Uworld Questions

Question 1

Parallel play is characteristic of what age

Answer 1

Toddlers typically exhibit parallel play, during which they participate in various activities alongside one another but remain primarily independent. Parallel play is without group organization or common goals.

Question 2

Cooperative play

Answer 2

is organized, requires the ability to follow rules, and involves a leader-follower approach to activities. One or two children direct the activity and assign roles. Cooperative play, which develops during the PRESCHOOL years, is goal-oriented and may involve a formal game or task

Question 3

Onlooker behavior

Answer 3

is when an interested child sits and observes others at play but does not engage in an activity.

Question 4

Toxoplasmosis

Answer 4

• is a disease due to Toxoplasma gondii, a parasite that infects humans via cat feces or ingestion of undercooked meat.
• In a normal healthy adult, the infection goes unnoticed (no symptoms or only flulike symptoms are present) and causes no long-term damage.
• However, in a pregnant client, the parasite can be passed from mother to baby in utero and can cause significant damage to the growing fetus. If toxoplasmosis is acquired during pregnancy, it can cause stillbirth or serious fetal malformations.
• Pregnant clients should be advised to stay away from a litter box or cat feces to reduce toxoplasmosis risk.

Question 5

Leukorrhea

Answer 5

• is a thin, milky white vaginal discharge that is normal during pregnancy.
• It is caused by increased levels of estrogen and is harmless.
• However, leukorrhea may become a problem if it changes color or develops a discernible odor, or if itching or burning occurs

Question 6

Cervical lacerations

Answer 6

• should be suspected if the uterine fundus is firm and midline on palpation despite continued vaginal bleeding. - The bleeding can be minimal to frank hemorrhage.
• Severe pain or a feeling of fullness is not associated with cervical lacerations.

Question 7

Complete inversion of the uterus presents

Answer 7

with a large, red mass protruding from the introitus.

Question 8

A vaginal hematoma

Answer 8

• formed when trauma to the tissues of the perineum occurs during delivery.
• more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy.
• pt reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off.
• Vaginal bleeding is unchanged.
• The uterus is firm and at the midline on palpation.
• If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma.

Question 9

Uterine atony presents

Answer 9

with a boggy uterus on palpation and an increase in vaginal bleeding

Question 10

Syndrome of inappropriate antidiuretic hormone (SIADH) secretion results in

Answer 10

• water retention and dilutional hyponatremia
• Clients with SIADH often require hypertonic saline for sodium repletion to increase serum sodium levels with a minimal infused volume of water.

Question 11

Treatment of Sickle Cell Crisis

Answer 11

Sickle cell disease (SCD) is a hereditary hemoglobinopathy in which normal hemoglobin is replaced with abnormal hemoglobin S in red blood cells. The cells change to a sickle shape with triggers (eg, dehydration, infection, high altitude, extremes in temperature). This causes occlusion of small blood vessels with ischemia and damage to organs.

Sickle cell crisis occurs when inadequate oxygenation or hydration exacerbates sickling and causes red blood cells (RBCs) to clump together in the capillaries (vasoocclusion). Vasoocclusion causes severe ischemic pain, hypoxia, and possible organ dysfunction if left untreated.

Adequate oxygenation and hydration may reverse the acute sickling response. In the sickled state, RBCs cannot carry enough oxygen from the lungs to the tissues, even with supplemental oxygen. The priority intervention is the administration of IV fluids to reduce blood viscosity and restore perfusion to the areas previously affected by vasoocclusion (Option 1). Only after IV rehydration reverses vasoocclusion can nonsickled RBCs effectively carry supplemental oxygen to the tissues

Management of sickle cell crisis focuses on the following:

1. Pain control with narcotics - analgesics are provided around the clock or with patient-controlled analgesia, rather than as needed, to prevent breakthrough pain.
2. Hydration - aggressive intravenous and oral hydration is recommended (to reduce the viscosity of the blood)
3. Oxygenation - to prevent pulmonary complications and provide comfort
4. Infection prevention – age-appropriate vaccination plus pneumococcal, influenza, and meningococcal vaccination
5. Diet - the client is encouraged to have a high-protein, high-calorie diet with folic acid and a multivitamin without iron
6. Folic acid - given to help in the creation of the new red blood cells needed due to the hemolysis

• Don’t increase Iron in theses pts - The anemia in SCD is related to the destruction of red blood cells from sickling, not a deficiency in iron. Increased iron intake is not needed. Clients often require blood transfusions and run the risk of iron overload from multiple transfusions.
• Cold promotes sickling and should be avoided. Ice packs are used on joints with bleeding in hemophilia to promote vasoconstriction.

Question 12

Priority interventions for active or suspected air embolism from a central line:

Answer 12

1. Clamp the catheter to prevent more air from embolizing into the venous circulation.
2. Place the client in Trendelenburg position on the left side, causing any existing air to rise and become trapped in the right atrium.
3. Administer oxygen if necessary to relieve dyspnea.
4. Notify the HCP or call an RRT to provide further resuscitation measures.
5. Stay with the client to provide reassurance and monitoring as the air trapped in the right atrium is slowly absorbed into the bloodstream over the course of a few hours.

Question 13

latex allergy

Answer 13

The greatest risk factor for latex allergy is long-term multiple exposures to latex products. Powdered latex gloves were banned in the 1990s, and the incidence of latex allergy is decreasing. It is estimated that 73% of clients with spina bifida have a sensitivity to latex. This can be a result of frequent exposure to latex during their lifelong care.

A classic screening question is whether the lips swell when blowing up balloons (which have latex in them). Another is if your hands itch and/or burn after wearing rubber gloves

Some proteins in rubber are similar to plant-derived food proteins. Therefore, certain foods may cause a latex-food syndrome in clients with an allergy to latex. Common foods include bananas, avocados, tomatoes, chestnuts, kiwis, potatoes, peaches, grapes, and apricots

bananas, kiwis, avocados, tomatoes, peaches, and grapes because some proteins in rubber are similar to food proteins

Question 14

Steps for chest tube removal include:

Answer 14

A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if present) is resolved, and the lung has reexpanded.

The general steps for chest tube removal include:

1. Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence indicates that most clients report significant pain during removal
2. Provide the health care provider (HCP) with sterile suture removal equipment
3. Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique to increase intrathoracic pressure and prevent air from entering the pleural space (Option 2).
4. Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will prevent air from entering the pleural space
5. Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure pneumothorax or fluid accumulation usually develops within this time frame.

• The client should be placed in semi-Fowler’s position or on the unaffected side to promote comfort and facilitate access for tube removal.

Question 15

Testing for CSF

Answer 15

Cerebrospinal fluid (CSF) rhinorrhea (or CSF otorrhea) can confirm that a skull fracture has occurred and transversed the dura.

• If the drainage is clear, dextrose testing can determine if it is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose.
• In this case, the halo/ring test should be performed by adding a few drops of the blood-tinged fluid to gauze and assessing for the characteristic pattern of coagulated blood surrounded by CSF.
• Identification of this pattern is very important as CSF leakage places the client at risk for infection. The client’s nose should not be packed. No nasogastric or oral gastric tube should be inserted blindly when a basilar skull fracture is suspected as there is a risk of penetrating the skull through the fracture site and having the tube ascend into the brain. These tubes are placed under fluoroscopic guidance in clients with such fractures.

Question 16

Polycythemia is expected with COPD because

Answer 16

• The client with severe COPD will have a chronically low oxygen level, hypoxemia.
• To compensate, the body produces more red blood cells (RBCs) to carry needed oxygen to the cells.
• A high RBC count is called polycythemia.

Question 17

Characteristics of schizophrenia with catatonia

Answer 17

A diagnosis of schizophrenia with catatonia can be made if the clinical features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following additional features:

• Immobility—the client remains in a fixed stupor or position for long periods
  Refuses to move about or engage in activities of daily living
• May have brief spurts of excitement or hyperactivity
• Remaining mute
• Bizarre postures—the client holds the body rigidly in one position
• Extreme negativism—the client resists instructions or attempts to be moved
• Waxy flexibility—the client’s limbs stay in the same position in which they are placed by another person
• Staring
• Stereotyped movements, prominent mannerisms, or grimacing

Question 18

Infants with cyanotic cardiac defects can develop polycythemia

Answer 18

Infants with cyanotic cardiac defects can develop polycythemia (elevated hemoglobin levels) as a compensatory mechanism due to prolonged tissue hypoxia.

• Polycythemia will increase blood viscosity, placing an infant at risk for stroke or thromboembolism
• An infant with polycythemia must stay hydrated.

Question 19

Decerebrate posturing is a sign

Answer 19

of severe brain damage.

• During assessment, the nurse would observe arms and legs straight out, toes pointed down, and the head/neck arched back

Question 20

carotid endarterectomy

Answer 20

• surgical procedure that removes atherosclerotic plaque from the carotid artery.
• Clients with carotid artery disease are at increased risk for transient ischemic attack and stroke. Post-surgical risks include cerebral ischemia and infarction as well as bleeding.
• Blood pressure is closely monitored during the first 24 hours post surgery. Hypertension may strain the surgical site and trigger hematoma formation, which can cause hemorrhage or airway obstruction. Systolic blood pressure is maintained at 100-150 mm Hg to ensure adequate cerebral perfusion and avoidance of hemorrhage or strain.

Question 21

Rationalization - defense mechanism

Answer 21

using excuses to explain away threatening circumstances

Question 22

Displacement - defense mechanism

Answer 22

transferring thoughts and feelings toward one person or object onto another person or object

Question 23

Regression - defense mechanism

Answer 23

returning to a previous level of development

Question 24

Introjection - defense mechanism

Answer 24

taking on the qualities or attitudes of others without thought or examination

Question 25

Reaction formation - defense mechanism

Answer 25

behaving in a manner or expressing a feeling opposite of one's true feelings

Question 26

Repression - defense mechanism

Answer 26

keeping unacceptable thoughts or traumatic events buried in the unconscious

Question 27

sublimation - defense mechanism

Answer 27

transforming unacceptable thought or needs into acceptable actions

Question 28

When should kids go to the dentist?

Answer 28

children have their first dental visit within 6 months of first tooth eruption or by their first birthday

Question 29

After delivery of the placenta, how should the fundus be?

Answer 29

- After delivery of the placenta, the uterus begins the process of involution. - The fundus should be firm, midline, and halfway between the umbilicus and symphysis pubis

Question 30

A "boggy uterus"

Answer 30

indicates that the uterus is not in a contracted state and there is a risk of excessive blood loss. The contracted uterus muscle compresses the open vessels at the placental site and decreases the amount of blood loss. - The immediate nursing action when a "midline, boggy uterus" is assessed is to massage the fundus with the palm of the hand in a circular motion. - Fundal massage stimulates contraction of the uterus. - If the uterus responds, the nurse should then recheck the uterine tone and position in 30 minutes. - The first action is to use massage. If the uterus does not respond to massage, the next actions are to administer oxytocin (Pitocin) - Oxytocin promotes contraction by stimulating the smooth muscle of the uterus. - The HCP should be notified if there is no response to the massage as this lack of response can indicate complications such as retained placental tissue

Question 31

If the uterus shifted to the side...

Answer 31

- it may indicate a distended bladder that is interfering with uterine contractibility. - After massage, a woman with a uterus that is deviated, soft, or elevated above the umbilicus should then void. The nurse should reassess after the woman voids. - If the woman cannot void, catheterization may be required.

Question 32

Nonmaleficence means

Answer 32

doing no harm. - It also relates to protecting clients who are unable to protect themselves due to their physical or mental condition. Examples include infants/children, clients under the effects of anesthesia, and clients with dementia

Question 33

Autonomy is

Answer 33

freedom for a competent client to make decisions for oneself, even if the nurse or family does not agree (eg, informed consent, advanced directive). The nurse can provide information and should respect the client's decisions.

Question 34

neuroleptic malignant syndrome (NMS)

Answer 34

uncommon but life-threatening adverse reaction to anti-psychotic medications. most often seen with the "typical" antipsychotics (eg, haloperidol, fluphenazine). However, even the newer "atypical" antipsychotic drugs (eg, clozapine, risperidone, olanzapine) can cause the syndrome. - diaphoresis, tachycardia, hypertension, tachypnea, dysrhymthia, altered mental status, fever, muscle rigidity - characterized by fever, muscular rigidity, altered mental status, and autonomic dysfunction (eg, sweating, hypertension, tachycardia). - Treatment is supportive and is directed at reducing fever and muscle rigidity and preventing complications. Treatment in an intensive care unit (ICU) may be required. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment. - Treatment includes supportive care (eg, rehydration, cooling body temperature) and immediate discontinuation of the medication.

Question 35

Signs of subsequent hypovolemic (hemorrhagic) shock from tubal rupture include

Answer 35

- dizziness, hypotension, tachycardia, and decreased urinary output to <30 mL/hr. - Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain. - Peritoneal signs (eg, tenderness, rigidity, low-grade fever) develop subsequently. - hypovolemic (internal hemorrhage) shock. - Jugular veins would be flat in hypovolemic shock.

Question 36

If a chest tube is dislodged from the client and the nurse hears air leaking from the site, the nurse's immediate action should be

Answer 36

- to apply a sterile occlusive dressing (eg, petroleum jelly dressing) taped on 3 sides. - This action permits air to escape on exhalation and inhibits air intake on inspiration. - The nurse would then notify the HCP and arrange for the reinsertion of another chest tube Why not tape 4 sides??? A tension pneumothorax develops when air enters the pleural space but cannot escape. Increased intrapleural pressure and excessive accumulation of air can apply pressure to the heart and great vessels and drastically decrease cardiac output. An occlusive dressing taped on 4 sides would prevent the air in the pleural space from escaping on exhalation and would increase the risk for a tension pneumothorax.

Question 37

The procedure for bowel irrigation for someone with a colostomy is as follows:

Answer 37

- Fill the irrigation container with 500-1000 mL of lukewarm water, flush irrigation tubing, and reclamp; hang the container on a hook or intravenous pole - Instruct the client to sit on the toilet, place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma - Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place - Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes - Clamp the tubing if cramping occurs, until it subsides - Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet

Question 38

If a client reports cramping or pain during instillation of an enema...

Answer 38

Too rapid infusion of an enema solution may cause intestinal spasms that result in a feeling of fullness, cramping, and pain. - If the client reports any of these symptoms, instillation should be stopped for 30 seconds and then resumed at a slower rate. - Slow infusion will also decrease the likelihood of premature ejection of the solution, which would not allow for adequate bowel evacuation.

Question 39

Clients with paroxysmal supraventricular tachycardia (SVT) are initially treated with

Answer 39

(regular, narrow QRS complex tachycardia) are initially treated with vagal maneuvers.

Question 40

Cardioversion or defibrillation with supraventricular tachycardia

Answer 40

Cardioversion (not defibrillation) is used with this type of arrhythmia when it is refractory to medication. Cardioversion delivers a synchronized electrical current to the heart. This works by stopping the electrical activity to the heart and briefly allowing a normal heartbeat to return.

Question 41

Lipomas are

Answer 41

benign, fatty masses and rarely become malignant. They are subcutaneous, have a soft doughy feel, and are mobile and asymptomatic. Masses that are hard and fixed, not soft and mobile, usually indicate malignancy.

Question 42

The warning signs of cancer

Answer 42

can be remembered with the acronym CAUTION: C - change in bowel or bladder habits A - a sore that does not heal U - unusual bleeding or discharge from a body orifice T - thickening or a lump in the breast or elsewhere I - indigestion or difficulty in swallowing O - obvious change in a wart or mole N - nagging cough or hoarseness - Unintentional weight loss of >10% of usual weight (in non-obese clients) requires evaluation and could indicate underlying cancer. Nausea, anorexia, and dysgeusia (altered taste sensation) are also clinical features of cancer and contribute to weight loss

Question 43

nutrients in cow's milk

Answer 43

calcium and vitamin D

Question 44

food sources of calcium

Answer 44

cow's milk, beans, dark green vegetables, and calcium-fortified cereals and juices

Question 45

sources of vitamin D

Answer 45

- exposure to direct sunlight. | - Alternate dietary sources include fish oils, egg yolks, and vitamin D-fortified foods (eg, orange juice), cow's milk

Question 46

Dietary sources of iron include

Answer 46

Meats (eg, beef, lamb, liver, chicken, pork) Shellfish (eg, oysters, clams, shrimp) Eggs, green leafy vegetables, broccoli, dried fruits, dried beans, brown rice, and oatmeal

Question 47

sources of vitamin K

Answer 47

dark green vegetables, fish, and eggs

Question 48

Hirschsprung's disease

Answer 48

- a portion of the colon has no innervation and must be removed. - Some children require a temporary colostomy.

Question 49

operating a fire extinguisher

Answer 49

P - Pull the pin A - Aim the spray at the base of the fire S - Squeeze the handle S - Sweep the spray.

Question 50

When planning to become pregnant what prevents neural tube defects

Answer 50

- Women who are planning on becoming pregnant should consume 400-800 mcg of folic acid daily. - Food options that are rich in folic acid include fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables - Inadequate maternal intake of folic acid during the critical first 8 weeks after conception increases the risk of fetal neural tube defects (NTDs), which inhibit proper development of the brain and spinal cord.

Question 51

Food options that are rich in folic acid

Answer 51

fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables (best choice), cooked beans, rice, fortified cereals, and peanut butter

Question 52

anencephaly

Answer 52

lack of cerebral hemispheres and overlying skull - a neural tube defect that results in very little to no brain tissue forming in utero. - The majority of fetuses with anencephaly will be stillborn. Those born alive will not survive for long. - Comfort care should be provided for the neonate. Drying, bundling, or placing the neonate skin-to-skin with the mother for warmth and possibly administering oxygen to the neonate will decrease the discomforts of impending death. - Allowing the mother to hold the neonate will assist with the grieving process.

Question 53

true labor signs

Answer 53

- A key indicator of true labor is the progressive effacement and dilation of the cervix - Contractions in true labor are regular, and increase in frequency, duration, and intensity - The pain may initially start in the lower back and radiate to the abdomen

Question 54

when developed to eat with spoon

Answer 54

18 mo

Question 55

trichomoniasis

Answer 55

- sexually transmitted infection (STI). - Many women with trichomoniasis are asymptomatic but can have profuse frothy gray or yellow-green vaginal discharge with a fishy odor. - Small red lesions (strawberry) may be present in the vagina or cervix. Pruritus is common.

Question 56

signs of diabetic ketoacidosis (DKA)

Answer 56

lethargy, abdominal pain, hyperglycemia, urine ketones characterized by hyperglycemia, ketosis, and acidosis - Glucose cannot be used properly for energy when this deficit occurs and the body begins to break down fat stores, producing ketones, a byproduct of fat metabolism, resulting in metabolic acidosis. The lack of insulin also results in increased production of glucose in the liver, further exacerbating hyperglycemia. - Hyperglycemia can cause osmotic diuresis, leading to dehydration. In addition, ketones are excreted in the urine as the body tries to restore its pH balance. Vital electrolytes such as sodium, potassium, chloride, phosphate, and magnesium become depleted during the process. Cardinal signs of dehydration such as poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension, weakness, and lethargy can occur - Other signs associated with DKA include Kussmaul respirations, deep, rapid respirations that have a fruity/acetone smell as the carbon dioxide is exhaled. This compensatory mechanism results in a lowered PaC02 in an attempt to restore the body's normal pH level and should not be reversed

Question 57

toxic megacolon

Answer 57

- severe inflammatory colon distension - Clients with ulcerative colitis are at risk for developing - Symptoms include fever, nausea, vomiting, pain, and abdominal distension. - Clients require close monitoring, nasogastric tube for decompression, IV fluids, and antibiotics. - Emergency surgery may be required.

Question 58

Acute angle-closure glaucoma

Answer 58

is a form of glaucoma that requires immediate medical intervention to prevent permanent blindness - Glaucoma disorders are characterized by increased intraocular pressure (IOP) due to decreased outflow of the aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness. - In acute angle-closure glaucoma, IOP increases rapidly and drastically, which can lead to the following manifestations: - -Sudden onset of severe eye pain - -Reduced central vision - -Blurred vision - -Ocular redness - -Report of seeing halos around lights

Question 59

open-angle glaucoma

Answer 59

- Gradual loss of peripheral vision and difficulty adjusting to different lighting are manifestations of chronic open-angle glaucoma - Although further evaluation and treatment are necessary, this condition develops slowly and is not considered an emergency situation.

Question 60

Opaque lenses are characteristic of

Answer 60

cataracts, not an emergency

Question 61

Discharge teaching for the client with a permanent pacemaker should include the following:

Answer 61

- Report fever or any signs of redness, swelling, or drainage at the incision site - Keep a pacemaker ID card with you, and wear a medic alert bracelet - Microwave ovens are safe to use and do not interfere with the pacemaker - Learn to take your pulse and report it to the health care provider (HCP) if it is below the predetermined rate - Do not place a cell phone in a pocket located directly over the pacemaker. Also, when talking on the cell phone, hold it to the ear on the opposite side of the pacemaker's implantation site - MRI scans can affect or damage a pacemaker - Avoid lifting your arm above the shoulder on the side that the pacemaker is implanted until approved by the HCP. It can cause dislodgement of the pacemaker lead wires - Air travel is not restricted. Notify security personnel that you have a pacemaker, which may set off the metal detector. A handheld screening wand should not be held directly over the pacemaker - Avoid standing near antitheft detectors in store entryways. Walk through at a normal pace and do not linger near the device.

