UWORLD NCLEX REVIEW STUDY GUIDE

UWORLD NCLEX REVIEW STUDY GUIDE • Clozapine is an atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis and is therefore used only in clients with treatment-resistant schizophrenia. must have their WBC and ANC monitored regularly throughout the course of therapy (initially once every week). the health care provider (HCP) immediately if fever or a sore throat develops, as this may indicate an underlying infection from neutropenia. also cause metabolic syndrome (weight gain, hyperlipidemia, insulin resistance/diabetes) and seizures. • Weight gain—a baseline height, weight, and waist circumference should be obtained, and a BMI can be calculated • Hyperglycemia—symptoms of hyperglycemia (eg, increased thirst and urination, weakness, increased blood glucose) should be monitored • Dyslipidemia—a lipid profile should be obtained A hemorrhagic stroke occurs when a blood vessel ruptures in the brain and causes bleeding into the brain tissue or subarachnoid space. Seizure activity may occur due to increased intracranial pressure (ICP) (Option 3). During the acute phase, a client may develop dysphagia. To prevent aspiration, the client must remain NPO until a swallow function screen reveals no deficits (Option 4). The nurse should perform neurological assessments (eg, level of consciousness, pupillary response) at regular intervals and report any acute changes (Option 5). Preventing activities that increase ICP or blood pressure will minimize further bleeding. The nurse should: • Reduce stimulation, maintain a quiet and dimly lit environment, limit visitors • Administer stool softeners to reduce strain during bowel movements (Option 1) • Reduce exertion, maintain strict bed rest, assist with activities of daily living • Maintain head in midline position to improve jugular venous return to the heart Sulfonylureas (eg, glyburide) stimulate insulin release via the pancreas and carry a risk for severe and prolonged hypoglycemia in the geriatric population due to potential delayed elimination. Avoidance of these drugs is recommended by the Beers Criteria. Instead, other medications that are at lower risk for hypoglycemia should be used (eg, metformin) Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (renin-angiontensin-aldosterone system). Clients will have generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output. Loss of immunoglobulins makes children susceptible to infection. Treatment typically includes: • Corticosteroids and other immunosuppressants (eg, cyclosporine) • Loss of appetite management by making foods fun and attractive • Infection prevention (eg, limiting social interaction until the child is better) Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome: • Massive proteinuria – caused by increased glomerular permeability • Hypoalbuminemia – resulting from excess protein loss in the urine • Edema – specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities • Hyperlipidemia – related to increased compensatory protein and lipid production by the liver Additional symptoms include decreased urine output, fatigue, pallor, and weight gain. The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome. Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Common substances include ice, cornstarch, chalk, clay, dirt, and paper. Although the condition is not exclusive to pregnancy, many women only have pica when they are pregnant. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia. Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. Although antiemetic medications are typically administered immediately after surgery to control nausea and vomiting, nausea is still a common complication caused by anesthetic side effects and decreased gastrointestinal motility. Clients are at high risk for aspiration (and possible asphyxiation) due to their altered level of consciousness, which is caused by anesthesia. Clients reporting nausea should be placed immediately on their side to prevent aspiration of vomit. Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness (caused by anesthesia). These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications. The needle is inserted between ribs 6 and 7 or 8 and 9 while the client lies supine with the right arm over the head and holding the breath. A full bladder is a concern with paracentesis when a trocar needle is inserted into the abdomen to drain ascites. An empty bladder may aid comfort, but it is not essential for safety. The client must lie on the right side for a minimum of 2-4 hours to splint the incision site. The liver is a "heavy" organ and can "fall on itself" to tamponade any bleeding. The client stays on bed rest for 12-14 hours. Essential nursing actions related to a needle liver biopsy include checking coagulation, blood type, and crossmatch beforehand, positioning the client on the right side for hours afterward, and monitoring vital signs and for potential signs of shock. Albuterol (Proventil) is a short-acting beta-2 agonist that produces immediate bronchodilation by relaxing smooth muscles. Bronchodilation decreases airway resistance, facilitates mucus drainage, decreases the work of breathing, and increases oxygenation. Peak flow will improve. The most frequent side effects are tremor, tachycardia, restlessness, and hypokalemia. Following open radical prostatectomy, any rectal interventions such as suppositories or enemas must be avoided to prevent stress on the suture lines and problems with healing in the surgical area. The client should not strain when having a bowel movement for these reasons. Central chemoreceptors located in the respiratory center of the brain (medulla) respond to changes in blood carbon dioxide and hydrogen ions by either increasing or decreasing ventilation to normalize the pH. When the receptors sense a low pH (acidosis), ventilation increases to rid the body of excess carbon dioxide; when the receptors sense a high pH (alkalosis), ventilation decreases to retain carbon dioxide. Peripheral chemoreceptors located in the carotid and aortic bodies respond to low levels of oxygen and stimulate the respiratory center to increase ventilation. Many clients with COPD breathe because their oxygen levels are low rather than because carbon dioxide levels are high. This is commonly referred to as the hypoxemic drive. If they receive too high a level of inspired oxygen, this drive can be blunted. It is therefore important for these clients to receive a "guaranteed" amount of oxygen as an increase in inspired oxygen can decrease the drive to breathe. To promote adequate gas exchange, the nurse should use a high-flow Venturi mask to deliver a specified, guaranteed amount of oxygen. Because this device has a mechanism that controls the mixture of room air, the inspired oxygen concentration remains constant despite changes in respiratory rate, depth, or tidal volume. It is the most appropriate intervention to promote adequate gas exchange. Amniotomy refers to the artificial rupture of membranes (AROM) and may be performed by the health care provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The nurse should assess the fetal heart rate before and after the procedure (Option 