to self-administer nasal sprays, the nurse teaches the client to:

Assume a high Fowler's position with head slightly tilted forward (Option 1) Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger (Option 3) Point the nasal spray tip toward the side and away from the center of the nose (Option 2) Spray the medication into the nose while inhaling deeply (Option 4) Remove the nozzle from the nose and breathe through the mouth Repeat the above steps for the other nostril Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation

obstructive sleep apnea (OSA)

At night, clients with obstructive sleep apnea experience repeated periods of apnea, loud snoring, and interrupted sleep. During the day, morning headaches, irritability, and excessive sleepiness are common.

Bowel sounds

Auscultation of abdominal sounds during physical assessment includes bowel and cardiovascular components. Bowel sounds are normally intermittent (every 5-15 seconds), high-pitched, gurgling sounds that can be auscultated with the diaphragm of the stethoscope in all 4 quadrants. Cardiovascular bruits (swishing, humming, buzzing) are rarely benign and usually indicate arterial narrowing or dilation. Procedures that require bowel manipulation cause a temporary halting of peristalsis (paralytic ileus) for the first 24-48 hours, resulting in absent bowel sounds (Option 1). For bowel sounds to be considered absent, the nurse must auscultate for 2-5 minutes in each quadrant. Peristalsis will usually return in the small intestine in 24 hours, but the large intestine may be delayed 3-5 days. Other procedures requiring general anesthesia, late stages of mechanical obstruction, and peritonitis may cause absent bowel sounds. (Option 2) Borborygmi sounds are loud, gurgling sounds suggesting increased peristalsis. Potential disease processes resulting in borborygmi include gastroenteritis, diarrhea, and the early phases of mechanical obstruction. (Option 3) High-pitched, gurgling sounds signify normal bowel sounds and are unlikely to be heard immediately following abdominal surgery. (Option 4) A swishing, humming, or buzzing sound (bruit) may be cardiovascular in origin; a bruit indicates turbulent blood flow as with artery dilation (aneurysm) or narrowing (obstruction). A bruit can best be auscultated with the bell of the stethoscope. Educational objective: Bowel sounds following abdominal manipulation may be absent for 24-48 hours. Any disease process that causes an increase in peristalsis may cause borborygmi (loud, gurgling sounds). Swishing and humming sounds heard best with the bell of the stethoscope may be indicative of turbulent blood flow.

If client in respiratory distress you should

Auscultation the lung sound to assess for patent airway

Bacterial meningitis / meningococcal meningitis.

Bacterial meningitis is an inflammation of the membranes that cover the brain and spinal cord and is caused by bacterial infection. Symptoms include headache, neck stiffness, nausea, vomiting, photophobia, fever, and altered mental status. The client with meningitis is at risk for seizure due to increased neuroirritability from fever and alterations in intracranial pressure. Bacterial meningitis is frequently caused by Neisseria meningitidis (meningococcus) in adults. Meningococcal meningitis is highly infectious and requires strict droplet isolation precautions (eg, surgical mask, private room, client masked during transport) (Options 1 and 2). For clients with meningitis, a restful, reduced stimulus environment (eg, quiet, dimly lighted, cool temperature) promotes healing and reduces neuroirritability and seizure risk (Option 5). The client should be on bed rest with the head of the bed elevated 10-30 degrees to promote venous return from the brain and reduce sudden changes in intracranial pressure (Option 3)

Billroth II surgery (Gastrojejunostomy)

Billroth II surgery (gastrojejunostomy) removes part of the stomach and shortens the upper gastrointestinal tract. After a partial gastrectomy, many clients experience dumping syndrome, which occurs when gastric contents empty too rapidly into the duodenum, causing a fluid shift into the small intestine. This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia. To reduce the occurrence of symptoms, clients should avoid fluids with meals and lie down after eating to slow gastric emptying (Option 4). An upright or sitting position increases the force of gravity, which increases the rate of gastric emptying. (Option 1) Hypoglycemia can cause symptoms similar to those of dumping syndrome (eg, sweating, dizziness) but is unlikely to occur 30 minutes after eating. (Option 2) Clients should avoid consuming fluids with meals, which causes stomach contents to pass faster into the jejunum and worsens symptoms. Fluid intake should occur at least 30 minutes before/after meals. (Option 3) Reports of dizziness after standing may indicate orthostatic hypotension and warrant assessment of blood pressure while lying and standing; dizziness after eating is indicative of dumping syndrome. Educational objective: Clients are at risk of dumping syndrome after a gastrectomy and may experience abdominal cramping, nausea, vomiting, and diarrhea. To delay gastric emptying, clients should avoid fluids with meals and lie down after eating.

When taking sodium nitroprusside monitor (Vasodilator that decrease preload and afterload)

Blood pressure Nitroprusside begins to act within 1 minute and can produce a sudden and drastic drop in blood pressure (symptomatic hypotension) if not monitored properly. Therefore, the client's blood pressure should be monitored closely (every 5-10 minutes). This client's lightheadedness and cold clammy skin are likely due to hypotension. Nitroprusside metabolizes to cyanide, and clients with renal disease can occasionally develop fatal cyanide toxicity.

Blunt-force trauma

Blunt-force trauma to the head is associated with potentially severe complications (eg, brain damage and herniation, retinal detachment, seizures). Prompt recognition of potential complications is essential to prevent irreversible changes to the client's neurological status and level of function. Retinal detachment is a separation of the retina from the posterior wall of the eye that may occur following head trauma. This is an ocular emergency as permanent blindness may result without intervention. Signs of retinal detachment include perception of lightning flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect throughout the visual field (Option 1).

breast cancer risk factors

Breast cancer is the unregulated growth of abnormal breast tissue cells and the second most common cause of cancer deaths among women. When palpated, the breast lump is usually described as hard, irregularly shaped, non-mobile, and nontender. Mammography usually detects breast cancer. Non-modifiable breast cancer risk factors include: Female sex and age ≥50 (Options 4 and 5) First-degree relative (mother or sister) with history of breast cancer (Option 1) BRCA1 and BRCA2 genetic mutations (Option 2) Personal history of endometrial or ovarian cancer Menarche before age 12 or menopause after age 55 Modifiable breast cancer risk factors include: Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause) (Option 5) Postmenopausal weight gain and obesity as fat cells store estrogen (Option 4) History of smoking and alcohol consumption Dietary fat intake Sedentary lifestyle

Burn injuries

Burn injuries are caused by direct tissue damage from exposure to caustic (eg, thermal, chemical, electrical) sources. These injuries may be life-threatening, depending on the extent of tissue injury and organ damage. To prioritize the initial management of burn injuries, nurses should use the ABCs (ie, airway, breathing, circulation). Circulatory compromise is common after sustaining a burn, as extensive tissue injury combined with the systemic inflammatory response causes increased capillary permeability, fluid and electrolyte shifts, and decreased intravascular volume. These intravascular losses begin rapidly after a burn and may lead to hypovolemic shock and death. Therefore, the nurse should prioritize initiation of fluid resuscitation (Option 3). Lactated Ringer's is the standard for fluid resuscitation in burn clients due to its similarity in chemical composition to human plasma. Hypotonic, hypertonic, and dextrose-containing solutions should not be used for fluid resuscitation.

Burn injuries

Burn injuries cause tissue damage that leads to increased vascular permeability and fluid shifts (eg, second and third spacing). In the emergent phase after a burn (first 24-72 hours), fluid, proteins, and intravascular components leak into the surrounding interstitium, causing decreased intravascular oncotic pressure and decreased intravascular volume, and resulting in fluid shifts and hypovolemia. Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting in hyperkalemia (potassium >5.0 mEq [5.0 mmol/L]). Clients with hyperkalemia experience muscle weakness, ECG changes (tall, peaked T waves, shortened QT interval), and cardiac arrhythmias (Option 4). (Option 1) Hematocrit and hemoglobin values will be elevated due to hypovolemia (hemoconcentration). (Option 2) The sympathetic nervous system is activated in response to a burn, causing decreased peristalsis. Nausea, vomiting, gastric distension, and paralytic ileus may occur. (Option 3) Sodium is the most abundant extracellular cation. Hyponatremia (sodium <135 mEq/L [135 mmol/L]) occurs as sodium is lost via fluid shifts and insensible losses. Educational objective: Burn injuries cause cellular destruction, capillary leaking, and fluid shifts. Fluids are lost during the emergent phase (first 24-72 hours), resulting in hypovolemia and hyponatremia. The blood becomes more viscous and increased hematocrit and hemoglobin values result. Cellular damage releases potassium, which causes hyperkalemia.

Burns

Burns cause large fluid shifts and can decrease perfusion to the gastrointestinal tract, resulting in inconsistent absorption of oral medications. Burns damage the muscle and subcutaneous tissue, causing generalized body edema and decreased circulating blood volume. These physiological changes reduce the absorption ability for the intramuscular and subcutaneous routes (Options 1, 3, and 4). The best way to get medication into the system of a client with severe burns is to access the circulatory system directly via the intravenous route.

COPD

The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces more red blood cells (RBCs) to carry needed oxygen to the cells. A high RBC count is called polycythemia. Polycythemia, an increase in RBCs, is an anticipated compensatory response to chronically low blood oxygen levels in clients with severe COPD.

Cystic fibrosis (trait)

Carrier screening offers clients who are unaffected by a genetic disorder the option to discover whether they possess an abnormal gene (ie, are carriers) that may affect health outcomes of future offspring. This type of genetic testing is frequently offered preconceptionally/prenatally to guide pregnancy decision-making. Cystic fibrosis follows an autosomal recessive inheritance pattern, meaning that offspring must receive two abnormal genes (one from each parent) to be affected with the disorder (Option 1). Other disorders following this inheritance pattern include phenylketonuria, Tay-Sachs disease, and sickle cell disease. (Option 2) Male and female offspring have the same likelihood of inheriting autosomal recessive disorders because the abnormal gene is not linked to a sex chromosome. (Option 3) X-linked recessive disorders (eg, hemophilia, Duchenne muscular dystrophy) most often affect male offspring. This inheritance pattern occurs because male offspring who receive an abnormal sex chromosome from a female carrier (ie, X chromosome) will have the disorder because, unlike female offspring, they only have one X chromosome. (Option 4) Because carriers with no evidence of the disorder can pass an abnormal gene to offspring, autosomal recessive conditions may not present in every generation. However, autosomal dominant inheritance patterns (eg, Huntington disease, achondroplasia) are noted in each previous generation because affected offspring must have an affected parent. Educational objective: Cystic fibrosis is a disorder with an autosomal recessive inheritance pattern. Affected offspring must inherit two abnormal genes (one from each parent). Male and female offspring are equally affected because the disorder is not sex-linked.

Treatment for sinus bradycardia

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

Cystic fibrosis (intervention)

Chest physiotherapy before meal Intervention: -give pancreatic enzyme supplement with every meAl - high carbohydrate, high protein, high fat diet -increase salt intake during times of perspiration -chest physiotherapy and excercise

Chlamydia

Chlamydia is the most common sexually transmitted infection and is diagnosed frequently among women, adolescents, and those with multiple sexual partners. Many clients are asymptomatic or have minor symptoms (eg, spotting after sex, dysuria, abnormal vaginal discharge) but can still transmit the infection (Option 3). Therefore, all sexually active women age <25 and any client age ≥25 at high risk (eg, new or several sexual partners) are screened annually for chlamydia and gonorrhea (Option 4). The client's sexual partners should also receive treatment to prevent transmission and reinfection (Option 5). If not treated appropriately, chlamydia can ascend the female genital tract, producing serious complications such as pelvic inflammatory disease and infertility (Option 1). Clients should also be instructed in general safe sex practices (eg, using condoms, avoiding multiple partners) to help prevent transmission of sexually transmitted infections. Clients with a chlamydial infection may be asymptomatic or experience minor symptoms (eg, spotting after sex, dysuria, abnormal vaginal discharge). Clients should abstain from sexual intercourse for 7 days after antibiotic treatment is initiated and until all sexual partners have completed treatment to prevent transmission and serious complications. Sexually active clients age <25 or those age ≥25 at high risk should be screened annually.

Cholecystectomy (removal of the gallbladder)

Cholecystectomy (removal of the gallbladder) is performed through laparoscopic or open surgery. Signs of postoperative infection typically appear 3-7 days after surgery. Systemic signs may include fever, elevated WBC count, and fatigue. Some potential postoperative infections include: Pneumonia can occur when atelectasis (alveolar collapse) prevents clearing of secretions, promoting bacterial growth. Symptoms include cough with or without sputum, tachypnea, and shortness of breath. Postoperative incentive spirometry, ambulation, and cough/deep breathing exercises help keep alveoli open and prevent pneumonia (Option 3). Surgical site infections present with localized redness, warmth, swelling, and purulent drainage. Proper wound care and sterile dressing changes help prevent infection (Options 2 and 5). Urinary tract infections (UTIs), caused by the use of indwelling urinary catheters during surgery, can present with frequency, urgency, and dysuria. Prompt removal of catheters after surgery helps prevent UTIs. Peritonitis (peritoneal infection) presents with rebound tenderness, boardlike abdominal rigidity, and shallow breathing related to abdominal distension. Peritonitis may lead to sepsis and death if untreated (Option 4). (Option 1) Clients recovering from laparoscopic surgery may experience referred left shoulder pain during the first few postoperative days. This is due to diaphragmatic nerve irritation caused by the carbon dioxide used to inflate the abdomen during laparoscopic surgery. Educational objective: Some potential postoperative infections related to abdominal surgery include pneumonia, surgical site infection, and peritonitis. Signs of infection may include cough, tachypnea, and shortness of breath; warmth or redness around the incision; purulent incisional drainage; or rigid, painful abdomen.

Chronic venous insufficiency (CVI)

Chronic venous insufficiency (CVI) occurs when the valves in the veins of the lower extremities consistently fail to keep venous blood moving forward, which causes chronic increased venous pressure. The increased pressure pushes fluid out of the vascular space and into the surrounding tissues, where tissue enzymes break down red blood cells. The destruction of red blood cells releases hemosiderin (a reddish-brown protein that stores iron), which causes a brownish skin discoloration; chronic edema and inflammation cause the tissue to harden and appear leathery (Option 1). Affected skin is highly prone to breakdown and ulcerations (eg, venous leg ulcers), commonly on the inside of the ankle. (Options 2, 3, and 4) Diminished pulses, nonhealing ulcers on a toe, and shiny, hairless extremities are usually associated with peripheral arterial disease due to hardening of the arterial walls, which constricts blood flow and impairs transportation of nutrients to tissues. Educational objective: Chronic venous insufficiency occurs when the valves in the veins of the lower extremities fail to keep blood moving forward. Chronic edema and inflammatory changes lead to brownish, thickened skin on the extremities and venous leg ulcers (commonly on the inside of the ankle).

Cirrhosis

Cirrhosis is a progressive, degenerative disease caused by destruction and subsequent disordered regeneration of the liver parenchyma. Clients with cirrhosis suffer from various complications (eg, ascites, varices, encephalopathy) that will progressively intensify without lifestyle modifications. (Option 1) Alcoholism is one of the leading causes of cirrhosis. All clients with alcoholism should abstain from drinking to prevent further liver damage. (Option 2) Aspirin and ibuprofen (a nonsteroidal anti-inflammatory drug [NSAID]) may cause gastrointestinal bleeding. Clients with esophageal varices or portal hypertension have an increased risk of bleeding and should avoid these medications. They should contact the health care provider regarding any pain or fever. (Option 4) Although a low-sodium diet is important to prevent worsening hypertension and ascites, a low-protein diet is not usually recommended. Many clients with cirrhosis suffer from protein-calorie malnutrition; therefore, an intake of 1.2-1.5 g/kg of protein a day is commonly prescribed. Educational objective: Clients with cirrhosis should eat a high-calorie, high-carbohydrate, low-sodium, and low-fat diet; moderate protein intake is recommended. They should avoid hepatotoxic substances (eg, alcohol, acetaminophen) and medications (NSAIDs) that increase bleeding risk and reduce activities that increase intraabdominal pressure.

heart failure (HF)

Client and family education is important for those with heart failure to prevent/minimize exacerbations, decrease symptoms, prevent target organ damage, and improve quality of life. The use of any nonsteroidal anti-inflammatory drugs (NSAIDS) is contraindicated as they contribute to sodium retention, and therefore fluid retention (Option 5). To monitor fluid status, clients are instructed to weigh themselves daily, at the same time, with the same amount of clothing, and on the same scale (Option 3). Weights should be recorded to allow for day-to-day comparisons to help identify early signs of fluid retention. (Option 1) Frozen meals are often high in sodium. Most heart failure clients are instructed to limit sodium intake. All foods high in sodium (>400 mg/serving) should be avoided. (Option 2) Diuretic medications cause clients to urinate more. Morning is the appropriate time to take this type of medication. Evening administration would cause nocturia and interrupted sleep. (Option 4) Exercise training, such as cardiac rehabilitation, improves symptoms of chronic heart failure. It has been found to be safe and improves the client's overall sense of well-being. It has also been correlated with reduction in mortality. Educational objective: Discharge education for the client with chronic heart failure should include daily weights, drug regimens, diet, and exercise plans. The use of any NSAIDS is contraindicated in heart failure as these contribute to sodium retention, and therefore fluid retention.

Skin Cancer Screening

Client education on early detection of skin cancer is important as most cases of malignant melanoma are discovered by the client. A full medical workup of every mole is unnecessary. Routine self-evaluation followed by medical assessment of questionable growths is sufficient. Clients with advanced age or reduced mobility may need to see a dermatologist for a full-body skin survey. (Option 1) Rapid changes in a mole should be evaluated immediately. (Option 3) Amelanotic melanomas are pink growths similar to basal cell carcinomas of the skin. Blue, white, and red colorations can occur in melanoma. (Option 4) Malignant expansions of previous growths (moles, nevi) are common. Educational objective: Skin cancer screening should cover the basics - uneven, large, blotchy moles, or any sudden changes in mole size or color need to be checked out by a health care provider.

Peptic Ulcer Disease (PUD)

Client teaching related to peptic ulcer disease (PUD) includes lifestyle changes (eg, dietary modifications, stress reduction), PUD complications, and medication administration. Helicobacter pylori infection and treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are risk factors for complicated PUD. H pylori treatment includes antibiotics and proton-pump inhibitors for acid suppression. The recommended initial treatment is 7-14 days of triple-drug therapy with omeprazole (Prilosec), amoxicillin, and clarithromycin (Biaxin). (Option 5) Clients with PUD should avoid NSAIDs [eg, aspirin, ibuprofen (Motrin)] as they inhibit prostaglandin synthesis, increase gastric secretion, and reduce the integrity of the mucosal barrier. Educational objective: Clients with peptic ulcer disease should avoid NSAIDs, smoking, and excess use of alcohol or caffeine.

Ineffective Endocarditis (IE)

Clients with IE usually have fever for several days during the initial stages of antibiotic therapy. By the time they are discharged, fever subsides or becomes occasional and low-grade. The nurse should teach the client to monitor temperature regularly at home. Persistent temperature elevations may mean that the antibiotic therapy is ineffective or complications have developed. The client should notify the HCP if a fever persists at home. (Option 1) A client who has had IE is at risk for reoccurrence. This client should receive prophylactic antibiotics for certain high-risk procedures (eg, manipulation of gingival tissue). (Option 2) IE causes the formation of vegetations on valve and endocardial surfaces. Embolization to various organ sites can occur. Slurred speech could indicate that embolization has caused a possible stroke. (Option 4) IE can require IV antibiotics for up to 4-6 weeks. The client may be discharged home once hemodynamically stable, and a home health nurse will come to administer the antibiotics through the client's PICC line. Educational objective: The nurse should teach the client with IE to expect to receive IV antibiotics for several weeks after returning home and to report a persistent fever; any signs of embolization such as slurred speech, one-sided weakness, or paralysis; or a painful, cold extremity. Prophylactic antibiotics will be required for certain high-risk procedure

Mitral valve placement

Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Client teaching for MVP includes the following: Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms (Option 3) Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms Reduce stress and avoid alcohol use (Option 1) Clients should be taught to begin or maintain an exercise program, preferably aerobic exercise, to achieve optimal health. (Option 2) Although MVP may place the client at an increased risk for infective endocarditis, there is no clinical evidence to support the need for prophylactic antibiotics prior to dental procedures. Antibiotic prophylaxis is indicated for clients who have prosthetic valve replacement, repaired valves, or a history of infectious endocarditis. (Option 4) There is no need for a medical alert bracelet. MVP is usually a benign condition. Educational objective: The nurse should teach the client with MVP to stay hydrated, avoid caffeine and alcohol, exercise regularly, reduce stress, and take beta blockers as prescribed for palpitations and chest pain. Nitrates are usually not effective for chest pain from MVP.

congestive heart failure (CHF) Combination of both right and left sided heart failure manifestations

Clients with a diagnosis of chronic congestive heart failure experience clinical manifestations of both right-sided (systemic venous congestion) and left-sided (pulmonary congestion) failure. Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the presence of pulmonary congestion (left-sided failure) in this client. Increased jugular venous distention reflects an increase in pressure and volume in the systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided failure) in this client. Although dependent pitting edema of the extremities can be associated with other conditions (eg, hypoproteinemia, venous insufficiency), it is related to sodium and fluid retention (right-sided failure) in this client.

