Free Nclex Review Questions 10

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The endotracheal tube is moved from one corner of the mouth to the other at least every day to minimize the risk of necrosis of the mouth and pharynx due to pressure from the tube. Doing this every 6 hours is excessive. The nurse suctions the oropharynx above the endotracheal tube frequently to prevent accumulation of secretions above the endotracheal tube cuff. Products with lemon or alcohol are not used because they dry the oral mucosa. For the same reason, the lips are lubricated as needed.

Unresolved sexual trauma occurs when the following conditions are present: development of a persistent phobia such as that of being alone or going out; retreat from sexual themes and possessing low self-esteem and guilt feelings; reoccurrence of the symptoms of rape trauma triggered by seemingly minor events; reoccurrence of the symptoms of rape trauma triggered by the anniversary date of the rape trauma; avoidance of contact with members of the opposite sex; and negatively altered relationships with family and friends, such as withdrawal, unusual anger, or silence.

A power rapist wants to place a woman in a helpless controlled situation where she cannot resist or refuse him. In this situation, the power rapist is provided with a reassuring sense of strength, mastery, security, and control. He uses these feelings to compensate for his feelings of inadequacy. Although the power rapist usually does not consciously intend to hurt his victim, he does aim to have complete control over her. As the power rapist's behavior becomes repetitive and compulsive, his need to achieve feelings of power, control, and adequacy may lead him to increase the aggression over time.

The establishment of a therapeutic relationship with the suicidal client increases feelings of acceptance. Although the suicidal behavior and thinking of the client is unacceptable, the use of unconditional positive regard acknowledges the client in a human-to-human context and increases the client's sense of self-worth. Isolating the client in a private room would intensify the client's feelings of worthlessness. Placing the client in charge of the morning chess game is a premature intervention that can overwhelm and cause the client to fail. This can reinforce the client's feelings of worthlessness. Distances of 18 inches or less between two individuals constitutes intimate space. Invasion of this space may be misinterpreted by the client and increase the client's tension and feelings of helplessness.

Caring for a child in traction includes ensuring that the child's body is in proper alignment. Crutchfield tongs are a type of cervical skeletal traction that requires pin-site assessment and pin care to prevent infection.

An adolescent with juvenile rheumatoid arthritis may be dealing with issues related to disturbed body image. To plan care appropriately, the nurse would initially assess the adolescent's perception of the chronic illness.

In assessment of the perineum, the lochia is checked for amount, color, and the presence of clots. The color of the lochia during the fourth stage of labor (the first 1 to 4 hours after birth) is a dark red color.

Lochial flow should be distinguished from bleeding originating from a laceration or episiotomy, which is usually brighter red than lochia, and appears as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and must be reported.

Involution is a progressive descent of the uterus into the pelvic cavity. After birth, descent occurs approximately 1 fingerbreadth or approximately 1 cm/day.

Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down; wearing a supportive well-fitting bra at all times; taking a warm shower just before feeding or applying warm compresses; and alternating the breasts during feeding.

Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. If the fundus is above the umbilicus, this may indicate that blood clots in the uterus should be expelled by fundal massage. A fundus that is not located in the midline may indicate a full bladder.

During the first 24 hours after delivery, the mother's temperature may increase to 100° F (38° C) as a result of the dehydrating effects of labor. Therefore the initial nursing action is to encourage fluid intake. The nurse would document the temperature, but this is not the initial action.

The fetus is at risk in this situation. The greatest danger of a prolapsed cord is fetal cord compression, which will be indicated by changes in the fetal monitor pattern. Fetal heart rate and variability are the primary measures to determine fetal well-being and are thus the most vital indicators of the effectiveness of interventions. If interventions are ineffective, the fetal heart monitor will show a pattern of increasing early decelerations and a decreasing baseline as the situation deteriorates

Signs of hypothermia include a decrease in skin temperature; increased activity; pallor or mottling; cool skin, hands, and feet; and a flexed position. The newborn attempts to maintain temperature by vasoconstriction, increased muscle activity, metabolizing brown fat, and increased metabolism. A flexed position decreases body surface through which heat can be lost.

Jaundice is a complication of the term SGA infant and occurs as a result of an increased hematocrit. Jaundice in the 4-day-old infant should be reported to the physician, because determination of the bilirubin level and treatment for the jaundice may be appropriate. Four-day-old SGA infants should be fed at least every 3 hours because they require more calories per kilogram because of increased metabolic activity and oxygen consumption. The newborn should be fed small feedings of high-calorie formula because of decreased stomach capacity. Feedings should be done even through the night. Newborns usually wet at least six to eight diapers per day. Urine output less than normal indicates dehydration.

The preferred injection site for vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle in the newborn's thigh. This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication.

The mother needs to be taught to feed the newborn soon after delivery, and often, as a prophylactic measure to decrease the possibility of hypoglycemia. Newborns of diabetic mothers may become hypoglycemic within 15 minutes of delivery, as exhibited by lethargy and poor feeding in the first hour after delivery. Hypoglycemia is a result of hyperinsulinism and loss of maternal glucose. Cold stress increases the metabolism of glucose. Jitteriness is one of the classic symptoms of hypoglycemia. A risk of a newborn of a diabetic mother is immature lungs.

Use of condoms is a primary method to prevent sexually transmitted diseases (STDs).

An increase in calories is needed with pregnancy, but concentrated sugars should be avoided because they may cause hyperglycemia. The fat intake should remain at 30% of the total calories. The fetus of a diabetic mother is prone to macrosomia. The diabetic client needs about 40% to 50% of the diet from carbohydrates and about 20% to 25% of the diet from protein. High-fiber foods will cause blood glucose levels to increase more slowly by delaying gastrointestinal absorption.

When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord.

Signs of a fetal or maternal compromise include a persistent nonreassuring fetal heart rate, fetal acidosis, and the passage of meconium. Maternal fatigue and infection can occur if the labor is prolonged but does not indicate a fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

Management of hypertonic uterine dysfunction depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows. The client with hypertonic uterine dysfunction would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.

Dystocia (antonym eutocia) is an abnormal or difficult childbirth or labour.

It is recommended that the woman refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped.

Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman also is unable to show pleasure or love and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and experience sleep disturbances.

The Moro reflex is elicited by a loud noise, such as a hand clap or a slap on the mattress. The neonate should respond (in sequence) with extension and abduction of the limbs, followed by flexion and abduction of the limbs, followed by flexion and adduction of the limbs. This reflex disappears at age 6 months. The rooting reflex is elicited by stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand by firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure.

More than one medication may be used to prevent growth of resistant organisms in the pregnant woman with tuberculosis. Treatment must continue for a prolonged period. The preferred treatment for a pregnant woman is daily isoniazid plus rifampin for a total of 9 months. Ethambutol also is added initially if drug resistance is suspected. Pyridoxine (vitamin B6) is often administered with isoniazid to prevent fetal neurotoxicity. The infant will be tested at birth and may be started on preventive isoniazid therapy. Skin testing should be repeated at 3 months on the infant, and isoniazid may be stopped if the skin test result remains negative. If the skin test result converts to positive, a full course of isoniazid would be given.

The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy.

The effects of maternal iron-deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin, and iron stores.

Station is the relation of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line.

The normal temperature during pregnancy is 98µ to 99.6° F (36.2µ to 37.6° C). A temperature above this level may suggest infection that might require medical management.

Because position affects blood pressure in the pregnant woman, the method for obtaining blood pressure should be standardized as much as possible. Blood pressure should be obtained with the client in the sitting position with the arm supported in a horizontal position at heart level.

From 22 weeks until term, the fundal height measured in centimeters is roughly plus or minus 2 cm of the gestational age of the fetus in weeks. If the fundal height exceeds weeks of gestation, additional assessment is necessary to investigate the cause for the unexpected uterine size. If an unexpected increase in uterine size is present, it may be that the estimated date of delivery is incorrect and the pregnancy is further advanced than previously thought. If the estimated date of delivery is correct, more than one fetus may be present.

Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy,

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A nursing consideration for rubeola is eye care. The child usually has photophobia, so in planning for care, the nurse should suggest to the parent to keep the child out of brightly lit areas. Children with viral infections are not to be given aspirin because of the risk of Reye syndrome. Warm baths will aggravate itching.

Depositing the DTP vaccine deep into the muscle can reduce the irritating effect. Warming the vaccine may alter its chemical makeup. Adhering strictly to manufacturer's temperature requirements is very important. Divided doses and a topical anesthetic may be used only with a physician's order to do so.

Aspirin, an antiplatelet agent, inhibits prostaglandin synthesis and inhibits platelet aggregation. It is used to treat TIAs, ischemic stroke, angina, acute myocardial infarction, and rheumatologic conditions.

Fluid-volume status is a concern in the preoperative period of an infant with pyloric stenosis. Determining fluid-volume status provides information regarding the infant's hydration needs. Preoperatively, important nursing responsibilities include strict monitoring of intake and output including intravenous infusion intake and monitoring urine specific gravity measurements. Weighing the infant's diapers provides information regarding output. Preoperatively, the infant is placed on a nothing-by-mouth (NPO) status. Enemas until clear would further compromise the fluid-volume status and would not be an option for an infant who most likely has a fluid-volume deficit.

During early therapy with cyclosporine, the client is most at risk of developing hypersensitivity reactions (wheezing, dyspnea, and flushing of the face and neck) and anaphylaxis. The nurse should be ready to manage this emergency by having oxygen and epinephrine readily available. A code cart also should be in close proximity.

Cyclosporine is an immunosuppressant medication. Because of the effects of the medication, the client should not receive any vaccinations without first consulting the physician. The client should report decreased urine output or cloudy urine, which could indicate either kidney rejection or infection, respectively. The client must be able to self-monitor blood pressure to check for the side effect of hypertension. The client needs dental examinations every 3 months for dental cleaning, which will help to prevent gingival hyperplasia. Meticulous oral care also will help control gingival hyperplasia.

Azathioprine is an immunosuppressant medication that is taken for life. Because of the effects of the medication, the client must monitor self for signs of infection, which are reported immediately to the health care provider. The client should also call the provider if more than one dose is missed. The medication may be taken with meals to minimize nausea.

Phenazopyridine is a urinary tract analgesic with no antimicrobial or antibacterial properties. It is used to relieve frequency, burning, or dysuria that follows urological procedures or accompanies infection. The medication is usually taken for 2 days as prescribed or until symptoms have resolved, and then is discontinued. Any accompanying antibiotics are continued until finished. It causes the urine to turn a reddish-orange color that can stain clothing and bedclothes permanently. This is a harmless side effect; however, female clients are advised to wear sanitary napkins to protect undergarments. The medication is best taken with food to avoid gastrointestinal upset.

Before plugging a cuffed tracheostomy tube, the cuff must be deflated. Otherwise, the client cannot ventilate around the tube and could experience respiratory arrest. Other correct nursing actions include suctioning the airway to promote ventilation and monitoring adequacy of oxygen saturation (baseline may vary slightly depending on the client). The client may have some residual abnormality on chest x-ray, depending on the client's underlying pathology.

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A client with a twin pregnancy is at increased risk for preterm labor. Preterm delivery has negative implications for the infant's growth and development. With increased blood volume, cardiac output normally increases 30% to 50% in the second trimester of a twin pregnancy. Hyperglycemia and infection are not associated with a twin pregnancy.

Hyperactive clients receive insufficient nutrition because they are too involved mentally to attend to physiological signals. Offering frequent high-calorie snacks and finger foods will assist best in providing adequate nutrition during this period.

The client with depression experiences decreased energy and psychomotor retardation and requires assistance. Both the client and his family need to know that the nurse will assist the client until he can resume self-care activities.

Client safety always takes priority over other nursing care concerns.

The client with decreased cardiac output and possible dysrhythmias should be placed on continuous cardiac monitoring so myocardial perfusion can be most accurately assessed.

The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smooth ed as needed with a special cast knife. A plaster cast gives off heat as it dries. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.

Immobility and the weight of a casted arm may cause the shoulder above an arm fracture to become stiff. The shoulder of a casted arm should be lifted over the head periodically as a preventive measure. The use of slings further immobilizes the shoulder and may be contraindicated. Making fists with the left hand provides good isometric exercise to maintain muscle strength but will not prevent the left shoulder from becoming stiff. Range of motion of the affected fingers also is a useful general measure, but again will not prevent the left shoulder from becoming stiff. Lifting the right arm is of no particular value.

With a suspected fracture, the victim is not moved unless it is dangerous to remain in that spot. The nurse should remain with the victim and have someone else call for emergency help. A fracture is not reduced at the scene. Before moving the victim, the site of fracture is immobilized to prevent further injury.

