QB# 1 Flashcards
Growth spurt in females and males will peak at which age ?
12 & 14, respectively
_________ teeth will appear in the period of adolescence
wisdom
Male changes during adolescence
increase in genital size pubic, facial, axillary and chest hair deepening voice production of functional sperm nocturnal emissions
Female changes during adolescence
breast development appearance of axillary & pubic hair menarche - first menstrual period
psychosocial development during adolescence
conforms to peer pressure moody increased independence
potential problems during adolescence
adolescent pregnancy poor self image automobile accidents drug/alcohol abuse AIDS high school dropout violence
When on heparin or other anticoagulants, Herbal supplements such as ______________________________may increase the client’s risk for bleeding
Herbal supplements (e.g., garlic, ginger, ginkgo, ginseng, and licorice) may increase the client’s risk for bleeding
Some medications can cause confusion and hallucinations. Older adult clients are more prone to experiencing these manifestations as the _______________declines with age, decreasing the rate at which medications are eliminated from the body.
renal function
Adverse drug reactions among older adult clients may manifest as ________________________
altered mental status, delirium, orthostatic hypotension, incontinence, and gastrointestinal manifestations such as anorexia and nausea.
For a client with hallucinations, what is the first priority ?
What interventions can we perform for the client with hallucinations?
Safety
Ask the client directly about the hallucination
avoid reacting to the hallucination as if it were real
decrease stimuli or move the client to antoher area
do not negate the clients experience
Gently challenge the client’s perceptions.
Monitor the client’s verbalized thought patterns and perceptions, as well as associated behavior.
Tactfully ask the client about current and past experiences with hallucinations.
Monitor for increased negativity of content, anxiety, and agitation, or for social withdrawal.
focus on reality based topics
attempt to engage the clients attention through a concrete activity
respond verbally to anything real that client talks about
avoid touching the client
monitor for signs of increasing anxiety or agitation, which may indicate that hallucinations are increasing
Conduct urinalysis for toxicology as indicated if hallucinations are suspected to be related to substance abuse.
what to know about STI syphilis
3 stages
Stage 1- painless chancre ( genital ulcer) fades after 6 weeks
stage 2 - copper colored rash on palms & soles
stage 3 - cardiac and CNS dysfunction
spread via mucous membranes, skin, congenitally
TREAT WITH IM penicillin G
what to know about Gonorrhea
frequently asymptomatic in females
symptoms in females include- purulent vaginal discharge, dysuria, dyspareunia
symptoms in males - painful urination, yellow-green discharge
spread via mucous membranes, congenitally, sexual activity
IM ceftriaxone with PO doxycycline
IM aqueous penicillin with PO probenecid
COMPLICATION of Gonorrhea - Pelvic Inflammatory Disease
what to know about genital herpes
painful vesicular genital lesions
difficulty voiding
reoccurs with stress, infection, menses
spread via mucous membranes, congenitally
Acyclovir, Sitz bath, topical medication
Monitor Pap smears regularly
precautions about vaginal delivery (can cause blindness in newborn)
what to know about chlymydia
Men - urethritis, dysuria, watery discharge
Women - may be asymptomatic- symptoms include thick vaginal discharge with acrid odor, pelvic pain
Spread via mucuous membranes/sexual contact
Tetracycline or Doxycycline PO
complication - sterility
Clients should be taught that the risks of developing sexually transmitted infections are greatly reduced by
being in a mutually monogamous sexual relationship, reducing the number of sex partners, and using latex condoms.
Post-tonsillectomy, the nursing interventions are focused on these 3 things
assessing for airway clearance, providing pain relief, and monitoring for excessive bleeding.
The nurse should instruct the client to avoid crunchy, hard foods and hot or spicy foods
After a tonsillectomy, monitor for bleeding or airway obstruction due to edema and swelling.
Frequent swallowing may indicate bleeding. Discourage coughing, clearing the throat, or nose to prevent bleeding.
Monitor the back of the throat frequently in the post-operative period for bleeding. Monitor vital signs. Once the gag reflex has returned post-operatively, offer cool fluids and ice chips. Assess and treat pain as prescribed. Corticosteroids may be administered to reduce edema.
What is conversion disorder ?
The sudden onset of a physical symptom or a deficit suggesting loss of or altered body function related to psychological conflict or a neurological disorder
conversion disorder is an expression of a psychological conflict or need
The most common conversion symptoms are blindness, deafness, paralysis, and the inability to talk
conversion disorder has no organic cause
What is post-herpetic neuralgia?
common in clients after the acute outbreak of herpes zoster (shingles) has been resolved.
client may experience persistent pain after the resolution of herpes zoster
A client being discharged from the postpartum care area requests perineal pads, diapers, wipes, and perineal spray. Which response is the best for the nurse to make to this client?