Signs and symptoms of chronic heart failure

Clients with a diagnosis of chronic congestive heart failure experience clinical manifestations of both right-sided (systemic venous congestion) and left-sided (pulmonary congestion) failure. Crackles are discontinuous, adventitious lung sounds usually heard on inspiration and indicate the presence of pulmonary congestion (left-sided failure) in this client. Increased jugular venous distention reflects an increase in pressure and volume in the systemic circulation, resulting in elevated central venous pressure (CVP) (right-sided failure) in this client. Although dependent pitting edema of the extremities can be associated with other conditions (eg, hypoproteinemia, venous insufficiency), it is related to sodium and fluid retention (right-sided failure) in this client. (Option 2) Dry mucous membranes are associated with dehydration (increased serum sodium level), not fluid overload (heart failure). (Option 4) Rhonchi are continuous lung sounds usually heard on expiration that indicate the presence of secretions in the larger airways. They are not a classic manifestation of chronic heart failure. (Option 5) Poor skin turgor or "tenting" is associated with skin moisture and elasticity. It is usually associated with dehydration, not fluid overload. Educational objective: Clients with chronic heart failure experience clinical manifestations of both right-sided and left-sided failure. Therefore, the nurse must be able to assess for the clinical manifestations related to systemic volume increases and pulmonary congestion.

cardiomyopathy

Clients with cardiomyopathy may develop cardiogenic shock due to the heart's inability to circulate blood effectively, causing reduced cardiac output. Treatment of cardiogenic shock includes supplemental oxygen, an ECG, cardiac enzyme testing, and interventions to reduce cardiac workload.

COPD (chronic obstructive pulmonary disease)

Clients with chronic obstructive pulmonary disease should be instructed to consume a high-calorie diet, seek medical attention for signs of infection (eg, increased sputum, worsening dyspnea, fever), and obtain appropriate vaccinations (eg, influenza, pneumococcal) to prevent exacerbations.

lactase deficiency (lactose intolerance)

Clients with lactase deficiency (lactose intolerance) experience varying degrees of gastrointestinal symptoms after ingesting milk products, including flatulence, diarrhea, bloating, and cramping. This is due to a deficiency of the enzyme lactase, which is required for digestion of lactose. Treatment includes restricting lactose-containing foods in the diet. These clients may also take lactase enzyme replacements (eg, Lactaid) to decrease symptoms (Option 4). Supplementation of calcium and vitamin D is recommended due to insufficient intake of fortified milk (Option 2). Milk and ice cream contain the highest amounts of lactose and should be restricted depending on the client's individual tolerance (Option 3). Some dairy products, including aged cheeses and live-culture yogurts, contain little to no lactose and can be tolerated by most clients with lactase deficiency (Option 1). (Option 5) Lactase deficiency is not an immune reaction (allergy) to milk products. Rather, the gastrointestinal symptoms are due to a deficiency of the enzyme lactase and the resultant inability to digest lactose. Educational objective: Clients with lactase deficiency can prevent unpleasant gastrointestinal symptoms by avoiding lactose-containing dairy products (eg, milk, ice cream), eating cheese or yogurt in moderation, and supplementing with lactase enzymes. Vitamin D and calcium supplementation is also recommended.

peripheral arterial disease (PAD)

Clients with peripheral arterial disease (PAD) have decreased sensations from nerve ischemia or coexisting diabetes mellitus. They should never apply direct heat to the extremity due to the risk for a burn wound. Wound healing is impaired in these clients. Swelling in the extremities (edema) could result from venous stasis (venous valve incompetence or varicose veins); these clients are asked to elevate their extremities during rest. However, clients with PAD usually do not have swelling, but rather have decreased blood supply. The extremities should not be elevated above the level of the heart because extreme elevation further impedes arterial blood flow to the feet. Additional teaching for the client with PAD includes the following: Smoking cessation Regular exercise Achieving or maintaining ideal body weight Low-sodium diet Tight glucose control in diabetics Tight blood pressure control Use of lipid management medications Use of antiplatelet medications Proper limb and foot care

Clinical manifestations indicating impending respiratory failure include:

Clinical manifestations indicating impending respiratory failure include: PaCO2 ≥45 mm Hg (6.0 kPa): Indicates hypercapnia and hypoventilation resulting from fatigue and labored breathing. As initial tachypnea subsides and respiratory rate returns to normal, PaCO2 rises and respiratory acidosis develops (Option 2). PaO2 ≤60 mm Hg (8.0 kPa): Indicates hypoxemia resulting from increased work of breathing, decreased gas exchange (hyperinflation and air trapping), and inability of the lungs to meet the body's oxygen demand (Option 3) Paradoxical breathing (ie, abnormal inward movement of the chest on inspiration and outward movement on expiration): Indicates diaphragm muscle fatigue and use of respiratory accessory muscles (Option 4) Mental status changes (eg, restlessness, confusion, lethargy, drowsiness): Sensitive indicators of hypoxemia and hypoxia (Option 5) Absence of wheezing and silent chest (ie, no sound of air movement on auscultation): Ominous signs indicating severe hyperinflation and air trapping in the lungs Single-word dyspnea: Inability to speak >1 word before pausing to breathe due to shortness of breath

Clomiphene (infertility treatment)

Clomiphene is an infertility treatment for women that works by stimulating ovulation. It is necessary to engage in frequent sexual intercourse 5 days after completing the medication regimen. Clomiphene may cause mood swings, nausea, hot flashes, and headaches and increases the risk of multiple gestation.

Clostridium difficile

Clostridium difficile overgrowth in the intestine often occurs when normal gastrointestinal (GI) flora is destroyed (eg, antibiotic use). Clients with C difficile often have watery diarrhea, nausea, fever, and abdominal pain. Hypovolemia can easily develop through the loss of fluids and electrolytes in the stool, especially in infants and the elderly. Clients with hypovolemia from GI losses will often have hyponatremia, hypokalemia, and elevated blood urea nitrogen (BUN) (poor renal perfusion). This client has hyponatremia (normal, 135-145 mEq/L [135-145 mmol/L]), hypokalemia (normal, 3.5-5.0 mEq/L [3.5-5.0 mmol/L]), and an elevated BUN (normal, 6-20 mg/dL [2.1-7.1 mmol/L]). Hypovolemia can cause hypotension and renal failure, and electrolyte abnormalities can cause cardiac arrhythmias; therefore, these are priority to report. Fluid resuscitation and electrolyte replacement should be initiated promptly to prevent complications

Colonoscopy prep

Colonoscopy evaluates colonic mucosa. Therefore, clients should follow instructions to keep the colon clean with no stool left for better visualization during the procedure. These instructions include: Clear liquid diet the day before Nothing by mouth 8-12 hours prior to the examination The health care provider prescribes a bowel-cleansing agent such as a cathartic, enema, or polyethylene glycol (GoLYTELY) the day before the test. The type of prep depends on the health care provider's preference and client health status. (Option 2) Healthy clients screened for colon disease do not require antibiotics prior to the procedure. (Option 3) The instructions prior to a nuclear gastric emptying scan include teaching the client to avoid smoking the day of the examination as delay of gastric emptying occurs with tobacco use. Smoking cessation per se has no role in colonoscopy, but it is good for general health. Educational objective: Instructions for clients scheduled for a colonoscopy include a clear liquid diet the day before the procedure, avoiding any food or liquids (nothing by mouth) 8-12 hours prior to the examination, and taking the bowel-cleansing agent as prescribed.

Colorectal cancer

Colorectal cancer is the third most common cancer and the second leading cause of cancer deaths affecting both genders equally. Various risk factors for colorectal cancer include: Personal or family (first-degree relative) history of colorectal cancer/polyps Personal history of inflammatory bowel disease, Crohn's disease, or ulcerative colitis History of hereditary non-polyposis colorectal cancer (Lynch syndrome) Lifestyle factors such as obesity, a diet high in red meat, cigarette smoking, and alcohol consumption (Option 4) Eating fruits, vegetables, and grains may decrease colorectal cancer risk but diets high in fat and low in fiber increase this risk. Educational objective: Medical risk factors for colorectal cancer include a personal or family history of inflammatory bowel disease. Lifestyle risk factors include a history of obesity, a diet high in red meat, cigarette smoking, and alcohol consumption.

Colorectal cancer manifestations

Colorectal cancer occurs most often in adults over age 50. Risk factors include history of colon polyps; family history of colorectal cancer; inflammatory bowel disease (eg, Crohn disease, ulcerative colitis); and history of other cancers (eg, gastric, ovarian). Symptoms of colorectal cancer may include: Blood in the stool (eg, positive occult blood, melena) from fragile, bleeding polyps or tumors (Option 2) Abdominal discomfort and/or mass (not common) (Option 1) Anemia due to intestinal bleeding, which may result in fatigue and dyspnea with exertion (Option 4) Change in bowel habits (eg, diarrhea, constipation) due to obstruction by polyps or tumors (Option 3) Unexplained weight loss due to impaired nutrition from altered intestinal absorption (Option 5) Colorectal cancer often goes unnoticed, as many of the symptoms are painless and nonspecific. Clients should be assessed for these symptoms and receive regular routine colorectal cancer screening tests (eg, occult blood test every year, colonoscopy every 10 years). Educational objective: Clients over age 50 should receive routine colorectal cancer screening for symptoms such as blood in the stool, anemia, abdominal discomfort, change in bowel habits, and weight loss. Symptoms result from intestinal polyps or tumors that cause intestinal bleeding, obstruction, and impaired intestinal absorption.

hiatal hernia

Conditions that increase intraabdominal pressure (eg, pregnancy, obesity, ascites, tumors, heavy lifting) and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm, causing a hiatal hernia. A sliding hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm. A paraesophageal hernia (rolling hernia) occurs when the gastroesophageal junction remains in place but a portion of upper stomach folds up along the esophagus and forms a pocket. Paraesophageal hernias are a medical emergency. Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated with gastroesophageal reflux disease (GERD), including heartburn, dysphagia, and pain caused by increased intraabdominal pressure or supine positioning. Interventions to reduce herniation include the following: Diet modification—avoid high-fat foods and those that decrease lower esophageal sphincter pressure (eg, chocolate, peppermint, tomatoes, caffeine). Eat small, frequent meals, and decrease fluid intake during meals to prevent gastric distension. Avoid consumption of meals close to bedtime and nocturnal eating (Option 3). Lifestyle changes—smoking cessation, weight loss (Option 2). Avoid lifting or straining (Option 5). Elevate the head of the bed to approximately 30 degrees—this can be done at home using pillows or 4 - 6 inch blocks under the bed (Option 1). (Option 4) Wearing a girdle or tight clothes increases intraabdominal pressure and should be avoided. Educational objective: Hiatal hernias occur due to a weakening diaphragm and increased intraabdominal pressure. Nursing interventions to prevent hiatal hernias are similar to those used for gastroesophageal reflux disease (GERD), and they focus on decreasing intraabdominal pressure.

ventricular septal defect

large hole between two ventricles lets venous blood pass from the right to the left ventricle and out to the aorta without oxygenation -can progress to CHF -cause left to right shunting -lead to excessive blood flow to lungs

Genu varum (bowlegs)

lateral bowing of the legs

Normal troponin level

less than 0.6 0.6 and higher indicates MI (myocardial infarction)/ heart attack

Dietary Fiber Benefits

Dietary fiber is composed of indigestible complex carbohydrates that absorb and retain water, which increases stool bulk and makes stool softer and easier to pass. Consuming a diet high in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) improves stool elimination, which helps prevent constipation and decreases the risk of colorectal cancer (Options 1 and 5). Fiber-rich foods tend to have a low glycemic load (less sugar per serving) and are nutrient dense, yet they have lower caloric density. Clients may also experience increased satiety as fiber absorbs water and produces fullness. This may help reduce caloric intake, improve blood glucose control, and promote weight loss (Options 2 and 3). Fiber binds to cholesterol in the intestines, which reduces serum cholesterol levels by decreasing the amount of dietary cholesterol that enters the bloodstream. Decreasing serum cholesterol levels helps reduce vascular plaque buildup and atherosclerosis. A high intake of fiber-rich foods directly correlates with a reduced risk of vascular diseases, including coronary artery disease and stroke (Option 4). Educational objective: Dietary fiber increases stool bulk and makes stool softer and easier to pass. A fiber-rich diet helps prevent constipation; decreases risk of colorectal cancer; promotes weight loss; improves blood glucose control; and decreases serum cholesterol levels, which reduces the risk of coronary artery disease and stroke.

Hyponatremia symptoms

lethargy, headache, confusion, apprehension, seizures, coma

respiratory acidosis s/s

lethargy, light headedness, confusion, tachycardia, hypokalemia (dyerhythmias), nausea, vomitting, epigastric pain, numbness and tingling in extremities, hyperventilation (tachycardia occurs)

permanent pacemaker

Discharge teaching for the client with a permanent pacemaker should include the following: Report fever or any signs of redness, swelling, or drainage at the incision site. Carry a pacemaker identification card and wear a medical alert bracelet. Take the pulse daily and report it to the health care provider (HCP) if below the predetermined rate. Avoid MRI scans, which can affect or damage a pacemaker (Option 1). Avoid carrying a cell phone in a pocket directly over the pacemaker and, when talking on a cell phone, hold it to the ear on the opposite side of the pacemaker (Option 2). Notify airport security of a pacemaker; a handheld screening wand should not be held directly over the device (Option 3). Avoid standing near antitheft detectors in store entryways; walk through at a normal pace and do not linger near the device. (Option 4) The client should avoid lifting the arm above the shoulder on the side of the pacemaker until approved by the HCP as this can cause dislodgement of the pacemaker lead wires. (Option 5) Microwave ovens are safe to use and do not interfere with pacemakers. Educational objective: Clients with permanent pacemakers should carry a pacemaker identification card, wear a medical alert bracelet, avoid MRI scans, avoid placing a cell phone over the pacemaker, and inform airport security personnel. Above-the-shoulder exercises should be avoided on the side of the pacemaker until cleared by the health care provider. Microwave ovens are safe to use.

Diverticular Disease of the Colon

Diverticular disease of the colon is a condition in which there are sac-like protrusions in the large intestine (diverticula). Diverticulosis is characterized by the presence of these protrusions; the client is asymptomatic and may not even be aware of the condition. Diverticulitis occurs when diverticula become infected and inflamed. Complications of diverticulitis include abscess, fistula formation, intestinal obstruction, peritonitis, and sepsis. Diverticular bleeding occurs when a blood vessel next to one of these pouches bursts; this may cause blood in the stool. The etiology of diverticular disease has been linked to chronic constipation, a major cause of excess intracolonic pressure. Preventing constipation may help reduce the risk of diverticula forming and becoming inflamed. Measures to prevent constipation include a diet high in fiber (whole grains, fruits, vegetables), daily intake of at least 8 glasses of water or other fluids, and exercise. A fiber supplement such as psyllium or bran may be advised. In the past, clients have been taught to avoid consuming seeds, nuts, and popcorn; however, current evidence does not indicate that avoidance of these foods will prevent an episode of diverticulitis. (Option 3) A low-residue diet, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes. (Option 5) Increased consumption of red meat and other high-fat foods can increase the risk of diverticulitis. Educational objective: Clients with diverticulosis should take measures to prevent constipation (eg, high-fiber diet, increased fluid intake, regular exercise), which may help prevent recurring episodes of acute diverticulitis.

Diverticulitis

Diverticular disease of the colon occurs when saclike protrusions form in the large intestine. When diverticula become infected and inflamed, the client has diverticulitis. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes the following: IV antibiotic therapy - to cover the gram-negative and anaerobic organisms that reside in the colon and contribute to diverticulitis; these commonly include metronidazole (Flagyl) plus trimethoprim/sulfamethoxazole (TMZ) (Bactrim or Bactrim DS; Septra) or ciprofloxacin (Cipro) (Option 1) NPO status - more acute cases require complete rest of the bowel (NPO status); less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet (Option 3) NG suction - in severe cases of abdominal distention, nausea, or vomiting (Option 2) IV fluids - prevent dehydration Bed rest (Option 4) Any procedure or treatment that increases intraabdominal pressure (lifting, straining, coughing, bending), increases peristalsis (laxative, enema), or could lead to perforation or rupture of the inflamed diverticula should be avoided during the acute disease process. A barium enema may be used after treatment with antibiotics and the inflammation is resolved. Diagnostic examinations, such as abdominal x-rays or CT scans, may be used without risking rupture. Educational objective: Management of acute diverticulitis focuses on bowel rest (NPO status, NG suction, bed rest), and drug therapy (IV antibiotics, analgesics). Any procedure or treatment that increases intraabdominal pressure or may cause rupture of the inflamed diverticula should be avoided.

Diverticulitis care

Diverticulosis is a condition in which saclike protrusions (ie, diverticula) develop in the large intestine, caused by increased intraabdominal pressure (eg, straining, lifting, tight clothing) and/or chronic constipation. When diverticula become infected and inflamed, the individual has diverticulitis. Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes: NPO status: More acute cases require complete rest of the bowel; less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet (Option 4) IV fluids to prevent dehydration when NPO (Option 5) Pain relief with IV medications to maintain NPO status: Opioids (eg, morphine sulfate) are indicated in moderate to severe cases of acute diverticulitis that require hospitalization (Option 1) Preventing increased intraabdominal pressure (eg, straining, coughing, lifting) to avoid perforation and rupture (Option 3) Preventing increased intestinal motility by avoiding laxatives and enemas (Option 2) The most common area for diverticula to form is the sigmoid colon. Inserting a rectal tube, colonoscope, or sigmoidoscope may cause further damage or perforation of the inflamed diverticula by increasing pressure and stimulating the rectum. Educational objective: Management of acute diverticulitis focuses on bowel rest (NPO status, bed rest) and drug therapy (IV antibiotics, analgesics). Any procedure or treatment that increases intraabdominal pressure or may cause rupture of the inflamed diverticula should be avoided.

poly pharmacy/beers criteria

list that classifies potentially harmful drugs to avoid or administer with caution in the elderly list to avoid: antipsychotics anticholinergics antihistamines antihypertensive benzodiazepines, diuretics opiods sliding scale insulin

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL (50 g/L). The nurse should anticipate which findings? Select all that apply. 1. Coarse crackles 2. Dyspnea 3. Pallor 4. Respiratory depression 5. Tachycardia

Dyspraxia Pallor Tachycardia Explanation A normal hemoglobin level for an adult male is 13.2-17.3 g/dL (132-173 g/L) and female is 11.7-15.5 g/dL (117-155 g/L). A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath (dyspnea) may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor (pale complexion) occurs from reduced blood flow to the skin. (Option 1) Coarse crackles occur with fluid overload but not with anemia. (Option 4) Respiratory depression does not occur with anemia. Respiratory depression may occur post-administration of a narcotic or during oversedation. Educational objective: Cardiac and respiratory drive is increased to maintain cardiac output and oxygenation in the setting of anemia.