Question 62

Do not __________ chest tubes when transferring a pt

Answer 62

- Clamping the chest tube during transport is contraindicated. - Doing so can cause air to accumulate in the pleural cavity as it has no means of escape. This can lead to the development of a tension pneumothorax, a potentially life-threatening condition. - A tension pneumothorax results in compression of the unaffected lung and pressure on the heart and great vessels. As the pressure increases, venous return is decreased and cardiac output falls.

Question 63

Uterine contraction duration should not exceed

Answer 63

exceed 90 seconds. - A duration exceeding 90 seconds can result in reduction of blood flow to the placenta due to uterine hypertonicity. - contractions should not be less than 2 mins apart

Question 64

Mastitis

Answer 64

- a common infection in postpartum women due to multiple risk factors leading to inadequate milk duct drainage (eg, poor latch). Bacteria are transmitted from the infant's nasopharynx or the mother's skin through the nipple and multiply in stagnant milk. Staphylococcus aureus is the most common offending organism. Symptoms of mastitis include fever, breast pain, and focal inflammation (redness, edema). In addition to antistaphylococcal antibiotics (dicloxacillin or cephalexin) and analgesics (eg, ibuprofen), treatment of lactational mastitis requires effective and frequent milk drainage. Milk ducts are most efficiently drained by direct breastfeeding. The correct position for optimal milk intake involves the infant forming a tight seal around most of the areola. However, a common cause of severe pain during latching occurs when the infant only suckles on the nipple. This improper position can cause nipple blistering. Adequate rest and increase of oral fluid intake is also recommended. - Breastfeeding should be continued every 2-3 hours to relieve milk duct obstruction. Mothers should be reassured that the infant can safely feed from the infected breast as the newborn is already colonized with the mother's skin flora. - Underwire bras (tight bras) are not recommended with breastfeeding or mastitis as milk flow is impeded, worsening engorgement. Soft cup bras are recommended for support and to encourage milk flow.

Question 65

Testicular torsion

Answer 65

- an emergency condition in which blood flow to the testis (scrotum) has stopped. The testicle rotates and twists the spermatic cord, initially causing venous drainage obstruction that leads to swelling and severe pain. Arterial blood supply is subsequently interrupted, resulting in testicular ischemia and necrosis, which require surgical removal of the testis. - The condition can be diagnosed with ultrasound. - There is a short time frame in which testicular torsion can be treated (to untwist the rotation), generally 4-6 hours, making this condition a priority.

Question 66

Right lower quadrant pain referred from the periumbilical area is a classic sign of

Answer 66

- appendicitis. - If left untreated, the appendix could perforate and release bacteria into the abdomen, causing peritonitis, a more serious condition. - Surgery is usually required within 24 hours.

Question 67

Sudden-onset, right-sided flank pain radiating to the groin is classic for

Answer 67

- renal stones. - Kidney stones are very painful but in most cases cause no permanent damage unless a stone completely blocks kidney flow.

Question 68

postoperative cognitive dysfunction (POCD)

Answer 68

- Clients who have undergone surgery may experience - This may include memory impairment and problems with concentration, language comprehension, and social integration. - Some clients may cry easily or become teary. - The risk for POCD increases with advanced age and in clients with preexisting cognitive deficits, longer operative times, intraoperative complications, and postsurgical infections. - POCD can occur days to weeks following surgery. - Most symptoms typically resolve after complete healing has occurred. - In some cases, this condition can become a permanent disorder

Question 69

when should you introduce pureed foods to baby

Answer 69

6 mo | - iron-fortified cereals (usually rice) offered first due to their low allergy potential and ease of digestion

Question 70

Ventricular Fibrillation

Answer 70

- characterized on the ECG by irregular waveforms of varying shapes and amplitudes. - This represents the firing of multiple ectopic foci originating in the ventricle. Mechanically, the ventricle is quivering with no effective contraction or cardiac output. VF is considered a lethal dysrhythmia. It results in an unresponsive, pulseless, apneic state. If not treated rapidly, the client will not recover. - VF commonly occurs in acute myocardial infarction and myocardial ischemia and in chronic heart diseases such as heart failure and cardiac myopathy. It may occur in cardiac pacing or catheterization procedures due to catheter stimulation of the ventricle. - Treatment consists of rapid initiation of CPR, defibrillation, and the use of drug therapy (eg, epinephrine, vasopressin, amiodarone).

Question 71

Clients of the Orthodox Jewish faith follow Kosher rules which means

Answer 71

- no pork, shellfish, or fish without scales. | - When meat or poultry is consumed, at least 3-6 hours must pass before a dairy product can be consumed.

Question 72

Third-spacing

Answer 72

- can occur following extensive abdominal surgery and can lead to hypovolemia, decreased cardiac output, hypotension and tachycardia, and decreased urine output. - Monitoring vital signs and urine output, and maintaining IV fluids are appropriate interventions to prevent prerenal failure and hypovolemic shock.

Question 73

If Group B Streptococcus (GBS) status is unknown in pregnant woman then

Answer 73

- antibiotics are typically indicated when membranes have been ruptured for ≥18 hours, maternal temperature is ≥100.4 F (38 C), or gestation is <37 weeks Group B Streptococcus (GBS) may be present as part of normal vaginal flora in up to 30% of pregnant clients. Although colonization with GBS rarely poses harm to the client, it can be transmitted to the newborn during labor and birth, resulting in serious complications (eg, neonatal GBS sepsis, pneumonia). Pregnant clients are tested for GBS colonization at 35-37 weeks gestation and receive prophylactic antibiotics during labor if results are positive.

Question 74

Assault vs Battery

Answer 74

Assault is an act that threatens the client and causes the client to fear harm, but without the client being touched Assault is the threat of battery. Battery involves making physical contact with the client without permission. This includes harmful acts or acts that the client refuses (eg, performing a procedure). When interacting with the client, it is important to practice veracity, the ethical principle of being truthful.

Question 75

Splenic sequestration crisis is

Answer 75

a potentially life-threatening emergency of sickle cell disease. - A rapidly enlarging spleen and hypotension are the characteristic assessment findings. - occurs when a large number of "sickled" cells get trapped in the spleen, causing splenomegaly - This is a life-threatening emergency as it can lead to severe hypovolemic (hypotensive) shock

Question 76

The caregiver of a child with a VP shunt must understand symptoms of

Answer 76

- Increased ICP may occur with VP shunt malfunctions. - The caregiver must recognize symptoms of vomiting, headaches, vision changes, and changes in mental status. - Early intervention by the HCP will decrease the risk of damage to the brain tissue

Question 77

hemoglobin normal values

Answer 77

- 11.7-15.5 g/dL for females | - 13.2-17.3 g/dL for males

Question 78

positive TB test

Answer 78

>5 - positive if Immunocompromised clients cannot elicit a good inflammatory response -- these clients include all HIV and organ transplant recipients (who are usually on immunosuppressant medications). An individual exposed to active TB is at very high risk of developing TB infection >15 is all normal healthy individuals with no known risk factors >10 is Clients who do not belong to either the ≥5 mm group or the ≥15 mm group

Question 79

Receptive aphasia refers

Answer 79

to impairment or loss of comprehension. - ask questions that require simple "yes" or "no" responses. - It is helpful to see gestures or pictures of the goal of the activity

Question 80

When caring for a client with severe burns, the nurse can expect to administer pain medication via which route?

Answer 80

IV

Question 81

Bell palsy

Answer 81

- presents as acute onset of unilateral facial paralysis related to inflammation of the facial nerve (ie, cranial nerve VII) that may be triggered by a viral illness (eg, herpes simplex virus). - Standard treatment includes corticosteroids (eg, prednisone) within 72 hours of symptom onset. Symptoms include the following: - Inability to completely close the eye on the affected side - Flattening of the nasolabial fold on the side of the paralysis - Inability to smile or frown symmetrically - Alteration in tear production (eg, decreased tearing with extreme dryness, excessive tearing) due to lower eyelid muscle weakness Client teaching should include the following: - Eye care: Use glasses during the day; wear a patch (or tape the eyelids) at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea - Oral care: Chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food (eg, parotitis, dental caries)

Question 82

for kids with scabies what to do with to disinfect home

Answer 82

Scabies mites do not survive away from human skin for more than 2-3 days. Therefore, disinfecting the client's clothes, linens and stuffed animals involves placing these in a plastic bag (for a minimum of 3 days) or machine washing them in hot water and drying them on the hottest dryer cycle. - Fumigation of living areas is also not needed for the same reason

Question 83

Serotonin syndrome

Answer 83

- potentially life-threatening condition - develops when drugs affecting the body's serotonin levels are administered simultaneously or in overdose. - Drugs, which may trigger this reaction, include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), dextromethorphan, ondansetron, St. John's wort, and tramadol. - Symptoms may include mental status changes (eg, anxiety, agitation, disorientation), autonomic dysregulation (eg, hyperthermia, diaphoresis, tachycardia/hypertension), and neuromuscular hyperactivity (eg, tremor, muscle rigidity, clonus, hyperreflexia).

Question 84

trisomy 21 =

Answer 84

Down syndrome | - Characteristic features include a single palmar crease and a short neck with excess skin (nuchal fold).

Question 85

signs of fetal alcohol syndrome

Answer 85

growth deficiency, neurological symptoms (eg, microcephaly), or specific facial characteristics (indistinct philtrum, thin upper lip, epicanthal folds, flat midface, and short palpebral fissures).

Question 86

nonmaleficence =

Answer 86

do no harm

Question 87

Beneficence =

Answer 87

is a nurse's duty to promote good and do what is best for the client Beneficence is the ethical principle of doing good. It involves helping to meet the client's (including the family) emotional needs through understanding. This can involve withholding information at times.

Question 88

Paternalism =

Answer 88

is a type of beneficence whereby clients are treated as children. The nurse claims to know what is best for the client and coerces the client to act as the nurse wishes without considering the client's autonomy.

Question 89

Veracity =

Answer 89

the duty to tell the truth. This principle should always be applied to client care and documentation.

Question 90

cardiac tamponade

Answer 90

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac tamponade. - This results in the build-up of fluid in the pericardial sac, which leads to compression of the heart. - Cardiac output begins to fall as cardiac compression increases, resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea, tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus paradoxus. - Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg during inspiration.

Question 91

what is in airborne isolation

Answer 91

Tuberculosis Varicella (chickenpox)* Rubeola (measles) negative pressure room with N95 particle respirator

Question 92

The nurse should take immediate action when a client recovering from a vaginal hysterectomy saturates how many peripads

Answer 92

more than one perineal pad in an hour.

Question 93

The nurse should assess the client for pulsus paradoxus when

Answer 93

cardiac tamponade is suspected. The amount of paradox is the difference between the pressure heard at the first Korotkoff sound during expiration and the Korotkoff sounds heard throughout inspiration and expiration. A difference of <10 mm Hg is normal, but if it is >10 mm Hg, this may indicate cardiac tamponade.

Question 94

laparoscopic cholecystectomy is the safest and most commonly used procedure for

Answer 94

gallbladder removal

Question 95

Babinski reflex

Answer 95

<1 year - toes fan out and big toe goes up >1 year - plantar flex - so toes go down = no Babinski the toes going upward in an adult (Babinski) indicates an upper motor neuron (brain or spinal cord) lesion.

Question 96

The presence of sunset eyes (sclera above iris) is a late sign of

Answer 96

increased intracranial pressure

Question 97

when you see umbilical cord protruding out of vagina

Answer 97

- Position the client on hands and knees (eg, knee-chest position) or Trendelenburg position is used to relieve pressure on the compressed cord - the nurse may also use a sterile, gloved hand to help lift the presenting part off the cord; the hand should remain in the vagina until the HCP arrives. Other actions include administration of oxygen and IV fluids.

Question 98

Umbilical cord prolapse

Answer 98

may occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix. Cord compression caused by a prolapsed cord will produce abrupt fetal heart rate deceleration, fetal bradycardia, and disruption of fetal oxygen supply. The priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord. If a prolapsed cord is visualized or palpated, the nurse should then manually elevate the presenting fetal part off the umbilical cord, leave the hand in place, and call for help An emergency cesarean section is usually required unless vaginal birth is imminent and considered safe by the health care provider .

Question 99

Suprapubic pressure helps to

Answer 99

dislodge an impacted anterior shoulder from under the client's pubic bone in the event of shoulder dystocia

Question 100

Leopold maneuvers are used as

Answer 100

a systematic approach to palpating the pregnant abdomen to identify fetal presentation

Question 101

The McRoberts maneuver consists of

Answer 101

- sharply flexing the thigh onto the maternal abdomen to straighten the sacrum. - It is used for shoulder dystocia

Question 102

The Bishop score is

Answer 102

- a system for the assessment and rating of cervical favorability and readiness for induction of labor. - The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part. - A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score ≥8 usually indicates that induction will be successful

Question 103

Strabismus =

Answer 103

crossed eye | - one eye may appear deviated inward (esotropia) or outward (exotropia)

Question 104

Epiglottitis refers to

Answer 104

- inflammation of the epiglottis that may result in life-threatening airway obstruction. - Edema can develop rapidly (as quickly as a few minutes) and obstruct the airway by occluding the trachea. There has been a 10-fold decrease in its incidence due to the widespread use of the Hib (Haemophilus influenzae type B) vaccine. - The affected child will typically progress from having no symptoms to having a completely occluded airway within hours. - Symptoms begin with abrupt onset of high-grade fever and a severe sore throat, followed by the 4 Ds: drooling, dysphonia, dysphagia, and distressed airway (inspiratory stridor). - Children are typically toxic-appearing and may be "tripoding" (sitting up and leaning forward) with inspiratory stridor. - The child should be allowed to assume a position of comfort (usually sitting rather than lying down). The priority nursing response is to protect the airway - throat inspection should not be done until emergency intubation is readily available (if necessary). - This is a pediatric emergency and should be managed with endotracheal intubation; however, intubation of such clients is difficult, and preparation for possible tracheostomy is also standard. The complications of epiglottitis are serious and include sudden airway obstruction.

Question 105

Rotavirus is

Answer 105

a contagious virus and the leading cause of diarrhea in children less than 5 years old - spread via the fecal-oral route. - Because the virus lives easily outside a human host, transmission can occur through contact with food, toys, diapers, and hands. Meticulous handwashing and proper diaper disposal prevent the spread of the virus - Symptoms include foul-smelling, watery diarrhea that lasts 5-7 days and is often accompanied by fever and vomiting. - Vaccination is available and must be given before the child is 8 months old. However, vaccinated children can still acquire Rotavirus as many strains are not covered by the vaccine. Antibiotics are not effective against this viral agent. - Because the virus can easily lead to dehydration, parents should be taught the symptoms (eg, lack of tears when crying, extremely fussy or sleepy, decreased urination, dry mucous membranes). Oral rehydration solutions should be used to combat dehydration

Question 106

Sepsis neonatorum is

Answer 106

- a medical emergency. - Newborns may not exhibit obvious signs of infection but instead may have elevated temperature or be hypothermic. Subtle changes such as irritability, increased sleepiness, and poor feeding should be considered red flags. - Blood, urine, and cerebrospinal fluid cultures should be obtained immediately and broad-spectrum antibiotics started.

Question 107

hydrocele

Answer 107

a fluid-filled testicular mass | - painless, bilateral testicular swelling

Question 108

Signs and symptoms of cardiac tamponade include:

Answer 108

- Hypotension with narrowed pulse pressure - Muffled or distant heart tones - Jugular venous distension - Pulsus paradoxus - Dyspnea, tachypnea - Tachycardia

Question 109

cardiac tamponade

Answer 109

Pericardial effusion is a buildup of fluid in the pericardium. Tamponade, a serious complication of pericardial effusion, develops as the effusion increases in volume and results in compression of the heart. The heart struggles to contract effectively against the fluid, and cardiac output can decrease drastically. This life-threatening complication requires an emergency pericardiocentesis (a needle inserted into the pericardial sac to remove fluid).

Question 110

open-angle glaucoma

Answer 110

- eye condition characterized by an increase in intraocular pressure and gradual loss of peripheral vision (ie, tunnel vision). - The signs/symptoms of POAG develop slowly and include painless impairment of peripheral vision with normal central vision, difficulty with vision in dim lighting, increased sensitivity to glare, and halos observed around bright lights. - POAG can lead to blindness if left untreated.

Question 111

Retinal detachment

Answer 111

- separation of the retina from the underlying epithelium that allows fluid to collect in the space. - The signs/symptoms include sudden onset of light flashes!!, floaters, cloudy vision, or a curtain appearing in the vision. - emergency management. - An unrepaired complete retinal detachment can cause blindness

Question 112

macular degeneration

Answer 112

- progressive, incurable disease of the eye in which the central portion of the retina, the macula, begins to deteriorate with age. - This causes distortion (blurred or wavy disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact. - "Dry" macular degeneration occurs when the microvasculature supplying the macula is blocked, causing ischemia. - "wet" macular degeneration, abnormal blood vessels form and eventually destroy the macula. If it is diagnosed early, further progression of wet macular degeneration can be slowed or stopped using surgery or antineoplastic agents. - Age and heredity are the biggest risk factors for macular degeneration.

Question 113

cataract

Answer 113

- cloudiness (ie, opacity) of the lens that may occur at birth or more commonly in older adults. - The signs/symptoms of a cataract include painless, gradual loss of visual acuity with blurry vision; scattered light on the lens producing glare and halos, which are worse at night; and decreased color perception.

Question 114

Anaphylaxis is

Answer 114

a medical emergency requiring rapid assessment and intervention. Symptoms of an anaphylactic reaction include signs of respiratory compromise (eg, oral and airway swelling, stridor, wheezing, chest tightness) and shock (eg, dizziness, loss of consciousness).

Question 115

SIRS → Sepsis → Septic shock → MODS

Answer 115

SIRS → Generalized inflammatory response to an infectious or noninfectious insult to the body Sepsis → Presence (probable or documented) of infection along with systemic manifestations of infection Septic shock → Sepsis-induced hypotension despite adequate fluid resuscitation (30 mL/kg)

Question 116

SIRS

Answer 116

- systemic inflammatory response syndrome - Generalized inflammatory response to an infectious or noninfectious insult to the body - fever, tachycardia, tachypnea Diagnostic criteria for SIRS include 2 or more of the following manifestations: - Hyperthermia (temperature >100.4 F) or hypothermia (temperature <96.8 F) - Heart rate >90/min - Respiratory rate >20/min or alkalosis (PaCO2 <32 mm Hg) - Leukocytosis (WBC count >12,000/mm3)

Question 117

Sepsis

Answer 117

- SIRS + infected source Identified - ex pneumonia, UTI - systemic inflammatory response (ie, increased heart rate, respirations, temperature, and decreased systolic blood pressure) to a documented or suspected infection is a systemic inflammatory response to an infection and can occur as a complication of pneumonia in clients who do not respond to antibiotic therapy. It is caused by the entry of bacteria from the alveoli into the bloodstream. Manifestations characteristic of sepsis include heart rate >90 beats/min, temperature >100.9 F (38.3 C), systolic blood pressure <90 mm Hg, altered mental status, and hyperglycemia (>140 mg/dL [7.8 mmol/L]) in the absence of diabetes. The assessment findings most important for the nurse to report to the health care provider include the following: - Absent bowel sounds. Paralytic ileus occurs in the presence of sepsis and hypoxia as blood is shunted away from the gastrointestinal tract to the vital organs. - Capillary refill 5 seconds. Prolonged capillary refill (>3-4 seconds in an adult) indicates inadequate blood flow to peripheral tissues. - Serum glucose >140 mg/dL (7.8 mmol/L). Gluconeogenesis occurs in response to the physiologic stress of infection. Insulin resistance is associated with anaerobic metabolism

Question 118

Septic Shock

Answer 118

- Sepsis + hypotension despite adequate IV fluid intake ex 2L of NS

Question 119

MODS

Answer 119

- multi-organ dysfunction syndrome - the failure of 2 or more body organs (eg, acute kidney injury, acute respiratory distress syndrome). - Septic shock can progress to multiorgan dysfunction (ie, severe end of sepsis and septic shock).

Question 120

Kawasaki disease (KD)

Answer 120

- a childhood condition that causes inflammation of arterial walls (vasculitis). The coronary arteries are affected in KD, and some children develop coronary aneurysms. - The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. - KD has 3 phases: - --Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red (strawberry tongue). - --Subacute - skin begins to peel from the hands and feet. The child remains very irritable. - --Convalescent - symptoms disappear slowly. The child's temperament returns to normal. - Initial treatment consists of IV gamma globulin (IVIG) and aspirin. IVIG creates high plasma oncotic pressure, and signs of fluid overload and pulmonary edema develop if it is given in large quantities. Therefore, the child should be monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing). Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion. KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms. When children with KD are discharged home, parents are instructed to monitor them for fever by checking the temperature (orally or rectally) every 6 hours for the first 48 hours following the last fever. Temperature should also be checked daily until the follow-up appointment. If the child develops a fever, the health care provider should be notified as this may indicate the acute phase of KD recurrence. The child may require additional treatment with IV immunoglobulin to prevent development of coronary artery aneurysms and occlusions.

