Practice Question 12

Intraocular Pressure

- 10-21 - diabetes associated w/glaucoma - aging common cause of glaucoma - neurovascular disorder can cause secondary glaucoma

Lithium Toxicity - Early sign

- N/V, muscle weakness, slurred speech, increased thirst, and polyuria - withhold medication, obtain lithium level, dose will be re-evaluated

Beta-blocker and Insulin

- beta blocker sbind beta-adrenergic receptor sites, w/c prevents adrenaline from causing symptoms and glycogenolysis - propranolol may mask symptoms of hypoglycemia, removing your body's early warning system

Comatose client

- greet the client and tell him/her the time of day - reorienting f clients should be conducted at least Q8 hrs

Meningitis - Increased ICP

- high-pitched cry - 1st signs of increased ICP - other: irritability, poor feeding, increased frontal occipital circumference; pupils respond slowly to light

Hypoxia

- increased RR, restlessness, cyanosis, anxiety, tachycardia - assess for patent airway by listen to breath sounds, assess need for suctioning, suction as needed

Hepatitis B vaccine

- total of 3 doses given - should schedule the 3rd dose 3-4 months after the second dose - second dose usually given 1-2 months after 1st dose

Autonomic Dysreflexia - SCI at T6 or higher

- triggered by sustained stimuli at T-6 or below from restrictive clothing, full bladder or UTI, pressure areas, fecal impaction - S/S: pounding HA, profuse sweating, nasal congestion, HTN, precipitated by full bladder or bowel

Veracity

- truthfulness and fidelity refers to being faithful and loyal to honoring commitments made to self or others

Albumin

3.5-5.5 - deficit decreases oncotic pressure and fluid shift from vascular area to tissue

Alzheimer's

Early stage: restlessness and pacing; recent memory loss and changes in motor activity, such as pacing, wandering, and agitation

Flail chest

- caused by fracture of multiple adjacent ribs, causing the chest wall to become unstable and respond paradoxically - chest on the affected side is pulled inward during inspiration and bulges outward during expiration

Gout

- characterized by overproduction or under secretion of uric acid - high purine foods increase incidence of gout - organ meats, meat soups, gravy, anchovies, sardines, fish, seafood, asparagus, spinach, peas, dried legumes, wild game Intervention - drink at least 2000-3000 ml/day - increases urinary uric acid excretion; eliminate/restrict alcohol intake - drug therapy: colchicine, allopurinol, and NSAIDs - foods high in calcium (dairy) can provide moderate protein - low-carb diet - cause formation of ketones that inhibit uric acid excretion; high-carb diet increases uric acid secretion

Rheumatoid arthritis

- chronic,progressive, systemic inflammatory process; complete relief of symptoms is not possible - S/S: joint pain, swelling, contracture deformity, ulnar drift Tx: Prednisone - antiinflammatory and immunosuppressive drug - to minimize the body's rxn to sudden loss of exogenous steroids, drugs is decreased gradually S.E: euphoria, insomnia, PUD, acute adrenal insufficiency after increased stress or abrupt withdrawal

Lithium Toxicity - Late sign

- coarse hand tremor, ataxia, persistent GI upset, mental confusion, incoordination

Nonorganic FTT

- consistent team of nurses helps build trust; cycle of dissatisfaction and frustration causes difficulty between parent and child; feeding techniques best taught to parents by example and demonstration - quiet, non stimulating atmosphere is best for feeding; controlled stimulation through planned program of play is important

Beta-blocker

- decreases excitability of the heart - reduces cardiac workload and O2 consumption - decreases release of renin - lowers BP by reducing SNS stimuli - should not be discontinued abruptly - may develop tachycardia, diaphoresis, malaise

Exercise - Cocaine Craving

- decreasing physical tension will reduce the craving for cocaine - low-impact physical activity will dissipate anxiety will help avoid weight gain that may occur w/recovery, stimulates release of endorphins - S/S of abuse: insomnia, rhinorrhea, and facial pain

BUN

- elevate din salt and water depletion - High BUN S/S: confusion, disorientation, convulsions, w/c could easily lead to falls - water depletion could also result in falls due to orthostatic hypotension

ECT procedure

- explain the procedure; client will have convulsions similar to grand mal SZ; explain about potential temporary memory loss and confusion - ask the client to void - void and remove dentures, glasses and jewelry about 1 hour before the procedure - administer atropine about 30 minutes before treatment to decrease secretions - orient client - client will be confused after treatment; stay with client during confusion and frequently orient client; obtain client's VS