1) INCORRECT - The nurse is responsible for maintaining costs of the care area. Many insurance companies consider ordering extra supplies the day of discharge as stockpiling and may refuse to pay the bill.
2) INCORRECT - The client does need to be responsible for obtaining needed items, but this response is not therapeutic.
3) INCORRECT - Saying that the client does not need any more supplies is argumentative and not therapeutic.
4) CORRECT— Offering supplies for one hour provides for the client ’s immediate needs in a cost-effective way.
The nurse is responsible for providing cost-effective care and should only supply the client with supplies that are needed until the client is able to obtain/purchase the items after discharge. Health insurance companies may not pay for additional items that are charged on the day of discharge. Confronting the client is not therapeutic. The client will need supplies; however, the nurse can only provide a limited amount.
An ___________________ is a non-invasive diagnostic tool used to differentiate arterial from venous insufficiency
ankle-brachial index (ABI)
What to remember about chronic venous insufficiency ?
results from prolonged venous hypertension, which stretches the veins and damages the valves
The resultant edema and venous stasis cause venous stasis ulcers, swelling, cellulitis, brown discoloration along the ankles extending up to the calf, pain during walking or activity, edema, non-healing wounds, and skin color changes.
Varicose veins are consistent with the diagnosis of chronic venous insufficiency. `
Pain in the lower extremities while sitting is consistent with the diagnosis of chronic venous insufficiency. Venous insufficiency may cause pain in dependent positions.
Phlebitis
Symptoms include redness, warmth, and pain in the affected area.
Inflammation of a vein.
Phlebitis may occur with or without a blood clot. It can affect surface or deep veins. When caused by a blood clot, it’s called thrombophlebitis. Trauma to the vein, for instance from an intravenous catheter, is a possible cause.
Treatments may include a warm compress, anti-inflammatory medication, compression stockings, and blood thinners.
Sickle cell disease is a severe hereditary form of anemia in which a _______________form of hemoglobin ___________the red blood cells into a crescent shape at low oxygen levels. When planning care for this client, the nurse needs to promote ______________________-
mutated; distorts; optimal oxygenation, adequate rest periods, hydration, and adequate pain management.
A client with sickle cell disease can experience a “crisis.” The crisis is usually precipitated by low fluid volume.
Serious side effects of Clozapine
Clozapine is an atypical antipsychotic agent. It is not likely to cause extrapyramidal syndrome (EPS). Serious side effects include seizure and agranulocytosis.
Clozapine is a medication that has the potential to suppress bone marrow and cause agranulocytosis. This potentially fatal side effect occurs in 1% to 2% of clients.
The health care provider will monitor the CBC, specifically the client’s WBC count. Clozapine will be discontinued if the WBCs fall below 2000/mm3.
Clozapine is excreted in breast milk, so breastfeeding is contraindicated.
Clozapine is an antipsychotic used for the treatment of schizophrenia
What to know about hypercalcemia
serum calcium level that exceeds 10.5 mg/dL
caused by increase in parathyroid hormone (hyperparathyroidism), increased absorption of calcium (excessive intake of vitamin D), or decreased excretion of calcium. Elevated calcium levels can negatively affect bones, kidneys, and cardiac output. Signs and symptoms include muscle weakness, headache, irritability, depression, bone pain, anorexia, nausea, vomiting, and constipation. Can also be associated with renal lithiasis. Bradycardia or arrhythmias may also be noted. Heart block is a late sign.
Manifestations of an elevated calcium level begin with muscle weakness and constipation. If the condition continues without effective treatment, the rising calcium level can adversely effect the conduction system of the heart. The client is at risk for developing a life-threatening dysrhythmia or complete heart block.
EKG changes - shortened ST segment, widened T wave
What is lactose intolerance ?
Lactase breaks down lactose, which is a form of sugar, into glucose and galactose for absorption. Without lactase, undigested lactose builds up in the colon. As bacteria in the colon interact with the undigested lactose, gas is produced. In turn, the client experiences bloating and abdominal pain. In most cases, lactose intolerance is caused by lactase deficiency. Unlike a milk allergy, which involves an immune response, lactase deficiency is not an allergic reaction. Usually, some milk products can be consumed without side effects, but the client must pay attention to ensure adequate calcium and vitamin D are consumed. Alternate calcium sources include salmon, rhubarb, kale, spinach. Vitamin D can be obtained from salmon, tuna, eggs, and fortified foods like cereal.
