NCLEX/RN - rlyonga

Warning signs; Infant's arms or legs are stiff or rigid. High risk factor for CP is very low birth weight. Has feeding difficulties, such as poor sucking & swallowing. If able to crawl, only one side is used to propel himself or herself. By 8 months of age, if infant cannot sit up without support. Poor head control by 3 months of age, when head control should be strong.

Cerebral palsy (CP)

Goal treatment rest bowel & allow inflammation to subside. NPO & placed on bed rest. Pain occurs from bowel spasms, & increased intra-abdominal pressure (coughing & deep breathing) may precipitate an attack.

Acute diverticulitis

Activity limited, most children because of fatigue, voluntarily restrict their activities during active phase of disease. Catheterization may cause infection. Child should be allowed to express feelings with play. Visitors limited to allow for adequate rest.

Acute glomerulonephritis

Acute kidney injury or chronic kidney disease, potassium intake must be restricted as much as possible (to 60 to 70 mEq/day). Primary mechanism of potassium removal during AKI is dialysis.

Acute kidney injury (AKI)

Causes increased blood pressure (initially), increased pulse & respiratory rate, dilated pupils, & perspiration

Acute pain

Severe & unrelenting, located epigastric area & radiating to back. NPO (nothing by mouth) status decrease activity of pancreas. Pain management typically administration opioids patient-controlled analgesia. Morphine or hydromorphone (Dilaudid) are typically used. Nasogastric tube insertion is done to provide suction secretions & administer medications as necessary.

Acute pancreatitis

often occurs first 2 weeks after transplantation. Manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, & deteriorating renal function.

Acute rejection

earliest sign is increased respiratory rate, can begin from 1 to 96 hours after initial insult to body. Followed by increasing dyspnea, air hunger, retraction accessory muscles, & cyanosis.

Acute respiratory distress syndrome

Tachypnea & dyspnea first clinical manifestations. Blood-tinged frothy sputum would present later sign, after development pulmonary edema. Breath sounds in early stages ARDS usually are clear.

Acute respiratory distress syndrome (ARDS)

Humidifier help liquefy secretions & promote drainage. Consumption large amounts fluids important to help liquefy secretions. Sleeping head of bed elevated to 45-degree angle will assist in promoting drainage. Apply heat in form of wet packs over affected sinuses to promote comfort & help resolve the infection.

Acute sinusitis

Prescribed diet; low fiber & does not include milk. Help reduce frequency of diarrhea.

Acute ulcerative colitis

Does not occur suddenly. In few days or hours preceding thrombotic stroke, experience transient loss of speech, hemiparesis, or paresthesias on one side of body. Signs; include dizziness, cognitive changes, or seizures.

Cerebral thrombosis (thrombotic stroke)

Experience shortness of breath & fatigue because of decreased ability of blood to carry oxygen to tissues to meet metabolic demands. Tachycardia result efforts by body compensate for effects of anemia.

Anemia that developed as a result of blood loss after a traumatic injury

Edema resulting from bleeding below periosteum of cranium. Does not cross suture line. Most likely caused by ruptured blood vessels from head trauma during birth. Lesion develops within 24 to 48 hours after birth & may take 2 to 3 weeks to resolve.

Cephalohematoma

Assessed for possible allergy contrast dye, determined by questioning about allergies to iodine or shellfish

Cerebral angiography

Chronic disability characterized by impaired muscle movement & posture

Cerebral palsy

Liver damage most serious adverse effect. To reduce risk of liver damage, liver function tests should be performed before treatment & throughout treatment. Administered lowest effective dosage for shortest time necessary.

Dantrolene sodium (Dantrium)

Considered a risk factor for disseminated intravascular coagulation (DIC).

Dead fetus syndrome

(extension) posturing characterized: rigid extension & pronation of arms & legs. Abnormal extension upper extremities with internal rotation of upper arms & wrists & extension of lower extremities with some internal rotation. Indicates damage in diencephalon, midbrain, or pons

Decerebrate posturing

(flexion) posturing; Abnormal flexion of upper extremities & extension of lower extremities with possible plantar flexion of feet. Indicates lesion in cerebral hemisphere or disruption of the corticospinal tracts.

Decorticate posturing

Primary effect decrease blood pressure is reduced blood flow to myocardium. This decreases oxygenation of cardiac tissue. Cardiac tissue likely to become excitable or irritable in presence of hypoxia. Heart rate is likely to increase in response to change. Effects of tissue ischemia lead to decreased contractility over time.

Decrease in blood pressure

With vitamin B6 & B12 deficiencies, iron deficiency, chronic infection, bone marrow depression, multiple myeloma, leukemia, hemolytic anemia, & pernicious anemia. Decrease RBC count also may be noted in older client.

Decreased RBC counts occur

Crackers, Melba toast, dry cereal at bedside; eat before getting up in morning; eating smaller more frequent meals; decreasing fats; & consuming adequate fluid between meals but not with meals. High-carbohydrate diet could increase episodes nausea.

Decreasing morning nausea in pregnancy

Risk for perforation of ulcer. Will experience sudden, sharp, intolerable severe pain beginning in midepigastric area & spreading over abdomen, becomes rigid & board-like.

Deep duodenal ulcer

Bed rest; limb elevation; relief of discomfort warm, moist heat; & analgesics as needed. pain normally relieved acetaminophen (Tylenol).

Deep vein thrombosis (DVT)

Pigmented malignant lesions originating melanin-producing cells of epidermis. This skin cancer highly metastatic, & survival depends on early diagnosis & treatment

Melanoma

Pigmented malignant lesions. This skin cancer highly metastatic, & survival depends on early diagnosis & treatment. Not a contagious lesion. Irregularly shaped pigmented papule or plaque with a red, white, or blue tone.

Melanomas

Blotchy brown macules across cheeks & forehead. Condition caused by hormonal influences on melanin production.

Melasma

Temporal lobe, hippocampus, & frontal lobe

Memory

Infectious process central nervous system.

Meningitis

Transmitted by droplet infection. Precautions include private room or cohort client & use of standard precaution mask.

Meningococcal pneumonia

Older adults should not meperidine hydrochloride because prolonged half-life accumulates with repeated dosing; can lead to life-threatening seizures. Because physical changes of aging, older clients excrete this medication slowly, leading to risk for cerebral irritation & seizures.

Meperidine hydrochloride (Demerol)

Opioid analgesic. Side/adverse effects; respiratory depression, drowsiness, hypotension, constipation, urinary retention, N&V, tremors.

Meperidine hydrochloride (Demerol)

Hyperpnea with Kussmaul's respirations; headache; nausea, vomiting, & diarrhea; fruity-smelling breath resulting from improper fat metabolism; central nervous system depression, including mental dullness, drowsiness, stupor, & coma; twitching; & convulsions. Hyperkalemia will occur.

Metabolic acidosis

Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or diarrhea.

Metabolic acidotic

Because hydrogen ions contribute to acidosis in the body, the kidneys retain hydrogen ions in alkalosis to restore acid-base balance

Metabolic alkalosis

Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms experienced would include hypoventilation & tachycardia.

Metabolic alkalosis

Oral hypoglycemic given combination repaglinide, works decreasing hepatic glucose production. Common side effect metformin is diarrhea. Used with caution; kidney/liver disease, heart failure, chronic lung disease, history heavy alcohol consumption.

Metformin (Glucophage)

Most common side effect GI disturbances, including decreased appetite, nausea, & diarrhea. These generally subside over time. May lose average of 7-8 lb because medication causes nausea & decreased appetite.

Metformin (Glucophage); Type II Diabetes

Abuse causes vasoconstriction, resulting commonly in poor wound healing & hypertension.

Methamphetamine

Treats UTI; under acidic conditions, decomposes into ammonia & formaldehyde. Formaldehyde denatures bacterial proteins, causing death of organism.

Methenamine (Mandelamine)

Contact precautions required; private room, gloves, gowns, & face shields in case a splash from wound drainage occurs, such as with wound irrigation.

Methicillin-resistant Staphylococcus aureus (MRSA)

Skeletal muscle relaxant. May cause urine to turn brown, black, dark green color. Needs to be told; harmless effect. Medication can cause hypotension & bradycardia. Drowsiness & dizziness can also occur.

Methocarbamol (Robaxin)

Loss of half visual field. Objects placed in intact field vision, & also should approach from intact side. Instructs to scan environment to overcome visual deficit & client teaching from within intact field vision. Encourage use personal eyeglasses, if available.

Homonymous hemianopsia

(Stye); application warm compresses 15 mins four times day & instillation ophthalmic antibiotic ointment for causative infectious organism & prevent spread infection surrounding lid glands. Warm compresses promote comfort & aid bringing purulent contents to head, causing rupture with drainage.

Hordeolum

Needed during pregnancy for healthy cell growth & repair. Pregnant woman should have at least four servings of folic acid-rich foods per day. Food items; glandular meats, yeast, legumes, whole grains, and dark green, leafy vegetables.

Folic acid

Green leafy vegetables, whole grains, fruits, liver, dried peas, & beans.

Folic acid food items

Medication used to treat known or suspected ethylene glycol (antifreeze) intoxication. Administered IV route. Diluted in at least 100 mL 0.9% normal saline or 5% dextrose in water & administered over 30-min period.

Fomepizole (Antizol)

Is temporary opening between right & left atria.

Foramen ovale

Child has the ability to think abstractly and logically.

Formal operations stage of Piaget's cognitive developmental theory

Short-term parenteral IV infusion. Client who is not tolerating medications orally (N&V) & has seizure disorder would need anticonvulsant administered parenteral route. (If client is unable to keep anticonvulsants down orally, this medication would be given)

Fosphenytoin sodium (Cerebyx)

symptom; pain, loss of function in area, deformity, shortening of extremity, crepitus, swelling, & ecchymosis.

Fracture

Long, wide, &/or protruding ears; long, narrow face with prominent jaw; large protruding ears; & large testes.

Fragile X syndrome

Pulling, Vegetable juice, Pureed vegetables, plain ice cream, sherbet, breakfast drinks, milk, pudding & custard, soups that are strained, refined cooked cereals, & strained vegetable juices.

Full liquid diet:

Involve epidermis, full dermis, & some of subcutaneous fat layer. Burn appears tan or fawn color, with skin hard, dry, & inelastic. Edema severe, & accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings damaged, & area may be insensitive to touch, with little or no pain.

Full-thickness burn

Potassium-losing diuretic, & insufficient replacement potassium may lead to hypokalemia. Acting to excrete sodium, potassium, & chloride in ascending limb of loop of Henley. Administered by IV injection, each 40 mg or fraction thereof should be given over a 1- to 2-minute period

Furosemide (Lasix)

Greater 150 mL, may be experiencing delayed gastric emptying. Feeding stopped, & HCP notified. Assess whether abdominal girth enlarged & auscultate bowel sounds rule out intestinal obstruction. Some benefit from administration metoclopramide (Reglan) stimulate gastric emptying. Agency procedure followed regarding gastric residuals.

Gastric residual

Weight loss or nausea & vomiting. exacerbated by intake of food. Pain occurs 30-60 minutes after meal & rarely occurs at night

Gastric ulcer

Avoid chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, & alcohol

Gastroesophageal reflux disease (GERD

Bowel herniates through defect abdominal wall to right of umbilical cord. No membrane covering exposed bowel. Surgical repair done as soon as possible because risk infection in unprotected bowel. Highest risk immediately after delivery is infection

Gastroschisis

One adverse effect is hepatotoxicity.

Gemfibrozil (Lopid)

Emphasizes self-expression, self-exploration, & self-awareness in present. Client & therapist focus on everyday problems & try to solve them.

Gestalt therapy

Increase Risk factor; obesity (more than 198 pounds, depending on height), chronic hypertension, family history DM, previous birth large infant (greater 4000 g), & gestational diabetes previous pregnancy. Glucose crosses placenta; insulin does not. High fetal demands glucose, combined with insulin resistance caused by hormonal changes last half pregnancy, result elevation maternal blood glucose levels. Increases demand for insulin. Referred to as diabetogenic effect pregnancy.

Gestational diabetes

Symptom; vaginal bleeding, excessive N&V, larger-than-normal uterus for gestational age, elevated levels hCG, failure detect fetal heart activity even with sensitive instruments, early development gestational hypertension. Fetal activity not noted.

Gestational trophoblastic disease (Hydatidiform mole)

used for nausea & vomiting

Ginger

Motor response points are as follows: Obeys a simple response = 6 Localizes painful stimuli = 5 Normal flexion (withdrawal) = 4 Abnormal flexion (decorticate posturing) = 3 Extensor response (decerebrate posture)= 2 No motor response to pain = 1. Verbal response points are as follows: Oriented = 5 Confused conversation = 4 Inappropriate words = 3 Respond with incomprehensible sounds = 2 No verbal response = 1 Eye opening points are as follows: Spontaneous = 4 In response to sound = 3 In response to pain = 2 No response, even to painful stimuli = 1

Glasgow Coma Scale (GCS)

Hypertension, cardiovascular disease, diabetes mellitus, & obesity associated with development

Glaucoma

Condition affected person has few language skills as result extensive damage left hemisphere. Speech is nonfluent & associated with poor comprehension & limited ability to name objects or repeat words.

Global aphasia

Means that if any part of object or situation changes, whole thing has changed.

Global organization

Gross hematuria & proteinuria: urine may be small in volume, specific gravity elevated, & urine may appear dark & smoky; cola-colored/brown-colored. Foamy urine from proteinuria. Hypertension common. Blood urea nitrogen levels may be elevated. Moderately elevated high urinary specific gravity. Common experiences excess fluid volume & fatigue. Intervention; fluid restriction, monitoring weight, I&O. Diet high calorie but low protein. Placed bed rest, encouraged rest, because direct correlation between proteinuria & hematuria & increased activity level.

Glomerulonephritis

Treat hypoglycemia because it increases blood glucose levels. Family instructed how to administer. Unconscious client, arousal usually occurs within 20 min glucagon injection. When consciousness regained, oral carbohydrates should be given.

Glucagon

Flashbacks, recurrence perceptual distortions; unique to use of hallucinogenic drugs.

Hallucinogenic drug

Antipsychotic. Toxic effects include drowsiness & lethargy, excessive salivation, fixed stare, akathisia, acute dystonia, & tardive dyskinesia. Nausea, hypotension, & blurred vision occasional side effects.

Haloperidol (Haldol)

Maneuver open airway by tilting forehead back & lifting the chin; do not use with trauma patients.

Head tilt-chin lift

Not worn if ear infection present. Wash frequently with mild soap/water & use pipe cleaner to clean cannula. Turn hearing aid off before removing from ear prevent squealing feedback. Turned off when not in use, & client keep extra batteries at all times.

Hearing aid

Precipitated or exacerbated by physical or emotional stress, dysrhythmias, infections, anemia, thyroid disorders, pregnancy, Paget's disease, nutritional deficiencies (thiamine, alcoholism), pulmonary disease, & hypervolemia.

Heart failure

Abnormal heart sound & described as gentle, blowing, swooshing sound.

Heart murmur

Characterized by ecchymosis, swelling, & leakage at IV insertion site, as well as hard & painful lumps at site.

Hematoma

Blindness in half visual field. Taught scan environment. Allows client take in entire visual field, necessary for proper functioning in environment & helps prevent injury to client

Hemianopsia

Acts more rapidly than regular insulin, shorter duration action. Effect begin 25 minutes after subcutaneous injection, peak 0.5 to 1.5 hours, & duration action 5 hours. Because rapid onset, administered 15 minutes to immediately before eating.

Lispro insulin (Humalog)

Serum level 0.6 to 1.2 mEq/L. Symptoms toxicity appear levels 1.5 to 2 mEq/L. Lithium toxicity requires immediate medical attention with lavage & possible peritoneal dialysis or hemodialysis. Symptoms toxicity; vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, & tremors.

Lithium carbonate

Normal diet, salt & fluid intake (1500-3000 mL per day) maintained,lithium decreases sodium reabsorption renal tubules, leading to sodium depletion. Low sodium intake causes relative increase lithium retention & could lead to toxicity. Lithium irritating to gastric mucosa, taken with meals. Therapeutic & toxic dosage ranges narrow, lithium blood level monitored closely. More frequently when begins medication & once every several months after levels stabilize. Stop taking med, call HCP if excessive diarrhea, vomiting, diaphoresis occur.

Lithium carbonate (Lithobid)

Therapeutic serum level lithium 0.6 to 1.2 mEq/L. Serum lithium 1.5 to 2.0 mEq/L may produce symptoms; vomiting, diarrhea, drowsiness, incoordination, coarse hand tremors, muscle tremors, mental confusion.

Lithium carbonate (Lithobid)

Crisis of disaster; it is unplanned or accidental; Witnessing a murder, fire destroyed home, recent rape episode experienced

adventitious crisis

administered empty stomach unless it causes GI upset, & then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before. Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently.

rifampin (Rifadin)

Move safe area away from snake & rest to decrease venom circulation. Next jewelry & constricting clothing removed before swelling occurs. Immobilize extremity & maintain below heart level done next. Kept warm & calm. Stimulants alcohol/caffeinated beverages not given: may speed absorption of venom

snakebite first priority intervention

Painless blurring central vision is chief clinical manifestation. Early symptom include slightly blurred vision & decrease in color perception.

early stages of cataract formation

Surgical removal eyeball. Presence bright red drainage on dressing,reported to HCP, indicates hemorrhage.

enucleation

check restraints, circulatory status, & skin integrity every 30 minutes. ]Removed at least every 2 hours to permit muscle exercise & promote circulation. Restraints not secured bedrails because this could cause injury if rails are lowered. Agency guidelines regarding the use of restraints should always be followed.

hand restraints

urinary retention can be triggered by decongestants, anticholinergics, & antidepressants. Should be questioned about use of these medications if has urinary retention. Retention also precipitated by other factors, such as alcoholic beverages, infection, bed rest, & becoming chilled.

history of benign prostatic hyperplasia with an inability to void

Thiazide diuretics; sulfa-based, risk for allergic sulfa reaction. Also, Risk hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, & hyperuricemia.

hydrochlorothiazide

Used manage HIV in clients who do not respond to or who cannot tolerate conventional therapy. Can cause peripheral neuropathy. Should monitor gait closely & ask about paresthesia.

stavudine (d4T, Zerit)

Nephrotoxicity, bone marrow depression, GI effects, hepatotoxicity, dermatological effects, & neurological symptoms; headache, dizziness, vertigo, ataxia, depression, & seizures.

sulfonamide monitor for signs/symptoms of which side/adverse effects

Oxytocic agent used prevent/control postpartum hemorrhage by contracting uterus. Causes constant uterine contractions & may cause BP to elevate. Assessment before administering is obtaining baseline blood pressure. BP also monitored during administration of medication.

Methylergonovine (Methergine)

Stimulates motility upper GI track. Used to stimulate gastric emptying, for treatment of gastroparesis & treat gastroesophageal reflux disease. May also be prescribed to relieve nausea & vomiting

Metoclopramide (Reglan)

Risk of aspiration. Turn head to side & place emesis basin underneath mouth. Bite stick or padded tongue blade used open mouth, not gloved finger, to prevent injury to caregiver. Small volumes fluids used to rinse mouth.

Mouth care on an unconscious client

Opioid analgesic.

Nalbuphine (Nubain)

Opioid antagonist, which reverses effects of opioids & given for respiratory depression.

Naloxone

Antidote opioids & postoperative clients treat respiratory depression. Given postoperatively for respiratory depression, it may reverse effects of analgesics. Must assess for a sudden increase level of postoperative pain

Naloxone hydrochloride

Antispasmodic relieve symptoms urinary urgency, frequency, nocturia, & incontinence clients uninhibited or reflex neurogenic bladder. Expected effects; improved urinary control & decreased urinary frequency, incontinence, & nocturia.

Oxybutynin (Ditropan XL)

Antispasmodic medications; used as treatment for Bladder spasm after prostatectomy.

Oxybutynin (Ditropan)

Taught minor activity restrictions apply with this type of catheter. Protect site during bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as needed because catheter is for long-term use.

PICC line

Represents time takes cardiac impulse spread from atria to ventricles. Normal range PR interval 0.12 to 0.20 second.

PR interval

Bone pain most common symptom & may manifest in areas close to a joint. Pain related to progressive enlargement & deformity of bone. Hearing loss, numbness face, or (more rarely) blindness can occur when thickened bone of Paget's disease compresses vital nerves in skull. Fatigue or difficulty with ambulation may occur but would not be most common symptom.

Paget's disease

Child is able to classify, order, and sort facts.

Paiget's concrete operational stage

Child learns to think in terms of past, present, & future.

Paiget's preoperational stage

Child begins to understand the environment.

Paiget's sensorimotor stage

Failure fetal ductus arteriosus (artery connecting aorta & pulmonary artery) to close. Characteristic machinery-like murmur is present, & infant may show signs of heart failure

Patent ductus arteriosus

Monitor signs of bleeding. Hemorrhage is complication of any type of thrombolytic medication

receiving tissue plasminogen activator, alteplase (Activase, tPA).

Voids in increments of less than 50 mL under conditions of increased abdominal pressure.

Stress incontinence

Use a 25- to 26-gauge, ⅝-inch needle.

Subcutaneous injection of heparin sodium

Condition after childbirth; uterus does not return to normal size. Retained placental fragments & infection primary cause. When either of these processes present, uterus will have difficulty contracting.

Subinvolution

Incomplete dislocation of joint surfaces.

Subluxation

Medication treat lead poisoning. Renal function (BUN & creatinine) is monitored closely during administration chelation therapy because excreted via kidneys.

Succimer (Chemet)

Gastric protectant administered 1 hour before meals & bedtime. Timed to allow it to form protective coating over ulcer before food intake stimulates gastric acid production & mechanical irritation.

Sucralfate (Carafate)

1. Place in semi-Fowler's position 2. Turn on suction device & set regulator at 80 mm Hg. 3. Apply gloves & attach suction tubing to suction catheter. 4. Hyperoxygenate client. 5. Insert catheter into tracheostomy until resistance is met, & then pull it back 1 cm. 6. Apply intermittent suction & slowly withdraw catheter while rotating it back & forth

Suction airway tracheostomy tube

preoxygenate before suction & limit suction pass to 10 seconds

Suctioning

Limit insertion & suctioning time to 5 seconds to prevent hypoxia.

Suctioning a tracheostomy in infant

Suction equipment kept bedside of unconscious client, regardless if artificial airway used. Auscultates breath sounds every 2-4 hours, or more frequently. Hyperoxygenated before, during, & after suctioning minimize cerebral hypoxia. Intermittent suction applied while catheter withdrawn. Suctioning not performed longer than 10 seconds at one time; prevent cerebral hypoxia & rise in intracranial pressure.

Suctioning unconscious client with tracheostomy

Paradoxical chest movement

Suffered flail chest

Administered with full glass of water; maintain high fluid intake. Medication is more soluble in alkaline urine.

Sulfamethoxazole

Promote insulin secretion by pancreas & may also increase tissue response to insulin

Sulfonylureas

Treat migraine headaches. Constricts blood vessels around brain & reduces substances in body that can trigger headache pain.

Sumatriptan (Imitrex)

Relieve mild/moderate manifestations that occur in benign prostatic hypertrophy. Also improves urinary flow rates. Treat Urinary obstruction. Administered 30 minutes after meals.

Tamsulosin hydrochloride (Flomax)

Scald burns & tar or asphalt burns are treated immediate cooling with water, or immediate removal saturated clothing. Clothing burned into skin not removed because increased tissue damage & bleeding may result. No attempt made remove tar from skin at scene.

Tar burn

Reaction antipsychotic medication. Ucontrollable involuntary movements of body, extremities, mouth, face, & particularly tongue.

Tardive dyskinesia

Uncontrolled rhythmic movements mouth, face, extremities. Can include lip smacking or puckering, puffing of cheeks, uncontrolled chewing, & presence rapid or undulating (wormlike) movements of tongue.