Question 121

Appropriate actions for a client in Buck's skin traction include:

Answer 121

- The client should be supine or in semi-Fowler's position (maximum of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding - These clients are at increased risk for impaired skin integrity and neurovascular status as traction exerts pressure on nerves, blood vessels, and soft tissue. Skin breakdown can occur very quickly, especially at pressure points. Therefore, the nurse should perform neurovascular (eg, pulse, capillary refill, color, temperature, sensation, movement) and skin assessments (eg, heel, dorsum of foot) every 2 hours - Loosen Velcro straps if the boot is too tight as they can impair neurovascular status and skin integrity; tighten the straps if the boot is too loose as this can decrease effectiveness of the traction. When a change is made in the application of the boot or traction pulley system, the nurse should reassess neurovascular status in 30 minutes - Provide a fracture pan, which is smaller than a bedpan, for elimination needs to minimize client movement and provide comfort - Weights should be free-hanging at all times and should never be placed onto the bed or touch the floor. A staff member should support the weight while the client is repositioned up in bed to prevent excessive pull on the extremity - Do not turn a client in Buck's traction from side to side. An abduction pillow is used to maintain proper thigh and hip alignment in postoperative hip arthroplasty. The nurse encourages the client to use the overhead trapeze to lift, move the upper body, and change position frequently. - The extremity in traction should be kept above the client's heart level for effective countertraction (between body and weights)

Question 122

Atopic dermatitis

Answer 122

(eczema) - a chronic skin disorder characterized by pruritus, erythema, and dry skin. - In infants, red, crusted, scaly lesions may also be present. - It is commonly first diagnosed before age 1 year. - The exact cause is unknown, although it is associated with an impaired skin barrier that allows penetration of allergens, leading to an immune response. - The primary goals of management are to alleviate pruritus and keep the skin hydrated to prevent scratching. Scratching leads to the formation of new lesions and predisposes to secondary infections. - Important measures to prevent scratching include cutting and filing nails short, placing gloves or cotton stockings over the hands, not wearing rough fabrics or woolen clothing, and applying moisturizer.

Question 123

Preeclampsia

Answer 123

a systemic disease characterized by hypertension and proteinuria after the 20th gestational week with unknown etiology.

Question 124

Eclampsia

Answer 124

is the onset of convulsions or seizures that cannot be attributed to other causes in a woman with preeclampsia.

Question 125

sleep apnea

Answer 125

At night, clients experience repeated periods of apnea, loud snoring, and interrupted sleep. During the day, morning headaches, irritability, and excessive sleepiness are common. Interventions: - Continuous positive airway pressure device at night to keep the structures of the pharynx and tongue from collapsing backward - Limiting alcohol intake at bedtime as it can cause muscles of the oral airway to relax and lead to airway obstruction - Weight loss and exercise can reduce snoring and sleep apnea-associated airway obstruction. Obesity contributes to the development of OSA - Avoiding sedating medications (eg, benzodiazepines, sedating antidepressants, antihistamines, opiates) as they may exacerbate OSA and worsen daytime sleepiness

Question 126

Cataplexy

Answer 126

is a brief loss of skeletal muscle tone or weakness that can result in a client falling down. - It is associated with narcolepsy, a chronic neurologic sleep disorder.

Question 127

Bacterial conjunctivitis

Answer 127

(pink eye) presents with conjunctival erythema; thick, purulent drainage; and "crusted" eyelids. - The client will receive antibiotic drops or ointment, warm soaks/cool compresses, and infection control. - Pink eye is highly contagious but not emergent. - washing hands is very important

Question 128

C-reactive Protein test

Answer 128

- CRP is a non-specific test used to detect acute or chronic inflammation in the body. - can be used to evaluate the effectiveness of medications that decrease inflammation. - An elevation would be expected in clients with RA, especially during a flare

Question 129

Genu varum

Answer 129

(bowlegs) , the lateral bowing of the legs, is common in toddlers as they learn to walk. - resolves by 18-24 months after they develop strength in their legs and lower back. - After 2 years, normal alignment will again progress to valgus deformity until age 4 and then will return to normal adult alignment by age 7. - All of this is a normal physiologic alignment.

Question 130

Teaching topics for clients on anticoagulants:

Answer 130

- Take medication at the same time daily - Depending on medication, report for periodic blood tests to assess therapeutic effect - Avoid any action that may cause trauma/injury and lead to bleeding (eg, contact sports, vigorous teeth brushing, use of a razor blade) - Avoid aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) - Limit alcohol consumption - Avoid changing eating habits frequently (eg, dramatically increasing intake of foods high in vitamin K such as kale, spinach, broccoli, greens) and do not take vitamin K supplements - Consult with health care provider before beginning or discontinuing any medication or dietary/herbal supplement (eg, Ginkgo biloba and ginseng affect blood clotting and may increase bleeding risk) - Wear a medical alert bracelet indicating what anticoagulant is being taken

Question 131

Mechanical prosthetic valves are more durable than biological valves but require

Answer 131

long-term anticoagulation therapy due to the increased risk of thromboembolism

Question 132

Trisomy 18

Answer 132

(Edwards syndrome) is a chromosome anomaly characterized by severe cardiac defects and multiple musculoskeletal deformities. - Life expectancy for trisomy 18 is a few weeks after birth, neonates rarely survive to their first birthday. - End-of-life issues should be discussed early after the diagnosis is confirmed. - Trisomy 13 (Patau syndrome) also results in early death.

Question 133

A client diagnosed with cirrhosis may experience

Answer 133

- pruritus (itching) due to buildup of bile salts beneath the skin. The nurse encourages the client to cut the nails short, wear cotton gloves, and wear long-sleeved shirts to avoid injury to the skin from scratching. Other comfort measures include baking soda baths; calamine lotion; and cool, wet cloths, which cool and soothe irritated skin. Cholestyramine (Questran) may be prescribed to increase the excretion of bile salts in the feces, thereby decreasing pruritus. It is packaged in a powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given one hour after all other medications are administered.

Question 134

To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at

Answer 134

the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter (½ AP)of the chest wall. - If the transducer is placed too low, the reading will be falsely high; if placed too high, the reading will be falsely low. - This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure-monitoring device. The upper arm should be at the level of the phlebostatic axis

Question 135

Celiac disease

Answer 135

- an autoimmune disorder in which the body is unable to process gluten, a protein found in most grains. - Gluten consumption will damage the villi of the small intestine; this results in malabsorption of fats (steatorrhea, foul-smelling stools) and other nutrients, which can lead to malnutrition and failure to thrive. - The child will need to adhere to a gluten-free diet for life. A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW) !!!! The following are important dietary principles to teach clients with celiac disease: - All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. - Rice, corn, and potatoes are gluten free and are allowed on the diet - Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten, such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. - Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from their diet reduces the risk for nutritional deficiencies and intestinal cancer (lymphoma). - Eating even small amounts of gluten will damage the intestinal villi, although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet.

Question 136

To prevent air embolism when discontinuing a central venous catheter, the nurse should perform the following interventions:

Answer 136

- Instruct the client to lie in a supine position. This will increase the central venous pressure and decrease the possibility of air getting into the vessel - Instruct the client to bear down or exhale. The client should never inhale during removal of the line; inhalation will suck more air into the blood vessel via negative suction pressure - Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help prevent a delayed air embolism. If possible, the nurse should attempt to cover the site with the occlusive dressing while pulling out the line - Pull the line cautiously and never pull harder if there is resistance. Doing so could cause the catheter to break or become dislodged in the client's vessel

Question 137

oral candidiasis

Answer 137

from Candida albicans (thrush) include white patches on the oral mucosa, palate, and tongue. - The patches are nonremovable and tend to bleed when touched. - The affected infant may have difficulty sucking or feeding due to the associated pain. - Thrush is generally linked to antibiotic therapy or poor caregiver hand hygiene. - The infection is usually self-limiting, but treatment with a fungicide (eg, nystatin) may hasten recovery. often occurs after a course of antibiotics or corticosteroids or can occur in infants with immature immune systems. An infant who is breastfed can transfer candidiasis to the mother's breast. There is also a small risk of transmission when infants place pacifiers or toys in their mouths and subsequently transfer these items to another child's mouth. Immunosuppressed individuals such as those taking corticosteroid medications, clients undergoing chemotherapy or radiation, or clients with immune deficiency states (eg, AIDS) have an increased incidence. Clients receiving prolonged or high-dose antibiotic treatment are at increased risk as the normal microbial flora of the mouth is reduced, allowing other opportunistic infections to arise. Individuals with dentures and infants also commonly experience monilial infections. Treatment is antifungal medications (eg, nystatin) and proper oral hygiene.

Question 138

Erythema toxicum neonatarum

Answer 138

- characterized by firm, white or yellow papules or pustules surrounded by erythema. - This idiopathic rash, which closely resembles flea bites, appears in the first few days after birth and resolves within 5-7 days. - There are no additional systemic effects, and the rash requires no treatment.

Question 139

Epstein pearls

Answer 139

are small, white cysts found on the hard palate of newborns. These cysts are considered common findings, and they disappear a few weeks after birth.

Question 140

The sequence of basic life support (BLS) for an unconscious, pulseless client includes:

Answer 140

1. Verify unresponsiveness by tapping or gently shaking the client while calling by name or shouting, "Are you all right?" 2. Activate the emergency response system by calling for help if in the hospital, or by calling 911 and obtaining an automated external defibrillator (AED) if outside the hospital. The emergency response system should be activated for all unresponsive clients. This allows the nurse to quickly proceed with assessment of pulse and respirations without delaying to retrieve a defibrillator. 3. Simultaneously check the carotid pulse and check the client for breathing for no more than 10 seconds 4. Attempt cardiopulmonary resuscitation if no pulse is felt, starting with chest compressions (circulation, airway, breathing [CAB] sequence) - - Chest compression rate should be 100-120/min. - - Chest compression depth should be 2-2.4 in (5-6 cm). 5. Notify the health care provider if not already on scene

Question 141

if pt with peritoneal dialysis has Insufficient outflow

Answer 141

- results most often from constipation when distended intestines block the catheter's holes. - If outflow becomes sluggish, the nurse should assess the client's bowel patterns and administer appropriate prescribed medications (eg, stool softeners) - The nurse should also check the tubing for kinks and reposition the client to a side-lying position or assist with ambulation - The drainage bag should be maintained below the abdomen to promote gravity flow. - The nurse should assess for fibrin clots and milk the tubing to dislodge or administer fibrinolytics (eg, alteplase) as prescribed. - If these measures are ineffective, an x-ray may be needed to check the catheter location.

Question 142

Hyperparathyroidism

Answer 142

- usually due to a benign adenoma on the parathyroid gland. - The parathyroid gland produces parathyroid hormone (PTH), which regulates serum calcium levels. - The majority of the body's calcium is stored in the bones, and elevated levels in PTH will accelerate osteoporosis as calcium is released from storage. - Elevated serum calcium is excreted into the urine, forming kidney stones (nephrolithiasis). In addition, calcium has a diuretic effect, producing symptoms of polyuria and polydipsia. - High calcium levels can cause constipation.

Question 143

Fifth disease

Answer 143

Parvovirus B-19 - ("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. - The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. - The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. - Affected children typically recover quickly, within 7-10 days. - Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition. - Pregnant women should avoid contact with infected individuals as the virus can be transmitted to the fetus and cause anemia or cause fetal anomalies (eg, hydrops fetalis, stillbirth)

Question 144

Percutaneous kidney biopsy

Answer 144

- an invasive diagnostic procedure that involves inserting a needle through the skin to obtain a tissue sample that is then used to determine the cause of certain kidney diseases. - The kidney is a highly vascular organ; therefore, uncontrolled hypertension is a contraindication for kidney biopsy as increased renal arterial pressure places the client at risk for post-procedure bleeding. Blood pressure must be lowered and well-controlled (goal <140/90 mm Hg) using antihypertensive medications before performing a kidney biopsy

Question 145

The client being admitted for heart failure-related fluid overload is likely to have

Answer 145

dyspnea (difficulty breathing), orthopnea (labored breathing in a supine position), and paroxysmal nocturnal dyspnea (waking suddenly with difficulty breathing). - Rales or "crackles" may be auscultated in the lungs as a result of pulmonary congestion.

Question 146

Hemophilia

Answer 146

is a bleeding disorder caused by a deficiency in coagulation proteins. - Clients with classic hemophilia, or hemophilia A, lack factor VIII. - Clients with hemophilia B (Christmas disease) lack factor IX. - When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. - The most frequent sites of bleeding are the joints (80%), especially the knee. - Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory. - Over time, chronic swelling and deformity can occur - The nurse should avoid procedures that can cause bleeding (eg, intramuscular injections, rectal temperature measurement). Vaccinations are administered subcutaneously whenever possible to prevent intramuscular hematoma. The smallest gauge needle is used, and firm, continuous pressure is applied at the site for 5 minutes - Children with hemophilia should avoid aspirin and nonsteroidal anti-inflammatory drugs due to the risk of bleeding. Acetaminophen is recommended for pain relief. - Firm pressure should be held on the site without rubbing or massaging due to the risk of bleeding and hematoma formation. Superficial bleeding can be controlled using ice packs, which promote vasoconstriction. Applying a warm compress would cause vasodilation and prolong bleeding

Question 147

Treatment of frostbite should include the following:

Answer 147

- Remove clothing and jewelry to prevent constriction. - Do not massage, rub, or squeeze the area involved. Injured tissue is easily damaged - Immerse the affected area in water heated to 98.6-102.2 F (37-39 C), preferably in a whirlpool. Higher temperatures do not significantly decrease rewarming time but can intensify pain - Avoid heavy blankets or clothing to prevent tissue sloughing. - Provide analgesia as the rewarming procedure is extremely painful - As thawing occurs, the injured area will become edematous and may blister. Elevate the injured area after rewarming to reduce edema - Keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings - Monitor for signs of compartment syndrome.

Question 148

pincer grasp

Answer 148

- a thumb to forefinger movement, develops at age 8-10 months. - This is the time to start offering small finger foods, such as Cheerios or cut-up pieces of nutritious foods. - Caregivers should inform their health care provider if the infant does not achieve this significant milestone in fine motor development.

Question 149

nitrazine pH test strip

Answer 149

- is inserted into the vagina can differentiate between amniotic fluid, which is alkaline, and vaginal fluid, which is acidic. - A blue-green, blue-gray, or deep blue color indicates a positive result and probable rupture of membranes. - A yellow, olive-yellow, or olive green color indicates a negative result and suggests that membranes are intact.

Question 150

Magnesium toxicity

Answer 150

- causes central nervous system depression because the toxic levels block neuromuscular transmission. - Absent or decreased deep-tendon reflexes (DTRs) are the earliest sign of magnesium toxicity. DTRs are scored on a scale of 0-4+ and should be assessed during magnesium infusion; normal findings are 2+ - Urine output <30 mL/hr is a sign of magnesium toxicity - If toxicity is not recognized early (eg, decreasing DTRs), clients can progress to respiratory depression, followed by cardiac arrest - Assessments (including vital signs) should be performed every 5-15 minutes during the loading dose, followed by 30- to 60-minute intervals until the client stabilizes, then every 2 hours. - Treatment for magnesium toxicity is immediate discontinuation of the infusion. - Administration of calcium gluconate (antidote) is recommended only in the event of cardiorespiratory compromise.

Question 151

signs of hyperglycemia

Answer 151

excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision

Question 152

Paracentesis is performed to

Answer 152

- remove excess fluid from the abdominal cavity or to provide a specimen of ascitic fluid for diagnostic testing. - it is not a permanent solution for resolving ascites and is performed only if the client is experiencing impaired breathing or pain due to ascites. Nursing actions include: - Explain the procedure, sensations, and expected results - Instruct the client to void to prevent puncturing the bladder - Assess the client's abdominal girth, weight, and vital signs - Place the client in high Fowler's position and remain with the client during the procedure - After the procedure, assess and bandage the puncture site and reassess client weight, girth, and vital signs

Question 153

Diverticulitis

Answer 153

- Diverticula are saclike protrusions or outpouchings of the intestinal mucosa of the large intestine caused by increased intraluminal pressure (chronic constipation). The left (descending, sigmoid) colon is the most common area for diverticula to develop. - When these diverticula become inflamed (diverticulitis), the client may experience acute pain (usually in the left lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis). - Complications that can occur in some clients are abscess formation (continuous fever despite antibiotics and palpable mass) and intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding, rebound tenderness). - The client with peritonitis prefers to lie still and take shallow breaths to avoid stretching the inflamed peritoneum. Peritonitis is a potentially lethal complication and should be reported immediately.

Question 154

ventriculoperitoneal shunt

Answer 154

- used to treat hydrocephalus and is usually placed at age 3-4 months. - Blockage and infection are complications of shunt placement. - Blockage results in signs of increased intracranial pressure (ICP). - The normal pulse range for a 1-year-old is 100-160/min. A pulse of 78/min is considered bradycardia, a part of Cushing's triad (bradycardia, slowed respiration, widened pulse pressure).

Question 155

Meningocele is

Answer 155

- a saclike protrusion through a bony defect that contains meninges and cerebrospinal fluid - it is corrected with surgery. - In some children, residual bowel and bladder incontinence can result despite surgery. If bowel and bladder control is obtained but incontinence reoccurs, the child should be evaluated for infection (a common complication).

Question 156

Muscular dystrophy is

Answer 156

- an inherited condition of muscle fiber degeneration and muscle wasting. (muscle fibers are replaced by connective tissue) - Respiratory and cardiac problems are the leading causes of mortality. - These clients should take precautions to prevent respiratory infections (eg, pneumococcal and influenza vaccination, avoiding contact with infected individuals).

Question 157

Discharge teaching after tonsillectomy

Answer 157

- Avoid coughing, clearing the throat, or blowing of the nose - Limit physical activity - Milk products are discouraged due to their coating effect, which can prompt clearing of the throat - Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation

Question 158

Lithium therapeutic levels

Answer 158

- usual ranges are 1.0-1.5 mEq/L (1.0-1.5 mmol/L) for treatment of acute mania - and 0.6-1.2 mEq/L (0.6-1.2 mmol/L) for maintenance therapy - Acute lithium toxicity >1.5 mEq/L

Question 159

when do you give the MMR vaccine ?

Answer 159

given to children between age 12-15 months to ensure optimal vaccine response. As advised by the CDC, a child age <12 months can and should receive the MMR vaccine when there is an outbreak of measles and the child risks contracting the illness due to an exposure. The child will need to be revaccinated between age 12-15 months and between age 4-6 years.

Question 160

Hepatic encephalopathy is a

Answer 160

reversible neurological complication of cirrhosis caused primarily by increased ammonia levels in the blood. - Normally, ammonia created in the intestines is converted to urea in the liver and excreted in the kidneys. - However, in the presence of liver damage, blood is shunted around the liver portal system and ammonia is able to cross the blood-brain barrier, leading to neurological dysfunction - Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person. A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists. Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts. - Oral lactulose is given to reduce the ammonia by trapping it in the gut and then expelling it with a laxative effect. Improved mental status implies reduction of ammonia levels

Question 161

Pre-procedure client instructions for a pharmacologic nuclear stress test include the following:

Answer 161

- Do not eat, drink, or smoke on the day of the test (NPO for at least 4 hours). Small sips of water may be taken with medications - Avoid caffeine products 24 hours before the test - Avoid decaffeinated products 24 hours before the test as these contain trace amounts of caffeine - Do not take theophylline 24-48 hours prior to the test (if tolerated). - If insulin/pills are prescribed for diabetes, consult the HCP about appropriate dosage on the day of the test. Hypoglycemia can result if the medicine is taken without food - Some medications can interfere with the test results by masking angina. Do not take the following cardiac medications unless the HCP directs otherwise, or unless needed to treat chest discomfort on the day of the test: - -Nitrates (nitroglycerine or isosorbide) - -Dipyridamole - -Beta blockers

Question 162

The most common clinical manifestations of hip fractures include:

Answer 162

- Ecchymosis and tenderness over the thigh and hip – occur from bleeding into the surrounding tissue as the femur is very vascular and a fracture can result in significant blood loss (>1000 mL) - Groin and hip pain with weight bearing - Muscle spasm in the injured area – occurs as the muscles surrounding the fracture contract to try to protect and stabilize the injured area - Shortening of the affected extremity – occurs because the fracture can reduce the length of the bone and the muscles above the fracture line pull the extremity upward - Abduction or adduction of the affected extremity depending on location and mechanism of injury. - The affected extremity is usually externally rotated.

Question 163

Retinoblastoma

Answer 163

a unilateral or bilateral retinal tumor, is the most common childhood intraocular malignancy. - it is typically diagnosed in children under age 2 and is usually first recognized when parents report a white "glow" of the pupil (leukocoria). - Light reflecting off the tumor will cause the pupil to appear white instead of displaying the usual red reflex - Parents may even accidentally visualize leukocoria when taking a photograph of the child using a flash. - Strabismus (misalignment of the eyes) is the second most common sign; visual impairment is a late sign indicative of advanced disease.

