QB 3 Flashcards
Arteriosclerotic Heart Disease (ASHD) and heart failure both require what kind of diet
a low fat, low sodium diet.
A client with arterial and heart disease should adhere to a low-fat, low-sodium diet.
Processed foods, such as hot dogs and ham, and canned foods such as canned soup, are high in sodium. Avocados are high in fat. Fresh or frozen fruits and vegetables, including wild rice, are naturally low in fat and sodium and should be encouraged.
Low sodium is defined as
Low fat diet is defined as
any product containing 140 mg of sodium or less
A diet in which 25% of daily calorie intake comes from fats. It is recommended in managing cardiovascular diseases, elevated cholesterol levels, and diabetes mellitus.
When caring for a client with a cast, the nurse should perform a thorough neurovascular assessment of both lower extremities, focusing on _________________(the 4 Ps)
pain, pallor, pulse, and paresthesia
Heat under a cast is a sign of _______________.
The nurse should first perform a ____________assessment to evaluate circulation
pressure; neurovascular
Fracture Assessment - what would you expect to see ?
Swelling, pallor, ecchymosis, Loss of sensation, crepitus, decreased or absent pulses, deformity
Complications of a fracture
Fat Emboli- occur after fracture of a long bone such as the femur. Fat globules may move into the bloodstream and occlude major vessels. S/S - tachypnea, dyspnea, cyanosis, petechial rash, fever
Delayed Unioned, Malunion, nonunion of the bone
Sepsis
Compartment Syndrome- high pressure within a muscle compartment of the extremity that compromises circulation. Results from bleeding or swelling. high pressure impedes blood flow to the tissue. S/S -swelling, tightness, numbness/tingling in extremity, severe pain (unrelieved pain)
Emergency Care of client with a fracture
nurse should begin to immobilize the joint above and below the fracture. Open fracture should be covered with a sterile dressing. Nurse should check color, temperature, sensation and capillary refill distal to fracture
Fracture Care Implementation- This is immobilization to prevent movement
Splinting
___________________ fixation uses screws, plates and nails to stabilize
Internal
________________ reduction uses surgical dissection for reduction and alignment
Open
_________________ reduction uses manual manipulation or traction
Closed
What is traction?
What are the two types?
A nonsurgical method to correct a fracture
reduces the fracture
alleviates pain and muscle spasms
Prevents or correct deformities
Promotes healing
Skin Traction - pulling force applied to skin
Skeletal Traction - pulling force applied to bone
What is Buck’s tractions?
A form of skin traction used to relieve muscle spasms of the legs and back.
Russell’s traction
combines suspection and traction to immobilize the extremity. Used to treat fractures and contractures of the lower extremity
What are cervical tongs used for ?
To hyperextend the head and neck of a client with a fracture of the cervical vertebrae. Will align the vertebrae and immobilize it
What is a Halo fixation device ?
Prevents immobilization of the cervical spine
Casting immediate care
Don’t cover until dry
handle cast with palms of hands, not fingertips
don’t rest cast on hard surface
keep cast above the level of the heart
Check pulses, color, sensation
Intermediate care for client with the cast
Perform isometric exercise
Check for odors
Don’t put anything into cast
After cast care
wash area gently
apply baby powder, cornstarch to extremity
swelling is very common after removal of cast- elevate legs on pillows and apply elastic bandage
A bruit heard over the abdominal aorta can indicate an ________________.
aneurysm
This finding should be immediately reported to the health care provider for further assessment and intervention.
Abdominal aortic aneurysms (AAA) may be ________________-However, the client may present with__________- onset of pain that occurs in the back or lower abdomen, a feeling of abdominal fullness, shortness of breath, or difficulty swallowing or hoarseness. A common contributing factor is hypertension._________________ is a serious risk for the client with AAA. The client may report severe pain, and use pain descriptors such as “sharp,” “tearing,” “ripping,” or “stabbing.” Nausea and vomiting, diaphoresis, faintness, and apprehension are other manifestations. Aortic dissection is a medical emergency.
asymptomatic; sudden
Aortic Dissection- A tear in the inner layer of the large blood vessel branching off the heart (aorta)
Cachexia
weakness and wasting of the body due to severe chronic illness.
Pubic symphysis .
The pubic symphysis is a secondary cartilaginous joint (a joint made of hyaline cartilage and fibrocartilage) located between the left and right pubic bones near the midline of the body. More specifically, it is located above any external genitalia and in front of the bladder
Communication between a client and health care provider that results in the client’s authorization or agreement to undergo a specific medical intervention. The health care provider must make every effort to ensure the client understands the purpose, benefits, risks, and other options of the test or treatment.
Informed Consent
Pre-operative teaching does not occur a few minutes before surgery. Pre-operative skin preparation begins the night before the surgery
TRUE OR FALSE
TRUE
A temporary reduction in blood flow to the brain resulting in a brief loss of consciousness and muscle tone.
Syncope
Older adults have lower ____________reserve and have an increased risk for fainting, or syncope. Serious heart conditions, such as___________________, may lead to syncope. The nurse should examine this client first. Serious cardiac conditions (e.g., atrial fibrillation, heart failure) can cause ______________syncopal episodes in older adults, with a sharp increase after ________years of age. The nurse should obtain a 12-lead ECG and send specimen for cardiac markers. The client should be placed on bed rest and the vital signs frequently monitored.
cardiac; bradycardia, tachycardia, or blood flow obstruction’ recurrent; 70
Dysrhythmias are cardiac rhythm disturbances that affect ________________-.
perfusion
The dysrhythmias may be fast, slow, regular, or irregular. Life-threatening dysrhythmias lower cardiac output and are unable to maintain adequate perfusion. Dysrhythmias are caused by ischemia, hypertrophy, electrolyte imbalances, hypoxia, and valvular disorders.
Clinical manifestations include palpitations, skipped beats, syncope, confusion, dyspnea, chest pain, and fatigue.
Treatment for dysrhythmias includes medications, pacemaker insertion, internal cardioverter/defibrillator insertion, external cardioversion, external defibrillation, and ablation
Difference between Defibrillation and Cardioversion
defibrillation is an emergency procedure
cardioversion is an elective procedure (need informed consent)
Risk factors for breast cancer
Family history of mother, sister, daughter developing premenopausal breast cancer
- women over the age of 50
- menses before the age of 12
- no children, 1st pregnancy after 30
- menopause after age 55
Breast cancer assessment
small, fixed, painless lump
puckering or dimpling of the skin
nipple retraction
discharge
Breast cancer implementation
mammography
surgery
radiation or chemotherapy
A breast examination should be performed____________—after the menstrual cycle has finished.
monthly
A procedure performed after a radical cystectomy. Urine is diverted through an ileal passageway to a stoma formed on the abdomen. It requires placement of a urostomy bag for the collection of urine.