Intrahepatic cholestasis of pregnancy

liver disorder exclusive to pregnancy that manifests with intense, generalized itching but no rash. The condition requires priority assessment and intervention (eg, bile acid testing, fetal surveillance, ursodeoxycholic acid) due to an increased risk of fetal demise.

emergency contraception (EC)

Emergency contraception (EC) prevents pregnancy after unprotected intercourse. Over-the-counter EC pills (eg, high-dose levonorgestrel [Plan B One-Step]) should be taken within 3 days (72 hr) of unprotected sexual intercourse (Option 3). If taken after 3 days, levonorgestrel will not harm an established pregnancy but may be less effective. Copper intrauterine device (IUD) insertion and oral ulipristal (eg, Ella) require a prescription and offer EC for up to 5 days (120 hr) after unprotected intercourse.

pulmonic stenosis

narrowing of the opening and valvular area between the pulmonary artery and right ventricle

endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP. Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (eg, amylase, lipase) (Option 3). (Option 1) Abdominal cramps can occur after a colonoscopy due to air inflation during the procedure. (Option 2) The barium contrast solution used during the procedure may make the client's stool white for up to 3 days. The nurse should encourage fluids, if appropriate, to assist in expulsion of the contrast medium. (Option 4) Copious, bile-colored (greenish-brown) drainage is expected in a client with a small bowel obstruction. The nurse should watch for signs and symptoms of electrolyte imbalances (hypokalemia), dehydration, and metabolic alkalosis. Educational objective: Acute pancreatitis, a potentially life-threatening complication, can occur following an endoscopic retrograde cholangiopancreatography. Manifestations include acute abdominal pain, often radiating to the back, and a rise in pancreatic enzymes (eg, amylase, lipase).

Endovascular abdominal aortic aneurysm repair

Endovascular abdominal aortic aneurysm repair is a minimally invasive procedure that involves the placement of a sutureless aortic graft inside the aortic aneurysm via the femoral artery. It does not require an abdominal incision. The nurse will need to monitor the puncture sites in the groin area for bleeding or hematoma formation (Option 2). Peripheral pulses should be palpated and monitored frequently in the early post-op period and routinely afterward (Option 5). Renal artery occlusion can occur due to graft migration or thrombosis so careful monitoring of urine output and kidney function should be part of nursing care (Option 4). (Option 1) No abdominal incision is required in endovascular repair. (Option 3) Chest tubes are not required in endovascular repair. Educational objective: The nurse needs to monitor groin puncture sites, peripheral pulses, urine output, and kidney function in the client who has had minimally invasive endovascular repair of an abdominal aneurysm.

Drugs that cannot be given though the nasogastric (NG) route

Enteric-coated drugs have a barrier coating that dissolves at a slower rate (usually in the small intestine) to protect the stomach from irritant effects. Crushing enteric-coated medications (eg, ibuprofen) disrupts the barrier coating and may cause stomach irritation. In addition, the particles from the coating may clog the NG tube, particularly small-bore NG tubes. Slow-, extended-, or sustained-release drug formulations are designed to dissolve very slowly within a specific time frame. Crushing these medications alters this property and introduces the risk of adverse effects from toxic blood levels due to more rapid drug absorption. Therefore, the nurse should first contact the PHCP for clarification.

Esophageal cancer

Esophageal cancer is a rare, rapidly growing malignancy of the esophageal lining with a low 5-year survival rate. Squamous cell carcinoma usually develops in the upper part of the esophagus, whereas adenocarcinoma usually develops in the lower part. Major risk factors include smoking (eg, cigarettes, pipe, cigars) and excessive alcohol consumption (ie, approximately >15 drinks/week for men, >8 drinks/week for women) (Options 1 and 3). Barrett esophagus is also a significant risk factor for esophageal cancer; this condition occurs when the distal portion of the esophagus develops precancerous changes. Obesity (which allows stomach acid to flow upward into the esophagus due to increased abdominal pressure) and uncontrolled gastroesophageal reflux disease contribute to the development of Barrett esophagus; they are both closely linked with esophageal cancer (Options 2 and 4). (Option 5) Consumption of salty foods is not associated with an increased risk of esophageal cancer but increases the risk of gastric cancer. Dietary factors that may increase a client's risk of esophageal cancer include high intake of nitrosamine-containing foods (eg, pickled foods, beer), frequent ingestion of extremely hot beverages (thermal injury), and deficient intake of fruits and vegetables. Educational objective: Esophageal cancer is a rapidly growing malignancy of the esophageal lining. Risk factors for esophageal cancer include smoking, excessive alcohol consumption, obesity, and gastroesophageal reflux disease.

pyloric stenosis

narrowing of the opening of the stomach to the duodenum

nurse is screening clients at a community health event. Which of the following client statements should the nurse recognize as a warning sign of cancer? Select all that apply. 1. "For the past few years, I get a productive cough in the winter that goes away in spring." 2. "I occasionally have heartburn an hour after I eat fried foods and sausage." 3. "Last month when I was doing my breast self-examination, I noticed a marble-sized lump." 4. "My mole is itchy, and the borders have become uneven with a blackish to bluish color." 5. "Recently I have noticed that my bowel movements appear black."

Explanation Cancer is a growth of abnormal cells in an organ system that may impair the organ's function and spread throughout the body. Many cancers are invasive and life threatening if allowed to reach late stages of development. However, cancer is often difficult to identify early as the client may be asymptomatic or have only vague symptoms. Nurses should screen clients for and immediately report warning signs of cancer, which can be remembered with the mnemonic CAUTION: Change in bowel or bladder habits (Option 5) A sore that does not heal Unusual bleeding or discharge from a body orifice Thickening or a lump in the breast or elsewhere (Option 3) Indigestion or difficulty in swallowing that does not go away Obvious change in a wart or mole (Option 4) Nagging cough or hoarseness (Option 1) A productive cough that is annual and seasonal, particularly occurring in the winter, may indicate chronic bronchitis. The nagging cough found in clients with lung cancer is persistent, rather than seasonal. (Option 2) A client report of occasional indigestion after specific triggers (eg, high-fat or spicy food, caffeine) may indicate gastroesophageal reflux disease. However, indigestion that is persistent or chronic indigestion may indicate cancer. Educational objective: Warning signs of cancer for nurses to monitor include change in bowel or bladder habits, a sore that does not heal, unusual bleeding or discharge, thickening or a lump in the breast or elsewhere, indigestion or difficulty swallowing, any obvious change in a wart or mole, and nagging cough or hoarseness (mnemonic: CAUTION).

A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client? Select all that apply. 1. Avoid massaging the area 2. Avoid receiving vaccinations in the affected arm 3. Elevate the arm above the heart 4. Perform isometric exercises 5. Use an intermittent pneumatic compression sleeve

Explanation Lymphedema is the accumulation of lymph fluid in the soft tissue. It can occur as a result of lymph node removal or radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid can accumulate in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor function may be impaired. The presence of lymphedema increases the client's risk for infection or injury of the affected limb. Interventions to manage lymphedema include: Decongestive therapy (massage technique to mobilize fluid) Compression sleeves or intermittent pneumatic compression sleeve (Option 5) Compression sleeves are graduated with increased distal pressure and less proximal pressure. Clothing should also be less constrictive at the proximal arm and over the chest. Elevation of arm above the heart (Option 3) Isometric exercises (Option 4) Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure measurements, and injections (eg, vaccinations) on the affected limb (Option 2) Injury prevention (limb less sensitive to temperature changes) Infection prevention (limb more prone to infection through skin breaks) (Option 1) Clients often learn massage techniques (ie, decongestive therapy) from physical therapists to increase lymphatic drainage and promote circulation of the extremity. Educational objective: Management for lymphedema includes decongestive massage therapy, compression bandages or sleeves, elevation of the arm above heart level, isometric exercises, and avoidance of venipuncture or blood pressure measurements on the affected limb.

morphine toxicity s/s

nausea, vomitting, diarrhea, vision changes, (seeing halos usually green/yellow around light)

Which of the following diets would place a client at the highest risk for macrocytic anemia? 1. Lacto-ovo-vegetarian[13%] 2. Lacto-vegetarian[8%] 3. Macrobiotic[15%] 4. Vegan[61%]

Explanation Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12 supplement is recommended when dietary intake is inadequate. (Option 1) Lacto-ovo-vegetarian — eggs, milk, and milk products are included, but no meat is consumed. (Option 2) Lacto-vegetarian — milk and milk products are included in the diet; eggs and meats are excluded. (Option 3) Macrobiotic — whole grains, vegetables, fruits, and seaweeds are emphasized; fish and seafood may be included in the diet up to several times a week. Educational objective: Individuals who follow a plant-based diet, especially vegans, are at risk for vitamin B12 deficiency and the resulting macrocytic anemia.

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery. During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm. What action should the nurse take? 1. Anticipate the scheduling of a biopsy[66%] 2. Apply ice to the node[3%] 3. Reassure the client that it is an expected finding[28%] 4. Request an antibiotic[2%]

Explanation Ordinarily, lymph nodes are not palpable in adults. However, a lymph node that is palpable, superficial, small (0.5-1 cm), mobile, firm, and nontender is considered a normal finding. It could easily be explained by the relatively recent mastectomy (trauma) with resulting inflammation and lymph flow interference. A tender, hard, fixed, or enlarged node is an abnormal finding. Tender nodes are usually due to inflammation but hard or fixed nodes could indicate malignancy. (Option 1) A biopsy is performed for an abnormal lymph node finding that could suggest malignancy. (Option 2) The swelling is caused by inadequate lymph drainage or inflammation, not localized edema. Ice is not recommended for this normal finding. (Option 4) There is no indication of lymphangiitis requiring antibiotics. This may produce a red streak with induration following the course of the lymphatic collecting duct. Infected skin lesions may also be present. Educational objective: A lymph node that is superficial, palpable, small (≤1 cm ), mobile, firm, and nontender is a normal finding. Hard and fixed nodes are most concerning as they are likely due to malignancy. Tender nodes usually indicate inflammation/infection.

Fasting

Fasting for more than 1 or 2 days can cause a number of health problems: Increased stress - when fasting, the body goes into "starvation mode;" metabolism slows down and cortisol production increases Muscle damage - in starvation mode, the body breaks down muscle and converts amino acids to glucose Fluid loss - glycogen stores in the liver are also broken down as an energy source; this metabolic process releases water, resulting in fluid loss Increased hunger - appetite hormones are suppressed during a fast; however, when regular eating habits are resumed, appetite will be increased Depletion of essential nutrients Fatigue, headache, dehydration, dizziness, and muscle weakness (Option 1) Fasting for more than 1 or 2 days can lead to health problems. (Option 2) In starvation mode, the body will use protein, fat, and stored carbohydrates as energy sources. Protein is not spared. (Option 3) Appetite may be suppressed during a fast after the first few hours/days; however, when regular intake is resumed, hunger will return. Educational objective: Fasting can cause multiple health problems, including increased stress, slowing of the body's metabolism, muscle damage, fluid loss, increased hunger, depletion of nutrients, and physical symptoms such as headache, dizziness, fatigue, and muscle weakness.

cataract surgery

Following cataract surgery, the client will be instructed that for several days (or until approved by the surgeon), activities that may increase intraocular pressure should be avoided to decrease the risk of damage to sutures or surgical site. These include bending (eg, vacuuming floors, playing golf), lifting more than 5 lb, sneezing, coughing, rubbing or placing pressure on the eye, or straining during a bowel movement. The nurse should encourage this client to increase fluids and fiber in the diet as well as consider an over-the-counter stool softener or laxative.

Gestational Diabetes Mellitus (GDM)

Gestational diabetes mellitus (GDM) is diagnosed in clients who have impaired blood glucose (BG) regulation due to physiologic pregnancy changes (eg, rising BG levels, insulin resistance). GDM screening occurs at 24-28 weeks gestation. If GDM is diagnosed, management includes nutritional counseling and, if needed, pharmacologic therapy. Two-step GDM testing begins with a screening test: the 1-hour glucose challenge test (GCT). The 1-hour GCT can be performed any time of day and does not require fasting (Option 1). If the client's serum BG is <140 mg/dL (7.8 mmol/L), GDM is unlikely, and the client requires no further testing. If serum BG is ≥140 mg/dL (7.8 mmol/L), the client requires a 2- or 3-hour glucose tolerance test (GTT) to diagnose GDM.

prostatectomy

Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Therefore, interventions to prevent constipation are an important part of postoperative care and discharge teaching. Prevention of constipation is particularly important while the client remains on opioid analgesics, which can cause constipation (Option 4). (Option 1) Fluid intake should be encouraged in this client. (Option 2) The client is at risk for postoperative deep vein thrombosis and pulmonary embolism. Ambulation is an important part of preventing these serious surgical complications. Ambulation will also help reduce constipation. (Option 3) The client who goes home with an indwelling catheter should learn how to clean around the catheter at the urinary meatus with warm water and soap to prevent infection. Educational objective: Clients who have had an open radical prostatectomy for prostate cancer should avoid anything that could cause strain on the rectal area. Straining, suppositories, and enemas are contraindicated in these clients, and interventions should be implemented to prevent constipation.

Appropriate needle length and injection site are essential for proper administration of IM immunizations

For infants, use of a 1-in (25-mm) needle to administer medication in the vastus lateralis muscle is recommended to reach the IM tissue and minimize local reactions.

Gastric suction intervention

General interventions to maintain gastric suction using a Salem sump tube include: Place the client in semi-Fowler's position to help keep the tube from lying against the stomach wall; this is done to help prevent gastric reflux (Option 2). Provide mouth care every 4 hours as this helps to maintain moisture of oral mucosa and promote client comfort (Option 4). Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds (Option 5). Inspect the drainage system for patency (eg, tubing kink or blockage). Educational objective: General interventions to maintain gastric suction when using a Salem sump tube include: Maintaining client in semi-Fowler's position Accurate assessment of bowel sounds Keeping the air vent (blue pigtail) open and above the level of the client's stomach Providing mouth care every 4 hours to maintain moisture of oral mucosa and promote comfort Inspecting the drainage system for patency

gestational hypertension

Gestational hypertension is new-onset high blood pressure (≥140/90 mm Hg) that occurs after 20 weeks gestationwithout proteinuria. -The development of proteinuria with hypertension indicates preeclampsia, which may manifest with symptoms such as headache, visual disturbances, and facial swelling. This client is exhibiting symptoms of preeclampsia and should be assessed first (Option 3). -Complications of preeclampsia may include thrombocytopenia, liver dysfunction, and renal insufficiency. Clients with preeclampsia must be monitored closely for sudden worsening, which can lead to serious complications, including eclampsia and/or HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets).

Giving oral medications to infants

Giving oral medications to infants requires specialized techniques for safe administration. A plastic, disposable oral syringe can be used for accurate dosing and ease of delivery (Option 4). Oral medication should be administered with the infant in a semi-reclining position, which is similar to the feeding position (Option 3). This position promotes comfort, prevents aspiration, and may be better controlled by the nurse if the infant resists the medication. Liquid medications administered by oral syringe should be directed toward the back and inside of the infant's cheek (Option 2). The medication should be dispensed slowly in small amounts, allowing the infant to swallow between squirts to prevent aspiration.

pelvic inflammatory disease (PID) causes

Gonorrhea and chlamydia can lead to pelvic inflammatory disease (PID) and infertility. They are referred to as "silent infections" because many affected women show no symptoms. Infections of the fallopian tubes and uterus can lead to permanent damage and infertility. The Centers for Disease Control and Prevention recommend annual chlamydia and gonorrhea screening for all sexually active females age <25 and older females with risk factors. Both chlamydia and gonorrhea are treatable. The use of latex condoms is recommended to reduce the risk of contracting chlamydia and gonorrhea.

Hemophilia

Hemophilia is a group of disorders characterized by deficiencies in production or use of coagulation proteins (eg, factor VIII, factor IX), resulting in impaired clot formation and increased risk for uncontrolled bleeding. Hemophilia is typically identified by prolonged or excessive bleeding, severe bruising, or joint bleeding (ie, hemarthrosis) after injuries or procedures. Administration of supplemental IV clotting factors (eg, factor VIII, factor IX) is the primary treatment for acute bleeding in clients with hemophilia (Option 1). Clients with hemophilia have increased risk of hemarthrosis (ie, bleeding in joint). In addition to administration of IV clotting factors, hemarthrosis is managed with rest, ice, compression, and elevation (RICE). Application of ice or cold packs promotes local vasoconstriction and clot formation (Option 3). The affected joint should be maintained in the extended position to prevent flexion contracture (Option 4). Frequent neurologic assessments are required for clients with hemophilia who have suspected (facial laceration in this client) or confirmed head trauma, as neurologic alteration may indicate intracranial bleeding (Option 5). (Option 2) When caring for clients with hemophilia, the nurse should eliminate factors that increase bleeding risk or promote complications from bleeding. NSAIDs (eg, aspirin, ibuprofen) are avoided as they inhibit platelet aggregation, which increases bleeding risk Educational objective: For acute bleeding, clients with hemophilia are treated with supplemental IV clotting factors. Hemarthrosis is managed with rest, ice, compression, and elevation, and the affected joint should remain extended to prevent contractures. NSAIDs (eg, ibuprofen) increase bleeding risk and should be avoided for clients with hemophilia.

hemorrhoidectomy

Hemorrhoids (distended, inflamed veins located in the anus or lower rectum) are caused by increased anorectal pressure (straining to defecate, constipation). Clients may experience symptoms such as rectal bleeding, pain, pruritus, and prolapse. Although removal of hemorrhoids (hemorrhoidectomy) is a minor procedure, the pain associated with it is due to spasms of the anal sphincter and is severe. Nursing management for the post-hemorrhoidectomy client includes the following: Pain relief: Initially, pain is managed with pain medications, including nonsteroidal anti-inflammatory drugs (eg, ibuprofen) and/or acetaminophen; opioids can be prescribed initially but may worsen constipation. Beginning 1-2 days postoperatively, warm sitz baths are used as a means to relieve pain. Clients often dread their first bowel movement due to severe pain with defecation. Therefore, pain must be appropriately controlled to prevent further constipation (Option 2). Preventing constipation: Encourage a high-fiber diet and adequate fluid intake (at least 1500 mL/day). Administer a stool softener such as docusate (Colace) as prescribed. An oil-retention enema may be used if constipation persists for 2-3 days (Option 1). (Option 3) Postoperatively, the health care provider may pack the rectum and apply a T-binder to hold the packing in place. The dressing is usually removed 1-2 days postoperatively unless excess soaking is noted before. (Option 4) Warm sitz baths are used beginning 1-2 days postoperatively, 2-3 times daily (15-20 minutes each) for 7-10 days to provide pain relief, decrease swelling, and cleanse the rectal area. Educational objective: Post-hemorrhoidectomy pain is excruciating. Providing pain relief and preventing constipation are the primary goals for these clients. Sitz baths should begin 1-2 days postoperatively. Hemorrhoids may recur with increased anorectal pressure. Therefore, clients should maintain a high-fiber diet, use stool softeners, and drink adequate fluids (at least 1500 mL/day) to prevent constipation.

Hepatic encephalopathy (HE)

Hepatic encephalopathy (HE) is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood. Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. (Option 3) Spider angiomas (eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver. (Option 4) Jaundice occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy. (Option 5) Amylase and lipase are enzymes from pancreatic tissue. Alanine aminotransferase and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis. Educational objective: HE manifests with sleep disturbances, altered mental status, and lethargy. Asterixis and elevated ammonia are characteristic of HE.

Hepatic encephalopathy (lactulose)

Hepatic encephalopathy is a reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood-brain barrier, leading to neurological dysfunction (Option 1). Lactulose is the most common treatment for hepatic encephalopathy. Lactulose is not digested or absorbed until it reaches the large intestines where it is metabolized, producing an acidic environment and a hyperosmotic effect (laxative). In this acidic environment, ammonia (NH3) is converted to ammonium (NH4+) and excreted rapidly. Lactulose can be given orally with water, juice, or milk (to improve flavor) or it can be administered via enema (Option 4). For faster results, it can be administered on an empty stomach (Option 2). The desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached (improved mental status, decreased ammonia levels) (Option 3). The client's electrolyte levels should be closely monitored during therapy as lactulose is a laxative that can cause dehydration, hypernatremia, and hypokalemia. Educational objective: Increased ammonia levels in the blood can lead to hepatic encephalopathy, a complication of liver disease. Lactulose, a laxative, removes ammonia and is given orally with juice, milk, or water or rectally via enema to produce 2-3 soft bowel movements a day. Therapeutic effects are evident via laboratory results and improving mental status.

genital herpes

Herpes simplex virus type 2 (HSV-2) is usually associated with genital herpes. Lesions are painful and appear as multiple small, vesicular lesions. Management strategies focus on disease spread, including autoinoculation (eg, fingers) and pain relief, and include: Avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak (Option 1). After the outbreak has resolved, condoms should be used in future sexual encounters as transmission is possible even in the absence of active lesions. Keep the area with lesions clean and dry. Avoid use of perfumed soaps and bubble baths. Maintain proper hand hygiene and avoid touching the lesions to prevent spreading. Use sitz baths and oatmeal baths to provide comfort and relief of itching and burning. (Option 2) Vesicles contain numerous virus particles, leading to the possibility of self-inoculation. This can be prevented by avoidance of hand contact with lesions during an outbreak. (Option 3) Use of a hair dryer on a cool setting is an effective means of drying the lesions and promoting client comfort. (Option 4) Warm water provides symptomatic relief. Mild soap containing no perfumes reduces the risk of irritation to the area. Educational objective: Clients experiencing an outbreak of genital herpes should abstain from sexual activity when lesions are present and use condoms in future sexual encounters as transmission is possible even in the absence of active lesions.