Question 164

Distension of jugular neck veins should be performed with the client sitting with the head of the bed at a

Answer 164

30- to 45-degree angle. - The nurse will observe for distension and prominent pulsation of the neck veins. - The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overload.

Question 165

Intussusception

Answer 165

- a common obstructive disorder in infancy that occurs when one segment of the bowel telescopes into another. - The classic clinical triad is intermittent, severe, crampy abdominal pain; a palpable "sausage-shaped" mass on the right side of the abdomen; and "currant jelly" stools - the stools are mixed with blood and mucus - Other manifestations include inconsolable crying, drawing the knees up to the chest during episodes of pain, and vomiting. The child may appear normal and comfortable between episodes. - Most cases of intussusception are successfully treated without surgery using hydrostatic (saline) or pneumatic (air) enema. - The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the HCP should be notified immediately to modify the plan of care and stop all plans for surgery. occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may result. If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly. A contrast enema is used for diagnostic purposes and often reduces the intussusceptions. An air enema is considered safer than a barium enema.

Question 166

Ear irrigation may be prescribed to remove impacted or excess cerumen; the following steps describe this procedure:

Answer 166

1. Assess client for contraindications (eg, fever, ear infection). Use an otoscope to inspect the external ear canal. Verify that the tympanic membrane is intact and ensure there are no foreign bodies 2. Explain the procedure to the client, including possible sensations (eg, vertigo, fullness, warmth). 3. Place the client in a side-lying or sitting position with the head tilted toward the affected ear. Place a towel and an emesis basin under the ear 4. Verify that the irrigation solution is at body temperature (98.6 F [37 C]) to minimize discomfort. 5. Straighten the ear canal, pulling the pinna up and back for adults or down and back for children age ≤3 years 6. Irrigate gently with a slow, steady flow of solution, directing the syringe tip toward the top of the ear canal. Avoid occluding the canal to prevent increased pressure and rupture of the tympanic membrane. Stop immediately if the client experiences severe pain, nausea, or dizziness. 7. Repeat as tolerated until the ear canal is clear or the prescribed amount is instilled. 8, Document the type, temperature, and volume of solution; exudate characteristics; response to the irrigation; and client teaching.

Question 167

Pica

Answer 167

- is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. - Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. - The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia.

Question 168

what to do with recently extubated pts

Answer 168

Recently extubated clients are at high risk for aspiration, airway obstruction (laryngeal edema and/or spasm), and respiratory distress. - To prevent complications, clients are placed in high Fowler position to maximize lung expansion and prevent aspiration of secretions. - Warmed, humidified oxygen is administered immediately after extubation to provide high concentrations of supplemental oxygen without drying out the mucosa - Oral care is provided to decrease bacteria and contaminants as well as promote comfort - Clients are instructed to frequently cough, deep breathe, and use an incentive spirometer to expand alveoli and prevent atelectasis - Clients are kept NPO after extubation to prevent aspiration. They may have either a bedside swallow screen or a more formal swallow evaluation by a speech therapist prior to swallowing any food, drink, or medication.

Question 169

Accidental dislodgement of the tube in a fresh (immature, < 1 week) tracheostomy

Answer 169

is a medical emergency. - Immediate nursing actions include pulling the retention sutures apart if present, or inserting a curved hemostat to hold the stoma open if sutures are absent. - If desaturation progresses, the nurse should apply a sterile occlusive dressing over the stoma and ventilate the client with a bag-valve mask over the nose and mouth.

Question 170

Some risk factors for preterm birth include:

Answer 170

- History of spontaneous preterm birth in a previous pregnancy (single largest independent risk factor) - Previous cervical surgery, such as a cone biopsy (weakens cervical support) - Tobacco and/or illicit drug use - Maternal ages <17 and >35 are associated with increased risk for preterm birth. - Maternal undernutrition can increase the risk for preterm birth and low infant birth weight. - Non-Hispanic black women have the highest rates of preterm labor and birth. - Infection is strongly associated with preterm labor, particularly when untreated - Infection causes release of inflammatory mediators such as prostaglandins, which are uterotonic (ie, promote contractions) and contribute to cervical softening.

Question 171

Abdominal aneurysms

Answer 171

- may present with a pulsatile mass in the periumbilical area slightly to the left of the midline. - A bruit may be auscultated over the site. - Back/abdominal pain can be present due to compression of nearby anatomical sites or nerve compression from an expanding/rupturing abdominal aortic aneurysm (AAA). - Rupture of an abdominal aneurysm can quickly cause exsanguination and death.

Question 172

Hypovolemic shock

Answer 172

- most common type of shock - occurs when blood volume decreases through hemorrhage or movement of fluid from the intravascular compartment into the interstitial space (third-spacing). - most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute (eg, hemorrhage, surgery, gastrointestinal bleeding, vomiting, diarrhea) or a relative (eg, pancreatitis, sepsis) fluid loss. Reduced intravascular volume results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism. Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: - Change in mental status - Tachycardia with thready pulse - Cool, clammy skin - Oliguria - Tachypnea - Treatment involves preventing additional fluid loss, restoring volume through IV fluids, and improving hemodynamic stability through vasoactive medications (eg, norepinephrine, dopamine).

Question 173

Femoral central venous catheters

Answer 173

- may be placed in emergency situations | - but should be removed/replaced as soon as possible due to the high risk of contamination and infection.

Question 174

Signs and symptoms of hepatitis include

Answer 174

jaundice of the eyes and skin, fatigue, weakness, nausea, and anorexia

Question 175

pyloric stenosis

Answer 175

Pyloric stenosis is a hypertrophy of the pyloric sphincter that eventually causes complete obstruction. Classic signs - often present with excessive hunger (frequent feeder) - a palpable olive-shaped mass in the epigastrium to the right of the umbilicus - projectile vomiting (can be up to 3 feet) - weight loss - dehydration (eg, sunken fontanelle, decreased skin turgor, delayed capillary refill) - and/or electrolyte imbalance (metabolic alkalosis). The amount of milk consumed (particularly with bottle feedings) along with the mother's technique (mainly adequate burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology.

Question 176

The proper method of delivering a dose via Metered Dose Inhaler (MDI) includes the following steps:

Answer 176

1. First shake MDI and attach it to the spacer. 2. Exhale completely to optimize inhalation of the medication. 3. Place lips tightly around the mouth piece. 4. Deliver a single puff of medication into spacer. 5. Take a slow, deep breath and hold it for 10 seconds to allow for effective medication distribution. 6. After the dose, rinse mouth with water to remove any left-over medication from oral mucous membranes. Spit out the water to ensure no medication is swallowed.

Question 177

Ankylosing spondylitis (AS)

Answer 177

- an inflammatory disease affecting the spine that has no known cause or cure. - characterized by stiffness and fusion of the axial joints (eg, spine, sacroiliac), leading to restricted spinal mobility. - Low back pain and morning stiffness that improve with activity are the classic findings. - Involvement of the thoracic spine (costovertebral) and costosternal junctions can limit chest wall expansion, leading to hypoventilation. The client with AS should do the following: - Promote extension of the spine with proper posture, daily stretching, and swimming or racquet sports - Stop smoking and practice breathing exercises to increase chest expansion and reduce lung complications - Manage pain with moist heat and nonsteroidal anti-inflammatory drugs (NSAIDs) - Take immunosuppressant and anti-inflammatory medications as prescribed to reduce inflammation and increase mobility - It is best to rest during flare-ups. The client should wait to exercise until the pain and inflammation are under control. - Clients with AS are encouraged to sleep on their backs on a firm mattress to prevent spinal flexion and the resulting deformity.

Question 178

Metabolic syndrome

Answer 178

(insulin resistance syndrome) is characterized by a group of health complications that increase a client's risk for the development of diabetes mellitus and cardiovascular disease. - The presence of abdominal obesity causes increased insulin production (hyperinsulinemia); this excess insulin leads to insulin resistance, the primary feature of metabolic syndrome - presence of 3 or more of the following conditions: abdominal obesity, hyperglycemia, low HDL, high triglycerides, and hypertension. Criteria for metabolic syndrome include the presence of 3 or more of the following 5 conditions: - Abdominal obesity with increased waist circumference (≥40 inches in men, ≥35 inches in women) - High serum triglycerides >150 mg/dL or on drug treatment for elevated triglycerides - Low HDL cholesterol (<40 mg/dL in men, <50 mg/dL in women) - Hypertension ≥130/85 mm Hg or on drug treatment for elevated blood pressure - Fasting blood glucose level ≥100 mg/dL or on drug treatment for hyperglycemia

Question 179

Delusions

Answer 179

Delusions are one of the positive symptoms of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence. When presented with proof that the delusion is irrational or untrue, the client continues to believe it is real. - delusions of reference - will believe that songs, newspaper articles, and other events are personal and significant to them. - Grandeur – "I need to get to Washington for my meeting with the president." - Control – "Don't drink the tap water. That's how the government controls us." - Nihilistic – "It doesn't matter if I take my medicine. I'm already dead." - Somatic – "The doctor said I'm fine, but I really have lung cancer."

Question 180

lumbar puncture procedure

Answer 180

(spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal fluid (CSF) for diagnostic purposes (eg, meningitis). - A needle is inserted into the vertebral spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. - The nurse's role when assisting with a lumbar puncture includes the following: 1. Verify informed consent 2. Gather the lumbar puncture tray and needed supplies 3. Explain the procedure to older child and adult 4. Have client empty the bladder 5. Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table) 6. Assist the client in maintaining the proper position (hold the client if necessary) 7. Provide a distraction and reassure the client throughout the procedure 8. Label specimen containers as they are collected 9. Apply a bandage to the insertion site 10. Deliver specimens to the laboratory

Question 181

Herpes zoster

Answer 181

or shingles, has a characteristic unilateral, linear pattern of fluid-filled blisters. - Affected clients commonly report pain and itching. - due to the varicella-zoster virus (VZV), which also causes chickenpox. - After initial VZV infection (chickenpox) in early childhood, the virus remains dormant in the sensory nerves. - Reactivation of VZV when the immune system is compromised (eg, aging, immunosuppression) results in the formation of lesions along the distribution of one or more such nerves (dermatomal distribution). - Vaccination can prevent shingles. - Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital. - Localized shingles require only standard precautions for clients with intact immune systems and contained/covered lesions.

Question 182

presbyopia

Answer 182

- Inability to see things close up | - occurs when the lens of the eye becomes less elastic with age and thus unable to adjust to near and far vision.

Question 183

Otitis media (OM)

Answer 183

- inflammation or infection of the middle ear. - OM typically occurs in infants and children under age 2, sometimes following a respiratory tract infection. - The eustachian tubes in infants and young children are short, wide, and fairly horizontal, which results in ineffective draining of respiratory secretions and a potential for recurrent infections. - Episodes of OM often follow a respiratory tract infection, such as influenza or respiratory syncytial virus (RSV). - OM risk also increases when fluid pools in the mouth and then reaches the eustachian tubes (eg, drinking from a bottle while lying down). Potential complications of AOM include hearing loss and spread of the infection. To prevent permanent damage, severe cases of AOM are treated with antibiotics. Amoxicillin is the standard treatment in most cases. However, if AOM symptoms do not improve within 48-72 hours of initiating antibiotic therapy, the client should return for further assessment. The HCP will then assess for other causes of persistent symptoms and determine if a different antibiotic is required to treat drug-resistant organisms.Following treatment with antibiotics, clients with AOM should be evaluated for complete infection resolution and screened for hearing impairment. Established family patterns that can play a role in recurrent OM should be assessed and include: - Recurring exposure to tobacco smoke - Regular pacifier use, particularly after age 6 months - Drinking from a bottle while lying down - Lack of immunizations, particularly the pneumococcal vaccine series Key preventive measures include eliminating exposure to smoke, obtaining routine immunizations to prevent infection, and reducing or eliminating use of a pacifier after age 6 months

Question 184

low pressure alarm with arterial line could mean

Answer 184

can indicate the presence of hypotension or disconnected tubing

Question 185

Necrotizing enterocolitis

Answer 185

- occurs predominantly in preterm infants secondary to gastrointestinal and immunologic immaturity. On initiation of enteral feeding, bacteria can be introduced into the bowel, where they can proliferate excessively due to compromised immune clearance. This results in inflammation and ischemic necrosis of the intestine. As the disease progresses, the bowel becomes congested and gangrenous with gas collections forming inside the bowel wall. - Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. - Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. - Parenteral hydration and nutrition and IV antibiotics are given. - Clients are placed supine and undiapered. - Rectal temperatures should be avoided due to the risk of perforation.

Question 186

Psychomotor retardation is

Answer 186

a clinical symptom of major depressive disorder. - Manifestations include slowed speech, decreased movement, and impaired cognitive function. - The individual may not have the energy or ability to perform activities of daily living or to interact with others. - Psychomotor retardation may range from severe (total immobility and speechlessness -catatonia) or mild (slowing of speech and behavior). Specific clinical findings of psychomotor retardation include the following: - Movement impairment - body immobility, slumping posture, slowed movement, delay in motor activity, slow gait - Lack of facial expression - Downcast gaze - Speech impairment – reduced voice volume, slurring of speech, delayed verbal responses, short responses - Social interaction – reduced or non-interaction - Clients with major depressive disorder may also show symptoms of psychomotor agitation, characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic eye movement.

Question 187

Psychogenic dystonia is a

Answer 187

psychogenic movement disorder characterized by involuntary muscle contractions that cause slow, repetitive movements such as twisting and abnormal postures.

Question 188

Psychogenic gait is a

Answer 188

psychogenic movement disorder characterized by unusual standing postures and walking. The client may experience knee buckling and falling or may veer from side to side as if staggering.

Question 189

Somatization is

Answer 189

a term to describe physical symptoms that cannot be explained by a medical condition or disease.

Question 190

Ventricular bigeminy

Answer 190

- is a rhythm in which every other heartbeat is a premature ventricular contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia, ventricular fibrillation). - Possible causes of ventricular bigeminy include electrolyte imbalances and ischemia. - After assessing the client's vital signs, the nurse should assess potassium and magnesium levels and apical-radial pulse, administer the scheduled amiodarone, and notify the health care provider (HCP).

Question 191

Postoperative nursing care after laparoscopic cholecystectomy

Answer 191

focuses on prevention of respiratory complications. - The client is placed in the Sims' position to facilitate movement of carbon dioxide (CO2) utilized during surgery to fill the abdominal cavity. CO2 can irritate the phrenic nerve and diaphragm, potentially causing breathing difficulty.

Question 192

esophageal atresia (EA) and tracheoesophageal fistula (TEF)

Answer 192

consist of a variety of congenital malformations that occur when the esophagus and trachea do not properly separate or develop. In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected with surgery. Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, and drooling. Clients may also develop apnea and cyanosis during feeding. Aspiration is the greatest risk for clients with EA/TEF, and newborns who demonstrate signs of the condition are immediately placed on nothing by mouth (NPO) status. A newborn with EA/TEF may have a distended abdomen due to the buildup of air in the stomach via the fistula from the trachea to the lower esophagus. A concave (ie, scaphoid) abdomen is associated with a congenital diaphragmatic hernia due to the migration of abdominal organs to the thoracic space. - Excessive frothy mucus and cyanosis could be seen - If EA/TEF is suspected, the infant should be kept supine with the head elevated at least 30 degrees to prevent aspiration. - A nasogastric tube should be inserted and connected to continuous or intermittent suction until surgical repair Aspiration is the greatest risk for clients with EA/TEF. Priority nursing interventions for infants with suspected EA/TEF include maintaining NPO status, positioning the client supine, elevating the head at least 30 degrees, and keeping suction equipment by the bed to clear secretions from the mouth. If surgery must be staged or delayed due to the infant's condition, the priority is to maintain a clear airway and prevent aspiration..

Question 193

Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Answer 193

- caused by the ectopic production of ADH by a malignant lung tumor (eg, lung cancer). Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. - Severe neurologic dysfunction (eg, confusion, seizures) can occur when serum sodium drops below 120 mEq/L (normal: 135-145 mEq/L). - Hyponatremia requires immediate evaluation and treatment (eg, seizure precautions, fluid restriction, intravenous hypertonic saline) by the health care provider.

