NCLEX RN LATEST EXAM QUESTIONS AND ANSWERS 2023 VERSION

NCLEX RN LATEST EXAM QUESTIONS AND ANSWERS 2023 VERSION Is a process of learning a different culture to adapt to a new or changing environment. - answerAcculturation. It is a subjective perspective of the person's heritage and a sense of belonging to a group - answerEthnic identity Include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, & spiritual measures (prayer). - answerLow-risk therapies: Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans. - answerHigh risk of obesity & diabetes mellitus Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products. - answerJehovah's Witnesses Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. - answerOrthodox Judaism include whole medical systems, mind-body medicine, biologically based practices, manipulative & body-based practices, & energy medicine. - answerFive categories of complementary and alternative medicine (CAM): Focused, maintains strong control, makes decisions, & addresses all problems. Dominates group & commands, rather than seeks suggestions or input. Manager addresses problem (quality improvement) with taff, designs a plan without input, & wants all problems reported directly back to her - answerAutocratic leader Participative & would likely meet with each staff person individually to determine staff member's perception of problem. Would also speak with the staff about any issues & ask the staff for input with developing a plan. - answerDemocratic leader Passive and nondirective. Would state what the problem was & inform staff that the staff needed to come up with a plan to "fix it." - answerLaissez-faire leader Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck & hand vein distention, altered LOC, & decreased hematocrit. - answerOverhydration or fluid overload & occurs when fluid intake or fluid retention Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, & tomatoes - answerCommon food sources of potassium: Muscle weakness, increased urinary output, & decreased specific gravity of the urine would be noted - answerHyponatremia Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. - answerHypophosphatemia Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors. Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole grains, & carbonated beverages. - answerHyperphosphatemia Vomiting, diarrhea, conditions that increased respiration's or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy. Diuretics, & gastrointestinal suctioning. - answerCauses of a fluid volume deficit Decreased kidney function, heart failure, hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds & body cavities, & excessive ingestion of sodium. - answerCauses of overhydration or fluid overload: Trauma, burns, sepsis, or metabolic or respiratory acidosis. - answerHyperkalemia causes: Cushing's syndrome or colitis & over use of laxatives. - answerHypokalemia causes: Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or diarrhea. - answerMetabolic acidotic Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms experienced would include hypoventilation & tachycardia. - answerMetabolic alkalosis Decreased pH and an increased CO2. Hypoventalation & COPD - answerRespiratory acidotic Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea) occurs. - answerRespiratory alkalotic Sample for PT & INR level to determine anticoagulation status & risk for bleeding - answerWarfarin (Coumadin) aPTT monitors the effects. Anticoagulant used most often during hemodialysis. Monitors extent of anticoagulation checking PTT, which is appropriate measure heparin effect. Protamine sulfate is antidote. - answerHeparin Dark green leafy vegetables good source iron, oranges are a good source of vitamin C, which enhances iron absorption. - answerIron deficiency anemia foods in diet: May lack B12 in diet. - answerVegans Include fruits & vegetables - answerLow sodium foods: Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish & shellfish. Smoked foods, - answerHigh Sodium foods: Water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. - answerClear liquid diet: Pulling, Vegetable juice, Pureed vegetables, plain ice cream, sherbet, breakfast drinks, milk, pudding & custard, soups that are strained, refined cooked cereals, & strained vegetable juices. - answerFull liquid diet: Pork products rich in this vitamin. Other good food sources include nuts, whole grain cereals, & legumes. - answerHigh Thiamine foods On the left side, with the head lower than the feet. This position used to minimize effect of air traveling as a bolus to lungs by trapping it in right side of heart. - answerSuspects air embolism. Should immediately place client in which position? Assess for known allergies to eggs to prevent anaphylaxis. - answerFat emulsion (lipids) Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, & coma when severe. If has these symptoms, blood glucose level should be checked immediately. - answerHyperglycemia: Temperature and weight: Temperature monitored to detect infection, potential complication of therapy. Infection also could result in sepsis because catheter in blood vessel. Weight monitored for effectiveness nutritional therapy & detect hypervolemia. - answerParenteral nutrition; PN monitor Burns, exacerbation Crohn's disease, persistent nausea & vomiting due to chemotherapy. Had extensive surgery, multiple fractures, are septic, have advanced cancer or AIDS. (Electronic infusion pump used to administer) - answerParenteral nutrition; Patients needing 10% dextrose in water until new PN solution becomes available. - answerParenteral nutrition; If PN bag empty hang IV dislodged from vein & is lying in subcutaneous tissue. Pallor, coolness, & swelling are results of IV fluid being deposited in tissue. Corrective action is remove catheter & start new IV line at another site. - answerInfiltrated IV Discomfort at site, redness, warmth, & swelling proximal to catheter. If phlebitis occurs, discontinue IV line & insert new IV line at different site. Apply warm moist compresses to area speed resolution of inflammation. Notify (HCP). Document occurrence, actions taken, & client response. - answerPhlebitis at IV site: Produces a rash, redness, & itching. - answerAn allergic reaction at IV site: Characterized by ecchymosis, swelling, & leakage at IV insertion site, as well as hard & painful lumps at site. - answerHematoma Dyspnea, a swollen tongue, & cyanosis. - answerHypersensitivity reaction: Taught minor activity restrictions apply with this type of catheter. Protect site during bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as needed because catheter is for long-term use. - answerPICC line Before beginning administration IV solution, assess whether chest radiograph reveals central catheter is in proper place. Portable chest X-ray. - answerCentral venous catheter insertion: Characterized by chills, fever, malaise, headache, nausea, vomiting, backache, & tachycardia. - answerSystemic infection Characterized by tachycardia, dyspnea, hypotension, cyanosis, decreased LOC, anxiety, feelings of impending doom, chest pain, & hypotension. Place left side in Trendelenburg's position. Lying left side may prevent air from flowing into pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases amount of blood pulled into vena cava during inspiration. - answerAir embolism Occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, & development of shock - answerSepticemia Necessary for proper blood clotting. Insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, & mucous membranes. - answerPlatelets Order of priority is to rescue patient in immediate danger. Next activate fire alarm. Close all doors & fire