1). The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong, foul odor may indicate infection (Option 5). Once the membranes are ruptured, there is an increased risk for infection. The nurse should monitor the client's temperature at least every 2 hours after AROM (Option 2). (Option 3) As with any vaginal examination, the client may feel some pressure and discomfort during an amniotomy. However, the actual AROM procedure, or "breaking the bag of water," is painless. (Option 4) Supine positioning decreases uteroplacental blood flow and fetal oxygenation. The client should be assisted to upright positions after AROM to allow for drainage of amniotic fluid and to encourage the fetal head to remain firmly applied to the cervix. Clients with schizophrenia have difficulty initiating and maintaining social interactions with other people. The nurse can facilitate interpersonal functioning by providing one-on-one interaction in which the client can practice basic social skills in a non-threatening way. Once the client feels more comfortable, the nurse can encourage participation in activities that require some interaction with others. Impaired social interaction is one of the negative symptoms of schizophrenia; others include the following: • Inappropriate, flat, or bland affect, and apathy • Emotional ambivalence, disheveled appearance • Inability to establish and move toward goal accomplishment • Lack of energy, pacing and rocking, odd posturing • Regressive behavior, inability to experience pleasure • Seeming lack of interest in the world and people It is the negative symptoms of schizophrenia that affect a client's ability to establish personal relationships and manage day-to-day social interactions. The positive symptoms of schizophrenia (hallucinations, delusions, thought impairment) often improve with psychotropic medications; negative symptoms tend to persist even with medication. Psychosocial and supportive treatment, including psychotherapy, education, behavioral training, cognitive therapy, and social skills therapy, may be beneficial in improving the quality of life for clients with schizophrenia. Ankylosing spondylitis (AS) is an inflammatory disease affecting the spine that has no known cause or cure. AS is characterized by stiffness and fusion of the axial joints (eg, spine, sacroiliac), leading to restricted spinal mobility. Low back pain and morning stiffness that improve with activity are the classic findings. Involvement of the thoracic spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation. The client with AS should do the following: • Promote extension of the spine with proper posture, daily stretching, and swimming or racquet sports (Option 2) • Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications (Option 3) • Manage pain with moist heat and nonsteroidal anti-inflammatory drugs (NSAIDs) • Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility (Option 1) It is best to rest during flare-ups. The client should wait to exercise until the pain and inflammation are under control. (Option 4) Clients with AS are encouraged to sleep on their backs on a firm mattress to prevent spinal flexion and the resulting deformity. (Option 5) Ibuprofen and other NSAIDs should be taken with a meal or snack to avoid gastric upset. Influenza is a respiratory illness common during the cooler months of the year. Each year, a new influenza vaccine is created to help protect against specific viral strains. The Centers for Disease Control and Prevention and Public Health Agency of Canada recommend that all clients age ≥6 months receive the influenza vaccine annually unless the client has a life-threatening allergy to the vaccine or one of its ingredients. Immune thrombocytopenic purpura (ITP) is an autoimmune condition in which antibodies bind to and cause destruction of platelets. Clients with ITP have a platelet count <150,000/mm3 (150 x 109/L) and are at increased risk of bleeding. Key teaching to reduce the client's risk of bleeding includes: • Use soft-bristle toothbrushes, gentle flossing, and nonalcoholic mouthwashes. These prevent periodontal disease and gingival bleeding (Option 1). • Avoid activities that may cause trauma (eg, high-intensity sports). Appropriate exercise includes low- impact activity (eg, walking) while wearing nonskid footwear to help prevent falls (Option 2). • Take prescribed stool softeners and laxatives as needed. These medications prevent hard stools and straining, which can cause anorectal fissuring, bleeding, and hemorrhoids (Option 4). (Option 3) Clients with ITP should use electric razors instead of safety or straight razors. Electric razors have a more complete guard, reducing the risk of accidentally nicking the skin. (Option 5) Clients with ITP should avoid nonsteroidal anti-inflammatory drugs (eg, aspirin, ibuprofen, ketorolac), which further impair platelet function. Acetaminophen and opiates are better options for pain management. Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in theAirway swelling is a life-threatening complication of thyroid surgery. Signs of respiratory distress such as stridor and dyspnea require rapid intervention. surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated. Metformin is an oral antidiabetic medication used to manage hyperglycemia in clients with type 2 diabetes. Metformin increases the sensitivity of insulin receptors in cells and reduces glucose production by the liver. These actions increase the efficacy of insulin present in the body and prevent large rises in blood glucose after meals. Because metformin does not stimulate insulin secretion by the pancreas, the risk of hypoglycemia is minimal (Option 3). Although skipping meals would cause a drop in blood glucose, metformin would not cause further hypoglycemia. Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Client teaching for MVP includes the following: • Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms (Option 3) • Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms • Reduce stress and avoid alcohol use • Obstructive sleep apnea (OSA) is a chronic condition that involves the relaxation of pharyngeal muscles during sleep. The resulting upper airway obstruction with multiple events of apnea and shallow breathing (hypopnea) leads to hypoxemia and hypercapnia. CPAP is an effective treatment for OSA; it involves using a nasal or full face mask that delivers positive pressure to the upper airway to keep it open during sleep. • In this case, the nurse's first action should be to check the tightness of the straps that hold the mask in place. The full face mask must fit snugly over the client's nose and mouth without air leakage to maintain the positive airway pressure and prevent obstruction of upper airway airflow. Readjustment of the head straps may be necessary • Buerger's disease (thromboangiitis obliterans) is a nonatherosclerotic vasculitis involving the arteries and veins of the lower and upper extremities. It occurs most often in young men (age <45) with a long history of tobacco or marijuana use and chronic periodontal infection, but no other cardiovascular risk factors. • Clients experience thrombus formation, resulting in distal extremity ischemia, ischemic digit