Question 194

s/s of PE

Answer 194

``` Dyspnea (85%) Pleuritic chest pain (60%) Tachycardia Tachypnea Hypoxemia (impaired gas exchange, decreased perfusion with normal alveolar ventilation, shunting) Apprehension and anxiety ```

Question 195

client with osteoporosis and calcium

Answer 195

- take supplemental calcium with food to increase its absorption. - Vitamin D will also enhance absorption. - Multiple daily doses are recommended as calcium absorption is impaired when taken in excess of 500 mg per dose. - Constipation is a frequent side effect of calcium supplementation.

Question 196

normal urine specific gravity values

Answer 196

ranges from 1.003 to 1.030. | - Causes of increased specific gravity include fluid deficit.

Question 197

Trismus

Answer 197

(inability to open the mouth due to a tonic contraction of the muscles used for chewing) may indicate a more serious complication of tonsillitis, a peritonsillar or retropharyngeal abscess (collection of pus). - Other features include a "hot potato" or muffled voice, pooling of saliva, and deviation of the uvula to one side. - This abscess can occlude the airway, making it a medical emergency. Surgical intervention (tonsillectomy or incision and drainage) is often required. In the meantime, maintaining an adequate airway is essential.

Question 198

administering medications through feeding tube

Answer 198

- When a feeding tube is used, medications should be crushed, dissolved, and administered separately to prevent interactions. - Sterile water should be used to dissolve medications and flush the feeding tube. - Liquid medications should be used if possible.

Question 199

Hemorrhagic cystitis

Answer 199

(eg, bladder inflammation) is a well-known complication of cyclophosphamide (immunosuppressant and chemotherapy agent). - The client is instructed to drink plenty of fluids. This client may need IV hydration and other preventive measures (eg, mesna therapy). - Bleeding is usually minimal and occasionally requires a blood transfusion, but is rarely life threatening.

Question 200

Supine hypotensive syndrome

Answer 200

- occurs when the weight of the abdominal contents compresses the vena cava causing decreased venous return to the heart. This results in low cardiac output (maternal hypotension) and reflex tachycardia. - Manifestations include dizziness, pallor, and cold and clammy skin. - The client should be immediately repositioned onto the right or left side until the symptoms subside. - Prevention of this condition includes using a wedge under the client's hip while in a supine position.

Question 201

A foul odor of lochia suggests

Answer 201

endometrial infection - The odor of lochia is usually described as "fleshy" or "musty." A foul smell warrants further evaluation. - Other signs of endometrial infection are maternal fever, tachycardia, and uterine pain/tenderness. - During the first 24 hours postpartum, temperature and WBC count are normally elevated

Question 202

Nephrotic syndrome

Answer 202

a collection of symptoms resulting from various causes of glomerular injury. Below are the 4 classic manifestations of nephrotic syndrome: - Massive proteinuria – caused by increased glomerular permeability - Hypoalbuminemia – resulting from excess protein loss in the urine - Edema – specifically periorbital and peripheral edema and ascites; caused by low serum protein and albumin as fluid is pulled into interstitial spaces and body cavities - Hyperlipidemia – related to increased compensatory protein and lipid production by the liver - Additional symptoms include decreased urine output, fatigue, pallor, and weight gain. The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome.

Question 203

Supportive care for symptom relief and prevention of complications are the major goals in clients with acute pancreatitis. These strategies include:

Answer 203

- NPO status - The client is maintained on NPO status as any ingestion of food will stimulate the excretion of pancreatic enzymes. A nasogastric tube is used to suction out gastric secretions; this will reduce nausea and lessen stimulation of the pancreas as these juices will move to the duodenum. - Pain management - Intravenous opioids (eg, hydromorphone, fentanyl) are frequently utilized for pain management. Morphine can also be used; worsening pancreatitis due to increase in sphincter of Oddi pressure has not been proven in studies. - IV fluids - Aggressive fluid replacement to prevent hypovolemic shock is critical. Inflammation of the pancreas releases chemical mediators that increase capillary permeability and cause third spacing (fluid going into empty spaces).

Question 204

borderline personality disorder (BPD)

Answer 204

- people live in fear of rejection and abandonment. To avoid abandonment, they use manipulation and control, often unconsciously, to prevent a person from leaving. The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person. An individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain attention from the other person and keep that person from leaving. For this client, the nursing care plan must include the assignment of different staff members. This will help diminish the client's dependence on a particular individual and help the client learn to relate to more than one person.

Question 205

Hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include:

Answer 205

- Adherence to a high calorie diet (4000-5000 calories per day). - Consumption of approximately 6 full meals and snacks per day. These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals - Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract. High-fiber foods may increase GI symptoms (eg, diarrhea) However, high-fiber diets are recommended if the client with hyperthyroidism has constipation. - Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks). - Avoidance of spicy foods as these can also increase GI stimulation.

Question 206

Neologisms –

Answer 206

made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox."

Question 207

Concrete thinking –

Answer 207

literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener

Question 208

Loose associations –

Answer 208

rapid shifting from one idea to another, with little or no connection to logic or rationality

Question 209

Echolalia –

Answer 209

repetition of words, usually uttered by someone else

Question 210

Tangentiality –

Answer 210

going from one topic to the next without getting to the point of the original idea or topic

Question 211

Word salad –

Answer 211

a mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table, sky, apple."

Question 212

Clang associations –

Answer 212

rhyming words in a meaningless, illogical manner. | Example: "The pike likes to hike and Mike fed the bike near the tyke."

Question 213

Perseveration –

Answer 213

repeating the same words or phrases in response to different questions

Question 214

normal urine output

Answer 214

30ml/hr | or 0.5 mL/kg/hr

Question 215

chest tube drainage

Answer 215

Chest drainage >100 mL/hr should be reported to the HCP. - Large losses of blood may indicate a compromise of the surgical suture site and may require repair. The client can quickly become hemodynamically unstable and may require a return to surgery or transfusion of blood products.

Question 216

Desquamation

Answer 216

(peeling skin) is a normal finding in newborns, especially those born at post-term gestation. Moisturizers can be applied if desired, but desquamation resolves on its own over several days.

Question 217

If ineffective breastfeeding occurs, the nurse should:

Answer 217

- Assess the baby's sucking reflex and physical condition - Assess the mother's breastfeeding technique (positioning, behavior/anxiety during breastfeeding) - Teach how to express milk by hand and use an electric pump to enhance milk production - Refer to a lactation consultant for a thorough assessment and breastfeeding plan if ineffective breastfeeding occurs longer than 24 hours - Supplemental formula feedings and the use of artificial nipples are avoided when ineffective breastfeeding is present, as they interfere with the mother's ability to breastfeed exclusively. Supplemental formula feeds are only used after a full assessment and if other techniques are unsuccessful.

Question 218

The CDC suggests the following sequence for donning PPE:

Answer 218

1. hand hygiene 2. gown 3. mask or respirator 4. goggles or face shield 5. gloves.

Question 219

When administering IV medications through a CVC, the nurse should use the safest syringe possible to avoid exerting too much pressure, which may damage the CVC.

Answer 219

The smaller the syringe, the greater the amount of pressure exerted during the flush. A 10 mL syringe is generally recommended; however, it is important to consult the manufacturer guidelines.

Question 220

Candida albicans

Answer 220

(yeast) can colonize and cause infections of the vulvovaginal region. Vaginal candidiasis often causes itching and painful urination due to urine stinging the inflamed areas of the vulva. Assessment shows a thick, white, curd-like vaginal discharge and reddened vulvar lesions. - Miconazole (Monistat), an antifungal cream commonly prescribed to treat vaginal candidiasis, is inserted high into the vagina using an applicator. It is best applied at bedtime so that it will remain in the vagina for an extended period. - Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately 3-7 days. However, sexual activity is not a significant cause of infection or reinfection of candida, and partner evaluation is not needed. Trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted; therefore, partners should be evaluated and treated. - Ensuring proper hygiene of the perineum - cleansing from anterior to posterior (front to back) to prevent accidental introduction of fecal organisms - Wearing loosely fitted cotton underwear and avoiding synthetic undergarments to promote ventilation, decrease friction, and reduce moisture - Refraining from douching, which can introduce organisms higher up into the vaginal canal and cervix

Question 221

Carpal tunnel syndrome (CTS)

Answer 221

is caused by compression of a median nerve within the carpal tunnel at the wrist. Any swelling in the canal puts pressure on the nerve and produces pain and paresthesia in the median nerve distribution (first 3½ digits). These symptoms are often worse at night when the wrists are flexed during sleep. The most commonly used conservative treatment is wrist splinting, particularly at nighttime. Splinting of the wrist prevents excessive flexion or extension, which could narrow the carpal tunnel.

Question 222

cryptorchidism

Answer 222

An undescended testicle at birth is not concerning. Most undescended testes descend spontaneously by age 6 months.

Question 223

Endoscopic retrograde cholangiopancreatography (ERCP)

Answer 223

- is a procedure in which an endoscope is passed through the mouth into the duodenum to assess the pancreatic and biliary ducts. Using fluoroscopy with contrast media, the ducts can be visualized and treatments including removal of obstructions, dilation of strictures, and biopsies can be performed. - Perforation or irritation of these areas during the procedure can cause acute pancreatitis, a potentially life-threatening complication after an ERCP. - Signs and symptoms include acute epigastric or left upper quadrant pain, often radiating to the back, and a rapid rise in pancreatic enzymes (eg, amylase, lipase)

Question 224

positive TB test

Answer 224

In a heathy client, an induration >15 mm indicates a positive TST - this means that the client was exposed to TB, developed antibodies to the disease, and has a TB infection. - Additional tests are needed to determine if the client has latent TB infection (LTBI) or active TB disease. - Clients with LTBI are asymptomatic and cannot transmit the microorganism to others. - Clients with active TB disease usually are symptomatic and can transmit the microorganisms through the air.

Question 225

Acute pericarditis

Answer 225

is an inflammation of the pericardium, the double-walled, membranous sac that surrounds the heart. The inflammation can cause pericardial effusion, a buildup of fluid between the pericardial layers. A serious, sometimes fatal, complication of acute pericarditis is cardiac tamponade, in which large amounts of pericardial fluid cause the heart to be squeezed and unable to contract effectively. Heart tones become muffled, cardiac output and blood pressure drop, pulse increases, and the client develops jugular venous distension, pulsus paradoxus, and narrowed pulse pressure. This life-threatening condition requires emergency pericardiocentesis (insertion of a needle into the pericardial sac to remove the fluid). - In acute pericarditis, the inflamed layers of the pericardium rub against the heart and cause pain. This pain is often worse with deep breathing or in the supine position and is relieved by sitting upright and leaning forward. The client should be placed in Fowler's or high Fowler's position for comfort. - In acute pericarditis, ST-segment elevation is seen in almost all leads (as the entire pericardium is inflamed). This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in localized leads (depending on which vessel is occluded). - Pericardial friction rub is an expected finding with acute pericarditis. The rubbing together of the inflamed pericardial layers causes the characteristic high-pitched, leathery, and scratchy sound.

Question 226

The examination for skin cancer follows the ABCDE rule:

Answer 226

``` Asymmetry (eg, one half unlike the other) ( Border irregularity (eg, edges are notched or irregular) Color changes and variation (eg, different brown or black pigmentation) Diameter of 6 mm or larger (about the size of a pencil eraser) Evolving (eg, appearance is changing in shape, size, color) ```

Question 227

syndrome of inappropriate antidiuretic hormone (SIADH)

Answer 227

SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions. SIADH treatment includes: 1. Fluid restriction to <1000 mL/day 2. Oral salt tablets to increase serum sodium 3. Hypertonic saline (3%) during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations 4. Vasopressin receptor antagonists (eg, conivaptan) - The nurse should also maintain a strict fluid intake and output chart and daily weights and carefully monitor neurologic status to evaluate for improvement or deterioration.

Question 228

A VP shunt

Answer 228

drains excess fluid in the brain down to the abdomen, where it is absorbed by the body. - A CT scan can accurately assess shunt malfunction. - Any malfunction would need to be treated promptly to prevent future seizures and damage.

Question 229

A pleural effusion

Answer 229

is an abnormal collection of fluid (>15-20 mL) in the pleural space between the parietal and visceral pleurae that prevents the lung from expanding fully. - This results in decreased lung volume, atelectasis, and ineffective gas exchange. - Clients commonly have dyspnea on exertion and non-productive cough. Examination shows diminished breath sounds, dullness to percussion, and decreased tactile fremitus. If the effusion is large, the trachea (mediastinum) is deviated to the opposite side.

Question 230

pancreatic abscess

Answer 230

A high-grade fever or abrupt increase in temperature with worsening abdominal pain could be an indication of a pancreatic abscess, a significant complication of acute pancreatitis. - A pancreatic abscess requires immediate intervention (eg, antibiotics, surgical drainage) to reduce the risk of rupture and sepsis; therefore, the health care provider should be notified immediately

Question 231

The nurse cares for a client following a percutaneous coronary intervention via the right groin. The client received an IV infusion of abciximab during the procedure. Which actions should the nurse implement?

Answer 231

- Glycoprotein (GP) IIb/IIIa receptor inhibitors (eg, abciximab, eptifibatide, tirofiban) are used as platelet inhibitors to prevent the occlusion of treated coronary arteries during percutaneous coronary intervention procedures and prevent acute ischemic complications. GP IIb/IIIa receptor inhibitors can cause serious bleeding. The nurse should closely monitor the client for any bleeding at the groin puncture site after the percutaneous coronary intervention - The nurse should check the client's baseline complete blood count (eg, hemoglobin, platelet count). Some clients may develop serious thrombocytopenia within a few hours, further increasing the bleeding risk. Hypotension, tachycardia, changes in heart rhythm, blood in the urine, abdominal/back pain, mental status changes, and black tarry stools may also indicate internal bleeding and should be monitored carefully when GP IIb/IIIa receptor inhibitors are administered - During and after the infusion of GP IIb/IIIa receptor inhibitors, no traumatic procedures (initiation of IV sites, intramuscular injections) should be performed unless absolutely necessary due to the risk of bleeding

Question 232

Subjective (presumptive) signs of pregnancy vs. Objective (probable) signs and Positive signs of pregnancy

Answer 232

Subjective (presumptive) signs - those that are self-reported by a pregnant client. These signs may have pathologic medical causes and therefore cannot be considered diagnostic for pregnancy. Subjective signs include: - Breast fullness and tenderness (may occur just prior to menstrual periods or with use of birth control hormones) - Amenorrhea (may be seen with early menopause, endocrine dysfunction, acute or chronic diseases, or psychological stress) - Nausea and vomiting that begin around the sixth week after the last menstrual period (may be result of many other conditions, such as gastroenteritis) Objective (probable) signs of pregnancy are those that can be observed by the health care provider during assessment and examination. Combined with subjective signs, these may be more indicative of pregnancy but may still have some pathologic causes. Positive signs of pregnancy represent conclusive proof of pregnancy and cannot be confused with any pathologic state as they are all related to the fetus.

Question 233

Percutaneous nephrolithotripsy

Answer 233

involves inserting a needle into the pelvis of the kidney through the skin. A nephroscope is inserted through the created track to break and remove stones that are too large to remove with other methods. - Post procedure, a temporary percutaneous nephrostomy tube may be placed to prevent obstruction by stone fragments and promote healing of injured tissue, and so maintaining tube patency is critical.

Question 234

Nursing care for a child with known or suspected meningococcal meningitis includes

Answer 234

key safety and comfort measures. - Droplet precautions are initiated because this form of meningitis is easily transferred through secretions. Precautions should be continued for 24 hours after initiation of antibiotic therapy. - Clients with somnolence or other altered level of consciousness should be kept on NPO status to prevent aspiration - Comfort measures include promoting a quiet environment, minimizing stimuli in the room, and allowing the client to self-position Due to nuchal rigidity, most clients prefer to lie with the head of the bed slightly raised and without a pillow, or in a side-lying position.

Question 235

Autonomic dysreflexia (autonomic hyperreflexia)

Answer 235

is a massive, uncompensated cardiovascular reaction by the sympathetic nervous system (SNS) in a spinal injury at T6 or higher. - Due to the injury, the parasympathetic nervous system cannot counteract the SNS stimulation below the injury. - Classic triggers are distended bladder or rectum. - Classic manifestations include severe hypertension, throbbing headache, marked diaphoresis above the level of injury, bradycardia, piloerection (goose bumps), and flushing. - This is an emergency condition requiring immediate intervention. - Management includes raising the head of the bed and then treating the cause.

Question 236

withdrawal s/s

Answer 236

Withdrawal symptoms (eg, anxiety/restlessness, nausea/vomiting, pupillary dilation, tachycardia) are related to increased sympathetic nervous system activity as the depressant effect of the opioid wanes Although opioid withdrawal is seldom life-threatening, clients who demonstrate signs of acute withdrawal may be given medications, such as methadone, to alleviate discomfort. The nurse should alert the health care provider of suspected withdrawal to facilitate appropriate opioid weaning or maintenance interventions.

Question 237

pilorection =

Answer 237

goosebumps

Question 238

hypothyroidism

Answer 238

Hypothyroidism is a thyroid disorder characterized by thyroid hormone deficit (low T3 and T4). TSH is elevated due to compensatory increase from pituitary. Hypothyroidism affects almost every body system and is predominately associated with a slow metabolic rate. Some common manifestations include the following: - Decreased gut motility leading to constipation - Cool and pale skin due to decreased blood flow; hyperkeratosis results in dry and rough skin - Brittle nails and hair; hair loss due to poor blood supply - Bradycardia from low metabolic state - Joint pains and muscle aches are common - Clients can develop dementia and depression due to mental slowing - Cold intolerance characteristic - Modest weight gain Fatigue and weight gain are classic manifestations of hypothyroidism. Features of hypothyroidism typically result from decreased metabolic rate and include cold intolerance, constipation, dry skin, irregular or prolonged menstrual periods, and mental slowing or difficulty concentrating.

Question 239

do not feed honey to

Answer 239

a child under 1 Honey (especially raw or wild) is not recommended for children under age 1 due to the risk for infant botulism. An infant under age 1 has an immature gut system that can allow Clostridium botulinum spores contaminated in honey to colonize the gastrointestinal tract and release toxin that causes botulism. Botulinum toxin produces muscle paralysis by inhibiting the release of acetylcholine at the neuromuscular junction. Infants often present with constipation, diminished deep tendon reflexes, and generalized weakness. Additional symptoms are lack of head control, difficulty in feeding, and decreased gag reflex, which can progress to respiratory failure. Isolation of the organism from the child's stool can take several days; therefore, diagnosis is usually made by history, and treatment with botulism immune globulin is started before laboratory results are known.

Question 240

Hemolytic uremic syndrome

Answer 240

(HUS) is a life-threatening complication of Escherichia coli diarrhea and results in red cell hemolysis, low platelets, and acute kidney injury. Hemolysis results in anemia, and low platelets manifest as petechiae or purpura.

Question 241

HIV and pregnancy

Answer 241

Transmission of HIV infection from mother to baby can occur during antepartum, intrapartum, or postpartum periods. Maternal antiretroviral therapy (ART) during pregnancy is imperative for decreasing the risk of perinatal transmission. Pregnant clients who are HIV positive should receive recommended inactivated vaccines. Newborns born to HIV-positive clients should not breastfeed and should receive 4-6 weeks of ART after birth.

Question 242

elevated levels in pancreatitis

Answer 242

Acute pancreatitis is an acute inflammation of the pancreas, characterized by abdominal pain and elevated levels of amylase and lipase, which are digestive enzymes produced by the pancreas. The pain is treated with opioids (eg, hydromorphone, fentanyl).

Question 243

metabolic acidosis

Answer 243

Metabolic acidosis is due to an increase in the production or retention of acid (eg, lactic acidosis, ketoacidosis, renal failure) or the depletion of bicarbonate (HCO3-) via the kidneys or gastrointestinal tract. In metabolic acidosis, there is a decrease in pH (<7.35) and HCO3- (<22 mEq). Acidosis damages cells, causing them to release intracellular contents (eg, potassium). Hyperkalemia (potassium >5.0 mEq/L) frequently occurs with acidosis, putting the client at risk for cardiac arrhythmias. Depending on the cause and severity of acidosis, the client can exhibit altered mental status and tachypnea. Management focuses on treating the underlying cause and administering IV sodium bicarbonate to correct the imbalance. Common causes of metabolic acidosis include: - GI bicarbonate losses (eg, diarrhea) - Ketoacidosis (eg, diabetes, alcoholism, starvation) - Lactic acidosis (eg, sepsis, hypoperfusion) - Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) - Salicylate toxicity

Question 244

CK-MB

Answer 244

is a cardiospecific isozyme that is released in the presence of myocardial tissue injury. Elevations are highly indicative of a myocardial infarction but not specific for heart failure

Question 245

Magnetic resonance cholangiopancreatography

Answer 245

(MRCP) is a noninvasive diagnostic test used to visualize the biliary and hepatic ducts via MRI. MRCP uses oral or IV gadolinium (noniodine contrast material) and is a safer, less invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP) to determine the cause of cholecystitis, cholelithiasis, or biliary obstruction. The nurse must assess for contraindications prior to the procedure, including presence of certain metal implants (eg, pacemaker, aneurysm clip, cochlear implant), pregnancy, or any previous allergy or reaction to gadolinium. Most orthopedic implants (eg, rods, pins, artificial joints) are considered safe for MRI imaging.

Question 246

Addison's disease

Answer 246

an adrenocortical insufficiency - occurs when the adrenal glands do not produce adequate amounts of steroid hormones (mineralocorticoids, glucocorticoids, androgens). - Symptoms include weight loss, muscle weakness, low blood pressure, hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease). Hyperpigmented skin is a characteristic universal finding; this results from increased adrenocorticotropic hormone which is due to a decrease in cortisol negative feedback. - Treatment consists of replacement therapy with oral mineralocorticoids and corticosteroids - Corticosteroid therapy is the primary classification of drugs used to treat Addison's disease

Question 247

acanothosis nigricans

Answer 247

is a skin condition that occurs with obesity and diabetes and appears as velvet-like patches of darkened, thick skin. These areas typically occur around the back of the neck and in the groin and armpits.

Question 248

Hirsutism

Answer 248

is a condition in women that consists of male-pattern hair growth on the face, lower abdomen, chest, and back. Common causes are polycystic ovary syndrome and Cushing's syndrome

Question 249

priapism

Answer 249

is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). the condition is a medical emergency that can result in permanent erectile dysfunction Bluish discoloration is of most concern as it can be a sign of ischemia to the penis

Question 250

malignant hyperthermia

Answer 250

(MH) is a rare and life-threatening condition precipitated by certain medications used for anesthesia, including inhaled anesthetics (eg, desflurane, isoflurane, halothane) and succinylcholine (a paralytic used adjunctively for intubation and general anesthesia). Skeletal muscles become unable to control calcium levels, leading to a hypermetabolic state manifested by contracture and increased temperature. Early signs of MH include tachypnea, tachycardia, and a rigid jaw or generalized rigidity. As the condition progresses, the client develops a high fever. Muscle tissue is broken down, leading to hyperkalemia, cardiac dysrhythmias, and myoglobinuria. MH requires emergent treatment with IV dantrolene to reverse the process by slowing metabolism. Succinylcholine should be discontinued. Other interventions include applying cooling blankets to reduce temperature and treating high potassium levels.

Question 251

poison ivy

Answer 251

can cause a contact dermatitis rash in those who are sensitive to the oily resin found on the leaves, stems, and roots of the plant. About 50% of people who come in contact with the plant develop a rash. It is often linear in appearance where the plant brushed against the skin. The rash develops 12-48 hours after exposure and can last for several weeks. The severity of the rash depends on the amount of resin on the skin. It is most important to first thoroughly wash the area to remove the resin and prevent its spread to other areas of the body.

Question 252

nocturnal enuresis

Answer 252

Involuntary bed-wetting at night in a child beyond the age of expected bladder control is known as nocturnal enuresis. Primary enuresis is bed-wetting in children who have never had bladder control. Secondary enuresis occurs in a child who has had a previous period of bladder control. Pharmacologic and nonpharmacologic interventions can be used in the treatment of enuresis. Parents should be educated on the following therapeutic techniques for nocturnal enuresis: - Encourage fluids during the day but restrict after the evening meal - Have the child void before going to bed - Use bed alarms that waken the child when voiding begins - Use positive reinforcement and motivation (eg, a calendar showing wet and dry nights) - Avoid punishing, scolding, or ridiculing the child - Avoid the use of Pull-Ups and diapers at bedtime - Have the child assist with wet linen changes but reassure that this is not a punishment - Awaken the child at a specified time each night to void

Question 253

life threatening complications of thyroid surgery

Answer 253

Respiratory distress is a life-threatening complication of thyroid surgery that occurs when swelling in the surgical area at the base of the neck compresses the airway. Stridor and/or difficulty breathing in the client who has had thyroid surgery should be reported immediately to the registered nurse, and a rapid response should be activated.

Question 254

installing ear drops

Answer 254

1. Perform hand hygiene and don clean gloves. The ear canal is not sterile, but aseptic technique is used 2. Position the client side-lying with the affected ear up (if not contraindicated). This facilitates administration and prevents drops from leaking out of the ear 3. Warm ear drops to room temperature (ie, use hand or warm water) to help avoid vertigo, dizziness, or nausea as the internal ear is sensitive to temperature extremes 4. Pull the pinna up and back to straighten the ear canal in clients >4 years old and adults. Pull the pinna down and back in clients <3 years old 5. Support hand on the client's head and instill the prescribed number of drops by holding the dropper 1 cm (1/2 in) above the ear canal. This avoids damaging the ear canal with the dropper 6. Apply gentle pressure to the tragus (fleshy part of external ear canal) if it does not cause pain, which facilitates the flow of medication into the ear canal 7. Instruct the client to remain side-lying for at least 2-3 minutes to facilitate medication distribution and prevent leakage 8. Place a cotton ball loosely in the client's outermost ear canal for 15 minutes, only if needed, to absorb excess medication. Perform this with caution and avoid in infants or very young clients as it is a choking hazard

Question 255

seizure stages

Answer 255

A seizure is an uncontrolled electrical discharge of neurons in the brain that interrupts normal function. Seizure manifestations generally are classified into 4 phases: 1. The prodromal phase is the period with warning signs that precede the seizure (before the aural phase). 2. The aural phase is the period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure. 3. The ictal phase is the period of active seizure activity. 4. During the postictal phase, the client may experience confusion while recovering from the seizure. The client may also experience a headache. Postictal confusion can help identify clients by differentiating seizures from syncope. In syncope, there will be only a brief loss of consciousness without prolonged post-event confusion.