Home modifications to reduce the risk for falls includes the use of railings on all staircases, ample lighting, removing scatter rugs, and placing hand rails in the bathroom.

When the dialysate becomes cloudy, peritonitis is suspected. A culture and sensitivity of the peritoneal outflow is done, and broad-spectrum antibiotics are added to the dialysis solution, pending culture and sensitivity results. The dialysate also may be heparinized to prevent catheter occlusion. Some clients must switch to hemodialysis if peritonitis is severe or reoccurring, but it is not done on an emergency basis with this situation.

The client's comfort is enhanced during insertion of the peritoneal dialysis catheter by premedicating the client and by use of a local anesthetic before introducing the catheter. The client is not placed in a side-lying position for insertion. Holding the breath will not promote comfort, but would increase tension on the abdominal wall, which is counterproductive. The client should be encouraged to speak as needed during the procedure.

To prevent bladder perforation during peritoneal dialysis catheter insertion, the client's bladder should be emptied before the procedure. The client is positioned lying in bed, not standing for this procedure. An opioid analgesic may be prescribed, and a local anesthetic is used before catheter insertion. However, these interventions may not prevent complications of peritoneal catheter insertion. A baseline temperature is useful, but it also does not prevent complications from occurring.

The dialysate solution is warmed slightly before infusing it into the client. This prevents the client from becoming chilled and also helps to dilate the peritoneal blood vessels for better excretion of waste metabolites. Special warming pads or other devices specific for this use are used to warm the dialysate solution.

Compulsive rituals control the client's anxiety. It is usually not productive to interfere prematurely with a ritual, unless it threatens the client's health.

A client is at high risk for a barium impaction after a barium enema. To prevent this, the nurse should obtain a physician's order for a laxative or enema to follow the procedure, encourage the intake of fluids, and monitor bowel movements.

Regurgitation with tracheal aspiration is a major complication of a hiatal hernia. Although antacids, avoidance of smoking, and losing weight will assist in alleviating the discomfort that can occur, these measures will not prevent aspiration.

Balloon tamponade is one method used to stop bleeding from esophageal varices, but the pressure may cause tissue necrosis. Scissors should be kept at the bedside to cut and remove the tube in an emergency. Saliva and secretions may accumulate above the tube, so to prevent aspiration, suction may be used. It is not necessary to elevate the head of the bed 90 degrees.

Antacids are medications used to relieve the symptoms of ulcers because they decrease gastric acidity and the acid content of chyme reaching the duodenum. In addition, some antacids bind to bile salts and decrease the harmful effects of acid on gastric mucosa. Because of its antiplatelet and irritating properties, enteric-coated aspirin is contraindicated in ulcer disease

Tuberculosis is spread by droplet nuclei; therefore, strict isolation is not required. A well-ventilated room with fresh-air exchange is important. The particulate respirator (not a simple, disposable facemask) is used in the care of clients with actual or suspected tuberculosis infection. A simple disposable facemask would not provide adequate protection for the health care worker.

The client being suctioned, who is awake, is placed in semi-Fowler's position to increase ease of breathing. The nurse should explain the procedure to alleviate some of the client's anxiety. The postoperative client benefits from pain medication to minimize pain that could occur with coughing during the procedure. The catheter size should be large enough to obtain secretions, but small enough to prevent inducing hypoxia for the client.

When transporting a client with portable oxygen, the nurse checks the amount of oxygen in the cylinder by turning the key counterclockwise and reading the pressure gauge and attaching a humidifier bottle between the flow-meter adapter and the client's cannula. Any excess tubing is coiled and placed under the pillow or secured to the client's gown. The nurse avoids putting the cylinder on the stretcher, so that the client does not experience injury. The cylinder is always secured in the proper holder.

Common allergens in the home include animal dander, dust, smoke, fumes, and mold. Animal dander can be eliminated by not having pets with hair. Use of a damp cloth will prevent dust from being dispersed in the air with dusting. Air conditioners and furnace humidifiers are sources of mold that could be allergenic. These should be cleaned periodically to prevent accumulation of mold. Use of a humidifier year round is of no particular benefit. It could be contraindicated in summer months when a dehumidifier is needed to reduce environmental moisture (and subsequent mold growth).

Clients with schizophrenia exhibit isolation from others as a result of mistrust. Trust must be established before therapeutic intervention can occur, and it lays the foundation of the nurse-client relationship.

Defense-oriented behavior is using mental mechanisms to lessen uncomfortable feelings of anxiety and to prevent pain regardless of cost. The person has little awareness of what is happening or has a lack of control over events. Initially, these reactions may help reduce anxiety, but they interfere with the ability to grow or cope successfully. The nurse must decrease the anxiety so that more constructive behavior occurs.

Neurapraxia is the interruption of nerve conduction without loss of continuity of the axon. It can occur if the nerves have been stretched by the traction force. The location of the nerves at the base of the skull (cervical region) makes them more susceptible to damage by the force of the traction. If identified early, the paralysis can be reversed. An Allen wrench is needed, not pliers, for vest removal for emergencies only, not for hygiene needs. The release screws must be brightly marked. Clients in halo-vest traction cannot turn their heads. The purpose of the traction is provide for complete immobilization of the head and neck while allowing client mobility. Halo-vest traction does not involve the use of weights, although cervical skin traction and Crutchfield tongs involve the use of weights.

The most important nursing diagnosis is to Ineffective Airway Clearance. Because of the copious, thick secretions that occur with pertussis and the small airway of an infant, air exchange is critical. Fluid volume would be possibly less than body requirements because of the thick secretions and vomiting that may occur. Sleep patterns may be disturbed because of the coughing, but it is not the most important issue. Risk problems are addressed after actual problems.

The pacemaker is shielded from interference from most electric devices. Radios, TVs, electric blankets, toasters, microwave ovens, heating pads, and hair dryers are considered to be safe. Devices to be forewarned about are those that have strong electric currents or magnetic fields and include antitheft devices in stores and metal detectors used in airports.

The procedure for using support stockings is as follows: apply the stockings every morning (before the development of edema) while lying down if able, from the foot to the ankle to the calf, checking for proper fit and comfort, and removing if cyanosis or discomfort occurs.

Treatment in Buerger's disease is aimed toward slowing the progress of the disease, controlling the pain, protecting the extremity from extremes in temperature, elimination of tobacco use, performing foot care daily, and performing Buerger-Allen exercises. The disease does not necessarily have a poor prognosis if correct life-style measures are implemented. The disease cannot be eliminated. No need exists to move to a warmer climate; this will not arrest the disease.

Raynaud's disease, occurring primarily in women in their teens or early 20s, causes vasospasm and pain in the digits with exposure to cold, vibration, or stress. Raynaud's disease produces closure of the small arteries in the distal extremities. Diminished or absent peripheral pulses can occur.

HIV infection causes immunosuppression and is indicated by a T4 lymphocyte count of less than 200/mm3. Although bacterial, fungal, and protozoan infection can occur, these infections occur as opportunistic ones as a result of the immunosuppression.

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No item should be placed inside a cast because of the risk for alteration in skin integrity. A cotton-tipped applicator with rubbing alcohol may be used near the cast edges to relieve itching. The skin around the cast edges should be checked for redness, irritation, or blistering. The extremity should be elevated as much as possible to minimize swelling. The physician should be notified for any unusual odor and/or sudden unexplained fever indicating infection, or if numbness, tingling, pallor, cyanosis, and/or pain unrelieved by medication occurs because these signs indicate neurovascular compromise.

Although signs of neglecting parents are not always easily identified, some behavioral characteristics emerge. These include a lack of concern for the child's well-being, unreasonable punishments, high demands and unrealistic expectations for the child, and a view of the child as a small adult who can meet their personal needs. Assessment of the parents in their role may provide the nurse with clues as to the family dynamics and assist in determining the educational needs of the parents.

Trauma, often due to falls, is the most common cause of spinal cord injury. Roller-blading, especially without a helmet, is a risk factor. Other risk factors include bicycling, motorcycling, horseback riding, diving into unknown waters, and occupations at elevations over 5 feet.

Constipation with ribbon-like, foul-smelling stools is particularly characteristic of Hirschsprung's disease. A distended abdomen, poor feeding habits, irritability, and signs of undernutrition also are characteristic of Hirschsprung's disease. Inguinal swelling indicates inguinal hernia. Projectile vomiting indicates pyloric stenosis. Intussusception is indicated by acute, colicky abdominal pain and currant jelly-like stool.

A "slapped face" appearance and circumoral paleness can be indicative of the presence of a communicable disease, specifically fifth disease. Therefore a complete and thorough assessment should be done before deciding on the appropriate nursing intervention.

Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. Before administering the medication, the nurse should assess the apical heart rate for 60 seconds. If the pulse rate is less than 60 beats per minute in an adult client, the nurse would withhold the medication and contact the physician, because a low pulse rate may be an indication of toxicity.

Allergy to seafood, iodine, or iodine contrast media in the preprocedure period may necessitate a skin test for allergy severity and the use of prophylactic antihistamines to prevent an allergic response to the contrast medium.

Progressive, gradual increases in activity should be done after MI. Gradual increases in activity prevent or minimize overtaxing of the heart and fatigue. The nurse's role is to monitor and adjust the client's activity level according to individual tolerance. Providing positive reinforcement and encouragement during physical activity and providing adequate fluid intake will not prevent or minimize activity intolerance.

Clients with polycystic kidney disease seem to waste rather than to retain sodium. Thus they need an increased sodium intake and fluid intake of 1500 mL to 2000 mL per day.

Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointestinal disturbances such as anorexia, nausea, and vomiting. Neurological abnormalities also can occur early and include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular disturbances (photophobia, light flashes, halos around bright objects, yellow or green color perception) also are signs of toxicity but are not early signs.

The best initial action that begins the attachment process and promotes bonding is to encourage the parents to touch their infant. The parents' initial need is to become acquainted with their newborn infant.

Ambulatory clients with visual field deficits do not distinguish between colors very well and therefore require bright (not pastel) colored doors, doorknobs, hallway corners, etc.

Photon absorptiometry uses two sources of radiation of different energies to measure the density of the bone, and a low dose of radiation is used. This diagnostic test requires no invasive technique such as an injection or placement of a scope and is painless. The test does not use a magnetic field, so no danger is associated with metal objects on or in the client.

Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft mattress and footboards will not be helpful to inflamed joints and should be avoided.

According to category-specific (respiratory) isolation precautions, acid-fast bacteria isolation always requires a private room. The room needs to be well ventilated and should have at least six exchanges of fresh air per hour and should be ventilated to the outside if possible.

The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene. Balloons are unsafe because of the potential aspiration of latex. The peak flow meter is used to assess vital capacity rather than to encourage breathing. Chest percussion and postural drainage will not affect depth of respiration.

A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities. If only one lower extremity is included, it is called a single hip spica; if two are included, it is called a double hip spica. Short and long leg casts are applied to the leg. A body jacket cast is applied to the upper torso.

The decrease in cortisol secretion that characterizes Addison's disease can result in hypoglycemia. Fluid intake should be encouraged to compensate for dehydration. Potassium intake should be restricted because of hyperkalemia.

General anesthesia depresses the gag reflex that, in turn, increases the risk for aspiration. Suction equipment must be available in the event the client aspirates

Florinef is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity that is used for long-term management of Addison's disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. In small doses, fludrocortisone acetate causes sodium retention and increased urinary potassium excretion. Hypotension and fluid and electrolyte imbalance can develop rapidly if the medication is discontinued abruptly.

Denial is a failure to recognize what is occurring in a situation and generates inappropriate behavior. Projection is the disowning and attributing process that enables a person to remain blind to aspects of self and distant to the perception of others. Setting firm limits on unacceptable and inappropriate behaviors in a nondefensive manner is the initial nursing action in this situation.

The individual with retinopathy has varying degrees of visual impairment. Thus falls are a major concern, especially for the older client. Disturbed Body Image and Chronic Low Self-Esteem are psychosocial needs and are not the priority. Although Risk for Bathing/Hygiene Self-Care Deficit relates to a physiological need, for this client, the Risk for Injury presents the greatest threat.

Clients with hypothyroidism have Imbalanced Nutrition: More than Body Requirements due to their decreased metabolic need. They should consume foods from all food groups, which will provide them with the necessary nutrients; however, the foods should be low in calories.

Clients with Parkinson's disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these individuals imagine lines on the floor to step over can keep them moving forward.