Bloating, flatulence, abdominal pain and cramping, and diarrhea are symptoms of lactose intolerance. Symptoms usually occur about 30 minutes to several hours after ingesting milk or a milk product. The client may be able to tolerate small amounts of lactose. If lactose is ingested in the diet, cheese and live culture yogurt are better options than milk and ice cream because they contain less lactose. Also, some clients tolerate lactose better if lactose is ingested with meals. Instruct the client to read food labels to identify potential hidden sources of milk products.
In newborns, what is the most reliable assessment indicator for decreased bilirubin levels ?
the color of the oral mucosa and gum tissue is the most reliable indictor that the serum bilirubin levels are decreasing
The nurse provides care for a newborn who is prescribed phototherapy for hyperbilirubinemia. Which actions will the nurse implement when providing care to this client? (Select all that apply.)
- Remove the newborn’s eye patches during feedings.
- Place the newborn 15 cm (6 in) below the phototherapy lights.
- Reposition the newborn every 4 hours.
- Cover the newborn with light cotton clothing.
- Cluster activities when caring for the newborn
1) CORRECT — The nurse should place eye patches over the newborn’s eyes to prevent retinal damage, but should remove them at least every 2 to 3 hours to assess the skin and to promote stimulation and bonding with parents during feedings.
2) INCORRECT - The newborn should be placed about 30 to 40 cm (12 to 16 in) below the bank of phototherapy lights to prevent injury to the skin.
3) INCORRECT - The nurse should reposition the newborn at least every 2 hours to provide stimulation, maximize skin exposure to the lights, and prevent skin breakdown.
4) INCORRECT - The nurse should dress the newborn only in a diaper to maximize skin exposure to the lights.
5) CORRECT — When performing care for the newborn, the nurse should cluster care to ensure the newborn obtains maximum exposure to the lights.
Phototherapy requires the newborn to be exposed to a special fluorescent light. Increased skin area exposed increases the therapy’s effectiveness. The light is absorbed through the skin and blood, and then breaks down the bilirubin in the newborn’s body so that it can be flushed out of the body in stool and urine. When administered appropriately, phototherapy is not harmful to the newborn’s skin. However, eye protection is applied to prevent injury to the newborn’s eyes. Exposure to UV filtered sunlight at home may be prescribed for treatment of clients with mild cases of jaundice, but caution is required to avoid sunburn.
Content Refresher
Phototherapy is used to promote bilirubin excretion. Closely monitor the infant’s temperature because phototherapy can increase the body temperature. Monitor the infant’s skin for burns. Monitor for side effects of phototherapy, including loose, greenish stools; hyperthermia or hypothermia; increased metabolic rate; priapism; dehydration; and electrolyte imbalances, such as hypocalcemia (uncommon, but possible). The full-term and late-preterm infant may require additional fluid volume or feedings to compensate for insensible and intestinal fluid loss.
For the term newborn, hyperbilirubinemia is indicated when serum levels are greater than _______________ mg/dL.
12
Thereapy is aimed at preventing kernicterus, which results in permanent neurological damage resulting from the disposition of bilirubin in the brain cells
6 year old growth & development
self centered, show off
sensitive to criticism
begins losing temporary teeth
7 year old growth & development
team games/sports
develops concept of time
prefers playing with same sex child
8 year old growth and development
seeks out friends
writing replaces printing
9 year growth and development
conflicts between adult authority & peer group
conflicts between independence and dependence
10-12 years growth & development
remainder of teeth (except Wisdom) erupt
uses phone- loves conversation
- increasingly responsible
- more selective when choosing friends
- begins to develop interest in opposite sex
Potential problems that can occur with school aged child
Enuresis - bed wetting
Encopresis - incontinent of stool
Safety - child is more independent and will go places alone this age
Head Lice (Pediculosis Capitis)
Age appropriate toys for school aged child
- Construction Toys
Household & sewing tools
table games, sports
Bicycle with helmet
Erikson’s stage of psychosocial developmetn for school aged children (6-12 years old)
Industry versus inferiority
the task consists of developing social, physical and learning skills
Children who are 10 years of age need to feel competent at performing a task or skill (e.g., household chores, mechanical activities, repairing or building toys). Developmentally, the 10-year-old is in the stage of industry versus inferiority. The developmental stage of a 10-year-old is focused on the achievement of specific tasks or skills,
In people with hemophilia, bleeding may be more ______________
excessive or severe
In considering how to best provide transitional care as the client transitions home, the nurse will first perform a gap analysis and identify _________________.
the client’s needs
The nurse will assess the client’s needs, including the client’s abilities to perform activities of daily living,
Once the client’s needs are identified, further planning and teaching can occur.