extinguished. - answerFire event Transmitted by droplet infection. Precautions include private room or cohort client & use of standard precaution mask. - answerMeningococcal pneumonia Best results sitting head of bed elevated 45 to 90 degrees. Semi-Fowler's or high Fowler's position. Mouthpiece should be covered completely & tightly while inhales slowly, with constant flow through unit. Breath should be held for 5 seconds before exhaling slowly. - answerIncentive spirometer Placed in left Sims position so enema solution can flow by gravity in natural direction of colon. - answerCleansing enema Preconventional stage, morals are thought to be motivated by punishment & reward. - answerKohlberg's theory of moral development Should not try anticipate newborn infant needs but allow newborn infant to signal needs. If newborn infant is not allowed to signal a need, newborn will not learn how to control environment. Delayed or prolonged response to newborn infant's signal would inhibit development trust & lead to mistrust of others - answerErikson's psychosocial development theory Child has the ability to think abstractly and logically. - answerFormal operations stage of Piaget's cognitive developmental theory Child begins to understand the environment. - answerPaiget's sensorimotor stage Child is able to classify, order, and sort facts. - answerPaiget's concrete operational stage Child learns to think in terms of past, present, & future. - answerPaiget's preoperational stage 20 to 40 breaths/minute - answerNormal respiratory rate in a 12-month-old 90 to 130 beats/minute - answerNormal apical heart rate in a 12-month-old 90/56 mm Hg - answerAverage blood pressure in a 12-month-old Diamond-shaped & located on top of head. Soft & flat in normal infant, & it normally closes by 12- 18 months of age - answerAnterior fontane Decreased lean body mass & age-associated decreased glomerular filtration rate. - answerolder client is at risk for medication toxicity because Stand feet together & arms at sides, close eyes & hold position; normally client can maintain posture & balance. Positive Romberg's sign is a vestibular neurological sign found when client exhibits loss balance when closing eyes. - answerRomberg's test Rhythmic respirations with periods of apnea. Periods apnea followed by deep rapid breathing - answerCheyne-Stokes respirations Physical obstruction to transmission of sound waves - answerConductive hearing loss occurs as result pathological process in inner ear, defect in 8th cranial nerve, or defect of sensory fibers that lead to cerebral cortex. - answerSensorineural hearing loss Abnormal heart sound & described as gentle, blowing, swooshing sound. - answerHeart murmur Described as a scratchy, leathery heart sound. - answerPericardial friction rub Tests the six cardinal positions of gaze - answerAssess for muscle weakness in eyes Visual acuity & cranial nerve II (optic). - answerSnellen eye chart Close eyes & then lightly touching areas of face & testing corneal reflexes assess cranial nerve V (trigeminal). - answerTesting sensory function tested insupine position. Flexes head (gently moves head to chest) & there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if passively flexes hip & knee in response to neck flexion & reports pain in vertebral column. - answerPositive Brudzinski's sign Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned by one umbilical vein. Arteries carry deoxygenated blood & waste products from fetus, umbilical vein carries oxygenated blood & provides oxygen & nutrients to fetus. - answerFetal circulation Connects umbilical vein to inferior vena cava - answerDuctus venosus Is temporary opening between right & left atria. - answerForamen ovale Joins the aorta & pulmonary artery - answerDuctus arteriosus Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement, Braxton Hicks contractions, & positive pregnancy test for presence of HCG. - answerProbable signs of pregnancy Fetal heart rate detected by electronic device (Doppler transducer), active fetal movements palpable by examiner, & outline fetus by radiography or ultrasonography. - answerPositive signs of pregnancy *Pregnancy avoided for 1-3 months. *Vaccine administered subcutaneous route.*Exposure immunosuppressed individuals avoided. *Hypersensitivity reaction can occur if client has allergy to eggs. - answerRubella virus vaccine Postpartum Three classic signs are hypertension, generalized edema, & proteinuria. - answerClassic signs of preeclampsia Can trigger disseminated intravascular coagulation (DIC). Evidence of bleeding, such as in gums, petechiae, & purpura should be reported to HCP if noted on assessment. - answerSevere preeclampsia Considered a risk factor for disseminated intravascular coagulation (DIC). - answerDead fetus syndrome Isoniazid plus rifampin (Rifadin) will be required for 9 months. - answerPregnant client tuberculosis is suspected; sputum culture obtained & identifies Mycobacterium tuberculosis When the cervix is dilated completely & ends with birth of the neonate. - answerSecond Stage of Labor begins Occur if umbilical cord becomes compressed, reducing blood flow between placenta & the fetus. - answerVariable decelerations Result from pressure on fetal head during a contraction. - answerEarly decelerations Fetal heart rate assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Minimal vaginal examinations would be done because of risk of infection. - answerAssessment finding following an amniotomy should be conducted first Acute abdominal pain present. Uterine tenderness with abruption, especially central abruption & trapped blood behind placenta. Abdomen feels hard/boardlike on palpation as blood penetrates myometrium & causes uterine irritability. Premature separation placenta from uterine wall after 20th week gestation, before fetus delivered. Associated conditions; hypertension, smoking, alcohol/ cocaine abuse. Overdistention uterus; multiple gestation, polyhydramnios. In addition, short umbilical cord, physical trauma, increased maternal age & parity are risk factors. Painful vaginal bleeding, abdominal pain, & back pain identify signs/symptoms of abruptio placentae. - answerAbruptio placentae Symptoms increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability. - answerConcealed bleeding Prenatal Improperly implanted placenta lower uterine segment. Manual pelvic exam contraindicated vaginal bleeding apparent until diagnosis made & placenta previa ruled out. Digital exam cervix can lead to hemorrhage. Diagnosis by ultrasound. Hemoglobin/Hematocrit level monitored, external electronic fetal heart rate monitoring initiated; crucial evaluating status fetus, risk for severe hypoxia. Soft abdomen & painless, bright red vaginal bleeding in second/third trimester pregnancy symptom. (Sudden onset painless vaginal bleeding) - answerPlacenta previa Oxygen administered, 8 to 10 L/min, by face mask. Oxygen used decrease hypoxia. Kept on bed rest with head of bed slightly elevated reduce dyspnea. Morphine sulfate may be prescribed, not initial nursing action. IV also required, & vital signs need to be monitored, but these actions would follow administration of oxygen. - answerPulmonary embolism is suspected Infection of bladder. Should consume 3000 mL of fluids per day if not contraindicated. - answerCystitis May present clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. - answerNewborn infant with respiratory distress syndrome Bluish discoloration of hands & feet, is associated with immature peripheral circulation, & common in first few hours of life. - answerAcrocyanosis Craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, & respiratory distress. Hypotonia, irritability, & poor