The halo vest is used to treat cervical fractures. The halo vest or jacket has a ring that is fixed to the skull with pins. This ring is then attached to the vest or jacket by rods. This device provides the traction required to maintain cervical alignment and allows early mobilization and rehabilitation. A body jacket cast is applied to the upper torso. Skull tong traction involves the use of one of a variety of tongs (Gardner-Wells, Crutchfield, Vinke, or Barton). These tongs are drilled into the skull or placed below the scalp and attached to ropes, pulleys, or weights. This type of traction is used for cervical vertebrae fractures and involves the use of special beds or turning frames to facilitate nursing care. A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities.

Hypocalcemia is the result of hypoparathyroidism because of either a lack of parathyroid hormone (PTH) secretion or ineffective PTH influence on tissue. Calcium is the major controlling factor of PTH secretion. Because of this, the diet needs to be high in calcium but low in phosphorus, because these two electrolytes must exist in inverse proportions in the body.

The vast majority of clients with Guillain-Barré syndrome recover from the paralysis because it affects peripheral nerves that have the capacity to remyelinate. Maximal paralysis can take up to 4 weeks to develop. Paralysis progresses distally to proximally. Rehabilitation can take from 6 months to 2 years.

Pyridostigmine bromide (Mestinon) is an anticholinesterase that is used to improve muscle strength in the client with myasthenia gravis. Taking the medication before activities such as working or eating helps lessen fatigue and dysphagia and improves muscle strength. The medication should be taken with food. Clients should avoid quinine, antacids, magnesium, and morphine sulfate and its derivatives, because these medications can reverse the action of the pyridostigmine bromide and increase weakness. The medication should be taken regularly and on time to prevent fluctuating blood levels, which can cause weakness.

Typically, infants of diabetic mothers are large for gestational age. Maternal glucose crosses over the placenta to the fetus. The fetus is able to produce its own insulin; therefore excessive body growth (macrosomia) results from high maternal glucose. After birth, hypoglycemia may be a problem because the infant's pancreas continues to produce large amounts of insulin (hyperinsulinemia), which quickly deplete the infant's glucose supply. Infants of diabetic mothers are usually delivered just before or at term because of an increased risk of ketoacidosis and intrauterine fetal death after 36 weeks.

The tuberculin syringe has a long, thin barrel. The syringe, calibrated in sixteenths of a minim and hundredths of a milliliter, has a capacity of 1 mL. It is used to prepare small amounts of medication such as small, precise doses for infants or young children.

Erythromycin (Ilotycin) is effective in protecting the newborn from against both Neisseria gonorrhea and Chlamydia trachomatis. It is less irritating to the newborn's eyes than silver nitrate, does not stain, and may be administered at any safe temperature.

Parents must give informed consent for treatment of a minor with three exceptions. The first is to give emergency treatment. The second is when the consent of the minor is sufficient, such as for treatment of a sexually transmitted disease. The third is when a court order or other legal authorization has been made.

A sign of an adverse effect of terbutaline (Brethine) is tachycardia. Therefore the nurse would instruct the mother to check her pulse rate before taking each medication dose. Side effects of the medication include tremors, shakiness, nervousness, drowsiness, headache, nausea, heartburn, dizziness, flushing, and weakness.

With neurogenic bladder, vesicoureteral reflux can occur because of enlargement of the ureters and incomplete emptying of the neurogenic bladder. Urine flows back up into the ureters and eventually into the kidneys, causing hydronephrosis (enlarged kidneys). Protein, not blood, would be found in the urine at this time. Treatments include intermittent catheterization carried out around the clock and ureteral reimplantation surgery.

Autonomic dysreflexia (hyperreflexia) is a serious, potentially life-threatening complication of spinal cord injury. It results from an excessive autonomic response to normal stimuli and affects primarily clients with upper motor neuron lesions. The most frequent cause is bladder distention or feces in the rectum, although it can be triggered by visceral distention or stimulation of pain receptors in the skin. Clients are taught to perform self-catheterization regularly to prevent this problem, measures to prevent constipation, and other measures to prevent stimulation of pain receptors in the skin.

Digoxin (Lanoxin) is a cardiac glycoside that improves cardiac contraction, slows the heart rate, promotes diuresis, and increases cardiac output.

During the planning stage for client teaching, the nurse's first action would be to determine what the client's understanding of the topic is. This information provides the basis for planning further teaching. In this case, the nurse would determine the client's knowledge and understanding of the ECG rhythm. Although the nurse also may identify any concerns that the client has about his condition, this information is not specifically related to client teaching as addressed in this question. Most clients would not know how to interpret an ECG rhythm strip; this activity is one that requires special training.

Propranolol (Inderal) is a beta-blocker that has side effects that could be disturbing to the client. These include decreased sexual ability, drowsiness, difficulty sleeping, and unusual tiredness and weakness. The client should know what these side effects are, so appropriate follow-up care can be sought.

Digoxin is a cardiac glycoside. The client is taught how to monitor his or her own pulse rate. The client is told to call the physician if the pulse rate is less than 60 beats/minute because bradycardia is a sign of medication toxicity. The client is not told to stop taking the medication. The medication must be taken daily and at the same time each day to ensure a consistent and stable blood level of the medication.

In cardiogenic shock, the nurse must take an active role in ensuring the client's safety and physical comfort. A major role of the nurse is monitoring the client's hemodynamic and cardiac status, and then planning care to maximize cardiac function and provide safety. Having the client sit on the side of the bed before the transfer allows the body's baroreceptors to adjust and stabilize vital centers to position changes, thereby avoiding a fall due to postural hypotension. The nurse should remain with the client and assist in the transfer to the chair. Although a hydraulic lift may be appropriate for transferring a client from a bed to a chair, it is unrelated to this situation and the issue that the client experiences postural hypotension. A transfer (sliding) board is appropriate to use for transferring a client from a bed to a stretcher, not a chair.

Amitriptyline (Elavil), a tricyclic antidepressant, lowers the seizure threshold, increasing the risk of seizures. Therefore this medication is used with caution in the client with a history of seizures.

Client preparation for an oral glucose tolerance test includes ingestion of a diet with at least 150 grams of carbohydrates per day for 3 days before the test.

Chlorpropamide is a first-generation sulfonylurea (oral hypoglycemic agent) that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. Pioglitazone (Actos) is a thiazolidinedione, and miglitol and acarbose are glucosidase inhibitors used as oral hypoglycemic agents. These agents do not exert an antidiuretic effect.

To stimulate circulation as an aid in obtaining an adequate capillary blood sample, the client should wash the hands first by using warm water. The arm should be allowed to hang dependently, and the finger may be milked to promote obtaining an adequate size blood drop. The finger should be punctured near the side, not the center, because fewer nerve endings are found along the side of the finger. The puncture is only as deep as needed to obtain an adequate blood drop. Excessively deep punctures may lead to pain and bruising.

The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to the lowered pH. Once the client is treated with fluid replacement and insulin therapy, the potassium level begins to decrease quickly. This is because potassium is carried into the cells along with glucose and insulin, and also because potassium is excreted in the urine once rehydration has occurred. Thus the nurse must plan to monitor the results of serum potassium levels carefully and to report hypokalemia promptly.

One of the biggest concerns for diabetics during air travel, especially for long-distance flights, is the availability of food at times that corresponds with the timing and peak action of the client's insulin. For this reason, the nurse may suggest that the client have carbohydrate snacks on hand for use as needed. Insulin equipment and supplies should always be placed in carry-on luggage

The normal value for glycosylated hemoglobin is 6% to 7%, and this test result provides an indication of glycemic control over the previous 3-month period. With elevations in blood glucose, some of the glucose molecules attach to the red blood cell (RBC) and remain there for the life of the RBC. Therefore high values in this test correlate with high blood glucose levels, indicating poor long-term control of blood glucose. Poor control of blood glucose is thought to be related to the development of complications in the client with diabetes mellitus.

The client is exhibiting signs of shock and requires emergency intervention. The nurse would immediately place the client in a modified Trendelenburg position. This position increases blood return from the legs, which increases venous return and subsequently the blood pressure. The nurse can then verify the client's volume status by assessing the urine output and whether the IV is infusing. The nurse should obtain all this information quickly and then call the physician. The nurse would also monitor the client's blood pressure, but retaking the blood pressure as a first action would delay necessary and potentially lifesaving intervention.

Standard measures for control of morning sickness include eating crackers or toast before arising from bed in the morning, eating small frequent meals, avoiding fatty and spicy foods, and arising slowly to avoid orthostatic hypotension.

Proper skin care during radiation therapy is extremely important to prevent skin breakdown and resultant infection. The nurse teaches the client to wash the skin gently with lukewarm water and a mild soap and patting the skin dry. The skin should not be rubbed, nor should that area of skin be shaved. The client should use only mild soaps for cleansing to avoid chemical irritation of the skin and should avoid lotions, creams, powders, or perfumes in the affected area. Finally, the client should not remove any skin markings placed by the radiologist to guide the radiation therapy.

The nasal cannula provides for lower concentrations of oxygen and can even be used with mouth breathers because movement of air through the oropharynx creates the Bernoulli effect, pulling oxygen from the nasopharynx. It is not necessary to instruct a client to breathe only through the nose.

Determining what to teach a client begins with an assessment of the client's own knowledge and learning needs. Once these have been determined, the nurse can effectively plan a teaching approach, the actual content, and resource materials that may be needed. The evaluation is done after teaching is completed.

Basic procedure for drawing up medication from an ampule involves tapping the top chamber until the medication lies in the lower area, placing an alcohol wipe around the neck of the ampule, snapping the top of the ampule toward the nurse so it opens away from the nurse, and withdrawing the medication without injecting air into the ampule. Shaking the ampule will cause medication to trap in the top of the ampule. Snapping the ampule so that it opens away from the nurse prevents injury from possible shattered glass fragments. The neck is not wiped with the gauze, because first, it is unnecessary and could contaminate the ampule or medication, and second, it could cause injury to the nurse's fingers from sharp glass edges.

Suctioning is indicated when the client cannot expectorate mucus by using a variety of other assistive methods. The need for suctioning is best determined by listening for coarse gurgling or bubbling respirations, or by hearing adventitious breath sounds with auscultation.

The nurse removes the sleeves of the pneumatic compression device 3 times a day for 20 to 30 minutes so that hygiene may be performed and skin integrity and circulation can be checked. The circulation to the extremities and the placement of the sleeves should also be checked every 2 to 3 hours for client safety.

Wound irrigation with normal saline is done before obtaining a wound culture because it can remove substances such as proteins or exudate.

The most effective means of preventing irregularities in volume infusion for the pediatric client is the use of an infusion pump. This prevents both overhydration and underhydration. A small-bore catheter is used in the pediatric client because of the small vein size, and a microdrip infusion set is used, rather than a macrodrip set. An arm board may be helpful in certain instances to minimize movement of the extremity with the catheter but is not the most effective means for regulating IV flow rate.

Phenelzine (Nardil) is a monoamine oxidase inhibitor (MAOI) that produces an antidepressant effect. Hypertensive crisis is an adverse effect of the medication, and the client must be instructed in the signs of this adverse effect. The onset of a headache that is sudden, severe, or unusual may be a sign of hypertensive crisis. In addition to a headache, a stiff neck, vomiting, and a sudden increase in blood pressure are manifestations of hypertensive crisis. Hypertensive crisis can lead to intracranial bleeding and is one of the most threatening side effects of MAOIs. Hypertensive crisis can be caused by the ingestion of foods containing the amino acid tyramine, and the client is instructed to avoid foods that contain this amino acid. It is not necessary for the client to avoid high-carbohydrate foods, limit fluid intake, or eat bran every day.

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No item should be placed inside a cast because of the risk for alteration in skin integrity. A cotton-tipped applicator with rubbing alcohol may be used near the cast edges to relieve itching. The skin around the cast edges should be checked for redness, irritation, or blistering. The extremity should be elevated as much as possible to minimize swelling. The physician should be notified for any unusual odor and/or sudden unexplained fever indicating infection, or if numbness, tingling, pallor, cyanosis, and/or pain unrelieved by medication occurs because these signs indicate neurovascular compromise.

Although signs of neglecting parents are not always easily identified, some behavioral characteristics emerge. These include a lack of concern for the child's well-being, unreasonable punishments, high demands and unrealistic expectations for the child, and a view of the child as a small adult who can meet their personal needs. Assessment of the parents in their role may provide the nurse with clues as to the family dynamics and assist in determining the educational needs of the parents.

Trauma, often due to falls, is the most common cause of spinal cord injury. Roller-blading, especially without a helmet, is a risk factor. Other risk factors include bicycling, motorcycling, horseback riding, diving into unknown waters, and occupations at elevations over 5 feet.