Hiatal hernia

Hiatal hernia is characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to diaphragmatic weakness. Nurses educating clients with hiatal hernias about symptom management should instruct them to avoid activities that increase abdominal pressure (eg, weight lifting), sleep with the head of the bed elevated, and remain upright for several hours after meals.

Histoplasmosis

Histoplasmosis is an opportunistic fungal infection that results when fungal spores from soil that contains bird or bat droppings is inhaled. Histoplasmosis is usually asymptomatic or mild, but can result in widespread, life-threatening infections in immunocompromised individuals.

human immunodeficiency virus (HIV)

Human immunodeficiency virus (HIV) is a viral infection of the CD4+ (helper T) cells, resulting in progressive immune system impairment. Clients with HIV are susceptible to opportunistic infections that typically occur during periods of low CD4+ counts. To reduce the risk of infection, nurses should educate clients with HIV to: Obtain and remain up to date on vaccinations, including the annual influenza vaccination (Option 2). Avoid eating undercooked meats (eg, steak that is pink) and having contact with cat feces (eg, cat litter box) because both are sources of Toxoplasma gondii, an opportunistic parasite that causes encephalitis (Options 1 and 3). Avoid drinking water from poorly sanitized (eg, developing countries) or potentially contaminated (eg, rivers, wells) sources because it may contain infectious pathogens (eg, Cryptosporidium, Isospora, Giardia). Instead, use bottled or purified water when drinking and brushing teeth (Option 4). (Option 5) Educate clients with HIV to always use synthetic barriers (eg, condoms) during sex to reduce the risk of transmitting HIV and being infected with additional HIV strains or other sexually transmitted infections. Clients with an undetectable viral load have a lower risk of transmitting HIV to a sexual partner but should still use barrier contraception. Educational objective: Clients with HIV should take precautions to prevent opportunistic infections, including: staying up to date on vaccinations, eating thoroughly cooked meat, avoiding changing cat litter boxes, and using bottled water to brush teeth when traveling to developing countries. Clients with HIV, even those with a low viral load, should always use condoms.

Human Papillomavirus (HPV)

Human papillomavirus (HPV), one of the most common sexually transmitted infections, is associated with genital warts and cervical cancer. There are many different strains of HPV, with types 16 and 18 causing nearly all cases of cervical cancer. HPV infection is often asymptomatic, and genital warts due to HPV are typically painless. Prevention includes vaccination against HPV before sexual activity begins and safe sex practices/abstinence. The recommended age for vaccination in both boys and girls is age 11-12, but the vaccine can be given as early as age 9 and up to age 26. Clients with HPV and their partners should be educated that the virus can still be spread through skin-to-skin contact, even with the use of condoms (Option 4). Safe sex practices decrease the risk of disease transmission but do not prevent it entirely. (Option 1) HPV can be spread through sexual contact, even if symptoms are not present. (Option 2) HPV may be transmitted through vaginal, anal, or oral sex. (Option 3) Clients with HPV need to have annual Papanicolaou tests as the virus increases the risk of cervical cell changes (ie, dysplasia) and subsequent risk of cervical cancer. Educational objective: Human papillomavirus (HPV) is associated with genital warts and cervical cancer. Condoms used during sex decrease, but do not completely eliminate, the risk of transmission. Prevention includes vaccination against HPV, preferably before sexual activity begins, and safe sex practices.

Fifth disease (Slapped-cheek erythema infectiosum)

Human parvovirus B19 Mild flulike symptoms; red rash on cheeks. Highly contagious and communicable before onset and symptoms begin. Rash will spread to extremity then to the proximal and distal surface. -symptoms are general malaise and joint pain that NSAID can treat. -recover in 5-7 days -once children develop symptoms they are no longer infected, isolation is not required unless the child is hospitalized with aplastic crisis and ummunocompramise

hypertensive crisis

Hypertensive crisis is a life-threatening medical emergency characterized by severely elevated blood pressure (systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). The client may have symptoms of hypertensive encephalopathy, including severe headache, confusion, nausea/vomiting, and seizure. Hypertensive crisis poses a high risk for end-organ damage (eg, hemorrhagic stroke, kidney injury, heart failure, papilledema). The nurse should prioritize neurological assessment (eg, level of consciousness [LOC], cranial nerves) as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention (Option 2). Treatment for hypertensive crisis typically includes IV nitrates or antihypertensives (eg, nitroprusside, labetalol, nicardipine) and continuous monitoring (eg, blood pressure, telemetry, urine output) in a critical care setting.

Hypomagnesemia related to heart failure

Hypomagnesemia (normal: 1.5-2.5 mEq/L [0.75-1.25 mmol/L]) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. The American Heart Association recommends treatment with IV magnesium sulfate. (Option 1) Characteristics of atrial fibrillation (AF) include an irregularly irregular rhythm and replacement of P waves by fibrillatory waves. Although electrolyte disturbances increase the likelihood of developing AF, clients can have this chronic condition managed with anticoagulation therapy. AF is usually associated with an underlying heart disease and is rarely immediately life-threatening. (Option 2) Atrial flutter is characterized by sawtooth-shaped flutter waves. There is no clinical evidence suggesting that hypomagnesemia leads to atrial flutter, which is associated with underlying heart disease (eg, mitral valve disorders, cardiomyopathy, cor pulmonale). (Option 3) Mobitz II (type II second-degree atrioventricular block) is usually not associated with electrolyte disturbances but is more often associated with conduction system disease or drug toxicity (eg, beta blockers, calcium channel blockers). Educational objective: In a client with hypomagnesemia, it is important to assess the QT interval. The client is most at risk for torsades de pointes, a serious complication that can develop quickly into ventricular fibrillation (lethal arrhythmia).

Immune Thrombocytopenic Purpura (ITP)

Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which antibodies bind to and cause destruction of platelets. Clients with ITP have a platelet count <150,000/mm3 (150 x 109/L) and are at increased risk of bleeding. Key teaching to reduce the client's risk of bleeding includes: Use soft-bristle toothbrushes, gentle flossing, and nonalcoholic mouthwashes. These prevent periodontal disease and gingival bleeding (Option 1). Avoid activities that may cause trauma (eg, high-intensity sports). Appropriate exercise includes low-impact activity (eg, walking) while wearing nonskid footwear to help prevent falls (Option 2). Take prescribed stool softeners and laxatives as needed. These medications prevent hard stools and straining, which can cause anorectal fissuring, bleeding, and hemorrhoids (Option 4)

peripheral artery disease (PAD) risk factors

In peripheral artery disease (PAD), the arteries of the extremities become atherosclerotic (progressive thickening and hardening due to chronic vascular damage). PAD reduces tissue perfusion and can cause ischemic pain of the lower extremities with movement or exercise (intermittent claudication). Pain with PAD can also occur at rest and manifests in the lower extremities as burning, aching, or numbness. Factors that cause chronic vascular changes and increase risk for PAD include: Hypertension: Vessel damage from chronically elevated vascular resistance Diabetes mellitus: Inflammatory vascular changes from hyperglycemia (Option 2) Hyperlipidemia: Increased plaque formation (ie, atherosclerosis) (Option 3) Smoking: Chronic vasoconstriction from nicotine inhalation (Option 1) (Option 4) Elevated estrogen levels (eg, oral contraceptive use, pregnancy, hormone replacement therapy) make blood hypercoagulable. However, elevated estrogen levels are more likely to form thrombi in veins than in arteries due to lower venous pressure and slower blood flow (eg, venous stasis). (Option 5) Unlike chronic venous insufficiency, in which vessels ineffectively return blood from the feet to the central circulation, standing is not a risk factor for PAD, as standing facilitates blood flow by gravity to the lower extremities. Educational objective: In peripheral artery disease, arteries in the extremities become atherosclerotic (progressive thickening and hardening due to chronic damage). Peripheral tissue perfusion is impaired, causing pain with exercise (eg, intermittent claudication) and at rest. Risk factors include hypertension, diabetes mellitus, hyperlipidemia, and smoking.

Who needs isotonic IV fluids

Indications of a need for IV isotonic fluids include capillary refill more than 3 seconds and mottling, prehydration before an epidural anesthesia, and inadequate urine output and tachycardia due to hyperemesis gravidarum.

Risk factors for cervical cancer

Infection with high-risk HPV strains (eg, 16, 18) History of sexually transmitted diseases Early onset of sexual activity Multiple or high-risk sexual partners Immunosuppression Oral contraceptive use Low socioeconomic status Tobacco use HPV = human papillomavirus.

Infertility and depression

Infertility is diagnosed when a couple fails to conceive after 12 months (women age <35) or 6 months (women age ≥35) of frequent, unprotected intercourse. Difficulty achieving pregnancy may affect a couple's social, financial, and intimate relationships. Therefore, clients may benefit from a holistic approach to care. The nurse should be alert for signs of psychosocial distress such as expressions of guilt, denial, anger, or isolation. Anxiety and depression are common among couples with infertility concerns and require further evaluation of the client's emotions. Active listening and open-ended questions may help clients speak more openly and honestly about their feelings (Option 4).

Risk factors contributing to infertility

Infertility is the inability to conceive after unprotected intercourse (ie, no contraceptive use) for >12 months. Female fertility declines as women age, with the first significant decrease seen after age 35 (Option 3). Hormonal dysfunction (eg, polycystic ovarian syndrome) can cause ovarian cysts and anovulatory cycles (ie, lack of ovulation during a menstrual cycle), which impair fertility (Option 4). Some sexually transmitted infections (eg, chlamydia) may be asymptomatic in females, which can delay treatment (eg, antibiotics). Untreated or recurrent infections cause inflammation (eg, pelvic inflammatory disease), scarring, and damage to the reproductive tract, leading to infertility (Option 5). Endometriosis is characterized by endometrial tissue (ie, inner lining of the uterus) depositing outside the uterus. These endometrial lesions can result in chronic inflammation, pelvic pain, menstrual cycle abnormalities, and infertility (Option 2). Infertility is the inability to conceive after unprotected intercourse for >12 months. Factors contributing to female infertility include hormonal dysfunction (eg, polycystic ovarian syndrome) with anovulation, high or low BMI, and conditions that can lead to reproductive tract scarring and damage (eg, infection, endometriosis).

Influenza (flu)

Influenza (flu) is a contagious viral infection that affects the respiratory tract. Symptoms include fever, chills, severe muscle aches, headache, cough, sore throat, nasal congestion, and malaise. Influenza treatment includes rest, hydration, humidified air, and antipyretics/analgesics. Antiviral medications (eg, zanamivir [Relenza], oseltamivir [Tamiflu]) are given to clients with symptom onset within the last 48-72 hours. These medications inhibit viral reproduction and can shorten the duration of the illness. Annual vaccination is recommended to prevent influenza (Option 4). To prevent spreading influenza, infected clients should be on droplet precautions (eg, surgical mask, private room), wear a mask when being transported out of the room, and be taught to cover the mouth and nose while coughing or sneezing (Options 2 and 3). Hand hygiene should also be emphasized as the influenza virus can persist on unwashed hands and surfaces.

Irritable bowel syndrome (IBS)

Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder characterized by abdominal pain and altered bowel motility (constipation, diarrhea, or a combination of both). Clients with IBS also commonly experience bloating, nausea, urgency, and flatulence. Symptoms of IBS are often managed through lifestyle and diet modifications. Appropriate management strategies include: Keep a daily record of symptoms, dietary intake, and stress level to help identify IBS triggers (Option 2). Limit intake of gas-producing foods: legumes (eg, beans), cruciferous vegetables (eg, cabbage, broccoli), and foods containing fructose (eg, honey, apples) (Option 3). Practice stress reduction techniques (eg, meditation, yoga) and perform regular exercise (Option 4). Anxiety and stress are associated with increased IBS symptoms. Physical exercise improves bloating, constipation, and may help further reduce stress. Reduce daily caffeine intake, as caffeine can affect bowel motility and trigger symptoms (Option 5). (Option 1) To prevent malnutrition, clients with IBS should not fast or otherwise drastically reduce their oral intake (eg, clear liquid diet), even during periods of moderate or severe symptoms. Clients experiencing increased symptoms should talk with the health care provider, as pharmacologic intervention may be required. Educational objective: Irritable bowel syndrome (IBS) is a chronic disorder characterized by abdominal pain and altered bowel motility (constipation, diarrhea, or a combination of both). IBS is managed primarily through lifestyle and diet modifications, including exercise, stress reduction, and reduced intake of gas-producing foods and caffeine.

menopause

Loss of ovarian function during menopause causes a decrease in estrogen production, leading to reduced osteoblast activity and cardioprotective effect. Therefore, postmenopausal clients are at increased risk for osteoporosis and coronary artery disease (CAD). Other physiological changes after menopause may include weight gain, sleep disturbances, fat redistribution, and vaginal atrophy. Clients should utilize health promotion strategies to reduce the effects of decreased estrogen levels, including: Consuming optimal amounts of dietary calcium (green, leafy vegetables; dairy products) and engaging in weight-bearing exercise to promote bone health (Options 3 and 4) Closely monitoring cholesterol levels (eg, HDL, LDL, triglycerides), as increased LDL cholesterol increases risk for CAD (Option 2) Considering seeking the assistance of a dietitian, and maintaining a low-calorie diet rich in fruits and vegetables, as hormone changes may cause a predisposition to weight gain (Option 1) Seeking support to cope with any emotional symptoms (eg, depression, mood swings, sadness, difficulty concentrating) caused by changing hormone levels (Option 5) Educational objective: Postmenopausal women should consume plenty of calcium-rich foods (eg, dairy products; green, leafy vegetables), engage in weight-bearing exercise, monitor cholesterol levels, consider dietary counseling to maintain a healthy weight, eat a diet rich in fruits and vegetables, and seek support for any emotional symptoms.

Lyme disease

Lyme disease develops after a bite from a deer tick infected with Borrelia burgdorferi. Clients initially develop flulike symptoms (eg, headache, fever, myalgia, fatigue). Many clients develop erythema migrans, a bull's-eye rash; however, it is not always present. Any of these symptoms should be reported immediately to a health care provider (Option 4). The client will likely be prescribed antibiotics (eg, doxycycline, amoxicillin) to treat Lyme disease and prevent it from causing complications (eg, carditis, chronic arthritis, meningitis, facial paralysis). To prevent tick bites during outdoor activities, clients should: Apply an insect repellent spray that contains tick-repelling ingredients (eg, DEET, picaridin) (Option 1) Avoid tall grass and thick underbrush, and hike only in the center of the trails (Option 2) Wear long-sleeved shirts tucked into pants, long pants tucked into socks or boots, and closed-toed shoes (Option 5) (Option 3) Covering attached ticks with petroleum jelly or nail polish is a folk remedy that actually increases the chance of infection by keeping the tick on the skin. Ticks should be promptly removed using tweezers, being careful to grasp the tick close to the attachment site and not crush it during removal. Educational objective: Clients should be taught to prevent tick bites while hiking by using insect repellent; avoiding tall grass and thick underbrush; and wearing long-sleeved shirts, long pants, and closed-toed shoes. Ticks should be promptly removed with tweezers, keeping them intact. Flulike symptoms and a bull's-eye rash should be reported immediately to the health care provider.

Hodgkin lymphoma

Lymphoma is a form of cancer that begins in the body's lymphatic system (eg, lymph nodes, spleen) and is characterized by abnormal growth of lymphocytes. It is usually classified within two major subtypes, Hodgkin lymphoma and non-Hodgkin lymphoma (NHL), and is further identified by numerous subcategories. To be diagnosed with Hodgkin lymphoma, malignant Reed-Sternberg cells must be found in the lymphatic tissue. Furthermore, Hodgkin lymphoma tends to follow a predictable path of metastasis, whereas NHL tends to be more widely disseminated. The most common clinical manifestation of any form of lymphoma is the presence of at least one painless, enlarged lymph node, often in the neck, underarm, or groin (Option 2). Clients may also present with or develop fever; significant, unexplainable, and/or unintentional weight loss (>10% of body weight); and/or drenching night sweats (ie, "B symptoms"); which typically associate with a poor prognosis (Options 1, 3, and 5). Additional indications are nonspecific (eg, itching, fatigue), although some clients are asymptomatic at the time of diagnosis (Option 4). It is critical that nurses are alert to potential symptoms of lymphoma because early identification and treatment improve the client's chance for complete remission. Educational objective: Lymphoma is a form of cancer beginning in the body's lymphatic tissues. The most common clinical manifestation of any form of lymphoma is the presence of at least one painless, enlarged lymph node. Additional manifestations include fever; significant, unintentional weight loss; night sweats; itching; and fatigue.

macular degeneration (MD)

Macular degeneration is a progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate. This deterioration causes distortion (blurred or wavy visual disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact (Option 4). Macular degeneration has two different etiologies. "Dry" macular degeneration involves ischemia and atrophy of the macula that results from blockage of the retinal microvasculature. "Wet" macular degeneration involves the abnormal growth of new blood vessels in the macula that bleed and leak fluid, eventually destroying the macula. Progression of macular degeneration may be slowed with smoking cessation, intake of specific supplements (eg, carotenoids, vitamins C and E), laser therapy, and injection of antineoplastic medications. Risk factors for macular degeneration include advanced age, family history, hypertension, smoking, and long-term poor intake of carotenoid-containing fruits and vegetables. (Option 1) Seeing small flashes of light is associated with retinal detachment. (Option 2) Inability to see things close up, known as presbyopia, occurs when the lens of the eye becomes less elastic with age and therefore unable to adjust to near and far vision. (Option 3) Poor peripheral vision, also called tunnel vision, can result from optic nerve damage seen in glaucoma. Educational objective: Macular degeneration is a progressive, incurable eye disease that occurs when the central portion of the retina deteriorates, giving rise to distortion (blurred or wavy visual disturbances) or loss in the center of the visual field.

Anticoagulants teaching for patients with mechanical heart valve

Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding. Teaching topics for clients on anticoagulants: Take medication at the same time daily Depending on medication, report for periodic blood tests to assess therapeutic effect Avoid any action that may cause trauma/injury and lead to bleeding (eg, contact sports, vigorous teeth brushing, use of a razor blade) (Option 4) Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) Limit alcohol consumption Avoid changing eating habits frequently (eg, dramatically increasing intake of foods high in vitamin K such as kale, spinach, broccoli, greens) (Option 2) and do not take vitamin K supplements Consult with health care provider before beginning or discontinuing any medication or dietary/herbal supplement (eg, Ginkgo biloba and ginseng affect blood clotting and may increase bleeding risk) (Option 1) Wear a medical alert bracelet indicating what anticoagulant is being taken

Mediastinal chest tubes

Mediastinal chest tubes are used to drain air or fluid from the mediastinal space and/or pericardial cavity (ie, after cardiac surgery). Obstruction (eg, clot) of the chest tube will result in excess fluid buildup in the pericardium, leading to inhibited cardiac contractility and eventual diagnosis of cardiac tamponade. Cardiac tamponade is a life-threatening form of obstructive shock marked by decreased cardiac output and eventually obstructive cardiac arrest if untreated. If chest tube drainage is markedly decreased, the nurse should quickly assess for signs of cardiac tamponade (Option 1) and if no such signs are present should troubleshoot other possible causes of chest tube occlusion.