Ileal Conduit
Fever, abdominal rigidity and pain are indications of ___________
peritonitis.
What is an enema ?
An enema is the administration of solution into the rectum or sigmoid colon. The purpose is to relieve constipation and promote defecation.
To administer an enema, assist client to left side-lying position and gather supplies (waterproof pad, enema, gloves and lubricant) and bedpan if needed. If an enema bag is used, fill bag to ordered amount of warm tap water and release clamp to fill tubing. Lubricate the tip of tube and gently insert into the rectum approximately 3 to 4 inches for an adult or 2 to 3 inches for a child. Never force the tubing. Once in position, unclamp tubing and instill the fluid. Instruct the client to hold the fluid as long as possible. Assist the client to the bathroom or position on a bedpan. Observe and document results.
Types of enemas
Oil retention - softens feces. We want our client to retain the solution for several hours
Soapsuds enemas- we use castile soap and tap water or normal saline. Only soap that is safe for this enema. Irritates colon and stimulates peristalsis
Tap water - hypotonic so moves from bowel into interstitial spaces and stimulates defecation.
How should we position the adult client for enema administration ?
Sim’s position - left side with right knee flexed
Left Lateral Sims
Enema implementation
1) Explain procuedure
2) position in Sim’s position with right knee flexed
3) Use tepid solution
4) Hold irrigation set at 12-18 inches above rectum for high enema, 3 inches for low enema (holding 3 inches above hip)
5) Insert tube no more than 3-4 inches for adult, 2-3 inches for child, 1-1.5 inches for infant
6) Ask client to retain solution for 5-10 minutes
7) Do not administer in presence of abdominal pain, nausea, vomiting or suspected appendicitis
Symptoms of Alcohol Withdrawal
Tremors,
Insomnia
Anxiety
Anorexia
Alcoholic hallucinations
Easily startled
Symptoms of Delirum Tremens
Tremors
Anxiety
Panic
Disorientation, confusion
Hallucination
Vomiting
Diarrhea
Paranoia
Delusional symptoms
ideas of reference
suicide attempts
Grand mal convulsions (especially first 48 hr after drinking stopped)
Potential Coma/death
Alcohol WIthdrawal
Many institutions have an alcohol withdrawal treatment protocol, an algorithm to follow to prevent adverse events like seizures during withdrawal. This usually includes symptom monitoring every 1 to 4 hours for tachycardia, tremors, hallucinations, hypertension, and fever. The central nervous system has worked hard to maintain adequate neurological activity, but when the alcohol level drops, the central nervous system continues to work hard, creating a state of neurological over-excitability. Based on a score of these symptoms, the nurse administers a benzodiazepine to reduce the client’s symptoms.
Symptoms of alcohol withdrawal include restlessness, irritability, agitation, nausea, vomiting, confusion, tremors, increased heart rate and blood pressure, increased sensitivity to sounds, hallucinations and delusions, hyperthermia, and seizures 1 to 3 days after the last drink. Risk factors for alcohol withdrawal are related to length of time drinking and amount of alcohol ingested daily.
How will the patient with Trigeminal Neuralgia present ?
How do we care for this client ?
Stabbing, buring facial pain - brief but intense attacks that can be debilitating
Twitching/grimacing of facial muscles
Identify and avoid stimuli that exacerbate the attacks
Administer medications - carbamazepine is drug of choice for this condition. Analgesics also
Treatment - Carbamazepine, alcohol injection to nerve, resection of the nerve, microvascular decompression
Avoid rubbing eye
Chew on opposite side of mouth
A decrease in secretion of antidiuretic hormone (ADH or vasopressin) by the pituitary, which leads to excessive fluid excretion and dehydration.
Diabetes Insipidus
The nurse provides care for a client who had a hypophysectomy. The client reports being thirsty and having to urinate frequently. Which action does the nurse take?
- Assess for glucose in the urine.
- Increase fluid intake.
- Assess urine specific gravity.
- Document the client’s concerns.
1) INCORRECT - Glucose in the urine points to diabetes mellitus. Diabetes mellitus is not a complication of this procedure.
2) INCORRECT - Increased fluid intake will not address the problem.
3) CORRECT — After this procedure, diabetes insipidus can temporarily occur because of an antidiuretic hormone deficiency.
4) INCORRECT - This records but does not address the complication of the procedure.
A _________________- is the removal of a part or the entire pituitary gland, which controls specific hormones. One hormone is the ______________, which controls fluid balance. After surgery and due to the lack of this hormone, the client will have ___________-urine output, which is indicative of the complication _______________-The nurse should expect to find ___________urine specific gravity due to high urine output and high serum sodium (hypernatremia) due to low fluid volume.
Content Refresher
hypophysectomy; antidiuretic hormone; increased; diabetes insipidus; low
When caring for a client that is post-hypophysectomy, the nurse should assess for potential complications. An example includes diabetes insipidus. Assess color, amount, and specific gravity of urine. Assess intake and output. Ask client about thirst, urinary frequency, and nocturia. Signs of diabetes insipidus include excessive urine output, decreased urine osmolarity and specific gravity (less than 1.005), increased serum sodium and osmolarity, weight loss, dehydration, hypotension, tachycardia.
Medical therapy is directed at increasing antidiuretic hormone levels by administration of desmopressin (synthetic form of vasopressin), preventing further dehydration, and promoting fluid and electrolyte balance.
On the NCLEX, teaching is psychosocial.
TRUE OR FALSE
TRUE
_____________syndromes are all conditions in which foreign matter is inhaled into the lungs
Aspiration
A swallow evaluation can be used by the nurse to screen and refer for further testing in children, adolescents, and adults at risk for dysphagia (using the Toronto Bedside Swallowing Screening Test or the 3-oz Water Swallow Screening Test). Determine underlying risk condition, history, and treatment plan.For those at risk of aspiration, the nurse should place the client in a high-Fowler position. Do not allow the client to consume foods or fluids until risk evaluation is completed.
Before identifying the client who is priority, the nurse should stop and review each client’s acuity level, disease process, and risk for infection or life-threatening situation. Any client with a______________ need should be addressed first
physical
non-specific manifestations of myocardial ischemia.