Constipation with ribbon-like, foul-smelling stools is particularly characteristic of Hirschsprung's disease. A distended abdomen, poor feeding habits, irritability, and signs of undernutrition also are characteristic of Hirschsprung's disease. Inguinal swelling indicates inguinal hernia. Projectile vomiting indicates pyloric stenosis. Intussusception is indicated by acute, colicky abdominal pain and currant jelly-like stool.

A "slapped face" appearance and circumoral paleness can be indicative of the presence of a communicable disease, specifically fifth disease. Therefore a complete and thorough assessment should be done before deciding on the appropriate nursing intervention.

Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. Before administering the medication, the nurse should assess the apical heart rate for 60 seconds. If the pulse rate is less than 60 beats per minute in an adult client, the nurse would withhold the medication and contact the physician, because a low pulse rate may be an indication of toxicity.

Allergy to seafood, iodine, or iodine contrast media in the preprocedure period may necessitate a skin test for allergy severity and the use of prophylactic antihistamines to prevent an allergic response to the contrast medium.

Progressive, gradual increases in activity should be done after MI. Gradual increases in activity prevent or minimize overtaxing of the heart and fatigue. The nurse's role is to monitor and adjust the client's activity level according to individual tolerance. Providing positive reinforcement and encouragement during physical activity and providing adequate fluid intake will not prevent or minimize activity intolerance.

Clients with polycystic kidney disease seem to waste rather than to retain sodium. Thus they need an increased sodium intake and fluid intake of 1500 mL to 2000 mL per day.

Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointestinal disturbances such as anorexia, nausea, and vomiting. Neurological abnormalities also can occur early and include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular disturbances (photophobia, light flashes, halos around bright objects, yellow or green color perception) also are signs of toxicity but are not early signs.

The best initial action that begins the attachment process and promotes bonding is to encourage the parents to touch their infant. The parents' initial need is to become acquainted with their newborn infant.

Ambulatory clients with visual field deficits do not distinguish between colors very well and therefore require bright (not pastel) colored doors, doorknobs, hallway corners, etc.

Photon absorptiometry uses two sources of radiation of different energies to measure the density of the bone, and a low dose of radiation is used. This diagnostic test requires no invasive technique such as an injection or placement of a scope and is painless. The test does not use a magnetic field, so no danger is associated with metal objects on or in the client.

Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft mattress and footboards will not be helpful to inflamed joints and should be avoided.

According to category-specific (respiratory) isolation precautions, acid-fast bacteria isolation always requires a private room. The room needs to be well ventilated and should have at least six exchanges of fresh air per hour and should be ventilated to the outside if possible.

The preschooler has a vivid imagination and loves to pretend. Engaging the child in therapeutic play appropriate to age is considered the most effective way to intervene. Balloons are unsafe because of the potential aspiration of latex. The peak flow meter is used to assess vital capacity rather than to encourage breathing. Chest percussion and postural drainage will not affect depth of respiration.

A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities. If only one lower extremity is included, it is called a single hip spica; if two are included, it is called a double hip spica. Short and long leg casts are applied to the leg. A body jacket cast is applied to the upper torso.

The decrease in cortisol secretion that characterizes Addison's disease can result in hypoglycemia. Fluid intake should be encouraged to compensate for dehydration. Potassium intake should be restricted because of hyperkalemia.

General anesthesia depresses the gag reflex that, in turn, increases the risk for aspiration. Suction equipment must be available in the event the client aspirates

Florinef is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity that is used for long-term management of Addison's disease. Mineralocorticoids act on the renal distal tubules to enhance the reabsorption of sodium and chloride ions and the excretion of potassium and hydrogen ions. In small doses, fludrocortisone acetate causes sodium retention and increased urinary potassium excretion. Hypotension and fluid and electrolyte imbalance can develop rapidly if the medication is discontinued abruptly.

Denial is a failure to recognize what is occurring in a situation and generates inappropriate behavior. Projection is the disowning and attributing process that enables a person to remain blind to aspects of self and distant to the perception of others. Setting firm limits on unacceptable and inappropriate behaviors in a nondefensive manner is the initial nursing action in this situation.

The individual with retinopathy has varying degrees of visual impairment. Thus falls are a major concern, especially for the older client. Disturbed Body Image and Chronic Low Self-Esteem are psychosocial needs and are not the priority. Although Risk for Bathing/Hygiene Self-Care Deficit relates to a physiological need, for this client, the Risk for Injury presents the greatest threat.

Clients with hypothyroidism have Imbalanced Nutrition: More than Body Requirements due to their decreased metabolic need. They should consume foods from all food groups, which will provide them with the necessary nutrients; however, the foods should be low in calories.

Clients with Parkinson's disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these individuals imagine lines on the floor to step over can keep them moving forward.

The halo vest is used to treat cervical fractures. The halo vest or jacket has a ring that is fixed to the skull with pins. This ring is then attached to the vest or jacket by rods. This device provides the traction required to maintain cervical alignment and allows early mobilization and rehabilitation. A body jacket cast is applied to the upper torso. Skull tong traction involves the use of one of a variety of tongs (Gardner-Wells, Crutchfield, Vinke, or Barton). These tongs are drilled into the skull or placed below the scalp and attached to ropes, pulleys, or weights. This type of traction is used for cervical vertebrae fractures and involves the use of special beds or turning frames to facilitate nursing care. A hip spica cast is used to treat pelvic and femoral fractures. The cast covers the lower torso and extends to one or both lower extremities.

Hypocalcemia is the result of hypoparathyroidism because of either a lack of parathyroid hormone (PTH) secretion or ineffective PTH influence on tissue. Calcium is the major controlling factor of PTH secretion. Because of this, the diet needs to be high in calcium but low in phosphorus, because these two electrolytes must exist in inverse proportions in the body.

The vast majority of clients with Guillain-Barré syndrome recover from the paralysis because it affects peripheral nerves that have the capacity to remyelinate. Maximal paralysis can take up to 4 weeks to develop. Paralysis progresses distally to proximally. Rehabilitation can take from 6 months to 2 years.

Pyridostigmine bromide (Mestinon) is an anticholinesterase that is used to improve muscle strength in the client with myasthenia gravis. Taking the medication before activities such as working or eating helps lessen fatigue and dysphagia and improves muscle strength. The medication should be taken with food. Clients should avoid quinine, antacids, magnesium, and morphine sulfate and its derivatives, because these medications can reverse the action of the pyridostigmine bromide and increase weakness. The medication should be taken regularly and on time to prevent fluctuating blood levels, which can cause weakness.

Typically, infants of diabetic mothers are large for gestational age. Maternal glucose crosses over the placenta to the fetus. The fetus is able to produce its own insulin; therefore excessive body growth (macrosomia) results from high maternal glucose. After birth, hypoglycemia may be a problem because the infant's pancreas continues to produce large amounts of insulin (hyperinsulinemia), which quickly deplete the infant's glucose supply. Infants of diabetic mothers are usually delivered just before or at term because of an increased risk of ketoacidosis and intrauterine fetal death after 36 weeks.

The tuberculin syringe has a long, thin barrel. The syringe, calibrated in sixteenths of a minim and hundredths of a milliliter, has a capacity of 1 mL. It is used to prepare small amounts of medication such as small, precise doses for infants or young children.

Erythromycin (Ilotycin) is effective in protecting the newborn from against both Neisseria gonorrhea and Chlamydia trachomatis. It is less irritating to the newborn's eyes than silver nitrate, does not stain, and may be administered at any safe temperature.

Parents must give informed consent for treatment of a minor with three exceptions. The first is to give emergency treatment. The second is when the consent of the minor is sufficient, such as for treatment of a sexually transmitted disease. The third is when a court order or other legal authorization has been made.

A sign of an adverse effect of terbutaline (Brethine) is tachycardia. Therefore the nurse would instruct the mother to check her pulse rate before taking each medication dose. Side effects of the medication include tremors, shakiness, nervousness, drowsiness, headache, nausea, heartburn, dizziness, flushing, and weakness.

With neurogenic bladder, vesicoureteral reflux can occur because of enlargement of the ureters and incomplete emptying of the neurogenic bladder. Urine flows back up into the ureters and eventually into the kidneys, causing hydronephrosis (enlarged kidneys). Protein, not blood, would be found in the urine at this time. Treatments include intermittent catheterization carried out around the clock and ureteral reimplantation surgery.

Autonomic dysreflexia (hyperreflexia) is a serious, potentially life-threatening complication of spinal cord injury. It results from an excessive autonomic response to normal stimuli and affects primarily clients with upper motor neuron lesions. The most frequent cause is bladder distention or feces in the rectum, although it can be triggered by visceral distention or stimulation of pain receptors in the skin. Clients are taught to perform self-catheterization regularly to prevent this problem, measures to prevent constipation, and other measures to prevent stimulation of pain receptors in the skin.

Digoxin (Lanoxin) is a cardiac glycoside that improves cardiac contraction, slows the heart rate, promotes diuresis, and increases cardiac output.

During the planning stage for client teaching, the nurse's first action would be to determine what the client's understanding of the topic is. This information provides the basis for planning further teaching. In this case, the nurse would determine the client's knowledge and understanding of the ECG rhythm. Although the nurse also may identify any concerns that the client has about his condition, this information is not specifically related to client teaching as addressed in this question. Most clients would not know how to interpret an ECG rhythm strip; this activity is one that requires special training.

Propranolol (Inderal) is a beta-blocker that has side effects that could be disturbing to the client. These include decreased sexual ability, drowsiness, difficulty sleeping, and unusual tiredness and weakness. The client should know what these side effects are, so appropriate follow-up care can be sought.

Digoxin is a cardiac glycoside. The client is taught how to monitor his or her own pulse rate. The client is told to call the physician if the pulse rate is less than 60 beats/minute because bradycardia is a sign of medication toxicity. The client is not told to stop taking the medication. The medication must be taken daily and at the same time each day to ensure a consistent and stable blood level of the medication.

In cardiogenic shock, the nurse must take an active role in ensuring the client's safety and physical comfort. A major role of the nurse is monitoring the client's hemodynamic and cardiac status, and then planning care to maximize cardiac function and provide safety. Having the client sit on the side of the bed before the transfer allows the body's baroreceptors to adjust and stabilize vital centers to position changes, thereby avoiding a fall due to postural hypotension. The nurse should remain with the client and assist in the transfer to the chair. Although a hydraulic lift may be appropriate for transferring a client from a bed to a chair, it is unrelated to this situation and the issue that the client experiences postural hypotension. A transfer (sliding) board is appropriate to use for transferring a client from a bed to a stretcher, not a chair.

Amitriptyline (Elavil), a tricyclic antidepressant, lowers the seizure threshold, increasing the risk of seizures. Therefore this medication is used with caution in the client with a history of seizures.

Client preparation for an oral glucose tolerance test includes ingestion of a diet with at least 150 grams of carbohydrates per day for 3 days before the test.

Chlorpropamide is a first-generation sulfonylurea (oral hypoglycemic agent) that exerts an antidiuretic effect and should be administered cautiously or avoided in the client with cardiac impairment or fluid retention. Pioglitazone (Actos) is a thiazolidinedione, and miglitol and acarbose are glucosidase inhibitors used as oral hypoglycemic agents. These agents do not exert an antidiuretic effect.

To stimulate circulation as an aid in obtaining an adequate capillary blood sample, the client should wash the hands first by using warm water. The arm should be allowed to hang dependently, and the finger may be milked to promote obtaining an adequate size blood drop. The finger should be punctured near the side, not the center, because fewer nerve endings are found along the side of the finger. The puncture is only as deep as needed to obtain an adequate blood drop. Excessively deep punctures may lead to pain and bruising.

The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to the lowered pH. Once the client is treated with fluid replacement and insulin therapy, the potassium level begins to decrease quickly. This is because potassium is carried into the cells along with glucose and insulin, and also because potassium is excreted in the urine once rehydration has occurred. Thus the nurse must plan to monitor the results of serum potassium levels carefully and to report hypokalemia promptly.

One of the biggest concerns for diabetics during air travel, especially for long-distance flights, is the availability of food at times that corresponds with the timing and peak action of the client's insulin. For this reason, the nurse may suggest that the client have carbohydrate snacks on hand for use as needed. Insulin equipment and supplies should always be placed in carry-on luggage

The normal value for glycosylated hemoglobin is 6% to 7%, and this test result provides an indication of glycemic control over the previous 3-month period. With elevations in blood glucose, some of the glucose molecules attach to the red blood cell (RBC) and remain there for the life of the RBC. Therefore high values in this test correlate with high blood glucose levels, indicating poor long-term control of blood glucose. Poor control of blood glucose is thought to be related to the development of complications in the client with diabetes mellitus.