Meniere disease (endolymphatic hydrops)

Meniere disease (endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and feelings of fullness or pressure in the ear. The disorder typically affects only one ear and can lead to permanent hearing loss. Attacks of Meniere disease can result in a total loss of proprioception, and clients often report feeling "pulled to the ground" (drop attacks), making client safety a priority. Vertigo can be severe and is associated with nausea, vomiting, and feelings of anxiety. Self-care for Meniere disease may include: Consuming a low-sodium diet to decrease the potential for fluid excess within the inner ear. Intake of potassium and other electrolytes does not need to be restricted (Option 2). Limiting or avoiding aggravating substances (eg, nicotine, caffeine, alcohol) and stimuli (eg, flickering lights, watching television) (Options 1 and 4) Adhering to prescribed therapies for relief of symptoms (eg, antiemetics, antihistamines, sedatives, and mild diuretics) Avoiding sudden changes in the position of the head (eg, bending over) during vertigo spells Participating in vestibular rehabilitation therapy Implementing safety measures during attacks (eg, assistance with walking, bed rest) (Option 3)

Mitral valve regurgitation

Mitral valve regurgitation is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are often asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue). This client should be assessed first due to possible heart failure, which would require immediate intervention. (Option 1) Kidney transplant recipients are on an immunosuppressant regimen to prevent rejection of the transplanted organ, which can leave them susceptible to infections such as candidiasis (thrush) of the oral cavity. (Option 3) The client with a spider bite is displaying signs and symptoms of infection, and further assessment is required to evaluate for conditions such as cellulitis. This client should be called second. (Option 4) Clients with hypertension who develop sinus or nasal congestion have limited options for symptom relief. Decongestants containing a vasoconstrictor (eg, pseudoephedrine) can exacerbate hypertension. Educational objective: Chronic mitral valve regurgitation is often asymptomatic, but many clients eventually develop heart failure; therefore, early recognition of symptoms is a priority. Mitral regurgitation causes a backflow of blood from the left ventricle to the left atrium, resulting in pulmonary edema (eg, dyspnea, orthopnea) and decreased cardiac output (eg, fatigue). Left atrial enlargement can also result in atrial fibrillation (eg, palpitations).

cranial nerves

Option 1) Cranial nerve I is the olfactory sensory nerve. This nerve is tested by having the client identify a readily recognized odor. (Option 2) Cranial nerve III is a motor nerve of the eye, which is tested by having the client track an object, such as a finger, through the fields of vision. (Option 3) Cranial nerve II is the optic nerve and is a sensory nerve. It is assessed by testing the fields of vision for the client's ability to see objects in the field. The facial nerve, cranial nerve VII, is tested by assessing exaggerated facial movements.

The community health nurse provides an education program about risk factors for prostate cancer. Which of the following statements by program attendees indicate that teaching has been effective? Select all that apply. 1. "African American men have a higher risk for prostate cancer than other men." 2. "Eating large amounts of red meat may increase my risk for prostate cancer." 4. "My father had prostate cancer, so I have an increased risk for it." 5. "My risk for prostate cancer increases as I become older."

My father had prostate cancer, so I have an increased risk for it." 5. "My risk for prostate cancer increases as I become older." Explanation Prostate cancer is a slow-growing and predictable malignancy. If not treated, it can metastasize to nearby lymph nodes, liver, lungs, and bone. Clients should discuss the risks and benefits of screening for prostate cancer (eg, checking serum prostate-specific antigen) with their health care provider. Certain factors place clients at greater risk, and early screening can detect prostate cancer before it becomes invasive (metastasizes). The nurse should educate clients about risk factors. Nonmodifiable risk factors (eg, those the client cannot control) include African American ethnicity, having a first-degree relative with prostate cancer, and increasing age (>50) (Options 1, 4, and 5). Clients can lower the risk for prostate cancer by avoiding modifiable (ie, those the client can control) risk factors, which include: Diet high in red meat, animal fat, high-fat dairy products, and refined carbohydrates (Option 2) Low fiber intake Obesity (Option 3) Long-term use of NSAIDs (eg, aspirin, ibuprofen) can be a protective factor against certain types of cancer (eg, colorectal, prostate). However, before regularly taking NSAIDs, clients should speak with their health care provider because NSAIDs can increase the risk for adverse effects (eg, cardiovascular disease, bleeding). Educational objective: Risk factors for developing prostate cancer include African American ethnicity, having a first-degree relative with prostate cancer, increasing age (>50), and a diet high in red meat, animal fat, high-fat dairy products, and refined carbohydrates.

Tubercolosis

Mycobacterium tuberculosis is a gram-positive, acid-fast bacillus that is transmitted through the airborne route. TB is usually (85%) pulmonary but can also be extrapulmonary (eg, meninges, genitourinary, bone and joints, gastrointestinal). TB, regardless of location, commonly presents with constitutional symptoms, including: Low-grade fever Night sweats Anorexia and weight loss Fatigue Additional symptoms depend on the location of the infection. Pulmonary tuberculosis typically includes: Cough Purulent or blood-tinged sputum Shortness of breath Dyspnea and hemoptysis are typically seen in the late stages. The classic manifestations of TB can be absent in immunocompromised clients and the elderly. (Option 1) Dysuria is a symptom of extrapulmonary genitourinary TB. (Option 2) Jaundice can be present in disseminated TB with liver involvement. It can also be a side effect associated with drugs used to treat pulmonary TB (eg, isoniazid). (Option 3) Back pain indicates spinal TB. Educational objective: The characteristic signs and symptoms associated with pulmonary TB disease include cardinal (major) signs (eg, cough, sputum production, dyspnea) and constitutional (minor) signs (eg, anorexia, weight loss, fatigue, fever, night sweats). Mycobacterium tuberculosis microorganisms from a client with active pulmonary TB disease are transmitted to another person via airborne droplets. A positive reaction to TST means that a client was exposed to TB, developed antibodies, and now has a TB infection. Additional testing is needed to determine if a client has LTBI or active TB disease.

Oral mucositis

Oral mucositis, inflammation or ulceration of the oral mucosa, results from chemotherapy or radiation therapy. Oral hygiene practices that minimize oral mucositis and promote comfort include the following: Cleansing the mouth with normal saline after meals and at bedtime to promote oral health Use of a soft-bristle toothbrush to decrease gum irritation Application of prescribed viscous lidocaine HCl (Xylocaine) to alleviate oral pain Use of water-soluble lubricating agents to moisten mouth tissues that may become dry due to therapy Avoidance of hot liquids and spicy/acidic foods, which can cause oral discomfort

Drugs you can give after myocardial infarction

Myocardial infarctions (MIs) damage heart muscle and require medications to improve heart function and prevent reinfarction (eg, aspirin). Aspirin, an antiplatelet agent, inhibits platelet aggregation, prevents thrombus formation, and reduces heart inflammation. Clients without signs of bleeding or low platelet levels may safely receive aspirin (Option 1). Atorvastatin is a lipid-lowering medication given to clients to lower cholesterol levels (ie, LDL cholesterol), which reduces plaque and reinfarction risk (Option 2). However, statins may cause rhabdomyolysis and require monitoring for muscle weakness and pain. Docusate sodium is a stool softener that reduces straining during bowel movements, thereby decreasing the workload on the heart. Straining can also cause bradycardia due to vagal response (Option 3). Lisinopril is an ACE inhibitor often prescribed to clients after an MI to prevent ventricular remodeling and progression of heart failure. Lisinopril may cause hyperkalemia and hypotension, and should be administered only to clients with normokalemia and normotension (Option 4). (Option 5) Metoprolol is a beta blocker prescribed to clients after MI to reduce the risk of reinfarction and heart failure. Metoprolol lowers blood pressure and heart rate; therefore, the nurse should hold the medication and notify the health care provider of hypotension or a heart rate <50/min. Educational objective: Nurses should use clinical data and assessment to determine prescription safety. Beta blockers require monitoring of heart rate and blood pressure. ACE inhibitors require monitoring of potassium and blood pressure. Aspirin requires monitoring of platelet levels and signs of bleeding. Statins require monitoring for muscle pain.

Obesity behavior management

Obesity is a health alteration that may be caused by multiple factors (eg, genetics, diet, pathology, lifestyle choices). Diet and exercise modifications are the main components of weight reduction. However, clients with obesity may also require education and assistance with psychosocial aspects and behavioral modification. Behavioral management includes: Creating a reward system with many small, attainable goals to incentivize positive health behaviors (Option 2) Developing health goals unrelated to weight (eg, climbing stairs without shortness of breath) to measure progress regardless of current weight (Option 3) Adopting anxiety-reducing diversional activities (eg, reading, meditating, listening to music) as coping mechanisms to reduce stress eating (Option 4) Placing visual cues (eg, motivational quotes) throughout the environment as positive reinforcement (Option 5) (Option 1) Avoiding social activities in a food setting promotes isolation and negative perceptions. Clients who struggle to make healthy choices in these settings should plan ahead for what will be eaten or bring a separate meal. Educational objective: Obesity is a health alteration with multiple causative factors (eg, genetics, diet, pathology, lifestyle choices). Successful behavioral modification is achieved by goal setting, incentivized behavior, diversion, and positive reinforcement.

fibrocystic breast changes

One of the most common benign breast disorders is fibrocystic breast changes. Fibrocystic changes correlate to estrogen/progesterone hormone fluctuations during the menstrual cycle. Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. The condition typically resolves after menopause. The nurse instructs the client on breast self-awareness and emphasizes that any noncyclic breast changes (ie, not related to the menstrual cycle) may indicate malignancy (ie, cancer) and should be immediately reported to the health care provider (HCP) (Option 1).

Oral cancer

Oral refers to cancers of the lips, tongue, mouth, pharynx (ie, throat), and larynx (ie, vocal cords). The most common type of oral cancer is squamous cell carcinoma, which initially presents as a nonhealing lesion or ulcer. Other symptoms of oral cancer include mucosal thickening, difficulty swallowing, mouth bleeding, sore spots, leukoplakia (ie, white patch), and changes in salivation. Modifiable risk factors include: Chronic alcohol and/or tobacco use (Options 1 and 2) Poor oral hygiene habits Chronic irritation to the mucosa (eg, chipped teeth, improperly fitted dental appliances) (Option 3) Excessive exposure to ultraviolet light (Option 4) In addition, unprotected sexual activity (eg, oral sex, multiple partners) increases the risk for sexually transmitted infections in the oral cavity (eg, human papillomavirus virus), which can cause oral cancer. Educational objective: Oral cancer typically manifests as a nonhealing lesion on the lip, tongue, oral cavity, or oropharynx. Modifiable risks for oral cancer include chronic alcohol and/or tobacco use, poor oral hygiene, chronic irritation to the mucosa, increased exposure to ultraviolet light, and sexually transmitted infections in the oral cavity due to unprotected sexual activity.

ovarian cancer (

Ovarian cancer results in more deaths than any other gynecologic cancer. Symptoms are often subtle and may include abdominal bloating; pelvic pain or pressure; abdominal girth increase; early satiety; abdominal, back, or leg pain; urinary urgency/frequency; and gastrointestinal disturbances (Option 4). Due to the lack of routine screening and reports of vague symptoms, ovarian cancer may not be diagnosed until an advanced stage. (Option 1) A fish-like vaginal odor is often caused by bacterial vaginosis, an overgrowth of vaginal bacterial flora. This condition is not usually serious and is treated with oral or vaginal antibiotics (eg, metronidazole). (Option 2) Heavy menstrual bleeding is a common disadvantage of having an intrauterine device. If the client cannot tolerate heavy bleeding or if excessive bleeding results in anemia, another form of birth control should be considered. (Option 3) Reports of painful intercourse are not unusual in clients with endometriosis. Disease management and pain control should be discussed. Educational objective: Symptoms of ovarian cancer are often subtle, and the condition is often not discovered until an advanced stage due to a lack of routine screening guidelines. Clients may present with bloating, early satiety, urinary symptoms (pressure on the bladder), and pelvic pressure.

peripheral arterial disease (PAD) risk factors

Pain with PAD can also occur at rest and manifests in the lower extremities as burning, aching, or numbness. Factors that cause chronic vascular changes and increase risk for PAD include: Hypertension: Vessel damage from chronically elevated vascular resistance Diabetes mellitus: Inflammatory vascular changes from hyperglycemia (Option 2) Hyperlipidemia: Increased plaque formation (ie, atherosclerosis) (Option 3) Smoking: Chronic vasoconstriction from nicotine inhalation (Option 1)

pancreatitis

Pancreatitis is an acute inflammation of the pancreas that results in autodigestion. The most common causes are cholelithiasis and alcoholism. Classic presentation includes severe epigastric pain radiating to the back due to the retroperitoneal location of the pancreas. The pancreatic enzymes (amylase and lipase) are elevated. Serious complications to monitor for include hyperglycemia, hypovolemia (capillary leak → third spacing), latent hypoxia or acute respiratory distress syndrome (ARDS), peritonitis, and hypocalcemia. Pancreatitis can cause hypocalcemia, but the etiology is unclear. Chvostek's (facial twitching) and Trousseau's (carpal spasm) signs are an indication of hypocalcemia from the decrease in threshold for contraction. Sustained muscle contraction (tetany) and decreased cardiac contractility (cardiac arrhythmia) are concerns related to hypocalcemia. (Option 1) Decreased albumin levels are seen with malnutrition; clients who are alcoholics can have low serum albumin but that alone is not responsible for the client's symptom. (Option 2) Troponin elevation is specific to myocardial infarction and is unrelated to pancreatitis. (Option 3) Potassium abnormalities are not usually present in acute pancreatitis. They are more likely to occur with hemolysis, when the intracellular potassium enters the serum. The ecchymoses in pancreatitis (Grey Turner's sign, Cullen's sign) are due to the blood-stained exudates from autodigestion and are usually only seen in severe cases. Educational objective: Complications of acute severe pancreatitis include hyperglycemia, hypocalcemia, hypovolemia, and ARDS. Trousseau's (carpal spasm) and Chvostek's (facial twitching) signs are an indication of hypocalcemia from the decrease in threshold for contraction.

Pap testing (cervical cancer screening )

Pap testing allows early detection of cervical dysplasia (ie, abnormal cell growth) that may indicate cervical cancer. Human papillomavirus (HPV), an extremely common sexually transmitted infection (STI), causes almost all cases of cervical cancer. However, most women have transient infections that resolve spontaneously. Therefore, cervical cancer screening guidelines balance the need to screen for persistent (cancer-causing) infection with the knowledge that overtreating (eg, cold knife cone) may cause more harm than good. Cervical cancer screening is typically initiated at age ≥21, regardless of age at onset of sexual activity. Women age 21-29 should be screened with Pap testing every 3 years in the United States or every 1-3 years in Canada (Option 2).

Paracentesis

Paracentesis is performed to remove excess fluid from the abdominal cavity or to collect a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for treating ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Prior to a paracentesis, nursing actions include: Verify that the client received necessary information to give consent and witness informed consent Instruct the client to void to prevent puncturing the bladder (Option 5) Assess the client's abdominal girth, weight, and vital signs (Option 3) Place the client in the high Fowler position or as upright as possible (Option 4) (Option 1) Paracentesis is an invasive procedure requiring delivery of informed consent by the health care provider (HCP). The HCP explains the benefits and risks of the procedure. The nurse's role is to witness informed consent and verify that it has occurred. (Option 2) NPO status is not required for paracentesis, which is often performed at the bedside or in an HCP's office using only a local anesthetic. Educational objective: Paracentesis is an invasive procedure for removing fluid from the abdominal cavity to improve symptoms or collect a specimen for testing. After informed consent has been obtained, the client should be encouraged to void to prevent bladder trauma, be positioned upright, and have a set of baseline vitals, weight, and abdominal circumference measurements collected before the procedure begins.

Parenteral medication administration

Parenteral medications are administered via injection into body tissues using aseptic technique (eg, intradermal, intramuscular, subcutaneous, IV). Intradermal Administer injections at a 5- to 15-degree angle to reduce risk of injection into subcutaneous tissue (Option 2). Apply firm pressure to the injection site to reduce bleeding. Massaging the site introduces medication into deeper tissues and should be avoided (Option 3). Subcutaneous Administer injections at 90 degrees if 2 in (5 cm) of subcutaneous tissue can be grasped or at 45 degrees if only 1 in (2.5 cm) can be grasped (Option 1). Intramuscular Acceptable sites include the deltoid, vastus lateralis, and ventrogluteal. The ventrogluteal is preferred as fewer large blood vessels and nerves are present. Position the client supine, prone, or side-lying with the knee and hip flexed when administering ventrogluteal injections. Flexing the knee and hip reduces muscle tension, improves access, and promotes client comfort (Option 4).

pelvic inflammatory disease (PID

Pelvic inflammatory disease (PID), a leading cause of ectopic pregnancy and infertility, occurs when bacteria from the genital tract spread upward through the cervix and cause infection of the female reproductive organs (eg, uterus, fallopian tubes, ovaries) and pelvic cavity. Symptoms may include pelvic or lower abdominal pain, menstrual irregularities or increased menstrual cramps, painful intercourse, fever, and abnormal vaginal discharge. Untreated sexually transmitted infections (STIs) (eg, gonorrhea, chlamydia) are the most common cause of PID. The nurse should assess for other risk factors, including: History of PID Multiple sexual partners (Option 3) Previous STI (Option 4) Unprotected sexual intercourse (ie, without condom use) Placement of an intrauterine device within the past 3 weeks Recent abortion or pelvic surgery (Option 5) (Options 1 and 2) Oral contraceptive use and age at menarche are not associated with an increased risk of PID. Educational objective: Pelvic inflammatory disease (PID) is a leading cause of ectopic pregnancy and infertility. The nurse assessing a client with suspected PID should assess for risk factors such as a history of PID or sexually transmitted infections; number of sexual partners; condom use during sexual intercourse; and recent abortion, pelvic surgery, or placement of an intrauterine device.

Peptic ulcer disease (PUD)

Peptic ulcer disease (PUD) is characterized by ulceration of the protective layers (ie, mucosa) of the esophagus, stomach, and/or duodenum. Mucosal "breaks" allow digestive enzymes and stomach acid to digest underlying tissues, leading to potential gastrointestinal bleeding and perforation. Risk factors for PUD include gastrointestinal Helicobacter pylori infections, genetic predisposition, chronic NSAID (eg, aspirin, ibuprofen, naproxen) use, stress, and diet and lifestyle choices. Nurses educating clients with PUD about ulcer prevention should focus on modifiable risk factors: NSAIDs: Chronic use of NSAIDs can damage the gastric mucosa and delay ulcer healing (Option 1). Caffeine: Cola, tea, and coffee should be avoided as they stimulate stomach acid secretion (Option 2). Smoking: Tobacco increases secretion of stomach acid and delays ulcer healing (Option 3). Alcohol: Alcohol should be avoided as it stimulates stomach acid secretion and impairs ulcer healing (Option 4). Meal timing: Eating multiple small meals throughout the day or eating shortly before sleeping may actually worsen PUD by increasing stomach acid secretion. (Option 5) Evidence does not support the standard elimination of specific foods from the diet in clients with PUD. However, clients should avoid foods that exacerbate their symptoms.

Peritonitis (complication of peritoneal dialysis )

Peritonitis is a common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent. Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity. The nurse should collect peritoneal effluent from the drainage bag for culture and sensitivity (Option 1). Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously. (Option 2) The client's chills and rebound tenderness are signs of infection that require further assessment. Dialysate is typically warmed to body temperature before instillation to prevent abdominal discomfort and increase urea clearance through vessel dilation. Dry heating with a heating cabinet or incubator rather than a microwave is recommended to reduce the danger of burning the peritoneum. The dwell time is based on the prescribed dialysis method and should not be extended without a prescription. (Option 3) High Fowler's position can help reduce shortness of breath if the client has volume overload, but it may worsen abdominal pain. (Option 4) Glucose (dextrose) is the osmotic agent in dialysate. Therefore, glucose levels must be monitored closely, particularly in clients with diabetes. However, a glucose level of 210 mg/dL (11.65 mmol/L) does not necessitate IV administration of regular insulin. Regular insulin can be added to the dialysate before the solution is instilled, or it can be administered subcutaneously to control glucose levels. Educational objective: Peritonitis is a common but serious complication of peritoneal dialysis. Manifestations include cloudy effluent, fever, abdominal pain, and rebound tenderness. Treatment is based on culture of the peritoneal fluid.

Phenylketonuria (PKU) Don't metabolize protein so stay away from protein or foods high in protein

Phenylketonuria (PKU) is characterized by deficiency or absence of an enzyme required to metabolize phenylalanine, an amnio acid found in protein foods. High levels of phenylalanine can cause intellectual disability by interfering with brain growth and development, which is particularly concerning for the developing fetus and infant. Clients with PKU should follow a low-phenylalanine diet before and during pregnancy to prevent potential teratogenic effects (eg, microcephaly, mental disability, heart defects). Avoiding high-protein foods (eg, meat, dairy, dry beans, nuts, eggs) helps to maintain phenylalanine levels in a safe range (Option 1).