Question 256

precipitous birth

Answer 256

occurs when the newborn is delivered ≤3 hours after the onset of contractions. In the event of precipitous labor, the nurse should be prepared to assist with the birth if the health care provider is unable to arrive in time. Immediately after the birth, the newborn should be dried and placed skin-to-skin on the mother's abdomen at uterine level to promote warmth; this prevents cold stress that can lead to newborn hypoglycemia or respiratory distress (Option 3). If the newborn is stable, the cord can be clamped and cut with sterile scissors after it has stopped pulsating or after the placenta has been expelled.

Question 257

hypoglycemia

Answer 257

(blood glucose <70 mg/dL) occurs when the proportion of insulin exceeds the glucose in the blood. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing multiple hypoglycemia-associated symptoms, including increased heart rate, shakiness, sweating, hunger, anxiety, and pallor. The lack of glucose in the brain is also responsible for other symptoms, including disorientation, impaired vision and speech, seizures, and coma. However, most clients respond rapidly to the correction of hypoglycemia.

Question 258

botulism

Answer 258

Children age <1 year should not be given honey (in raw or wild form) due to the risk of infant botulism. Botulism can vary in severity from constipation to respiratory failure secondary to loss of neurologic function. Infants initially have constipation, generalized weakness, and diminished deep-tendon reflexes. Additional symptoms include lack of head control, difficulty feeding, and decreased gag reflex. Infants with botulism should be admitted to the intensive care unit for monitoring of respiratory status, nasogastric tube feedings, laxative medication, and physical and occupational therapies. Intravenous human-derived botulism immune globulin should be given as soon as possible to reduce the severity and duration of symptoms.

Question 259

acute respiratory distress syndrome

Answer 259

ARDS involves damage to the alveolar-capillary membrane, the blood-gas barrier across which oxygen diffuses into the alveoli. When the membrane is damaged, the alveoli collapse and fluid leaks into the alveolar space and impairs gas exchange. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is the priority ND for a client with ARDS

Question 260

osteoporosis

Answer 260

The primary treatment goal for elderly clients with osteoporosis is to prevent bone fracture, especially hip fracture. Teaching to increase bone mineral density and prevent bone loss (resorption) includes: - Bisphosphonate medication (eg, alendronate [Fosamax], risedronate [Actonel], zoledronic [Reclast]) - Calcium and Vitamin D supplementation - Smoking cessation and alcohol avoidance, as these increase bone resorption and contribute to falls - Weight-bearing exercise (eg, walking, dancing) and resistance training (eg, weights) ≥3 times a week for 30 minutes, as increasing mechanical stress on bone increases bone density

Question 261

hypothermia

Answer 261

Hypothermia occurs when the core temperature is below 95 F and the body is unable to compensate for heat loss. As the core temperature decreases, the cold myocardium becomes extremely irritable and prone to dysrhythmias. The client should be handled gently as spontaneous ventricular fibrillation could develop when moved or touched. Therefore, placing the client on a cardiac monitor is a high priority; the nurse should anticipate defibrillation in these clients.

Question 262

what affects ABG results

Answer 262

Arterial blood gases (ABGs) indicate the acid-base balance in the body and how well oxygen is being carried to the tissues. It is common to measure ABGs after a ventilator change to assess how well the client has tolerated it. Factors such as changes in the client's activity level or oxygen settings, or suctioning within 20 minutes prior to the blood draw can cause inaccurate results. Unless the client's condition dictates otherwise, the nurse should avoid suctioning as it will deplete the client's oxygen level and cause inaccurate test results.

Question 263

continuous bladder irrigation

Answer 263

The rate of continuous bladder irrigation after transurethral resection of the prostate is adjusted to keep the urinary output light pink in color. Bladder spasms (treated with belladonna-opium suppositories) are expected after the procedure.

Question 264

lumbar procedure

Answer 264

A lumbar puncture involves removing a sample of cerebrospinal fluid through a needle inserted between vertebrae. Elevated intracranial pressure is a contraindication to performing a lumbar puncture. The client is placed in the fetal position or sitting and leaning over a table. Continued leaking fluid indicates that the site did not seal off and a blood patch (autologous blood into the epidural space) is required.

Question 265

thoracentesis

Answer 265

involves the insertion of a large-bore needle through an intercostal space to remove excess fluid. The procedure has the following advantages: - Diagnostic - analysis of fluid to diagnose the underlying cause of the pleural effusion (eg, infection, malignancy, heart failure), including cytology, bacterial culture, and related testing - Therapeutic - removal of excess fluid (>1 L) improves dyspnea and client comfort During a thoracentesis, a needle is inserted into the pleural space to remove fluid for diagnostic or therapeutic purposes. Before the procedure, the nurse places the client in an upright sitting position on the side of the bed, leaning forward over the bedside table, with arms supported on pillows. This position ensures that the diaphragm is dependent, facilitates access to the pleural space through the intercostal spaces, and promotes client comfort. Complications from insertion of the needle and removal of large amounts of fluid include iatrogenic pneumothorax, hemothorax, pulmonary edema, and infection. After the procedure, the nurse assesses for pain and difficulty breathing; monitors vital signs and oxygen saturation; and observes for changes in respiratory rate and depth, symmetry of chest expansion, and breath sounds. If any abnormalities are noted, a post-procedure chest x-ray is obtained. Decreased chest expansion with inspiration and breath sounds on the affected side, tachypnea, tracheal deviation to the opposite side, and hyperresonance (air) on the affected side are manifestations of a pneumothorax. These should be reported immediately.

Question 266

hypoglycemia in newborns

Answer 266

In women with poorly controlled diabetes mellitus during pregnancy, the fetus is subjected to high blood glucose levels. Fetal hyperglycemia leads to insulin hypersecretion by the fetus, which promotes abnormal growth and storage of excess calories as fat (macrosomia). After birth, the infant is no longer exposed to the mother's high blood glucose levels, but a transient hyperinsulinemic state will persist for several days, during which the infant is susceptible to developing hypoglycemia. The normal range for serum glucose in a newborn at day 1 is 40-60 mg/dL; however, no standard definition for newborn hypoglycemia currently exists. Treatment plans are based on clinical signs and overall status of the infant. The most common sign of low blood glucose is jitteriness or tremors. If the blood glucose is low, newborns should be fed immediately with formula or breast milk. If the infant continues to exhibit signs of hypoglycemia and/or blood glucose levels are <40-45 mg/dL after feeding, the pediatrician should be notified. Further treatment, such as oral or IV glucose, may be required.

Question 267

clear colorless drainage

Answer 267

Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage. When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics.

Question 268

assessment of renal system

Answer 268

1. Empty the bladder to avoid discomfort during percussion and palpation and to provide a clean-catch sample (if prescribed) 2. Inspect the abdomen and lower back for color, contour, symmetry, distension, and movements (eg, visible peristalsis). Inspection is always done first during physical examination. 3. The nurse should auscultate immediately after inspection as percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation. Listen for renal artery bruits in the right and left upper abdominal quadrants 4. Percuss for kidney borders, costovertebral angle tenderness, and bladder distension. A dull percussion sound indicates solid structures or fluid-filled cavities (eg, distended bladder). Palpate for bladder distension, masses, and tenderness. A distended bladder may be palpated at any point from the symphysis pubis to the umbilicus and is felt as a firm, rounded organ. A normal kidney is not usually palpable; a palpable kidney may indicate hydronephrosis or polycystic kidney disease 5. Document all renal assessment findings immediately after the examination

Question 269

1st intervention with blood loss

Answer 269

Acute blood loss is a medical emergency, and the nurse needs to carry out interventions rapidly. Lowering the head of the bed or placing the client in the supine position maintains blood perfusion to the brain and other vital organs. This can be done quickly to help stabilize the client before performing other interventions.

Question 270

C diff causing hypovolemia

Answer 270

Clostridium difficile overgrowth in the intestine often occurs when normal gastrointestinal (GI) flora is destroyed (eg, antibiotic use). Clients with C difficile often have watery diarrhea, nausea, fever, and abdominal pain. Hypovolemia can easily develop through the loss of fluids and electrolytes in the stool, especially in infants and the elderly. Clients with hypovolemia from GI losses will often have hyponatremia, hypokalemia, and elevated blood urea nitrogen (BUN) (poor renal perfusion). This client has hyponatremia (normal, 135-145 mEq/L), hypokalemia (normal, 3.5-5.0 mEq/L), and an elevated BUN (normal, 6-20 mg/dL). Hypovolemia can cause hypotension and renal failure, and electrolyte abnormalities can cause cardiac arrhythmias; therefore, these are priority to report. Fluid resuscitation and electrolyte replacement should be initiated promptly to prevent complications

Question 271

coup countercoup

Answer 271

Coup-contrecoup injury occurs when a body in motion stops suddenly (eg, head hits car windshield), causing contusions (bruising) of brain tissue as the brain moves back and forth within the skull. First, the soft tissue strikes the hard skull in the same direction as the momentum (coup). As the body bounces back, the brain strikes the opposing side of the skull (contrecoup). When the forward collision occurred, the frontal lobe most likely suffered the primary impact (coup). Executive function, memory, speech (Broca area), and voluntary movement are controlled by the frontal lobe. The contrecoup most likely injured the occipital lobe, where vision is processed. This type of injury is common in motor vehicle accidents and shaken baby syndrome.

Question 272

to prevent fluid overload and hyperkalemia with chronic kidney disease

Answer 272

- Sodium restriction involves avoiding high-sodium foods such as cured meats, pickled foods, canned soups, frankfurters, cold cuts, soy sauce, and salad dressings - Fluid intake must be monitored accurately and often is restricted - Potassium restrictions will vary depending on kidney function. Raw carrots, tomatoes, and orange juice are high-potassium foods that clients with advanced kidney disease or on hemodialysis should avoid - Low-protein diet (0.6–0.8 g/kg/day) helps prevent kidney disease progression. If the client is already on dialysis, liberal protein intake is recommended to prevent malnutrition.

Question 273

rehabilitation phase of burns

Answer 273

The rehabilitation phase begins after the client's wounds have fully healed and lasts about 12 months. The initiation of this phase depends on the extent of the burns and the client's ability to care for themselves. Interventions in the rehabilitation phase are aimed at improving mobility and independence and minimizing the potential for long-term complications. These interventions include: - Counseling or other psychosocial support - Gentle massage with water-based lotion to alleviate itching and minimize scarring - Planning for reconstructive surgery - Pressure garments to prevent hypertrophic scars and promote circulation - Range-of-motion exercises to prevent contractures - Sunscreen and protective clothing to prevent sunburns and hyperpigmentation

Question 274

tension pneumothorax

Answer 274

causes marked compression and shifting of mediastinal structures (tracheal deviation), including the heart and great vessels, resulting in reduced cardiac output and hypotension. This is a life-threatening emergency. The client should have emergency large-bore needle decompression, followed by chest tube placement, to relieve the compression on the mediastinal structures.

Question 275

systemic analgesics during labor

Answer 275

Systemic analgesia may be administered to the laboring client who is in the active phase of stage 1 labor. Systemic analgesia crosses the blood-brain barrier to provide a central analgesic effect. These medications also cross the placental barrier, with a resulting effect on the fetus depending on dose and time of administration prior to delivery. Parameters for safer administration include the following: - Stable maternal vital signs - Fetus with heart rate of 110-160 beats/min - Well-established labor contractions - Cervix dilated to at least 4-5 cm in primipara and 4 cm in multipara Opioid agonist-antagonist medications commonly used in labor are butorphanol tartrate (Stadol) and nalbuphine hydrochloride (Nubain). IV push is the preferred route and is given over the peak of 2 contractions to decrease the bolus of medication to the fetus. During contractions, the uterine muscle is very tense and blood flow to the fetus is slowed. Therefore, medication reaches the fetus at a slower rate. This class of medications has a ceiling effect—after a certain dosage, subsequent or higher doses will not be effective or produce pain relief. Therefore, usually no more than 3 doses will be prescribed. The medications can precipitate withdrawal in opioid-dependent clients and should not be used.

Question 276

bronchoscopy

Answer 276

An endoscopic bronchoscopy is a procedure in which the bronchi are visualized with a flexible fiberoptic bronchoscope that is passed down through the nose (or through the mouth, or endotracheal or tracheostomy tube). The client receives mild sedation (eg, midazolam) to provide relaxation and promote comfort. A topical anesthetic (eg, lidocaine, benzocaine) is applied to the nares and throat to suppress the gag and cough reflexes, prevent laryngospasm, and facilitate passage of the scope. The procedure is done to diagnose, obtain tissue samples for biopsy, lavage, and to remove secretions (mucus plugs), foreign objects, or abnormal tissue with a laser. Blood-tinged sputum is common and can occur from inflammation of the airway, but hemoptysis of bright red blood can indicate hemorrhage, especially if a biopsy was performed. Other complications include hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia, pneumothorax (rare), and adverse effects from medications used before and during the procedure. Absence of the gag reflex for about 2 hours following the procedure is expected from the topical anesthetic. The client who just underwent a bronchoscopy is at risk for becoming unstable. During a bronchoscopy, the larynx, trachea, and bronchi are visualized using an endoscope while the client is under sedation. Respiratory status, airway patency, vital signs, and sedation level should be assessed immediately upon return from the procedure and at regular intervals until the client becomes stable. The client must be kept NPO until alert with a positive gag reflex.

Question 277

hanging blood

Answer 277

The procedure for safe blood administration includes the following: - Obtain a unit of blood from the blood bank and verify the blood product with type and crossmatch results and at least 2 client identifiers with another nurse at the client's bedside. The blood is obtained and infused one unit at a time). - Assess the client, obtain vital signs for baseline, and teach signs of a transfusion reaction and how to call for help. - Use a Y tubing, prime with NS, and then clamp the NS side. - Spike the blood product, leaving the blood side of the Y tube open while keeping the saline side clamped for infusion. The saline is only used to prime the tubing and flush after the infusion. It does not infuse simultaneously. - Set the infusion pump to deliver blood over 2–4 hours as prescribed. Rapid infusion of the blood puts the client at greater risk for transfusion reaction and fluid volume overload. - Remain with the client for at least the 1st 15 minutes and watch for signs of blood transfusion reaction, including fever, chills, nausea, vomiting, pruritus, hypotension, decreased urine output, back pain, and dyspnea. Stop the transfusion immediately if a reaction occurs. The first 15 minutes of infusion should be slow to watch for these reactions. - Take another set of vital signs 15 minutes after infusion starts and continue in accordance with facility policy. Always take a final set of vital signs after the infusion is complete. - On completion of the blood transfusion, open the saline side clamp of the Y tubing to flush all blood in the tubing through with NS. - Return the blood bag with the attached set-up to the laboratory after completion or dispose of in accordance with hospital policy. Use new IV Y tubing set-up for the second unit of blood. Safe blood transfusion protocol includes checking of at least 2 client identifiers by 2 qualified health professionals, using normal saline to prime, and giving the infusion in 2-4 hours. The unlicensed assistive personnel can take vital signs during the later part of the transfusion. O- is the universal donor blood type and AB+ is the universal recipient.

Question 278

radiation to the head and neck

Answer 278

Radiation therapy to the head and neck can decrease a client's oral intake due to the development of mucositis (ie, inflammation of the mouth, esophagus, and oropharynx) and xerostomia (ie, dry mouth). These adverse side effects affect speech, taste, and ability to swallow and can have a significant impact on the client's nutritional status. The nurse teaches the client to: - Avoid irritants such as spicy, acidic, dry, or crumbly foods; coffee; and alcohol - Consume supplemental nutritional drinks (eg, Ensure), which are often easier to swallow - Use artificial saliva to manage xerostomia and the production of thick saliva due to altered salivary gland function. Sipping water throughout the day is equally effective and less expensive. - Topical anesthetics (eg, lidocaine) have been found to increase comfort and improve oral intake in clients with mucositis due to radiation therapy. - Clients on radiation therapy need to maintain more frequent (eg, before and after meals, at bedtime) oral hygiene (eg, using soft toothbrush, rinsing with baking soda solution) due to the drying effects of mucositis.

Question 279

anaphylactic shock

Answer 279

has an acute onset (20-30 minutes) caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs (eg, antibiotics), foods (eg, shellfish, peanuts), diagnostic agents (eg, contrast), biologic agents (eg, blood, vaccines), and venom (eg, bees, snakes) and results in circulatory failure, laryngeal edema, and severe bronchoconstriction. Management of anaphylactic shock includes: 1. Stop the infusion that is causing the reaction and call for help (eg, rapid response team) 2. Ensure patent airway, then administer oxygen via a high-flow nonrebreather mask and prepare for intubation if needed 3. Give epinephrine intramuscularly. Epinephrine counteracts the effect of the histamines released, dilating bronchial smooth muscles and providing vasoconstriction. Most deaths from anaphylaxis are due to delaying epinephrine. Maintain blood pressure with normal saline IV fluid 4. Administer adjunctive therapies: Bronchodilators (eg, albuterol) to dilate the small airways and reverse bronchoconstriction, antihistamines (eg, diphenhydramine) to modify the hypersensitivity reaction, and corticosteroids (eg, methylprednisolone) to decrease airway inflammation and swelling associated with the allergic reaction 5. Continue to reassess vital signs for any changes

Question 280

ventilator associated pneumonia

Answer 280

Ventilator-associated pneumonia (VAP), classified as a diagnosis of pneumonia more than 48 hours post-endotracheal intubation, is a key area of preventable morbidity and mortality in the hospitalized client. Assessment of suspected pneumonia would denote fever, elevated white blood cell count, purulent or odorous sputum, crackles on auscultation, and pulmonary opacities on x-ray. Prevention of pneumonia in a client on ventilation focuses on minimizing time spent on ventilation, reducing bacterial colonization with sterile equipment, regular oral hygiene, and aspiration prevention protocols

Question 281

placenta accreta

Answer 281

The placenta is normally expelled from the uterus within 30 minutes of delivery. The most morbid cause of a retained placenta is placenta accreta, a condition of abnormal placentation that involves implantation in the myometrium (normal implantation is in the endometrium). A placenta accreta adheres very strongly to the myometrium, and attempted separation results in life-threatening hemorrhage. These clients should have a type and crossmatch on the chart in case an immediate blood transfusion is needed. They also require an IV site in addition to the one used for anesthesia in case a blood transfusion is necessary. Transfusion requires a large-bore IV site (18-gauge preferred) that is patent

Question 282

Tinea corporis

Answer 282

Tinea corporis (ringworm) is a fungal infection of the skin often transmitted from one person to another or from an infected animal to a human. It appears as a scaly, pruritic patch that is often circular or oval in shape. It is highly contagious and can be spread via items such as grooming tools, hats, towels, and bedding. Tinea corporis often spreads via shared athletic equipment or in athletic locker rooms due to the proximity of infected gear. This condition is treated with topical antifungals (eg, tolnaftate, haloprogin, miconazole, clotrimazole)

Question 283

eczema

Answer 283

is a skin rash caused by an immune disorder that is often triggered by an allergy. Itching is common, but the rash is not contagious

Question 284

psoriasis

Answer 284

is a chronic autoimmune disease that most often affects the skin by causing dry, scaly, red rashes. Psoriasis is not contagious. chronic autoimmune disease that causes a rapid turnover of epidermal cells. Characteristic silver plaques on reddened skin may be found bilaterally on the elbows, knees, scalp, lower back, and/or buttocks. The goal of therapy is to slow epidermal turnover, heal lesions, and control exacerbations. There is no cure for psoriasis; disease management includes avoidance of triggers (eg, stress, trauma, infection), topical therapy (eg, corticosteroids, moisturizers), phototherapy (eg, ultraviolet light), and systemic medications, including cytotoxic (eg, methotrexate) and biologic (eg, infliximab) agents. The client should avoid alcohol as it can worsen psoriasis. In addition, the liver, kidneys, and bone marrow are specifically affected by the systemic medications commonly used to control psoriasis. Exposure to ultraviolet light (eg, phototherapy, sunlight) can help slow epidermal turnover and decrease exacerbations; however, there is a greater long-term risk of skin cancer. Therefore, frequent skin examinations by a health care provider are important.