ulcers, or digit gangrene. They often have intermittent claudication of the feet and hands. Over time, rest pain and ischemic ulcerations may occur. Many clients also develop secondary Raynaud phenomenon (cold sensitivity). • The mainstay treatment of Buerger's disease is the cessation of all tobacco and marijuana use in any form. Nicotine replacement products (eg, nicotine patch) are contraindicated. However, bupropion and varenicline can be used for smoking cessation. Clients may have to choose between continued use of tobacco and marijuana and their affected limbs. Conservative management includes avoidance of cold exposure to affected limbs, a walking program, antibiotics for any infected ulcers, analgesics for ischemic pain, and avoidance of trauma to the extremities. • (Option 1) Clients should avoid exposure to cold (not warm) weather to prevent vasoconstriction and worsening of symptoms. • (Option 2) Statins do not provide much benefit as this is a vasculitis and not an atherosclerotic condition. • (Option 3) Warfarin is an anticoagulant and is not indicated in the treatment of Buerger's disease. Calcium channel blockers, cilostazol, and sildenafil have been used, but there is insufficient evidence to support their effectiveness. Intravenous iloprost has been shown to improve rest pain, promote healing of ulcers, and decrease the need for amputation. • Educational objective: Buerger's disease is a nonatherosclerotic vasculitis involving small to medium arteries and veins of the upper and lower extremities. Young male smokers are typically affected. Clients should avoid exposure to cold weather and cease using tobacco and marijuana in all forms. Smoking cessation can be achieved with bupropion or varenicline but not with nicotine replacement products. Major predisposing factors for the development of delirium in hospitalized clients include: 1. Advanced age 2. Underlying neurodegenerative disease (stroke, dementia) 3. Polypharmacy 4. Coexisting medical conditions (eg, infection) 5. Acid-base/arterial blood gas imbalances (eg, acidosis, hypercarbia, hypoxemia) 6. Metabolic and electrolyte disturbances 7. Impaired mobility - early ambulation prevents delirium 8. Surgery (postoperative setting) 9. Untreated pain and inadequate analgesia Client 4 has 4 predisposing risk factors: advanced age, acidosis and hypoxemia associated with chronic respiratory failure, and sepsis. This client is at greatest risk for developing delirium. The following should be taught to clients taking tetracyclines (eg, tetracycline, doxycycline, minocycline): 1. Take on an empty stomach – for optimum absorption, tetracyclines should be taken 1 hour before or 2 hours after meals (Option 3) 2. Avoid antacids or dairy products – tetracyclines should not be taken with iron supplements, antacids, or dairy products as they bind with the drug and decrease its absorption (Option 1) 3. Take with a full glass of water – tetracyclines can cause pill-induced esophagitis and gastritis; the risk can be reduced by taking with a full glass of water and remaining upright after pill ingestion 4. Photosensitivity – severe sunburn can occur with tetracycline. The client should use sunblock (Option 5). Medications such as tetracycline and rifampin can decrease the effectiveness of oral contraceptives; additional contraceptive techniques will be needed People with latex allergy usually have a cross-allergy to foods such as bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins. Latex sensitivity increases with exposure and should be suspected in the following situations: 1. Allergic contact dermatitis (rash, itching, vesicles) developing 3–4 days after exposure to a rubber latex product. This is a type IV hypersensitivity reaction (delayed onset). 2. Anaphylaxis - many cases of anaphylaxis have been reported in both medical and non-medical settings. These represent a type I hypersensitivity reaction and should be treated with intramuscular epinephrine injections. Some common settings include: o Glove use o Procedures involving balloon-tipped catheters (eg, arterial catheterization) o Blowing up toy balloons o Use of bottle nipples, pacifiers o Use of condoms or diaphragms during sex Clients with severe allergies should wear a Medic Alert bracelet and carry an injectable epinephrine pen due to cross-sensitivity with many food and industrial products that can be impossible to avoid. Peripherally acting calcium channel blockers (eg, nifedipine, amlodipine, felodipine) cause vasodilation, and clients may develop peripheral edema. Necrotizing enterocolitis occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral hydration and nutrition and IV antibiotics are given. To avoid pressure on the abdomen and facilitate observation for a distended abdomen, clients are placed supine and undiapered. Rectal temperatures should be avoided due to the risk of perforation. Postpartum psychosis is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous discontinuation of mood-stabilizing medications (eg, lithium). Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and feelings that someone will harm the baby (Option 2). Postpartum psychosis is a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby. Cirrhosis, the end stage of many chronic liver diseases, is characterized by diffuse hepatic fibrosis with replacement of the normal architecture by regenerative nodules. The resulting structural changes alter blood flow through the liver and decrease the liver's functionality. Elevated bilirubin (jaundice) results from functional derangement of liver cells and compression of bile ducts by nodules. The liver has a decreased ability to conjugate and excrete bilirubin (Option 3). Most coagulation factors are produced in the liver. A cirrhotic liver cannot produce the factors essential for blood clotting. As a result, coagulation studies (prothrombin time [PT]/International Normalized Ratio [INR] and activated partial thromboplastin time [aPTT]) are usually elevated (Option 4). Ammonia from intestinal deamination of amino acids normally goes to the liver and is converted to urea and excreted by the kidney. This does not happen in cirrhosis. Instead, the ammonia level rises as the cirrhosis progresses; ammonia crosses the blood-brain barrier and results in hepatic encephalopathy (Option 2). (Options 1 and 5) Albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so hypoalbuminemia would be expected. This is the primary reason that fluid leaks out of vascular spaces into interstitial spaces (eg, edema, ascites). The kidneys perceive this as low perfusion and try to reabsorb (conserve) both sodium and water. The large amount of water in the body results in a dilutional effect (low sodium). Educational objective: The chronic, progressive destruction characteristic of cirrhosis causes bilirubin, ammonia, and coagulation studies (PT/INR and aPTT) to become elevated. Hyponatremia and hypoalbuminemia are to be expected. Systemic inflammatory response syndrome (SIRS) occurs when the body undergoes a major insult (eg, trauma, infection, burns, hemorrhage, multiple transfusions). Stimulation of the immune response leads to activation of white blood cells (WBCs), release of inflammatory