sucking reflex. - answerFetal alcohol syndrome May exhibit hyperirritability, vomiting, diarrhea, or uncoordinated sucking & swallowing ability. Quiet environment with minimal stimuli & handling would help establish appropriate sleep-rest cycles in newborn as well. - answerFetal alcohol syndrome Used as prophylactic treatment for ophthalmia neonatorum, which is caused by bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law - answerErythromycin ophthalmic ointment Central nervous system depressant & relaxes smooth muscle, including uterus. Used to halt preterm labor contractions & used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, & elevated serum magnesium levels. - answerMagnesiumSulfate Glucocorticoid, given increase production of surfactant to stimulate fetal lung maturation. Administered clients preterm labor at 28 to 32 weeks of gestation if labor can be inhibited for 48 hours. - answerBetamethasone (Celestone) Opioid analgesic. - answerNalbuphine (Nubain) Given to Rh-negative clients to prevent sensitization. - answerRho(D) immune globulin (RhoGAM) Prostaglandin given ripen & soften cervix & stimulate uterine contraction - answerDinoprostone (Cervidil vaginal insert) Respiratory Distress Syndrome serious lung disorder caused by immaturity & inability to produce surfactant, resulting in hypoxia & acidosis. Common premature infants & may be due to lung immaturity: result of surfactant deficiency. Mainstay treatment administration exogenous surfactant, administered by intratracheal route - answerBeractant (Survanta) Opioid antagonist, which reverses effects of opioids & given for respiratory depression. - answerNaloxone Appears burrows or fine, grayish red, threadlike lines. May be difficult to see if they are obscured by excoriation & inflammation. Multiple straight or wavy, threadlike lines beneath skin. Wear a gown & gloves for close contact. - answerScabies Clusters of fluid-filled vesicles - answerHerpesvirus infection Contagious bacterial infection skin. Common during hot, humid summer months. May begin area broken skin, such as an insect bite or atopic dermatitis. Impetigo very contagious. Lesions usually located around mouth & nose, but may be on hands & extremities. Mupirocin(Bactroban) topical antibacterial agent active against impetigo. - answerImpetigo Group bleeding disorders resulting from deficiency specific coagulation proteins Abnormal laboratory results indicate prolonged partial thromboplastin time. Female offspring of affected male & carrier female are at risk for hemorrhage once puberty is attained & menstrual cycles begin, depending on severity of hemophilia, hysterectomy or ablation may be performed - answerHemophilia Classified as antidote for acute iron toxicity. - answerDeferoxamine (Desferal) Early sign slight change LOC, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late sign ICP include significant decrease LOC, bradycardia, decreased motor & sensory responses, alterations pupil size & reactivity, posturing, Cheyne-Stokes respirations, & coma. - answerSymptom of increased ICP Confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate & biopsy. - answerLeukemia Malignancy lymph nodes. Presence of giant, multinucleated cells (Reed-Sternberg cells) is classic characteristic of this disease. - answerHodgkin's disease Never be administered in the presence of oliguria or anuria. Checks amount urine output before administration. - answerpotassium chloride Also known as congenital aganglionosis or megacolon. Pellet or ribbon-like stools: foul-smelling is clinical manifestation of disorder. Delayed passage or absence of meconium stool in neonatal period also a sign. Bowel obstruction in neonatal period, abdominal pain & distention, & failure to thrive also clinical manifestations. - answerHirschsprung's disease Projectile vomiting, irritability, hunger & crying, constipation, & signs dehydration including decrease urine output. - answerPyloric stenosis Invagination of section of intestine into distal bowel. Most common cause of bowel obstruction children aged 3 months to 6 years. Severe abdominal pain; crampy & intermittent, child draw in knees to chest. Vomiting may be present, but not projectile. Bright red blood & mucus passed through rectum & commonly described as currant jelly-like stools - answerIntussusception Preoperative period, child observed presence loose teeth to decrease risk aspiration during surgery. Bleeding during surgery controlled via packing & suction as needed. Frequent swallowing, restlessness, fast/thready pulse, & vomiting bright red blood are signs of bleeding. Bad mouth odor normal after tonsillectomy & may be relieved by drinking more liquids. - answerTonsillectomy (Surgical removal tonsils) condition eyes not aligned because lack coordination of extraocular muscles. May in child when complains frequent headaches, squints, tilts head to see. Other manifestations include crossed eyes, closing one eye to see, diplopia, photophobia, loss of binocular vision, or impairment of depth perception. - answerStrabismus Decreased wheezing in child with asthma may be interpreted incorrectly as positive sign when may actually signal inability move air. "Silent chest" is an ominous sign during an asthma episode. - answerChild with asthma Highly communicable disorder. Not transmitted airborne route. Usually transferred by hands. Use contact & standard precaution during care (wearing gloves & gown) reduce nosocomial transmission of RSV. Isolated private room or room with another infant with RSV infection. Cool humidified oxygen delivered relieve dyspnea, hypoxemia, & insensible water loss from tachypnea. - answerRespiratory syncytial virus (RSV) Acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, & enlargement cervical lymph nodes. Subacute stage, cracking lips & fissures, desquamation skin on tips of fingers & toes, joint pain, cardiac manifestation, & thrombocytosis. Convalescent stage, appear normal, but signs inflammation may be present. - answerKawasaki disease Narrowing or stricture of aortic valve. Signs of exercise intolerance, chest pain, & dizziness when standing for long periods. - answerAortic stenosis Failure fetal ductus arteriosus (artery connecting aorta & pulmonary artery) to close. Characteristic machinery-like murmur is present, & infant may show signs of heart failure - answerPatent ductus arteriosus Abnormal opening between the atria - answerAtrial septal defect Abnormal opening between the right and left ventricles. - answerVentricular septal defect Gross hematuria & proteinuria: urine may be small in volume, specific gravity elevated, & urine may appear dark & smoky; cola-colored/brown-colored. Foamy urine from proteinuria. Hypertension common. Blood urea nitrogen levels may be elevated. Moderately elevated high urinary specific gravity. Common experiences excess fluid volume & fatigue. Intervention; fluid restriction, monitoring weight, I&O. Diet high calorie but low protein. Placed bed rest, encouraged rest, because direct correlation between proteinuria & hematuria & increased activity level. - answerGlomerulonephritis Symptoms include increased serum lipids, edema, increased excretion of protein in the urine, & decreased serum albumin levels. Kidney disorder characterized massive proteinuria, hypoalbuminemia (hypoproteinemia), & edema. Child with edema from nephrotic syndrome high risk skin breakdown. Skin surfaces cleaned & separated with clothing to prevent irritation & resultant skin breakdown. Child will be anorexic. - answerNephrotic syndrome Weight gain; periorbital & facial edema most prominent in morning; leg, ankle, labial, or scrotal edema; decreased urine output & urine dark & frothy; abdominal swelling; blood pressure normal or slightly decreased. Massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, & pallor. - answerNephrotic syndrome Condition which one or both testes fail descend through inguinal canal into scrotal sac. Surgical correction may be necessary. Vigorous activities restricted 2 weeks after surgery help healing & prevent injury. - answerCryptorchidism: orchiopexy surgery Congenital defect involving abnormal placement urethral orifice of penis. Urethral orifice located below glans penis along ventral surface. Should not be circumcised because dorsal foreskin tissue used for surgical repair of hypospadias. - answerHypospadias Congenital defect abnormal placement urethral orifice of penis. Urethral opening located anywhere on dorsum of penis. Anatomical characteristic facilitates entry bacteria into urine. - answerEpispadias Chronic disability characterized by impaired muscle movement & posture - answerCerebral palsy Inflammation brain occurs as a result of viral illness or central nervous system infection. - answerEncephalitis Infectious process central nervous system. - answerMeningitis Congenital condition results in moderate to severe retardation. More likely to develop acute leukemia than average child - answerDown syndrome Not able extend leg when thigh is flexed anteriorly at hip. Raise child's leg with knee flexed & then extend the leg at knee & assess for pain; resistance is noted or pain is felt, result is positive Kernig's sign. - answerKernig's sign Neck flexion causes adduction & flexion movements lower extremities children & adolescents - answerBrudzinski's sign (extension) posturing characterized: rigid extension & pronation of arms & legs. Abnormal extension upper extremities with internal rotation of upper arms & wrists & extension of lower extremities with some internal rotation. Indicates damage in diencephalon, midbrain, or pons - answerDecerebrate posturing (flexion) posturing; Abnormal flexion of upper extremities & extension of lower extremities with possible plantar flexion of feet. Indicates lesion in cerebral hemisphere or disruption of the corticospinal tracts. - answerDecorticate posturing supportive care, monitoring & managing cerebral edema. Decrease stimuli environment quiet & dimmed lighting would decrease stress on cerebral tissue & neuron responses. - answerReye's syndrome Assess hip instability. Abducts thigh & applies gentle pressure forward over greater trochanter. A "clicking" sensation indicates dislocated femoral head moving into acetabulum. - answerOrtolani maneuver confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. - answerDetection of HIV in infants Contains neomycin. History of anaphylactic reaction neomycin considered a contraindication to IPV. - answerInactivated polio vaccine (IPV) Administered subcutaneously outer aspect of upper arm - answer(MMR) vaccine Transmitted airborne particles or direct contact with infectious droplets. Airborne droplet precautions required, & should wear masks. Private room if hospitalized, & door remains closed. Standard precautions used. Needs rest. consideration in rubeola is eye care. Child usually has photophobia, suggest parent keep child out of brightly lit areas. - answerRubeola (measles) Move safe area away from snake & rest to decrease venom circulation. Next jewelry & constricting clothing removed before swelling occurs. Immobilize extremity & maintain below heart level done next. Kept warm & calm. Stimulants alcohol/caffeinated beverages not given: may speed absorption of venom - answersnakebite first priority intervention Infection dermis & underlying hypodermis: results in deep red erythema without sharp borders & spreads widely throughout tissue spaces. Skin is erythematous, edematous, tender, & sometimes nodular. Antibiotic therapy; after blood cultures obtained. Warm compresses to the affected area - answerCellulitis Lesions or patches appear as red, raised papules that may coalesce into large plaques covered by silvery scales. Affected areas include scalp, elbows, knees, shins, sacral area, & trunk. Incidence is lower in darker-skinned races & ethnic groups. - answerPsoriasis Pigmented malignant lesions originating melanin-producing cells of epidermis. This skin cancer highly metastatic, & survival depends on early diagnosis & treatment - answerMelanoma The skin is intact in stage I. stage II, skin not intact. Partial-thickness skin loss dermis. Shallow open ulcer with red-pink wound bed, without slough or intact, open or ruptured, serum-filled blister. Full-thickness skin loss occurs stage III. Exposed bone, tendon, muscle present stage IV - answerPressure ulcers Early signs Periorbital edema, edema face, tightness of a shirt or blouse collar. As worsens, experiences edema hands & arms. Cyanosis & mental status changes are late signs. - answerSuperior vena cava syndrome Classic symptoms polydipsia, polyuria, & polyphagia - answerHyperglycemia Results from insufficient ADH production. Triad clinical symptoms including polyuria, polydipsia, excessive thirst often occurs in client with diabetes insipidus. Urine dilute, with specific gravity lower than 1.005, & urine osmolality low (50-200 mOsm/L). High serum osmolality (300 mOsm/kg of water). There is (insufficient ADH production), which causes kidneys excrete large volumes of urine. - answerDiabetes insipidus Decreased blood glucose levels produce autonomic nervous system symptoms, manifested as nervousness, irritability, & tremors. Usually feels hunger. Profuse sweating & shakiness would be noted - answerHypoglycemic reaction Caused by excessive amounts cortisol. Diet low carbohydrates & sodium but ample protein/potassium encouraged. Promotes weight loss, reduction edema & hypertension, control of hypokalemia, rebuilding of wasted tissue. Appearance buffalo hump develop but most physical changes resolve with treatment. Rounded moon-like face; prominent jowls; red cheeks; hirsutism upper lip, lower cheek, & chin. (Moon facies & truncal obesity) - answerCushing's syndrome Catecholamine-producing tumor. Severe Hypertension can precipitate stroke or sudden blindness. Monitor vital signs, particularly blood pressure. Normal range of urinary catecholamines is14 mcg/100 mL of urine, higher levels in pheochromocytoma. - answerPheochromocytoma Deficiency thyroid hormone. Puffy, edematous face, around eyes (periorbital edema), along with coarse facial features, dry skin, & dry, coarse hair & eyebrows. Feeling cold, hair loss, lethargy facial puffiness are signs. - answerHypothyroidism Goiter (increase size thyroid gland) & exophthalmos (bulging eyeballs). Nervousness, fatigue, weight loss, muscle cramps, heat intolerance. Tachycardia; shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair & thin skin; infrequent blinking; & staring appearance. - answerHyperthyroidism Acute, life-threatening condition occurs in uncontrollable hyperthyroidism. Systolic hypertension, tachycardia, diarrhea, & fever as high as 106° F, abdominal pain, dehydration, extreme vasodilation, stupor rapidly progressing to coma, atrial fibrillation, & cardiovascular collapse. Fever, nausea, tremors. As condition progresses they become confused. Restless, anxious & experiences tachycardia. - answerThyroid storm Incretin mimetic used for type 2 diabetes mellitus only. Not recommended clients taking insulin. - answerExenatide (Byetta) Rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals approximately 30 minutes before meals & should be withheld if client does not eat. Hypoglycemia is a side effect of repaglinide & client should always be prepared by carrying a simple sugar with her or him at all times. - answerRepaglinide(Prandin) Oral