Polycythemia vera (PV)

Polycythemia vera (PV) is a chronic myeloproliferative disorder in which the bone marrow produces an abnormally high number of RBCs. Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic hypoxemia, such as chronic obstructive pulmonary disease or chronic lung disease. The danger of PV is seen when the client develops blood clots—due to the increased viscosity of the blood, which makes the circulation sluggish—and decreased tissue perfusion. Treatment of PV usually includes periodic phlebotomy, the removal of 300-500 mL of blood through venipuncture, to reduce the RBC count and achieve a hematocrit <45%. Initially, clients may require phlebotomy every other day until the goal hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary.

For patients with myocardial infarction give

Potassium Clients with myocardial infarction (MI) are at risk for life-threatening dysrhythmias (eg, heart block, ventricular tachycardia, ventricular fibrillation) both during the MI and following reperfusion therapy (eg, coronary artery stenting). Myocardial ischemia damages cardiac muscle cells, causing electrical irritability (eg, premature ventricular contractions) that can be exacerbated by electrolyte imbalances (eg, hypokalemia). Hypokalemia hyperpolarizes cardiac electrical conduction pathways, increasing the risk for dysrhythmias. Therefore, prompt potassium replacement is the priority in these clients (Option 3).

Nitrazine pH test strip

Testing vaginal secretions with a nitrazine pH test strip can help differentiate between amniotic fluid, which is alkaline, and normal vaginal fluids or urine, which are acidic. A yellow, olive, or green color suggests that amniotic membranes are intact. A bluish color suggests probable rupture of membranes (ROM). However, the presence of blood or semenmay result in a false positive, as serum and prostatic fluid are alkaline. A client history of recent sexual intercourse should alert the nurse to notify the health care provider that nitrazine results may be falsely positive due to the presence of semen in the vagina (Option 1).

Pregnant Adolescent

Pregnant adolescent clients are a unique population because of their increased risk for complications during pregnancy (eg, low birth weight, preterm birth, preeclampsia) and developmental needs. During an initial encounter with a pregnant adolescent, the nurse should discuss the client's emotional response to the pregnancy to build rapport and provide psychosocial support (Option 2). Discussing the client's level of family/social support or fear of social discrimination is appropriate because these factors may prevent the client from obtaining prenatal care (Option 3). Pregnant adolescents are vulnerable to poverty, dangerous living conditions, exposure to teratogens (eg, tobacco, alcohol, illicit drugs), poor nutritional status, and physical or sexual abuse, which can cause adverse fetal/maternal outcomes. Therefore, discussing these topics openly as soon as possible is appropriate to prevent harm (Option 4)

priapism

Priapism is a sustained, painful erection often associated with sickle cell anemia, as the sickling (crescent shaping) of red blood cells can lead to penile vascular occlusion, erectile tissue hypoxia, and tissue necrosis. Bluish discoloration is of most concern as it can be a sign of ischemia to the penis. Priapism is a sustained, painful erection that lasts for more than 2 hours. Common associated clinical manifestations include discoloration of the penis, intense pain, rigid penis, difficulty voiding, and anxiety and embarrassment.

Primary open-angle glaucoma (POAG)

Primary open-angle glaucoma (POAG) is an eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision). The signs/symptoms of POAG develop slowly and include painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, and halos observed around bright lights. POAG can lead to blindness if left untreated.

Progestin-only pills (POPs) /contraceptive

Progestin-only pills (POPs), a form of oral contraception, work by thickening cervical mucus (ie, hinders sperm motility), thinning the endometrium (ie, hinders implantation), and preventing ovulation. Cervical mucus changes last only approximately 24 hours, so the client must take the pill at the same time every day for it to be effective. If the pill is taken ≥3 hours late, a barrier method (eg, condom) is advised until the pill is taken correctly for 2 days (Option 2).

individuals should receive prophylactic antibiotics prior to dental procedures to prevent infective endocarditis (IE). These include the following:

Prosthetic heart valve or prosthetic material used to repair heart valve Previous history of IE Some forms of congenital heart disease Unrepaired cyanotic congenital defect Repaired congenital defect with prosthetic material or device for 6 months after procedure Repaired congenital defect with residual defects at the site or adjacent to the site of a prosthetic patch or device Cardiac transplantation recipients who develop heart valve disease

Refeeding syndrome

Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients (eg, anorexia nervosa, chronic alcoholism). The client's lack of oral intake results in the pancreas making less insulin. After the client receives food or IV fluids with glucose, insulin secretion is increased, leading to phosphorous, potassium, and magnesium shifting intracellularly. Phosphorus is the primary deficient electrolyte as it is required for energy (adenosine triphosphate). Hypophosphatemia causes muscle weakness and respiratory failure. Deficiencies in potassium and magnesium potentiate cardiac arrhythmias. Therefore, aggressive initiation of nutrition without adequate electrolyte repletion can quickly precipitate cardiopulmonary failure. (Option 1) Daily weights and periodic serum albumin level are indicated to evaluate the efficacy of nutritional replenishment but are not the most important assessment as failure to monitor these does not result in death. (Option 3) Dumping syndrome is seen after surgery for stomach cancer or bariatric surgery, which results in decreased storage area in the stomach. Eating concentrated carbohydrates or excess fluids causes the food to be "dumped"/emptied rapidly into the small intestine. Symptoms include diaphoresis, cramping, weakness, and diarrhea within 30 minutes of eating. Dumping syndrome is not seen with anorexia nervosa. (Option 4) The central lines carry a risk of infection. The signs of infection include leukocytosis and left shift. However, risk of infection is not greatest in the first few days of parenteral nutrition. Educational objective: Refeeding syndrome is a potentially fatal complication of nutritional rehabilitation in chronically malnourished clients. Electrolytes, especially phosphorous, potassium, and magnesium, must be monitored frequently during the first few days of nutritional replenishment.

Refeeding syndrome

Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphorous, potassium, and/or magnesium (mnemonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency. Actions to prevent refeeding syndrome include the following: Obtaining baseline electrolytes Initiating nutrition support cautiously with hypocaloric feedings Closely monitoring electrolytes Increasing caloric intake gradually (Option 2) These values are within normal ranges for phosphorus (2.4-4.4 mg/dL [0.78-1.42 mmol/L]), potassium (3.5-5.0 mEq/L [3.5-5.0 mmol/L]), and magnesium (1.5-2.5 mEq/L [0.75-1.25 mmol/L]). In refeeding syndrome, the values for one or more of these electrolytes are decreased. (Option 3) These laboratory values are below normal ranges but are not associated with refeeding syndrome. (Option 4) These are normal laboratory values and are not associated with refeeding syndrome. Educational objective: Refeeding syndrome is a serious complication of nutritional replenishment. It is marked by declines in serum phosphorus, potassium, and/or magnesium (mnemonic PPM). Clients can also develop fluid overload. Low-calorie feedings and a gradual increase in calories can prevent refeeding syndrome. Electrolytes should be monitored frequently.

acute pancreatitis symptom management

The major goals in acute pancreatitis are symptom management (eg, opioids, NPO status, nasogastric suction) and monitoring and prevention of complications (eg, IV fluids), giving the pancreas time to heal.

Treatment for a sprained joint (RICE)

Rest, Ice, Compression, Elevation (RICE)

Right sided heart failure s/s

Right-sided heart failure results from pulmonary hypertension, right ventricular myocardial infarction, or left-sided heart failure. The right ventricle cannot effectively pump blood to the lungs, which results in incomplete emptying of the right ventricle. The resulting decrease in forward blood flow causes blood to back up into the right atrium and then into venous circulation, resulting in venous congestion and increased venous pressure throughout the systemic circulation. Clinical manifestations of right-sided heart failure include: Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities (Option 4). Jugular venous distension (Option 3). Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation (Option 2). Hepatomegaly due to hepatic venous congestion. In clients with right-sided heart failure, the heart cannot effectively pump blood to the lungs. Clinical manifestations result from systemic venous congestion and include peripheral edema, jugular venous distension, increased abdominal girth (hepatomegaly, splenomegaly), and ascites.

hypertension (HTN)

Risk factors for hypertension Nonmodifiable Increasing age Positive family history African American ethnicity Diabetes mellitus type 1 Modifiable Excessive alcohol intake Smoking Obesity Excessive sodium intake Sedentary lifestyle Increased stress Hyperlipidemia Diabetes mellitus type 2 Hypertension is referred to as the "silent killer" as many clients are asymptomatic. Untreated chronic hypertension can result in damage of various organs and tissues and increases the risk for renal failure, coronary artery disease, stroke, and heart failure. Appropriate client screening based on risk factors is key to preventing complications. This client has both nonmodifiable (eg, African American ethnicity) and modifiable (eg, diabetes mellitus type 2, chronic stress, smoking) risk factors (Options 1, 2, 3, and 5). To prevent future comorbidities, the nurse should educate the client on smoking cessation, appropriate diabetes management, and therapeutic strategies for stress management at work. (Option 4) Clients should be screened for potential hyperlipidemia. An LDL laboratory value of 94 mg/dL (2.43 mmol/L) is within recommended parameters (<100 mg/dL [<2.6 mmol/L]). Educational objective: Key risk factors for developing hypertension include African American ethnicity, increasing age, positive family history, smoking, excessive sodium and alcohol use, diabetes mellitus, obesity, hyperlipidemia, chronic stress, and sedentary lifestyle. Untreated hypertension increases client risk for coronary artery disease, stroke, heart failure, and renal failure.

Burn stages

Second-degree (partial-thickness) burns appear as moist or weeping wounds with blisters and shiny, fluid-filled vesicles, and clients have moderate to severe pain. Both the epidermis and dermis are damaged. Immediate care of minor burn injuries involves removal of clothing and debris from the affected area, cooling and cleansing of the wound, and pain management. Minor burn injuries can be treated on an outpatient basis with wound care and dressing changes. Major burn injuries require hospitalization and emergency interventions (eg, airway management, fluid resuscitation). (Option 1) First-degree (superficial) burns are dry with blanchable redness. They usually damage the epidermis only. (Options 3 and 4) Third-degree (full-thickness) burns are dry and inelastic with waxy white, leathery, or charred black color. They destroy the dermis and may involve subcutaneous tissue. Fourth-degree (full-thickness) burns have the same appearance as third-degree burns, with additional involvement of fascia, muscle, and/or bone tissue. Due to nerve damage, pain is not the major feature, unlike with second-degree burns. Educational objective: Second-degree (partial-thickness) burns damage both the epidermis and the dermis, and appear as moist or weeping wounds with redness, blisters, shiny fluid-filled vesicles, and moderate to severe pain.

Septic shock

Sepsis is an overwhelming response to infection that causes impaired organ function. Septic shock occurs when sepsis causes cardiovascular collapse and/or impairs the body's ability to maintain normal metabolic and cellular processes. Manifestations of septic shock include: Fever or hypothermia (>100.4 F [38 C]; <96.8 F [36 C]) - Either fever or low body temperature is found in sepsis and septic shock. Fever occurs in response to infection, whereas low body temperature can occur as shock worsens due to metabolic alterations and inadequate tissue perfusion (Option 3). Hypotension - Systolic blood pressure <90 mm Hg or mean arterial pressure <65 mm Hg in a client with infection may indicate septic shock. Altered perfusion from hypotension may cause lactic acid accumulation and metabolic acidosis (Option 1). Prolonged capillary refill - A refill time >3-4 seconds in adults indicates inadequate tissue perfusion as a result of altered peripheral circulation and hypotension (Option 2). Tachycardia - A resting heart rate >90/min is common in septic shock to compensate for decreased systemic vascular tone and hypotension. WBC count >12,000/mm3 (12 x 109/L) or immature neutrophils (bands) of >10% - An increased WBC count, especially with bands, indicates severe infection (Option 5). (Option 4) Clients with septic shock typically develop decreased urine output (ie, <0.5 mL/kg/hr) due to inadequate organ perfusion. Educational objective: Septic shock is a life-threatening systemic response to infection that causes impaired organ function, cardiovascular collapse, and/or impairment of normal metabolic and cellular processes. Signs of septic shock include fever or hypothermia, hypotension, tachycardia, and leukocytosis.

sexual assault/rape

Sexual assault, or the coercing or forcing of sexual encounters (eg, groping, rape, incest, human trafficking), may happen to any individual regardless of age, gender, ethnicity, or relationship to the perpetrator. Nurses providing emergency care should support victims' complex physical and psychosocial needs, initiate preventive and therapeutic treatments, and collect and preserve forensic evidence. Priority nursing actions include: Determining whether the client has bathed, showered, or douched, as these actions may compromise evidence (Option 1) Educating the victim that a pelvic examination is recommended to identify injuries and collect evidence (Option 2) Obtaining the date of the client's last menstrual period and current method of birth control to identify risk for pregnancy (Option 3) Performing a head-to-toe assessment to identify physical injuries requiring treatment and thoroughly documenting all injuries on a body map (Option 4) Providing prophylactic therapies for sexually transmitted infections and pregnancy

Sjögren's syndrome -- CF

Sjögren's syndrome is an autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help (Option 1). Sjögren's syndrome is an autoimmune condition that can cause dry eyes and mouth. Clients are instructed to use artificial tears and saliva. Clients with Sjögren's syndrome need measures to combat the effects of damaged moisture-producing glands. These include eye drops, sugar-free candy or artificial saliva, vaginal lubricants, frequent dental examinations, lukewarm showers with mild soap, and avoiding decongestants.

How to avoid getting sunburns

Skin cancers are most often caused by damage to the skin's DNA. This damage is typically due to exposure to ultraviolet (UV) radiation, primarily from the sun but also from other sources (eg, tanning beds, sunlamps). The instructions to prevent sunburn and other sun-related damage include: Avoid the sun, if possible, especially between 10 AM and 4 PM. UV rays are not blocked by cloud coverage and can be reflected off water, sand, snow, and concrete. As a result, clients can burn in the shade or even during outdoor winter activities (eg, skiing) (Option 4). Wear protective clothing (eg, long sleeves, wide-brimmed hats, umbrellas) when possible. Apply sunscreen: Use a broad-spectrum sunscreen to block both UVA and UVB rays. Choose a sunscreen with SPF ≥15 for daily use or SPF ≥30 for outdoor activities and sun-sensitive individuals. Sunscreen should be applied 15-30 minutes prior to sun exposure to allow the formation of a protective film on the skin. Regardless of the type of sunscreen used, it should be reapplied at least every 2 hours, or more often if possible (Options 1 and 2). Because sunscreen is washed off with swimming and sweating, it should be reapplied, even for products labeled "water-resistant" or "very water-resistant" (Option 3). Avoid the use of tanning beds as they emit UV radiation (Option 5). Educational objective: To prevent sunburn, instruct clients to avoid sun exposure from 10 AM to 4 PM, wear protective clothing, use sunscreen properly (daily application; minimum SPF of 15-30; 15-30 minutes before going outside; reapplication when wet and every 2 hours), and avoid non-solar exposure to ultraviolet radiation (eg, tanning beds, sunlamps).

Skin cancers

Skin cancers are most often linked to damage of skin cells' DNA by overexposure to ultraviolet radiation (eg, sunlight, tanning beds). The three most common types of skin cancer are squamous cell carcinoma, basal cell carcinoma, and melanoma. Melanomas grow rapidly and are highly metastatic, making them the deadliest form of skin cancer. Basal cell and squamous cell carcinomas generally have a much lower risk of metastasis. Risk factors for skin cancer include: Family or personal history of skin cancer (Option 1) Celtic ancestry traits (eg, light skin, red or blond hair, blue or green eyes, many freckles) Aging Atypical or high number of moles because some skin cancers develop from pre-existing moles (Option 2) Immunosuppression (eg, immunosuppressant medications, HIV), which lowers the body's ability to defend against cancerous mutations (Option 4) Ultraviolet light exposure (eg, chronic sun exposure, outdoor occupation, tanning bed use, history of severe sunburns) (Option 5)

Hypertension diet

The Dietary Approaches to Stop Hypertension (DASH) diet is often suggested to clients with hypertension due to its ability to reduce blood pressure. The diet focuses on elimination or reduction of foods and beverages high in sodium, sugar, cholesterol, and trans or saturated fats, which all contribute to increased blood pressure. The DASH diet focuses on: Including fresh fruits and vegetables, and whole grains in the daily diet Choosing fat-free or low-fat dairy products Choosing meats lower in cholesterol (eg, fish, poultry) and alternate protein sources (eg, legumes) instead of red meats (Option 1) Limiting intake of sweets, foods high in sodium (eg, potato chips, frozen meals, canned foods), and sugary beverages to the occasional treat (Options 2 and 3)

Stress ulcers (enteral feeding prevent stress ulcers)

Stress ulcers are a common complication in critically ill clients because the gastrointestinal tract is not a preferential organ. In the presence of hypoxemia, blood is shunted to the more vital organs, increasing the risk of stress ulcers. The early initiation of enteral feedings helps preserve the function of the gut mucosa, limits movement of bacteria (translocation) from the intestines into the bloodstream, and prevents stress ulcers. Enteral feedings are also associated with lower risk of infectious complications compared with TPN. However, the mortality is the same. (Option 1) Complications/problems commonly associated with enteral feedings include aspiration, tube displacement, hyperglycemia, diarrhea, abdominal distension, enteral tube misconnections, and clogged tubes. (Option 3) Caloric and metabolic needs can usually be met adequately using enteral feedings or TPN. Multiple enteral or TPN formulas are available to meet individual client needs. If metabolic demands are not being met using enteral feedings alone, TPN can be added. (Option 4) Illness-related stress hyperglycemia (gluconeogenesis) occurs in clients receiving both enteral feedings and TPN. Educational objective: The enteral route is preferred for feeding. Enteral feedings maintain the integrity of the gut, prevent stress ulcers, and help prevent the translocation of bacteria into the bloodstream.

sunburn

Sunburn is a painful inflammatory skin reaction resulting from overexposure to ultraviolet radiation (eg, natural sunlight, tanning beds). Sunburns may be classified as superficial (ie, red, painful) or partial-thickness (ie, blistering, weeping) burns. Severe sunburns may cause systemic symptoms such as fever, chills, nausea, and headache. Sunburns increase insensible fluid loss and place the client at an increased risk for dehydration. Sunburn prevention is important because sunburn may cause permanent skin damage and increases the risk of skin cancers. However, when minor sunburns occur, symptom management includes: Protecting the burned area from further sun exposure (eg, avoid going outside during midday when the sun's rays are hottest) (Option 1) Promoting increased fluid intake to avoid dehydration (Option 2) Providing pain relief with over-the-counter analgesics such as ibuprofen or acetaminophen (Option 3) Reducing inflammation and pain by taking tepid baths; using cool compresses; and applying soothing, protective lotions or gels (eg, aloe vera, calamine) to the sunburned area (Option 4)

Systemic lupus erythematosus (SLE)

Systemic lupus erythematosus (SLE) is an autoimmune disorder in which an abnormal immune response leads to chronic inflammation of different parts of the body. SLE ranges in severity from mild (eg, affecting skin, muscles, joints) to severe (eg, affecting kidneys, heart, lung, blood vessels, central nervous system) disease. Increased creatinine (normal 0.6-1.3 mg/dL [53-115 µmol/L]), increased blood urea nitrogen (normal 6-20 mg/dL [2.1-7.1 mmol/L]), and an abnormal urinalysis (eg, protein, red blood cells, cellular casts) can indicate the presence of lupus nephritis (occurring in 50%), a potentially serious complication of SLE. Early recognition and aggressive immunosuppressive treatment are essential to preserve renal function and prevent irreversible kidney damage (Option 1). (Option 2) An elevated erythrocyte sedimentation rate (normal <30 mm/hr) can indicate the presence of an active inflammatory process and would be expected in a client with an inflammatory disease such as SLE, especially during a disease flare. This is nonspecific and does not give information as to which organ is being attacked by inflammation. (Option 3) A positive antinuclear antibody (ANA) titer (>1:40) indicates the presence of ANAs, which the body produces against it own DNA and nuclear material. This would be expected in a client diagnosed with SLE. (Option 4) Anemia, mild leukopenia (white blood cell count <4,000/mm3 [4.0×109/L]), and thrombocytopenia (platelet count <150,000/mm3 [150×109/L]) are often present in SLE. The nurse would report these to the health care provider, but they are not of greatest concern. Clients with SLE should be advised to avoid harsh sunlight and ultraviolet light exposure as well as harsh soaps and chemicals. These clients often receive corticosteroids and are susceptible to infection; therefore, annual influenza vaccination (eg, killed vaccines) is important. The characteristic cutaneous manifestation of SLE is a flat or raised red rash that forms a butterfly shape across the bridge of the nose and cheeks.