Nausea, vomiting, diaphoresis
Use the “PQRST” mnemonic to collect information regarding a myocardia infarction
Precipitating events; Quality of pain; Radiation of pain; Severity of pain (using a 0 to 10 scale, with 0 being no pain and 10 being the worst imaginable pain); Timing (onset of symptoms)
______________is a common, subjective response to a perceived or actual threat. It may range from vague discomfort to total panic leading to loss of control. Assess for agitation, restlessness, tachycardia, hypertension, and tachypnea
Anxiety
_______________________differs from the typical sense of anxiety that each person occasionally experiences. Physical symptoms associated with GAD may include fatigue, diarrhea, diaphoresis, and insomnia. This disorder routinely interferes with daily activities and the anxiety does not always have an identifiable cause. Without proper treatment, GAD may lead to or exacerbate conditions such as depression and substance abuse.
Generalized anxiety disorder (GAD)
The root of anxiety for generalized anxiety disorder is the conflict between expressing unacceptable impulses and the need to hold onto social approval.
A ______________is a condition in which an individual experiences bizarre thinking associated with one of the following: erotomania, grandiosity, jealousy, persecution, and/or somaticism.
How should the nurse deal with delusions ?
delusion
The nurse needs to acknowledge the client ’s concern about false belief(s), but does not agree with them. The nurse does not argue about delusions, but reorients the client. The nurse focuses on feelings such as fear or anxiety and offers alternative thoughts and behaviors to reduce negative feelings. The nurse should make brief, frequent contact and offer orienting information.
Risk factors for a pressure injury include
malnutrition, diabetes mellitus, moisture, immobility, loss of sensory perception, chronic steroid use, immunosuppression, and poor perfusion and oxygenation.
Elevating the head of the bed no more than 30 degrees will decrease the chance of pressure injury development from shearing forces.
________________-leaders communicate their vision in a manner that is so meaningful and exciting that it reduces negativity and inspires commitment in the people with whom they work.
Transformational
A chancre
A chancre is a painless genital ulcer most commonly formed during the primary stage of syphilis. This infectious lesion forms approximately 21 days after the initial exposure to Treponema pallidum, the gram-negative spirochaete bacterium yielding syphilis.
A ___________- is a circumscribed, solid elevation of skin with no visible fluid, varying in area from a pinhead to 1 cm. Papules can be brown, purple, pink or red in color, and can cluster into a papular rash
papule
Syphilis
a bacterial infection that is transmitted through sexual contact. If left untreated, it progresses through three stages (primary, secondary, and tertiary syphilis).
There is also a latent stage when no signs or symptoms of the infection are present. Symptoms of primary syphilis include one or more chancres at the infection site, whereas secondary syphilis is manifested by a skin rash, mucocutaneous lesions, and lymphadenopathy.
Individuals with tertiary syphilis exhibit cardiac symptoms, gummatous lesions, tabes dorsalis, and general paresis. Intravenous penicillin is used to treat individuals during all phases of the disease. All sexual partners should also be treated.
A Venereal Disease Research Laboratory (VDRL) test is a blood test to detect syphilis, and becomes reactive 2 to 6 weeks after the primary infection. Syphilis is treated with antibiotics.
Genital herpes is identified by the appearance of clusters of _______________. The infected client may have difficulty voiding and there may be a recurrence during times of stress, infection, or menses.
painful blisters
Remember, “When in distress, do not assess.”
TRUE OR FALSE
TRUE
__________________ is the state of insufficient oxygen in the cells, tissues, and organs to meet their metabolic demands. There is a direct correlation with ____________, which is a reduction of oxygen levels in the blood. When caring for a client experiencing hypoxia, the nurse needs to position the client in a way that facilitates ________expansion, and supplemental oxygen is administered at the prescribed rate and method. Monitor the client’s breathing pattern and observe for signs of respiratory distress. Report and take appropriate actions if the client’s status deteriorates.
Hypoxia; hypoxemia; lung
When a client is in distress, the nurse should respond immediately with the intervention that will relieve or alleviate the distress. Other nursing actions such as assessment can follow. Remember, “When in distress, do not assess.”
TRUE OR FALSE
TRUE
Supplemental oxygen increases the oxygen percentage of ____________—air, and the nurse takes this action after maximizing lung expansion by______________-
inspiratory; raising the head of the bed.
Apgar scoring is based on
heart rate
respiratory effort
muscle tone
reflexes
color
The Apgar score is performed at _________ and _________ minutes of age
1 and 5
Apgar scoring
0-3 = poor/critical
4-6= fair
7-10= excellent
While newborns rarely have a perfect Apgar score at birth, this tool is useful to the nurse in quickly assessing the newborn’s wellness. Scores between 7 and 10 mean the newborn needs routine care. Scores of 4 to 6 indicate the nurse will need to support the newborn’s airway and breathing. Scores of less than 4 require emergency intervention for the newborn. If the newborn’s follow-up score at 5 minutes is less than 7, the newborn stays with nursing staff for monitoring and intervention.
Content Refresher
An Apgar score evaluates the physical health of the newborn following the birth. A score is given at 1 minute after delivery and again at 5 minutes following the birth.
Assess the heart rate and determine a score from 0 to 2 (0 = no heart rate, 1 = heart rate less than 100, 2 = heart rate above 100). Likewise assess respiratory effort (0 = not breathing, 1 = weak cry, 2 = strong cry), muscle tone (0 = flaccid, 1 = some flexion of extremities, 2 = actively moving), reflex response (0 = no response, 1 = grimace upon stimulation, 2 = crying) and skin color (0 = blue/pale, 1 = blue extremities with pink body, 2 = pink).
Which finding during a newborn client examination requires immediate action by the nurse?
- The left side of the newborn’s face is drooping.
- The newborn’s uvula has two lobes.
- The newborn’s ears are low-set bilaterally.
- The red reflex is absent in the newborn’s right eye.
1) INCORRECT — Facial drooping may indicate facial paralysis from damage to cranial nerve VII (facial nerve), which occurred during delivery. This paralysis usually resolves within a few days to 3 weeks, though it can be permanent. This is a self-resolving matter. The nurse needs to teach the parents about care and feeding.
2) INCORRECT — A bifurcated uvula indicates there may be a cleft in the palate. Further assessment of sucking ability and/or hard and soft palate size, shape, and cleft formations should be made, but this is not urgent.
3) INCORRECT — Low set ears are an indication that Down syndrome may be present. Further assessment findings to confirm this include flat occiput, broad nasal bridges, eyes that have epicanthal folds and slant upward, large tongue, high palate, and small chin. The nurse needs to begin teaching the parents about this child’s needs.