hypoglycemic given combination repaglinide, works decreasing hepatic glucose production. Common side effect metformin is diarrhea. Used with caution; kidney/liver disease, heart failure, chronic lung disease, history heavy alcohol consumption. - answerMetformin (Glucophage) Insomnia, weight loss, & mild heat intolerance side effects. Taken on empty stomach enhance absorption. Dosing morning before breakfast. - answerlevothyroxine sodium (Synthroid) Treat hyperthyroidism, or Graves' disease. Excessive dosing may convert hyperthyroid state to hypothyroid state. If this occurs, dosage should be reduced. Adverse effect of PTU is agranulocytosis. Early signs adverse effect; fever & sore throat. - answerPropylthiouracil (PTU) may decrease effect oral hypoglycemics, insulin, diuretics, & potassium supplements. - answerPrednisone Severe & unrelenting, located epigastric area & radiating to back. NPO (nothing by mouth) status decrease activity of pancreas. Pain management typically administration opioids patient-controlled analgesia. Morphine or hydromorphone (Dilaudid) are typically used. Nasogastric tube insertion is done to provide suction secretions & administer medications as necessary. - answerAcute pancreatitis Avoid chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, & alcohol - answerGastroesophageal reflux disease (GERD Inability absorb vitamin B12. This leads to development of pernicious anemia. - answerChronic gastritis Nonbloody diarrhea usually not more than four to five stools daily. Over time, diarrhea episodes increase in frequency, duration, & severity. - answerCrohn's disease Irregular flapping movements fingers & wrists when hands & arms are outstretched, with palms down, wrists bent up, & fingers spread. - answerAsterixis Pain relieved by food intake. Burning, heavy, sharp, or "hungry" pain that often localizes in mid-epigastric area. 90 minutes to 3 hours after eating & often awakens client at night. - answerDuodenal ulcer Weight loss or nausea & vomiting. exacerbated by intake of food. Pain occurs 30-60 minutes after meal & rarely occurs at night - answerGastric ulcer Bowel protrudes through stoma, causing elongated & swollen appearance to stoma - answerProlapsed stoma Sunken & hidden stoma (Sinking in of stoma) - answerStoma retraction Frequent complication that occurs is fluid & electrolyte imbalance. I & O monitored. - answerIleostomy Narrow opening - answerStenosed Stoma Early manifestation occur 5- 30 mins after eating. Symptoms; vertigo, tachycardia, syncope, sweating, pallor, palpitations, & desire to lie down. Instruct maintain low Fowler position while eating & lie down for 30 mins after eating. Small, frequent meals best & avoid liquids with meals. Avoiding high-carbohydrate food sources also assist. - answerDumping syndrome Immunomodulator that reduces degree inflammation in colon, reducing diarrhea - answerInfliximab (Remicade): Used in Crohn's disease antiemetic treat postoperative nausea/vomiting, also N&V associated with chemotherapy. - answerOndansetron (Zofran) Pancreatic enzyme used as digestive aid for pancreatitis. Reduce amount fatty stools (steatorrhea). Also help improve nutritional status - answerPancrelipase (Pancrease MT) Gastric protectant administered 1 hour before meals & bedtime. Timed to allow it to form protective coating over ulcer before food intake stimulates gastric acid production & mechanical irritation. - answerSucralfate (Carafate) Antiulcer agent. Intended effect is relief of pain from gastric irritation, often called heartburn by clients - answerOmeprazole (Prilosec) Promote carbon dioxide elimination; facilitates maximal expiration with obstructive lung disease. Allows better expiration by increasing airway pressure that keeps air passages open during exhalation. - answerPursed-lip breathing preoxygenate before suction & limit suction pass to 10 seconds - answerSuctioning Paradoxical chest movement - answerSuffered flail chest earliest sign is increased respiratory rate, can begin from 1 to 96 hours after initial insult to body. Followed by increasing dyspnea, air hunger, retraction accessory muscles, & cyanosis. - answerAcute respiratory distress syndrome Common initial symptom chest pain; sudden in onset. Next common symptom dyspnea, accompanied by increased respiratory rate. Other symptoms PE include apprehension, restlessness, tachycardia, cough, & cyanosis. - answerPulmonary embolism Sitting up & leaning on overbed table, sitting up & rest elbows on knees, standing & leaning against wall. - answerEmphysema positions that help breathing First pulmonary manifestations cough with expectoration mucoid sputum. Sputum cultures performed every 2-4 weeks after initiation drug therapy. Return work when three sputum cultures are negative; considered noninfectious at that point. - answerTuberculosis Antitubercular medication. Side effect peripheral neuritis. Symptoms; numbness, tingling, paresthesias in extremities. Minimized w/pyridoxine (vitamin B6) intake. Report yellow eyes/skin immediately. Hepatotoxic. Monitor liver enzyme first 3 months therapy. Children HIV infection who demonstrate positive Mantoux tuberculin skin test result, minimum 12 months treatment recommended. - answerIsoniazid Used caution impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or history seizures. Medication may increase blood glucose levels. - answerTerbutaline: is an bronchodilator Treat bronchial asthma. Used with caution impaired hepatic function. Liver function laboratory tests should be performed and monitored with treatment. - answerZafirlukast (Accolate) administered empty stomach unless it causes GI upset, & then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before. Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently. - answerrifampin (Rifadin) causes optic neuritis, decreases visual acuity & ability discriminate between color red & green. - answerEthambutol (Myambutol) Single daily dose (bronchodilator) early in morning. Enables maximal benefit during daytime activities. Additionally, causes insomnia. Take in at least 2 L of fluid per day; decrease viscosity of secretions. Limit intake Coffee, cola, & chocolate - answerTheophylline (Theo-24) antiinflammatory for long-term control asthma. Anaphylactic reactions can occur with administration. Swelling lips & tongue are indication of adverse reaction - answeromalizumab (Xolair) Used treatment of pulseless ventricular tachycardia & ventricular fibrillation - answerDefibrillation Regular rhythm, with rate 60 to 100 beats/min. PR & QRS normal 0.12 to 0.20 second & 0.04 to 0.10 seconds. - answerNormal sinus rhythm Characterized absence P waves, wide QRS complexes (longer than 0.12 sec) & typically rate between 140-180 impulses/min. Rhythm is regular. Restorative coughing techniques sometimes used unstable V tachycardia. Cough cardiopulmonary resuscitation (CPR), if prescribed, by inhaling deeply & coughing forcefully every 1-3 seconds. Cough CPR may terminate the dysrhythmia or sustain cerebral & coronary circulation for short time until other measures can be implemented. - answerVentricular tachycardia Life-threatening dysrhythmia results from irritable ectopic focus that takes over pacemaker for heart. Low cardiac results can lead quickly to cerebral & myocardial ischemia. Feeling of impending doom. - answerVentricular tachycardia Loss P waves & fibrillatory waves before each QRS complex. aia quiver, which can lead to thrombus formation - answerAtrial fibrillation energy level used defibrillation attempts is 360 joules. - answermonophasic defibrillator machine maintenance first patent airway, & then oxygen administration, assessment of vital signs & LOC, & dysrhythmia