mediators, increased capillary permeability, and inflammation of organs. The sepsis continuum progresses in severity from sepsis, to severe sepsis, to septic shock, to multiple organ dysfunction (MODS). Sepsis is an exaggerated systemic inflammatory response associated with a documented or suspected infection. Severe sepsis is sepsis complicated by organ dysfunction. Septic shock is severe sepsis with hypotension despite fluid resuscitation. MODS occurs in relation to decreased perfusion and is the end point of the sepsis continuum. It is important for the nurse to recognize manifestations of SIRS to promote early recognition, prevention, and treatment of infection and to limit its progression to MODS. Diagnostic criteria for SIRS include 2 or more of the following manifestations: • Hyperthermia (temperature >100.4 F [38 C]) or hypothermia (temperature <96.8 F [36 C]) • Heart rate >90/min • Respiratory rate >20/min or alkalosis (PaCO2 <32 mm Hg [4.3 kPa]) • Leukocytosis (WBC count >12,000/mm3 [12.0 x 109/L] or 10% immature neutrophils [bands]) The heart rate, respiratory rate, and temperature are elevated, and the WBC count is increased; these findings indicate the presence of SIRS. (Option 1) CVP (normal 2-8 mm Hg) indicates circulating volume. It is decreased, not increased, in septic shock due to massive vasodilation and maldistribution of blood flow. An abnormal finding is not associated with SIRS and would not be expected in this client. (Option 2) Sepsis with hypotension and decreased perfusion despite fluid resuscitation is a characteristic finding in septic shock. An MAP of 80 mm Hg is within the normal range (70-105 mm Hg). It is not associated with SIRS and is not an expected finding in this client. Educational objective: Temperature (hyper- or hypothermia), respirations >20/min, heart rate >90/min, and WBC count >12,000/mm3 (12.0 x 109/L) are assessed to document SIRS. The presence of 2 or more of these findings indicates the syndrome. Systemic inflammatory response syndrome (SIRS) occurs due to trauma, ischemia, infection (ie, sepsis), or other distributive shock processes that trigger systemic inflammation remote from the primary source. This overwhelming inflammatory response can rapidly progress to hemodynamic instability, respiratory failure, and end-organ dysfunction. This client has fever and decreased arterial pCO2. Due to the high morbidity and mortality of clients with SIRS, early therapy with aggressive fluid resuscitation and other indicated treatments (eg, antibiotics) based on cause is crucial, so this client is the highest priority Hemophilia is a hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: • Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties (Option 4). • Avoid intramuscular injections; subcutaneous injections are preferred. • Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective equipment (eg, helmets, padding) are encouraged (Option 5). • Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used. • MedicAlert bracelets should be worn at all times (Option 3). Diabetic neuropathy is caused by nerve damage as a result of the metabolic disturbances associated with diabetes mellitus. Autonomic neuropathy is nerve damage to the autonomic nervous system, the system responsible for involuntary body functions such as blood pressure, heart rate, perspiration, sexual function, and digestion. Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension, tachycardia, painless myocardial infarction, bowel incontinence, diarrhea, urinary retention, and hypoglycemic unawareness. The client with postural hypotension is also at risk for falls and should be taught to get up from a lying or sitting position slowly. An external fixator is a metallic device composed of metal pins (screws) placed into the bone to stabilize it; these are positioned above and below the fracture through small incisions in the skin and muscle. After the pins are placed, they are attached to an adjustable external rod or frame outside the skin. Infection of the pin tract is a major complication associated with the device. The nurse should notify the HCP immediately if there are signs or symptoms of infection (eg, drainage, pain, erythema, swelling, fever, pin looseness) at the pin sites. Prompt treatment with antibiotic therapy is necessary as a localized pin tract infection can progress to osteomyelitis, an infection of the bone (Option 3). Infection can also cause the pins to loosen, and this can lead to bone displacement. Therefore, the nurse should perform meticulous sterile pin care with 1/2-strength hydrogen peroxide and NSS or chlorhexidine solution, or as directed by institution policy and procedure (Option 5). Regular neurovascular assessment is important after fixator placement as inadvertent pin placement can compromise the integrity of nerves and vessels (Option 4). (Option 1) Loosening of the pins can compromise bone alignment and healing. The nurse should assess the pins regularly and notify the HCP if they are loose but should not turn the bolts to tighten. (Option 2) An external fixator device allows for early ambulation with the device in place, increases independence while maintaining bone immobilization, and prevents immobility hazards. If used long-term (>4 weeks), the fixator is removed when the bone is healed. Educational objective: Nursing interventions to prevent common complications (eg, infection, loosening of pins) associated with an external fixator include meticulous sterile pin care with an antimicrobial solution, regular assessment of pin tightness, and immediate HCP notification if pins are loose or there are signs of infection. Toddlers (age 1-3) display an egocentric approach as they strive for autonomy. They attempt to control their experiences through intense emotional displays, such as temper tantrums or forceful negative responses (eg, "no!"). Hospitalization results in loss of a toddler's usual routines and rituals, often resulting in regressive behavior. The toddler may also be frequently separated from the parents, leading to separation anxiety. Nursing care activities should be similar to home routines, such as providing preferred snacks and anticipating nap time. The toddler should be given options rather than asked yes/no questions to limit the potential negative responses. It is also important to encourage participation and presence of the parents whene Myelomeningocele occurs when the neural tube fails to fuse properly during fetal development. An outpouching of spinal fluid, spinal cord, and nerves covered by only a thin membrane occurs, typically in the lumbar area. The newborn is at high risk for infection at this area. A priority nursing intervention is to cover the area with a sterile, moist dressing to decrease the risk of infection until surgical repair can occur. (Option 1) Assessing for an anal wink will assist in the assessment of the level of neurologic deficit but is not a priority intervention. (Option 3) Myelomeningocele may decrease the absorption of cerebrospinal fluid, which would place the newborn at risk for hydrocephalus from the excess cerebrospinal fluid. An occipital frontal circumference is needed as a baseline measurement but is not a