4) CORRECT — The absence of a red reflex indicates an ophthalmic emergency. This is because light is not being transmitted to the retina, and the early suppression of optic nerve function, which results in the obstruction of the light, can cause blindness. Notify the health care provider immediately.
Red reflex testing is an essential component of the neonatal, infant, and child physical examination. A red reflex should emanate from both eyes and be symmetric in character to be classified as normal. An ophthalmologist skilled in performing pediatric examinations should be consulted for all infants or children with an absent red reflex. Children also should be seen by an ophthalmologist for a markedly diminished reflex, asymmetry of the reflexes (Bruckner reflex), or dark spots in the red reflex, or if a white reflex is present.
this cranial nerve is responsible for the constriction of the pupil and the raising of the eyelids and most eye movement
How do we test for it ?
CN III
Oculomotor
Have client look up, down and open eyes
Shine penlight into eyes- PERRLA
This cranial nerve controls downward and inward movement of the eye
Trochlear CN IV
Have client look down, watch finger go toward face
This cranial nerve controls jaw movement and sensation on the face and neck, including the nasal and oral mucosa and facial skin
How do we test it ?
Trigeminal Nerve CN V
To test motor function, have client clench the teeth, open jaw and bite down. Try to open the clients jaws after asking the client to keep them tightly closed
Corneal reflex (this test may be omitted if the client is alert and blinking normally)
Check sensory function by asking the client to close the eyes; lightly touch forehead, cheeks and chin, noting whether the touch is felt equally on the 2 sides
This cranial nerve controls the lateral movement of the eyes
How do we test it ?
CN VI Abducens
Have client look up, down, inward, and watch nurses fingers go towards clients face
This cranial nerve controls movement of the face and taste sensation
How do we assess for this ?
Facial Nerve CN VII
Have client frown, smile and raise the eyebrows
Ask the client to puff out the cheeks
Test taste perception on the anterior two thirds of the tongue; the client should be able to taste salty and sweet tastes
This cranial nerve controls the sense of hearing and balance
Acoustic or Vesibulocochlear CN VIII
Assessing the clients ability to hear tests the cochlear portion
assessing the clients sense of equilibrium tests the vestibular portion
- check the clients hearing, using acuity tests
- observe the clients balance and watch for swaying when he or she is walking or swaying
- assessment of sensorineural hearing loss may be done with the Weber or Rinne Test
This cranial nerve controls swallowing and tast on the posterior third of the tongue. Also controls sensation in the pharyngeal soft palate and tonsillar mucosa, and salivation
Check swallowing, elicit gag reflex by touchign the posterior pharyngeal wall with a tongue depressor
Place sweet, sour, bitter, salty substance on tongue
This cranial nerve controls swallowing and phonation, sensation in the exterior ear’s posterior wall and sensation behind the ear
Also controls sensation in the thoracic and abdominal viscera
Inspect the soft palate and watch for symmetricla elevation when the cleint says “aaah”- uvula should be in midline position
Uvula should be in midline position
Client should speak to assess voice
This cranial nerve controls flexion and rotation of head and the shrugging of shoulders
How do we test for this ?
Have client shrug and move head side to side against resistance
this cranial nerve controls movements of the tongue involved in swallowing and speech
CN XII
Have client stick out tongue (tongue should be midline)
Have client move the tongue rapidly in and out and from side to side
Observe the tongue for asymmetry. atrophy, deviation to 1 side, and fascciculations (uncontrollable twitching)
Neurogenic Bladder
The pathway between the bladder, spinal cord, and cerebral cortex must be intact for bladder sensation and urethral sphincter action to be intact. A neurogenic bladder, which lacks this pathway, can be the result of multiple sclerosis, Parkinson disease, stroke, or spinal cord injury. Incorrectly managed neurogenic bladder can lead to autonomic dysreflexia or urinary tract infections secondary to hydronephrosis. (When urine is forced from the overfilled bladder back into the kidneys.)
The nurse anticipates that a medication such as bethanechol will be prescribed because it is a cholinergic or parasympathomimetic medication used to treat functional urinary retention.
Content Refresher
Neurogenic bladder, a disorder of the bladder caused by disruption of nervous system innervation, may lead to urinary retention, infection, and overflow incontinence. Neurogenic bladder usually requires continuous or intermittent self-catheterization, so it is important to teach the client and family how to perform the necessary procedure. Monitoring fluid intake and consuming a low-calcium diet to prevent the development of urinary/kidney stones should be included in the teaching plan. Bladder retraining and scheduled toileting should also be taught for clients with urinary retention. Medications may decrease retention and assist urine flow. Surgical procedures, such as urinary diversion, may also be considered.
A serious complication of spinal cord injuries (SCIs) at or above the level of T6, in which a noxious stimuli below the SCI sets off a cascade of uncoordinated responses that result in a unregulated and potentially life threatening hypertensive episode.
Autonomic Dysreflexia
Antiembolism stockings vs Knee-high nylon stockings
knee-high nylon stockings should be discouraged because these constrict circulation and may contribute to the the development of deep vein thrombosis (DVT), as the tight band of pressure at the top constricts venous return. Unlike anti-embolism stockings, which provide the greatest compression pressure at the toes and then gradual decreased pressure towards the knees, nylon stockings provide minimal pressure at the toes and then a sharp constriction at the knees.
Anti-embolism stockings are used to promote perfusion by compressing the veins in the legs, thus facilitating return of venous blood to the heart.
Diabetes mellitus, hypertension, smoking, sedentary lifestyle, and high triglyceride or cholesterol levels place clients at risk for decreased ________________-
perfusion
the client with obsessive compulsive disorder and therapeutic care
Establish a trusting relationship with the client with obsessive-compulsive disorder, providing care with unconditional positive regard. Monitor signs/symptoms for changes in behavior indicative of increasing anxiety. If ritualistic behavior is harmless, work toward increasing insight about anxiety and compulsion and gradually decreasing time for behavior. Encourage distraction and involvement in non-ritualistic behaviors.
If compulsions are harmful, redirect and set limits on behavior.
The nurse experiences a needlestick injury while providing care for a client. Which action will the nurse take first?
- Report the incident.
- Complete an incident or injury report.
- Clean the exposed area with soap and water.
- Inform the facility of the source of the exposure.
3) CORRECT — Immediately after a needlestick injury, the nurse should wash the area with soap and water to attempt to flush the puncture site of pathogens.
Then the nurse should complete an incident or injury report and inform the facility of the source (client’s name) and nature of the exposure.
Immediately following a needlestick injury……
wash the site with soap and water and report the incident to the supervisor.