detection. - answerNursing responsibilities after cardioversion Irregular chaotic undulations varying amplitudes. Ventricular fibrillation has no measurable rate & no visible P waves or QRS complexes & results from electrical chaos in ventricles. - answerVentricular fibrillation Induced by exercise & relieved by rest or nitroglycerin tablets. Triggered by a predictable amount effort or emotion - answerStable angina Prolonged & severe & occurs same time each day, most often at rest. Triggered by coronary artery spasm; attacks are of longer duration than in classic angina & tend to occur early in day & at rest. - answerVariant angina, or Prinzmetal's angin Chronic & incapacitating and is refractory to medical therapy - answerIntractable angina Occur lower level activity/rest less predictable, often precursor of myocardial infarction. Triggered by unpredictable amount exertion or emotion & may occur at night; attacks increase in number, duration, & severity over time. - answerUnstable angina Considered dangerous when frequent (more than 6 per minute), occur in pairs or couplets, are multifocal (multiform), or fall on T wave. - answerPremature ventricular contractions (PVCs) Common lab range for APTT are 20-36 seconds. Should be 1.5 to 2.5 times normal value if heparin therapy is theraputic, considered therapeutic if 60 seconds - answerActivated partial thromboplastin Antidysrhythmic used treat ventricular dysrhythmias client allergic to lidocaine - answerProcainamide Monitor signs of bleeding. Hemorrhage is complication of any type of thrombolytic medication - answerreceiving tissue plasminogen activator, alteplase (Activase, tPA). Thiazide diuretics; sulfa-based, risk for allergic sulfa reaction. Also, Risk hypokalemia, hyperglycemia, hypercalcemia, hyperlipidemia, & hyperuricemia. - answerhydrochlorothiazide Early sign toxicity GI: anorexia, nausea, vomiting, & diarrhea. Subsequent manifestation: headache, visual disturbances diplopia, blurred vision, yellow-green halos, & photophobia; drowsiness; fatigue; & weakness. Cardiac rhythm abnormalities can occur. Monitors digoxin level. Therapeutic level digoxin range from 0.5 to 2 ng/mL. - answerDigoxin toxicity Diuretic & expected outcome increased urine output, decreased crackles, & decreased weight. Can be used for client who needs diuresis. - answerBumetanide Antidote is protamine sulfate; readily available to use if excessive bleeding or hemorrhage should occur. - answerHeparin Vitamin K is an antidote - answerWarfarin sodium Contraindicated number of preexisting conditions in which there is risk uncontrolled bleeding. Also contraindicated severe uncontrolled hypertension because risk cerebral hemorrhage. - answerThrombolytic therapy Check patency fistula by palpating for presence of a thrill or auscultating for a bruit. - answerarteriovenous fistula for hemodialysis Symptoms: Dysuria & penile discharge. In male often results from chlamydial infection & characterized: dysuria accompanied by clear to mucopurulent discharge. Because disorder often coexists with gonorrhea, diagnostic tests done for both & include culture & rapid assays - answerUrethritis Symptoms: scrotal pain & edema, accompanied by fever, nausea & vomiting, chills. Often caused by infection, although sometimes by trauma. Common interventions; bed rest with bathroom privileges, elevation scrotum, ice packs, sitz baths, analgesics, & antibiotics. - answerEpididymitis Signs: Pallor, diminished pulse, & pain in left hand - answerArterial steal syndrome from left arm fistula Creatinine level frequently used laboratory test determine renal function. Increases when at least 50% of renal function is lost. - answerRenal function disorder often occurs first 2 weeks after transplantation. Manifestations include fever, malaise, elevated white blood cell count, acute hypertension, graft tenderness, & deteriorating renal function. - answerAcute rejection occurs gradually over period of months to years. - answerChronic rejection characterized headache, mental confusion, decreased LOC, nausea, vomiting, twitching, & possible seizure activity. Disequilibrium syndrome is caused by rapid removal solutes from body during hemodialysis. - answerDisequilibrium syndrome urinary retention can be triggered by decongestants, anticholinergics, & antidepressants. Should be questioned about use of these medications if has urinary retention. Retention also precipitated by other factors, such as alcoholic beverages, infection, bed rest, & becoming chilled. - answerhistory of benign prostatic hyperplasia with an inability to void Administered with full glass of water; maintain high fluid intake. Medication is more soluble in alkaline urine. - answerSulfamethoxazole May be administered IV infusion; not mixed with any other medications or solutions. Infused over 60-90 minutes, & bolus infusion or rapid infusions must be avoided. Early sign/symptom blood disorders that can occur; sore throat, fever, pallor, & instructed notify (HCP) if these occur. - answerTrimethoprim-sulfamethoxazole Because risk anaphylaxis during administration IV route, epinephrine & oxygen must be immediately available for use. Nephrotoxicity evaluated by monitoring elevated BUN & serum creatinine levels. Adverse effects; are nephrotoxicity, infection, hypertension, tremors, & hirsutism. Nephrotoxicity & infection are most serious. - answerCyclosporine (Sandimmune) grapefruit juice inhibits metabolism. As result, consumption grapefruit juice can raise cyclosporine levels by 50% to 100%, greatly increasing risk of toxicity. - answerCyclosporine (Sandimmune) Used for urinary tract infection. Imparts harmless brown color to urine - answerNitrofurantoin (Furadantin) Reverse anemia associated with chronic kidney disease. Therapeutic effect seen hematocrit between 30% & 33% (Treat anemia) Medication administer subcutaneously or intravenously as prescribed. - answerEpoetin alfa (Epogen) Severe pain or pain accompanied by nausea is indicator increased intraocular pressure & should be reported to HCP immediately - answerCataract extraction Reveals red, dull, thick, immobile tympanic membrane, with/without perforation. Postauricular lymph nodes tender & enlarged. Low-grade fever, malaise, anorexia, swelling behind ear, pain with minimal movement of head. - answerOtoscopic examination with mastoiditis Painless blurring central vision is chief clinical manifestation. Early symptom include slightly blurred vision & decrease in color perception. - answerearly stages of cataract formation Surgical removal eyeball. Presence bright red drainage on dressing,reported to HCP, indicates hemorrhage. - answerenucleation Sensorineural hearing loss that occurs with aging. - answerPresbycusis Right eye tested, then left eye, & then both eyes tested. Visual acuity measured with or without corrective lenses & at distance 20 feet from chart. - answerSnellen chart Vision 20/20 normal; client able read from 20 feet what person with normal vision can read from 20 feet. Visual acuity 20/60 can read distance of 20 feet what person with normal vision can read at 60 feet. - answerSnellen chart Wash hands & put gloves on. Tilt head backward, open eyes, & look up. Nurse pulls lower lid down against cheekbone & holds bottle like pencil with tip downward. Nurse gently rests wrist of hand on cheek & squeezes bottle gently to allow drop to fall into conjunctival sac. Instructed close eyes gently & not to squeeze eyes shut to prevent loss of medication. - answerAdminister eye medications Steps Contraindicated for gastrointestinal bleeding & potentially ototoxic. Mild intoxication with acetylsalicylic acid (aspirin) called salicylism. Tinnitus (ringing in the ears) is