Tardive dyskinesia

Refrigeration preserves elements of urine. If stands room temperature, warmth causes bacteria & WBCs to decompose. Also, urea breaks down to ammonia & becomes more alkaline. pH decreases in an acidic condition.

Urine specimen put in lab refrigerator because?

Loss ability to think clearly & rapidly

Confusion

Providing information, giving positive feedback, & encouraging relaxation

Guillain-Barré syndrome help cope with this illness

Is a normal female pelvis

Gynecoid pelvis

Discontinue wearing contacts until infection cleared completely. New contact lenses eliminate chance reinfection from contaminated contact lenses & would lessen risk corneal ulceration.

Conjunctivitis & use of contact lenses

Dorsiflex foot & assess for pain in calf area. Presence of pain may indicate positive Homans' sign.

Homans' sign

Head of bed usually kept flat ensure adequate blood flow & thus oxygenation to brain.

Ischemic stroke

Administered subcutaneously outer aspect of upper arm

(MMR) vaccine

Hypotonic, which pulls fluid into intracellular space. Inappropriate for cerebral edema because hypotonic solutions have potential to cause cellular swelling & cerebral edema.

0.45% normal saline

Start test empty bladder. Collected urine refrigerated or placed on ice to prevent change in urine. Fifteen mins before end collection time, should be asked to void, & this specimen added to collection.

24 hour urine

Hypertonic soluition. Advantage is they may be used to treat hypovolemia when plasma expanders are not readily available.

5% dextrose in 0.45% sodium chloride

1. Clamp intravenous (IV) catheter. 2. Position client left Trendelenburg's position. 3. Contact health care provider (HCP). 4. Administer oxygen. 5. Take the client's vital signs. 6. Document the occurrence.

A nurse is monitoring a client receiving total parenteral nutrition (TPN). The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. In order of priority, how should the nurse plan the actions to take?

Common lab range for APTT are 20-36 seconds. Should be 1.5 to 2.5 times normal value if heparin therapy is theraputic, considered therapeutic if 60 seconds

Activated partial thromboplastin

1. Stop the oxytocin infusion. 2. Reposition the client. 3. Administer oxygen face mask 8-10 L/min. 4. Perform a vaginal examination. 5. Check the client's blood pressure. 6. Administer medication as prescribed to reduce uterine activity.

A nurse is monitoring a client in labor who is receiving oxytocin (Pitocin) and notes that the client is experiencing hypertonic uterine contractions. In order of priority, how should the nurse plan the actions to take?

1. Assess unconsciousness. 2. Open the airway. 3. Look in mouth & remove object blocking airway if seen. 4. Attempt ventilation. 5. Perform abdominal thrusts.

A nursing student is asked to describe the correct steps for performing abdominal thrusts on an unconscious adult. In order of priority, how should the nurse perform this technique?

1.Verify (HCP) prescription blood transfusion 2. Ensure informed consent has been signed 3. Insert 18- or 19-gauge IV catheter 4. Obtain unit of blood from the blood bank. 5. Ask licensed nurse assist confirming blood compatibility & verifying client identity. 6. Hang the bag of blood.

A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit levels. The nurse notifies the blood bank of the prescription, and a blood specimen is drawn from the client for typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take?

Lasts much longer & more effective at preventing subsequent infections than passive immunity. Active immunity lasts for years & can be easily reactivated by booster dose of antigen. Protection from active immunity takes 5-14 days to develop after first exposure to antigen & 1-3 days after subsequent exposures.

Active immunity

Treat HIV infection, in combination with other agents.

Abacavir (Ziagen)

Acute abdominal pain present. Uterine tenderness with abruption, especially central abruption & trapped blood behind placenta. Abdomen feels hard/boardlike on palpation as blood penetrates myometrium & causes uterine irritability. Premature separation placenta from uterine wall after 20th week gestation, before fetus delivered. Associated conditions; hypertension, smoking, alcohol/ cocaine abuse. Overdistention uterus; multiple gestation, polyhydramnios. In addition, short umbilical cord, physical trauma, increased maternal age & parity are risk factors. Painful vaginal bleeding, abdominal pain, & back pain identify signs/symptoms of abruptio placentae.

Abruptio placentae

Brief episodes altered awareness or momentary LOC. No muscle activity occurs except eyelid fluttering or twitching. Blank facial expression. Seizures last only 5 to 10 seconds, but may occur one after another several times a day

Absence seizures

Antidiabetic med administered alone or conjunction with another antidiabetic med. Contraindicated; significant renal dysfunction, inflammatory bowel disease, colonic ulceration, or partial intestinal obstruction.

Acarbose (Precose)

Is a process of learning a different culture to adapt to a new or changing environment.

Acculturation.

Potentially hepatotoxic. Use of this medication investigated with symptoms compatible with liver disease (such as ascites & jaundice) acetylcysteine (Mucomyst) is antidote. To administered mix medication in flavored ice drink & allowing drink the medicine. Drink though straw also will minimize contact with mouth due to unpleasant taste.

Acetaminophen (Tylenol)

Assess for an allergy to Sulfa drugs

Acetazolamide (Diamox Sequels)

Orally or nasogastric tube treat acetaminophen overdose. Inhalation for use as mucolytic. Before administration medication as antidote, ensure that stomach is empty through emesis or gastric lavage. Solution is diluted in cola, water, or juice to make more palatable

Acetylcysteine (Mucomyst)

Low-grade toxicity characterized; ringing in ears, generalized pruritus (which may be severe), headache, dizziness, flushing, tachycardia, hyperventilation, sweating, & thirst. Marked toxicity manifested; hyperthermia, restlessness, abnormal breathing pattern, seizures, respiratory failure, and coma. High doses can produce GI bleeding or gastric mucosal lesions.

Acetylsalicylic acid (ASA)

Contraindicated for gastrointestinal bleeding & potentially ototoxic. Mild intoxication with acetylsalicylic acid (aspirin) called salicylism. Tinnitus (ringing in the ears) is most frequent effect noted with intoxication

Acetylsalicylic acid (aspirin)

Includes all antigen-specific immunities that person develops during a lifetime.

Acquired immunity

Bluish discoloration of hands & feet, is associated with immature peripheral circulation, & common in first few hours of life.

Acrocyanosis

Diispensed as powder reconstituted IV administration & slow IV infusion over 1 hour. To minimize risk renal damage, should be hydrated during infusion & for 2 hours after infusion. Common adverse reaction are phlebitis & inflammation at IV site, reversible nephrotoxicity, evidenced by elevated serum creatinine & BUN can occur. Ccause of nephrotoxicity is deposition of acyclovir in renal tubules. Risk renal injury is increased by dehydration & use of other nephrotoxic medications

Acyclovir (Zovirax) by (IV) route

Symptoms; postural Hypotension from fluid loss, syncope, muscle weakness, anorexia, nausea & vomiting, abdominal cramps, weight loss, depression, & irritability.

Addison's disease

Wash hands & put gloves on. Tilt head backward, open eyes, & look up. Nurse pulls lower lid down against cheekbone & holds bottle like pencil with tip downward. Nurse gently rests wrist of hand on cheek & squeezes bottle gently to allow drop to fall into conjunctival sac. Instructed close eyes gently & not to squeeze eyes shut to prevent loss of medication.

Administer eye medications Steps

(Prone toe-in position) will promote internal rotation of hips, which will relax muscle, thereby making injection less painful.

Administering (IM) injection gluteal muscle, position to best relax the muscle.

Produces cortisol, androgens, & aldosterone

Adrenal cortex

Symptoms; weakness, hypotension, fever, & mental status changes

Adrenal insufficiency after adrenalectomy

Produces Epinephrine & norepinephrine

Adrenal medulla

Considered intrusive to ask personal questions on the initial contact or meeting.

African-American culture

1. Fill volume control container desired amount (IV) fluid by opening clamp between volume control container & main IV bag. 2. Close clamp & check to be sure clamp on air vent volume control container is open. 3. Clean injection port on top of volume control container with antiseptic swab 4. Remove needle cap & insert needleless syringe tip through port, then inject medication & label volume control container with name medication, dosage, total volume including diluents, & time of administration. 5. Regulate IV infusion rate to allow medication infuse in time recommended by institutional policies. 6. Dispose syringe puncture proof & leakproof container. Discard supplies & perform hand hygiene.

After correctly completing rights of medication administration, performing hand hygiene, and ensuring the correct position of the client, which steps should nurse take to administer medication via a volume control container?

Advance diet from cool clear liquids to full liquids. Hot fluids & carbonated beverages avoided because irritating to throat. Milk & milk products (pudding) avoided because they may cause to cough; could cause pain at surgical site. Raw fruits or vegetables, avoided for 10 days protect operative site & prevent bleeding. Instructed to rest in bed or on couch for 24 hours after & gradually resume full activity.

After tonsillectomy

Operative positioned elevated on pillow & not exceeding shoulder elevation. Promotes optimal drainage from limb, without impairing circulation to arm.

After undergoing right mastectomy. Place right arm in which position?

Inability identify well-known objects & people

Agnosia

Fear open spaces & fear of being trapped in situation from which there may not be escape.

Agoraphobia

Characterized by reduced number leukocytes (leukopenia) & neutrophils (neutropenia) in blood. High risk infection because decreased body defenses against microorganisms.

Agranulocytosis

Characterized by tachycardia, dyspnea, hypotension, cyanosis, decreased LOC, anxiety, feelings of impending doom, chest pain, & hypotension. Place left side in Trendelenburg's position. Lying left side may prevent air from flowing into pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases amount of blood pulled into vena cava during inspiration.

Air embolism

Restlessness or urge to keep moving. constant generalized movement.

Akathisia

Used as a plasma expander. Responsible for maintaining osmolality of blood. When albumin low; can lead to peripheral edema.

Albumin

Greater risk post operation complications; history alcohol abuse risk for liver disease, including altered metabolism & elimination of medications, impaired wound healing, & clotting & bleeding abnormalities. Client with this risk factor also would be at risk for experiencing alcohol withdrawal during postoperative period.

Alcohol abuse

Males more likely to be alcohol abusers. Alcohol abuser high risk self-inflected injury, & simultaneous use of more than one substance common. Few of those abusing alcohol receive needed treatment. Alcoholics are found at all economic strata & occur equally among married & single clients.

Alcohol abuser

Most likely occur within first 6 to 8 hours after abrupt cessation; however, it can occur over next several days.

Alcohol withdrawal

Delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes LOC, agitation, fever, & delusions.

Alcohol withdrawl

Prevent or treat osteoporosis. Taken in morning at same time, on empty stomach is a priority, remain upright 30 mins after ingestion,

Alendronate (Fosamax)

Take medication with full glass of water after rising in morning. Not eat or drink anything for 30 minutes following administration

Alendronate (Fosamax) prescribed for osteoporosis

Is heart-shaped

Android pelvis

Encourage drink 3000 mL fluid day. Full effect may take 1 week or longer. Given with, or immediately after, meals or milk. Develops rash, irritation eyes, swelling of lips or mouth;contact HCP because may indicate hypersensitivity. Medication prevents, treats hyperuricemia caused by chemotherapy. May increase effect of Warfarin sodium if this medication was prescribed for client, should verify prescription with HCP

Allopurinol (Zyloprim)

loss of hair.

Alopecia

Usedmanage acute MI. Lyses thrombi obstructing coronary arteries, decreases infarct size, improves ventricular function, decreases risk of heart failure, & limits risk of death associated with myocardial infarction.(Dissolve any clots that are obstructing coronary arteries)

Alteplase (Activase)

Aluminum-containing antacids constipating, take stool softener or additional bulk-type laxatives relieve side effect. Chew tablets thoroughly & follow with 4 oz of water.

Aluminum hydroxide (Amphojel)

Characterized by changes in dendrites of neurons. Decrease in number & composition of dendrites responsible for symptoms of disease.

Alzheimer's disease

Kept on strong side body. Assisting weakened leg, so weakened leg moves with cane, or right after it, ambulating or going down stairs. Height cane even with greater trochanter. Allows elbow held approximately 15 to 30 degrees of flexion. Flexion necessary allow client to push off without bending over when ambulating.

Ambulate with cane

Potassium-retaining diuretic treat edema or hypertension. Taken in morning avoid nocturia, & medication with food to increase bioavailability. Sodium restricted or limited as prescribed.

Amiloride (Midamor)

Antidysrhythmic treat life-threatening ventricular dysrhythmias. Requires continuous cardiac monitoring, with infusion of medication by intravenous pump.

Amiodarone (Cordarone)

Assess for airway or breathing immediately. Examine amputation site & apply direct pressure using layers of dry gauze or another type of cloth. Sterile gloves & sterile gauze should always be used if available. If sterile materials not available, clean materials should be used. Gauze applied is pressure dressing & not removed because risk dislodgement of clot that may be forming; pressure dressing removed at hospital. Extremity elevated above heart level to decrease bleeding. Severed finger wrapped dry, sterile gauze (if available) or a clean cloth. Placed watertight, sealed plastic bag. Then watertight, sealed plastic bag placed in bag of ice water; never placed directly on ice, & contact between finger & water avoided because of risk tissue damage. Severed part transported hospital with victim for possible replanting. Additionally, emergency medical services called to transport victim to hospital.

Amputation of a finger

Initial symptom; mild clumsiness, usually noted distal portion of one extremity. Complain of tripping & drag one leg when lower extremities are involved

Amyotrophic lateral sclerosis (ALS)

Produces a rash, redness, & itching.

An allergic reaction at IV site:

Bone protrudes through skin, disrupting soft tissue.

An open (or compound) fracture

Place on bed rest (as prescribed) in quiet setting. Stimulants; caffeine & nicotine prohibited; decaffeinated coffee/tea may be used. Lights dim minimize environmental stimulation. Any activity increases blood pressure or impedes venous return from brain prohibited; pushing, pulling, sneezing, coughing, or straining. Nurse provide physical care minimize increases BP. For same reason, visitors, radio, television, & reading materials prohibited or limited.

Aneurysm precautions

Pain results from ischemia myocardial cells. Pain often precipitated by activity that places more oxygen demand heart muscle. Supplemental oxygen will help to meet added demands on heart muscle

Angina pectoris

All inanimate objects are given living meaning. (Piaget's theory)

Animism

Ring-shaped.

Annular lesions

Desire please others. Need to be correct or perfect interferes with rational decision-making processes. Moralistic. Rules & rituals help manage anxiety. Observe rigid rules/regulations

Anorexia nervosa

Neglects affected side of body. May ignore presence of affected side (often creating safety hazard as result of potential injuries) or may state that involved arm or leg belongs to someone else

Anosognosia

Diamond-shaped & located on top of head. Soft & flat in normal infant, & it normally closes by 12- 18 months of age

Anterior fontane

Diamond-shaped & located on top of head. Should be soft & flat & may range in size from almost nonexistent to 4 to 5 cm across. Normally closes by 18 to 24 months of age. Depressed fontanel may indicate dehydration.

Anterior fontanel

produces GH, LH, and FSH

Anterior pituitary gland

Has an oval shape

Anthropoid pelvis

Stimuli ADH release; increased plasma osmolality, decreased blood volume, hypotension, pain, dehydration from nausea, vomiting, or diarrhea, & stress.

Antidiuretic hormone (ADH)

Acetylcysteine (Mucomyst). Normal therapeutic serum level acetaminophen is 10-20 mcg /mL. Toxic level higher than 50 mcg/mL, & levels higher than 200 mcg/mL could indicate hepatotoxicity.

Antidote for acetaminophen

Narrowing or stricture of aortic valve. Signs of exercise intolerance, chest pain, & dizziness when standing for long periods.

Aortic stenosis

Test performed 1 minute after birth & again 5 minutes after birth.

Apgar score

Scores 0-10. Five criteria used measure infant adaptation. Heart rate: absent=0; less 100 =1; greater 100= 2 Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp/hypotonic = 0; some extremity flexion = 1; active, moving, & well flexed = 2. Irritability/reflexe (measured bulb suction): no response=0; grimace =1; cough, sneeze, vigorous cry = 2. Color:cyanotic/pale = 0; acrocyanotic, cyanosis extremities = 1; pink =2. Newborn infant Apgar score 5-7 often require resuscitative intervention. Scores less 5 indicate newborn infant having difficulty adjusting extrauterine life and requires more vigorous resuscitation.

Apgar scoring for a newborn immediately after birth

Difficulty finding right word to use. Loss of a previously held ability to speak or understand spoken or written language.

Aphasia

Apex of lung is rounded, uppermost part of lung. Nurse would place stethoscope just under left clavicle

Apical pneumothorax

Labs do not establish diagnosis but often an elevation white blood cell count (leukocytosis) with shift to left (increased number of immature white blood cells). Sudden relief pain; suspected appendicitis is commonly indicative of ruptured appendix. Risk for peritonitis & shock. HCP notified immediately because need begin IV antibiotics to prevent further complication. NPO in anticipation of surgery.

Appendicitis

Inability to perform familiar skilled activities, perform purposeful movements or use objects appropriately

Apraxia

Shaped like an arc.

Arciform lesions

Allen test performed determine adequate ulnar circulation. Failure to determine presence adequate collateral circulation could result in severe ischemic injury to hand if damage to radial artery occurs with arterial puncture.

Arterial blood gas (ABG) analysis

Radial artery site requires at least 5 minutes pressure, femoral artery site requires 10 minutes. Small pressure dressing placed on site after this time period. When receiving anticoagulant therapy, application pressure for longer period may be needed.

Arterial blood gas analysis

Signs: Pallor, diminished pulse, & pain in left hand

Arterial steal syndrome from left arm fistula

Diagnose acute & chronic conditions of the joint. In addition, surgical repairs can be done during this procedure.

Arthroscopy

Ice applied affected joint; pain & swelling, & analgesics administered as prescribed. Avoid excessive use of joint for several days, elevate knee while sitting, avoid twisting knee, & return for suture removal in 7 days.

Arthroscopy of knee

Diet generally vegetarian, although meat may be consumed small amounts. Native Asians generally do not drink milk because of genetic tendency for lactose intolerance. Most Asian-Americans do not eat desserts high sugar content.

Asian-American

Rapid-acting insulin. Onset of action 15 minutes; peaks in 1-3 hours, & its duration of action 3-5 hours. Hypoglycemic reactions are most likely to occur during peak time.

Aspart insulin (NovoLog)

Ingests large amount; risk for developing metabolic acidosis 24 hours after poisoning. Metabolic acidosis occurs, may exhibit hyperpnea with Kussmaul's respirations, headache, nausea, vomiting, diarrhea, fruity-smelling breath because of improper fat metabolism, CNS depression, twitching, convulsions, & hyperkalemia. Shortly after aspirin overdose, may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours post-overdose, however, compensatory mechanism fails and the client reverts to metabolic acidosis.

Aspirin (acetylsalicylic acid)

Person puts another person in fear of harmful or offensive contact & victim fears & believes that harm will result as a result of threat.

Assault

Antidote for cholinergic crisis. Anticholinergic ; Causes tachycardia, drowsiness, blurred vision, dry mouth, constipation, & urinary retention. Monitors for any of these effects in immediate postoperative period.

Atropine sulfate

Contraindicated clients glaucoma. Mydriatic medications dilate pupil & cause increased intraocular pressure in eye.

Atropine sulfate

Tests the six cardinal positions of gaze

Assess for muscle weakness in eyes

Fetal heart rate assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Minimal vaginal examinations would be done because of risk of infection.

Assessment finding following an amniotomy should be conducted first

Inability discern form, configuration common objects using sense of touch. Close eyes & identify object placed in hands.

Astereognosis

Irregular flapping movements fingers & wrists when hands & arms are outstretched, with palms down, wrists bent up, & fingers spread.

Asterixis

Abnormal shape to curvature of cornea, which is impairing ability to see clearly. Misshapen cornea not perfectly spherical. Cornea cannot bend light rays equally in all directions, resulting impairment both near & far vision. Corrected by use of cylindrical lenses.

Astigmatism

Altered motor function; Disturbance in gait.

Ataxia

Unsteadiness & staggering.

Ataxic gait

Treat hypercholesterolemia & hypertriglyceridemia. Decreases LDL cholesterol & plasma triglycerides & increases HDL cholesterol (good cholesterol). Contraindications; include active liver disease, unexplained elevated liver function tests, pregnancy, & lactation. Frequent side effect; headache. Adverse effects; photosensitivity & potential for developing cataracts.

Atorvastatin (Lipitor)

Loss P waves & fibrillatory waves before each QRS complex. aia quiver, which can lead to thrombus formation

Atrial fibrillation

Oxygen & metoprolol (to slow ventricular response) are appropriate. Echocardiogram will help to assess heart valve function because mitral valve disease can lead to atrial fibrillation. Bolus of intravenous heparin followed by a continuous infusion to prevent thrombus.

Atrial fibrillation the ventricles

Abnormal opening between the atria

Atrial septal defect

Gold preparation given orally rather than injection. (GI) reaction including diarrhea, abdominal pain, nausea, & loss of appetite common early therapy but subside first 3 months. Early signs & symptoms toxic reactions; rash, purple blotches, pruritus, mouth lesions, & metallic taste in mouth. Signs & symptoms toxic reactions reported HCP.

Auranofin (Ridaura)

Begin right lower quadrant, ileocecal valve area; normally bowel sounds are always present there.

Auscultate bowel sound

Focused, maintains strong control, makes decisions, & addresses all problems. Dominates group & commands, rather than seeks suggestions or input. Manager addresses problem (quality improvement) with taff, designs a plan without input, & wants all problems reported directly back to her

Autocratic leader

Task oriented & directive.

Autocratic style

90/56 mm Hg

Average blood pressure in a 12-month-old

Anticholinergic. Urinary retention side effect, must assess for dysuria, distended abdomen, infrequent voiding in small amounts, & overflow incontinence

Benztropine mesylate (Cogentin)

Skeletal muscle relaxant. Acts at spinal cord level decrease frequency & amplitude of muscle spasms in clients with spinal cord injuries or diseases or with multiple sclerosis. Can cause urinary retention. Constipation is an adverse effect. Fatigue is CNS effect most intense during early phase therapy & diminishes with continued medication use.

Baclofen (Lioresal)

If bacterial infection CSF present, findings; reduced glucose level, protein level greater 15 mg/dL, increased WBC, cloudy appearance CSF, & CSF pressure greater than 200 mm H2O.

Bacterial meningitis

Cerebellum

Balance & coordination

Central nervous system (CNS) depressants, major cause of fatal drug overdoses. Abuse of barbiturates results in both physical & psychological dependency

Barbiturates

Maintain low-fiber diet 1-3 days before test. Clear liquids or water allowed 12-24 hours before test. Laxatives & enemas prescribed before test to cleanse bowel. Encouraged drink liquids after procedure to facilitate passage of barium.

Barium enema

Head neutral, midline position. Head of bed raised to 30 to 45 degrees. Avoid flexing or extending neck or turning head from side to side.

Basilar skull fracture risk Increase ICP. Place in which positions?

Based on rewards & punishment

Behavior modification

One-side facial paralysis cause; compression facial nerve. Signs; facial droop from paralysis facial muscles; increased lacrimation; painful sensations eye, face, or behind ear; speech or chewing difficulties. Facial drooping associated with Bell's palsy makes it difficult to close eyelid on affected side. Widening of palpebral fissure (opening between eyelids) & asymmetrical smile are seen.

Bell's palsy

Nocturia, incontinence, & enlarged prostate characteristics & need to be assessed all male clients over 50 years of age. Nocturnal emissions are commonly associated with prepubescent males.

Benign prostatic hyperplasia

High risk for abuse, physical & psychological dependence. For this reason, limited amounts of medications given to client at one time.

Benzodiazepine

Locally acting antitussive decreases intensity & frequency cough without eliminating cough reflex.

Benzonatate (Tessalon)

Treat drug-induced extrapyramidal reactions (except tardive dyskinesia)

Benztropine

Anticholinergic medication & used treat Parkinson's disease. Common GI side effects include constipation, dry mouth, & nausea. Adverse effect is ileus.