Coronary artery bypass graft

The RN providing discharge instructions for a client recovering from a CABG should include the following guidelines: Explain the need for modification of cardiac risk factors, including smoking cessation, weight reduction, maintaining a healthy diet, and increasing activity levels through exercise. Encourage a daily shower (Option 4) as a bath could introduce microorganisms into the surgical incision sites. Surgical incisions are washed gently with mild soap and water and patted dry. The incisions should not be soaked or have lotions or creams applied as this could introduce pathogens (Option 5). Explain that light house work may begin in 2 weeks, but there is to be no lifting of any object weighing >5 lb (2.26 kg) without approval of the HCP (Option 3). Lifting, carrying, and pushing heavy objects are isometric activities. Heart rate and blood pressure increase rapidly during isometric activities, which should be limited until approved by the HCP, generally about 6 weeks after discharge. Guide the client to gradually resume activity and possibly participate in a cardiac rehabilitation program. Clarify no driving for 4-6 weeks or until the HCP approves. If the client is able to walk 1 block or climb 2 flights of stairs without symptoms (eg, chest pain, shortness of breath, fatigue), it is usually safe to resume sexual activity (Option 1). Notify the HCP if the following symptoms occur: Chest pain or shortness of breath that does not subside with rest Fever >101 F (38.3 C) Redness, drainage, or swelling at the incision sites (Option 2)

menstrual cycle physiology (teaching for clients who wants to become pregnant

Teaching about menstrual cycle physiology increases fertility awareness and helps couples optimize their chances of becoming pregnant sooner. Timing of sexual intercourse near ovulation (ie, "fertile window") is essential to conception because the ovum and sperm have limited viability in the reproductive tract. Instructing the client about how to track menstrual cycles (eg, length and regularity of menses) and recognize signs of ovulation (eg, cyclic changes in cervical mucus) may improve fertility awareness. Urine ovulation predictor kits may also be used to detect the surge of luteinizing hormone (LH) that precedes ovulation by 12-24 hours. These predictor kits are easily accessed, over-the-counter tests that can help the client time intercourse during the "fertile window" to improve chances of conceiving (Option 4).

Heart failure (weight gaining)

The client with chronic heart failure is at risk for exacerbations. Clients should be instructed to report a weight gain of 3 lb (1.36 kg) over 2 days or a 3-5 lb (1.36-2.26 kg) gain over a week. The nurse's priority assessment should be any physiological signs or symptoms of fluid overload.( shortness of breath, coughing or edema)

cervical cap

The cervical cap is a barrier method of contraception used with spermicide (eg, nonoxynol-9). The reusable, cup-shaped cap is placed over the cervix before intercourse to block sperm from the uterus. To allow time for sperm to die, the cap should remain in place for ≥6 hours after intercourse but should not remain for more than 48 hours (Option 3). The cap may remain in place for multiple acts of intercourse, but clients should confirm correct placement and insert additional spermicide into the vagina each time.

toxic megacolon

The client with ulcerative colitis who has abdominal distension, bloody diarrhea, and fever likely has toxic megacolon. This is a common, life-threatening complication of inflammatory bowel disease and is seen more frequently in ulcerative colitis than in Crohn disease. Toxic megacolon can also be associated with Clostridium difficile infection and other forms of infectious colitis. Severe colonic inflammation causes release of inflammatory mediators and bacterial products which contribute to colonic smooth muscle paralysis. Rapid colonic distension ensues, thinning the intestinal wall and making it prone to perforation. Imaging confirms the diagnosis. (Option 1) This client with liver cirrhosis and ascites needs periodic paracentesis for relief of distension in addition to diuretics (eg, spironolactone, furosemide) for advanced-stage disease. However, this client is not the priority. (Option 2) This client needs paracentesis for fluid cytology (eg, diagnostic paracentesis) to evaluate for malignancy. This client is not the priority. (Option 4) Clients with dementia have decreased mobility, drink less fluid (eg, impaired thirst, do not ask for water), and often take medications with anticholinergic properties. Such factors make these clients prone to severe constipation, and they often need manual disimpaction. This client is not the priority. Educational objective: Toxic megacolon is a common, life-threatening complication of inflammatory bowel disease. Clients present with abdominal pain/distension, bloody diarrhea, fever, and signs of shock (eg, hypotension, tachycardia).

The general procedure for instilling ear drops includes the following steps:

The general procedure for instilling ear drops includes the following steps: Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used Position the client side-lying with the affected ear up (if not contraindicated). This facilitates administration and prevents drops from leaking out of the ear Warm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremes (Option 1) Pull the pinna up and back to straighten the ear canal in clients >4 years old and adults. Pull the pinna down and back in clients <3 years old (Option 4) Support hand on the client's head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the ear canal. This avoids damaging the ear canal with the dropper (Option 2) Apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain, which facilitates the flow of medication into the ear canal Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage Place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication. Perform this with caution and avoid in infants or very young clients as it is a choking hazard (Option 3)

The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client's seizure activity? 1. Aural phase[5%] 2. Ictal phase[3%] 3. Postictal phase[79%] 4. Prodromal phase[11%]

The nurse is caring for a client with a history of tonic-clonic seizures. After a seizure lasting 25 seconds, the nurse notes that the client is confused for 20 minutes. The client does not know the current location, does not know the current season, and has a headache. The nurse documents the confusion and headache as which phase of the client's seizure activity? 1. Aural phase[5%] 2. Ictal phase[3%] 3. Postictal phase[79%] 4. Prodromal phase[11%] Explanation A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. The ictal phase is the period of active seizure activity. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion. Educational objective: Clients may experience confusion after a seizure during the postictal phase. The client should be observed for safety and abnormalities documented before and during this phase.

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? 1. "I need to raise the head of my bed on blocks by at least 6 inches."[11%] 2. "I will remain sitting up for several hours after I eat any food."[11%] 3. "If my reflux and abdominal pain don't improve, I might need surgery."[5%] 4. "Losing weight may reduce my reflux, so I plan to take a weight-lifting class."[71%] Explanation

The nurse is reinforcing teaching to a client with a hiatal hernia. Which statement by the client indicates that further teaching is needed? 1. "I need to raise the head of my bed on blocks by at least 6 inches."[11%] 2. "I will remain sitting up for several hours after I eat any food."[11%] 3. "If my reflux and abdominal pain don't improve, I might need surgery."[5%] 4. "Losing weight may reduce my reflux, so I plan to take a weight-lifting class."[71%] Explanation Hiatal hernia is a group of medical conditions characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to a weakness in the diaphragm. Although hiatal hernias may be asymptomatic, many people experience heartburn, chest pain, dysphagia, and shortness of breath when the abdominal organs move into the chest. Symptoms of hiatal hernias are often exacerbated by increased abdominal pressure, which promotes upward movement of abdominal organs. Clients with hiatal hernias who are obese are often encouraged to lose excess weight by performing light activities (eg, short walks) because obesity increases abdominal pressure. However, nurses should teach clients to avoid activities that promote straining (eg, weight lifting), which increases abdominal pressure (Option 4). (Options 1 and 2) Sitting up for several hours after meals and sleeping with the head of the bed elevated at least 6 inches (15 cm) reduces upward movement of the hernia and decreases the risk of gastric reflux. (Option 3) If symptoms of hiatal hernias are uncontrolled with home management (eg, weight loss, diet modification, positioning after meals), surgical revision of the diaphragm may be required to prevent organ movement. Educational objective: Hiatal hernia is characterized by abnormal movement of the stomach and/or esophagogastric junction into the chest due to diaphragmatic weakness. Nurses educating clients with hiatal hernias about symptom management should instruct them to avoid activities that increase abdominal pressure (eg, weight lifting), sleep with the head of the bed elevated, and remain upright for several hours after meals.

4. Wear a cotton t-shirt under the brace at all times[68%]

The nurse plans teaching for an adolescent client being discharged home with a Boston brace for treatment of scoliosis. Which instruction will the nurse include in the discharge teaching plan? 1. Apply body lotion or powder under the brace to prevent skin irritation[6%] 2. Avoid any exercises that require the use of spinal muscles[13%] 3. Keep the brace on for all activities, including showering[11%] 4. Wear a cotton t-shirt under the brace at all times[68%] Explanation The Boston brace, Wilmington brace, thoracolumbosacral orthosis (TLSO) brace, and Milwaukee brace are used to diminish the progression of deformed spinal curves in scoliosis. Braces do not cure the existing spinal deformities but do prevent further worsening. These braces are also sometimes used for clients who undergo spinal fusion. The braces are molded plastic shells worn around the trunk of the body under the client's outer clothing. Due to the risk for skin breakdown, clients should wear a cotton t-shirt under the brace to decrease skin irritation and absorb sweat. Compliance is a major problem in most adolescents as they are preoccupied with body image and appearance. Psychosocial issues (eg, body image, sense of control, socialization) are very important to discuss. Many clients may find it helpful to meet other individuals their age who also wear the braces. (Option 1) The use of lotion or powder can cause skin irritation due to heat buildup beneath the brace. (Option 2) It is important to build and maintain strength in the spinal muscles to promote stabilization throughout treatment. Most prescribed bracing courses allow brace removal for such exercises. (Option 3) The exact course of bracing treatment varies based on the type of brace and severity of spinal curvature. Most braces are worn for 18-23 hours per day and removed for bathing and exercise. Clients should never shower while wearing a hard brace as padding will absorb moisture and promote skin breakdown. Educational objective: Clients wearing a brace during treatment for scoliosis must perform proper skin care, wear a cotton t-shirt under the brace, and understand the importance of wearing the brace as prescribed to slow curvature progression. Psychosocial issues (eg, body image, socialization) should also be addressed to promote compliance.

Abdominal Aortic Aneurysm (AAA)

The nurse should carefully monitor renal status in a client who has had abdominal aortic aneurysm repair. BUN, creatinine, and urine output should be assessed. Urine output of at least 30 mL/hr is expected. Report low back pain too

lifestyle changes to reduce heartburn (pyrosis)

The nurse should educate the client about lifestyle changes for reducing heartburn, such as: -Keep the head of the bed elevated using pillows -Sit upright after meals -Eat small, frequent meals (Option 3) -Avoid tight-fitting clothing -Eliminate common dietary triggers (eg, fried/fatty foods, caffeine, citrus, chocolate, spicy foods, tomatoes, carbonated drinks, peppermint) (Option 4)

Anaphylaxis reaction

The nurse should instruct the parent to first assess for signs of swelling of the mouth, tongue, lips, and upper airway. The child will have wheezing and difficulty breathing next, followed soon by cardiovascular symptoms. These include lightheadedness due to hypotension, loss of consciousness, and cardiovascular collapse. An anaphylactic reaction is life-threatening and requires rapid assessment and intervention.

Use of IV

The nurse should question the administration of a hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. IsotonicIV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. (Option 2) Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients. (Option 3) Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. (Option 4) A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature. Educational objective: Isotonic IV solutions, which have the same osmolality as plasma, are administered to expand intravascular fluid volume and replace the fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury.

inflammatory breast cancer (IBC)

The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In this aggressive form of cancer, breast lymph channels are blocked by cancer cells, creating breast tissue that becomes red, warm, and has an orange peel (peau d'orange), pitting appearance on the skin surface. The nurse would be most concerned about this client and make an immediate referral to the health care provider for examination and evaluation.

Facial eye nerves

The oculomotor (cranial nerve III), trochlear (cranial nerve IV), and abducens (cranial nerve VI) are motor nerves of the eye that are tested by having the client track an object, such as a finger, through the fields of vision. The oculomotor nerve is also tested by checking for pupillary constriction and accommodation (constriction with near vision). Deficits in cranial nerves III, IV, and VI can include disconjugate gaze (eyes do not move together), nystagmus (fine, rapid jerking eye movements), or ptosis (drooping of the eyelid). (Option 1) Cranial nerve II is the optic nerve and a sensory nerve. This nerve is assessed by testing the fields of vision for the client's ability to see objects in the field. In contrast to cranial nerves III, IV, and VI, the client does not track the object in the fields of vision, but instead keeps the eyes fixed and uses the peripheral vision to recognize objects or deficits in the field of vision. (Option 4) Cranial nerve V is the trigeminal nerve. The sensory portion of this nerve is assessed by testing sensation at the ophthalmic (forehead), maxillary (cheekbone), and mandibular (jaw line) branches by light touch. Corneal sensation is also a portion of the trigeminal nerve, but this is typically not tested by the nurse.

The rehabilitation phase of wound healing

The rehabilitation phase begins after the client's wounds have fully healed and lasts about 12 months. The initiation of this phase depends on the extent of the burns and the client's ability to care for themselves. Interventions in the rehabilitation phase are aimed at improving mobility and independence and minimizing the potential for long-term complications. These interventions include: Counseling or other psychosocial support Gentle massage with water-based lotion to alleviate itching and minimize scarring Planning for reconstructive surgery Pressure garments to prevent hypertrophic scars and promote circulation (Option 4) Range-of-motion exercises to prevent contractures (Option 2) Sunscreen and protective clothing to prevent sunburns and hyperpigmentation (Option 3) (Option 1) Daily application of water-based lotion is necessary to minimize scar formation and alleviate itching. Infection is not likely as the rehabilitation phase begins after the wounds are fully healed. Educational objective: The rehabilitation phase begins after the client's wounds are healed. The goals of this phase are to increase the client's ability to perform activities of daily living and prevent long-term complications.

The rule of nines

The rule of nines is used to estimate quickly the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client. Superficial burns (first-degree burns) are not included in the calculation of affected TBSA. For a client who has sustained partial-thickness burns to all anterior body surfaces below the neck, TBSA is calculated as follows: TBSA = [anterior torso] + [anterior arms] + [anterior legs] + [perineum] TBSA = [18] + [4.5 + 4.5] + [9 + 9] + [1] TBSA = 18 + 9 + 18 + 1 = 46% Once the affected TBSA has been estimated, the volume of necessary fluid resuscitation can be calculated (eg, Parkland formula [4 mL × kg of body weight × TBSA]). TBSA also determines the required level of care. In general, clients require transfer to a burn center for specialty care for: Full-thickness burns Partial-thickness burns >10% TBSA Electrical or chemical burns Inhalation injuries Educational objective: The rule of nines provides a quick estimate of the percentage of total body surface area (TBSA) affected by partial- and full-thickness burns in an adult client. TBSA determines the volume of necessary fluid resuscitation and the required level of care. The rule of nines assigns 9% per arm, 18% per leg, 36% for the torso, 1% for the perineum, and 9% for the head and neck.

hepatitis A

The transmission of hepatitis A occurs most commonly through the fecal-oral route through poor hand hygiene and improper food handling by infected persons. It is seen primarily in developing countries. After infection, the hepatitis A virus reproduces in the liver and is secreted in bile. Therefore, hand hygiene (especially after toileting and before meals) is the most important intervention to reduce the occurrence of hepatitis A infection (Option 4). Vaccination against hepatitis A is recommended for all children at age 1 and for adults at risk of contracting the virus (health care workers, men who have sex with men, drug users, those who travel to areas with a high prevalence, those with clotting disorders, and those with liver disease).

Nephroblastoma (Wilms tumor)

cancerous kidney tumor of childhood ages <5 symptom: unusual bulging/contour in abdomen treatment: -place a sign that say do not palpate abdomen at bedside -handle child carefully during bathing

pulmonary edema

This client is exhibiting signs of pulmonary edema, a life-threatening condition. In the presence of acute left ventricular failure, pulmonary vasculature overload causes increased pulmonary venous pressure that forces fluid out of the vascular space into the pulmonary interstitium and, if untreated, into the alveoli. Clinical manifestations of pulmonary edema include: A history of orthopnea and/or paroxysmal nocturnal dyspnea Anxiety and restlessness Tachypnea (often >30/min), dyspnea, and use of accessory muscles Frothy, blood-tinged sputum Crackles on auscultation The priority of care is to improve oxygenation by reducing pulmonary pressure and congestion. Diuretics (eg, furosemide) are prescribed to remove excess fluid in pulmonary edema (Option 2). Management of acute decompensated heart failure (ADHF) may also include oxygen therapy, vasodilators (eg, nitroglycerin, nesiritide), and positive inotropes (eg, dopamine, dobutamine). Vasodilators decrease preload thus improving cardiac output and decreasing pulmonary congestion. Positive inotropes improve contractility but are only recommended if other medications have failed or in the presence of hypotension.

Gonorrhea

To avoid re-infection with gonorrhea, it is essential that the client's partner be tested and treated. During the visit, the nurse should counsel the client about the importance of partner evaluation and treatment and the likely recurrence of the infection if the partner refuses to be treated. The client should avoid sexual relations until treatment is completed and the client and partner no longer have symptoms.

Evisceration Total separation of wound layers with protrusion of the internal viscera through the incision is known as evisceration

Total separation of wound layers with protrusion of the internal viscera through the incision is known as evisceration. Evisceration is a medical emergency that can lead to localized ischemia, peritonitis, and shock. Emergency surgical repair is necessary. Clients at risk for poor wound healing (eg, obesity, diabetes mellitus) are at increased risk for evisceration. When an abdominal wound evisceration occurs, the nurse should take the following actions: Remain calm and stay with the client. Have someone notify the HCP immediately and bring sterile supplies. Instruct the client not to cough or strain. Place the client in low Fowler's position (no more than 20 degrees) with knees slightly flexed to relieve pressure on the abdominal incision and have the client maintain absolute bed rest to prevent tissue injury. Assess vital signs (and repeat every 15 minutes) to detect possible signs and symptoms of shock (eg, hypotension, tachycardia, tachypnea). Cover the viscera with sterile dressings saturated in NS solution to prevent bacterial invasion and keep the exposed viscera from drying out. Document interventions taken and the appearance of the wound and eviscerated organ (eg, color, drainage). If the blood supply is interrupted, the protruding organs can become ischemic (dusky) and necrotic (black).

Toxic Epidermal Necrolysis (TEN)

Toxic epidermal necrolysis is an acute skin disorder, most commonly associated with a medication reaction, that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion (ie, denuded skin). It is a severe form of Stevens-Johnson syndrome. The major cause of death related to toxic epidermal necrolysis is sepsis; therefore, infection prevention is critical. Basic supportive care includes: Wound care: Sterile, moist dressings are applied to open areas of skin (Option 2). Infection prevention: Strict sterile technique and reverse isolation decrease infection risk. The nurse should also monitor for any signs of infection (eg, fever) (Option 3). Fluids and nutrition: Vital signs and urine output are monitored for signs of hypovolemia. Oral feeding should be initiated early to promote wound healing; a nasogastric tube may be necessary. Hypothermia prevention: Maintain a room temperature of 85 F (29.4 C) or more, and use passive rewarming methods such as sterile, single-use warming blankets or digitally regulated warming pads (Option 4). Pain management: Analgesics are administered around the clock and before painful procedures.

Toxoplasmosis

Toxoplasmosis is a parasitic infection caused by Toxoplasma gondii, which may be acquired from exposure to infected cat feces or ingestion of undercooked meat or soil-contaminated fruits/vegetables. Pregnant clients who contract toxoplasmosis can transfer the infection to the fetus and potentially cause serious fetal harm (eg, stillbirth, malformations, blindness, mental disability). Pregnant clients should be advised to take precautions when gardening and thoroughly wash all produce to decrease exposure risk.

prevention of HIV/AIDS from mother to fetus

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

Tuberculosis (TB) (do not take steroids if have latent TB)

Tuberculosis is an infection caused by the Mycobacterium tuberculosis microorganism. A client with active, primary TB disease has a positive tuberculin skin test (TST), usually feels sick, has symptoms, and can spread the disease to others if not treated with medications. A client with a latent TB infection (LTBI) has a positive TST, negative chest x-ray, is asymptomatic, cannot transmit the disease to others, and can complete a full course of treatment to prevent activation of the disease. Malignancy, immunosuppressant medications, including chemotherapy, and prolonged debilitating disease (eg, HIV), can convert LTBI to active disease. A client with LTBI who begins treatment with a corticosteroid (Prednisone) is at increased risk for conversion to active TB disease. Therefore, the nurse should notify the HCP.