Determine whether the source client is infected with hepatitis B, hepatitis C, or human immunodeficiency virus (HIV). The nurse’s hepatitis B, hepatitis C, and HIV statuses are also obtained.
To protect against hepatitis B, the nurse (if previously immunized) should receive a single vaccine booster dose. If the nurse has not had the series of hepatitis B vaccines, the nurse should receive a dose of hepatitis B immune globulin (HBIG) and the complete vaccine series. Immune globulin and antiviral agents are not recommended for post-exposure prophylaxis (PEP) of hepatitis C. HIV PEP consists of using three or more drugs for 4 weeks.
Symptoms of fluid volume overload
bounding pulse
hypertension
dyspnea
rale/crackles
peripheral edema
decreased hematocrit & BUN
restlessness
weight gain, increased central venous pressure (CVP), , tachycardia, distended neck veins, edema, and anxiety.
The nurse recalls that a sudden increase in fluid volume may _________________-the circulation, and excess fluid may be routed to other areas of the body such as the lungs and peripheral tissues. If fluid is in the lungs, ____________ and ________________is affected, causing concern related to the ABCs.
overwhelm; oxygenation and ventilation
Moving a client with a fracture- what is necessary ?
Support should be provided above and below the level of the fracture when moving the client. The client should not be expected to move independently onto a stretcher with a fractured limb. The client should not move the injured limb, but keep immobile to prevent additional damage.
Fractures require immobilization either through splinting or casting. In the acute phase, a suspected fracture can be moved, but the limb must be supported above and below the suspected fracture site.
____________________-occurs when the body temperature is extremely high and the body is unable to disperse the heat through perspiration. Risk factors include low fluid volume caused by diuretic use or aging.
Heat stroke
Normal serum albumin level
The normal serum albumin is 3.5–5.5 g/dL (35–55 g/L). An albumin deficit decreases oncotic pressure, and fluids shift from the vascular area to tissue, which causes edema.
One reason for the development of edema is a low total body protein level. An adequate albumin level is required for fluid to stay in the vasculature. When this level decreases, fluid will shift to body tissues, causing edema.
The duration of warfarin therapy for the client recovering from a cerebral vascular (CVA) accident is ___ - ____________days.
2 to 5
Warfarin is routinely prescribed as a treatment for ischemic/embolic stroke. Failure to take warfarin can result in new clot formation and place the client at risk for experiencing another stroke.
The nurse provides an albuterol nebulizer treatment to a client recovering from respiratory failure. Which finding does the nurse expect to observe after treatment?
- Increased productive cough.
- Increased wheezes in upper lobes.
- Decreased crackles in lower lobes.
- Reports of decreased anxiety.
- Bilateral hand tremors.
1) CORRECT— Bronchodilators can loosen secretions, helping the client expectorate them from the lungs. The nurse expects to observe an increased productive cough after the albuterol nebulizer treatment.
2) INCORRECT — Bronchodilators, such as albuterol, decrease obstruction. Increased, not decreased, obstruction results in wheezing.
3) INCORRECT — Bronchodilators, such as albuterol, do not reduce fluid in lungs. Crackles are auscultated when the client has pulmonary congestion due to fluid overload.
4) CORRECT— Decreased oxygen causes anxiety and the client struggles to obtain enough air. Calmness should occur when the air passages are clearer or more dilated after the nebulized treatment.
5) CORRECT— Tremors are an expected side effect of albuterol and are not concerning.
Respiratory failure is diagnosed when
A diagnosis of respiratory failure is usually based on the client’s arterial blood gas (ABG) values, with less than 50 to 60 mm Hg (6.7 to 8 kPa) PO 2 and greater than 50 mm Hg (6.7 kPa) PCO 2 indicating the presence of the condition. Chronic obstructive pulmonary disorder (COPD) is the most common cause of the disorder. Signs and symptoms of impaired respiratory function include shortness of breath, cough, wheezing, anxiety, frequent upper respiratory infections, and sputum production.
Watery eyes, cramps, and mild tremors are symptoms of ________________-withdrawal.
narcotic
Insomnia, hyperactivity, and decreased appetite are symptoms of withdrawal from _________–derivatives.
cannabis
Early alcohol withdrawal symptoms
Hyperalertness, easily startled, and anorexia are symptoms of early withdrawal from alcohol. Other symptoms include increased pulse, anxiety, tremors, insomnia, and hallucinations.
Postoperative Cataract Implementations
Check for hemorrhage- sudden pain
Check for infection
Check Pupil - constricted with lens implant, dilated without lens
Eye drop administration
Use of night shields
Sleep on unaffected side- avoid straining or heavy lifting, anything that will increase intraocular pressure
The client post-cataract removal surgery should be taught to avoid activities that would jeopardize the surgical site and increase intra-ocular pressure. Activities that increase intra-ocular pressure include coughing, straining with defecation, lying on the operative side, and lifting heavy items. These activities are avoided. The client should also avoid washing the hair or getting water in the operative eye. Additional teaching includes instructing the client and caregiver about prescribed eye drops to prevent infection, reduce inflammation, and control eye pressure. The client should be informed to call the health care provider if the client experiences vision loss, persistent pain, increased eye redness, or if the client reports light flashes or multiple new spots (floaters) in front of the eye. The nurse should use the teach-back method in all teaching encounters.
A cataract is an opacity in the lens of the eye. Cataracts cause decreased visual acuity and glare. The nurse should prepare the client for surgery and provide support and plan discharge education to include the following: instilling prescribed eye drops; follow-up appointments; avoiding activities that increase intraocular pressure (coughing, sneezing, bending, lifting over 15 pounds, straining with bowel movements, and sleeping on operative side); wearing an eye patch at night and glasses during the day to protect eye; avoiding getting water in eye (showering and/or washing face); signs of complications and when to call the health care provider; and avoiding prolonged reading to reduce eye strain.
______________________________are measures used to control pancreatic insufficiency.
Diet, pancreatic enzyme replacements, control of diabetes mellitus
Diet should be bland and low fat. The client may eat small meals at frequent intervals instead of three regular meals for easier digestion. Alcohol and caffeine are best avoided with pancreatitis. The nurse can assist the client in choosing an appropriate diet based on the client ’s food preferences. The client may need to take pancreatic enzyme products during meals. Antacids and H2 blockers may be prescribed to manage gastrointestinal distress associated with pancreatitis.