Benztropine (Cogentin)

Respiratory Distress Syndrome serious lung disorder caused by immaturity & inability to produce surfactant, resulting in hypoxia & acidosis. Common premature infants & may be due to lung immaturity: result of surfactant deficiency. Mainstay treatment administration exogenous surfactant, administered by intratracheal route

Beractant (Survanta)

Increase surfactant level, promote lung maturation, reducing risk respiratory distress syndrome in newborn. Surfactant production not stable until after 32 weeks gestation, & if adequate amounts lung surfactant not present, respiratory distress & death of newborn infant could result. Delivery should be delayed for at least 48 hours after administration betamethasone allow time for lungs to mature.

Betamethasone

Glucocorticoid, given increase production of surfactant to stimulate fetal lung maturation. Administered clients preterm labor at 28 to 32 weeks of gestation if labor can be inhibited for 48 hours.

Betamethasone (Celestone)

Can produce a cholinergic reaction & antidote for this type reaction is atropine sulfate.

Bethanechol chloride

With food can cause N&V. Avoid problem, oral dose administered 1 hour before meals or 2 hours after meals.

Bethanechol chloride (Urecholine)

Assesse five parameters fetal activity: fetal heart rate, fetal breathing movement, gross fetal movemens, fetal tone, amniotic fluid volume. Each five parameters contribute 0-2 points, 8 considered normal, 10 perfect. Result available immediately.

Biophysical profile

Provide activities involv use of hands & gross motor movements; volleyball, finger-painting, drawing, & working with clay. Provide way to discharge motor tension.

Bipolar disorder experiencing psychomotor agitation

Produces estrogen-like effects.

Black cohosh

Gross, painless hematuria frequently first manifestation bladder cancer. As disease progresses, may experience dysuria, frequency, & urgency.

Bladder cancer

Bladder exposed & external to body through a defect in lower abdominal wall . Highest priority impaired tissue integrity related to exposed bladder mucosa.

Bladder exstrophy

Cleaned antiseptic swab & allowed dry completely. Lateral side of finger because central tip contains more nerves & may be more painful. Hold finger dependent position improves blood flow to puncture site. Gentle pressure may be needed to obtain adequate amount blood for test strip

Blood glucose monitor

Two thirds of distance between the antecubital fossa and the shoulder

Blood pressure school-age child. Obtain accurate measurement, how should nurse position blood pressure cuff?

Monitor site for swelling, bleeding, & hematoma formation. Elevated for 24 hours or as prescribed; reduce edema. Vital signs monitored every 4 hours for 24 hours for signs of complications such as infection & bleeding. Usually requires mild analgesics. More severe pain usually indicate complications. Encourage drink large amounts water for 24-48 hours flush radioisotope from system.

Bone biopsy

Most common sites in adult are iliac crest & sternum. Areas rich in bone marrow & easily accessible for testing.

Bone marrow aspiration

Allogeneic BMT, donor matches child's tissue type found. That bone marrow is given to child. Autologous BMT, child undergoes general anesthesia for aspiration of his/her bone marrow, which is processed in laboratory & frozen until marrow needs to be infused back into child. Syngeneic BMT is done when child has an identical twin.

Bone marrow transplantation (BMT)

Encouraged drink large amounts water 24-48 hours to facilitate urinary excretion radioisotope.

Bone scan

Glycerin suppositories least invasive method, usually stimulates bowel evacuation within half-hour. Enemas may be needed every-other-day basis, used cautiously because Valsalva maneuver can increase ICP. Fecal disimpaction; only when rectum impacted from constipation, result of inattention or failure other measures. Stool softeners may be prescribed on regular schedule to avoid hard, dry stools, but oral medication not administered unconscious client.

Bowel maintenance program unconscious client, stimulating bowel moveent.

Signs infection include pain, redness, heat, & swelling localized area of breast. Symptoms occur contact HCP.

Breast feeding

Lie down & place towel/pillow under shoulder on side of breast to be examined.

Breast self-examination (BSE)

Damage to area responsible for (aphasia) motor aspects of speech, through coordination muscular activity tongue, mouth, & larynx (difficulty articulating words)

Broca's area

(Antihistamine)Side effect; drowsiness/sedation, blurred vision, hypertension & sometimes hypotension, dry mouth, constipation, urinary retention, & sweating

Brompheniramine maleate (BroveX)

Heard over the trachea & larynx.

Bronchial (tracheal) breath sounds

Heard over major bronchi. The upper sternum area is where major bronchi are located.

Bronchovesicular breath sounds

Ipsilateral paralysis & loss of touch, pressure, vibration, & proprioception. Contralaterally, pain & temperature sensation are lost because these fibers decussate after entering cord.

Brown-Séquard syndrome

Neck flexion causes adduction & flexion movements lower extremities children & adolescents

Brudzinski's sign

Skin traction often applied after hip fracture before fracture is reduced in surgery. Traction reduces muscle spasms & helps immobilize fracture.

Buck's (extension) traction

Diuretic & expected outcome increased urine output, decreased crackles, & decreased weight. Can be used for client who needs diuresis.

Bumetanide

Seizure activity can occur taking dosage greater 450 mg daily. Weight gain occasional side effect, constipation common side effect.

Bupropion (Wellbutrin); antidepressive agent

Maximum amount edema with burn injury seen between 18 & 24 hours after injury. With adequate fluid resuscitation transmembrane potential restored normal within 24 to 36 hours after burn.

Burn injury

Effective if absence of these manifestations occurs; Rapid heartbeat or anxiety

Buspirone (Buspar); treatment of anxiety

Anxiolytic medication. Side effects; Dizziness, nausea, headaches, nervousness, lightheadedness, & excitement. Not addicting, tolerance does not develop, & not sedating.

Buspirone hydrochloride (BuSpar)

Opioid analgesic that can precipitate withdrawal symptoms in opioid-dependent client. Contraindicated if client history of opioid dependency. Client in labor may be given parenteral analgesia during first stage of labor, up to 2-3 hours before anticipated delivery

Butorphanol tartrate

Opioid analgesic provides systemic pain relief during labor

Butorphanol tartrate (Stadol)

Because compromise respiration leading cause death cervical cord injury, respiratory assessment highest priority. Assessment temperature & strength can be done after adequate oxygenation is ensured

C4 spinal cord injury

Before beginning administration IV solution, assess whether chest radiograph reveals central catheter is in proper place. Portable chest X-ray.

Central venous catheter insertion:

Sunken eyes; hollow cheeks; & exhausted, defeated expression

Cachexia

Signs; include sores that do not heal, nagging cough or hoarseness, indigestion or difficulty swallowing, & change in bowel or bladder habits, abnormal occurrence of menses

Cancer

Prescribed for Parkinson's disease. Adverse effect; Dyskinesia & Impaired voluntary movement. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, & akinesia frequent side effects.

Carbidopa-levodopa (Sinemet)

Normal cardiac output for adult can range from 4-8 L/min & varies greatly with body size. Heart normally pumps 5 L of blood every minute.

Cardiac output

Tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, & falling blood pressure accompanied by pulsus paradoxus (drop inspiratory blood pressure greater than 10 mm Hg).

Cardiac tamponade

Found to be protein marker detection myocardial infarction, & assay for this protein used some institutions to aid in diagnosis of myocardial infarction.

Cardiac troponin T or cardiac troponin I

Maintenance patent airway, oxygen administration, assessment of vital signs & LOC, & dysrhythmia detection. Airway highest priority.

Cardioversion

Caused by excessive pressure on median nerve as a result of injury, overuse, or disease.

Carpal tunnel syndrome

Laxative, causes nausea & abdominal cramps most frequent side effects. Hypokalemia can result from long-term use.

Cascara sagrada

Plaster cast 24-72 hours to dry (synthetic casts 20 min). Cast & extremity elevated reduce edema. Wet cast handled palms hand until dry, extremity turned (unless contraindicated) so that all sides of wet cast will dry. Cool setting hair dryer can be used dry plaster cast (heat cannot be used because cast heats up & burns skin). Kept clean & dry, Not stick anything under because risk break skin integrity. Monitor circulatory impairment; pain, swelling, discoloration, tingling, numbness, coolness, diminish pulse. HCP notified if circulatory impairment occurs

Cast

Clouding of Lens of eye & often is found with increasing age.

Cataract

Severe pain or pain accompanied by nausea is indicator increased intraocular pressure & should be reported to HCP immediately

Cataract extraction

Mydriatic medicationsused preoperatively in client with cataract. These medications act by dilating pupils; also constrict blood vessels.

Cataract surgery

Facilitates communication by sitting silence, ask open-ended questions rather than direct questions, pausing provide opportunities to respond.

Catatonic stupor

Water or a kink in tubing, biting on ET tube, increased secretions airway, wheezing or bronchospasm, displacement ETl tube, or fighting ventilator.

Causes high-pressure ventilator alarm

Disconnection or leak in system & ceasing to spontaneously breathe

Causes low-pressure ventilator alarm

Vomiting, diarrhea, conditions that increased respiration's or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy. Diuretics, & gastrointestinal suctioning.

Causes of a fluid volume deficit

Decreased kidney function, heart failure, hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds & body cavities, & excessive ingestion of sodium.

Causes of overhydration or fluid overload:

Treatment gonorrhea consists antibiotic therapy, usually with ceftriaxone & doxycycline (Vibramycin).

Ceftriaxone (Rocephin)

Following a gluten-free diet

Celiac disease

Infection dermis & underlying hypodermis: results in deep red erythema without sharp borders & spreads widely throughout tissue spaces. Skin is erythematous, edematous, tender, & sometimes nodular. Antibiotic therapy; after blood cultures obtained. Warm compresses to the affected area

Cellulitis

Lead shield kept bedside use when providing direct care to prevent exposure radiation. Visitors limited, & women who are pregnant or who may be pregnant should not enter room. Visitation allowed older 16 years of age. Must have warning sign posted on closed door & on chart (per agency policy) alert staff & visitors radiation therapy is in process. In private room.

Cervical-uterine radiation implant

In response increasing levels estrogen, cervix becomes congested with blood, resulting in characteristic bluish color that extends to include vagina & labia. This discoloration, referred to as Chadwick's sign, is one of earliest signs of pregnancy.

Chadwick's sign

Burning process continues as long as chemical in contact with skin. All clothing, including gloves & shoes, removed immediately, & water lavage instituted before & during transport to ED. Powdered chemicals brushed off before lavage performed.

Chemical burn injury

Occurs with increasing age & has no clinical significance. Appears assmall, round, bright red lesion on trunk or extremities

Cherry angioma

Sterile petrolatum gauze & sterile 4 × 4 gauze placed at insertion site. Entire dressing is securely taped to make sure it is occlusive.

Chest tube removed

Rhythmic respirations with periods of apnea. Periods apnea followed by deep rapid breathing

Cheyne-Stokes respirations

Transmitted direct contact, droplet (airborne) spread, & contaminated objects. Communicable period for 1 to 2 days before onset rash to 6 days after first crop of vesicles, when crusts have formed.

Chickenpox

Remove toys with sharp edges that may cause injury from play area. Wear a helmet and elbow pads during activities that could cause injury. Activities should be monitored.

Child hemophilia; safe environment

Decreased wheezing in child with asthma may be interpreted incorrectly as positive sign when may actually signal inability move air. "Silent chest" is an ominous sign during an asthma episode.

Child with asthma

Short nipple on bottle, & give baby food or baby food mixed with water. Straws, pacifiers, spoons, fingers must be kept away from mouth 7-10 days after surgery. Pacifier not used 2 weeks following repair. Avoid taking oral temperatures.

Child with cleft palate repair

1. Prepare for assisted ventilation & have necessary equipment available. 2. Assess breath sounds. 3. Obtain a pulse oximetry reading. 4. Obtain weight for correct antibiotic dose infusion. 5. Ask mother about precipitating events

Child with diagnosis epiglottis suspected. In anticipation of HCP prescriptions, in which order should nurse deliver interventions for this child?

Potassium-losing diuretic monitored for electrolyte imbalances that occur; Hypokalemia, hypercalcemia, hyponatremia, hypophosphatemia, & hypomagnesemia.

Chlorothiazide (HydroDIURIL)

Used control shivering hyperthermic states.

Chlorpromazine (Thorazine)

Removal of gallbladder. Teach coughing & deep breathing exercises afterwards because respiration tend to be shallow because deep breathing painful as result location for surgical procedure.

Cholecystectomy

Decrease intake dietary fat. Foods avoided; sausage, gravies, fatty meats, fried foods, products made with cream, & desserts. Appropriate food; fruits & vegetables, fish, poultry without skin.

Cholecystitis

Decrease amount of food taken at each sitting, eat in semirecumbent position, eliminate ingesting fluids with meals, & avoid consumption of high-carbohydrate meals.

Chronic dumping syndrome

Inability absorb vitamin B12. This leads to development of pernicious anemia.

Chronic gastritis

Reticular activating system in conjunction with cerebral hemispheres responsible for arousal.

Chronic insomnia

Do not manufacture adequate amounts of erythropoietin

Chronic kidney disease

Problem with constipation; result of fluid restriction, fatigue that limits exercise, dietary restrictions. Also phosphate-binding antacids such as aluminum hydroxide gel cause constipation as side effect. Weight gain between dialysis treatments ideally no more than 1 to 1.5 kg. Potentially life-threatening outcomes associated with hyperglycemia, hyperkalemia, & hypocalcemia, they are most relevant to nursing management of client with CKD

Chronic kidney disease (CKD)

Clinical manifestations; Dyspnea at rest, Clubbed fingers, Muscle retractions, & Prolonged expiratory breathing phase. Oxygen desaturation with exercise; use accessory respiratory muscles; & prolonged exhalation. Chest x-ray results indicate a hyperinflated chest & may indicate flattened diaphragm

Chronic obstructive pulmonary disease (COPD)

Physiological responses; normal blood pressure, heart rate, & respiratory rate, along with normal pupils & dry skin

Chronic pain

Occurs most often in alcoholics. Abstinence alcohol important to prevent from developing chronic pancreatitis. Usually experience malabsorption with weight loss. Limit fat in diet & take in small meals, will reduce amount of carbohydrates & protein that client must digest at any one time.

Chronic pancreatitis

occurs gradually over period of months to years.

Chronic rejection

Characterized by persistent purulent nasal discharge, chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, & headache worse on arising after sleep.

Chronic sinusitis

Most common side effect; confusion. Less common CNS side effects; headache, dizziness, drowsiness, & hallucinations.

Cimetidine (Tagamet)

Antimicrobial agent used treat urinary tract infections caused P. aeruginosa

Ciprofloxacin (Cipro)

Bifurcates from left coronary artery & supplies left atrium & lateral wall of left ventricle

Circumflex coronary artery

Three classic signs are hypertension, generalized edema, & proteinuria.

Classic signs of preeclampsia

Cleanse labia using cleansing towels, void into toilet, & then void into sterile specimen container

Clean-catch urine specimen for culture & sensitivity test

Placed in left Sims position so enema solution can flow by gravity in natural direction of colon.

Cleansing enema

Water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea.

Clear liquid diet:

Child who has a history of cleft palate should be routinely checked for hearing loss.

Cleft palate

Performed during first few weeks of life. Early repair improve bonding & makes feeding much easier. Revisions may be required at later age.

Cleft-lip repair

Pair of scissors must be kept at bedside at all times.

Client esophageal varices needs Sengstaken-Blakemore tube inserted

1. Gather information relevant to the case. 2. Examine; determine own values on issues. 3. Verbalize the problem. 4. Consider possible courses of action. 5. Negotiate the outcome. 6. Evaluate the action.

Client involved head-on automobile crash awakened from coma & asks for her husband, who was killed in same accident. Family does not want client to know that her husband has died. Family wants nursing staff to tell client, husband was taken to another hospital, has head injury, & in (ICU). Nurses Association Code of Ethics requires nurse to preserve integrity, but nurse wants to follow family's instruction, nurse faces an ethical dilemma. Steps nurse should take to systematically process this ethical dilemma?

Physical obstruction to transmission of sound waves

Conductive hearing loss

Responsible for perception of detail & color vision. Located center of retina, damage to cones can result in reduced central vision or color blindness.

Cones

Treatment of obsessive-compulsive disorder.

Clomipramine (Anafranil)

Tricyclic antidepressant treat obsessive-compulsive disorder. Sedation sometimes occurs. Weight gain & tachycardia side /adverse effects of medication.

Clomipramine (Anafranil); treats OCD

Tidaling stops when lung reexpanded or chest drainage tubes are kinked or obstructed.

Closed chest drainage system fluctuation (tidaling) in water-seal compartment has stopped

Topical antifungal agent treatment of cutaneous fungal infections. Monitors effectiveness by noting presence or absence of skin rash, which is characteristic of this infection.

Clotrimazole (Lotrimin AF)

topical antifungal agent; treatment of cutaneous fungal infections. Used on fungal rash

Clotrimazole (Lotrimin)

Antipsychotic medication. May experience agranulocytosis as adverse effect, monitored by weekly WBC counts. Treatment withheld if level drops below 3000 cells/mm3. Agranulocytosis could be fatal if undetected & untreated

Clozapine (Clozaril)

Monitor vital signs & assess for hypotension. Increase fluid intake, palpate bladder for urinary retention, auscultate bowel sounds, monitor bowel because cause constipation. Monitor respiratory status & initiate deep-breathing & coughing exercises. Monitors effectiveness pain medication.

Codeine sulfate

Prescribed for gout. Used with caution older adults, debilitated clients, & clients with cardiac, kidney, or GI disease.

Colchicine (Colcrys)

Fiber responsible skin's toughness & resiliency & plays important role in healing process.

Collagen

Placed left Sims position for procedure. Position takes best advantage of gastrointestinal (GI) anatomy for ease in introducing colonoscope.

Colonoscopy procedure

Deodorizing foods in diet: beet greens, parsley, buttermilk, & yogurt.

Colostomy measures reduce odor

Complete fracture across shaft bone, with splintering bone into fragments

Comminuted fracture

Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, & tomatoes

Common food sources of potassium:

Earliest symptom is paresthesia (numbness & tingling in fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, pallor & coolness to distal limb. Cyanosis is a late sign.

Compartment syndrome

Extends through full thickness of bone & often displaced, meaning that bone moves out of normal position.

Complete fracture

Also called open or complex fracture, is one in which skin or mucous membrane; broken & resulting wound extends to depth of fractured bone.

Compound fracture

Symptoms increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability.

Concealed bleeding Prenatal

Heat loss occurs when infant is on cold surface, such as a table

Conduction

Difficulty repeating words spoken by another, & speech characterized by literal paraphasia with intact comprehension.

Conduction aphasia

Closely approximates normal renal function. Need infuse/drain dialysis solution several times day. No machine used, CAPD manual procedure.

Continuous ambulatory peritoneal dialysis (CAPD)

High-pressure alarms triggered by increased airway resistance caused by excess secretions inairway, biting tube, coughing, bronchospasm, kinked ventilatory circuit, or excess condensation of water in ventilator tubing. Excess water should be emptied from tubing. Alarms should never be silenced until cause has been identified & corrected.

Continuous mechanical ventilation (CMV)

Low pressure alarm can be caused by disconnected tubing, ETT cuff leak, or apnea.

Continuous mechanical ventilation (CMV)

Soft tissue injury that results in hemorrhage into involved tissue.

Contusion

Air moving across infant's skin transfers heat to air.

Convection

Alteration loss of physical function cannot be explained by any known pathophysiological mechanism. Thought to be an expression of psychological need or conflict.

Conversion disorder

Can cause calcium & potassium depletion, sodium retention, & glucose intolerance. Elevate blood glucose levels. Monitor Blood glucose levels.

Corticosteroid therapy

Sound that is heard when few strands of hair are rubbed together & indicate fluid in alveoli.

Crackles

Responsible for visual acuity. Tested using Snellen chart assess distant vision. Another item used evaluate optic nerve function is Rosenbaum card; evaluate near vision. Hand-held card used test visual acuity. Records smallest line seen as well as distance that card is held from client

Cranial nerve II (the optic nerve)

Head kept 30- to 45-degree angle. Head & neck not be angled either anteriorly or laterally, kept in neutral (midline) position. Promotes venous return through jugular veins, which will help prevent rise in ICP. Sensitive to loud noises. Control environmental noise by others helpful. Seizures potential complication may occur for up to 1 year after surgery. Must take anticonvulsant medications, keep track of doses. Family learn seizure precautions & accompany during ambulation if dizziness/seizures tend to occur. Suture line kept dry until sutures removed to prevent infection.

Craniotomy/postcraniotomy

Nonbloody diarrhea usually not more than four to five stools daily. Over time, diarrhea episodes increase in frequency, duration, & severity.

Crohn's disease

Treat scabies, Massaged into skin entire body, starting with chin & work downward. Head & face are treated only if needed. Special attention should given skin folds & creases. Contact eyes, mucous membranes, & any region inflammation should be avoided. Second application made 24 hours after first. Cleansing bath shouldtaken 48 hours after second application; if needed, treatment can be repeated 7 days.

Crotamiton (Eurax)

Vaginal discharge should be clear & watery after cryosurgery with laser therapy. Vaginal discharge may be odorous as result sloughing of dead cell debris. Odor takes about 8 weeks to resolve. Avoid sitz or tub baths while area healing, approximately 10 weeks. Pain mild after procedure.

Cryosurgery with laser therapy

May occur as result hormone deficiency, intrinsic abnormality of testis, structural problem. Diagnostic tests for disorder performed to assess urinary & kidney function because kidneys & testes arise from same germ tissue.

Cryptorchidism (undescended testes)

Condition which one or both testes fail descend through inguinal canal into scrotal sac. Surgical correction may be necessary. Vigorous activities restricted 2 weeks after surgery help healing & prevent injury.

Cryptorchidism: orchiopexy surgery

Symptoms of watery diarrhea, flatus, abdominal distention, pain, & fever. Diagnostic tests include stool culture with bowel biopsy.

Cryptosporidiosis

Late sign increased ICP & consists of widening pulse pressure (systolic pressure rises faster than diastolic pressure) & bradycardia.

Cushing's reflex

Caused by excessive amounts cortisol. Diet low carbohydrates & sodium but ample protein/potassium encouraged. Promotes weight loss, reduction edema & hypertension, control of hypokalemia, rebuilding of wasted tissue. Appearance buffalo hump develop but most physical changes resolve with treatment. Rounded moon-like face; prominent jowls; red cheeks; hirsutism upper lip, lower cheek, & chin. (Moon facies & truncal obesity)

Cushing's syndrome

Used with caution history of urinary retention, glaucoma, & increased intraocular pressure.

Cyclobenzaprine hydrochloride (Flexeril)

Because risk anaphylaxis during administration IV route, epinephrine & oxygen must be immediately available for use. Nephrotoxicity evaluated by monitoring elevated BUN & serum creatinine levels. Adverse effects; are nephrotoxicity, infection, hypertension, tremors, & hirsutism. Nephrotoxicity & infection are most serious.

Cyclosporine (Sandimmune)

Immunosuppressive therapy & management of organ transplant patients. Dispense oral liquid into glass container using a specially calibrated pipette. Should not use any other type of dropper to calibrate amount of prescribed medication.

Cyclosporine (Sandimmune)

grapefruit juice inhibits metabolism. As result, consumption grapefruit juice can raise cyclosporine levels by 50% to 100%, greatly increasing risk of toxicity.

Cyclosporine (Sandimmune)

Chronic multisystem disorder that affects exocrine glands. Mucus produced by these glands (particularly those of bronchioles, small intestine, & pancreatic & bile ducts) is abnormally thick, causing obstruction small passageways of these organs. Transmitted as an autosomal recessive trait.

Cystic fibrosis (CF)

Infection of bladder. Should consume 3000 mL of fluids per day if not contraindicated.

Cystitis

Skeletal muscle relaxant & can cause liver damage; Monitor results liver function studies. Discontinued if no relief spasticity achieved in 6 weeks.