The client is exhibiting signs of shock and requires emergency intervention. The nurse would immediately place the client in a modified Trendelenburg position. This position increases blood return from the legs, which increases venous return and subsequently the blood pressure. The nurse can then verify the client's volume status by assessing the urine output and whether the IV is infusing. The nurse should obtain all this information quickly and then call the physician. The nurse would also monitor the client's blood pressure, but retaking the blood pressure as a first action would delay necessary and potentially lifesaving intervention.

Standard measures for control of morning sickness include eating crackers or toast before arising from bed in the morning, eating small frequent meals, avoiding fatty and spicy foods, and arising slowly to avoid orthostatic hypotension.

Proper skin care during radiation therapy is extremely important to prevent skin breakdown and resultant infection. The nurse teaches the client to wash the skin gently with lukewarm water and a mild soap and patting the skin dry. The skin should not be rubbed, nor should that area of skin be shaved. The client should use only mild soaps for cleansing to avoid chemical irritation of the skin and should avoid lotions, creams, powders, or perfumes in the affected area. Finally, the client should not remove any skin markings placed by the radiologist to guide the radiation therapy.

The nasal cannula provides for lower concentrations of oxygen and can even be used with mouth breathers because movement of air through the oropharynx creates the Bernoulli effect, pulling oxygen from the nasopharynx. It is not necessary to instruct a client to breathe only through the nose.

Determining what to teach a client begins with an assessment of the client's own knowledge and learning needs. Once these have been determined, the nurse can effectively plan a teaching approach, the actual content, and resource materials that may be needed. The evaluation is done after teaching is completed.

Basic procedure for drawing up medication from an ampule involves tapping the top chamber until the medication lies in the lower area, placing an alcohol wipe around the neck of the ampule, snapping the top of the ampule toward the nurse so it opens away from the nurse, and withdrawing the medication without injecting air into the ampule. Shaking the ampule will cause medication to trap in the top of the ampule. Snapping the ampule so that it opens away from the nurse prevents injury from possible shattered glass fragments. The neck is not wiped with the gauze, because first, it is unnecessary and could contaminate the ampule or medication, and second, it could cause injury to the nurse's fingers from sharp glass edges.

Suctioning is indicated when the client cannot expectorate mucus by using a variety of other assistive methods. The need for suctioning is best determined by listening for coarse gurgling or bubbling respirations, or by hearing adventitious breath sounds with auscultation.

The nurse removes the sleeves of the pneumatic compression device 3 times a day for 20 to 30 minutes so that hygiene may be performed and skin integrity and circulation can be checked. The circulation to the extremities and the placement of the sleeves should also be checked every 2 to 3 hours for client safety.

Wound irrigation with normal saline is done before obtaining a wound culture because it can remove substances such as proteins or exudate.

The most effective means of preventing irregularities in volume infusion for the pediatric client is the use of an infusion pump. This prevents both overhydration and underhydration. A small-bore catheter is used in the pediatric client because of the small vein size, and a microdrip infusion set is used, rather than a macrodrip set. An arm board may be helpful in certain instances to minimize movement of the extremity with the catheter but is not the most effective means for regulating IV flow rate.

Phenelzine (Nardil) is a monoamine oxidase inhibitor (MAOI) that produces an antidepressant effect. Hypertensive crisis is an adverse effect of the medication, and the client must be instructed in the signs of this adverse effect. The onset of a headache that is sudden, severe, or unusual may be a sign of hypertensive crisis. In addition to a headache, a stiff neck, vomiting, and a sudden increase in blood pressure are manifestations of hypertensive crisis. Hypertensive crisis can lead to intracranial bleeding and is one of the most threatening side effects of MAOIs. Hypertensive crisis can be caused by the ingestion of foods containing the amino acid tyramine, and the client is instructed to avoid foods that contain this amino acid. It is not necessary for the client to avoid high-carbohydrate foods, limit fluid intake, or eat bran every day.

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In ventricular septal defects, some defects may close spontaneously. If spontaneous closure does not occur, moderate or large defects require surgical closure before school age. If pulmonary hypertension is present, closure is necessary by age 1 year. Open-heart surgery is done for closure.

The MMR vaccine is contraindicated for children who have had an anaphylactic reaction to eggs or neomycin. Immunosuppression from corticosteroids, a low-grade fever, and TB skin testing are not contraindications for the MMR vaccine.

Activity guidelines for children with hemophilia are categorized into those that are usually safe, those that are riskier and should be discouraged, and those in which the risks outweigh the benefits and are not recommended for children with hemophilia. Archery, badminton, fishing, golf, hiking, Ping-Pong, swimming, and walking are usually considered safe for those with hemophilia.

The primary clinical manifestations of von Willebrand's disease are bruising and mucous membrane bleeding from the nose, mouth, and gastrointestinal tract. Prolonged bleeding after trauma and surgery, including tooth extraction, may be the first evidence of abnormal hemostasis in those with mild disease. In female clients, menorrhagia and profuse postpartum bleeding may occur. Bleeding associated with von Willebrand's disease may be severe and lead to anemia and shock, but unlike the situation in hemophilia, deep bleeding into joints and muscles is rare.

Desmopressin acetate (DDAVP) is prescribed via intranasal route for a child with von willebrand's disease and parents should be instructed to monitor intake and output and to avoid overhydration, but fluids should not be restricted. The medication should be refrigerated, but freezing should be avoided. Side effects include facial flushing, nasal congestion, increased blood pressure, nausea, abdominal cramps, decreased urination, and vulval pain. Signs and symptoms of water intoxication include headache, drowsiness, confusion, weight gain, seizures, and coma.

Idiopathic thrombocytopenic purpura (ITP) is a bleeding condition in which the blood doesn't clot as it should. This is due to a low number of blood cells called platelets

The laboratory manifestations of Idiopathic thrombocytopenic purpura (ITP) include the presence of a low platelet count of usually less than 50,000 cells/mm3. Thrombocytopenia is the only laboratory abnormality expected with ITP. If significant blood loss has occurred, evidence of anemia will be found in the complete blood cell count (CBC). If a bone marrow examination is performed, the results with ITP show a normal or increased number of megakaryocytes, the precursors of platelets. Also, with ITP, the bone marrow examination rules out aplastic anemia, leukemia, the presence of malignant tumors, and other bone marrow disorders.

In leukemia, bone marrow examination would indicate an increase number of immature white blood cells

Infant after a sugrgical procedure for insertion of a ventricular peritoneal shunt. If a shunt is malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area and result in intracranial pressure, which then causes the infant to cry. The cry is high-pitched. The infant should not have pressure placed on the shunt side. Skin breakdown and possible complications to the apparatus could result. This type of shunt affects the gastrointestinal system but not the genitourinary system.

Infants who weigh up to 20 pounds should be restrained in a car seat in a semireclined, rear-facing position to allow the seat and infant's spine to bear the forces of impact should a collision occur. The infant should never face forward or ride in the front seat.

To decrease the risk of recurrent otitis media, the mother should be encouraged to breastfeed during infancy and to discontinue bottle-feeding as soon as possible. The infant also is fed in an upright position and should never be given a bottle while in bed. The mother also is instructed not to smoke in the child's presence, because passive smoke increases the risk of otitis media.

Myringotomy is a surgical procedure in which a tiny incision is created in the eardrum, so as to relieve pressure caused by the excessive buildup of fluid

After a myringotomy with insertion of tympanostomy tubes, The mother should be assured that if the tympanostomy tubes fall out, it is not an emergency, but it is best if the physician or health care clinic is notified. The size and appearance of the tympanostomy tubes should be described to the mother after surgery so she will be familiar with the appearance.

After tonsillectomy, suction equipment should be available, but suctioning is not performed unless an airway obstruction occurs. Clear cool liquids are encouraged. Milk and milk products are restricted initially because they coat the throat, causing the child to clear the throat, increasing the risk of bleeding.

A pelvic sling is a traction device consisting of a hammock-like belt wherein the sling cradles the pelvis in its boundaries. It is used for the treatment of one or more pelvic fractures.

Getting out of bed in the morning is often a difficult task for a child with JRA because of the early morning stiffness that occurs. A warm morning bath is helpful, but this may be impractical for busy families. A warm bath at bedtime may provide comfort and assists in aiding sleep but will not prevent the morning stiffness. The nurse should suggest that the child use a sleeping bag at night to stay warm, use an electric blanket with a timer that turns on 1 hour before the child awakens, or sleep in a water bed to ease the stiffness.

Indoor swimming is frequently recommended as an ideal sport for children with asthma because the air is humidified. Exhaling underwater prolongs exhalation and increases end-expiratory pressure. With adequate treatment, however, a child with asthma can participate in most physical activities.

Nose drops are most helpful when administered 15 minutes before feeding and at bedtime. The parents are instructed to instill two nose drops and wait 5 minutes before instilling more drops, if prescribed, to increase effectiveness. Parents should be cautioned against using nose drops for more than 3 days. The vasoconstrictive effect of the decongestant nose drops can cause rebound congestion. Cough suppressants are not recommended because they impair removal of secretions, thus increasing the risk of secondary infection.

Children should wear long pants, long-sleeved shirts, and hats when in wooded or grassy areas. Ticks should be removed with tweezers and should be removed as close to the skin as possible. Repellants should be used with caution and should not be applied to the hands to avoid contact of the repellant with the child's eyes and mouth. Pets should be kept free of ticks during tick season. If a tick falls off a pet, it can travel and make contact with an individual and attach to the individual's skin.

In children with mild or moderate diarrhea older than 2 years, the mother should be instructed to give foods high in starch, such as breads, crackers, rice, mashed potatoes, and noodles, because these are easily absorbed during periods of diarrhea. Clear liquids are encouraged, and milk and milk products should be eliminated except for active culture yogurt, which containslactobacillus organisms. Raw fruits and vegetables, beans, spices, and any other foods that cause loose stools should be avoided.

The purpose of Crutchfield tongs is to stabilize fractures or displaced vertebra in cervical and thoracic areas. Tongs are inserted on the sides of the scalp through drill holes. Traction pull is always along the axis of the spine. The nurse should check the tongs every 8 hours and prn for displacement and looseness. The child can be repositioned by log-rolling or turned as a unit when repositioning. Neurological status should be checked frequently in the first 24 hours because spinal cord injury frequently accompanies this type of injury. Pin care is done every shift.

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Fans can be directed toward the cast to facilitate drying. Ice can be applied to the casted area, and the casted extremity should be elevated with pillows to prevent swelling. The fingers of the casted extremity should be the same color and temperature as on the other extremity. When assisting with bathing and showering, the mother should be instructed to cover the cast to keep the cast dry.

Rheumatic fever characteristically is first seen 2 to 6 weeks after an untreated or partially treated group A b-hemolytic streptococcal infection of the respiratory tract. Initially on assessment, the nurse determines whether any family member has had a sore throat or unexplained fever within the past few weeks

When the child is receiving chemotherapy, the nurse should avoid taking rectal temperatures. Oral temperatures also are avoided if mouth ulcers are present. Axially temperatures should be done to prevent alterations in skin integrity. Meticulous mouth care should be performed, but the nurse should avoid alcohol-based mouthwash and should use a soft-bristled toothbrush. The nurse should assess the mouth and anus each shift for ulcers, erythema, or breakdown. Bland, nonirritating foods and liquids should be provided to the child. Fresh fruits and vegetables should be avoided because they can harbor organisms. Chemotherapy can cause neutropenia, and the child should be maintained on a low-bacteria diet if the white blood cell count is low.

Impetigo is a bacterial skin infection characterized by blisters that may itch.

If impetigo is caused by B-hemolytic streptococci, the child should be observed for periorbital edema or blood in the urine, which may signal the development of acute glomerulonephritis.

With a fungal infection of the foot, the client should be instructed to wash the feet daily and keep them dry. Nonventilated athletic shoes should be allowed to dry thoroughly between wearing. If socks are needed, the child should wear heavy cotton socks and change the socks at least twice a day. The heavy cotton socks will absorb sweat and keep the feet dry. The child should avoid wearing socks, if possible, and wear sandals as much as possible. Talcum powder or antifungal powder applied twice daily may help keep the feet dry.