most frequent effect noted with intoxication - answerAcetylsalicylic acid (aspirin) Nail bed pressure tests - answerUnconscious patient test client's peripheral response to pain Tested using sternal rub, placing upward pressure orbital rim, or squeezing clavicle or sternocleidomastoid muscle. - answerUnconscious patient Cerebral responses to pain Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure - answerVital signs if the intracranial pressure is rising weakness one side body may occur after stroke. Involves weakness face, tongue, arm, & leg on one side. Also aphasic: unable to discriminate words & letters. Generally cautious & anxious when attempting new task. Right-sided hemiparesis has weakness right arm, leg & needs assistance with feeding, bathing, & ambulating. - answerHemiparesis Loss of half visual field. Objects placed in intact field vision, & also should approach from intact side. Instructs to scan environment to overcome visual deficit & client teaching from within intact field vision. Encourage use personal eyeglasses, if available. - answerHomonymous hemianopsia May experience episodes respiratory distress if excessively fatigued or with development of myasthenic or cholinergic crisis. Ambu bag, intubation tray, & suction equipment available at bedsideSpace. Activities conserve energy & restore muscle strength. Take medication correctly maintain blood levels. Muscle-strength exercises not helpful & fatigue client. Overeating cause exacerbation symptoms, as is exposure heat, crowds, erratic sleep habit, & emotional stress. - answerMyasthenia gravis Spasms pain start suddenly & last seconds to minutes. Characterized as stabbing; similar to electric shock. Accompanied spasms facial muscles, cause twitching parts of face, mouth, or closure eye.Triggered by Stimulation affected nerve by pressure & temperature. Pain minimized using cotton pads wash face; room temp water. Chew on unaffected side mouth, eat soft diet, & take in foods & beverages at room temperature. If toothbrushing triggers pain, oral rinse after meals may be helpful. Nnticonvulsant meds carbamazepine & gabapentin (Neurontin) help relieve pain. - answerTrigeminal neuralgia Clinical syndrome; Progressive muscle weakness that develops rapidly. Has unknown origin. Report history respiratory or GI infection 1- 4 weeks before onset neurological deficits. On occasion, syndrome can be triggered by vaccination surgery. Have dysphagia; more likely aspirate clear liquids than thick or semisolid foods. Passive ROM exercises help prevent contractures, & assessing calf measurements can help detect deep vein thrombosis, for which these clients are at risk. Are at risk for hypotension or hypertension, bradycardia, & respiratory depression, frequent monitoring vital signs required. Retain carbon dioxide, leading to respiratory acidosis & ventilatory failure as paralysis develops. - answerGuillain-Barré syndrome Providing information, giving positive feedback, & encouraging relaxation - answerGuillain-Barré syndrome help cope with this illness Affect is flat, with periods of emotional lability - answerLimbic system neurological deficit Nuchal rigidity, positive Brudzinski sign, & positive Kernig sign - answerIndicate developing meningitis Prescribed for Parkinson's disease. Adverse effect; Dyskinesia & Impaired voluntary movement. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, & akinesia frequent side effects. - answerCarbidopa-levodopa (Sinemet) Potential decreased effectiveness of birth control pills while taking phenytoin - answerphenytoin (Dilantin) for seziures Acetylcysteine (Mucomyst). Normal therapeutic serum level acetaminophen is 10-20 mcg /mL. Toxic level higher than 50 mcg/mL, & levels higher than 200 mcg/mL could indicate hepatotoxicity. - answerAntidote for acetaminophen Opioid analgesic. Side/adverse effects; respiratory depression, drowsiness, hypotension, constipation, urinary retention, N&V, tremors. - answerMeperidine hydrochloride (Demerol) Monitor vital signs & assess for hypotension. Increase fluid intake, palpate bladder for urinary retention, auscultate bowel sounds, monitor bowel because cause constipation. Monitor respiratory status & initiate deep-breathing & coughing exercises. Monitors effectiveness pain medication. - answerCodeine sulfate Plaster cast 24-72 hours to dry (synthetic casts 20 min). Cast & extremity elevated reduce edema. Wet cast handled palms hand until dry, extremity turned (unless contraindicated) so that all sides of wet cast will dry. Cool setting hair dryer can be used dry plaster cast (heat cannot be used because cast heats up & burns skin). Kept clean & dry, Not stick anything under because risk break skin integrity. Monitor circulatory impairment; pain, swelling, discoloration, tingling, numbness, coolness, diminish pulse. HCP notified if circulatory impairment occurs - answerCast Earliest symptom is paresthesia (numbness & tingling in fingers). Other symptoms include pain unrelieved by opioids, pain that increases with limb elevation, pallor & coolness to distal limb. Cyanosis is a late sign. - answerCompartment syndrome Skin traction often applied after hip fracture before fracture is reduced in surgery. Traction reduces muscle spasms & helps immobilize fracture. - answerBuck's (extension) traction Infection & pancytopenia are side/adverse effects. Assess white blood cell counts & platelet counts - answerEtanercept for treatment of rheumatoid arthritis Encourage drink 3000 mL fluid day. Full effect may take 1 week or longer. Given with, or immediately after, meals or milk. Develops rash, irritation eyes, swelling of lips or mouth;contact HCP because may indicate hypersensitivity. Medication prevents, treats hyperuricemia caused by chemotherapy. May increase effect of Warfarin sodium if this medication was prescribed for client, should verify prescription with HCP - answerAllopurinol (Zyloprim) Prescribed for gout. Used with caution older adults, debilitated clients, & clients with cardiac, kidney, or GI disease. - answerColchicine (Colcrys) Take medication with full glass of water after rising in morning. Not eat or drink anything for 30 minutes following administration - answerAlendronate (Fosamax) prescribed for osteoporosis Liver damage most serious adverse effect. To reduce risk of liver damage, liver function tests should be performed before treatment & throughout treatment. Administered lowest effective dosage for shortest time necessary. - answerDantrolene sodium (Dantrium) Used with caution history of urinary retention, glaucoma, & increased intraocular pressure. - answerCyclobenzaprine hydrochloride (Flexeril) Skeletal muscle relaxant. May cause urine to turn brown, black, dark green color. Needs to be told; harmless effect. Medication can cause hypotension & bradycardia. Drowsiness & dizziness can also occur. - answerMethocarbamol (Robaxin) Autoimmune disease causes blistering in epidermis. Large flaccid blisters (bullae). Blisters are in epidermis, have thin covering of skin & break easily, leaving large denuded areas of skin. On initial examination, clients may have crusting areas instead of intact blisters. - answerPemphigus Health care worker, people who work in rubber industry, or have had multiple surgeries, have spina bifida, wear gloves frequently; food handlers, hairdressers, & auto mechanics, or are allergic to kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, or water chestnuts. - answerIndividuals at risk for developing a latex allergy Multisystem infection that results from bite by tick carried by several species of deer. Blood to detect performed 4 to 6 weeks following tick bite. Antibody formation takes place in the following