priority. (Option 4) The newborn would be placed in the prone position (with face turned to the side) to prevent rupture of the myelomeningocele. • Dysfunctional gastric motility related to bowel manipulation during surgery, anesthesia, and opioid analgesia as evidenced by absent or hypoactive bowel sounds 48-72 hours following surgery secondary to a paralytic ileus. It is a common complication following abdominal surgery (Option 2). • Imbalanced nutrition, less than body requirements related to the increased metabolic demand needed for tissue and wound healing as evidenced by the inability to ingest adequate caloric intake secondary to a paralytic ileus and the lack of interest in eating secondary to the ileus, the adverse effects of anesthesia, and analgesic medications Fondaparinux (Arixtra), unfractionated heparin, and low molecular weight heparin (eg, enoxaparin, dalteparin) are anticoagulants commonly used for deep vein thrombosis and pulmonary embolism prophylaxis after hip/knee replacement or abdominal surgery. However, fondaparinux is not administered until more than 6 hours after any surgery, and anticoagulants are not given while an epidural catheter is in place (Option 2). Fondaparinux is associated with epidural hematoma. Any bleeding in the tight epidural space, which does not expand, could result in spinal cord compression. Signs of epidural spinal hematoma can include severe back pain and paralysis. (Option 1) Paresthesia is an expected finding from postoperative analgesia for 2-24 hours after surgery, depending on the agent and location. Continuously administered analgesia usually results in some paresthesia until approximately 4-6 hours after discontinuance. As long as the level remains relatively stable or improves, it is an acceptable finding. However, paresthesia or motor weakness is a concern when the sensory or motor block outlasts the expected duration. (Option 3) Client response to operative analgesia and postoperative continued analgesia can range from minimal to significant. As long as the analgesic is infusing and findings remain stable, reduced muscle strength is expected. (Option 4) Major orthopedic surgery can result in significant blood loss, and it is not unusual for the client to have hemoglobin drop of 1-2 g/dL (10-20 g/L). Blood loss should be monitored over time; transfusion usually is not indicated unless hemoglobin is <7-8 g/dL (70-80 g/L). Educational objective: Residual paresthesia and motor weakness for several hours are expected findings after regional anesthesia. Anticoagulants are not given while an epidural catheter is in place. Quadriplegia (tetraplegia) occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs. This is usually due to injury of the cervical spinal cord. Depending on the area of injury and extent of cord edema, the airway can be adversely affected. The priority assessment for this client is the status of the airway and oxygenation. The nurse should frequently assess breath sounds, accessory muscle use, vital capacity, tidal volume, and arterial blood gas values (if prescribed). (Options 2, 3, and 4) This client will need passive range of motion exercises on affected joints to prevent contractures. Turning the client will be necessary to prevent skin breakdown over bony prominences. The client will need to express feelings and work through the grief process related to loss of function. Bladder and bowel training programs will be necessary. All of these interventions are important for this client but are not the priority over maintenance of adequate oxygenation. Educational objective: The priority assessment in a client newly diagnosed with quadriplegia (tetraplegia) is airway management and oxygenation. Hepatic encephalopathy in cirrhosis results from higher serum ammonia levels that cause neurotoxic effects, including mental confusion. Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect. Improved mental status implies reduction of ammonia levels. (Option 1) Clients with cirrhosis typically have hypokalemia due to hyperaldosteronism (as aldosterone is not metabolized by the damaged liver). Hypokalemia can also result from diuretics used to treat the fluid retention and ascites. Lactulose is not intended to treat this pathology. (Option 3) Lactulose is a laxative. In cirrhosis, constipation (which allows more ammonia to be absorbed) and hard stool (which irritates hemorrhoids) are to be avoided. However, the main purpose of lactulose is expelling the ammonia, with resulting benefits. (Option 4) Abdominal distension (ascites) in cirrhosis is treated with diuretics (eg, furosemide, spironolactone) and paracentesis. Lactulose does not influence this pathology or symptom. Educational objective: Lactulose is a laxative used to trap and expel ammonia in clients with cirrhosis who have hepatic encephalopathy. Elevated ammonia levels cause mental confusion. Post-procedure care of a client who has undergone heart catheterization should focus on evaluating hemodynamics - blood pressure, heart rate, strength of the distal pulses, color, and temperature of extremities. The client should be also assessed several times per hour for active bleeding, hematoma, or pseudoaneurysm formation at the incision. The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of back or flank pain should be assessed for possible retroperitoneal bleeding as back pain, tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours before a significant drop in hematocrit can be measured. Internal bleeding after cardiac catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in these clients. Clostridium difficile overgrowth in the intestine often occurs when normal gastrointestinal (GI) flora is destroyed (eg, antibiotic use). Clients with C difficile often have watery diarrhea, nausea, fever, and abdominal pain. Hypovolemia can easily develop through the loss of fluids and electrolytes in the stool, especially in infants and the elderly. Clients with hypovolemia from GI losses will often have hyponatremia, hypokalemia, and elevated blood urea nitrogen (BUN) (poor renal perfusion). This client has hyponatremia (normal, 135-145 mEq/L [135-145 mmol/L]), hypokalemia (normal, 3.5-5.0 mEq/L [3.5-5.0 mmol/L]), and an elevated BUN (normal, 6-20 mg/dL [2.1-7.1 mmol/L]). Hypovolemia can cause hypotension and renal failure, and electrolyte abnormalities can cause cardiac arrhythmias; therefore, these are priority to report. Fluid resuscitation and electrolyte replacement should be initiated promptly to prevent complications. (Options 3 and 4) Expected findings of pneumonia include fever, chills, fatigue, crackles, and sputum production. There is nothing to indicate that the client is having respiratory difficulty. Therefore, electrolyte imbalance is a priority. Educational objective: Severe watery diarrhea can lead to hypovolemia. Clients should be monitored for hyponatremia, hypokalemia, elevated blood urea nitrogen, and other electrolyte imbalances. These should be reported and treated immediately to avoid cardiac arrhythmias, hypotension, and renal failure. Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) are often prescribed to resolve acute thrombotic events (eg, ischemic stroke, myocardial infarction, massive pulmonary embolism). They are recombinant plasminogen activators that activate the blood fibrinolytic system and dissolve thrombi. Thrombolytic agents are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension (blood pressure >180/110 mm Hg). Therefore, the health care provider should be consulted for clarification. Administering alteplase in the presence of these conditions can cause hemorrhage, including life-threatening intracerebral hemorrhage (Option 1). (Option 2) Most penicillin derivates (eg, ampicillin, amoxicillin) and cephalosporins (eg, cephalexin, ceftriaxone) are generally considered safe for use by women who are pregnant or lactating. (Option 3) Fentanyl is appropriate in postoperative clients with moderate to severe pain, even those with a history of allergies to codeine. Both drugs have opiate agonist effects but are chemically different. Codeine is a derivative of natural opiates (eg, morphine), whereas fentanyl is completely synthetic. (Option 4) Syndrome of inappropriate antidiuretic hormone (SIADH) secretion results in water retention and dilutional hyponatremia. Clients with SIADH often require hypertonic saline for sodium repletion to increase serum sodium levels with a minimal infused volume of water. Educational objective: Thrombolytic agents (eg, alteplase, tenecteplase, reteplase) place clients at risk for bleeding. Therefore, they are contraindicated in clients with active bleeding, recent trauma, aneurysm, arteriovenous malformation, history of hemorrhagic stroke, and uncontrolled hypertension. Acute urinary retention is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis (Option 2). However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury (Option 3). (Option 1) Dysuria from catheterization can be treated with analgesics or antispasmodic medications. Maintaining perfusion and adequate blood pressure is the priority concern. (Option 4) With sudden release of bladder obstruction, cardiovascular autonomic activity occurs and the blood pressure and heart rate are reduced due to the excitation of the parasympathetic system. Educational objective: Acute urinary retention is best treated with rapid complete bladder decompression. The nurse should carefully assess for hypotension and bradycardia, which are potential complications. Clients with sickle cell crisis often have excruciating pain and need large doses of narcotics. The most effective method is PCA of morphine or hydromorphone (Dilaudid). Posttraumatic stress disorder (PTSD) is a reaction to a traumatic or catastrophic event that is typically life- threatening to oneself or others. There are 3 categories of PTSD symptoms: 1. Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (rapid, pounding heart; gastrointestinal distress; diaphoresis) 2. Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could be trauma reminders, feeling detached and emotionally numb, loss of interest in life, lack of future goals, and amnesia related to important details of the event 3. Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of anger and/or rage, difficulty concentrating, hypervigilance, and feeling jumpy (Option 1) Auditory hallucinations and feelings of paranoia are not characteristic symptoms of PTSD. These are characteristic of schizophrenia. (Option 3) Rapidly changing emotions, delusions, and lethargy are not characteristic symptoms of PTSD. (Option 4) Daytime sleepiness is not characteristic of PTSD. Educational objective: The 3 categories of PTSD symptoms include reexperiencing the traumatic event, avoiding reminders of the trauma, and increased anxiety and emotional arousal. Antiplatelet medication (eg, prasugrel [Effient], clopidogrel [Plavix], ticagrelor [Brilinta]) are often prescribed to a client after a percutaneous coronary intervention such as angioplasty or stent placement. These agents should be stopped at least 5-7 days prior to the surgery to reduce the chance of intraoperative and postoperative bleeding. The nurse should immediately report to the HCP that the client is still taking prasugrel and took it the morning of the surgery. Unless the surgery is emergent, it will most likely be postponed at least a week. The following reflect a client's physiologic state and not equipment malfunction: Option 1: "HI" is displayed when a client's glucose is too high (usually 500 mg or above). Option 4: When a client does not have adequate circulation/perfusion at the location of the sensor, the pulse oximeter cannot locate an adequate pulsation and give a reading. Option 5: Ventilators sound an alarm to indicate high pressure when the machine is sensing increased resistance. The nurse should check to see if suctioning is needed (mucus causing resistance), if tubing is bent/kinked, or if tension pneumothorax is present. It is also possible that a client has a deteriorating lung condition causing the high pressure alarm to sound. The alarm is related to the client's condition and is not an indication of ventilator malfunction. Paracentesis is performed to remove excess fluid from the abdominal cavity or to provide a specimen of ascitic fluid for diagnostic testing. Paracentesis is not a permanent solution for resolving ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Nursing actions include: • Explain the procedure, sensations, and expected results • Instruct the client to void to prevent puncturing the bladder • Assess the client's abdominal girth, weight, and vital signs • Place the client in high Fowler's position and remain with the client during the procedure • After the procedure, assess and bandage the puncture site and reassess client weight, girth, and vital signs (Option 1) NPO status is not required for this procedure. Paracentesis is often performed at the bedside or an HCP's office with only a local anesthetic. (Option 2) Informed consent can be obtained only by an HCP. The nurse can witness informed consent verifying that it is given voluntarily, the signature is authentic, and the client appears competent to consent. Educational objective: Paracentesis removes fluid from the abdominal cavity to improve symptoms or provide a specimen for testing. Nurses are expected to prepare the client (encourage voiding and place in high Fowler's position) and assess symptoms, vital signs, weight, and abdominal girth before and after the procedure. Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia (>120/min), tachypnea (>30/min), saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of predicted or best (<150 L/min). Pharmacologic treatment modalities recommended by the Global initiative for Asthma (2014) to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: 1. Oxygen to maintain saturation >90% 2. High-dose inhaled short-acting beta agonist (SABA) (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes 3. Systemic corticosteroids (Solu-Medrol) (Option 4) Montelukast (Singulair) is a leukotriene receptor blocker with both bronchodilator and anti- inflammatory effects; it is used to prevent asthma attacks but is not recommended as an emergency rescue drug in asthma. (Option 5) A long-acting beta agonist (Salmeterol) is administered with an inhaled corticosteroid for long-term control of moderate to severe asthma; it is not used as an emergency rescue drug in asthma. Educational objective: Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia, tachypnea, saturation <90% on room air, use of accessory muscles of respiration, and PEF <40% predicted. Management includes the administration of high-dose inhaled SABA and ipratropium nebulizer, systemic corticosteroids, and oxygen to maintain saturation >90%. Antiplatelet agents (eg, clopidogrel, ticagrelor, prasugrel, aspirin) prevent platelet aggregation and are given to clients to prevent stent re-occlusion. They prolong bleeding time and should not be taken by clients with a bleeding peptic ulcer, active bleeding, or intracranial hemorrhage. Ginkgo biloba also interferes with platelet aggregation and can cause increased bleeding time. Antiplatelet agents and Ginkgo biloba should not be taken together. If this were to occur, this client would be at an increased risk for bleeding. This information should be reported to the prescribing health care provider before the client is discharged. (Option 1) This blood pressure is slightly elevated, but is unaffected by antiplatelet agents. (Option 2) Normal heart rate is between 60/min-100/min. (Option 3) This is a normal platelet count (150,000/mm3-400,000/mm3 [150-400 x 109/L]). Educational objective: If a client is prescribed clopidogrel, the nurse should be concerned about a history of peptic ulcer disease and Ginkgo biloba use. In this situation, the client would be at increased risk for bleeding. This data should be reported to the prescribing health care provider before the client is discharged. Cerebrospinal fluid (CSF) is assessed for color, contents, and pressure. Normal CSF is clear and colorless, and contains a little protein, a little glucose, minimal white blood cells, no red blood cells, and no microorganisms. Normal CSF pressure is 60–150 mm H2O. Abnormal CSF pressure or contents can help diagnose the cause of headaches in complicated cases. CSF is collected via lumbar puncture or ventriculostomy. Prior to a lumbar puncture, clients are instructed as follows: 1. Empty the bladder before the procedure (Option 2) 2. The procedure can be performed in the lateral recumbent position or sitting upright. These positions help widen the space between the vertebrae and allow easier insertion of the needle (Option 3). 3. A sterile needle will be inserted between the L3/4 or L4/5 interspace (Option 4) 4. Pain may be felt radiating down the leg, but it should be temporary (Option 1) After the procedure, instruct the client as follows: 1. Lie flat with no pillow for at least 4 hours to reduce the chance of spinal fluid leak and resultant headache 2. Increase fluid intake for at least 24 hours to prevent dehydration Educational objective: Lumbar puncture can be performed with clients in the sitting position or positioned on the left side with the knees drawn up (fetal position). Iron-deficiency anemia occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin. Iron-deficiency anemia can result from: 1. Diets low in iron (eg, vegetarian and low-protein diets) 2. Iron not being absorbed (eg, following many gastrointestinal [GI] surgeries, malabsorption syndrome) 3. Increased iron requirement (eg, children's growth spurts, pregnancy, breastfeeding) 4. Blood loss (eg, menstruation, bleeding in the GI tract [eg, ulcers, hemorrhoids]) Foods rich in iron include: • Meats (eg, beef, lamb, liver, chicken, pork) • Shellfish (eg, oysters, clams, shrimp) • Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal Eating foods rich in vitamin C (eg, citrus fruits, potatoes, tomatoes, green vegetables) with iron-rich foods will enhance iron absorption but coffee and tea consumption interferes with this process. A common risk factor for deep venous thrombosis (DVT) is traveling/sitting with prolonged periods (>4 hours) of inactivity. Common symptoms of a lower-extremity DVT include unilateral edema and calf pain. Diagnosis and treatment of DVT (circulation problem) is a high priority because a piece of the clot can break off, travel though the systemic and/or pulmonary circulation, and cause a life-threatening complication (eg, pulmonary embolus). Most bouts of diarrhea are self-limiting and last ≤48 hours. Clients experiencing diarrhea that lasts >48 hours or accompanied by fever or bloody stools should be evaluated by a health care provider (HCP). Causes may include infectious agents, dietary intolerances, malabsorption syndromes, medication side effects, or laxative overuse. The HCP will need to assess for dehydration and electrolyte imbalances and identify underlying causes of the diarrhea that may require further treatment (eg, Clostridium difficile). A Colles' fracture is a type of wrist fracture (distal radius fracture) that causes a characteristic dinner fork deformity of the wrist. It usually occurs when the client tries to break a fall with an outstretched arm or hand, and lands on the heel of the hand. It is one of the most common fractures in women age >50 and is related to osteopenia or osteoporosis. While the client is undergoing evaluation by the health care provider (HCP) in the emergency department (ED), nursing interventions should include: • Performing a neurovascular assessment (eg, pulse, temperature, color, capillary refill, sensation, movement). This is the priority nursing action as neurovascular insufficiency related to swelling (eg, compartment syndrome) or arterial/nerve damage by the bone fragments is associated with a Colles' fracture. If neurovascular status is compromised, urgent reduction of the fracture is indicated. • Administering analgesia to promote comfort (Option 1). • Applying an ice pack to the wrist to help reduce edema and inflammation (Option 2). • Elevating the extremity on a pillow above heart level to reduce edema (Option 4). • Instructing the client to move the fingers to reduce edema, increase venous return, and help improve range of motion. Educational objective: While a client with a traumatic wrist fracture is undergoing evaluation by the HCP in the ED to determine appropriate treatment, the nurse assesses circulation, sensation, and movement of the affected hand, and then performs nursing interventions to reduce pain and edema. isotretinoin is an oral acne medication derived from vitamin A. Due to teratogenic risk and severity of side effects (eg, Stevens-Johnson syndrome, suicide risk), isotretinoin is used to treat only severe and/or cystic acne not responding to other treatments. Exposure to any amount of this medication during pregnancy can cause birth defects. Clients are required to enter a Web-based risk management plan (iPLEDGE) and use 2 forms of contraception (Option 4). Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication (Option 3). (Option 1) Blood donation is also prohibited during the duration of treatment and up to a month after treatment ends due to the possibility of inadvertent transfusion to a pregnant woman. (Option 2) Isotretinoin should not be taken with tetracycline because the latter also increases the risk for intracranial hypertension. Educational objective: Isotretinoin is a vitamin A derivative prescribed to treat severe and/or cystic acne. Side effects include birth defects, skin changes (eg, dry skin, skin fragility, cutaneous atrophy), and risk for increased intracranial pressure. Clients need to be instructed to avoid tetracycline, excess sun and tanning, and vitamin A supplements. Women of child-bearing age should use 2 forms of contraception to prevent pregnancy. HAP is a bacterial infection acquired in a health care facility that was not present on admission. Almost all clients with bacterial pneumonia develop leukocytosis (WBC >11,000/mm3). Antibiotic therapy is the first-line treatment, but antibiotic resistance frequently occurs in HAP. If antibiotic therapy is effective, clinical improvement usually occurs within 3-4 days of initiation of IV antibiotics. Cystic fibrosis is an inherited autosomal recessive disorder of the exocrine glands that results in physiologic alterations in the respiratory, gastrointestinal, and reproductive systems. It is theorized that the chloride transport alternation and resulting thickened mucus inhibit normal ciliary action and cough clearance, and the lungs become clogged with mucus. The thickened mucus harbors bacteria. Over time, airways develop chronic colonization and frequent respiratory infections result. Bronchial hygiene therapy, such as manual chest physiotherapy, is used. For physiotherapy, various positions are used, and this should be performed before meals to avoid a full stomach and resultant regurgitation or vomiting. (Option 1) A white pupil (leukocoria, or cat's-eye reflex) is one of the first signs of retinoblastoma, an intraocular malignancy of the retina. Other symptoms include an absent red reflex, asymmetric or of a differing color in the affected eye, and fixed strabismus (constant deviation of one eye from the other). This disease is not related to cystic fibrosis. (Option 3) Hypercyanotic episodes are associated with tetralogy of Fallot. The knee-chest position increases systemic vascular resistance in the lower extremities. In addition, irritating stimuli should be limited, and supplemental oxygen should be provided. (Option 4) The pancreatic ducts become damaged, and there is a decreased ability to digest fats and proteins and absorb fat-soluble vitamins. Pancreatic enzyme supplements are used. Children with cystic fibrosis tend to be hungry but underweight due to a decreased ability to use fat and its calories. Educational objective: Cystic fibrosis causes thickened mucus, making respiratory infections common. Treatment includes chest physiotherapy performed usually before meals. This client with heart failure who is short of breath and coughing up pink frothy sputum has developed acute pulmonary edema (fluid filling the alveoli), a potentially life-threatening condition. Trousseau's sign may indicate hypocalcemia before other signs and symptoms of hypocalcemia, such as tetany, occur. Trousseau's sign can be elicited by placing the BP cuff on the arm, inflating to a pressure > than systolic BP, and holding in place for 3 minutes. This will occlude the brachial artery and induce a spasm of the muscles of the hand and forearm when hypocalcemia is present. Chevostek's sign another early indicator of hypocalcemia, should also be assessed. It may be elicited by tapping the face at the angle of the jaw and observing for contraction on the same side of the face. (Option 1) Phalen's maneuver is used to diagnose carpal tunnel syndrome. (Option 2) The heel-to-shin test is another means of assessing cerebellar function. An abnormal examination is evident when the client is unable to keep the foot on the shin. (Option 3) The Romberg test is a component of a neurological examination to assess vestibular function (perception of head position in space), proprioception (perception of the body in space), and vision. Hypospadias is a congenital defect in which the urethral opening is on the underside of the penis. Except in very mild cases, the condition is typically corrected around age 6-12 months by surgically redirecting the urethra to the penis tip. Circumcision is delayed so the foreskin can be used to reconstruct the urethra. If not corrected, clients may have toilet-training difficulties, more frequent urinary tract infections, and inability to achieve erections later in life. Postoperatively, the client will have a catheter or stent to maintain patency while the new meatus heals. Urinary output is an important indication of urethral patency. Fluids are encouraged, and the hourly output is documented. Absence of urinary output for an hour indicates that a kink or obstruction may have occurred A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: 1. The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). 2. The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. 3. The ictal phase is the period of active seizure activity. 4. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion. Educational objective: Clients may experience confusion after a seizure during the postictal phase. The client should be observed for safety and abnormalities documented before and during this phase. Infant growth is fast paced during the first year of life, with birth weight doubling by age 6 months and tripling by age 12 months. During the first year, birth length increases by approximately 50%. At birth, head circumference is slightly more than chest circumference, but these equalize by age 12 months. (Options 1 and 2) At birth, the infant has non-ossified membranes called fontanelles; these "soft spots" lie between the bones of the cranium. The 2 most noticeable are the anterior and posterior fontanelles, which are soft and non-fused. Fontanelles should be flat, but slight pulsations noted in the anterior fontanelle are normal as is temporary bulging when the infant cries, coughs, or is lying down. The posterior fontanelle fuses by age 2 months, and the anterior fontanelle fuses by age 18 months. (Option 4) This assessment shows tripling of the birth weight by age 12 months, a normal finding. Educational objective: Infants should double in birth weight by age 6 months and triple in birth weight by age 12 months. At birth, head circumference is slightly more than chest circumference, but these equalize by age 12 months. The posterior fontanelle fuses by age 2 months, and the anterior fontanelle fuses by age 18 months. Tinea corporis (ringworm) is a fungal infection of the skin often transmitted from one person to another or from an infected animal to a human. It appears as a scaly, pruritic patch that is often circular or oval in shape. It is highly contagious and can be spread via items such as grooming tools, hats, towels, and bedding. Tinea corporis often spreads via shared athletic equipment or in athletic locker rooms due to the proximity of infected gear. This condition is treated with topical antifungals (eg, tolnaftate, haloprogin, miconazole, clotrimazole). (Option 1) Eczema is a skin rash caused by an immune disorder that is often triggered by an allergy. Itching is common, but the rash is not contagious. (Option 2) Oral candidiasis, or thrush, often occurs after a course of antibiotics or corticosteroids or can occur in infants with immature immune systems. An infant who is breastfed can transfer c