Cleft-Lip repair

- feed the infant w/a tuber-tipped syringe and bubble frequently = rubber tip can be placed at the side of the mouth to avoid the operative area and to prevent sucking on the tubing - infants w/cleft lip swallow excessive amounts of air, so they require frequent bubbling - hold infant's head in an upright position - site is cleaned w/saline or hydrogen peroxide after feeding - position infant on back or side or in an infant seat to prevent trauma to suture line - usually repaired around 18 months to allow for bone growth; do not use suction or lace objects in the child's mouth such as tongue depressor, thermometer, small spoon, or straws; restrict for about 6 months until palate heals - cookies, toast, and the hard foods are discouraged to prevent damage to new repaired palate

Ileal Conduit Procedure

- fever and abdominal rigidity and pain are indications of PERITONITIS - urine may entered the peritoneal cavity from anastomosis site leakage or from separation of the ureter from the ideal segment (the condo); there may have been spillage from the intestine during the surgery; Notify HCP at once; requires immediate medical intervention - intestinal mucosa is very fragile and it is common that it bleeds during changing of the appliance or due to collection pouch not fitting properly - if the skin under the osmotic pouch is irritated, decrease frequency of pouch changing, using non-karaya skin barrier (urine erodes chary), leaving skin open to air when possible as changing pouch, promoting acid urine (alkaline urine irritates the skin), using Nystatin cream or powder if yeast infection - hypoactive bowel sounds in all 4 quadrants - due to the bowel manipulation and resection; there will be no peristalsis for several days; client will remain NPO and has IV lines and an NG tube in place until peristalsis is reestablished; bowel sounds do need to be assessed

Autonomy

- independence of the individual and the right to have his/her own opinions, make his/her choices, and take action based on personal beliefs and values

Restitution

- legal remedy in contract disputes w/c returns property or the financial value of a loss to the owner of the property

BSE

- look for any changes in appearance, asymmetry, nipple, or gesture and for any discharge - while standing in front of mirror w/arms at sides, inspect breast and nipples for asymmetry, changes, drainage, - w/hands firmly into hips and how slightly, examines breast and nipple - w/finger pads on left and palpate the right breast using light pressure that feels the tissue just below the skin, medium pressure that feels the deeper tissue, firm that feels the tissue closest to the chest wall and ribs; this method feels all the breast tissue; then use the fingers of the 8 hand to palpate the left breast; using a vertical pattern, the preferred method, palpate the entire breast from sternum outward including the Tail of Spence under the arm

SCI

- obtain the client's permission before touching the client = client w/SCI has reduced sensation; instruct personnel to respect all of the client's body and personal boundaries

Multiple Myeloma

- placed client in bed w/ HOB elevated 45 degrees and her hips and knees moderately flexed - flexing knees relieves pressure on sciatic nerve and disk

Eating Disorders

- poor self-identity and poor self-esteem - problems are inhibit the person's ability to be assertive and to be self-advocate

Internal radiation

- prior to client receiving implant, enema is given so rectum is empty in order to facilitate placing the implant though the vagina and into uterus; BM during implantation period (1-3 days) is avoided in order to prevent the implant from dislodging - client will be on strict bedrest on her back w/HOB elevated no more than 20 degrees; movement is restricted - foley catheter is inserted not bladder in order to prevent the implant from being dislodged by a full bladder or by voiding attempts; severe radiation burns can result from a distended bladder

Justice

- refers to being fair to all people, including - but not limited to - distribution of benefits and resources

Beneficence

- refers to doing good

Paternalism

- refers to interfering w/the liberty of another, under the assumption that the interferer knows better than the other what is best for the other

Nonmaleficence

- refers to preventing harm to others, harm being interfering w/the physical or mental well-being of others - includes both harm and the risk of harm, whether that harm may be intentional or unintentional

Lithium - Diet

- regular diet w/normal sodium and adequate fluid intake - is a salt prep, its retention w/in the body is directly r/t the body's sodium and fluid balance - avoid sodium depletion because lithium replaces sodium in cells, precipitating lithium toxicity

SIADH

- serum sodium of 115 - because of water retention, a dilution hyponatremia occurs - increased fluid volume causes tachycardia, and CNS disturbance causes hypothermia - S/S: N/V, lethargy, HA, change in LOC, confusion - specific gravity is elevated because kidneys can't excrete dilute urine; normal: 1.010-1.030 - Tx: restricting fluid intake, administer diuretics, daily weights, I&O

Hypoglycemia

S/S: confusion, tremors; HA, lightheadedness, slurred speech, impaired coordination

Amphetamines

S/S: increased hunger and thirst; dilated pupils, increase motor activity, mental alertness, decreased fatigue, and increased spirit - CNS stimulant

UTI

S/S: urinary frequency and dysuria; urgency, nocturia, incontinence, and suprapubic or pelvic pain - tx: abx