Dantrolene (Dantrium)

Disruption of a joint to extent that articulating surfaces are no longer in contact.

Dislocation

May require bedrest prevent embolization of thrombus, anticoagulation to prevent thrombus extension & allow for thrombus autodigestion, fluids for hemodilution & decrease blood viscosity, & elastic stockings to reduce peripheral edema & promote venous return. Prevents complications of immobility encouraging coughing & deep breathing. Venous return important maintain because it is contributing factor DVT. Avoids providing foods rich in vitamin K; dark green, leafy vegetables, because this vitamin can interfere with anticoagulation. Not include use of sequential compression boots for an existing thrombus. They are used only to prevent DVT, because they mimic skeletal muscle action & can disrupt an existing thrombus, leading to pulmonary embolism.

Deep vein thrombosis (DVT)

Medication used to treat iron overload

Deferoxamine

Classified as antidote for acute iron toxicity.

Deferoxamine (Desferal)

Used treatment of pulseless ventricular tachycardia & ventricular fibrillation

Defibrillation

Widened QRS complex

Delay in intraventricular conduction, such as bundle branch block

Consistent daily routine & low stimulating environment important when disoriented. Use an indirect light source & turn off TV.

Delirium becomes disoriented & confused at night

Mild cognitive deficits to severe, life-threatening alteration neurological function. Confabulation or fabrication events/experiences fill in memory gaps not unusual. Lack inhibitions first indication something "wrong" to significant others. As progresses; difficulty sleeping & episodes wandering/sun downing

Dementia

Participative & would likely meet with each staff person individually to determine staff member's perception of problem. Would also speak with the staff about any issues & ask the staff for input with developing a plan.

Democratic leader

Empower staff toward excellence because this style leadership allows nurses opportunity grow professionally

Democratic style

Often withdrawn, experience difficulty concentrating, loss of interest or pleasure, low energy, fatigue, feelings worthlessness & poor self-esteem. Plan of care provide successful experiences in stimulating yet structured environment.

Depression

Antidiuretic hormone treat; diabetes insipidus,& nocturnal enuresis . Promote renal conservation water acting on collecting ducts of kidney increase permeability to water, results increased water reabsorption. Urine output exceeds 9 L per day generally requires treatment with desmopressin.

Desmopressin (DDAVP)

Sudden burst of black spots or floaters indicates that bleeding has occurred as a result of detachment

Detached retina

confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction.

Detection of HIV in infants

Ability recognize place/person is lost.

Disorientation

Disturbance or alteration in normally integrative function identity, memory, consciousness

Dissociative disorder

Spread through infected aerosolized water. The mode of transmission is not person to person. Antibiotics must be given for the entire duration of the prescription

Legionnaires' disease

Results from insufficient ADH production. Triad clinical symptoms including polyuria, polydipsia, excessive thirst often occurs in client with diabetes insipidus. Urine dilute, with specific gravity lower than 1.005, & urine osmolality low (50-200 mOsm/L). High serum osmolality (>300 mOsm/kg of water). There is (insufficient ADH production), which causes kidneys excrete large volumes of urine.

Diabetes insipidus

Regular insulin intravenous route treatment choice for DKA. Short-acting insulin only insulin that can be given intravenously because it can be titrated to blood glucose levels. Expect to note blood glucose levels between 350 & 1500 mg/dL, ketonuria, serum pH less than 7.35, & serum bicarbonate less than 15 mEq/dL.

Diabetic ketoacidosis (DKA)

Sedative hypnotic; anticonvulsant & skeletal muscle relaxant properties. Institute safety measures before leaving room prevent injury as result medication side effects: dizziness, drowsiness, lethargy. Recommended rate of infusion of diazepam is to give each 5 mg of medication over at least 1 minute.

Diazepam (Valium)

Anticholinergic, antispasmodic agent treat IBS that is unresponsive to diet therapy. to be effective decreasing bowel motility, administered 30 minutes before meals.

Dicyclomine hydrochloride (Bentyl)

Can cause pancreatitis. Serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis. Medication is also hepatotoxic & can result in liver failure

Didanosine (Videx)

Purpose of test is provide information about blood vessels.

Digital subtraction angiography study

Early manifestations GI disturbances; anorexia, nausea, vomiting & neurological disturbances; fatigue, headache, weakness, drowsiness, confusion, & nightmares. Visual disturbances; photophobia, light flashes, halos around bright objects, & yellow or green color perception also may occur

Digoxin toxicity

Early sign toxicity GI: anorexia, nausea, vomiting, & diarrhea. Subsequent manifestation: headache, visual disturbances diplopia, blurred vision, yellow-green halos, & photophobia; drowsiness; fatigue; & weakness. Cardiac rhythm abnormalities can occur. Monitors digoxin level. Therapeutic level digoxin range from 0.5 to 2 ng/mL.

Digoxin toxicity

Calcium channel blocker treatment atrial flutter & fibrillation. Decreases myocardial contractility & workload, decreasing need for oxygen. Bolus given slowly over 2 minutes, & continuous infusion 5-10 mg/hour continued up to 24 hours.

Diltiazem hydrochloride

Prevent & treat symptoms dizziness, vertigo, nausea, & vomiting that accompany motion sickness.

Dimenhydrinate (Dramamine)

Prostaglandin given ripen & soften cervix & stimulate uterine contraction

Dinoprostone (Cervidil vaginal insert)

characterized headache, mental confusion, decreased LOC, nausea, vomiting, twitching, & possible seizure activity. Disequilibrium syndrome is caused by rapid removal solutes from body during hemodialysis.

Disequilibrium syndrome

Treatment chronic alcoholism maintaining enforced sobriety. Abstain from alcohol at least 12 hours before initial dose, most important assessment is when last alcoholic intake was consumed. Use cautiously: hypothyroidism, diabetes mellitus, epilepsy, cerebral damage, nephritis, & hepatic disease. Contraindicated; severe heart disease, psychosis, or hypersensitivity to medication.

Disulfiram (Antabuse)

Monitor results liver function studies & ammonia level determinations.

Divalproex sodium (Depakote)

Congenital condition results in moderate to severe retardation. More likely to develop acute leukemia than average child

Down syndrome

Antiemetic & used to treat nausea.

Droperidol (Inapsine)

Require less hand-to-lung coordination, deliver more medication to the lungs, do not require propellant, they are not risk to environment

Dry powder inhaler (DPI)

Joins the aorta & pulmonary artery

Ductus arteriosus

Connects umbilical vein to inferior vena cava

Ductus venosus

Early manifestation occur 5- 30 mins after eating. Symptoms; vertigo, tachycardia, syncope, sweating, pallor, palpitations, & desire to lie down. Instruct maintain low Fowler position while eating & lie down for 30 mins after eating. Small, frequent meals best & avoid liquids with meals. Avoiding high-carbohydrate food sources also assist.

Dumping syndrome

Protective hydrocolloid dressings designed to be left in place for 7 days unless leakage occurs around dressing. Dressing will need to be changed sooner if increased exudate is present.

DuoDERM

Pain relieved by food intake. Burning, heavy, sharp, or "hungry" pain that often localizes in mid-epigastric area. 90 minutes to 3 hours after eating & often awakens client at night.

Duodenal ulcer

Function best dim light. Because of this, impaired rod function results in night blindness.

Dysfunction of rods of eye

Distorted sense of taste

Dysgeusia

Nursing care: Preventing/identifying hypovolemic shock & controlling pain. Elevated pulse rate; indicator shock. β-hCG present but at lower levels

Ectopic pregnancy

Type cutaneous stimulation involving light stroking abdomen used before transition promote relaxation & relieve mild to moderate pain. Effleurage also provides tactile stimulation to fetus. Massaging abdomen during contractions, using both hands in circular motion.

Effleurage

Child talks just for fun & cannot see another's point of view.

Egocentric speech

Waddling, with weight shifting from side to side & legs far apart.

Dystrophic or broad-based gait

Early decreases fluid volume compensated for by increase in pulse rate. Although BP will decrease, it is not the earliest indicator.

Earliest indication of new decreases in fluid volume

Result from pressure on fetal head during a contraction.

Early decelerations

Forgetfulness begins interfere with daily routine. Difficulty concentrating & difficulty learning new material

Early-stage Alzheimer's disease

Purpuric lesion also known as a bruise

Ecchymosis

Stimulates immune system.

Echinacea

Obtain informed consent. Void before procedure. Remove dentures, contact lenses before. Aspiration safeguarded against by withhold food & fluids for 6 hours before treatment. Several conditions present risks in client scheduled for ECT; recent myocardial infarction, brain attack (stroke), & cerebrovascular malformation or an intracranial lesion.

Electroconvulsive therapy (ECT)

Sitting up & leaning on overbed table, sitting up & rest elbows on knees, standing & leaning against wall.

Emphysema positions that help breathing

Oxygen used cautiously & should not exceed 2 L/min. Because long-standing hypercapnia that occurs in emphysema, respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels.

Emphysema with chronic hypercarbia & receiving oxygen

Inflammation brain occurs as a result of viral illness or central nervous system infection.

Encephalitis

Fecal incontinence & major concern if child is constipated. Signs; soiled clothing, scratching or rubbing anal area because of irritation, fecal odor without apparent awareness by child, & social withdrawal.

Encopresis

Also known as uterine cycle, & Consists of three phases; menstruation, proliferative phase, & secretory phase.

Endometrial cycle.

Inserted too far into trachea, tube will enter right main bronchus. Occurs because right bronchus is shorter & wider than left & extends downward in more vertical plane. If tube not inserted far enough, no chest expansion at all will occur.

Endotracheal tube

Atropine sulfate should be available because it is antidote

Enlon (Tensilon) test

Anticoagulant. An adverse effect anticoagulant therapy is bleeding. Question about symptoms that could indicate bleeding: bleeding gums, bruising, hematuria, or dark tarry stools.

Enoxaparin (Lovenox)

Subcutaneous injection enoxaparin performed using same technique as heparin injection. Use 25 to 27 gauge, ⅝-inch needle prevent hematoma formation site. Bunch skin rather than placing it flat. Not aspirate before injecting medication & not massage area after injection.

Enoxaparin (Lovenox)

Anticoagulant. Accidental overdose of medication may lead to bleeding complications. Antidote is protamine sulfate.

Enoxaparin sodium (Lovenox)

Confirm presence inflammation or infection in body. Useful for management of connective tissue disease because rate measured directly correlates with degree of inflammation & later with severity of disease. Normal ESR range 0 to 30 mm/hr Mild inflamation; 30 to 40 mm/hr Moderate inflamation; 40 to 70 mm/hr Severe inflammation; 70 to 150 mm/hr

Erythrocyte sedimentation rate (ESR)

Require normal digestive capabilities of GI tract. May cause aspiration pneumonia from regurgitation of formula into lungs. Given room temperature avoid problems with diarrhea. Caloric value most standard enteral feeding formula 1 to 2 cal/mL.

Enteral nutrition

Positive antibody test child younger 18 months age indicates only mother infected because maternal antibodies persist infants for 6-9 months &, in some cases, as long as 18 months. Positive ELISA does not indicate true HIV infection or development AIDS, nor does it indicate that newborn will develop AIDS later in life

Enzyme-linked immunosorbent assay (ELISA)

Symptoms: scrotal pain & edema, accompanied by fever, nausea & vomiting, chills. Often caused by infection, although sometimes by trauma. Common interventions; bed rest with bathroom privileges, elevation scrotum, ice packs, sitz baths, analgesics, & antibiotics.

Epididymitis

Palpate bladder at frequent intervals

Epidural anesthesia

Throat suspected epiglottitis not examined/cultured stimulation with tongue depressor or culture swab could cause laryngospasm, thus completing airway obstruction. Humidified oxygen & antipyretics are components management. Axillary rather than oral temperatures taken to avoid stimulation & resultant laryngospasm. If suspected, priorities are maintain patent airway & obtain chest radiograph to confirm diagnosis. If present, child taken promptly to operating room for tracheal intubation or immediate placement of surgical airway.

Epiglottitis

1. Maintain a patent airway 2. Assess breath sounds by auscultation 3. Obtain oxygen saturation level using pulse oximetry. 4. Insert intravenous line for fluid administration. 5. Obtain an axillary temperature 6. Administer an antipyretic.

Epiglottitis suspected. Which order of priority would nurse implement actions?

1. Raise the head of the bed. 2. Loosen tight clothing on the client. 3. Check for bladder distention. 4. Contact the health care provider 5. Administer antihypertensive medication. 6. Document the occurrence, treatment, and response.

Episode autonomic dysreflexia. After checking vital signs, nurse takes following actions

Congenital defect abnormal placement urethral orifice of penis. Urethral opening located anywhere on dorsum of penis. Anatomical characteristic facilitates entry bacteria into urine.

Epispadias

Reverse anemia associated with chronic kidney disease. Therapeutic effect seen hematocrit between 30% & 33% (Treat anemia) Medication administer subcutaneously or intravenously as prescribed.

Epoetin alfa (Epogen)

Adverse effect hypertension. Occasionally tachycardia may occur. Medication may cause improved sense well-being. Takes 2-6 weeks therapy before significant increase hematocrit observed. Not intended client require immediate correction severe anemia, & not substitute for emergency blood transfusions. Administered parenterally by intravenous or subcutaneous route. Should be refrigerated at all times.

Epoetin alfa (Epogen, Procrit)

Stop ongoing migraine attack; & treat cluster headaches.

Ergotamine tartrate (Cafergot)

Should not try anticipate newborn infant needs but allow newborn infant to signal needs. If newborn infant is not allowed to signal a need, newborn will not learn how to control environment. Delayed or prolonged response to newborn infant's signal would inhibit development trust & lead to mistrust of others

Erikson's psychosocial development theory

Infant: Trust versus Mistrust Toddler: Autonomy versus Shame & Doubt stage. Develops sense control over self & bodily functions. . Preschool age: Initiative versus Guilt. school-aged child: Industry versus Inferiority

Erikson's psychosocial stages of development

Can be caused by vasodilation from high environmental temperatures, fever, or inflammation

Erythema (or redness) of the skin

Erythema on face, giving a "slapped cheeks" appearance

Erythema infectiosum (fifth disease)

Measuring ESR can confirm inflammation or infection anywhere in body. ESR useful for connective tissue disease because value directly correlates with degree inflammation & later with severity of the disease. ESR value of 30 to 40 mm/hr indicates mild inflammation, 40 to 70 mm/hr indicates moderate inflammation, & 70 to 150 mm/hr indicates severe inflammation.

Erythrocyte sedimentation rate (ESR)

Administered empty stomach with full glass water (1 hour before or 2 hours following ingestion of food).

Erythromycin (E-mycin).

Used as prophylactic treatment for ophthalmia neonatorum, which is caused by bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law

Erythromycin ophthalmic ointment

Infection & pancytopenia are side/adverse effects. Assess white blood cell counts & platelet counts

Etanercept for treatment of rheumatoid arthritis

causes optic neuritis, decreases visual acuity & ability discriminate between color red & green.

Ethambutol (Myambutol)

It is a subjective perspective of the person's heritage and a sense of belonging to a group

Ethnic identity

Normal sugar in the blood. Use glycosylated hemoglobin assay to measure glucose molecules that attach to the hemoglobin A molecules & remain there for life of red blood cell, approximately 120 days. This is not reversible and cannot be altered by human intervention. Glycosylated hemoglobin (hemoglobin A1c)

Euglycemia

Moisture from wet body surface dissipates heat along with moisture.

Evaporation

Invasive test uses contrast radiopaque dye assess ability kidneys excrete dye in urine. Bowel preparation necessary permit adequate visualization kidneys, ureters, and bladder.

Excretory urogram

Incretin mimetic used for type 2 diabetes mellitus only. Not recommended clients taking insulin.

Exenatide (Byetta)

Early signs include changes mental status & impaired respiratory function result of impaired perfusion distal to site of embolus. Dyspnea, petechiae, and chest pain are signs of fat embolism. Cardiovascular & renal impairment likely secondary to impaired respiratory function. Suspected fat embolism, position sitting (Fowler's) position relieve dyspnea. Supplemental oxygen reduce signs of hypoxia. HCP notified

Fat embolism

Assess for allergy egg yolks.

Fat emulsion (Intralipids)

Assess for known allergies to eggs to prevent anaphylaxis.

Fat emulsion (lipids)

Enhances reabsorption sodium & chloride ions distal tubules of kidney & excretion potassium & hydrogen ions. Promote water retention.

Fludrocortisone acetate (Florinef); prescribed for Addison's disease

Heart rate less 120 beats/min, urine output at least 30 mL/hr, peripheral pulses are +2 or better, & client oriented to client, place, & time.

Fluid resuscitation is adequate (Burn client)

Measures titer antibodies that destroy nuclei cells & cause tissue death. When fluorescent method used, test sometimes referred to as FANA. Test is positive value greater than 1:8 will be present.

Fluorescent antinuclear antibody titer (FANA)

Affects GI system by causing nausea & vomiting, cramping, & diarrhea.

Fluoxetine (Prozac)

Limbic system

Feelings & affect

Iron supplement treat anemia. Constipation; side effect associated with administration oral iron supplements. Stool softeners prescribed prevent constipation. Instructed to take medication with orange juice or tomato juice.

Ferrous sulfate (Feosol)

Walking on toes with accelerating pace.

Festinating gait

Craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, & respiratory distress. Hypotonia, irritability, & poor sucking reflex.

Fetal alcohol syndrome

May exhibit hyperirritability, vomiting, diarrhea, or uncoordinated sucking & swallowing ability. Quiet environment with minimal stimuli & handling would help establish appropriate sleep-rest cycles in newborn as well.

Fetal alcohol syndrome

Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned by one umbilical vein. Arteries carry deoxygenated blood & waste products from fetus, umbilical vein carries oxygenated blood & provides oxygen & nutrients to fetus.

Fetal circulation

Dry to touch within minutes & reaches full rigid strength in about 20 minutes. Can bear weight on cast within 20 to 30 minutes

Fiberglass cast

Administered clients agranulocytosis to promote growth neutrophils & enhance function mature neutrophils. Given subcutaneous injection or continuous intravenous infusion. Diluted only with D5W when administered by IV route.

Filgrastim (Neupogen)

View pain as part of living honorable life. May appear stoic & tolerant of high degree of pain. Offer pain medication on regular basis &, encourage pain relief interventions for client who does not complain pain despite physiological indicators.

Filipinos

Order of priority is to rescue patient in immediate danger. Next activate fire alarm. Close all doors & fire extinguished.

Fire event

1. Protect the client from injury. 2. Activate the fire alarm. 3. Close doors to other clients' rooms. 4. Pull the pin on the fire extinguisher. 5. Extinguish the fire.

Fire in hospital room. What actions should nurse take?

Implements usual coping methods to bring about relief from problem & shows signs of anxiety that these methods are failing.

First phase of the crisis response

Prolonged PR interval indicates first-degree

First-degree heart block

include whole medical systems, mind-body medicine, biologically based practices, manipulative & body-based practices, & energy medicine.

Five categories of complementary and alternative medicine (CAM):

Involves history & physical exam limited to specific problem, client complaint & most often used in walk-in clinic or ED

Focused assessment

Blood cells that destroy bacteria. With fewer than 10,000 cells/L circulating granulocytes, risk infection increases significantly

Granulocytes

Ability recognize form of written symbols. Can assess for this by tracing symbols, such as numbers, in client's palm.

Graphesthesia

Incomplete fracture, which occurs through part cross-section of bone-one side bone fractured, & other side bent.

Greenstick fracture

Hyperglycemia & Hypercalciuria can occur, particularly during first 2-3 months of therapy. Growth hormone therapy is associated with decline in thyroid function

Growth hormone replacement therapy

Clinical syndrome; Progressive muscle weakness that develops rapidly. Has unknown origin. Report history respiratory or GI infection 1- 4 weeks before onset neurological deficits. On occasion, syndrome can be triggered by vaccination surgery. Have dysphagia; more likely aspirate clear liquids than thick or semisolid foods. Passive ROM exercises help prevent contractures, & assessing calf measurements can help detect deep vein thrombosis, for which these clients are at risk. Are at risk for hypotension or hypertension, bradycardia, & respiratory depression, frequent monitoring vital signs required. Retain carbon dioxide, leading to respiratory acidosis & ventilatory failure as paralysis develops.

Guillain-Barré syndrome

weakness one side body may occur after stroke. Involves weakness face, tongue, arm, & leg on one side. Also aphasic: unable to discriminate words & letters. Generally cautious & anxious when attempting new task. Right-sided hemiparesis has weakness right arm, leg & needs assistance with feeding, bathing, & ambulating.

Hemiparesis

Sterile technique, application face mask; both nurse & client important. Standard precautions followed, use goggles, mask, gloves, & apron. Connection site visible to assess for bleeding, ischemia, & infection at site during procedure. Use standard precautions; appropriate handwashing & sterilization procedures; & prohibition of eating, drinking, or other hand-to-mouth activity in hemodialysis unit.

Hemodialysis

Group bleeding disorders resulting from deficiency specific coagulation proteins Abnormal laboratory results indicate prolonged partial thromboplastin time. Female offspring of affected male & carrier female are at risk for hemorrhage once puberty is attained & menstrual cycles begin, depending on severity of hemophilia, hysterectomy or ablation may be performed

Hemophilia

Elevates head of bed maintain airway patency & prevent aspiration. Apply pressure over bleeding site & call HCP immediately. Monitors airway & vital signs.

Hemorrhage from surgical site after radical neck dissection

Usually have head of bed elevated 30 degrees (Semi-Fowler's) reduce intracranial pressure that can occur from hemorrhage. Head should be in midline, neutral position; facilitate venous drainage from brain.

Hemorrhagic stroke

Antidote is protamine sulfate; readily available to use if excessive bleeding or hemorrhage should occur.

Heparin

aPTT monitors the effects. Anticoagulant used most often during hemodialysis. Monitors extent of anticoagulation checking PTT, which is appropriate measure heparin effect. Protamine sulfate is antidote.

Heparin

Medication prescribed; Lactulose hyperosmotic laxative agent has adjunct benefit lowering serum ammonia levels.

Hepatic encephalopathy

Diagnostic tests include viral culture & gross examination. Manifests painful, vesicular lesions that rupture & cause ulcers on tongue, lips, & buccal mucosa.

Herpes simplex

diagnosis made by a polymerase chain reaction (PCR) test. Test rapid & noninvasive.

Herpes simplex encephalitis.

Clustered skin vesicles

Herpes zoster

Clusters of fluid-filled vesicles

Herpesvirus infection

Cause vasodilation, which may cause headache. It will cause vasodilation of blood vessels in brain

High CO2 level

Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish & shellfish. Smoked foods,

High Sodium foods:

Pork products rich in this vitamin. Other good food sources include nuts, whole grain cereals, & legumes.

High Thiamine foods

Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans.

High risk of obesity & diabetes mellitus

Combination two nucleoside analogues, which target viral replication during reverse transcription phase of cell cycle, & protease inhibitor, which targets viral replication at a different phase.

Highly active antiretroviral therapy (HAART)

Responsible for storage of memory. Unable to recall past events.

Hippocampus

Also known as congenital aganglionosis or megacolon. Pellet or ribbon-like stools: foul-smelling is clinical manifestation of disorder. Delayed passage or absence of meconium stool in neonatal period also a sign. Bowel obstruction in neonatal period, abdominal pain & distention, & failure to thrive also clinical manifestations.

Hirschsprung's disease

Excessive hair growth

Hirsutism

Foods rich in color, flavor, texture, & spiciness. Any occasion is seen as time to celebrate with food. View food as primary form socialization.

Hispanic-American

Caused by inhalation of spores from bat or bird droppings. An opportunistic infection that affects lungs & can occur in client with HIV infection. Diagnostic tests include chest x-ray, sputum culture, lung biopsy, & bronchoscopy

Histoplasmosis

Malignancy lymph nodes. Presence of giant, multinucleated cells (Reed-Sternberg cells) is classic characteristic of this disease.

