Physiologic Adaptation

A pediatric nurse notes a "chubby" toddler who is pale. According to the parent, the toddler is easily fatigued. Based on this data, what initial question should the nurse ask the parent?

"How much milk does your toddler drink in a day?" Paleness and easily fatigued are common signs of anemia. Drinking large amounts of milk puts the child at increased risk for iron deficiency anemia. Breast milk and cow's milk are poor sources of iron. Milk also inhibits absorption of iron.

Kernig's Sign

= sever stiffness of neck meningitis

prevention of otitis externa

astringent drops in ear

The nurse in the emergency department is caring for a client admitted in diabetic ketoacidosis (DKA). Which central venous pressure (CVP) reading would the nurse anticipate?

1 mmhg Normal CVP is 2-6 mmHg. This is a CVP reading that would indicate fluid volume deficit. A client in DKA will have polyuria. A Hurst strategy is "with polyuria, think shock first". Less volume, less pressure!

What assessment data would a nurse expect to find in a client diagnosed with acute inflammatory bowel disease?

1. Bloody stools that contain mucus 2. Pallor 3. Anorectal excoriation 4. Urine output below 30 mL/hr

Which signs/symptoms should the nurse assess for the presence of in a client diagnosed with valvular heart disease?

1. Orthopnea. 2. Paroxysmal nocturnal dyspnea.

A client has been admitted with a stroke on the right side of the brain. What clinical manifestations does the nurse expect to find when assessing this client?

1. impaired judgement 2. impulsiveness The client with right sided brain damage will have left sided hemiplegia and will exhibit impulsive behavior and impaired judgment.

What independent nursing interventions should the nurse include when planning care for a client who is in a fluid volume excess (FVE)?

3. Monitor for orthopnea 4. Raise head of bed (HOB) to 45 degrees 5. Elevate edematous extremities

A client with hemophilia has been scheduled for extraction of wisdom teeth. The nurse anticipates that the client will receive what priority intervention before this procedure?

A unit of cryoprecipitate

A client has been admitted for observation after having a minor automobile accident. During the admission history, the client admits to being an alcoholic. Two hours after admission the nurse notes the client's cardiac rhythm displayed on the telemetry monitor. The client reports shortness of breath, chest discomfort, and nausea. What initial action should the nurse take?

Administer magnesium 1 gm IVP over 30 seconds. Magnesium is the drug of choice for suppressing Torsades and terminating the arrhythmia. Magnesium can be given at 1-2 g IV initially in 30-60 seconds, which then can be repeated in 5-15 minutes.

A client has experienced a cerebrovascular accident (CVA) which resulted in left homonymous hemianopia. Based on this fact, what measures will the nurse include in the client's initial plan of care?

Have client look at the left side of the body. Place the client's meal on the right side of the over bed table.

left homonymous hemianopia

Homonymous hemianopia is blindness in half of the visual field. The client has lost half of the visual field in the left side of both eyes. To avoid startling the client who has lost vision in half of their visual field and so the client can better view the food, the nurse should approach the client from the right side. Neglect of the left side can occur because the left side is out of the visual field. Encourage the client to intentionally look at the left side of the body to avoid neglect.

Which assessment finding in a client 5 hours post open cholecystectomy would require the nurse to notify the surgeon?

Jackson Pratt drain has 90 mL of blood. An open cholecystectomy will usually result in the placement of a drain. The drainage should be green (bile). Blood is a problem and needs immediate intervention.

tranylcypromine

MAOI OTC cold medications could result in hypertensive crisis when combined with the monoamine oxidase inhibitor. Warnings are placed on cold preparations and other medicines that are not to be taken with the MAOIs. Be cautious about adding over the counter medications and possible drug interactions.

glaucoma

Progressive tunnel vision occurs.

The nurse caring for a client who had a transurethral resection of the prostate (TURP) would increase the flow of the continuous bladder irrigation for which assessment data? You answered this question Incorrectly

The drainage is bright red. Indicates blood and increasing the flow helps flush the catheter.

A primigravida client at 35 weeks gestation has been diagnosed with human papillomavirus (HPV). The nurse knows that the most important information to discuss with this client is what?

The mother will need frequent follow up Pap smears. HPV is a sexually transmitted viral infection that can cause genital warts or even precancerous lesions. This virus is spread by direct contact with infected mucous membranes and is transmitted through sexual contact. Although HPV generally clears itself through the human immune system, clients diagnosed with this infection are recommended to have a follow-up Pap smear every six months for the first year, particularly if infected with HPV 16 or HPV 18.

ptosis

dropping of upper eyelid

fifth disease

erythemia infectulosium 1. Erythema on the cheeks. 2. Joint pain. 3. low grade fever 4. Swollen knees. 5. Pruritic rash on soles of feet.

pneumocystis carinii pneumonia (PCP)

fever dry cough dyspnea Pneumocystis carinii pneumonia, now known as pneumocystis jirovecii, is caused by a fungus and occurs in clients with weakened immune systems. Expected assessment findings include fever, dry non-productive cough and dyspnea. Any additional symptoms are related to other co-morbidities and not the pneumonia itself.

nephrotic syndrome

foamy urine periorbital edema extremitiy edema

Murphy's sign

gallbladder disease test fingers locked under fib border and supa painful upon inspiration

cystitis s/sx

hematuria nocturia frequency urgency incontinence

Trousseau's Sign

latent tetany "hand beak formation" = hypocalcemia

Which initial arterial blood gas (ABG) results would the nurse expect on a client who has overdosed on aspirin (ASA)?

pH 7.49, PaCO2 30, PaO2 88, SaO2 92, HCO3 25

myasthenia gravis

rapid weakness of muscles under voluntary control s/sx: ptosis, difficulty holding head erect, and limited facial expressions

Chovstek's Sign

twitching of cheek when pocked = hypocalcemia