The nurse needs to first determine the needs of the client when preparing to discharge the client to home.
Client education is an expected competency for every nurse. An essential first step is to assess the client’s teaching and learning needs, including____________- issues. Health literacy has been shown to be a stronger predictor of health status than age and educational level.
Comprehension and compliance are increased when client education materials are written at a sixth-grade or lower reading level and contain pictures and illustrations. The nurse should always use the teach-back method.
literacy
Treatment for emphysema is directed at risk reduction practices, such as _________cessation and occupational preventive strategies to reduce inhalation of irritating substances. Oxygen therapy may be necessary, as well as methods to __________________oxygen demands such as pacing activities, eating small frequent meals, positioning, and pursed lip breathing. Early recognition and appropriate management of exacerbation symptoms reduce the rate of disease progression.
smokingl reduce
Why are infants and children more vulnerable to fluid volume deficit?
Because more of their body water is in the extracellular fluid compartment. The organs that conserve water are also immature, placing them at risk for fluid volume deficit.
n many ways the signs of dehydration are universal; however, there are variations based upon the client’s age.
Dehydration is the loss of body fluids, mainly water, with resultant changes in serum electrolytes. Risk factors associated with dehydration include _______________________. _________________________are at risk for dehydration. Signs and symptoms of dehydration include __________________________________. Treatment for dehydration includes oral and/or IV fluid and electrolyte replacement.
inadequate fluid intake, diarrhea, vomiting, disorders that result in fluid losses (diabetes mellitus, diabetes insipidus, fluid shifts, burns, hemorrhage, certain medications such as diuretics);
Infants, children, and the older adult populations
thirst, decreased urine output, dry mucous membranes, poor skin turgor, weight loss, hypotension, tachycardia, and lethargy
The nurse knows that the first line of defense against the transmission of infection is
good hand hygiene.
This is the most important information to provide to the client’s caregiver to prevent the spread of infection. If needed, teach the caregiver how to properly wash his or her hands (wet hands, apply soap, lather for at least 20 seconds, rinse thoroughly, and dry).
Acquired immunodeficiency syndrome (AIDS) is a bloodborne sexually transmitted disease caused by a retrovirus, human immunodeficiency virus (HIV). Once the virus enters the body, it attaches to the_____________ receptor on T lymphocytes and uses the lymphocytes as hosts to replicate. With successive copying of the virus, the T lymphocytes die and_____________ results. Once the CD4 count drops below __________cells/mm 3, the client is diagnosed with ________________ and is susceptible to further complications from immunosuppression, such as infection. Promoting handwashing to prevent the transfer of an infection to the client is the priority.
CD4; immunosuppression; 200; AIDS
Transmission of HIV is through
sharing IV needles
sexual contact
transplacental
contaminated blood or body fluids
possibly through breast milk
When preparing a client for surgery, the nurse needs to think of multiple issues. “What is needed to perform the surgery?” The__________________________– should be verified on the medical record. Vital signs are measured and recorded. Other thought processes need to focus on the client. “What safety considerations are most important?” The client is ambulated to_______________- prior to administering preoperative medication. Once the preoperative medication is provided, the client is to remain _____________-
surgical consent form; void; in bed.
Preoperative care - newborn
newborns fear loud noises, sudden movements
use mummy restraint
6-12 months - fear of strangers/fear of heights
Preoperative Care - Toddlers
client fears separation, strangers, animals, changes in environment
Provide simple explanations
- Distract
- Allow choices
Preoperative Care - Preschoolers
Client fears separation, ghosts, scary people
- have play with puppets/dolls
- Demonstrate equipment/talk at eye level
Preoperative care- school age
- client fears dark, injury, being alone, death
- allow questions
- explain why
- allow to handle equipment
Preoperative Care- Adolescent
client fears social incompetance, war, accidents, death
- Explain long term benefits
- very cognizant of any altered body image due to surgery
- accept regression
- provide privacy
Who is responsible for obtaining the informed consent?
Informed Consent - surgeon is responsible for explaining the surgical procedure to the client and answering the clients questiolns . Often, the nurse is responsible for obtaining the clients signature on the consent form for surgery, which indicates the clients agreement ot the procedure based on the surgeons explanation
The nurse may witness the clients signing of the consent form, but the nurse must be sure that the client has understood the surgeons explanation of the surgery
The nurse needs to document the witnessing of the signing of the consent form after the client acknowledges understanding the procedure