Hodgkin's disease

1. Check the client's blood glucose level. 2. Give the client ½ cup of fruit juice to drink 3. Take the client's vital signs. 4. Retest the blood glucose level. 5. Give small snack carbohydrate & protein. 6. Document complaints, actions taken, & outcome.

Hospitalized client type 1 diabetes mellitus received Humulin N & Humulin R insulin 2 hours ago at 7:30 am. Calls nurse & reports feeling hungry, shaky, & weak. Ate breakfast at 8 am & is due to eat lunch at noon. (order of actions)

If result of ELISA is positive, Western blot is done to confirm findings. If the result of Western blot is positive, then considered to be seropositive for infection & to be infected with virus.

Human immunodeficiency virus (HIV) infection

Intermediate-acting insulin onset action 3-4 hours, peak action 4-12 hours, & duration action of 16-20 hours. Hypoglycemic reaction most likely to occur at peak time

Humulin N insulin

Onset action is 1.5 hours, peaks 4 to 12 hours, & duration action 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time.

Humulin N is an intermediate-acting insulin

Early symptoms; restlessness, forgetfulness, clumsiness, falls, balance & coordination problems, altered speech, & altered handwriting. Difficulty swallowing occurs in later stages

Huntington's disease

Antihypertensive medication used moderate to severe hypertension. Blood pressure & pulse monitored frequently after administration

Hydralazine (Apresoline)

Applied directly to wound & should be changed every 3-5 days (or more frequently if drainage from wound is excessive).

Hydrocolloid gel (DuoDERM)

Are cations that contribute to a state of acidosis in body.

Hydrogen ions

Classic symptoms polydipsia, polyuria, & polyphagia

Hyperglycemia

Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, & coma when severe. If has these symptoms, blood glucose level should be checked immediately.

Hyperglycemia:

Excessive sweating.

Hyperhidrosis

Tall, peaked T waves

Hyperkalemia

Trauma, burns, sepsis, or metabolic or respiratory acidosis.

Hyperkalemia causes:

Assessment; neurological depression, drowsiness & lethargy, loss of deep tendon reflexes, respiratory insufficiency, bradycardia, & hypotension.

Hypermagnesemia

Experiences blurred vision because focal point falls behind retina. Called farsightedness, condition may be caused by eyeball that is shorter than usual or cornea that has less curvature than normal. Corrected by use of convex or plus lens for close work, such as reading.

Hyperopia

Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors. Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole grains, & carbonated beverages.

Hyperphosphatemia

Excessive reflex action.

Hyperreflexia

Dyspnea, a swollen tongue, & cyanosis.

Hypersensitivity reaction:

Can occur from use monoamine oxidase inhibitor; hypertension, occipital headache radiating frontally, neck stiffness & soreness, N&V.

Hypertensive crisis

Goiter (increase size thyroid gland) & exophthalmos (bulging eyeballs). Nervousness, fatigue, weight loss, muscle cramps, heat intolerance. Tachycardia; shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair & thin skin; infrequent blinking; & staring appearance.

Hyperthyroidism

10% dextrose in water (D10W) 5% dextrose in 0.9% saline (5% D/NS) 5% dextrose in 0.45% saline (5% D/½ NS)

Hypertonic solutions

Decreased blood glucose levels trigger autonomic nervous system signs & symptoms, such as nervousness, irritability, & tremors.

Hypoglycemia

Decreased blood glucose levels produce autonomic nervous system symptoms, manifested as nervousness, irritability, & tremors. Usually feels hunger. Profuse sweating & shakiness would be noted

Hypoglycemic reaction

Cushing's syndrome or colitis & over use of laxatives.

Hypokalemia causes:

Assessment; Tetany, twitches, & positive Trousseau's sign. Tall T waves & depressed ST segment would be observed.

Hypomagnesemia

Muscle weakness, increased urinary output, & decreased specific gravity of the urine would be noted

Hyponatremia

Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism.

Hypophosphatemia

Congenital defect involving abnormal placement urethral orifice of penis. Urethral orifice located below glans penis along ventral surface. Should not be circumcised because dorsal foreskin tissue used for surgical repair of hypospadias.

Hypospadias

Autonomic nervous system functions, such as heart rate, blood pressure, temperature, & fluid & electrolyte balance (among others).

Hypothalamus

Decreased metabolism low levels of thyroid hormone. Interventions replace hormone. Cold intolerance, requires warm environment. Well-balanced diet low in fat for weight reduction & high in fluids & high-fiber foods to prevent constipation. Notify HCP chest pain because could indication overreplacement thyroid hormone.

Hypothyroidism

Deficiency thyroid hormone. Puffy, edematous face, around eyes (periorbital edema), along with coarse facial features, dry skin, & dry, coarse hair & eyebrows. Feeling cold, hair loss, lethargy facial puffiness are signs.

Hypothyroidism

Provide warm environment, consume low-fat diet, well balanced diet, thyroid replacement therapy will be needed.

Hypothyroidism

0.45% saline (½ NS)

Hypotonic solution

Changed every 48 to 72 hours, which is every 2 to 3 days

IV site dressings

Hypertonic solution 5% dextrose in 0.9% normal saline pull fluid into intravascular space; kidneys excrete excess fluid.

IV solution client experiencing excess fluid volume secondary to heart failure

Leafy green vegetables are rich in folate (folic acid)

Identifying food highest in folic acid.

Clear & maintain open airway. first action during seizure (eclampsia) is to ensure patent airway

If progresses from preeclampsia to eclampsia, nurse should take which first action?

Frequent complication that occurs is fluid & electrolyte imbalance. I & O monitored.

Ileostomy

Single dose at bedtime, because of side effects. Avoid alcohol or other CNS depressants during therapy. Effects may not be noticed 2 weeks. Dose missed, take as soon as possible unless almost time for another dose.

Imipramine (Tofranil)

maximum therapeutic effect may not occur for 2-3 weeks after antidepressant therapy initiated.

Imipramine (Tofranil)

Loss corneal (blink) reflex, risk eye dryness & corneal abrasions if foreign matter comes in contact with eye. Use sterile saline drops to keep eyes lubricated indicated.

Impaired corneal reflex

Contagious bacterial infection skin. Common during hot, humid summer months. May begin area broken skin, such as an insect bite or atopic dermatitis. Impetigo very contagious. Lesions usually located around mouth & nose, but may be on hands & extremities. Mupirocin(Bactroban) topical antibacterial agent active against impetigo.

Impetigo

Contains neomycin. History of anaphylactic reaction neomycin considered a contraindication to IPV.

Inactivated polio vaccine (IPV)

Best results sitting head of bed elevated 45 to 90 degrees. Semi-Fowler's or high Fowler's position. Mouthpiece should be covered completely & tightly while inhales slowly, with constant flow through unit. Breath should be held for 5 seconds before exhaling slowly.

Incentive spirometer

Heavy bleeding, severe cramping, cervical dilation, & passage large clots.

Incomplete abortion

One that extends through only part of thickness of bone. Usually are nondisplaced, meaning that bone remains in normal position.

Incomplete fracture

Nuchal rigidity, positive Brudzinski sign, & positive Kernig sign

Indicate developing meningitis

Some of client's WBC; tagged with indium, which will accumulate in infected bone.

Indium imaging

Health care worker, people who work in rubber industry, or have had multiple surgeries, have spina bifida, wear gloves frequently; food handlers, hairdressers, & auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts.

Individuals at risk for developing a latex allergy

Termination pregnancy that cannot be prevented. Moderate/severe bleeding with mild cramping & cervical dilation noted in this type of abortion.

Inevitable abortion

Hepatitis B immune globulin (HBIG) & hepatitis B vaccine given within 12 hours after birth

Infant is born to a mother with hepatitis B

When receiving ribavirin, exposure precautions observed. Anyone entering room wear a gown, mask, gloves, & hair covering. Pregnant or considering pregnancy & anyone with history respiratory problems or airway disease should not care for or visit receiving ribavirin. Hand washing absolutely necessary before leaving room prevent spread of germs.

Infant respiratory syncytial virus infection receiving ribavirin (Virazole)

IV dislodged from vein & is lying in subcutaneous tissue. Pallor, coolness, & swelling are results of IV fluid being deposited in tissue. Corrective action is remove catheter & start new IV line at another site.

Infiltrated IV

Immunomodulator that reduces degree inflammation in colon, reducing diarrhea

Infliximab (Remicade): Used in Crohn's disease

Swelling occurs when infant cries or strains.

Inguinal hernia

100% humidified oxygen by face mask used, assess respiratory rate every hour, monitoring oxygen saturation levels every hour, & assisting with coughing & deep breathing every hour. Head of bed elevated facilitate lung expansion.

Inhalation injury

Humulin R drawn up before Humulin N insulin, & can be drawn into same syringe. Usually administered 15-30 mins before meal. To mix Humulin N insulin suspension, vial should be gently rotated. Shaking introduces air bubbles into solution.

Insulin

Promotes individual's comfort in group, which then transfers to other relationships. Based on one-to-one or group therapy approach in which therapist-client relationship often used as way for client to examine other relationships in his/her life.

Interpersonal group therapy

Used treatment of cardiogenic shock; most effective instituted early. Contraindicated with aortic insufficiency & thoracic & abdominal aneurysms.

Intra-aortic balloon pump (IABP) therapy

Chronic & incapacitating and is refractory to medical therapy

Intractable angina

Young child, ages 3 to 6 years, max volume medication safely injected into ventral gluteal muscle is 1.5 mL.

Intramuscular (IM) injection in young child

Done for diagnostic purposes. Outlines both gallbladder & ducts, so gallstones that have moved into ductal system can be detected.

Intravenous cholangiogram

Invagination of section of intestine into distal bowel. Most common cause of bowel obstruction children aged 3 months to 6 years. Severe abdominal pain; crampy & intermittent, child draw in knees to chest. Vomiting may be present, but not projectile. Bright red blood & mucus passed through rectum & commonly described as currant jelly-like stools

Intussusception

Proximal segment of bowel prolapses into distal segment of bowel. Common cause of bowel obstruction in infants & young children

Intussusception

Angiotensin II type 1 receptor antagonist. Used for hypertension.

Irbesartan (Avapro)

Characterized by decreased iron-binding capacity & increased transferrin saturation. Best sources dietary iron: red meat, liver & other organ meats; blackstrap molasses; & oysters. Kidney beans, whole wheat bread, egg yolk, spinach, kale, turnip tops, beet greens, carrots, raisins, & apricots.

Iron deficiency anemia

Dark green leafy vegetables good source iron, oranges are a good source of vitamin C, which enhances iron absorption.

Iron deficiency anemia foods in diet:

Best absorbed taken empty stomach with water or vitamin C containing juice. Iron supplements usually cause constipation. Meats excellent source iron. Pregnant client take iron supplements regardless of food intake

Iron supplementation

Antitubercular medication. Side effect peripheral neuritis. Symptoms; numbness, tingling, paresthesias in extremities. Minimized w/pyridoxine (vitamin B6) intake. Report yellow eyes/skin immediately. Hepatotoxic. Monitor liver enzyme first 3 months therapy. Children HIV infection who demonstrate positive Mantoux tuberculin skin test result, minimum 12 months treatment recommended.

Isoniazid

5% dextrose in water (D5W) 0.9% saline (NS) 5% dextrose in 0.225% saline (5% D/¼ NS)

Isotonic solution

Inhibit inflammation severe cystic acne. Vitamin A supplements stopped during treatment because derivative of vitamin A, taking vitamin A concurrently induce additive effects. Adverse effects include elevated triglycerides, skin dryness, eye discomfort, such as dryness & burning. Lip inflammation, called cheilitis, also can occur.

Isotretinoin (Clavaris)

Whenever neck injury suspected, jaw thrust maneuver should be used during basic life support (BLS) to open airway. Head tilt-chin lift produces hyperextension of the neck & could cause complications if a neck injury is present.

Jaw thrust maneuver

Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products.

Jehovah's Witnesses

JIA twice as likely to occur in girls than in boys. Clinical manifestations of JIA include morning stiffness & painful, stiff, swollen joints. Most often occurs before age of 16. Complication of JIA is iridocyclitis.

Juvenile idiopathic arthritis (JIA)

Morning stiffness. Painful, stiff, & swollen joints. Limited range of motion of joints. History of late afternoon temperature, with temperature spiking up to 105° F. Systemic symptoms include malaise, fatigue, lethargy, anorexia, weight loss, & growth problems.

Juvenile rheumatoid arthritis (JRA)

Lesions begin red, dark blue, purple macules on lower legs change into plaques. Large plaques ulcerate or open & drain. Spread by metastasis to upper body, then face & oral mucosa. Lymphatic system, lungs, & (GI) tract can become involved. Late disease results swelling & pain in lower extremities, penis, scrotum, face. Diagnosis punch biopsy cutaneous lesions & biopsy pulmonary & GI lesions.

Kaposi's sarcoma

Acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, & enlargement cervical lymph nodes. Subacute stage, cracking lips & fissures, desquamation skin on tips of fingers & toes, joint pain, cardiac manifestation, & thrombocytosis. Convalescent stage, appear normal, but signs inflammation may be present.

Kawasaki disease

Not able extend leg when thigh is flexed anteriorly at hip. Raise child's leg with knee flexed & then extend the leg at knee & assess for pain; resistance is noted or pain is felt, result is positive Kernig's sign.

Kernig's sign

Continent internal ileal reservoir. Instructs technique of catheterization.

Kock's pouch

Preconventional stage, morals are thought to be motivated by punishment & reward.

Kohlberg's theory of moral development

Located in liver. These cells help filter blood by phagocytizing microorganisms & other foreign particles that pass through liver.

Kupffer's cells

Isotonic solutions given for fluid replacement

Lactated Ringer's & 0.9% normal saline solutions, 5% dextrose in water (D5W)

Prescribed hepatic encephalopathy reduce bacterial breakdown protein in bowel. Desired effect is two or three soft stools per day with an acid fecal pH. Creates acid environment in bowel & causes ammonia leave bloodstream & enter colon. Ammonia becomes trapped in bowel. Lactulose has laxative effect allows elimination of ammonia. Diarrhea may indicate excessive administration of medication.

Lactulose (Chronulac)

Results from long-term alcohol abuse

Laennec's cirrhosis

Allows staff to work without assistance, direction, or supervision.

Laissez-faire

Passive and nondirective. Would state what the problem was & inform staff that the staff needed to come up with a plan to "fix it."

Laissez-faire leader

Nucleoside reverse transcriptase inhibitor & antiviral medication. Slows HIV replication & reduces progression HIV infection. Also used treat chronic hepatitis B & provide prophylaxis health care workers at risk of acquiring HIV infection after occupational exposure to virus.

Lamivudine (Epivir)

Avoid cigarette smoking, alcohol consumption, exposure airborne carcinogens, & vocal abuse. Schedule routine physical examinations. Seek medical care if difficulty swallowing, persistent hoarseness, enlarged lymph nodes in neck, or unexplained weight loss occurs.

Laryngeal cancer

Homes older than 25 years may have lead paint & will most likely have lead pipes, which can contribute to lead poisoning.

Lead poisoning

Bifurcates from left main coronary artery to supply anterior wall of left ventricle & a few other structures

Left anterior descending coronary artery (LAD)

Indicates increased number of immature neutrophils, an increased number of bands. Signals presence of an acute infectious process.

Left shift

Often involve supraspinatus tendon of shoulder

Lesions of the rotator cuff

Palliative treatment advanced breast cancer postmenopausal woman with disease progression after treatment with antiestrogen therapy.

Letrozole (Femara)

Confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate & biopsy.

Leukemia

For hypothyroidism; Achieve normal thyroid hormone levels

Levothyroxine (Synthroid)

If taken with Warfarin sodium; decreased dosage of warfarin.

Levothyroxine (Synthroid); prescribed for Hypothyroidism

Skilled wound irrigation & dressing changes

Licensed practical (vocational) nurse

Can perform tasks that (UAP) can (skin care, range-of-motion exercises, grooming, ambulation, hygiene measures) as well as dressing changes, endotracheal suctioning, urinary catheterization, & medication administration (oral, subcutaneous, intramuscular, some piggy-back medications). *Oral medication administration. *Data collection, cannot assess. *Urinary catheterization *Endotracheal suctioning *Intramuscular medication administration *Subcutaneous medication administration

Licensed practical nurse (LPN)

Is responsible for emotion

Limbic system

Affect is flat, with periods of emotional lability

Limbic system neurological deficit

Treat Scabies; can penetrate intact skin & cause seizures if absorbed in sufficient quantities. Preexisting seizure disorder at high risk. Not be used pediatric client unless safer medications failed control infection

Lindane

Antidiarrheal; administered for loose stools. Treat both acute diarrhea & chronic diarrhea from disorders such as inflammatory bowel disease. Also used reduce volume of drainage from an ileostomy.

Loperamide (Imodium)

HMG-CoA reductase inhibitor used to lower blood cholesterol levels.

Lovastatin (Mevacor)

Cause vasoconstriction, which may cause lightheadedness

Low CO2 levels

Thrombin produced by liver & necessary for normal clotting. Insufficient level of this substance is at risk for bleeding.

Low serum levels of thrombin

Include fruits & vegetables

Low sodium foods:

Include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, & spiritual measures (prayer).

Low-risk therapies:

Informed consent; procedure is invasive. Test take 15 to 60 minutes. No dietary restrictions after test. Encouraged consume fluids. Bed rest after test. During procedure fetal position. After procedure flat positio for at least 2 hours.n. If able prone position with pillow under abdomen best position. Helps reduce cerebrospinal fluid leakage & decreases likelihood of post-lumbar puncture headache. Liberal fluid intake encouraged replace cerebrospinal fluid removed, unless contraindicated by client's condition. Checks puncture site for redness & drainage & assesses ability to void & move extremities.

Lumbar puncture

Postion: Lateral recumbent, with knees flexed to abdomen & head bent, chin resting on the chest

Lumbar puncture (LP)

Cough is most frequent early symptom lung cancer, begins as nonproductive & hacking, & progresses to productive. In smoker who already has a cough,change in character & frequency of cough usually occurs.

Lung cancer

Multisystem infection that results from bite by tick carried by several species of deer. Blood to detect performed 4 to 6 weeks following tick bite. Antibody formation takes place in the following manner. Ticks should be removed with tweezers & area washed with an antiseptic.

Lyme disease

Prevention; insect repellent on skin & clothes in an area where ticks likely found. Long-sleeved tops & long pants, closed shoes, & hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up & over pant legs to prevent ticks from entering under clothing.

Lyme disease

Arm edema on operative side; complication after mastectomy. Can occur immediately postoperatively or months to even years after surgery.

Lymphedema

Avocado, canned white tuna, cauliflower, green leafy vegetables; spinach & broccoli, milk, oatmeal, peanut butter, peas, pork, beef, chicken, potatoes, raisins, & yogurt.

Magnesium

Available as an oral solution & should be served chilled to make it more palatable

Magnesium citrate

Produces flushing/sweating owing to decreased peripheral blood pressure. Decreases central nervous system activity, acting as anticonvulsant, & decreases frequency & duration uterine contractions. Decreases acetylcholine, blocking neuromuscular transmission.

Magnesium sulfate

Therapeutic range 4-8 mg/dL. Signs toxicity include CNS depression. Maintain respiratory rate at or greater 16 bpm (or agency protocol), maintain presence deep tendon reflexes, & urinary output greater 30 mL/hour. Toxic effects may cause loss of deep tendon reflexes, heart block, respiratory paralysis, & cardiac arrest. Antidote magnesium sulfate is Calcium Gluconate.

Magnesium sulfate

Central nervous system depressant & relaxes smooth muscle, including uterus. Used to halt preterm labor contractions & used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, & elevated serum magnesium levels.

MagnesiumSulfate

Flat position 45 to 60 minutes. Painless test & contrast dye may or may not be used. No dietary restrictions necessary. May damage items such as credit cards & watches & jewelry & hair clips cause artifacts. These should be removed before test.

Magnetic resonance imaging (MRI)

Excitement, euphoria, hyperactivity, excessive energy, decreased need sleep, impaired ability concentrate or complete single train of thought. Mood predominantly elevated, expansive, or irritable. Nonstop physical activity & poor nutritional intake problem.

Mania

Injection administered needle bevel facing upward 10- to 15-degree angle. Injected slowly, & bleb should form under skin with injection. After withdrawing needle, area may be patted dry with 2 × 2 sterile gauze pad, but pressure should not be applied. Area not be rubbed because will cause medication spread beyond area injection. Area injection outlined or circled for later reference & interpretation of results of test.

Mantoux tuberculin skin test

Located midway between right anterior superior iliac crest & umbilicus. Usually location of greatest pain in child with appendicitis.

McBurney's point

Inside container is sterile. Fingers touching inside container, cause container to become unsterile. Meatus cleansed front to back (toward anus). Labia should remain open during procedure. If allowed to close, tissue will have to be cleansed again with antiseptic pads. Should void small amount intoilet before urinating into specimen container allow some of organisms near meatus to leave area.

Midstream urine specimen

"Therapeutic community," has as its focus living, learning, or working environment. Provide safe, therapeutic environment. All treatment team members are viewed significant & valuable to client's successful treatment outcomes.

Milieu therapy

Narrowing this valve will impede circulation blood through the Left atrium to left ventricle

Mitral stenosis

Humulin N bottle rotated at least 1 min between both hands resuspend insulin & warm medication. Humulin R insulin drawn before Humulin N. Insulin can be stored room temperature. Additional bottles insulin for future use stored in refrigerator.

Mix Humulin R & Humulin N insulin in the same syringe

Inject air into Humulin N bottle equal to amount of insulin prescribed. Next inject amount of air equal to amount of prescribed insulin into Humulin R bottle. Regular insulin then withdrawn, followed by Humulin N insulin. Contamination regular insulin with Humulin N insulin will convert part of Humulin R insulin into longer-acting form.

Mixture of Humulin N & Humulin R insulin.

Narrows perceptual field & selective inattentiveness occurs.

Moderate anxiety

For prophylaxis & maintenance therapy of asthma, maximal effects develop within 24 hours of first dose & maintained with once-daily dosing in evening. (Not for rescue)

Montelukast (Singulair)

Sebaceous glands located in areola.

Montgomery's tubercles of breast.

Naloxone (Narcan) opioid antagonist used treat opioid overdose.

Morphine sulfate

Positioned side prevent aspiration. Brushed twice daily small toothbrush. Gums, tongue, roof mouth, & oral mucous membranes cleansed soft spongesavoid encrustation & infection. Lips coated water-soluble lubricant to prevent drying, cracking, & encrustation. Pproducts alcohol should avoided because drying effect.

Mouth care unconscious client

Injection cap should be discarded & new one applied whenever blood is drawn from lumen.

Multilumen central venous catheter

Manage constipation; high-fiber diet, bulk formers, & stool softeners. Fluid intake 2000 mL/day recommended. Initiate bowel program every-other-day basis. Done approximately 45 minutes after largest meal of day take advantage of gastrocolic reflex. Glycerin suppository, bisacodyl suppository, or digital stimulation used initiate process. Laxatives & enemas avoided whenever possible because lead to dependence.

Multiple sclerosis

Transmitted direct contact with or droplet spread from infected person. Droplet precautions indicated during period communicability (immediately before & after swelling begins)

Mumps

Affected by several nutrients. Include protein (especially purines), calcium, phosphorus, fluid intake, & vitamins A, B, C, & D.

Musculoskeletal system

May experience episodes respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. Ambu bag, intubation tray, & suction equipment available at bedsideSpace. Activities conserve energy & restore muscle strength. Take medication correctly maintain blood levels. Muscle-strength exercises not helpful & fatigue client. Overeating cause exacerbation symptoms, as is exposure heat, crowds, erratic sleep habit, & emotional stress.