Antilice sprays are unnecessary and should never be used on a child. Combs and brushes should be boiled or soaked in antilice shampoo or water hotter than 140° F for 15 minutes. Bedding and linens should be washed with hot water and dried on a hot setting. Items that cannot be washed should be dry-cleaned or sealed in plastic bags and placed in a warm place for a period of 3 weeks. Thorough home cleaning is necessary to remove any remaining lice or nits. Parents should vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

The suctioning procedure for pediatric clients varies from that which is used in adults. Suctioning in infants and children requires the use of a smaller suction catheter and lower suction settings than in the adult. Suction settings for preterm infants is 40 to 60 mm Hg. The settings for an infant or child are 60 to 100 mm Hg.

Applying suctioning when inserting the catheter can cause trauma to tissues and should not be done. Intermittent suctioning is applied when withdrawing the catheter.

Oxaprozin (Daypro) is a nonsteroidal antiinflammatory medication that is used to treat acute and chronic osteoarthritis and rheumatoid arthritis.

Enuresis refers to a condition in which the child is unable to control bladder function, although he or she has reached an age at which control of voiding is expected. Children who have never been dry at night for prolonged periods are said to have primary nocturnal enuresis.

The vastus lateralis muscle is the best choice for intramuscular injections for all age groups and should always be used in children younger than 3 years. The ventrogluteal muscle is safe for children older than 18 months because it is free of major blood vessels and nerves. The dorsogluteal muscle develops with walking, so it should not be used until the child has been walking for at least 1 year. The deltoid muscle is not used in children because the small muscle mass cannot hold large volumes of medication or medications that must be injected deep into the muscle mass.

Intradermal injections are placed just below the outer layer of the skin in the epidermis. The sites most often used are the inner aspect of the forearm and the upper back. The needle is small (25 to 27 gauge) and short (1/2 to 5/8 inch). The volume also is small, usually 0.1 mL. The needle is inserted at a 15-degree angle, and the medication is injected to form a wheal.

Breast milk or formula provides all the nutrients required for growth for the first 6 months. Whole milk is not recommended for the first year. Cereals and baby food are not recommended before 4 to 6 months because they are difficult to digest and may lead to allergies. Frequency of feeding is individual, the average being every 4 to 6 hours by age 6 months.

Congenital hypothyroidism may have a number of causes and can be either permanent or transient. Congenital hypothyroidism may be caused by an embryonic defect in the development or placement of the thyroid gland or inborn errors of thyroid hormone synthesis, secretion, or utilization. Genetic counseling may be needed because an inborn error of thyroid hormone synthesis is an autosomal recessive trait. Transient primary hypothyroidism is often caused by a maternal ingestion of medication during pregnancy such as iodides for asthma, antithyroid medications, or maternal antibodies.

An infant that has adjusted to drug withdrawal is calm and quiet and interacts with caregivers or the parents. If the infant remains distressed when exposed to light or noise, or if the infant is not exhibiting weight gain appropriately, drug withdrawal is not complete.

Prednisone dosage needs to be maintained at the prescribed levels, and dosage adjustments are made only by the physician. To prevent withdrawal syndrome, doses are gradually reduced and are never abruptly stopped or started.

Fluid restrictions are needed to prevent fluid overload and complications of cerebral edema and increased ICP. Sitting up will decrease fluid retention in cerebral tissue and promote drainage. Keeping the child awake will assist in the accurate evaluation of cerebral edema that may be present and will detect early development of ICP. Pupil checks are part of a neurological examination. The parent can explain the pupil checks to the child. Preparing the child for this procedure will decrease anxiety about this testing.

The diagnosis of bacterial endocarditis is established primarily on the basis of a positive blood culture of the positive organisms and visualization of a vegetation on echocardiographic studies. Other laboratory tests that may help to confirm the diagnosis are an elevated sedimentation rate and C-reactive protein level. An ECG and EEG are not helpful in the diagnosis of bacterial endocarditis. Changes in the white blood cell count can occur in a variety of conditions and are not specific to bacterial endocarditis.

Measures that will decrease the workload on the heart include limiting the time the child is allowed to bottle-feed or nurse, elevating the head of the bed, allowing uninterrupted rest periods, and providing oxygen during stressful periods.

Platelets are necessary for the clotting of blood. Therefore a decreased number would promote bleeding tendencies. Decreased erythrocytes may indicate that the bone marrow function is decreased. A decreased white blood cell count is not necessarily related to bleeding. Decreased eosinophils indicate a decrease in an allergic reaction.

The glycosylated hemoglobin measures the glucose molecules that attach to the hemoglobin A molecules and remain there for the life of the red blood cell, which is approximately 120 days. This is not reversible and cannot be altered by human intervention. Daily glucose logs are useful if they are kept regularly and accurately. However, they reflect the blood glucose only at the time the test was done. A fasting blood glucose is time limited in its scope, as is the dietary history.

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In the first several hours after insertion of either a permanent or temporary pacemaker, the most common complication is pacing electrode dislodgement. The nurse helps prevent this complication by limiting the client's activities. Vigorous shoulder and arm movement on the affected side should be avoided. This is an important concept regarding the care of the client immediately after pacemaker insertion.

The term capture refers to the electrical and mechanical response of the heart to pacemaker stimulation. The pacemaker spike indicates pacemaker firing. The client should have a QRS complex that follows the spike. Failure to capture then would be the absence of a QRS after a pacemaker spike on the client's rhythm strip.

The sensing device of a demand pacemaker senses the heart's own electrical activity and allows the pacemaker to fire only when the client rate is less than the preset rate. Thus for the portion of time that the client's rhythm is adequate, no pacemaker spikes should appear on the ECG. Failure to sense occurs when regular pacing artifact appears on the ECG regardless of the client's own inherent rhythm.

The client who has been on bed rest for 7 days is at risk for all the complications of immobility. The peripheral vascular complication would most likely be deep vein thrombosis. If this occurs, the client would exhibit redness and/or warmth of the affected leg, tenderness at the site, possible dilated veins (if superficial), low-grade fever, edema distal to the obstruction, and possible positive Homans' sign in the affected extremity.

Pulmonary embolism is a life-threatening complication of deep vein thrombosis and thrombophlebitis. The nurse vigilantly assesses the client for the development of pulmonary embolism. Chest pain is the most common symptom, is sudden in onset, and may be aggravated by breathing. Other common signs and symptoms include dyspnea, cough, diaphoresis, and apprehension.

The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this will resolve as the therapy progresses, and that the client should gradually increase activity as energy levels permit. Remember that medication therapy for the client with TB lasts for 6 to 9 months and may continue for up to a year.

Haloperidol acts by blocking the binding of dopamine to the postsynaptic dopamine receptors in the brain. Imipramine hydrochloride (Tofranil) blocks the reuptake of norepinephrine and serotonin. Donepezil hydrochloride (Aricept) inhibits the breakdown of released acetylcholine. Fluoxetine hydrochloride (Prozac) is a potent serotonin reuptake blocker.

Before mixing different types of insulin, the bottle should be rotated for at least 1 minute between both hands. This resuspends the insulin and helps warm the medication. Insulin may be maintained at room temperature. Additional bottles of insulin for future use should be stored in the refrigerator. Regular insulin is drawn up before NPH insulin. Air does not need to be removed from the insulin bottle.

Dimenhydrinate (Dramamine) is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness

Omeprazole (Prilosec) is a gastric pump inhibitor and is classified as an antiulcer agent. The intended effect of the medication is relief of pain from gastric irritation, often referred to as heartburn by the client.

Droperidol may be administered by the intramuscular or intravenous (IV) routes. The IV route is used when relief of nausea is needed. The intramuscular route may be used when the medication is used as an adjunct to anesthesia. To administer this medication, the nurse should have a needle and syringe.

Propantheline (Pro-Banthine) is an antimuscarinic anticholinergic medication that decreases gastrointestinal (GI) secretions. It should be administered 30 minutes before meals.

In a client with tuberculosis (TB), the client is generally considered to be noncontagious after 2 to 3 weeks of medication therapy, although the client is continued on medication therapy for 9 to 12 months. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission.

The client with TB should wash the hands carefully after each contact with respiratory secretions. The client should cover the mouth and nose when laughing, sneezing, or coughing. Used tissues are discarded in a plastic bag.

The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the client will always test positive on Mantoux skin testing. This client should be evaluated for TB with a chest radiograph.

A client with AIDS has a nursing diagnosis of Fatigue, The client is taught to conserve energy by sitting for as many activities as possible, including dressing, shaving, preparing food, ironing, etc. The client should also sit in a shower chair instead of standing while bathing. The client should prioritize activities such as eating breakfast before bathing and should intersperse each major activity with a period of rest. Frequent short rest periods are more effective than fewer, longer ones.

The convalescent phase of illnesses is not a contraindication for immunizations. The general contraindication for all immunizations is a severe febrile illness or immunocompromise. The normal schedule for immunizations is recommended for this infant to provide protection from life-threatening diseases.

Bicycle safety requires always wearing a helmet when riding. Most injuries occur near home, and a potential exists for falls on bike paths and off roads. Five years is also a young age to be riding in the street.

Instructions on feeding an infant with a cleft palate, The mother should be taught to maintain constant pressure to the bottom of the bottle to decrease the risk of choking. The mother should also be taught to expect noise from the baby while feeding and to watch facial expressions as a cue to stop the feeding.

Instructions given to a mother on measures to take to reduce the incidence of gastroesophageal reflux (GER) in a child includes the child's formula will most likely be thickened with cereal. Cereal is added to the formula to increase the consistency and decrease the incidence of regurgitation. The nipple holes should be large to allow for easy flow of thicker formula. The child should receive small feedings throughout the day. Sucking on a pacifier in an upright position facilitates the flow of food through the esophagus.

The following outcome indicates that the infant receiving phototheraphy is improving is when the infant's stools often become loose and bright green owing to the excretion of excessive bilirubin as a result of the phototherapy. The infant's urine may become a dark color from urobilinogen formation. The normal reticulocyte count in an infant at 1 to 3 days of age is 1.8% to 4.6%. An increasing reticulocyte count indicates continued destruction of the infant's red blood cells. Phototherapy works by a process of photoisomerization and photo-oxidation that results in more water-soluble bilirubin end products, which can then be more rapidly excreted in the urine and stool. Therefore the bilirubin level would decrease.

Between the ages of 1 and 3 months, the infant will produce cooing sounds. Babbling sounds are common between the ages of 3 and 4 months. An increased interest in sounds occurs between 6 and 8 months, and the use of gestures occurs between 9 and 12 months.

The age-appropriate instruction that is most important to instruct a mother of a 1-month old infant is to instruct the mother not to shake or vigorously jiggle the baby's head.

Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats, introduced one at a time can begin at 6 months of age. Self-feeding is not appropriate until approximately age 9 months.

In the preschooler, play is simple, imaginative, and creative, and dramatic play is prominent. The preschooler likes to build and create things. In the bedridden child, the nurse should provide an activity that provides this type of stimulation.

Celiac disease, also known as gluten enteropathy or tropical sprue, results from the inability to digest fully the protein part of wheat, barley, rye, and oats.

Elbow restraints are used after cleft palate repair to prevent the child from touching the repair site, which could cause accidental rupture and tearing of the sutures. One restraint can be removed only if a parent or nurse is in constant attendance.

In an adolescent, age 15 years to adulthood, the maximum volume of intramuscular medication that can be safely administered in the dorsal gluteal muscle is 2 mL.

Care of a child with rubella involves contact isolation. Contact isolation requires the use of masks, gowns, and gloves for contact with any infectious material. Contaminated articles must be bagged and labeled before reprocessing.

Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology.

HIV is an acquired cell-mediated immunodeficiency disorder

Rheumatic fever is an inflammatory autoimmunune disease that affects the connective tissue of the heart, joints and subcutaneous tissues

Systemic lupus erythematosus is a chronic multisystem autoimmune disease characterized by the inflammation of connective tissue.

Human immune globulin is obtained from the pooled blood of many people. This type of vaccine provides antibodies to a variety of diseases such as measles, rubella, and infectious hepatitis. Its disadvantage is that it offers only temporary passive immunity. Some immune globulin can be disease specific and is derived from individuals with a specific disease.

Dietary sources of vitamin B12 are primarily from meat, eggs, milk, and milk products. Plant foods do not provide this vitamin. Leafy green vegetables, whole-grain cereals, wheat germ, and legumes are dietary sources of folate.

Dietary sources of folate include leafy green vegetables, whole-grain cereals, wheat germ, and legumes. Meat, eggs, milk, and milk products are dietary sources of vitamin B12.

Fifth disease is transmitted via airborne particles, respiratory droplets, blood, blood products, or by transplacental means.