Both of these signs are indicative of pancreatitis
Cullen’s sign - the discoloration of the abdomen and periumbilical area
Turner’s sign: bluish discoloration of the flanks
A condition that results from insufficient insulin, which causes hyperglycemia, ketosis, dehydration, electrolyte loss, and acidosis. Glucose is excreted by the kidney, which results in osmotic diuresis and electrolyte loss. The liver breaks down fat for energy, which results in ketosis. A large amount of ketones leads to metabolic acidosis.
Diabetic Ketoacidosis
Treatment of DKA involves treatment for these 3 things……………
Treatment of DKA involves treatment for dehydration, acidosis, and hyperglycemia.
Intravenous insulin is given for elevated blood glucose levels. An administration of 0.9% normal saline is given at a rapid rate to restore blood volume. Supplemental electrolyte solutions are also given for imbalances.
Hourly blood glucose is monitored and insulin is titrated to treat the hyperglycemia and restore the pH to normal values.
Reducing recurrence will depend upon the client’s motivation and ability to check blood glucose levels frequently and effectively manage activity, diet, and insulin to maintain stable blood glucose levels.
Safety is a priority concern when providing care to a client diagnosed with acute confusion and delirium. Possible causes of acute confusion include _____________________________Manifestations of delirium include ______________; however, delirium is notably different from confusion or dementia in that it occurs ___________and is accompanied by ________________. When providing care to this client, a calm, predictable, non-stimulating, and orderly environment is helpful in reversing delirium and enhancing safety.
fever, infection, ingestion of uncontrolled or inappropriate substances, substance withdrawal, metabolic imbalance, and excess or prolonged sensory stimulation.
confusion; suddenly; restlessness, hallucinations, and incoherence
Determine the extent of the client’s confusion. Complete a comprehensive health history and physical examination to determine potential causes of acute confusion (e.g., hypoglycemia, infection, electrolyte imbalances, dehydration, hypoxia, substance misuse, head injury, or sleep deprivation). Ensure a safe environment. Determine the client’s ability to perform activities of daily living and assist as needed. Provide frequent verbal, written, and visual orientation. Reduce stimulation. Use simple language when communicating. Redirect if the client is expressing false ideas.
Radiation site precautions
Avoid hot or cold applications to the radiation site.
Do not apply lotions, creams, or powders to the site.
Do not remove treatment area marks.
Irradiated skin should be open to air whenever possible. The client should avoid wearing tight clothing, clothing with prominent seams, bandages, and any other coverings that may cause contact irritation. The client does not have to avoid the sun, as appropriate sun exposure provides physical and psychological benefits. The nurse should teach the client to limit sun exposure to around 15 minutes and to protect the irradiated area from heat and direct sunlight.
During radiation therapy, the client may experience various skin reactions, such as erythema, desquamation, and possible ulceration. These skin reactions are referred to as radiation dermatitis. Radiation therapy can also cause an impaired immune response, making the client susceptible to infection. Monitor the client for signs and symptoms of infection. The WBC count may not increase, even in the presence of infection, if severe immunosuppression is present. Follow infection control protocols.
Complications of the cardiacc catherterization procedure include
bruising, bleeding, damage to artery or cardiac tissue, allergic reaction to dye, sepsis, stroke, and myocardial infarction, development of cardiac dysrhythmias
For a client who has undergone cardiac catheterization, primary concerns include ________________
risk for bleeding and potential development of cardiac dysrhythmias.
The nurse prevents bleeding by ensuring the integrity of the pressure dressing that covers the catheter insertion site. Maintaining the client on flat bed rest for a prescribed period (6-8 hours). Monitoring for cardiac dysrhythmias includes placing the client on telemetry monitoring and assessing for signs of inadequate cardiac output, including decreased blood pressure and reports of dizziness.
Glomerulonephritis
This is the inflammation of the glomeruli
The glomeruli are the filters of the kidney
They remove waste products, electrolytes and excess fluid from the blood
The basement membrane is damaged
Glomerulonephritis Assessment
Fever, chills
Hematuria
proteinuria
edema
hypertension
abdominal/flank pain
occurs 21 days after a beta hemolytic streptococcal throat infection
Acute glomerulonephritis is often diagnosed as a complication from a _____________—infection. This health problem affects all aspects of renal function, which control fluid balance and blood pressure. Because of this, the client will be prescribed _________to treat the infection, __________to maintain normal body fluid balance, and _______________-to control blood pressure until the kidneys heal and normal function returns.
streptococcus; antibiotics; diuretics; antihypertensives
Chronic glomerulonephritis may be treated using peritoneal dialysis if end-stage kidney disease develops, but acute glomerulonephritis does not require dialysis
Depending upon the underlying cause of glomerulonephritis, medications are prescribed to eliminate infection and reduce inflammation, suppress the immune system, and control hypertension. Dietary restriction of sodium and protein may reduce edema. Immunosuppressive therapy may be used in combination with plasmapheresis for clients with anti-glomerular basement membrane (anti-GBM) glomerulonephritis and Goodpasture’s syndrome. In renal failure, dialysis may be required.
A decrease in level of consciousness after a stroke may be a sign of increasing _______________ pressure, which could lead to _____________-, a life-threatening condition.
intracranial; brainstem herniation
Normal signs of aging in the eyes
a color change around the corneal margin, an onset of farsightedness, and the need for additional lighting to see clearly. What is not considered an expected age-related change in vision is a sudden change in visual acuity.
Arcus senilis is a white, grey, or blue opaque ring in the corneal margin or a white ring in front of the periphery of the iris. It is a common finding in older adults.
- Presbyopia is farsightedness caused by a loss of elasticity of the lens of the eye. It often occurs in middle-aged and older adults and necessitates holding items a little further away.
Vegan diets include …………
and excludes
includes fruits, vegetables, nuts, beans, seeds;
excludes all sources of animal protein, fortified foods, and nutritional supplements of animal origin
risk of vitamin B12 deficiency
Vegans are frequently deficient in calcium because they do not ingest dairy products.
Vegans are frequently deficient in vitamin B 12 because they do not eat meat, which is the primary source of B 12.
Vegans are deficient in vitamin D because it is mostly found in dairy products, which vegans do not consume.
If epiglottitis is suspected, no attempts should be made to visualize the posterior pharynx, obtain a throat culture or take an oral temperature. Otherwise, spasm of the epiglottis can occur, leading to complete airway occlusion
TRUE OR FALSE
TRUE
Assessment will not include visual examination of the client’s throat to avoid laryngeal spasms, which can cause airway occlusion
Never insert a tongue blade into the mouth of a child diagnosed with epiglottitis. The gag reflex can cause complete obstruction of the airway.
Crying should be minimized as it can cause obstruction of the airway.