manner. Ticks should be removed with tweezers & area washed with an antiseptic. - answerLyme disease Prevention; insect repellent on skin & clothes in an area where ticks likely found. Long-sleeved tops & long pants, closed shoes, & hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up & over pant legs to prevent ticks from entering under clothing. - answerLyme disease Avoid uncooked eggs & unpasteurized milk. Fruits & vegetables washed before eating. Contact materials possibly contaminated with cat feces; litter boxes, sand boxes, garden soil avoided. Avoid touching mucous membranes mouth or eyes while handling raw meat, wash all kitchen surfaces that come contact with uncooked meat, wash hands after handling raw meat. Symptoms; altered mental status, headache, & cognitive impairment. - answerToxoplasmosis Caused by inhalation of spores from bat or bird droppings. An opportunistic infection that affects lungs & can occur in client with HIV infection. Diagnostic tests include chest x-ray, sputum culture, lung biopsy, & bronchoscopy - answerHistoplasmosis Chronic connective tissue disease. Corticosteroids prescribed treat inflammation. Topical agents may provide some relief from joint pain. Activity encouraged as tolerated & room temperature constant. Clients need sit up for 1-2 hours after meal if esophageal involvement present - answerScleroderma Nephrotoxicity, bone marrow depression, GI effects, hepatotoxicity, dermatological effects, & neurological symptoms; headache, dizziness, vertigo, ataxia, depression, & seizures. - answersulfonamide monitor for signs/symptoms of which side/adverse effects Can cause pancreatitis. Serum amylase level that is increased 1.5 to 2 times normal may signify pancreatitis. Medication is also hepatotoxic & can result in liver failure - answerDidanosine (Videx) Used manage HIV in clients who do not respond to or who cannot tolerate conventional therapy. Can cause peripheral neuropathy. Should monitor gait closely & ask about paresthesia. - answerstavudine (d4T, Zerit) Emphasizes self-expression, self-exploration, & self-awareness in present. Client & therapist focus on everyday problems & try to solve them. - answerGestalt therapy Promotes individual's comfort in group, which then transfers to other relationships. Based on one-to-one or group therapy approach in which therapist-client relationship often used as way for client to examine other relationships in his/her life. - answerInterpersonal group therapy Focuses on how irrational beliefs and thoughts contribute to psychological distress. Correction distorted thinking. - answerRational emotive therapy Help others express their feelings toward one another during group sessions. - answerRogerian therapy "Therapeutic community," has as its focus living, learning, or working environment. Provide safe, therapeutic environment. All treatment team members are viewed significant & valuable to client's successful treatment outcomes. - answerMilieu therapy Based on rewards & punishment - answerBehavior modification Consistent daily routine & low stimulating environment important when disoriented. Use an indirect light source & turn off TV. - answerDelirium becomes disoriented & confused at night Often withdrawn, experience difficulty concentrating, loss of interest or pleasure, low energy, fatigue, feelings worthlessness & poor self-esteem. Plan of care provide successful experiences in stimulating yet structured environment. - answerDepression Fear situations which one might be embarrassed, criticized; fear of speaking, performing, eating in public. Fears making fool of oneself. - answerSocial phobia Fear open spaces & fear of being trapped in situation from which there may not be escape. - answerAgoraphobia Alteration loss of physical function cannot be explained by any known pathophysiological mechanism. Thought to be an expression of psychological need or conflict. - answerConversion disorder Disturbance or alteration in normally integrative function identity, memory, consciousness - answerDissociative disorder Facilitates communication by sitting silence, ask open-ended questions rather than direct questions, pausing provide opportunities to respond. - answerCatatonic stupor Prevent from harming self or others. Low-stimulation environment maintain client in calm state. Monitor vital signs closely & report abnormal findings. Reorient to reality frequently & would address hallucinations therapeutically. Adequate nutritional & fluid intake maintained. - answerWithdrawal from alcohol Delirium typically include anxiety, insomnia, anorexia, hypertension, disorientation, hallucinations, changes LOC, agitation, fever, & delusions. - answerAlcohol withdrawl Include loss of or change of job, death of loved one, abortion, change financial status, divorce, addition new family members, pregnancy, & severe illness - answerSituational crisis Crisis of disaster; it is unplanned or accidental; Witnessing a murder, fire destroyed home, recent rape episode experienced - answeradventitious crisis Administered once every 24 hours. Administered morning or evening, but evening administration may be preferable because drowsiness is side effect. - answerSertraline (Zoloft); antidepressant Anticonvulsant & hypnotic agent. Avoid taking any other central nervous system depressants such as alcohol while taking medication. - answerPhenobarbital sodium (Luminal) Causes constipation, instructed increase fluid intake & bulk (high fiber) in diet. If heart beats fast, HCP notified could indicate overdose. Diarrhea could indicate incomplete intestinal obstruction HCP notified. - answerOxazepam (Serax) Cause orthostatic hypotension. Sunlight avoided. Psychotropic med, caution with (driving, other activities requiring alertness) determine if alertness affected. Atypical antipsychotic renal & liver function studies done. - answerRisperidone (Risperdal) maximum therapeutic effect may not occur for 2-3 weeks after antidepressant therapy initiated. - answerImipramine (Tofranil) (MAOI) Avoid foods high in tyramine. Ingestion of these foods could trigger potentially fatal hypertensive crisis. Foods to avoid include yogurt; aged cheeses; smoked or processed meats; red wines; fruits such as avocados, raisins, or figs. - answerPhenelzine (Nardil); for depression Can occur from use monoamine oxidase inhibitor; hypertension, occipital headache radiating frontally, neck stiffness & soreness, N&V. - answerHypertensive crisis Reaction antipsychotic medication. Ucontrollable involuntary movements of body, extremities, mouth, face, & particularly tongue. - answerTardive dyskinesia Tremors, masklike facies, rigidity, & shuffling gait. - answerParkinsonism Potentially fatal syndrome, may occur any time during therapy neuroleptic (antipsychotic) medications. Characterized by dyspnea or tachypnea, tachycardia or irregular pulse rate, fever, blood pressure changes, increased sweating, loss of bladder control, & skeletal muscle rigidity. - answerNeuroleptic malignant syndrome Affects GI system by causing nausea & vomiting, cramping, & diarrhea. - answerFluoxetine (Prozac) Effective if absence of these manifestations occurs; Rapid heartbeat or anxiety - answerBuspirone (Buspar); treatment of anxiety Serum level 0.6 to 1.2 mEq/L. Symptoms toxicity appear levels 1.5 to 2 mEq/L. Lithium toxicity requires immediate medical attention with lavage & possible peritoneal dialysis or hemodialysis. Symptoms toxicity; vomiting, abdominal pain, diarrhea, blurred vision, tinnitus, & tremors. - answerLithium carbonate Tricyclic antidepressant treat obsessive-compulsive disorder. Sedation sometimes occurs. Weight gain & tachycardia side /adverse effects of medication. - answe