Epstein-Barr virus (Infectious mononucleosis) is transmitted via saliva, close intimate contact, or via blood. It is not transmitted via airborne particles, contact with sweat, or by the fecal-oral route.

The parents should be taught to wipe the child from front to back after urination or a bowel movement to avoid moving bacteria from the anus to the urethra. Fluid intake including water should be encouraged. The child should be encouraged to avoid holding urine and to urinate at least 4 times a day. Additionally, the bladder should be emptied with each void to avoid residual urine. Hand washing is necessary to prevent the spread of infection. Bubble baths also are avoided because they may cause possible urethral irritation.

In poststreptococcal glomerulonephritis, a urinalysis will reveal hematuria with red cell casts. Proteinuria also is present. If renal insufficiency is severe, the BUN and creatinine levels will be elevated. The WBC is usually within normal limits, and mild anemia is common.

Clinical manifestation associated with nephrotic syndrome include edema, anorexia, fatigue, abdominal pain from the presence of extra fluid in the peritoneal cavity, diarrhea due to edema of the bowel caused by decreased absorption of nutrients, increased weight, and a normal blood pressure.

Cryptorchidism occurs when one or both testes fail to descend through the inguinal canal into the scrotal sac.

After tonsillectomy, the child should be placed in a prone or side-lying position to facilitate drainage. The supine position is contraindicated because of the drainage that may occur and the risk of aspiration

Acute laryngotracheobronchitis (LTB) usually has a gradual onset and usually occurs at night.

Respiratory syncytial Virus (RSV) can live on paper or skin for up to 1 hour and on cribs or other nonporous surfaces for up to 6 hours. Although it is not airborne, it is highly communicable, and it is usually transferred by the hands. Meticulous hand washing decreases the spread of organisms. Personnel who care for these children should maintain contact precautions including wearing gloves and gowns and practicing good hand washing.

The therapeutic management for viral pneumonia is supportive. Antibiotics are not prescribed. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids.

A patent ductus arteriosus is a left-to-right shunt. Blood is shunted to the right side of the heart because the left side is normally functioning at a higher pressure than the right side. This shunting allows oxygenated and unoxygenated blood to mix. It results in increased pulmonary blood flow because the abnormal communication or opening sends more blood to the right side of the heart than normal.

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The client is at risk of deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Range-of-motion exercises, antiembolism stockings, and pneumatic compression boots are all helpful. The nurse should avoid using the knee latch on the bed or elevating the knees with the use of pillows, which inhibits venous return, thus placing the client more at risk for deep vein thrombosis or thrombophlebitis.

Orchidectomy = Surgery to remove one or both testicles

Signs of prostatism that may be reported to the nurse are reduced force and size of urinary stream, intermittent stream, hesitancy in beginning the flow of urine, inability to stop urinating quickly, a sensation of incomplete bladder emptying after voiding, and an increase in episodes of nocturia. These symptoms are the result of pressure of the enlarging prostate on the client's urethra.

The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal. Scabies is characterized by erythematous, papular eruptions. Genital warts are characterized by cauliflower-like growths or growths that are soft and fleshy.

The client in the case situation is expected to be dehydrated. The nurse assesses this client for weight loss, lethargy or headache, sunken eyes, poor skin turgor (such as tenting), flat neck and peripheral veins, tachycardia, or low blood pressure.

When calculating how to distribute a fluid restriction, the nurse usually allows half of the daily allotment during the day shift, when the client eats two meals and takes most medications. Another two fifths is allotted to the evening shift, with the balance allowed during the nighttime.

The potassium content of vegetables can be reduced by boiling vegetables and discarding the cooking water.

The client taking epoetin alfa is at risk of hypertension and seizure activity as the most serious adverse effects of therapy. This medication is used to treat anemia.

After (TURP), The client should expect that the urine will be pink-tinged for several days after this procedure. Dark red urine may be present initially, especially with inadequate bladder irrigation, and must be corrected if it occurs.

Early treatment of cervical infection can help prevent chronic cervicitis, which can lead to dysplasia of the cervix. Cervical dysplasia is an early cell change that is considered to be premalignant. Oral contraceptives and douches do not decrease the risk for this type of cancer.

A client had a postive papanicolaou smear and underwent cryosurgery with laser therapy. Vaginal discharge should be clear and watery after the procedure. The client will then begin to slough off dead cell debris, which may be odorous. This resolves within approximately 8 weeks. Tub and sitz baths are avoided while the area is healing, which takes about 10 weeks. Mild pain occurs after the procedure, and narcotic analgesics would not be required.

Infiltrating ductal carcinoma of the breast usually presents as a fixed, irregular-shaped mass. The mass is usually single and unilateral and is painless, nontender, and hard to the touch.

postanesthesia care of a client who has just had a mastectomy include during the first 24 hours after surgery, the client is assisted to move the fingers and hands and to flex and extend the elbow. The client also may use the arm for self-care, provided that the client does not raise the arm above shoulder level or abduct the shoulder.

After mastectomy and axillary lymph node dissection, the client is at risk for edema and infection. The client should avoid activities that increase edema such as carrying heavy objects (handbag or grocery bags) or having blood pressures taken on the affected arm. The client should also use a variety of techniques to avoid trauma to the affected arm because trauma can result in infection. Examples include using an electric razor to shave under the arm, wearing rubber gloves when washing dishes, using gloves when working in the garden, using a thimble when sewing, and using potholders when cooking.

The discomfort of reflux is aggravated by positions that compress the abdomen and the stomach. These include lying flat either on the back or stomach (prone) after a meal. Resting with the head elevated is most likely to give relief to the client.

The client has to lie still for endoscopic retrograde cholangiopancreatography (ERCP), which takes about an hour to perform. The client also has to sign an informed consent form. Intravenous (not oral) sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed.

The client is placed in the left Sims' position for the procedure. This position takes the best advantage of the client's anatomy for ease in introducing the colonoscope.

The client with cholecystitis should decrease overall intake of dietary fat. Foods that should be generally avoided to achieve this end include sauces and gravies, fatty meats, cheese, fried foods, high-fat snacks, products made with cream, and heavy desserts.

During an acute episode of cholecystitis, the client experiences severe right upper quadrant pain that radiates to the right scapula and shoulder. This is governed by the pattern of dermatomes in the body. The nurse who has administered pain medication determines whether this type of pain has been relieved.

Ammonia is yielded as a product of protein metabolism. Clients with hepatic encephalopathy have high serum ammonia levels, which are responsible for the encephalopathy symptoms. Limiting protein intake will curb the elevation in serum ammonia and prevent further deterioration of the client's mental status.

The client with weight gain and edema who also has cirrhosis complicated by ascites is retaining fluid. This is especially true when the client has not demonstrated an appreciable increase in food intake, or when the weight gain is massive in relation to the time frame given. This makes Excess Fluid Volume the highest priority nursing diagnosis. Furthermore, Excess Fluid Volume can place the client at risk for both respiratory and circulatory symptoms

Pain associated with Crohn's disease is alleviated by the use of analgesics and antispasmodics. It also is reduced by having the client practice relaxation techniques, applying local heat to the abdomen, and lying with the legs flexed. Lying supine with the legs straight does not help because it increases muscle tension in the abdomen and stretches abdominal muscles, which can aggravate inflamed intestinal tissues.

Dicyclomine is an anticholinergic, antispasmodic agent often used to treat irritable bowel syndrome unresponsive to diet therapy. To be effective in decreasing bowel motility, antispasmodic medications should be administered 30 minutes before mealtimes.

The client with a mild to moderate case of ulcerative colitis is often prescribed a diet that is low residue and with limited milk products. This will help to reduce the frequency of diarrhea for this client. Foods commonly avoided include foods with seeds or nuts and raw or dried fruits and vegetables.

The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back.

The client with chronic alcoholism who is experiencing acute pancreatitis is expected to show elevations in serum blood glucose, lipase, and amylase. The client with alcoholism typically has low magnesium levels

The client with chronic pancreatitis should limit fat in the diet. The client should also take in small meals at each sitting. This also will coincidentally reduce the amount of carbohydrate and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.

Quinapril hydrochloride is an angiotensin converting enzyme (ACE) inhibitor that is used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to a sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regard to food. If nausea occurs, the client should be instructed to take a noncola carbonated beverage and salted crackers or dry toast. A full therapeutic effect may take place in 1 to 2 weeks.

Quinupristin-dalfopristin is an antimicrobial medication used in the treatment of skin, urinary tract, central catheter, bone and joint, and respiratory infections, and for endocarditis or bacteremia. For intermittent IV infusion (piggyback), the medication should be infused over a 1-hour period.

Diarrhea, nausea, vomiting, loss of appetite, and dizziness are all common side effects of quinidine gluconate. If these occur, the physician or nurse should be notified; however, the medication should never be stopped abruptly because a rapid decrease in medication levels of antidysrhythmics could precipitate dysrhythmia.

Diltiazem hydrochloride is a calcium channel blocker that is used in the treatment of atrial flutter and fibrillation. It acts to decrease myocardial contractility and the workload on the heart, thus decreasing the need for oxygen. A diltiazem hydrochloride bolus of 0.25 mg/kg is administered slowly over a 2 minute period. A continuous drip of 5 to 10 mg/hr may be continued for up to 24 hours.

Vasopressin is a vasopressor and an antidiuretic. It directly stimulates contraction of smooth muscle, causes vasoconstriction, stimulates peristalsis, and increases reabsorption of water by the renal tubules, resulting in decreased urinary output.

The client taking benztropine mesylate should be instructed to avoid driving or operating hazardous equipment if drowsy or dizzy. Tolerance to heat may be reduced owing to a diminished ability to sweat, and the client should be instructed to plan rest periods in cool places during the day. The client should be instructed to contact the physician if difficulty swallowing or speaking, or vomiting occurs. The client should also inform the physician if central nervous system effects occur. The client should be instructed to monitor urinary output and to watch for signs of constipation.

Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with the medication. Adverse effects include blood dyscrasias. If the client has a fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, this may be indicative of a blood dyscrasia, and the physician should be notified.

Hematological reactions can occur in the client taking clozapine and include agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiating treatment and should be monitored closely during the use of this medication. The client also should be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever.

Disulfiram is used as an adjunct treatment for selective clients with chronic alcoholism who want to remain in a state of enforced sobriety. Clients must abstain from alcohol intake for at least 12 hours before the initial dose of the medication is administered. The most important assessment is to determine when the last alcoholic drink was consumed. The medication is used with caution in clients with diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, nephritis, and hepatic disease. It is also contraindicated in severe heart disease, psychosis, or hypersensitivity related to the medication.

Donepezil hydrochloride is a cholinergic agent that is used in the treatment of mild to moderate dementia of the Alzheimer's type. It enhances cholinergic functions by increasing the concentration of acetylcholine. It slows the progression of Alzheimer's disease.

As peristalsis returns after creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy.

The client should be taught to include deodorizing foods in the diet on clients with a colostomy, such as beet greens, parsley, buttermilk, and yogurt. Spinach also reduces odor, but is a gas-forming food as well. Cucumbers, eggs, and broccoli are gas-forming foods, and should be avoided or limited.

For the first 4 to 6 weeks after colostomy formation, the client should eat a low-residue diet. After this period, the client should eat a high-carbohydrate, high-protein diet. The client also is instructed to add new foods one at a time to determine tolerance to that food.

Ileostomy output is liquid by nature. Shredded wheat is high in dietary fiber, and thus will increase output of watery stool by increasing propulsion through the bowel. Foods that help to thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Addition or elimination of various foods can help to thicken or loosen this normally liquid drainage.

A complication that occurs frequently after ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to detect this complication. Losses require replacement by intravenous fluid until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period.

A Kock pouch is a continent ileostomy. As the ileostomy begins to function, the client drains it every 3 to 4 hours, then decreasing to about 3 times a day or as needed when full. The client does not need to wear a drainage bag but should wear an absorbent dressing to absorb mucous drainage from the stoma. Ileostomy drainage is liquid. The client would be able to pass stool from the rectum only if an ileal-anal pouch or anastomosis were created. This type of operation would be a two-stage procedure.

To maintain catheter patency and drainage, the catheter is irrigated with 10 to 20 mL normal saline. This prevents the pouch from overfilling, causing tension on the new suture lines. Water is not used because it is hypotonic. Small amounts are used to prevent rupture of suture lines in the newly created pouch.