Myasthenia gravis

Droplet precautions required because this type of pneumonia transmitted by droplet nuclei larger than 5 mm. Nurse wears mask while in room.

Mycoplasmal pneumonia

Using an oil-based contrast agentdye is removed at end of procedure. Positioned flat in bed for approximately 8 hours after dye is removed. If water-based contrast medium is used, positioned with head of bed elevated 30 degrees for 6-8 hours to keep dye from irritating cerebral meninges.

Myelography

Pain not relieved by rest & nitroglycerin & requires opioid analgesics; morphine sulfate, for relief. Pain may radiate to left arm, shoulder, jaw, and neck. Typically begins spontaneously, lasts longer than 30 minutes, & frequently is accompanied associated symptoms (such as nausea, vomiting, dyspnea, diaphoresis, or anxiety).

Myocardial infarction (MI)

ST segment elevation or depression observed.

Myocardial ischemia

Development of Q waves

Myocardial necrosis

Brief random contractions of muscle group that can occur on one or both sides of body.

Myoclonic seizure

Light rays come into focus in front of retina. Caused by an eyeball that is too long, which may be familial trait. Nearsightedness, corrected by use of concave or minus lenses in contact lenses or eyeglasses

Myopia

Surgical procedure will allow fluid to drain from middle ear & may be necessary to treat acute otitis media.

Myringotomy

Disturbance fluid endolymphatic system. Cause unknown. Can cause severe vertigo. Priority is safety issues to prevent falls or injury. Attacks may be preceded by feelings fullness in ear or by tinnitus. Dietary changes, consume low-sodium diet & restrict fluids as prescribed. Remain bed rest during acute attack. When out of bed, need assistance walking, sitting, or standing.

Ménière's disease

Possible complications: diarrhea, lactose intolerance, dumping syndrome, excess fluid volume. Aspiration pneumonia, caused by regurgitation formula contents into respiratory tract. Head of bed elevated 30 degrees at all times help prevent this complication. May be left in place from weeks to months depending on type of tube inserted.

NG tube feedings

Signs opioid withdrawal; increase temp & BP, abdominal cramping, vomiting, restlessness. Time onset few minutes to few hours after admin of naloxone hydrochloride, depending on opioid involved, degree of dependence, & dose of naloxone. Should be titrated every 2 to 5 minutes according to client response.

Naloxone hydrochloride (Narcan)

First step attempting to unclog feeding tube is gently aspirating tube. If not successful, flush tube with warm water can be tried. Carbonated liquids sometimes used for flushing clogged tube (depending agency policy & procedure), but tube must be rinsed thoroughly afterward to avoid stickiness. Replacement of tube is last step if other actions are unsuccessful.

Nasogastric (NG) feeding tube has become clogged

Check residual & placement every 4 hours. Check skin integrity site NG tube insertion. Check placement before administering medication or feeding. Feeding bag & tubing changed every 24 hours (per protocol) reduce risk bacterial contamination.

Nasogastric (NG) tube

Adverse effects include; cyanosis, excessively rapid/slow heart rate, & sudden development bloody secretions. If any of these signs observed, immediately stop suctioning & report adverse effect to HCP. Coughing normal response suctioning ,with intact cough reflex & does not indicate cannot tolerate procedure.

Nasotracheal suctioning

Diets may be deficient vitamin D because many suffer from lactose intolerance. Corn important staple in diets. Fried bread & mutton prepared in lard, & these dietary rituals have contributed increased risk gallbladder disease in population. Exhibit high-risk behaviors related alcohol abuse.

Native American

Use religion & spiritual & healing practices integrated into health care & illness practices. Eye contact avoided because; sign disrespect. Touching dead body usually is prohibited. Alcohol abuse common. Vitamin D deficiency is a concern. Corn important component diet. Increased risk for gallbladder disease.

Native-American culture

Also called innate inherited or innate-native immunity, is that immunity with which person is born. Does not require previous exposure to antigen.

Natural resistance

Symptoms; tremors, tachycardia, marked irritability, muscular rigidity, hypertension, & exaggerated startle reflex. Difficult to console & exhibit inability to respond to voices or environmental stimuli. Often poor feeders & have episodes of diarrhea.

Neonates exposed to cocaine in utero

Symptoms include increased serum lipids, edema, increased excretion of protein in the urine, & decreased serum albumin levels. Kidney disorder characterized massive proteinuria, hypoalbuminemia (hypoproteinemia), & edema. Child with edema from nephrotic syndrome high risk skin breakdown. Skin surfaces cleaned & separated with clothing to prevent irritation & resultant skin breakdown. Child will be anorexic.

Nephrotic syndrome

Weight gain; periorbital & facial edema most prominent in morning; leg, ankle, labial, or scrotal edema; decreased urine output & urine dark & frothy; abdominal swelling; blood pressure normal or slightly decreased. Massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, & pallor.

Nephrotic syndrome

Solid tumor found only in children. Arises from neural crest cells that develop into sympathetic nervous system & adrenal medulla. Tumor compresses adjacent normal tissue & organs. Neuroblastoma cells may excrete catecholamines & their metabolites. Urine samples will indicate elevated VMA levels.

Neuroblastoma

Potentially fatal syndrome, may occur any time during therapy neuroleptic (antipsychotic) medications. Characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, & skeletal muscle rigidity.

Neuroleptic malignant syndrome

Previous neurological problems; headache or back injury cause greater risk development neurological disorder. Chronic diseases; hypertension & diabetes mellitus increase risk.

Neurological disorder

WBC count drops, Reverse isolation, implemented protect the client from infection.

Neutropenic precautions

Provide first internal line defense, via phagocytosis, against foreign invaders (especially bacteria) in blood & extracellular fluid. If neutrophil count is low; risk for infection

Neutrophils

First 4-6 weeks after colostomy formation, should consume low-fiber diet. After this period, should eat high-carbohydrate, high-protein diet. Also instruct add new foods, including those with fiber, one at a time to determine tolerance to that food.

New colostomy

May be immersed in water after umbilical stump healed. Body must be supported at all times during bath. Water warm, not hot. Thermometer used to check temperature of water, should not exceed 100° F. If thermometer not available, water that is comfortable when tested on inside of wrist or elbow is appropriate.

Newborn bath

Normal heart rate ranges from approximately 120 to 160 beats/min.

Newborn infant normal heart rate

May present clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts.

Newborn infant with respiratory distress syndrome

Milk, eggs, meats, & dairy products are high in niacin.

Niacin

Epidermal blistering & sloughing precipitated by lateral finger pressure, commonly is present in pemphigus vulgaris

Nikolsky's sign

Used for urinary tract infection. Imparts harmless brown color to urine

Nitrofurantoin (Furadantin)

Contraindicated patient with renal impairment (Renal disease)

Nitrofurantoin (Macrobid

Monitoring only; fetus is not challenged or stressed by uterine contractions. Ultrasound transducer records fetal heart activity secured over abdomen, Fetal heart activity & movements are recorded.

Nonstress test

Administered 1 hour before or 2 hours after meals; food can hamper absorption. Normal dosage 400 mg orally twice daily for 7 to 10 days for mild infections or 10 to 21 days for severe infections.

Norfloxacin (Noroxin)

30 to 60 breaths per minute.

Normal Newborn Respiratory rate

90 to 130 beats/minute

Normal apical heart rate in a 12-month-old

5 to 10 mm Hg.

Normal intracranial pressure

20 to 40 breaths/minute

Normal respiratory rate in a 12-month-old

Normal 285 to 295 mOsm/kg H2O. Higher value indicates dehydration; lower value indicates overhydration.

Normal serum osmolality

Regular rhythm, with rate 60 to 100 beats/min. PR & QRS normal 0.12 to 0.20 second & 0.04 to 0.10 seconds.

Normal sinus rhythm

maintenance first patent airway, & then oxygen administration, assessment of vital signs & LOC, & dysrhythmia detection.

Nursing responsibilities after cardioversion

Presence involuntary rapid eye movements. Abnormal finding that may occur as result of disease or as a side effect of some medications.

Nystagmus

Realization that something out of sight still exists, occurs in later phases of sensorimotor stage of development.

Object permanence

Explain procedure. Clamp tubing drainage bag. Aspirate sample from port on drainage bag. Wiping port with alcohol swab before inserting syringe.

Obtain urinalysis specimen from a indwelling urinary catheter

Not easily arousable & limited interaction

Obtunded

Used to reduce growth hormone levels in clients with acromegaly. Common side effects: diarrhea, nausea, gallstone formation, & abdominal discomfort.

Octreotide (Sandostatin)

Contraindications performing test; cervical-level spinal cord injuries & severely increased intracranial pressure. Unconscious client, eye movements indication brainstem activity, doll's-eyes maneuver intact, eyes move opposite direction when head turned. Abnormal responses; movement eyes same direction as for head & maintenance midline position of eyes when head turned. Abnormal response indicates disruption processing information through brainstem.

Oculocephalic response (doll's-eyes maneuver)

Antipsychotic medication targets both positive & negative symptoms of schizophrenia

Olanzapine (Zyprexa)

Decreased stomach-emptying time & lowered basal metabolic rate cause constipation. Adequate dietary fiber aid bowel function. Dietary fiber increases fecal weight & water content & accelerates transit fecal mass through GI tract. Retention of water by fiber has ability soften stools & promote regularity. Fluid intake & exercise facilitate bowel elimination.

Older client has an increased tendency to experience constipation

Antiulcer agent. Intended effect is relief of pain from gastric irritation, often called heartburn by clients

Omeprazole (Prilosec)

Abdominal wall defect. Large herniation of gut into umbilical cord. The viscera are outside abdominal cavity but inside translucent sac covered with peritoneum & amniotic membrane.

Omphalocele

Antiemetic relief postoperative nausea & vomiting. Nausea & vomiting associated with chemotherapy

Ondansetron (Zofran)

antiemetic treat postoperative nausea/vomiting, also N&V associated with chemotherapy.

Ondansetron (Zofran)

Anticholinergic- Therapy overactive bladder. Side effects; dry mouth, constipation, tachycardia, urinary hesitancy, urinary retention, mydriasis, blurred vision, & dry eyes

Oxybutynin

Tachycardia & hypotension, confusion, tachypenia

Signs of hypovolemic shock

Has no visual ability & is blind spot of eye.

Optic disc

Vitamin C (ascorbic acid) increases absorption iron by body. (Orange Juice)

Oral iron supplements

Prescribed for portosystemic encephalopathy. Broad-spectrum antibiotic destroys normal bacteria found in bowel, decreasing protein breakdown & ammonia production.

Oral neomycin

Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered.

Orthodox Judaism

Assess hip instability. Abducts thigh & applies gentle pressure forward over greater trochanter. A "clicking" sensation indicates dislocated femoral head moving into acetabulum.

Ortolani maneuver

Bone infection & may be caused by direct contamination of bone through open wound. Bacteria invade bone tissue & produce inflammation. Ischemia & necrosis of bone tissue may follow if not treated.

Osteomyelitis

Factors increase risk; bottle-feeding, household smoking, exposure to illness from other children in day care, & congenital conditions; Down's syndrome & cleft palate. Use pacifier beyond 6 months has been identified as another risk factor. Allergies are also thought precipitate otitis media.

Otitis media

Reveals red, dull, thick, immobile tympanic membrane, with/without perforation. Postauricular lymph nodes tender & enlarged. Low-grade fever, malaise, anorexia, swelling behind ear, pain with minimal movement of head.

Otoscopic examination with mastoiditis

Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck & hand vein distention, altered LOC, & decreased hematocrit.

Overhydration or fluid overload & occurs when fluid intake or fluid retention

Circulating levels of estrogen & progesterone are high.

Ovulation ceases during pregnancy because?

Causes constipation, instructed increase fluid intake & bulk (high fiber) in diet. If heart beats fast, HCP notified could indicate overdose. Diarrhea could indicate incomplete intestinal obstruction HCP notified.

Oxazepam (Serax)

Aids digestion protein, carbohydrate, & fat in gastrointestinal tract. Treat steatorrhea associated with postgastrectomy syndrome after bowel resection. Record number of stools per day & stool consistency to monitor effectiveness of enzyme therapy. If effective, stools should become less frequent & less fatty.

Pancreatin (Viokase)

Pancreatic enzyme used as digestive aid for pancreatitis. Reduce amount fatty stools (steatorrhea). Also help improve nutritional status

Pancrelipase (Pancrease MT)

Associated with feeling dread & terror & sense of impending doom. If prolonged, panic can lead to exhaustion & death.

Panic

Stage I carcinoma strictly confined to cervix. Stage II, carcinoma has extended beyond cervix but has not extended to pelvic wall. Stage III carcinoma has extended to pelvic wall at lower third of vagina, & in stage IV, carcinoma has extended beyond true pelvis or has clinically involved mucosa of bladder or rectum.

Papanicolaou smear (PAP), test for cancer

Upright position allows intestine to float posteriorly & helps prevent intestinal laceration during catheter insertion. Ideally sits upright in chair, with feet flat on floor & with bladder emptied before procedure.

Paracentesis

Instructing to do what client fears &, if possible, exaggerate outcome of this exposure to point of humor

Paradoxical intention

Most common form nonmechanical obstruction, Inability to pass flatus, pain usually manifests as more constant generalized discomfort.

Paralytic ileus

Observes for signs of bleeding, may cause swelling & compression of adjacent tissues. Laryngeal stridor results from compression of trachea & is a harsh, high-pitched sound heard on inspiration & expiration. Laryngeal stridor is acute emergency, necessitating immediate attention to avoid complete obstruction airway.

Parathyroidectomy

10% dextrose in water until new PN solution becomes available.

Parenteral nutrition; If PN bag empty hang

Temperature and weight: Temperature monitored to detect infection, potential complication of therapy. Infection also could result in sepsis because catheter in blood vessel. Weight monitored for effectiveness nutritional therapy & detect hypervolemia.

Parenteral nutrition; PN monitor

Burns, exacerbation Crohn's disease, persistent nausea & vomiting due to chemotherapy. Had extensive surgery, multiple fractures, are septic, have advanced cancer or AIDS. (Electronic infusion pump used to administer)

Parenteral nutrition; Patients needing

Tremors, masklike facies, rigidity, & shuffling gait.

Parkinsonism

Formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn.

Parkland (Baxter) formula

Fungal infection; results inflammation nail fold, with separation fold from nail plate. Affected area generally is tender to touch & has purulent drainage.

Paronychia

Antidepressant treatment of major depression.

Paroxetine hydrochloride (Paxil)

Treat developmental dysplasia hip. Provides support & stability hips. Worn 16-23 hours day; removed only check skin & for bathing. Infant may be moved when out of harness, but hips & buttocks should be supported carefully. Harness does not need to be removed for diaper changes or feedings.

Pavlik harness

Avoid frequent douching; decreases natural flora that controls growth infectious organisms. Wear cotton undergarment, clothes should not fit tightly. Tampon changed frequently but not used during acute infection. Many HCPs recommend avoiding use tampons indefinitely. Intrauterine devices increase client susceptibility to PID.

Pelvic inflammatory disease (PID)

Autoimmune disease causes blistering in epidermis. Large flaccid blisters (bullae). Blisters are in epidermis, have thin covering of skin & break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters.

Pemphigus

Blood pressure is monitored during administration; can cause severe & sudden hypotension, even with single dose. Supine while receiving medication, & resuscitation equipment should be available.

Pentamidine (Pentam 300)

Helicobacter pylori infection, smoking (nicotine), chewing tobacco, corticosteroids, aspirin, (NSAIDs), caffeine, alcohol, & stress. Certain medical conditions; Crohn's disease, Zollinger-Ellison syndrome, & hepatic & biliary disease can increase risk.

Peptic ulcer disease risk factors

Described as a scratchy, leathery heart sound.

Pericardial friction rub

Positioned supine head of bed elevated at a 45- to 60-degree angle. Places heart close proximity to chest wall for easier insertion of needle into pericardial sac.

Pericardiocentesis to treat cardiac tamponade

Pericardial friction rub is heard when inflammation pericardial sac is present during inflammatory phase of pericarditis. Chest pain worsens inspiration characteristic of both pericarditis & pleurisy.

Pericarditis

Long-term management consists measures that increase peripheral circulation (exercise), promote vasodilation (warmth), relieve pain, & maintain tissue integrity (foot care & nutrition).

Peripheral arterial disease (PAD)

Central line inserted upper arm. Flexible catheter that terminates in superior vena cava of heart. Placement verified by x-ray. PICCs intended long-term intravenous catheter placement. Reasonable cost; do not need routine replacements; reliable. Less likely result in infiltration & can be used for administration of number different types medications without extravasation.

Peripherally inserted central catheter (PICC)

Classic sign; weakness, mild diarrhea, & smooth, sore, red tongue. May also have nervous system signs & symptoms; paresthesias, difficulty with balance, & occasional confusion. The Schilling test used determine cause vitamin B12 deficiency, which leads to pernicious anemia

Pernicious anemia

(MAOI) Avoid foods high in tyramine. Ingestion of these foods could trigger potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; fruits such as avocados, raisins, or figs.

Phenelzine (Nardil); for depression

Anticonvulsant & hypnotic agent. Avoid taking any other central nervous system depressants such as alcohol while taking medication.

Phenobarbital sodium (Luminal)

Target range therapeutic serum level of phenytoin between 10 & 20 mcg/mL. Below 10 mcg/mL too low control seizures. Above 20 mcg/mL, signs toxicity appear. IV admin performed slowly (no faster 50 mg/min) rapid administration can cause cardiovascular collapse. Monitors CBC because hematological effects of this therapy include aplastic anemia, agranulocytosis, leukopenia, & thrombocytopenia. (Antiseizure medication (specifically phenytoin) taken during pregnancy is known risk factor in development of cleft lip & cleft palate)

Phenytoin (Dilantin)

Therapeutic serum drug level range is 10 to 20 mcg/mL. Soft toothbrush while taking medication, Alcohol avoided, may turn urine pink, red, or brown

Phenytoin (Dilantin)

Catecholamine-producing tumor. Severe Hypertension can precipitate stroke or sudden blindness. Monitor vital signs, particularly blood pressure. Normal range of urinary catecholamines is14 mcg/100 mL of urine, higher levels in pheochromocytoma.

Pheochromocytoma

At IV site can be distinguished by discomfort at site, as well as redness, warmth, & swelling proximal to catheter. IV line should be discontinued, & new line should be inserted at different site.

Phlebitis

Discomfort at site, redness, warmth, & swelling proximal to catheter. If phlebitis occurs, discontinue IV line & insert new IV line at different site. Apply warm moist compresses to area speed resolution of inflammation. Notify (HCP). Document occurrence, actions taken, & client response.

Phlebitis at IV site:

Decreased appetite/thirst, decreased blood pressure, loss of consciousness, loss of bowel & bladder control, & decreased tactile sensation.

Physical signs of approaching death

Verifies placement by ventilating using Ambu bag & auscultating breath sounds bilaterally, which ensures ventilation both lungs. After this assessment, placement checked radiographically. Marks ET tube at point where enters nose/mouth for ongoing monitor correct placement, but will not determine initial adequate placement ET tube.

Placement endotracheal (ET)

Improperly implanted placenta lower uterine segment. Manual pelvic exam contraindicated vaginal bleeding apparent until diagnosis made & placenta previa ruled out. Digital exam cervix can lead to hemorrhage. Diagnosis by ultrasound. Hemoglobin/Hematocrit level monitored, external electronic fetal heart rate monitoring initiated; crucial evaluating status fetus, risk for severe hypoxia. Soft abdomen & painless, bright red vaginal bleeding in second/third trimester pregnancy symptom. (Sudden onset painless vaginal bleeding)

Placenta previa

Heavier material than synthetic cast. Molds to extremity & less expensive than synthetic cast. 24 hours to dry, but could be longer, depending on size of cast. Not water resistant & when wet begin to disintegrate. Elevate on pillow first day decrease swelling as cast molds to extremity. Imperative that child can wiggle fingers because extremity continues to swell. Color & sensation of fingers should also be assessed.

Plaster of Paris

Increased platelet aggregation may occur after surgery or with acute illness, venous thrombosis, & pulmonary embolism. Decreased platelet aggregation may occur with infectious mononucleosis, idiopathic thrombocytopenia purpura, acute leukemia, or von Willebrand's disease.

Platelet aggregation

Necessary for proper blood clotting. Insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, & mucous membranes.

Platelets

Has a flat shape

Platypelloid pelvis

Complications after include hemothorax, pneumothorax, & temporary pain from intercostal nerve injury. Have chest tube & drainage system available at bedside for use if hemothorax or pneumothorax develops

Pleural biopsy

Characterized sounds; creaking, groaning, or grating. Localized over area of inflammation on pleura & may be heard in both inspiratory & expiratory phases of respiratory cycle.

Pleural friction rub

Inflammation visceral & parietal pleurae. Inflammation prevents parietal & visceral pleural surfaces from gliding over each other with respiration. Experiences pain, especially with inspiration. Pleural friction rub auscultated early in course of pleurisy before pleural fluid accumulates. Once fluid accumulates in inflamed area, friction between visceral & parietal lung surfaces decreases, & pleural friction rub disappears.

Pleurisy

Surgical removal of all or part of lung. After surgery perform arm & shoulder exercises two or three times a day to prevent frozen shoulder. Encouraged drink liquids to liquefy secretions, making easier to expectorate. Expect soreness in chest & shoulder & altered feeling of sensation around incision site for several weeks. If signs respiratory infection occur, HCP notified. Perform breathing exercises first 3 weeks at home & space activities allow frequent rest periods. Avoid heavy lifting any objects more 20 pounds until muscles of chest wall have healed completely, which takes about 3-6 months. Expect feelings of weakness & fatigue first 3 weeks after surgery.

Pneumonectomy

Hematuria & flank or lumbar pain; colicky in nature or dull & aching. Proteinuria, calculi, uremia, palpable kidney masses & Hypertension other common findings.

Polycystic kidney disease

Disorder bone marrow, Excessive production WBC, red blood cells, & platelets. More likely form blood clots that can cause thrombi, strokes, myocardial infarctions, & abnormal bleeding. Hypertensive

Polycythemia vera

Necrosis & inflammation are seen in muscle fibers & myocardial fibers.

Polymyositis

Side-lying position with legs flexed or prone position to keep hips elevated. Positions will reduce edema & pressure on surgical site.

Position Infant after surgical intervention for imperforate anus

tested insupine position. Flexes head (gently moves head to chest) & there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if passively flexes hip & knee in response to neck flexion & reports pain in vertebral column.

Positive Brudzinski's sign

Fetal heart rate detected by electronic device (Doppler transducer), active fetal movements palpable by examiner, & outline fetus by radiography or ultrasonography.

Positive signs of pregnancy

Detect abnormal brain tissue metabolism. Detects abnormal glucose metabolism in brain.

Positron emission tomography (PET)

Supplies posterior wall of the heart.

Posterior descending coronary artery (PDA)

ADH & oxytocin are synthesized by hypothalamus & stored in posterior pituitary gland

Posterior pituitary gland

Every 15 minutes first hour, every 30 minutes 2 hours, every hour 4 hours, & then every 4 hours as needed

Postoperative assessment activities monitoring

Symptoms; delay uterine involution, foul-smelling lochia, tachycardia, abdominal tenderness, temp elevation up to 104° F. Intrauterine infection may lead to further maternal complications. infections; fallopian tubes, ovaries, & blood (sepsis). Care; Maintaining adequate hydration (3000-4000 mL/day), bed rest Fowler's position facilitate drainage & lessen congestion, provide appropriate analgesia lessen pain, & administering antibiotics prescribed.

Postpartum endometritis

Use specific positions; vary depending on affected (Lobe or Lobes). Usually place head lower than affected lung segments facilitate drainage of secretions. Postural drainage often done in conjunction chest percussion for maximum effectiveness.

Postural drainage

foods high in potassium; bananas, cantaloupe, kiwi, & oranges.