Question 285

thyroxisis

Answer 285

(thyroid storm), a complication of hyperthyroidism in which excessive thyroid hormones are released into the circulation life-threatening condition that can occur in uncontrolled hyperthyroidism or Graves' disease when a stressful incident, such as this client's motor vehicle accident, triggers a sudden surge of thyroid hormone. Manifestations of thyroid storm include a rapid onset of fever, tachycardia, and elevated blood pressure. The client often feels anxious, tremulous, or restless. Confusion and psychosis can occur, as can seizures and coma. Rapid treatment is necessary. Beta-adrenergic blockers (atenolol, metoprolol, and propranolol) are used to relieve some of the symptoms of thyrotoxicosis. Beta blockers block the effects of the sympathetic nervous system and treat symptoms such as tachycardia, hypertension, irritability, tremors, and nervousness in hyperthyroidism

Question 286

Clinical signs of fluid volume overload include the following:

Answer 286

- Peripheral edema - Increased urine output that is dilute - Acute, rapid weight gain - Jugular venous distension - S3 heart sound in adults - Tachypnea, dyspnea, crackles in lungs - Bounding peripheral pulses

Question 287

increased ICP

Answer 287

Clients with elevated ICP should avoid anything that increases intrathoracic or intraabdominal pressure as these also indirectly increase ICP. These activities include straining, coughing, and blowing the nose. Respiratory interventions, if needed, may include deep breathing and incentive spirometry in the absence of coughing. The head of the bed should be maintained at 30 degrees, high enough to allow for cerebrospinal fluid drainage, but low enough to maintain cerebral perfusion pressure. Clients should have minimal stimuli, including no bright lights or multiple visitors, as stimulation can increase ICP. The goal of treatment is to reduce ICP while still managing the client's basic needs. During interventions, ICP should not exceed 25 mm Hg and should return to baseline within a few minutes before continuing with nursing care. Nursing interventions should be performed in small clusters and spaced out during the shift. Metabolic demands such as pain, straining, agitation, shivering, fever, hypoxia, and seizures also increase brain blood supply and raise ICP. Important nursing interventions to control these include the following: - Elevate head of the bed to 30 degrees with the head in a neutral position - Administer stool softeners to reduce the risk of Valsalva maneuver - Manage pain well without sedating the client too much - Treat fever aggressively (cool sponges) but avoid having the client shiver or shake - Keep the client in a calm environment with minimal noise and disturbances (eg, alarms, television, hall noise) - Ensure adequate oxygenation to the brain (avoid hypoxia) - Hyperventilate and preoxygenate the client for brief periods such as before suctioning to help reduce ICP. CO2 is a potent cerebral vasodilator. Reducing CO2 by hyperventilation causes vasoconstriction and reduces ICP - Administer medications as prescribed by the health care provider to reduce ICP; these include mannitol and corticosteroids. Mannitol is an osmotic diuretic that can help reduce cerebral edema and ICP through use of a hyperosmolar solution to draw water from the brain and extracellular fluid, allowing for excretion.

Question 288

higher incidence in African Americans

Answer 288

The incidence of cervical cancer is higher among Hispanics, American Indians, and African Americans. The mortality rate for cervical cancer among African American women is twice as high as that for white American women African Americans have the highest incidence of hypertension in the world, and this condition is more prevalent among the women than men in this ethnic group. The mortality rate for hypertension among African American women is higher than that for white American women African Americans have a higher incidence of ischemic stroke than whites or Hispanics. Risk factors for stroke are related to an increased rate of hypertension, diabetes mellitus, and sickle cell anemia

Question 289

pyelonephritis

Answer 289

inflammation of the kidney parenchyma - is an infection of the kidney usually caused by an extension of infection from the lower urinary tract (bladder) causes flank pain that is experienced in the back at the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. Presence of these, fever, and signs and symptoms of a lower UTI (dysuria, urgency, and frequency) indicate pyelonephritis Chills and fever, vomiting, flank pain, and costovertebral tenderness are characteristic. Blood and urine cultures should be obtained prior to initiation of antibiotic therapy whenever possible to identify the causative microorganisms and determine the most effective antibiotics Clients with acute pyelonephritis require aggressive IV fluids and IV antibiotics to stop progression of the infection and kidney scarring. A patent IV line is the priority.

Question 290

TST

Answer 290

(Mantoux) is the standard method for conducting tuberculosis (TB) surveillance of HCWs and involves 2 steps: Injection of purified protein derivative solution under the first layer of skin of the forearm Evaluation of the injection site 48-72 hours later The health care practitioner inspects and palpates the site to determine if a local skin reaction has occurred. Induration (not redness) indicates a positive test, which means that the individual has been exposed to TB, has developed antibodies, and is infected with TB bacteria. Further testing is needed to determine the presence of latent TB infection or active TB disease. Presence of symptoms, positive sputum culture, and chest x-ray abnormalities confirm active TB. the QuantiFERON-TB (QFT) blood test is an alternative to TST that measures how the immune system reacts to TB bacteria. Like TST, a positive QFT test only indicates that the individual has been infected with TB bacteria. Although the test is more expensive, it requires only a single visit to the health care provider and results are available in 24 hours.

Question 291

hyperemesis gravidarum

Answer 291

is a disorder that causes pregnant clients to have severe nausea and vomiting. This leads to fluid and electrolyte imbalances, nutritional deficiencies, ketonuria, and weight loss. On assessment, the nurse should expect signs and symptoms of dehydration, which include dry mucous membranes, poor skin turgor, decreased urine output, tachycardia, and low blood pressure. Ketonuria indicates that the body is breaking down fat to use for energy due to the client's starvation state.

Question 292

balloon tamponade tube

Answer 292

(eg, Sengstaken-Blakemore, Minnesota) is used to temporarily control bleeding from esophageal varices. It contains 2 balloons and 3 lumens. The gastric lumen drains stomach contents, the esophageal balloon compresses bleeding varices above the esophageal sphincter, and the gastric balloon compresses from below. A weight is attached to the external end of the tube to provide tension and hold the gastric balloon securely in place below the esophageal sphincter. Airway obstruction can occur if the balloon tamponade tube becomes displaced and a balloon migrates into the oropharynx. Scissors are kept at the bedside as a precaution; in the event of airway obstruction, the nurse can emergently cut the tube for rapid balloon deflation and tube removal

Question 293

neonatal heel stick

Answer 293

(heel lancing) is used to collect a blood sample to assess capillary glucose and perform newborn screening for inherited disorders (eg, congenital hypothyroidism, phenylketonuria). Proper technique is essential for minimizing discomfort and preventing complications and includes: - Select a location on the medial or lateral side of the outer aspect of the heel. Avoid the center of the heel to prevent accidental insult to the calcaneus. Puncture should not occur over edematous or infected skin. - Warm the heel for several minutes with a warm towel compress or approved single-use instant heat pack to promote vasodilation. Cleanse the intended puncture site with alcohol. Sucrose and nonnutritive sucking on a pacifier may reduce procedural pain. - Use an automatic lancet, which controls the depth of puncture. Lancing the heel too deeply can result in penetration of the calcaneus bone, leading to osteochondritis or osteomyelitis.

Question 294

osteopenia

Answer 294

is more than normal bone loss for the client's age and sex. Adequate dietary intake of calcium and vitamin D is necessary to promote bone growth, prevent resorption (bone loss), and prevent progression to osteoporosis. Milk and milk products are the best sources of calcium. However, other food sources are available for individuals who are lactose intolerant. They include some fish (eg, sardines, salmon, trout), tofu, some green vegetables (eg, spinach, kale, broccoli), and almonds. Good food sources of vitamin D include egg yolks and oily fish (eg, salmon, sardines, tuna). Canned sardines are the best choice as sardines are an excellent source of calcium and vitamin D

Question 295

Peripheral artery disease

Answer 295

(PAD) refers to arteries that have thickened, have lost elasticity due to calcification of the artery walls, and are narrowed by atherosclerotic plaques (made up of fat and fibrin). - Pain due to decreased blood flow is the most common symptom of PAD. Cramping pain in the muscles of the legs during exercise, known as intermittent claudication, is usually relieved with rest. However, with critical arterial narrowing, pain can be present at rest and is typically described as "burning pain" that is worsened by elevating the legs and improved when the legs are dependent. - Skin becomes cool, dry, shiny, and hairless (due to lack of oxygen). - Ulcers and gangrene occur usually at the most distal part of the body, where circulation is poorest. - Clients should be advised that a progressive walking program will aid the development of collateral circulation.

Question 296

chronic venous insuffiency

Answer 296

refers to inadequate venous blood return to the heart. Too much venous blood remains in the lower legs, and venous pressure increases. This increased venous pressure inhibits arterial blood flow to the area, resulting in inadequate supply of oxygen and nutrients to area cells and the development of stasis ulcers, which are typically found around the medial side of the ankle. By the end of the day or after prolonged standing, the legs become edematous with dull pain due to venous engorgement. The skin of the lower leg becomes thick with a brown pigmentation. The client with CVI has leg veins and incompetent valves that allow retrograde blood flow. This client commonly has leg edema, chronic inflammatory changes, and is at risk for the development of venous leg ulcers. The client is taught to avoid any trauma to the limbs. The nurse should intervene when the HH aide is cutting the client's toenails as the toenails should be cut by a trained professional or podiatrist

Question 297

flu vaccine

Answer 297

Influenza is a respiratory illness common during the cooler months of the year. Each year, a new influenza vaccine is created to help protect against specific viral strains. The Centers for Disease Control and Prevention and Public Health Agency of Canada recommend that all clients age ≥6 months receive the influenza vaccine annually unless the client has a life-threatening allergy to the vaccine or one of its ingredients. Special emphasis should be placed on vaccinating the following high-risk individuals: - Clients with chronic conditions (eg, asthma, heart failure, cancer) may experience exacerbation of symptoms if infected - Immunocompromised clients (eg, HIV) have decreased ability to fight infection - Health care workers and caretakers are at greater risk for acquiring and transmitting infection to other clients - Healthy children age 6-23 months and clients age ≥65 are at greatest risk for serious, flu-related complications (eg, pneumonia, dehydration) - Pregnant clients are at increased risk for premature labor/delivery or influenza complications due to pregnancy-related physiologic changes.

Question 298

torsades de pointes

Answer 298

(ie, "twisting of the points") is a polymorphic ventricular tachycardia characterized by QRS complexes that change size and shape in a characteristic twisting pattern. it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation. Torsades de pointes is usually due to a prolonged QT interval (more than half the RR interval), which is the result of electrolyte imbalances, especially hypomagnesemia, or some medications. The first-line treatment is IV magnesium. Treatment may also include defibrillation and discontinuation of any QT-prolonging medications. The nurse should review the client's medical record for any condition or medication that may prolong the QT interval and precipitate another episode of torsades de pointes, including: - Antiarrhythmics (eg, sotalol, amiodarone, ibutilide, dofetilide) - Macrolide antibiotics (eg, erythromycin, azithromycin) - Electrolyte ab

Question 299

implantable cardioverter defibrillator

Answer 299

The ICD is designed to defibrillate potentially life-threatening dysrhythmias. Although the device is able to sense electrical activity of the heart and respond, it is unable to sense or treat pulselessness. CPR should be initiated in the pulseless client with an ICD.

Question 300

cystoscopy

Answer 300

is a procedure that uses a flexible fiber-optic scope inserted through the urethra into the urinary bladder with the client in the lithotomy position. Complications associated with cystoscopy include urinary retention, hemorrhage, and infection. Therefore, clients are instructed to notify the health care provider (HCP) immediately if they have bright red blood when urinating, blood clots, inability to urinate, fever >100.4 F (38 C) and chills, or abdominal pain unrelieved by analgesia. These conditions necessitate evaluation by the HCP and may require antibiotic therapy or the insertion of a urinary catheter to irrigate the bladder, remove clots, or drain the bladder

Question 301

documentation of pulse assessment

Answer 301

The DP pulse is located on the top or dorsal part of the foot. The nurse should compare the characteristics of the arteries on the right and left extremities simultaneously to determine symmetry. The force of the pulse should be rated on the following scale. 0 Absent 1+ Weak 2+ Normal 3+ Increased, full, bounding

Question 302

melena

Answer 302

black tarry stools | - indicates slow upper gastrointestinal bleeding

Question 303

pneumonia airway clearance

Answer 303

In pneumonia, the lung is filled with infectious debris and exudate. This increase in secretions and a simultaneous decrease in mucociliary clearance result in possible airway obstruction. Interventions to facilitate airway clearance include the following: - Hydration - IV fluids, oral intake (2-3 L/day), and respiratory humidification help thin secretions, maintain moisture of mucous membranes, and promote mucociliary clearance. - Huff coughing technique - the most effective way to raise secretions from the lower to the upper airway for expectoration. If pain limits deep breathing and coughing, analgesia can be prescribed. - Chest physiotherapy (percussion, vibration, and postural drainage) to open airways and break up thickened secretions - Fowler's position - Sitting upright with the head of the bed at 45-60 degrees promotes lung expansion and facilitates coughing and secretion removal.

Question 304

IV problems

Answer 304

Peripheral IV (PIV) catheter sites should be changed usually no more frequently than every 72-96 hours unless signs of complications develop. - Signs of phlebitis include erythema, edema, warmth, pain, and palpable venous cord. - Manifestations of infiltration include edema and coolness to the touch around the insertion site. - The nurse should also monitor for edema related to infiltration under the involved limb. Infiltrated fluid may leak into loose skin, causing edema in dependent areas without obvious signs of infiltration at the PIV site, particularly in the elderly. - If a PIV site is leaking fluid, the tubing and catheter connections should be assessed. If all connections are intact, possible problems include infiltration/extravasation, a thrombus at the catheter tip, or damage to the catheter; all of these issues require a site change

Question 305

Thyroid Storm

Answer 305

Hyperthyroidism results from excessive secretion of thyroid hormones. Affected clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism. Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea, vomiting, diarrhea, and altered mental status. Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure). is a serious and potentially life-threatening emergency for clients with Graves disease. This condition occurs when the thyroid gland releases large amounts of thyroid hormone in response to stress (eg, trauma, surgery, infection). Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 104-106 F (40-41 C). Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures. Rapid treatment is necessary.

Question 306

enteral feeding

Answer 306

The steps for administering a continuous enteral feeding include: 1. Identify the client using 2 identifiers (eg, first and last name, medical record number, date of birth) and explain the procedure to the client. Perform hand hygiene and apply clean gloves. 2. Elevate the head of the bed ≥30 degrees and keep it elevated for at least 30 minutes after feeding to minimize the risk of aspiration 3. Validate tube placement by checking the gastric pH as well as assessing the external tube length and comparing it with the measurement at the time of insertion. The tube should be marked at the nostril with a permanent marker during the initial x-ray validation 4. Check gastric residual volume. 5. Flush the tube with 30 mL of water after checking residual volume, every 4-6 hours during feeding, and before and after medication administration 6. Administer the prescribed enteral feeding solution by connecting the tubing and setting the rate on the infusion pump

Question 307

barium enema

Answer 307

or lower gastrointestinal series, uses fluoroscopy to visualize the colon outlined by contrast to detect polyps, ulcers, tumors, and diverticula. This procedure is contraindicated for clients with acute diverticulitis as it may rupture inflamed diverticula and cause subsequent peritonitis. Preprocedure instructions include: - Take a cathartic (eg, magnesium citrate, polyethylene glycol) to empty stool from the colon. - Follow a clear liquid diet the day before the procedure to aid in bowel preparation and to prevent dehydration; avoid red and purple liquids. - Do not eat or drink anything 8 hours before the test - Expect to be placed in various positions during the procedure. You may experience abdominal cramping and an urge to defecate Postprocedure instructions include: - Expect the passage of chalky, white stool until all barium contrast has been expelled - Take a laxative (eg, magnesium hydroxide [Milk of Magnesia]) to assist in expelling the barium. Retained barium can lead to fecal impaction - Drink plenty of fluids to promote hydration and eat a high-fiber diet to prevent constipation.

Question 308

pulmonary edema

Answer 308

life-threatening - in the presence of acute left ventricular failure, pulmonary vasculature overload cause increased pulmonary venous pressure that forces fluid out of the vascular space into the pulmonary interstitium and if untreated in the alveoli s/s: - hx of orthopnea and/or paroxysmal nocturnal dyspnea - anxiety and restlessness - tachypnea (often >30/min), dyspnea, and use of accessory muscles - frothy, blood-tinged (pink) sputum!!! - crackles on auscultation at lung bases priority of care - to improve oxygenation by reducing pulmonary pressure and congestion - diuretics (ex furosemide) used to remove excess fluid management of heart failure may also include O2 therapy, vasodilators (nitro, nesiritide), - decrease preload so improves cardiac output and decreasing pulmonary congestion, and positive inotropes (dopamine, dubutamine) - improve contractility but are only recommend if other meds have failed or in the presence of hypotension

Question 309

anemia

Answer 309

A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath (dyspnea) may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor (pale complexion) occurs from reduced blood flow to the skin.

Question 310

mandibular fracture

Answer 310

The priority for a client with a mandibular fracture whose teeth have been wired together is maintaining a patent airway. If the client begins to choke on oral secretions, the nurse should immediately attempt to clear the airway by suctioning via the oral or nasopharyngeal route. If this intervention is ineffective, cutting the wires may be necessary.

Question 311

fat embolism syndrome

Answer 311

FES is a rare, but life-threatening complication that occurs in clients with long bone and pelvis fractures. It can also occur in nontrauma–related conditions, such as pancreatitis and liposuction. It usually develops 24-72 hours following the injury or surgical repair. There are no specific diagnostic tests to identify FES. However, the initial characteristic signs and symptoms include: - Respiratory problems (eg, dyspnea, tachypnea, hypoxemia) after a fat embolus travels through the pulmonary circulation and lodges in a pulmonary capillary, leading to impaired gas exchange and acute respiratory failure. This pathophysiology is similar to that of a pulmonary embolus. - Neurologic changes (eg, altered mental status, confusion, restlessness), which occur due to cerebral embolism and hypoxia. - Petechial rash (eg, pin-sized purplish spots that do not blanch with pressure), which appears on the neck, chest, and axilla due to microvascular occlusion. This defining characteristic differentiates a fat embolus from a PE. - Fever (>101.4 F [38.6 C]), which is due to a cerebral embolism leading to hypothalamus dysfunction.

Question 312

directly observed therapy

Answer 312

(DOT program) TB is curable if the client completes the prescribed medication regimen. Noncompliance with the treatment plan is a major problem in treating TB due to the length of time drug therapy is required (usually about 6 months) and the associated unpleasant side effects. DOT is an effective patient-centered treatment strategy developed by the World Health Organization that increases compliance with drug therapy, prevents reinfection and the development of multi-drug resistant TB strains, and controls the spread of TB disease worldwide. The public health nurse provides and watches the client swallow every prescribed medication for at least the first 2 months of antitubercular medication therapy, preferably longer. Any designated person (ie, caregiver) can provide the medications and observe the client swallow them. This can take place in any designated area (eg, clinic, home, school, workplace).

Question 313

The 2 key clinical features of major depressive disorder (unipolar depression) are

Answer 313

depressed mood and loss of interest or pleasure. - One of these symptoms must be present daily for at least 2 weeks for the diagnosis of major depressive disorder to be made

Question 314

phototherapy

Answer 314

the use of fluorescent lights to treat hyperbilirubinemia or jaundice in newborns. The light is absorbed by the newborn's skin and converts bilirubin into a water-soluble form, allowing it to be excreted in the stool and urine. - newborn should be fully exposed, except for a diaper, when placed under the phototherapy lights - Lotions and ointments should not be applied as they can absorb the heat and cause burns - Maintaining skin integrity is important as bilirubin products in the stool can cause loose stool with frequency and produce skin excoriation and breakdown. - Adequate hydration with human milk or infant formula (not water) is important as infants are prone to dehydration from phototherapy

Question 315

Placental abruption

Answer 315

possible complication of preeclampsia that can be life-threatening to mother and baby. - occurs when the placenta tears away from the wall of the uterus due to stress, causing significant bleeding to the mother and depriving the baby of oxygen. - Bleeding can be concealed inside the uterus. - This may require immediate delivery of the baby. - Abruptions are classified as partial, complete, or marginal and may be overt (visible vaginal bleeding) or concealed (bleeding behind placenta). - Risk factors include abdominal trauma, hypertension, cocaine use, history of previous abruption, and preterm premature rupture of membranes. - Symptoms and their severity depend on extent of abruption and include abdominal and/or back pain, uterine contractions, uterine rigidity, and dark red vaginal bleeding. - Tachysystole (ie, excessive uterine contractions), with or without fetal distress, is often present, and continuous fetal monitoring is necessary - A type and crossmatch should be drawn as treatment may include blood transfusion - In severe cases, emergent cesarean birth is indicated - Although blood loss is maternal, the loss of functional placental surface area can result in decreased placental perfusion, impaired fetal oxygenation, and fetal death. - Maternal vital signs should be assessed frequently for signs of shock (eg, tachycardia, hypotension) as client condition can decline rapidly. - Abruption may require rapid volume replacement with IV fluid and blood products, requiring large-bore IV access. Peripheral IV access with a 16- or 18-gauge catheter should be initiated.

Question 316

HELLP

Answer 316

- Hemolysis - Elevated Liver enzymes - Low Platelets - complication of preeclampsia. - If HELLP is diagnosed, the only treatment is delivery.

Question 317

Lead poisoning

Answer 317

- Blood lead level (BLL) screenings are recommended at ages 1 and 2, and up to age 6 if not previously tested. - Because lead poisoning particularly affects the neurological system, elevated BLLs (≥5 mcg/dL [0.24 µmol/L]) are dangerous in young children due to immature development of the brain and nervous system. - A mild to moderate increase in BLL can manifest with hyperactivity and impulsiveness; prolonged low-level exposure can cause developmental delays, reading difficulties, and visual-motor issues. - Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, blindness, or even death.