The peristomal skin must receive meticulous cleansing because the ileostomy drainage has more enzymes and is therefore more irritating to the skin than colostomy drainage. The area below the ileostomy may be massaged as needed if the ileostomy becomes blocked by foods. It is unnecessary to massage around the stoma each day. Fluid intake should be maintained to at least 6 to 8 glasses of water per day to prevent dehydration. Food items such as nuts and seeds will pass through the ileostomy. The client should be taught that these foods will remain undigested.

Expected outcomes for the client with peptic ulcer disease experiencing pain include elimination of irritating foods from the diet, ability to take prescribed medications that will reduce pain, reporting that pain is relieved or prevented with medication, and an ability to sleep through the night without pain.

The most frequent symptom of duodenal ulcer is pain that is relieved by food intake. These clients generally describe the pain as a burning, heavy, sharp, or hunger pain that often localizes in the midepigastric area. It does not radiate down either arm. The client with duodenal ulcer does not usually experience weight loss or nausea and vomiting. These two symptoms are more typical in the client with a gastric ulcer.

Psychological or emotional stressors that exacerbate peptic ulcer disease may be found either at home or in the workplace. An inability to take breaks or days off is potentially the most stressful of all the options listed. This causes excess fatigue and psychological stress and also is the condition over which the client has least control.

Dietary modifications for the client with peptic ulcer disease include eliminating foods that are irritating to the client. Items that are generally eliminated or avoided include highly spiced foods, alcohol, caffeine, chocolate, and fresh fruits. Other foods may be taken according to the client's level of tolerance for that specific food.

Naprosyn is a nonsteroidal antiinflammatory drug (NSAID), which is typically irritating to the lining of the gastrointestinal (GI) tract and should be avoided by clients with a history of peptic ulcer disease. Sucralfate coats the surface of an ulcer to promote healing. Famotidine is a histamine-receptor antagonist that reduces the secretion of gastric acid. Omeprazole is a proton-pump inhibitor, which blocks the transport of hydrogen ions into the lumen of the GI tract.

Dumping syndrome occurs after gastric surgery because food is not held as long in the stomach and is "dumped" into the small intestine as a hypertonic mass. This causes fluid to shift into the intestines, causing cardiovascular as well as gastrointestinal symptoms. Symptoms typically include weakness, dizziness, diaphoresis, flushing, hypotension, abdominal pain and distention, hyperactive bowel sounds, and diarrhea.

Hiatal hernia is due to protrusion of a portion of the stomach above the diaphragm, where the esophagus usually is positioned. The client usually experiences pain due to reflux with ingestion of irritating foods, with lying flat after meals or at night, and with ingesting large or fatty meals. Relief is obtained with intake of small, frequent, and bland meals; with use of histamine antagonists and antacids; and with elevation of the thorax after meals and during sleep.

Factors to minimize dumping syndrome after gastric surgery include having the client lie down for at least 30 minutes after eating; giving small frequent meals; having the client maintain low-Fowler's position while eating; avoiding liquids with meals; and avoiding high-carbohydrate food sources. Antispasmodic medications may also be prescribed as needed to delay gastric emptying.

Dicyclomine is an anticholinergic, antispasmodic agent often used to treat irritable bowel syndrome unresponsive to diet therapy. The most frequent side effects of this medication are heartburn and constipation, due to the action of the medication. Other side effects include decreased sweating and salivation, drowsiness, and confusion.

Blood pressure should be taken with the client seated with the arm bared, positioned with support, and at heart level. The client should sit with the legs on the floor, feet uncrossed, and not speak during the recording. The client should not have smoked tobacco or ingested caffeine in the 30 minutes preceding the measurement. The client should rest quietly for 5 minutes before the reading is taken. The cuff bladder should encircle at least 80% of the limb being measured.

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Strict aseptic technique must be adhered to while performing endotracheal suctioning in order to prevent the introduction of pathogens into the lung field.

Myoglobinuria is a common finding after significant electrical injury or other significant muscular trauma and a potential complication of myoglobinuria is acute tubular necrosis. To prevent myoglobin from precipitating in the renal tubules, the IV rate is increased to maintain a urine output of 100 to 150 mL per hour until the urine is grossly clear of myoglobin.

Clients with Parkinson's disease generally have resting tremors and the tremor can be reduced with voluntary activity. Grasping coins or another object or holding onto the arm of a chair will assist in reducing the tremors. Tremors diminish (not stop completely) with medication and voluntary activities. Tremors worsen at rest.

Permanent sterility for males is a side effect of radiation to the abdominopelvic region as a treatment for Hodgkin's disease, and the nurse should plan to discuss sperm banking as a reproductive option with the client.

Warm packs applied to the affected side of the face can soothe the discomfort associated with Bell's palsy. Vigorous massage can be harmful and will not resolve the paralysis. The client should chew on the unaffected side and lubricating eye drops should be used to prevent eye dryness and resultant injury.

Tooth brushing can cause pain with trigeminal neuralgia, so a water pick or warm mouth wash should be used instead. Massage and exposure to cold can increase pain. Morning care should be carried out when pain medication has had a chance to take effect.

A decrease in blood pressure and tachycardia could indicate post-operative bleeding. Bleeding is a complication of a parathyroidectomy. Often bleeding cannot be observed on the front of the dressing in a client who had a parathyroidectomy, since it trickles around the neck to the back. Therefore, it is important for the nurse to check the front, sides, back of the dressing, and the sheets underneath the neck.

Every effort should be made to maintain the infant in a neutral thermal environment. Oxygen consumption increases rapidly above or below the neutral thermal environment. Handling the infant stimulates movement and thus oxygen consumption. This includes auscultating breath sounds and performing heel sticks.

Health care professionals must use caution during the intrapartal period to reduce the risk of the transmission of HIV to the fetus. Any procedure that exposes blood or body fluids from the mother to the fetus should be avoided. It is important for nurses to guard against procedures that would result in a loss of skin integrity and expose the fetus to maternal blood or body fluids. Direct (internal) fetal monitoring is a procedure that may expose the fetus to maternal blood or body fluids and therefore should be avoided. Exposure to cervical and vaginal secretions is a likely mechanism of transmission to the newborn therefore a cesarean birth is warranted.

The nurse caring for a client with PIH demonstrating the potential for seizures should pad the side rails on the bed and initiate seizure precautions to provide a safe and effective care environment.

Checking pupillary responses to light is a component of a neurological assessment. Urine is not positive for glucose and protein with cerebral trauma. Specific gravity is maintained between 1.002 and 1.030 to ensure adequate fluid balance in the body. Syndrome of inappropriate antidiuretic hormone (SIADH) is a complication of head trauma and in this complication the specific gravity drops to 1.000. Orthostatic blood pressures are not assessed in the client with head trauma; the head of the bed should remain elevated to at least 30 degrees to decrease the amount of cerebral edema.

Tremors, rigidity, and bradykinesia are manifestations of Parkinson's disease. Carbidopa-levodopa (Sinemet) is an antiparkinson agent and is used to control symptoms of Parkinson's disease. Phenytoin (Dilantin) is an anticonvulsant and antidysrhythmic. Pyridostigmine (Mestinon) is a cholinergic medication often used to treat myasthenia gravis. Warfarin (Coumadin) is an anticoagulant.

Intubation should always precede gastric lavage to prevent pulmonary aspiration.

Phytonadione (vitamin K) is routinely given to every newborn as an injection. Any injection would need to wait until after the bath of the newborn infant and after the skin is thoroughly cleansed. Newborns are covered with amniotic fluid, vernix, mucus, and maternal blood. Any of these fluids could contain the virus. An injection would transmit the virus directly into the newborn's system. Avoiding the use of forceps and vacuum extractions helps prevent lacerations to the infant's scalp. A bath immediately after delivery removes the body fluid, and breastfeeding is discouraged because it can transmit the virus to the baby.

A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as lisinopril, is the appearance of a persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the physician if the cough becomes very troublesome to them.

Nitroglycerin is a coronary vasodilator used in the management of angina pectoris. The client is generally advised to apply a new patch each morning and leave in place for 12 to 14 hours, as per physician directions. This prevents the client from developing tolerance (as happens with 24-hour use). The client should avoid placing the system in skin folds or excoriated areas. The client can apply a new patch if it becomes dislodged because the dose is released continuously in small amounts through the skin.

Tissue plasminogen activator is a thrombolytic medication that is used to dissolve thrombi or emboli due to thrombus. A frequent and potentially severe side effect of therapy is bleeding. The nurse assesses for signs of bleeding in clients receiving this therapy. Equipment needed by the nurse would include occult blood-test strips to monitor for occult blood in the urine, stool, or nasogastric drainage.

Headache is a frequent side effect of nitroglycerin because of the vasodilating action of the medication. It usually diminishes in frequency as the client becomes accustomed to the medication and is effectively treated with acetaminophen (Tylenol).

Betaxolol is a ß-adrenergic blocking agent used to lower blood pressure, relieve angina, or decrease dysrhythmias. Side effects include bradycardia and symptoms of congestive heart failure, such as weight gain and increased edema.

Verapamil is a calcium channel-blocking agent that may be used to treat rapid-rate supraventricular tachydysrhythmias, such as atrial flutter or atrial fibrillation. The client must be placed on a cardiac monitor to evaluate the effectiveness of the medication. A noninvasive blood-pressure monitor also is helpful, but is not as essential as the cardiac monitor.

Cola, coffee, and chocolate contain xanthine and should be avoided by the client taking a xanthine bronchodilator. This could lead to an increased incidence of cardiovascular and central nervous system side effects.

The client taking a potassium-wasting diuretic, such as chlorothiazide (Diuril), must be monitored for decreased potassium levels. Other fluid and electrolyte imbalances that occur with use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia.

Amiloride is a potassium-sparing diuretic used to treat edema or hypertension. A daily dose should be taken in the morning to avoid nocturia. The dose should be taken with food to increase bioavailability. Sodium should be restricted if used as an antihypertensive.

Diazepam is a sedative/hypnotic with anticonvulsant and skeletal muscle-relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure self. The most frequent side effects of this medication are dizziness, drowsiness, and lethargy. For this reason, the nurse puts the side rails up on the bed before leaving the room to prevent falls.

Because therapeutic and toxic dosage ranges are so close, lithium blood levels must be monitored very closely, more frequently at first and then once every several months after that. The client should be instructed to contact the physician immediately if excessive diarrhea, vomiting, or diaphoresis occurs. Lithium is irritating to the gastric mucosa; therefore lithium should be taken with food. A normal diet and normal salt and fluid intake (1500 to 3000 mL/day of fluid) should be maintained because lithium decreases sodium reabsorption in the renal tubules, which could cause sodium depletion. A low sodium intake causes an increase in lithium retention and could lead to toxicity.

Adverse effects of haloperidol include extrapyramidal symptoms noted as marked drowsiness and lethargy, excessive salivation, and a fixed stare. Hypotension, nausea, and blurred vision are occasional side effects.

Women who are postmenopausal are taught to do BSE on the same day of every month. Before menopause, women should do the procedure 7 days after the start of the menstrual cycle when the breasts are least tender. Each breast is examined with the opposite hand. The pads of the fingers should be used for palpation, and the client should press deeply feeling for lumps. The client may use a circular, up-and-down, or wedge method of assessment. Consistency of use of the same method is more important than the actual method used. The client would inspect the breasts while standing in front of a mirror. The client would palpate the breasts while in the shower because soapy wet skin makes it easy to slide the pads of the fingers across breast tissue, or the client would palpate the breasts while in the supine position.

Toxic shock syndrome is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse assesses the client for signs of this complication and notifies the physician promptly when a pattern of signs and symptoms is noted.

Testicular self-examination is an excellent self-screening examination for testicular cancer, which predominantly affects men in their late teens and twenties. The examination is performed once a month, as is breast self-examination (BSE). As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand and the testicle is rolled between the thumb and forefinger of the other hand. The examination should not be painful. It is easiest to do either during or after a warm shower (or bath) when the scrotum is relaxed.

The client with fibrocystic breast disorder experiences worsening of symptoms (breast lumps, painful breasts, and possible nipple discharge) before the onset of menses. This is associated with cyclical hormone changes. Clients should understand that this is part of the clinical picture of this disorder.

The client demonstrates the most difficulty adjusting to the loss of the breast by refusing to look at the wound or incisional drain. This indicates that the client is not ready or willing to begin to acknowledge and cope with the surgery.

After a radical vulvectomy, discharge instructions include, resume activity slowly, but walking is a beneficial activity. The client should know to rest when fatigue occurs. Activities to be avoided include driving, heavy housework, strenuous exercise, wearing tight clothing, crossing the legs, and prolonged standing or sitting. Sexual activity is prohibited for 4 to 6 weeks after surgery.