Chronic kidney disease is an irreversible loss of kidney function with a decrease in glomerular filtration rate to 10 mL/minute, resulting in pH and electrolyte imbalances and waste product accumulation. The nurse needs to plan client education about maintaining what kind of diet?
a high carbohydrate, low-protein diet, as well as limiting the intake of sodium, potassium, and phosphorus.
An elevated blood-urea-nitrogen level could indicate _______________. Manifestations of dehydration include _____________, all of which can increase the risk of client falls.
dehydration; confusion, disorientation, and seizure activity
In dehydration, fluid balance is disrupted as more fluid moves out of the cells and is eliminated than enters in the body. As fluid levels decrease, sodium levels may rise, causing hypernatremia._________________________- changes occur relative to the level of hypernatremia. Mild deficiency will cause muscle ____________________________. As the condition worsens, the nerves become less able to respond and muscle weakness progresses. The nurse needs to observe for twitching in muscle groups, and to assess for muscle strength. Hypernatremia presents a risk for client falls.
Skeletal muscle; twitching and irregular contractions
The client on transmission precautions is never placed with a client who is immunocompromised or infected with a different transmission precaution illness.
TRUE OR FALSE
TRUE
It is ideal to place a client with a transmissible infection in a private room, even when it is not an infection that requires transmission precautions.
For example, a client with methicillin-resistant Staphylococcus aureus (MRSA) and a client with vancomycin-resistant enterococci (VRE) should never be assigned to the same room, and, preferably, are never assigned to the same nurse.
Cross-contamination of antibiotic-resistant organisms can have lethal consequences.
What is neuroleptic malignant syndrome ?
a serious complication of antipsychotic drugs
The symptoms include sudden high fever, rigidity, tachycardia, hypertension, and decreased level of consciousness, increased sweating, pale skin.
NMS is a life-threatening complication. The nurse needs to manage fluid balance, reduce client temperature, and monitor for complications. The nurse should discontinue antipsychotic medications and administer bromocriptine (a medication to counteract the effects of NMS) and dantrolene as prescribed.
bromocriptine mesylate, a dopamine agonist, and dantrolene sodium, a muscle relaxant that works by inhibiting calcium release from the sarcoplasmic reticulum
When caring for a client who experiences hallucinations, the nurse should:
Ensure safe environment. Reduce external stimulation. Monitor client ’s thinking, perceptions, and associated behavior. Ask about voices, if indicated, and monitor for increased negativity of content, anxiety and agitation, or social withdrawal. Report increased anxiety and/or increasing risk for violence. Provide medications, as indicated. Establish trusting relationship. Provide alternatives to listening to voices or focusing on perceptual alternation. Gently challenge perceptions. Assist to socialize with others. Provide care with unconditional positive regard.
Urine output provides information about kidney function and cardiac function. Urine is collected during a specific period of time and assessed to determine the color, consistency, and amount. Urine should be _________ and _____________in color. The minimal amount of urine produced should be __________-mL/hr or _____mL/day. Urine output is used as a diagnostic test for electrolytes, glucose, protein, and infections.
clear and yellow; 30; 720
________________-prevention aimed at health promotion includes activities that may prevent the disease from developing. These activities include health education programs, immunizations, and physical and nutritional fitness activities.
Primary
The fight or flight response is designed to boost the body’s ability to act in an emergency.
What does long term stress do ? What does it increase the risk of ?
Long-term stress results in chronic activation of the sympathetic nervous system, which leads to a continually elevated heart rate, blood pressure, and blood glucose level.
Uncontrolled stress increases the risk for developing heart disease, cancer, and other health alterations. Increasing daily activity, taking purposeful deep breaths, eliminating distractions during certain hours, sleeping adequately, and taking time to enjoy healthy, balanced meals are all healthful strategies to combat stress.
From 6 to 9 months of age, infants discriminate strangers and demonstrate __________________ anxiety. Significant physiological changes occur during this stage, which include changes in weight, length, head and chest circumference, development of senses, fine and gross motor skills, and reflexes.
stranger/separation
Inadequate oxygenation can manifest as respiratory symptoms such as _________________________Hypoxia can also manifest with the client’s experiencing decreased level of _____________. Cardiac symptoms include signs of decreased perfusion such as _____________________
oxygen saturation below 95%, tachypnea, dyspnea, and ineffective quality, rate, and depth of respirations to meet demands
consciousness
hypotension, decreased pulse strength, pallor, cool skin, and prolonged capillary refill.
A small amount of serosanguineous drainage on the dressing of a new tracheostomy is an ___________-finding
expected
Clear fluid draining from a nasogastric tube indicates a complication
TRUE OR FALSE
FALSE
Dysrhythmias have the potential to be life-threatening when ___________________________
perfusion is decreased and cardiac output drops.
When a client attached to a nasogastric (NG) tube for gastrointestinal decompression (i.e., attached to low wall suction) vomits, it suggests that the NG tube is not working as intended or there is a clinical emergency. Vomiting with an NG tube increases the risk for _________________- as the esophagus is already partially propped open by the tube. The nurse should keep the client ____________during vomiting. Meticulous mouth care is done after vomiting and the scenario escalated to the next level by notifying the health care provider.
aspiration; upright
The nurse should verify correct placement of the nasogastric (NG) tube, and after doing so, assess the tube for an obstruction. Verify tube placement by aspirating contents and determining pH consistent with acidic stomach contents (usually ≤4). Verify that a chest X-ray confirms accurate placement of tube. Next, attempt to flush the tube with warm water. If prescribed, dissolve a crushed non-enteric-coated sodium bicarbonate tablet (650 mg) or 1/4 teaspoon of baking soda in 10 mL water. Add a pancrelipase tablet to the sodium bicarbonate solution and allow to dissolve. Instill solution into feeding tube and clamp for 30 to 60 minutes. Then, try to aspirate and flush with warm water.
What to remember about Peripheral Artery Disease
Peripheral artery disease (PAD) refers to narrowing or partial obstruction of blood flow in the peripheral blood vessels. Assess the quality of distal pulses (dorsalis pedis, posterior tibial, and popliteal) and color and temperature of the client’s extremities. Assess for any non-healing wounds. Ask the client about symptoms occurring with walking or activities (intermittent claudication). Teach the client strategies to control or reduce risk factors (e.g., diet, exercise, weight reduction, control of diabetes mellitus and hypertension, and smoking cessation).