Potassium

(Eyelid drooping) Sagging of upper lid of eye so that it covers part of pupil. It can be caused by edema, or it can be result of third cranial nerve disorders or neuromuscular disorders

Ptosis

Results from pulling force on muscle, resulting soreness & pain with muscle use

Strain

Completely immobile, lost protective reflexe shift body weight. Reposition every 2 hours. Use bed cradle protect toes from breakdown due to weight from linen. Protective pads can be applied heels & elbows reduce friction & shear. Appropriate perineal care essential keep waste products from excoriating skin. Reduce skin dryness & irritation adding superfatty solution (such as baby oil or castile soap) daily bath water. Drying agents such as alcohol avoided because dry skin can crack & break down.

Potential skin integrity problems for unconscious client

may decrease effect oral hypoglycemics, insulin, diuretics, & potassium supplements.

Prednisone

Calcium present in dark green leafy vegetables, broccoli, legumes, nuts, & dried fruits.

Pregnant client lactose intolerance

Isoniazid plus rifampin (Rifadin) will be required for 9 months.

Pregnant client tuberculosis is suspected; sputum culture obtained & identifies Mycobacterium tuberculosis

Absence of P waves, presence of wide & bizarre QRS complexes, & compensatory pause that follows ectopy. (Premature beats followed by a compensatory pause)

Premature ventricular contractions (PVCs)

Considered dangerous when frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on T wave.

Premature ventricular contractions (PVCs)

1. Close the roller clamp on the IV tubing. 2. Spike the IV bag & half-fill drip chamber. 3. Open roller clamp & fill the tubing. 4. Uncap the distal end of the tubing 5. Attach distal end of the tubing to the client

Prepares solution & IV tubing; Arrange actions in order

Sensorineural hearing loss that occurs with aging.

Presbycusis

1. Check compatibility phenytoin with IV solution. 2. Draw up medication in a 3-mL syringe. 3. Check client's identification (ID) bracelet. 4. Pinch off IV tubing above injection port. 5. Inject the medication. 6. Document medication was administered.

Prescription administer phenytoin (Dilantin) by intravenous push (IVP) throughIV line infusing 1000 mL of 0.9% sodium chloride. Arrange actions in order

Three enemas may be given when prescription for enemas until clear. If more than three necessary, should call HCP (or act according to agency policy). Excessive enemas could cause fluid & electrolyte depletion.

Prescription for enemas until clear

The skin is intact in stage I. stage II, skin not intact. Partial-thickness skin loss dermis. Shallow open ulcer with red-pink wound bed, without slough or intact, open or ruptured, serum-filled blister. Full-thickness skin loss occurs stage III. Exposed bone, tendon, muscle present stage IV

Pressure ulcers

Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea) occurs.

Respiratory alkalotic

Painless vision changes & "tunnel vision.

Primary open-angle glaucoma (POAG)

Keeping crisis from occurring. Activities are actions designed to prevent disease from occurring or to reduce probability of occurrence of a specific illness. Periodic well-baby examinations focus on health education, nutrition, concerns related to adequate housing, recreation, & genetics. Focus on prevention.

Primary prevention

Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement, Braxton Hicks contractions, & positive pregnancy test for presence of HCG.

Probable signs of pregnancy

Antidysrhythmic used treat ventricular dysrhythmias client allergic to lidocaine

Procainamide

Use 500 to 1000 mL warm tap water. Suspended 18 inches above stoma. Cone is inserted 2-4 inches into stoma but never be forced. Cramping occurs, decrease flow rate irrigant as needed by closing irrigation clamp.

Procedure colostomy irrigation

Antiemetic & antipsychotic agent. Side effect; blurred vision, constipation, dry mouth, & dry eyes.

Prochlorperazine

When umbilical cord protruding, actions immediately directed at reducing cord compression & facilitating delivery fetus. Cord wrapped loosely in sterile towel saturated warm normal saline, prevent from drying out & becoming compressed. Placed extreme Trendelenburg's or modified Sims' position or knee-chest position to reduce compression.

Prolapsed cord

Bowel protrudes through stoma, causing elongated & swollen appearance to stoma

Prolapsed stoma

caused decreased absorption vitamin K in intestine with decreased production prothrombin by liver.

Prolonged prothrombin time

Cannot maintain hands supinated position with arms extended & eyes closed. Assessment may be done to detect small changes muscle strength that might not otherwise be noted.

Pronator drift

Treat hyperthyroidism, or Graves' disease. Excessive dosing may convert hyperthyroid state to hypothyroid state. If this occurs, dosage should be reduced. Adverse effect of PTU is agranulocytosis. Early signs adverse effect; fever & sore throat.

Propylthiouracil (PTU)

Early signs; Nocturia, decreased force urinary stream, & difficulty initiating urinary stream.

Prostatic hyperplasia (BPH)

Symptoms; reduced force & size of urinary stream, intermittent stream, hesitancy beginning flow of urine, inability stop urinating, sensation of incomplete bladder emptying after voiding, postvoid dribbling of urine, & increase in episodes of nocturia.

Prostatism

Lesions or patches appear as red, raised papules that may coalesce into large plaques covered by silvery scales. Affected areas include scalp, elbows, knees, shins, sacral area, & trunk. Incidence is lower in darker-skinned races & ethnic groups.

Psoriasis

State in which person's mental capacity recognize reality, communicate, & relate to others is impaired, interfering with person's ability to deal with life's demands.

Psychosis

Informed consent form is required. Shaves & surgically cleans anticipated entry site. Procedure is explained, asked about allergies to shellfish or contrast media. Oral ingestion except for sips of water avoided for 4-6 hours before test. x-ray imaging blood vessels of lungs after injection of contrast material

Pulmonary angiography

Common initial symptom chest pain; sudden in onset. Next common symptom dyspnea, accompanied by increased respiratory rate. Other symptoms PE include apprehension, restlessness, tachycardia, cough, & cyanosis.

Pulmonary embolism

Oxygen administered, 8 to 10 L/min, by face mask. Oxygen used decrease hypoxia. Kept on bed rest with head of bed slightly elevated reduce dyspnea. Morphine sulfate may be prescribed, not initial nursing action. IV also required, & vital signs need to be monitored, but these actions would follow administration of oxygen.

Pulmonary embolism is suspected

Treated same way ventricular fibrillation with measures that include defibrillation, CPR & medication therapy, with agents such as vasopressin, epinephrine, amiodarone, lidocaine, & magnesium sulfate.

Pulseless ventricular tachycardia

Promote carbon dioxide elimination; facilitates maximal expiration with obstructive lung disease. Allows better expiration by increasing airway pressure that keeps air passages open during exhalation.

Pursed-lip breathing

Risk factors; DM, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities urinary tract, presence urinary stones, & presence indwelling urinary catheter or frequent catheterization.

Pyelonephritis

Projectile vomiting, irritability, hunger & crying, constipation, & signs dehydration including decrease urine output.

Pyloric stenosis

Vomit contains sour undigested food without bile, & constipation

Pyloric stenosis

Anti-TB medication given with other anti-tuberculosis medications. Pyrazinamide might not be discontinued if sputum cultures continue to be positive.

Pyrazinamide

Antituberculosis med given in conjunction with other TB meds. May be discontinued by HCP if sputum cultures become negative.

Pyrazinamide (Pyrazinamide)

Teaching & assessments

RN

Heat from body surface radiates to surrounding environment.

Radiation

Sometimes age has to do with decision for radiation therapy. Usually delayed until child 8 years old, whenever possible, prevent retardation of bone growth & soft tissue development.

Radiation therapy

Term used to describe spinal nerve root compression at the intervertebral foramen.

Radiculitis

Integrase inhibitor & acts by inhibiting human immunodeficiency virus (HIV) replication. Side effects include itching, nausea & diarrhea, headache, & fatigue. Temperature of 101.2° F indicative potential infection, adverse effect of this medication.

Raltegravir (Isentress)

Focuses on how irrational beliefs and thoughts contribute to psychological distress. Correction distorted thinking.

Rational emotive therapy

Peripheral vascular disease; abnormal vasoconstriction extremities. Smoking cessation most important lifestyle change must make. Palpation diminished/absent peripheral pulses checks for interruption of circulation. Skin changes include hair loss, thinning or tightening of skin, & delayed healing of cuts or injuries. Nails grow slowly, become brittle or deformed, & heal poorly around nail beds when infected.

Raynaud's disease

Surfactant replacement exogenous surfactant preparation instilled into lungs through endotracheal tube.

Respiratory distress syndrome diagnosed, surfactant replacement therapy prescribed. Route used to administer this medication?

Occurs rather predictable times that correspond when certain bladder volume is attained.

Reflex incontinence

Client on bed rest who requires range-of-motion (ROM) exercises every 4 hours

Registered nurse is planning client assignments for day. Which is most appropriate assignment for the unlicensed assistive personnel (UAP)?

ET tube suctioned first, & then cuff is deflated & tube is removed.

Removal endotracheal (ET) tube

Creatinine level frequently used laboratory test determine renal function. Increases when at least 50% of renal function is lost.

Renal function disorder

Rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals approximately 30 minutes before meals & should be withheld if client does not eat. Hypoglycemia is a side effect of repaglinide & client should always be prepared by carrying a simple sugar with her or him at all times.

Repaglinide(Prandin)

Respiratory rate & depth increase to compensate. Headache; restlessness; mental status changes, drowsiness & confusion. Visual disturbances; diaphoresis; cyanosis as hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; & dysrhythmias

Respiratory acidosis

Decreased pH and an increased CO2. Hypoventalation & COPD

Respiratory acidotic

Clinical manifestations include decrease respiratory rate & depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of fingers & toes, hypokalemia, hypocalcemia, tetany, & convulsions

Respiratory alkalosis

described as Pao2 of 60 mm Hg or lower & Paco2 of 50 mm Hg or higher in client with no history of respiratory disease.

Respiratory failure

Highly communicable disorder. Not transmitted airborne route. Usually transferred by hands. Use contact & standard precaution during care (wearing gloves & gown) reduce nosocomial transmission of RSV. Isolated private room or room with another infant with RSV infection. Cool humidified oxygen delivered relieve dyspnea, hypoxemia, & insensible water loss from tachypnea.

Respiratory syncytial virus (RSV)

CO2 acts as an acid in body. Rise in blood CO2 will result in a fall in blood pH.

Retaining carbon dioxide (CO2)

Is responsible for the sleep-wake cycle.

Reticular activating system

Resemble a net in appearance

Reticular skin lesions

Immature RBC. Count increased any time there is accelerated production of RBCs. Decreased when bone marrow has slowed production of RBCs.

Reticulocyte

supportive care, monitoring & managing cerebral edema. Decrease stimuli environment quiet & dimmed lighting would decrease stress on cerebral tissue & neuron responses.

Reye's syndrome

Child will exhibit elevated ASO titer, elevated ESR, leukocytosis, & positive result on CRP determination. Initial diagnosis is made by noting presence of Aschoff's bodies.

Rheumatic fever

Most likely cause is activation of an autoimmune response.Test for rheumatoid factor detects presence of unusual antibodies of IgG & IgM type, which develop in a number of connective tissue diseases.

Rheumatoid arthritis

Characterized by chronic joint pain, variable intensity, more severe on rising in morning. Age onset most common between 30-50 years. (Early symptoms; Fatigue & morning stiffness, generalized weakness, anorexia, & weight loss) may appear before joint manifestation

Rheumatoid arthritis (RA)

Tests for presence unusual antibodies of IgG & IgM types, which develop in some connective tissue diseases.

Rheumatoid factor assay tests

Given to Rh-negative clients to prevent sensitization.

Rho(D) immune globulin (RhoGAM)

Presence rhonchi; indication there are secretions in large airways. Require suction if he/she cannot expectorate them.

Rhonchi

Usually heard on expiration when there is excessive production mucus that accumulates in air passages.

Rhonchi

Active against RSV, influenza virus types A & B, & herpes simplex virus. Administered oral inhalation. Absorbed from lungs & achieves high concentrations respiratory tract secretions & erythrocytes.

Ribavirin (Virazole)

Antiviral respiratory medication used mainly for hospitalized children with severe RSV. Administration via hood, face mask, or oxygen tent.

Ribavirin (Virazole)

Causes orange-red discoloration body secretions & will permanently stain soft contact lenses. Wearing glasses instead of soft contact lenses will be necessary. Taken empty stomach unless GI upset, & then may be taken with food. Antacids, if prescribed, taken 1 hour before medication.

Rifampin (Rifadin)

Supplies right side of heart, including right atrium & right ventricle.

Right coronary artery (RCA

Represents increased number mature neutrophils

Right shift

Early menarche, Family history breast cancer, High-dose radiation exposure to chest, Previous cancer of breast, uterus, or ovaries

Risk factors for breast cancer

Cause orthostatic hypotension. Sunlight avoided. Psychotropic med, caution with (driving, other activities requiring alertness) determine if alertness affected. Atypical antipsychotic renal & liver function studies done.

Risperidone (Risperdal)

Help others express their feelings toward one another during group sessions.

Rogerian therapy

Stand feet together & arms at sides, close eyes & hold position; normally client can maintain posture & balance. Positive Romberg's sign is a vestibular neurological sign found when client exhibits loss balance when closing eyes.

Romberg's test

Contains 21% oxygen

Room air

Treat idiopathic parkinsonian syndrome. Normally administered three times day to treat client.

Ropinirole hydrochloride (Requip)

Transmitted via saliva, so others should not share drinking glasses or eating utensils.

Roseola

*Pregnancy avoided for 1-3 months. *Vaccine administered subcutaneous route.*Exposure immunosuppressed individuals avoided. *Hypersensitivity reaction can occur if client has allergy to eggs.

Rubella virus vaccine Postpartum

Communicable period 4 days before to 5 days after rash appears. Small blue-white spots with red base may appear in mouth; Koplik's spots. Respiratory symptoms; profuse runny nose, cough, & fever occur before rash. Rash usually begins on face & spreads downward toward feet

Rubeola (measles)

Transmitted airborne particles or direct contact with infectious droplets. Airborne droplet precautions required, & should wear masks. Private room if hospitalized, & door remains closed. Standard precautions used. Needs rest. consideration in rubeola is eye care. Child usually has photophobia, suggest parent keep child out of brightly lit areas.

Rubeola (measles)

Right arm is equal to 9%. Leg is equal to 18%. Anterior thorax equal to 18% Posterior thorax is equal to 18%. Head equal to 9% & perineum is equal to 1%

Rule of nines

Skin traction to realign fracture in lower extremity & immobilize hip & knee in a flexed position. Important keep hip flexion at prescribed angle prevent fracture malalignment.

Russell's traction

Early signs; localized itching & edema, followed by more severe symptoms such as respiratory distress, stridor, & decreased blood pressure.

Signs allergic reaction to contrast dye

Appears burrows or fine, grayish red, threadlike lines. May be difficult to see if they are obscured by excoriation & inflammation. Multiple straight or wavy, threadlike lines beneath skin. Wear a gown & gloves for close contact.

Scabies

Identified by multiple straight or wavy thread-like lines beneath skin

Scabies

Pastia's sign, White strawberry tongue, Edematous & beefy-red pharynx.

Scarlet fever

Relationship between brain levels dopamine & symptoms of schizophrenia. Prognosis is negatively affected when onset of symptoms occurs during adolescent years. Although medication compliance is a strong factor in minimizing recurrence of relapses, it is not only factor that has an effect. Schizophrenia has an effect on reasoning & perception, likelihood of experiencing difficulty in school is not certain. (Limit caffeine) Caffeine can inhibit action of psychotropic medications. Most clients will require continuous medication therapy to manage their symptoms. Although medication compliance is strong factor in minimizing reoccurrence of relapses, relapse could occur.

Schizophrenia

Expulsion placenta with fetal side presenting first.

Schultz presentation

Chronic connective tissue disease. Corticosteroids prescribed treat inflammation. Topical agents may provide some relief from joint pain. Activity encouraged as tolerated & room temperature constant. Clients need sit up for 1-2 hours after meal if esophageal involvement present

Scleroderma

Abnormal lateral curvature in any area spine. Region most commonly affected is right thoracic area, where it results in rib prominence

Scoliosis

Anticholinergic medication; side effect dry mouth, urinary retention, decreased sweating, & dilation pupils.

Scopolamine

When the cervix is dilated completely & ends with birth of the neonate.

Second Stage of Labor begins

Involves redefining threat; implementation of new coping methods that can result in resolution of problem. Resolution does not occur second phase, progresses to severe or panic levels of anxiety reflective of third phase of response.

Second phase of crisis response

Reducing intensity & duration of crisis. Screening level that entails such procedures as vision screening, mammography, or similar screening tests.

Secondary prevention

Antiparkinsonian medication. Increases dopaminergic action, assisting reduction tremor, akinesia, & rigidity of parkinsonism

Selegiline hydrochloride (Eldepryl)

Scissors kept bedside at all times. Observe for sudden respiratory distress, which occurs if gastric balloon ruptures, moving entire tube upward. If occurs, all balloon lumens cut & tube is removed.

Sengstaken-Blakemore tube

Used with diagnosis cirrhosis with ruptured esophageal varices if other treatment measures unsuccessful. Tube has esophageal & gastric balloon. Esophageal balloon exerts pressure on ruptured esophageal varices & stops bleeding. Gastric balloon holds tube in correct position & prevents migration of esophageal balloon, which could harm client. When balloon deflated and removed, may begin to bleed again from esophageal varices, manifested vomiting of blood (hematemesis). Complaint of severe pain with abrupt onset, the tube is cut & removed,

Sengstaken-Blakemore tube

Treatment of constipation, It increases peristalsis.

Senna (Senokot)

occurs as result pathological process in inner ear, defect in 8th cranial nerve, or defect of sensory fibers that lead to cerebral cortex.

Sensorineural hearing loss

manifests with bleeding with odor, cervical dilation, and fever. Cramping may or may not be present.

Septic Abortion

Occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, & development of shock

Septicemia

Administered once every 24 hours. Administered morning or evening, but evening administration may be preferable because drowsiness is side effect.

Sertraline (Zoloft); antidepressant

Therapeutic level 1.0 to 1.5 mEq/L during acute mania & levels of 0.6 to 1.4 mEq/L for maintenance treatment. A level of 3.9 mEq/L is in the toxic range, and seizures may occur at levels of 3.5 mEq/L and higher.

Serum lithium levels

Significant somatic complaints, ineffective functioning, loud or rapid speech, & purposeless activity. (Hyperventilation, pacing, rapid speech, & headache)

Severe anxiety

Can trigger disseminated intravascular coagulation (DIC). Evidence of bleeding, such as in gums, petechiae, & purpura should be reported to HCP if noted on assessment.

Severe preeclampsia

Maintained bed rest lateral position. Only bathroom privileges allowed. Keeping room semi-dark, initiating seizure precautions, & padding side rails of bed accurate interventions. Environmental stimuli such as interactions with visitors kept at minimum to avoid stimulating central nervous system & causing seizure.

Severe preeclampsia

Assessment finding include difficulty walking/sitting; torn, stained, bloody underclothing; pain, swelling, itching of genitals; & bruises, bleeding, lacerations in genital or anal area.

Sexually abused child

Severe anemia predominantly affects African Americans. Characterized by presence of Hgb S. Must have two abnormal genes encoding Hgb S to have sickle cell disease. Increased reticulocyte count, & presence nucleated red blood cells. Reticulocyte counts increased in children with sickle cell disease because life span of their sickled red blood cells is shortened.

Sickle cell anemia

Avoid infections, can increase metabolic demand & cause dehydration, precipitating a crisis. Fluids important prevent dehydration, which could lead to crisis. Warm weather & mild exercise not need to be avoided; should take measures avoid dehydration during these conditions. Priorities management are hydration therapy & pain relief. Given IV fluids promote hydration & reverse agglutination of sickled cells in small blood vessels. Opioid analgesics may be given relieve pain. Oxygen administered according individual need.

Sickle cell crisis

Fracture of bone across entire shaft with some possible displacement, but without breaking skin

Simple fracture

Consist twitching of extremity, face, or neck, or sensation of twitching or numbness in extremity or face or neck

Simple partial seizures

Include loss of or change of job, death of loved one, abortion, change financial status, divorce, addition new family members, pregnancy, & severe illness

Situational crisis

Outermost layer, Stratum corneum. Which contains the horny or cornified cells.

Skin cells that slough off

Achieved by Ace wraps, boots, & slings that apply direct force on skin. Traction maintained with 5 to 8 lb of weight, & this type of traction can cause skin breakdown.

Skin traction

multiply number packs smoked per day by number of years of smoking.

Smoking history pack years

Right eye tested, then left eye, & then both eyes tested. Visual acuity measured with or without corrective lenses & at distance 20 feet from chart.

Snellen chart

Vision 20/20 normal; client able read from 20 feet what person with normal vision can read from 20 feet. Visual acuity 20/60 can read distance of 20 feet what person with normal vision can read at 60 feet.

Snellen chart

Visual acuity & cranial nerve II (optic).

Snellen eye chart

Fear situations which one might be embarrassed, criticized; fear of speaking, performing, eating in public. Fears making fool of oneself.

Social phobia

Normal sodium level 135-145 mEq/L. Medications known to increase sodium levels include anabolic steroids, oral contraceptives, & nonsteroidal anti-inflammatory drugs.

Sodium

Used irrigating & cleaning necrotic or purulent wounds. Can be used for packing necrotic wounds but cannot be used pack purulent wound because solution inactivated by copious pus.

Sodium hypochlorite (Dakin's)

Used for treatment of hyperkalemia. Releases sodium ions primarily in exchange for potassium ions. Therapeutic effect occurs 2-12 hours after oral administration & longer after rectal administration.

Sodium polystyrene sulfonate (Kayexalate)

Stiff, short steps with legs held together, hip & knees flexed, & toes that catch & drag.

Spastic gait

Dissolve any clots in coronary arteries.

Streptokinase (Streptase)

Bright red center with legs that radiate outward. Commonly seen in liver disease & vitamin B deficiency, although they occasionally can occur without underlying pathology.

Spider angiomas

Motor nerve impacting shoulder function.

Spinal accessory nerve

Elevate the shoulders

Spinal accessory nerve (CN XI)

Must inspect environment for safety hazards. Avoiding prolonged sitting & standing. Loosen brace during meals & for 30 minutes after each meal. May have difficulty eating if brace too tight. Loosening brace after each meal will allow adequate nutritional intake & promote comfort.

Spinal fusion & wearing a brace

Risk for developing hyperkalemia. Potassium-sparing diuretic; results in excretion sodium, chloride, & water & retention of potassium & phosphate.

Spironolactone (Aldactone)

Maternal infection; syphilis, toxoplasmosis, & rubella are causes.

Spontaneous abortion

Injury ligament caused by wrenching or twisting motion & manifested by pain, swelling, & inability to use joint or bear weight normally.

Sprain

Soft tissue injuries; sprains treated with RICE (rest, ice, compression, & elevation) first 24-48 hours after injury. Iceapplied intermittently for 20- 30 minutes at time. Rest & not walk around, foot should be elevated.

Sprained ankle

Induced by exercise & relieved by rest or nitroglycerin tablets. Triggered by a predictable amount effort or emotion

Stable angina

Skin rash that appears within 2 to 30 days infection, generally at site of tick bite. Rash develops into concentric ring, giving bull's-eye appearance (however, not all clients develop this characteristic). Lesion enlarges to up to 50 to 60 cm, & smaller lesions develop farther away from original tick bite. In stage I, most infected persons experience flulike symptoms that last 7 to 10 days & may recur later in disease course. A 3- to 4-week course oral antibiotic therapy is recommended during stage I.

Stage I Lyme disease

Disease develops within 1-6 months in a majority untreated persons. Most serious problems include cardiac conduction deficits & neurological disorders; Bell's palsy & paralysis. Later stages of Lyme disease may require therapy with IV antibiotics, such as penicillin G.

Stage II of Lyme disease

Develops within month to several months after initial infection. Symptoms; arthralgias & enlargement or inflammation of joints, which can persist for several years after initial infection.