Tumor lysis syndrome (TLS),

Tumor lysis syndrome (TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in the release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: Hyperkalemia (>5.0 mEq/L [5.0 mmol/L]) that can cause lethal dysrhythmias Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) that can overwhelm the kidneys and cause hyperuricemia and acute kidney injury (AKI) from uric acid crystal formation Hyperphosphatemia (>4.4 mg/dL [1.42 mmol/L]) that can cause AKI and dysrhythmias Hypocalcemia (<8.6 mg/dL [2.15 mmol/L]) that can cause tetany and cardiac dysrhythmias Potassium-sparing medications (eg, spironolactone) can worsen hyperkalemia (Option 4). Loop or osmotic diuretics may be prescribed to increase urine output and lower serum potassium. Sodium polystyrene sulfonate (Kayexalate) also helps to reduce potassium. Tumor lysis syndrome is an oncologic emergency that results in hyperkalemia, hyperuricemia, hyperphosphatemia, and hypocalcemia. Treatment includes aggressive hydration, correction of electrolyte abnormalities (eg, loop diuretics, phosphate binders), and hypouricemic agents (eg, allopurinol).

Urinary tract infections (UTIs)

Urinary tract infections (UTIs) are usually bacterial in origin and are most often caused by Escherichia coli. The microorganisms from the perineal area enter the urethra, causing inflammation and infection (urethritis). They ascend to the bladder, where they multiply, causing inflammation and infection (cystitis). The bacteria may continue to ascend the urinary tract to the ureters and kidneys, causing inflammation and infection in the kidneys (pyelonephritis). A UTI is classified as upper or lower according to its location within the urinary tract.

Low urine output

Urine output of less than 30 mL/hr may indicate low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter). Given this client's heart failure, low urine output is likely due to decreased cardiac function and buildup of fluid in the lungs. The nurse should assess the lung sounds for crackles and report to the HCP, who can prescribe loop diuretics.

Risk factors for DVT

Venous thromboembolism includes both DVT and pulmonary embolism (PE). DVT is the most common form and occurs most often (80%) in the proximal deep veins (iliac, femoral) of the lower extremities. Virchow's triad describes the 3 most common theories behind the pathophysiology of the venous thrombosis: venous stasis, endothelial damage, and hypercoagulability of blood. Risk factors associated with DVT formation include the following: Trauma (endothelial injury and venous stasis from immobility) Major surgery (endothelial injury and venous stasis from immobility) Prolonged immobilization (eg, stroke, long travel) causing venous stasis Pregnancy (induced hypercoagulable state and some venous stasis by the pressure on inferior vena cava) Oral contraceptives (estrogen is thrombotic) Underlying malignancy (cancer cells release procoagulants) Smoking (produces endothelial damage by inflammation) Old age Obesity and varicose veins (venous stasis) Myeloproliferative disorders (increase blood viscosity) The 80-year-old 4-day postoperative client has the most risk factors: orthopedic hip surgery, prolonged period of immobility/inactivity, and advanced age, and is at greatest risk for developing a DVT. (Option 1) Smoking cigarettes and using oral contraceptives increase plasma fibrinogen and coagulation factors and cause hypercoagulability of blood, but the client is not at greatest risk. Hormonal contraceptives are not recommended if the client is age >35 and also smokes. (Option 2) Elevated hemoglobin/hematocrit level (erythrocytosis) causes increased blood viscosity and hypercoagulability of blood, which increases the risk for DVT. However, the client is not at greatest risk. (Option 3) Anticoagulants and antiplatelet agents are administered before and after coronary stent placement. This client is at increased risk due to endothelial damage and advanced age but is not at greatest risk. Educational objective: DVT is a frequent, often preventable complication of hospitalization, surgery, and immobilization. Factors that increase the risk for developing a DVT include trauma, surgery (especially orthopedic, knee, hip), prolonged immobility/inactivity, oral contraceptives, pregnancy, varicose veins, obesity, smoking, and advanced age.

Von Willebrand disease

Von Willebrand disease is a genetic bleeding disorder caused by a deficiency of von Willebrand factor (vWF), which plays an important role in coagulation. Intranasal desmopressin or topical therapies (eg, thrombin) may be prescribed to stop minor bleeding, whereas major bleeding may require replacement of vWF. Clients should wear medical identification bracelets in case of emergency. Client teaching includes: Notify the health care provider of signs of bleeding (eg, severe joint pain or swelling, headache [especially after injury], blood in urine/stool, uncontrollable nosebleed). Use a humidifier or nasal spray to keep the mucosa moist, reducing the risk of nosebleeds (Option 1). Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Avoid activities with a higher risk for injury (eg, contact sports) (Option 2). Maintain gum integrity (eg, soft-bristled toothbrush, gentle flossing) to minimize bleeding potential (Option 3). Report heavy menstrual bleeding (eg, soaking a pad in <3 hours), which can be managed with hormonal therapies and intranasal desmopressin (Option 4). (Option 5) Clients should avoid medications that can exacerbate bleeding, including aspirin and NSAIDs (eg, ibuprofen, naproxen, ketorolac). Clients should instead use the mnemonic RICE (rest, ice, compression, elevation) to help with pain and inflammation. Educational objective: In von Willebrand disease, a genetic bleeding disorder, deficient von Willebrand factor prevents effective coagulation. Clients can decrease bleeding risk by avoiding high-risk activities (eg, contact sports) and nonsteroidal anti-inflammatory drugs, keeping nasal mucosa moist, and maintaining gum integrity (eg, soft-bristled toothbrush).

Small Bowel Obstruction (SBO)

When a small-bowel obstruction develops, fluid and gas collect proximal to the obstruction, producing rapid onset of nausea and vomiting (Option 4), colicky intermittent abdominal pain (Option 3), and abdominal distension (Option 1). The nurse should recognize symptoms of bowel obstruction quickly as delay could lead to vascular compromise, bowel ischemia, or perforation. Nursing management of an obstruction includes placing the client on NPO status, inserting a nasogastric tube, administering prescribed IV fluids, and instituting pain control measures.

Administering optic medications

When administering an otic medication to an adult or child age 3 and older, the pinna is pulled upward and back to straighten the external ear canal (Option 2). For an infant, the pinna is pulled downward and straight back. (Option 1) The child should be placed in the prone or supine position with the head turned to the appropriate side.

Coronary artery disease vs NSAIDS (aspirin, ibuprofen, naproxen)

the use of NSAIDs increases the risk of thrombotic events (eg, heart attack, stroke) in clients with cardiovascular disease (eg, coronary artery disease [CAD]), especially with long-term use.

who needs parental nutrition

those who gastrointestinal tract is not functional or who cannot take a enteral diet for extended periods. these includes: clients with extensive burns severe exacerbation of chronic`s disease persistent nausea & vomiting from chemo extensive surgery multiple fractures septic advance cancer HIV

who is at risk for hyperkalemia

trauma, burns, sepsis, metabolic and respiratory acidosis

wound evisceration

Wound evisceration is the protrusion of internal organs through the wall of an incision. It typically occurs 6-8 days after surgery and is more common in clients who have had abdominal surgery, those with poor wound healing, and those who are obese. It is considered a medical emergency. The nurse should remain with the client while calling for help. The health care provider should be notified immediately and supplies brought to the room by another staff member. The wound should be covered with sterile normal saline dressings. While the nurse remains in the room, the client should be positioned in low Fowler's position with the knees bent. This position lessens abdominal tension on the suture line and can prevent further evisceration. The client should be prepared for immediate return to surgery. (Option 2) Prone positioning would put undue pressure on an open incision and protruding bowel and could contaminate the open wound. (Option 3) A side-lying lateral position (recovery position) is often used following emergency situations such as cardiac arrest or seizure, but it will not lessen the tension placed on this open wound. (Option 4) Supine with the head of the bed flat may actually increase tension placed on the open wound. Educational objective: Wound evisceration is a medical emergency. The client should be placed in low Fowler's position with the knees bent to reduce tension on the open wound. The nurse should remain with the client while another staff member obtains sterile saline and gauze to cover the wound.

Strabismus (cross-eyed)

abnormal deviation of the eye (misalignment of the eyes treatments: -strenghten the muscle of the weaker eye by wearing a patch over the stronger eye or use proper corrective lenses -surgery but not with a laser is used when non pharmacological measures don't work

Pica

abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.

Proton Pump Inhibitors

any med that ends in prazole (Omeprazole). decrease calcium promote osteoporosis take before meals causes: osteoporosis (main one) c diff pneumonia

GERD (gastroesophageal reflux disease) Lifestyle and dietary measures that help prevent or minimize symptoms of gastroesophageal reflux disease

avoiding dietary triggers such as alcohol, caffeine, chocolate peppermint high-fat foods. Clients should consume small, frequent meals and discontinue the use of tobacco products.

barium enema (BE)

barium enema, or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause subsequent peritonitis. Preprocedure instructions include: Take a cathartic (eg, magnesium citrate, polyethylene glycol) to empty stool from the colon. Follow a clear liquid diet the day before the procedure to aid in bowel preparation and to prevent dehydration; avoid red and purple liquids. Do not eat or drink anything 8 hours before the test (Option 2). Expect to be placed in various positions during the procedure. You may experience abdominal cramping and an urge to defecate (Option 3). Postprocedure instructions include: Expect the passage of chalky, white stool until all barium contrast has been expelled (Option 1). Take a laxative (eg, magnesium hydroxide [Milk of Magnesia]) to assist in expelling the barium. Retained barium can lead to fecal impaction (Option 4). Drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent constipation. Educational objective: A barium enema uses fluoroscopy with contrast to evaluate for colon abnormalities. Before the procedure, clients undergo bowel preparation using cathartics and a clear liquid diet. Laxatives after the procedure assist in expelling the contrast.

Hypothyroidism S/S

bradycardia hypotension weight gain cold intolerance dry skin cool skin constipation depression (decrease drive) fatigue decrease memory function edema low appetite muscle stiffness

who are at risk for hypokalemia

bushings syndrome, colitis, and patients overusing laxatives

Filgrastim (Neupogen)

cancer treatment used to stimulate neutrophil production

fluid volume overload/ increase (causes, risk factors)

congestive heart failure decreased kidney function excess sodium ingestion long term corticosteroid therapy patients receiving frequent wound irrigation

fluid overload excess s/s

cough, dyspnea, crackles, tachypnea, tachycardia, hypertension, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein dissension, altered level of consciousness, decreased hematocrit

Parenteral Nutrition (PN) discontinuation/transition to solid foods

decrease PN gradually to about 1/2 the Normal rate because abrupt disconnection can cause hypoglycemia

Hypernatremia S/S

extreme thirst, decreased urinary output, increase specific gravity

what will you see on the electrocardiogram with hyperkalemia

flat P waves prolonged PR intervals widened QRS complexes tall peaked T waves

A highly intoxicated client was brought to the emergency department after found lying on the sidewalk. On admission, the client is awake with a pulse of 70/min and blood pressure of 160/80 mm Hg. An hour later, the client is lethargic, pulse is 48/min, and blood pressure is 200/80 mm Hg. Which action does the nurse anticipate taking next? 1. Administer atropine for bradycardia[25%] 2. Administer nifedipine for hypertension[24%] 3. Have CT scan performed to rule out an intracranial bleed[41%] 4. Perform hourly neurologic checks with Glasgow coma scale (GCS)[8%] Cushing's triad/reflex

indicates increased intercerebral pressure. Classic signs include bradycardia, rising systolic blood pressure, widening pulse pressure, irregular respirations (such as Cheyne-Stokes).

Epiglottitis (Heamophilus Influenza virus)

inflammation of the epiglottis symptoms: inspiratory stridor -Toxic appearance -soar throat the 4 D'Souza: -dysphagia (difficultly swallowing, dysphonia( muffled voice), druling, distressed respiratory efforts treatment: -assume tripod position (sit forward) -prepare for emergency airway (surgery)

Pheytoin (Dilantin)

good oral care and dental follow up

Cardiac Tamponade s/s

heart rupture, trauma, pericarditis, recent heart surgery cancer and radiation therapy to the chest

if the PT (prothrombin time ) is 35 seconds what should you do?

hold the next dose of warfarin because the value is high and near critical range

patients on parenteral nutrition complaining of headaches, increase BP, bounding pulse, jugular vein dissension and bilateral crackles are showing signs of what?

hypervolemia

Clinical features of cardiac tamponade

hypotension or narrow pulse pressure, muffled heart sounds, and neck vein distension (Beck triad) pulsus paradoxus (ie, systolic blood pressure decrease >10 mm Hg during inhalation), chest pain, tachypnea, tachycardia may be present.

Cardiac temponade complication of acute pericarditis Cardiac temponade clinical features:

hypotension or narrow pulse pressure, muffled heart sounds, and neck vein distension (Beck triad) (Option 3). In addition, pulsus paradoxus (ie, systolic blood pressure decrease >10 mm Hg during inhalation), chest pain, tachypnea, and tachycardia may be present.

with nausea and vomiting what is seen on the ABGs?

increase PH and increase HCO3 (bicarb)

fluid volume

increase respiration, tachycardia, decreased CVP, weight loss poor skin tumor, dry mucos membrane, decrease urine output, increase specific gravity, increase hematocrit, altered level of consciousness

developmental dysplasia of the hip (DDH) barlow nd ortolani maneuvers

instability or dislocation of the hip joint present at birth risk factor: -breech birth -large infant size -family history symptoms: -presence of extra gluteal, inguinal or thigh folds -laxity of the hip joint on the affected side( hip laxity is tested through barlow and ortolan maneuvers interventions: -proper swaddle (with hip bent up=flexion; and out= abduction with room for hip movement -choose infant carrier or car seats with wide base -avoid any positioning device, seats or carriers that causes hip extensions with the knees strait and together treatment: -pavlik harness (worn 3-5 months or until joints is stable). the wraps a assessed and adjusted by doctor every 1-2 weeks to account for infant growth. parents should not attempt to altar the straps intervention for wearing pavlik harness: -assess skin 2-3 times daily -dress child in shirt and knee socks -apply diaper underneath strap -leave harness on at all times -massage the skin under the straps daily to promote circulation

hypothyroidism risk factors/ causes

iodine deficiency damage thyroid gland medications (amiodarone/ lithium)

Enoxaparin (Lovenox)

is a low molecular weight heparin mo avoid aspirin and NSAID monitor: CBC (thrombocytopenia)

pleurisy (pleuritis)

is characterized by stabbing chest pain that usually increases on inspiration or with cough. It is caused by inflammation of the visceral pleura (over the lung) and the parietal pleura (over the chest cavity). The pleural space (between the 2 layers) normally contains about 10 mL of fluid to help the layers glide easily with respiration. When inflamed, they rub together, causing pleuritic pain. A pleural friction rub is auscultated in the lateral lung fields over the area of inflammation. The sound is produced by the 2 layers rubbing together and can indicate pleurisy, a complication of pneumonia. It is characterized by squeaking, crackling, or the sound heard when the palm is placed over the ear and the back of the hand is rubbed with the fingers. Complications of pneumonia are more prevalent in elderly clients with underlying chronic disease. (Option 1) Clients with consolidative lung processes (pneumonia) may also have bronchial breath sounds due to over-transmission of sound over the chest wall. Breath sounds are diminished or absent over a pleural effusion or pneumothorax. (Option 2) Palpable vibration felt on the chest wall is known as fremitus. Sound travels faster in solids (consolidation) than in an aerated lung, resulting in increased fremitus in pneumonia. It is an expected finding in clients with pneumonia. It is concerning if decreased because the client may be developing pleural effusion. (Option 3) Low-pitched wheezing (rhonchi) is a continuous adventitious breath sound heard over the large airways, usually during expiration. It indicates the presence of secretions in the larger airways and is an expected finding as pneumonia resolves. Educational objective: Pleurisy is characterized by stabbing pleuritic chest pain that increases on inspiration. It is a complication of pneumonia caused by inflamed parietal and visceral pleurae rubbing together.

Hyponatremia

low sodium ( can cause by water intoxication

HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count)

medical emergency a severe form of preeclampsia. Its clinical presentation can be quite variable and may include nonspecific symptoms such as right upper quadrant/epigastric pain, nausea, vomiting, and malaise. Complications including placental abruption, stroke, and death may occur if HELLP syndrome is not treated immediately.

ectopic pregnancy

medical emergency Symptoms of ectopic pregnancy may include lower abdominal and pelvic pain; amenorrhea, possibly followed by vaginal spotting or bleeding; and a palpable adnexal mass on pelvic examination. -An ectopic pregnancy may implant in one of many locations outside the uterine cavity, including the fallopian tubes, ovaries, or abdominal cavity. As the ectopic pregnancy outgrows its environment, it may rupture, causing life-threatening maternal hemorrhage. -Symptoms indicative of a ruptured ectopic pregnancy include hypotension, tachycardia, dizziness, and referred shoulder pain (Option 4). Shoulder pain results from irritation of the diaphragm by intraabdominal blood. A ruptured ectopic pregnancy is a surgical emergency and requires immediate intervention.

Signs of adequate hydration or rehydration includes

normal urine specific gravity (1.003 to 1.030), adequate volume of urine output (>30 mL/hr), and capillary refill of less than 3 seconds.

Signs of compartment syndrome (CS) include the 6 Ps -

pain (unrelieved by repositioning or analgesics), pallor, pulselessness, paresthesias, poikilothermia (coolness), paralysis. Is a medical emergency, notify health care provider

Hypoglycemia S/S

palpitations, tachycardia, irritable, sweating, fatigue, drowsiness, hunger tremors/weakness

patent ductus arteriosus

passageway between the aorta and the pulmonary artery remains open after birth symptom is 1. a loud machine like murmur

who is at risk for hyponatremia

patients taking diuretics

who is at risk for hypernatremia

patients with: corticosteroids cushings syndrome hyperaldosteronism

what is seen on the electrocardiogram with hypocalcemia

prolonged ST QT interval

what will you see on the electrocardiogram with hypokalemia

prominent U waves

Left sided heart failure symptoms

pulmonary edema, coughing, shortness of breath, and dyspnea

hyperphosphatemia risk factors

renal insufficiency hypoparathyroidism tumor lysis syndrome

morphine toxicity s/s

respiratory depression, hypotension, bradycardia, vomitting, depression

what levels are elevated in cushing`s disease

salivary cortisol serum sodium serum glucose urine glucose cushings disease is a metabolic disorder characterize by excessive production of glucocorticoids (cortisol), mineralocorticoids (aldosterone) and sex hormone. note: aldosterone causes sodium and water retention

what is seen on the electrocardiogram with hypercalcemia

shortened ST segment widened T wave

visual acuity test

standard eye examination to determine the smallest letters a person can see using one eye at a time on a Snellen chart, or E chart, at a distance of 20 feet -4 out of 6 letters on the 10/15 line is equivalent to (20/30 vision) with both eyes -3-4 month old is assessed by following a target

Tinea Corporis (ringworm) treatment

terbinafine (topical antifungals)

in respiratory acidosis

the PH is decreased and the PACO2 is elevated

A molar pregnancy, or hydatidiform mole

type of gestational trophoblastic disease that results from abnormal fertilization. It causes rapidly growing trophoblastic tissue that is initially benign but may lead to gestational trophoblastic neoplasia (GTN) (eg, invasive mole, choriocarcinoma). If trophoblastic tissue continues to grow or metastasize after evacuation of a molar pregnancy, levels of human chorionic gonadotropin (hCG), a hormone that is also used to diagnose pregnancy, will continue to increase. Therefore, the nurse should emphasize the importance of avoiding pregnancy during follow-up care to allow health care providers to monitor for rising hCG levels, which may indicate malignant GTN (Option 3). Weekly monitoring of hCG levels is required at first, followed by continued monitoring for 6-12 months postpartum.

Glycoprotein (GP) IIb/IIIa Inhibitors (abciximab, eptifibatide, tirofiban) note: these clients needs to be put on bleeding monitoring/precautions

used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic stroke -these inhibitors can cause serious bleeding causing (hypotension, tachycardia) -develope serious thrombocytopenia within few hrs of treatment -during or after this procedure NO dramatic procedures (initiation of IV sites, intramuscular injections) should be performed unless absolutely necessary due to risk of bleeding

parathyroidism causes/ risk factors

vitamin D deficiency radiation of the neck or neck trauma parathyroid cancer hypocalcemia w/ chronic kidney disease congenital tissue overgrowth (hyperplasia)

fluid volume deficit risk factors

vomit, diarrhea, increase urinary output, conditions that cause increase increase respirations, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy, gastrointestinal suctioning

hyperthyroidism s/s (opposite of hypothyroidism)

weight loss heat intolerance tachycardia exothalamus (bulging eyes) hepatomegaly difficulty sleeping increase appetite palpitation diaphoreses warm skin