Peripheral artery disease (PAD) is characterized by decreased blood flow to the limbs due to narrowing or occlusion of peripheral blood vessels. The client diagnosed with PAD experiences muscle pain with activity, as impaired blood flow limits the delivery of oxygen to muscles and prevents adequate exchange of glucose and lactate. Additional effects of PAD may include delayed wound healing and cool extremities due to impaired circulation. Interventions emphasize maximizing blood flow to and from the extremities by engaging in mild to moderate exercise. To promote capillary dilatation and blood circulation, the client is advised to stay warm by dressing in non-constricting layers of clothing
Keeping warm, to the client’s comfort level, will cause vasodilation of the extremities and is safer than placing direct heat on the extremities.
An unpleasant feeling conveyed to the brain by sensory neurons in response to injury, disease, and actual or potential tissue damage. Pain has a physiological component, but reactions are considered “_____________ ” and Maslow states that physiological needs must be met firs
Pain; psychosocial
Treatment for pain includes
medications, surgery, relaxation techniques, meditation, progressive relaxation, yoga, distraction, guided imagery, herbal remedies, biofeedback, acupuncture, heat/cold application, therapeutic touch, massage, and hypnosis.
There are a variety of reasons for the development of low back pain. One major reason is excessive _____________–
standing.
Sleeping prone contributes to low back pain
Obesity and stress can contribute to low back pain
Long term steroid therapy dermatologic effects
Cortisol causes catabolism, altering the strength of tissues such as muscles and blood vessels. Collagen and elastic fibers in the epidermis are ruptured, resulting in decreased skin elasticity. While systemic steroid therapy does not typically cause changes in skin pigmentation, integumentary changes can include fragile skin, easy bruising, dry skin, acne, stretch marks, or infection, and delayed wound healing, decreased subcutaneous fat in the extremities.
Topical corticosteroid cream misuse can cause integumentary effects such as skin thinning and telangiectasia .
A left-sided cerebral infarct will impact the _____________function of the _________side of the body, speech, and problem solving.
motor; right
Impulsive behavior.
Disorientation to person, place, and time.
These symptoms are seen with a stroke in which hemisphere of the brain ?
Right hemisphere infarct
The left hemisphere controls speech, math skills, and analytical thinking.
_________________-occurs when there is an occlusion to the middle cerebral artery, which causes damage to the Broca’s area (speech and communication area of the brain).
Aphasia
Aphasia is defined as loss of speech and ability to write, or loss of comprehension of speech or written language. Expressive aphasia is the loss of the ability to speak, whereas receptive aphasia is the loss of ability to comprehend. Clients may experience both types.
The nurse is aware the body systems undergo major changes during pregnancy. One change is an _____________in blood volume to accommodate both the client and developing fetus. At times, the client’s body systems are not able to adequately adjust to an increase in body fluid and may retain fluid that is not required. This excess fluid appears as _________.
increase; edema
Facial edema in a pregnant client is not an expected finding and could indicate developing pregnancy-induced hypertension. The nurse is aware that pregnancy-induced hypertension is a precursor to preeclampsia. The client will be closely monitored for other manifestations, including headache, blurred vision, and lower extremity edema.
Pregnancy-induced hypertension.
Hypertension with an increase in blood pressure (BP) greater than 140/90 mm Hg exclusively found in pregnancy.
Hypertension is also seen in mothers after 20 weeks gestation accompanied by proteinuria in preeclampsia.
The nurse should assess the client’s blood pressure (BP). If BP is elevated, assess for edema, headaches, reduced urine output, and visual disturbances. Assess electrolytes and complete blood count. The nurse should also educate client about monitoring BP daily and notifying the health care provider for increases in blood pressure. Instruct the client to use lateral positioning after 20 weeks to facilitate venous return and increase blood flow to the placenta and fetus. Monitor for preterm labo
Low back pain, skin hyperpigmentation, and lightheadedness are all _________________ findings of pregnancy
expected
Principles of the nurse-client relationship
What strategies does the nurse use to establish a trusting nurse-client relationship ?
The nurse-client relationship develops in four stages: the pre-orientation, orientation, working, and termination phases. During each stage, the nurse assesses his/her use of therapeutic communication, any barriers to communication, client/family communication preferences, and the client/family response to communication as it impacts the development of an effective nurse-client relationship. T
The nurse establishes a trusting nurse-client relationship using the following strategies: 1) actively listening, 2) identifying emotions, 3) empathizing, 4) being honest, 5) being genuine, 6) reflecting on and addressing cultural and language differences, 7) being creative, 8) maintaining privacy and confidentiality, and 9) clearly defining the client/family roles and the professional nurse ’s role.
Therapeutic communication skills include:
1) being silent,
2) showing acceptance,
3) providing recognition,
4) offering self,
5) using broad openings,
6) providing leads and encouragement, 7) timing events, 8) focusing, 9) asking about thoughts/feelings, 10) encouraging comparisons, 11) restating and reframing, 12) reflecting, 13) presenting reality, 14) sharing observations, 15) clarifying meaning, 16) expressing doubt, 17) interpreting feelings, and 18) formulating a plan for care.
The nurse avoids non-therapeutic techniques such as reassuring, rejecting, approving/disapproving, agreeing/disagreeing, giving advice, belittling, stereotyping, probing, or using denial
How to interact with clients who have dementia
Clients diagnosed with dementia may experience confusion, fear, anger, and paranoia. Caregiver actions can dissipate the negative reactions or intensify them. The client with dementia usually responds best to unhurried, calm, tolerant care. When frightened, rushed, or startled, such clients may become aggressive or uncooperative. Simple and clear communication is best. Adding soothing music or music from the client’s generation can be comforting. Clients respond well to activity or thought redirection.
For the client diagnosed with dementia, skin breakdown may occur due to incontinence, immobility, and malnutrition.
Especially during late-stage dementia, the client is at high risk for alterations in skin integrity. During the bath, the nurse should carefully inspect the client’s skin for breakdown. Also, while providing client care, the nurse and the UAP should treat the client like an adult and with respect and dignity. The nurse and UAP should use gentle touch and maintain direct eye contact; remain patient, flexible, calm and understanding; provide directions using gestures or pictures; simplify tasks, focusing on one task at a time; use distraction (e.g., change subject, redirect to another activity); provide reassurance; and offer praise for success.
During IM administration, what is the purpose of the Z track method ?
During IM injection, encourage the client to breathe deeply and to relax the muscle to reduce discomfort. Using the Z-track technique prevents subcutaneous infiltration of the medication. Inadvertent subcutaneous injection may cause serious tissue damage.
The Z-track method is a variation of the standard intramuscular technique for administering medications that are highly irritating to subcutaneous and skin tissues. It primarily reduces irritation to the subcutaneous and skin tissues.