Stage III of Lyme disease

Narrow opening

Stenosed Stoma

1. Explain the procedure to the client. 2. Apply pressure over ulnar & radial arteries 3. Ask open & close the hand repeatedly. 4. Release pressure from the ulnar artery. 5. Assess color extremity distal to pressure point. 6. Document the findings

Steps in which order to conduct an Allen's test? Allens test; determines adequacy of ulnar circulation

Ability identify form common objects using sense of touch. Identify objects placed in hand, one at a time

Stereognosis

Sunken & hidden stoma (Sinking in of stoma)

Stoma retraction

Stomach capacity 10-20 mL newborn infant, 30-60 mL 1-week-old infant, 75-100 mL 2- to 3-week-old infant, & 90-150 mL 1-month-old.

Stomach capacity

Inflammation of mucous lining in the mouth.

Stomatitis

Obtained using sterile gloves & sterile container. After obtaining specimen, stool is sent immediately to laboratory

Stool smear specimen

condition eyes not aligned because lack coordination of extraocular muscles. May in child when complains frequent headaches, squints, tilts head to see. Other manifestations include crossed eyes, closing one eye to see, diplopia, photophobia, loss of binocular vision, or impairment of depth perception.

Strabismus

Muscle or ligament used beyond limit of its functional ability. Characterized by overstretching of muscle or ligament & also could involve tearing if strain is more severe (i.e., second- or third-degree strain versus first-degree strain).

Strain

Pink or red without any blistering. Skin blanches to touch, may be edematous & painful, & heals on its own, usually within 1 week.

Superficial burns

Early signs Periorbital edema, edema face, tightness of a shirt or blouse collar. As worsens, experiences edema hands & arms. Cyanosis & mental status changes are late signs.

Superior vena cava syndrome

Head of bed kept 30 degrees (Semi-Fowlers) promote venous outflow through jugular veins

Supratentorial craniotomy

On the left side, with the head lower than the feet. This position used to minimize effect of air traveling as a bolus to lungs by trapping it in right side of heart.

Suspects air embolism. Should immediately place client in which position?

Test for presence of cystic fibrosis; amount sweat chloride is measured. Chloride level higher than 60 mEq/L considered positive test result. Sweat chloride level lower than 40 mEq/L considered normal. Sweat chloride level higher than or equal to 40 mEq/L is suggestive of CF & requires repeat test.

Sweat test

Early sign slight change LOC, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late sign ICP include significant decrease LOC, bradycardia, decreased motor & sensory responses, alterations pupil size & reactivity, posturing, Cheyne-Stokes respirations, & coma.

Symptom of increased ICP

Characterized by chills, fever, malaise, headache, nausea, vomiting, backache, & tachycardia.

Systemic infection

Chronic inflammatory disease affects multiple body systems. (Butterfly rash) cheeks & bridge of nose is essential sign. CBC commonly shows pancytopenia. (Decrease in all cell types) Probably caused by direct attack on all blood cells or bone marrow by immune complexes.

Systemic lupus erythematosus (SLE)

Alternative med to cyclosporine (Sandimmune) prevention organ rejection after transplantation. More effective than cyclosporine but more toxic. Concurrent use Prednisone; glucocorticoids recommended during administration.

Tacrolimus (Prograf)

Used detect MI & decreased myocardial blood flow, & determine left ventricular function. Radioisotope injected intravenously; therefore a signed informed consent is necessary.

Technetium 99m ventriculography (multigated acquisition [MUGA] scan

Used caution impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or history seizures. Medication may increase blood glucose levels.

Terbutaline: is an bronchodilator

Reduction of amount & degree of disability, injury, & damage after a crisis. Focused on rehabilitation skills.

Tertiary prevention

Close eyes & then lightly touching areas of face & testing corneal reflexes assess cranial nerve V (trigeminal).

Testing sensory function

Place newborn flat surface. Striking surface or making loud, abrupt noise startle newborn. Assumes sharp extension & abduction of arms with thumbs & forefingers in a C position; followed by flexion & adduction to an "embrace" position (legs follow a similar pattern). Moro reflex present at birth & absent by 6 months age if neurological maturation is not delayed. Persistent response lasting more than 6 months may indicate a neurological abnormality.

The Moro reflex

4 mL × kilograms of body mass × percent total body surface area. Half of this total is administered in the first 8 hours after the burn. Example 90k weight with 83% burn Therefore 4 × 90 × 83 = 29,880 mL, divided by 2 = 14,940 mL.

The Parkland (Baxter) formula for estimating fluid requirements

Assesses ability vestibular apparatus in inner ear help maintain standing balance. Also assesses intactness of cerebellum & proprioception

The Romberg test

Sometimes referred to as vermiform appendix, attached to apex of cecum.

The appendix

Cartilaginous ridge separates opening two main (right & left) bronchi. Endotracheal tube inserted past carina, tube will enter right main bronchus as result natural curvature of airway. Hazardous because only right lung will be ventilated.

The carina

Responsible for balance & coordination. Walker would provide stability for client during ambulation.

The cerebellum

Thin, transparent layer mucous membrane that covers eyeballs & lines eyelids. Infection of conjunctiva is called conjunctivitis, which is a contagious condition

The conjunctiva

Area responsible for longitudinal bone growth. Fracture affecting this area places child at risk for uneven future growth if proper healing does not occur.

The epiphyseal line

Consists of three phases: follicular, ovulatory, & luteal.

The ovarian cycle

First pulmonary manifestations cough with expectoration mucoid sputum. Sputum cultures performed every 2-4 weeks after initiation drug therapy. Return work when three sputum cultures are negative; considered noninfectious at that point.

Tuberculosis

Ocular movements, track ocular movements horizontally & diagonally to the left & right

The six cardinal fields of gaze

Single daily dose (bronchodilator) early in morning. Enables maximal benefit during daytime activities. Additionally, causes insomnia. Take in at least 2 L of fluid per day; decrease viscosity of secretions. Limit intake Coffee, cola, & chocolate

Theophylline (Theo-24)

Resolution does not occur second phase, progresses to severe or panic levels of anxiety.

Third phase of crisis response

Slight/moderate bleeding, intermittent cramping without dilation.

Threatened abortion

Flulike symptoms only

Three stages associated with viral hepatitis. First (preicteric) stage

Appearance jaundice & associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, & clay-colored stools

Three stages associated with viral hepatitis. Second (icteric) stage

Jaundice decreases & colors of urine & stool return to normal.

Three stages associated with viral hepatitis. Third (posticteric) stage

Contraindicated number of preexisting conditions in which there is risk uncontrolled bleeding. Also contraindicated severe uncontrolled hypertension because risk cerebral hemorrhage.

Thrombolytic therapy

Most effective started within 4-6 hours after symptom onset & act to dissolve or lyse existing thrombi causing blockage.

Thrombolytics

Also known as DVT, exhibits redness or warmth of affected leg, tenderness at site, possibly dilated veins (if superficial), low-grade fever, edema distal to obstruction, & increased calf circumference affected extremity. Management DVT includes possible bed rest 5-7 days, limb elevation; relief discomfort; warm, moist heat, analgesics as needed; anticoagulant therapy; & monitor for signs PE. Ambulation contraindicated increases likelihood dislodgement tail of thrombus, which could travel to lungs as PE. (Ask about pain in calf area)

Thrombophlebitis

Acute, life-threatening condition occurs in uncontrollable hyperthyroidism. Systolic hypertension, tachycardia, diarrhea, & fever as high as 106° F, abdominal pain, dehydration, extreme vasodilation, stupor rapidly progressing to coma, atrial fibrillation, & cardiovascular collapse. Fever, nausea, tremors. As condition progresses they become confused. Restless, anxious & experiences tachycardia.

Thyroid storm

Neck circumference monitored every 4 hours assess occurrence postoperative edema. Upright position facilitate air exchange. Monitor dressing closely & should loosen dressing if necessary. Assist with deep breathing exercises, but coughing minimized prevent tissue damage & stress to incision. After surgery may experience temporary calcium imbalance. Assess for Chvostek's & Trousseau's signs. Treatment is administration of calcium gluconate or calcium lactate.

Thyroidectomy

Neutropenia most serious adverse effect. Baseline (CBC) count with differential performed. Neutropenia occurs often first 3 months therapy; CBC with differential recommended every 2 weeks during first 3 months. If diagnosis neutropenia determined, will be withdrawn from therapy. Used prevent stroke & not contraindicated in hypertension. GI disturbances can occur & instruct take with food to minimize these side effects.

Ticlopidine (Ticlid)

Over fifth intercostal space in the left midclavicular line. (Apex)

To hear first heart sound (S1)

Ringing ears & vertigo two symptoms ototoxicity. Frequent adverse effect of therapy with use of aminoglycosides & could result permanent hearing loss.

Tobramycin sulfate (Tobrex)

Method measuring IOP using calibrated instrument that indents or flattens corneal apex. Pressures between 10-21 mm Hg are considered to be within normal range. Increased IOP indicative of glaucoma.

Tonometry test

Placed in a prone or side-lying position after tonsillectomy to facilitate drainage.

Tonsillectomy

Preoperative period, child observed presence loose teeth to decrease risk aspiration during surgery. Bleeding during surgery controlled via packing & suction as needed. Frequent swallowing, restlessness, fast/thready pulse, & vomiting bright red blood are signs of bleeding. Bad mouth odor normal after tonsillectomy & may be relieved by drinking more liquids.

Tonsillectomy (Surgical removal tonsils)

Topical medication treat mild to moderate acne.

Topical azelaic acid (Azelex)

Loss of urine is unpredictable & continuous

Total incontinence

1 oz = 30 ml

Total intake Calculation

Most common complication Infection, monitor temperature indicate infection. Blood glucose level should be monitored every 4-6 hours during TPN therapy. (Weight gain) should not gain more than 3 lb per week, optimal weight gain 1-2 lb per week. Weight goal TPN is individual & depends on metabolic needs & baseline weight (whether underweight, overweight, or optimal weight).

Total parenteral nutrition (TPN)

Classic symptom; high fever (temperature 101º F or higher), vomiting, & severe diarrhea. Other symptoms; headache, myalgia, chills, abdominal pain, dizziness, lethargy, possible confusion, & agitation.

Toxic shock syndrome (TSS)

Avoid uncooked eggs & unpasteurized milk. Fruits & vegetables washed before eating. Contact materials possibly contaminated with cat feces; litter boxes, sand boxes, garden soil avoided. Avoid touching mucous membranes mouth or eyes while handling raw meat, wash all kitchen surfaces that come contact with uncooked meat, wash hands after handling raw meat. Symptoms; altered mental status, headache, & cognitive impairment.

Toxoplasmosis

Replacement tube same size & an obturator kept at bedside at all times in case tracheostomy tube becomes dislodged. Additionally, curved hemostat that could be used to hold trachea open if dislodgement occurs should also be kept at bedside

Tracheostomy

evaluates the kidneys' ability to regulate fluid balance and evaluates the hydration status of the body.

Urine specific gravity

Portable & client controls system for relieving pain & reducing need for analgesics. Attached to skin of body by electrodes. Hospitalization is not required.

Transcutaneous electrical nerve stimulation (TENS)

Assessment vital signs, level of consciousness, & patency IV lines are priority parameters

Transferring a client to another unit or area

IV catheter used should be at least 18 or 20 gauge. Large enough to prevent damage to blood cells.

Transfuse red blood cells

Pain, helplessness, panicking, & fear of losing control are possible behaviors

Transition phase of first stage of labor

Endoscopic procedure surgically remove pituitary tumor through incision in the sphenoid sinus. Brushing teeth not be permitted for at least 2 weeks after surgery to prevent disruption of surgical site.

Transsphenoidal hypophysectomy

Observe for clear nasal drainage; constant swallowing; & severe, persistent, generalized, frontal headache. Symptoms indicate cerebrospinal fluid leak into sinuses. Clear drainage noted after procedure, HCP notified.

Transsphenoidal hypophysectomy

Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, & shoulder dystocia can place at risk

Traumatic uterine rupture

Potassium-retaining diuretic. Potassium-retaining diuretics decrease reabsorption of sodium & water & inhibit excretion of potassium in renal collecting ducts. Avoid eating bananas.

Triamterene (Dyrenium)

Spasms pain start suddenly & last seconds to minutes. Characterized as stabbing; similar to electric shock. Accompanied spasms facial muscles, cause twitching parts of face, mouth, or closure eye.Triggered by Stimulation affected nerve by pressure & temperature. Pain minimized using cotton pads wash face; room temp water. Chew on unaffected side mouth, eat soft diet, & take in foods & beverages at room temperature. If toothbrushing triggers pain, oral rinse after meals may be helpful. Nnticonvulsant meds carbamazepine & gabapentin (Neurontin) help relieve pain.

Trigeminal neuralgia

Spasms pain, start suddenly, last seconds to minutes. Pain described stabbing, similar electric shock. Accompanied by spasm facial muscles that cause twitching of parts of face or mouth, closure of eye. Symptoms; triggered by pressure; washing face, brushing teeth, shaving, eating, drinking & draft or cold air. Needs eat or drink lukewarm, nutritious foods , soft & easy to chew. Extremes temperature will cause trigeminal nerve pain.

Trigeminal neuralgia (tic douloureux)

Results facial pain, also known as tic douloureux.

Trigeminal neuropathy

Antiemetic agent used for relief of nausea & vomiting

Trimethobenzamide (Tigan)

Antiemetic agent used to treat nausea & vomiting.

Trimethobenzamide hydrochloride (Tigan)

May be administered IV infusion; not mixed with any other medications or solutions. Infused over 60-90 minutes, & bolus infusion or rapid infusions must be avoided. Early sign/symptom blood disorders that can occur; sore throat, fever, pallor, & instructed notify (HCP) if these occur.

Trimethoprim-sulfamethoxazole

Interpretation done 48 to 72 hours after injection.

Tuberculin skin test

Family member/others close contact client TB placed on prophylactic therapy; isoniazid 6-12 months. Client usually not contagious after taking med 2-3 consecutive weeks. Must take full course therapy (6 month or longer) prevent reinfection/drug-resistant tuberculosis. Signs & symptoms that have been present for weeks or even months. Include fatigue, lethargy, chest pain, anorexia & weight loss, night sweats, low-grade fever, & cough with mucoid or blood-streaked sputum.

Tuberculosis

Abnormal opening between the right and left ventricles.

Ventricular septal defect

Transmitted droplet nuclei. Private room with at least six air exchanges per hour & negative pressure in relation to surrounding areas. Vented to outside & should have ultraviolet lights installed. Cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills & sweats (which may occur at night), & low-grade fever.

Tuberculosis (TB)

ambulating down the hallway

UAP

Inflammatory disease large colon. Symptom: diarrhea, 10-20 liquid bloody stools per day, weight loss, anorexia, fatigue, increase WBC count, increase erythrocyte sedimentation rate, dehydration, hyponatremia, & hypokalemia. Because loss of blood, decreased hemoglobin & hematocrit levels. Rebound tenderness may indicate peritonitis; report to HCP.

Ulcerative colitis

Two arteries carry blood from embryo to chorionic villi & one vein that returns blood to embryo.

Umbilical cord

Tested using sternal rub, placing upward pressure orbital rim, or squeezing clavicle or sternocleidomastoid muscle.

Unconscious patient Cerebral responses to pain

Nail bed pressure tests

Unconscious patient test client's peripheral response to pain

Ventricular rate greater 100 beats/min at risk low cardiac output due to loss of atrial kick. Assesses for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, & distended neck veins

Uncontrolled atrial fibrillation

Risk low cardiac output owing to loss of atrial kick. Assesse for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, & distended neck veins.

Uncontrolled atrial fibrillation with ventricular rate greater than 100 beats/min

(Non-invasive) *Range-of-motion (ROM) exercise *Cleaning a client's dentures *Ambulating a postoperative client *Taking vital signs on clients *Assist client with urinary drainage catheter into chair *A client needing a bed bath *A client needing to ambulate *A client requiring assistance with feeding *A client needing to use bedside commode *Providing distraction for client by engaging him/her in a board game *Client admitted dehydration on strict I&O *Client who requires turning every 2 hours *Confused older client who requires feeding *Client 4 days postoperative exploratory laparotomy require ambulation 4 times day *Measuring client's height & weight *Monitoring oral intake & urinary output

Unlicensed assistive personnel (UAP)

Collecting 24-hour urine & helping with bed bath & frequent ambulation.

Unlicensed assistive personnel (UAPs)

Occur lower level activity/rest less predictable, often precursor of myocardial infarction. Triggered by unpredictable amount exertion or emotion & may occur at night; attacks increase in number, duration, & severity over time.

Unstable angina

Point at which ureters enter bladder. Juncture, ureter runs obliquely for 1.5 to 2 cm through bladder wall before opening into bladder. Anatomical pathway prevents reflux urine back into ureter &, acts as a valve to prevent urine from traveling back into ureter & up to kidney.

Ureterovesical junction

Symptoms: Dysuria & penile discharge. In male often results from chlamydial infection & characterized: dysuria accompanied by clear to mucopurulent discharge. Because disorder often coexists with gonorrhea, diagnostic tests done for both & include culture & rapid assays

Urethritis

Experiences involuntary loss of urine soon after experiencing urgency.

Urge incontinence

Will receive the diphtheria, tetanus, acellular pertussis vaccine, IPV, MMR, and varicella vaccine.

Vaccines at age 4

symptoms; pain, itching, & thick, white vaginal discharge

Vaginal Candida infection

Anticonvulsant causes (CNS) depression. Side effects; sedation, dizziness, ataxia, confusion. Administering bedtime negates risk of injury from sedation & enhances client safety. Administered at same time each day.

Valproic acid (Depakene)

If experience chills, fever, flushing face/trunk, tachycardia, syncope, tingling, & an unpleasant taste in mouth; Manifestations of what is called "red neck syndrome." Corrective action administer medication more slowly.

Vancomycin (Vancocin)

Occur if umbilical cord becomes compressed, reducing blood flow between placenta & the fetus.

Variable decelerations

Prolonged & severe & occurs same time each day, most often at rest. Triggered by coronary artery spasm; attacks are of longer duration than in classic angina & tend to occur early in day & at rest.

Variant angina, or Prinzmetal's angin

May lack B12 in diet.

Vegans

Results from increased pressure in veins, usually in lower legs, & has irregularly shaped bluish center with radiating branches.

Venous star

Irregular chaotic undulations varying amplitudes. Ventricular fibrillation has no measurable rate & no visible P waves or QRS complexes & results from electrical chaos in ventricles.

Ventricular fibrillation

Characterized absence P waves, wide QRS complexes (longer than 0.12 sec) & typically rate between 140-180 impulses/min. Rhythm is regular. Restorative coughing techniques sometimes used unstable V tachycardia. Cough cardiopulmonary resuscitation (CPR), if prescribed, by inhaling deeply & coughing forcefully every 1-3 seconds. Cough CPR may terminate the dysrhythmia or sustain cerebral & coronary circulation for short time until other measures can be implemented.

Ventricular tachycardia

Life-threatening dysrhythmia results from irritable ectopic focus that takes over pacemaker for heart. Low cardiac results can lead quickly to cerebral & myocardial ischemia. Feeling of impending doom.

Ventricular tachycardia

In stable client, assesses circulation, airway, & breathing; administers oxygen; & confirms rhythm via a 12-lead ECG. HCP contacted, & antidysrhythmics may be prescribed. With pulseless VT, HCP or specially trained nurse must immediately defibrillate or initiate CPR followed by defibrillation as soon as possible.

Ventricular tachycardia (VT)

Heard over the peripheral lung fields.

Vesicular breath sounds

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

Vital signs if the intracranial pressure is rising

Carrots, Green & yellow leafy vegetables are good source. Deficiency associated with night blindness.

Vitamin A

Eggs, Grains

Vitamin B

Tomatoes, potatoes, Cabbage, & strawberries

Vitamin C

Milk products, dark green, leafy vegetables, tofu & other soy products, sardines, salmon with bones, & hard water. Deficiency can cause skeletal pain.

Vitamin D

Liver & green leafy vegetables such as spinach are high in vitamin K. Associated with production prothrombin, which helps blood to clot properly.

Vitamin K

Sample for PT & INR level to determine anticoagulation status & risk for bleeding

Warfarin (Coumadin)

Vitamin K is an antidote

Warfarin sodium

Tuning fork needed to perform test

Weber test

Exhibit a rambling type of speech.

Wernicke's aphasia

Function is understanding of language. Difficulty understanding language.

Wernicke's area

Musical noises heard on inspiration, expiration, or both & are result of narrowed airway passages.

Wheezes

The eyes are closed, head of bed is elevated to prevent edema formation, & gauze pads wet with saline are placed over them with a cool pack or small ice pack. Within 2 to 4 hours eyes are enucleated. Cornea is usually transplanted with 24 to 48 hours

When a corneal donor dies

Proximal port used because usually port with largest lumen. Blood cultures, initial specimen used for sample, line not flushed before. Turn off infusion for 1 min prevent contaminating sample with IV solution.

When drawing blood from double-lumen central venous catheter

Bed placed semi-Fowler's with knee gatch raised sufficiently flex knees. Relaxes muscles of lower back & relieves pressure on spinal nerve root.

Williams' position

Prevent from harming self or others. Low-stimulation environment maintain client in calm state. Monitor vital signs closely & report abnormal findings. Reorient to reality frequently & would address hallucinations therapeutically. Adequate nutritional & fluid intake maintained.

Withdrawal from alcohol

Dry skin

Xerosis

Dry mouth

Xerostomia

Treat bronchial asthma. Used with caution impaired hepatic function. Liver function laboratory tests should be performed and monitored with treatment.

Zafirlukast (Accolate)

Slows progression acquired immunodeficiency syndrome (AIDS) improving CD4+ cell count. Adverse effects agranulocytopenia & anemia. Monitor CBC

Zidovudine (Retrovir)

Stimulates immune system & used for its antiviral properties. stimulates the immune system and is used for its antiviral properties.

Zinc

Take bedtime & with full glass water. For faster onset of sleep, not take medication with food or immediately after meal. Antacids affect absorption of medication.

Zolpidem (Ambien)

Failure of aortic valve to close completely allows blood to flow retrograde through the Aorta to left ventricle

aortic regurgitation

Check patency fistula by palpating for presence of a thrill or auscultating for a bruit.

arteriovenous fistula for hemodialysis

Used treat metastatic breast cancer that is resistant to other therapy. Also used to treat colon cancer. Contraindication to use; severe renal impairment such as that which occurs in chronic kidney disease. Bone marrow depression can occur from use; CBC & blood chemistry studies should be done periodically

capecitabine (Xeloda)

The left coronary artery supplies right atrium & right ventricle with blood

coronary arteries

Insomnia, weight loss, & mild heat intolerance side effects. Taken on empty stomach enhance absorption. Dosing morning before breakfast.

levothyroxine sodium (Synthroid)

Immunosuppressant. Potentially fatal anaphylactic reactions can occur. Manifestations; pulmonary edema, cardiovascular collapse, & cardiac or respiratory arrest. Assessing lung sounds priority.

muromonab-CD3 (Orthoclone OKT3)

energy level used defibrillation attempts is 360 joules.

monophasic defibrillator machine

Decreased lean body mass & age-associated decreased glomerular filtration rate.

older client is at risk for medication toxicity because

antiinflammatory for long-term control asthma. Anaphylactic reactions can occur with administration. Swelling lips & tongue are indication of adverse reaction

omalizumab (Xolair)

Potential decreased effectiveness of birth control pills while taking phenytoin

phenytoin (Dilantin) for seziures

Never be administered in the presence of oliguria or anuria. Checks amount urine output before administration.

potassium chloride

Mechanical ventilator requiring frequent assessment & suctioning

registered nurse (RN

Magnesium sulfate is anticonvulsant, goal of care directed preventing eclampsia (seizures).

woman with preeclampsia is receiving magnesium sulfate