Question 318

Duchenne muscular dystrophy (DMD)

Answer 318

- is the most common form of childhood MD. - X-linked recessive (ie, carried by females and affects males) and is due to lack of a protein called dystrophin needed for muscle stabilization. - Disease onset is age 2–5 years. - Muscles of the proximal lower extremities and pelvis are affected first. Calf muscles hypertrophy (pseudohypertrophy) initially in response to proximal muscle weakness and are later replaced by fat and connective tissue. - The Gower sign involves the use of one's hands to rise from a squat or from a chair to compensate for proximal muscle weakness. - There is no effective cure. - Most children are wheelchair bound by adolescence and die by age 20–30 from respiratory failure. - It is important to avoid floor clutter (eg, throw rugs) and prevent falls/injury

Question 319

flushing a kidney pelvis catheter

Answer 319

Catheters placed in the kidney pelvis are irrigated using gentle pressure and small amounts of sterile saline solution (≤5 mL at one time) to avoid damaging renal tissues.

Question 320

Buerger's disease

Answer 320

(thromboangiitis obliterans) is a nonatherosclerotic vasculitis involving the arteries and veins of the lower and upper extremities. It occurs most often in young men (age <45) with a long history of tobacco or marijuana use and chronic periodontal infection, but no other cardiovascular risk factors. - Clients experience thrombus formation, resulting in distal extremity ischemia, ischemic digit ulcers, or digit gangrene. They often have intermittent claudication of the feet and hands. Over time, rest pain and ischemic ulcerations may occur. Many clients also develop secondary Raynaud phenomenon (cold sensitivity). - The mainstay treatment of Buerger's disease is the cessation of all tobacco and marijuana use in any form. Nicotine replacement products (eg, nicotine patch) are contraindicated. However, bupropion and varenicline can be used for smoking cessation. Clients may have to choose between continued use of tobacco and marijuana and their affected limbs. Conservative management includes avoidance of cold exposure to affected limbs, a walking program, antibiotics for any infected ulcers, analgesics for ischemic pain, and avoidance of trauma to the extremities.

Question 321

gastric lavage

Answer 321

performed through an orogastric tube to remove ingested toxins and irrigate the stomach - GL is rarely performed as it is associated with a high risk of complications (eg, aspiration, esophageal or gastric perforation, dysrhythmias). - only indicated if the overdose is potentially lethal and if GL can be initiated within one hour of the overdose. - Activated charcoal administration is the standard treatment for overdose, but it is ineffective for some drugs (eg, lithium, iron, alcohol). - Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress - During GL, clients should be placed on their side or with the head of bed elevated to minimize aspiration risk. - GL should be initiated within one hour of overdose ingestion to be effective. The client's stomach should be decompressed first, but lavage should be initiated as soon as possible afterwards.

Question 322

Diabetes insipidus

Answer 322

(DI) results in low levels of antidiuretic hormone (ADH), which is produced by the hypothalamus and stored in the pituitary gland. The function of ADH is to concentrate urine by signaling the kidneys to retain water in the setting of thirst. When ADH levels are insufficient, the kidneys excrete large quantities of very dilute urine (polyuria). This causes hypernatremia (elevated serum sodium due to deficit of free water) and increased serum osmolality, which lead to excessive thirst (polydipsia). Desmopressin acetate (DDAVP) is a synthetic form of ADH, which can be administered intravenously, orally, or via nasal spray. Effectiveness of therapy with desmopressin would be manifested by decreased urinary output and increased urine specific gravity as the urine becomes less dilute characterized by polydipsia (increased thirst) and polyuria (increased urine output) and can lead to dehydration resulting in weight loss, hypernatremia, and a high serum osmolality (>295 mOsm/kg). Urine is dilute and copious (2-20 L/day) with a low specific gravity (<1.003).

Question 323

hyperthyroidism

Answer 323

refers to sustained hyperfunctioning of the thyroid gland due to excessive secretion thyroid hormones (T3, T4) - this leads to an INCREASED metabolic rate. In clients with hyperthyroidism - ever, tachycardia, and sweating are signs of hyperthyroidism - The symptoms are a result of the hypermetabolic rate caused by the increase in thyroid hormones. These include weight loss, heart palpitations, heat intolerance, excessive sweating, anxiety, hand tremors, diarrhea, and insomnia. - Hyperthyroidism can also cause retro-orbital tissue expansion and weakness of the muscle fibers in the eye. Exophthalmos is an irreversible protrusion of the eyeballs. Eyelid lag (ie, Graefe's sign) is a delayed movement in the eyelid when the eye looks downward

Question 324

colorectal cancer

Answer 324

- Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. - Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. - Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually.

Question 325

lung contusion

Answer 325

(bruised lung) caused by blunt force can occur when an individual's chest hits a car steering wheel. - This injury is potentially life-threatening because bleeding into the lung and alveolar collapse can lead to acute respiratory distress syndrome. - Clients should be monitored for 24-48 hours as symptoms (eg, dyspnea, tachypnea, tachycardia) are usually absent initially but develop as the bruise worsens. - Inspiratory chest pain can lead to hypoventilation, and an oxygen saturation of 90% (normal: 95%-100%) indicates hypoxemia. - interventions to decrease the work of breathing and improve gas exchange (eg, supplemental oxygen, medications, ventilatory support) may be necessary.

Question 326

Some signs that the client is nearing death include the following:

Answer 326

- Coolness and paleness or mottling of the extremities - A slack, relaxed jaw and open mouth from loss of facial muscle tone - Difficulty in maintaining body posture or positions - Eyelids half-open - Cheyne-Stokes or uneven respirations with periods of apnea

Question 327

mitral valve prolapse

Answer 327

Clients with MVP may have palpitations, dizziness, and lightheadedness. Chest pain can occur but its etiology is unknown in this client population. It may be a result of abnormal tension on the papillary muscles. Chest pain that occurs in MVP does not typically respond to antianginal treatment such as nitrates. Beta blockers may be prescribed for palpitations and chest pain. Client teaching for MVP includes the following: - Adopt healthy eating habits and avoid caffeine as it is a stimulant and may exacerbate symptoms (Option 3) - Check ingredients of over-the-counter medications or diet pills for stimulants such as caffeine or ephedrine as they can exacerbate symptoms - Reduce stress and avoid alcohol use

Question 328

When infected or obstructed by a foreign body or fecal material, the appendix becomes inflamed, causing acute appendicitis. The appendix may rupture if left untreated, placing the client at risk for peritonitis, a potentially fatal infection of the peritoneum. When prioritizing multiple prescriptions, the nurse should first address issues of airway, breathing, circulation, and then vital signs. Initial interventions for acute appendicitis may include the following:

Answer 328

- Ensure patent airway and administer oxygen if hypoxic - Obtain IV access and administer prescribed fluids - Draw blood samples for complete blood count (CBC), electrolyte levels, clotting studies, and type and cross as prescribed - Insert indwelling urinary catheter and obtain urine sample for urinalysis, if prescribed - Insert a nasogastric (NG) tube if necessary Clients with acute appendicitis are at risk for rupture of the appendix and may require emergency surgery. Therefore, the nurse should ensure NPO status is maintained. Pain medications will be administered intravenously. In addition, circulation takes priority over the pain medication.

Question 329

Acute coronary syndrome (ACS)

Answer 329

is a broad term that encompasses a range of cardiac events, including unstable angina and myocardial infarction (with or without ST-segment elevation). Clients with ACS require immediate treatment to prevent continued ischemia of cardiac muscle. Intravenous nitroglycerin (glyceryl trinitrate) is used to increase cardiac blood flow and provide pain relief for clients with ACS until a definitive treatment plan (eg, percutaneous coronary intervention, thrombolytic therapy, bypass surgery) is determined. Because nitroglycerin is a vasodilator, continuous hemodynamic monitoring is required to prevent severe hypotension. The infusion rate is titrated by the nurse based on pain level and blood pressure (BP), usually every 3-5 minutes until pain is relieved and BP is stable. If systolic BP drops to <90 mm Hg or falls >30 mm Hg below client baseline, the infusion rate should be decreased or stopped.

Question 330

Cardinal symptoms of acute cholecystitis from cholelithiasis include

Answer 330

- pain in the RUQ with referred pain to the right shoulder and scapula - Clients often report fatty food ingestion 1–3 hours before the initial onset of pain. - Associated symptoms include low-grade fever, chills, nausea, vomiting, and anorexia During an acute attack, inflammation of the mucous lining and wall of the gallbladder occurs as a result of gallstone(s) obstruction of the cystic bile duct. The inflammation and increased pressure in the gallbladder from the blocked bile duct results in Murphy's sign; palpation over the RUQ causes pain and inability to take a deep breath. Laboratory results show leukocytosis.

Question 331

Murphy's sign

Answer 331

palpation over the RUQ causes pain and inability to take a deep breath

Question 332

Flank pain radiating to the groin is seen with

Answer 332

renal colic (ureteral stones).

Question 333

Anorexia nervosa is an eating disorder common among adolescents and young adults. Clinical manifestations of anorexia nervosa include:

Answer 333

- Fear of weight gain – clients resort to self-induced vomiting, extensive dieting, and intense exercise resulting in excessive weight loss (<85% expected weight). Clients who self-induce vomiting may experience enlargement of the salivary glands and erosion of tooth enamel. - Fluid and electrolyte imbalance – excessive vomiting can cause hypokalemia and metabolic alkalosis - Amenorrhea – clients are often amenorrheic due to decreased body fat (low estrogen) - Decreased metabolic rate – severe weight loss results in hypotension, bradycardia, decreased body temperature, and cold intolerance - Lanugo (fine terminal hair) can be seen in extreme cases Life-threatening complications, such as cardiac arrhythmias associated with hypokalemia, may develop.

Question 334

DASH diet

Answer 334

often suggested for clients to reduce hypertension as this diet: - Emphasizes intake of vegetables, fruits, and fat-free or low-fat dairy products - Includes whole grains, fish, poultry, beans, seeds, nuts, and vegetable oils - Limits ingestion of sodium, sweets, sugary beverages, and red meat Nutritionally, the DASH diet is low in saturated and trans fats and rich in potassium, calcium, magnesium, fiber, and protein.

Question 335

acute viral hepatitis

Answer 335

- Inflammation of the liver is present - Liver functions (eg, detoxifying the blood, manufacturing bile for lipid digestion) are disrupted, leading to signs and symptoms in various body systems. These include the digestive (eg, nausea, vomiting, anorexia, right upper-quadrant tenderness), urinary (eg, dark-colored urine), musculoskeletal (eg, fatigue, arthralgia, myalgia), and integumentary (eg, pruritus, jaundice) systems. Nursing interventions for the acute phase of hepatitis focus on resting the liver and providing nutrition for healing: Rest - Alternate periods of rest and activity - Avoid alcohol and other drugs that increase liver metabolism - Medications (eg, appetite stimulants, antipruritics, analgesics) should be used cautiously to allow hepatocytes to heal. Antiemetics can be used to prevent nausea Nutrition - Encourage small, frequent meals to decrease nausea. - Anorexia is lowest in the morning; promote eating a larger breakfast - Provide oral care and avoid extremes in food temperature to increase appetite - Drink adequate amounts of fluid (2500-3000 mL/day) and encourage a diet high in carbohydrates and calories - Clients with acute hepatitis should eat a diet high in calories and carbohydrates while decreasing fat and protein consumption. The liver produces bile, which aids in lipid digestion. A high-protein diet produces more ammonia and other toxic substances and the inflamed liver may not detoxify these well. Moderation of fat and protein intake allows the liver to rest.

Question 336

GTPAL

Answer 336

G - gravida - number of times a woman has been pregnant T - term - number of deliveries at 37 w 0 days gestation and beyond P - preterm - number of deliveries between 20 w through 36 w and 6 days gestation A - abortion - pregnancies ending before 20 w L - living - number of living children

Question 337

Peritonitis

Answer 337

intestinal perforation and peritonitis are common complications of intestinal obstruction (eg, intussusception). Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness and is a surgical emergency common but serious complication of peritoneal dialysis that typically occurs as a result of contamination during infusion connections or disconnections. Typically, the earliest indication of peritonitis is the presence of cloudy peritoneal effluent. Later manifestations include low-grade fever, chills, generalized abdominal pain, and rebound tenderness. To detect rebound tenderness, one hand is pressed firmly into the abdominal wall and quickly withdrawn. Rebound tenderness is present when there is pain on removal, indicating inflammation of the peritoneal cavity. - Treatment of peritonitis is antibiotic therapy based on the culture results. Antibiotics may be added to dialysate, given orally, or administered intravenously.

Question 338

Acute care for diverticulitis focuses on allowing the colon to rest and the inflammation to resolve. This includes:

Answer 338

- NPO status – more acute cases require complete rest of the bowel. Less severe cases may be handled at home, and clients may tolerate a low-fiber or clear liquid diet - IV fluids to prevent dehydration when NPO - Pain relief via IV medications to maintain NPO status - Preventing increased intraabdominal pressure to avoid perforation and rupture - Preventing increased intestinal motility – avoid laxatives and enemas

Question 339

Epistaxis

Answer 339

or nosebleed, is rarely serious and is usually due to mucosal irritation from dryness, local injury (eg, nose-picking), a foreign body, or rhinitis. Most bleeding arises from a highly vascular network on the anterior nasal septum. Epistaxis generally resolves spontaneously or with simple home management. The initial step in treatment is to tilt the client's head forward and apply direct, continuous pressure to the nose for 5-10 minutes. Pressure should be applied to the soft, compressible area below the nasal bone (ie, the nasal alae); holding pressure on the nasal bridge does not provide effective relief. Holding a cold cloth or ice pack to the bridge of the nose may also help to induce vasoconstriction. Keeping the child quiet and calm may help provide the adequate time and pressure necessary for clotting. Epistaxis can often be prevented by avoiding local trauma and maintaining hydration of the mucosa with saline nasal spray or a humidifier. A common mistake in epistaxis treatment includes having the client lie down and/or tilt the head back. These positions can cause blood to drain into the mouth and throat, increasing the risk of swallowing or aspirating blood. The client should sit upright and tilt the head forward.

Question 340

bacterial meningitis what type of isolation

Answer 340

droplet- requires surgical mask and gloves Bacterial meningitis and many respiratory illnesses (eg, influenza) are transmitted through large droplets of secretions spread into the air by coughing, sneezing, or talking. These droplets can land on surfaces up to 6 feet away from the client. Droplet precautions during routine care, such as during assessment or medication administration, require use of a surgical mask only, as the highest risk of transmission is through inhalation. However, when completing tasks during which there is a risk of contact with client bodily fluids (eg, assistance with toileting, suctioning), the nurse should also don gloves and a gown while in the room.

Question 341

Polycythemia vera

Answer 341

chronic disorder of the bone marrow in which excessive amounts of red blood cells, white blood cells, and platelets are produced. A secondary form of polycythemia can occur as a physiologic response to chronic hypoxemia. - Clients with PV are at risk for developing blood clots due to the increased volume, viscosity, and stasis of their blood. Clients should be taught to monitor for warning signs of thrombus formation; these include redness, tenderness, and swelling in the legs or symptoms of stroke. In addition, they should be taught preventive measures such as using support stockings, elevating the legs when sitting, and hydrating properly (especially during hot weather and exercise). - Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic hypoxemia, such as chronic obstructive pulmonary disease or chronic lung disease. The danger of PV is seen when the client develops blood clots—due to the increased viscosity of the blood, which makes the circulation sluggish—and decreasing tissue perfusion. - Treatment of PV usually includes periodic phlebotomy, the removal of 300 to 500 milliliters of blood through venipuncture, to reduce the RBC count and achieve a hematocrit of less than 45%. Initially, clients may require phlebotomy every other day until the goal hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws performed as necessary.

Question 342

Ventricular septal defect

Answer 342

Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. acyanotic congenital heart defect causing blood to shunt from the left side of the heart to the right (left-sided heart has higher pressure than right-sided). An increase in pulmonary blood flow causes an increase in workload of the right heart and pulmonary arteries, resulting in pulmonary hypertension. Eventually, blood does not go to the lungs, but instead the pressure on the right side of the heart increases, resulting in shunt reversal. This causes more blood to be shunted to the left ventricle, followed by the left atrium, and then back into the lungs (heart failure). Tachypnea is due to pulmonary volume overload. Diaphoresis is an indication that an infant is expending too much energy during feeding. A harsh systolic murmur is heard Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: - Tachypnea - Tachycardia, even at rest - Diaphoresis during feeding or exertion - Heart murmur or extra heart sounds - Signs of congestive heart failure - Increased metabolic rate with poor weight gain

Question 343

Coarctation of the aorta (COA)

Answer 343

an obstructive congenital heart defect resulting in decreased cardiac output. Children with COA will have stronger pulses in the upper extremities and diminished pulses in the lower extremities. This is expected until the obstruction is repaired surgically.

Question 344

patent ductus arteriosus (PDA)

Answer 344

an acyanotic congenital defect more common in premature infants. When fetal circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously. This closure is caused by increased oxygenation after birth. If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus. - Many newborns are asymptomatic except for a loud, machine-like systolic and diastolic murmur. - The PDA will be treated with surgical ligation or IV indomethacin to stimulate duct closure.

Question 345

Tetralogy of Fallot (TOF)

Answer 345

is a cyanotic congenital heart defect. Right-sided (venous) blood is shunted through the left ventricle via the ventricular septal defect due to the resistance at the pulmonary artery (pulmonary stenosis, one of the components of TOF). This will cause abnormally low oxygen saturation (often in the range of 65%-85%), which is expected until the defect is repaired surgically. a form of cyanotic congenital heart disease, causes hypercyanotic, or "tet," spells in which deoxygenated (venous) blood is shunted directly from the right ventricle, through the ventricular septal defect, into the left ventricle, and to the aorta without being oxygenated by the lungs. Clients with ToF instinctively squat, which increases systemic vascular resistance in the extremities, pushing blood into the pulmonary circulation to be oxygenated. Placing the infant in the knee-chest position achieves the same outcome. Calming the child helps reduce metabolic demand and lowers the respiratory and heart rates. Supplemental oxygen acts as a pulmonary vasodilator and systemic vasoconstrictor. Administering IV morphine decreases tachypnea by suppressing the respiratory drive, which in turn allows vasodilation and increased blood flow to the lungs.

Question 346

Pheochromocytoma

Answer 346

condition caused by a tumor in the adrenal medulla. This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis. Important points to note when caring for these clients include the following: - Hypertension is difficult to treat and is often resistant to multiple drugs. - The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver). - Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis. Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment. Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter.

Question 347

Sjögren's syndrome

Answer 347

an autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Can also affect skin (dry skin and rashes), throat and bronchi (chronic dry cough), vagina (dryness and painful intercourse) Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva or sugar free gum. Using a room humidifier and not sitting in front of fans and air vents can also help. Use lukewarm water and mild soap when showering. Avoid decongestants because they cause further dryness to the mouth and nasal mucosa, also avoid oral irritants (coffee, alcohol, nicotine)

Question 348

A sucking chest wound indicates

Answer 348

a traumatic, or "open," pneumothorax and is a medical emergency. Respiratory distress results from inability to expand the lung. The priority action is to apply a sterile occlusive dressing (eg, petroleum gauze) taped on three sides.

Question 349

Proper emergency care immediately following a burn can prevent infection, hypothermia, and further tissue damage. Once the source of the burn is contained, the nurse teaches the client home care that can be given prior to arrival to the emergency department. Client teaching includes:

Answer 349

- Soak area briefly in cool water to stop the burning process - Remove any clothing or jewelry around the burn to avoid constriction as edema develops. This also allows for quick assessment of the burn by clinicians. Only a health care provider may remove clothing that is stuck to the burned area - Cover with a clean, dry cloth to prevent contamination, further trauma, and hypothermia

Question 350

when assessing for jugular venous distension the pt should be

Answer 350

in semi-Fowler's position (ie, head of the bed elevated at a 30- to 45-degree angle).

Question 351

To assess the point of maximal impulse (PMI)

Answer 351

the client is positioned supine or with the head of the bed elevated to 45 degrees; the nurse should palpate for a short tap at the midclavicular line of the fourth or fifth ICS (pulsation may or may not be visible). A displaced PMI (eg, below the fifth ICS) may be an indication of an enlarged heart.

Question 352

fluid for burn victim

Answer 352

The greatest immediate threat to a client with severe and extensive burn injuries is hypovolemic shock and electrolyte imbalance. This is due to cellular damage and increased capillary permeability caused by direct thermal trauma, which result in fluid loss. In the emergent phase of burn management, it is critical to establish an airway and replenish lost intravascular fluid, proteins, and electrolytes. Lactated Ringer's (LR), also known as Ringer's lactate, is the solution of choice for fluid resuscitation of a burned client due to its similarity in chemical composition to human plasma. LR remains in the intravascular space longer than other solutions, which helps to stabilize blood pressure and avert shock.

Question 353

xerostomia =

Answer 353

dry mouth

Question 354

Tinnitus =

Answer 354

ringing in the ears

Question 355

After a mastectomy

Answer 355

Immediately after mastectomy surgery, the client is placed in a semi-Fowler's position with the affected side's arm and hand elevated on several pillows to promote drainage and prevent venous and lymphatic pooling. Flexing and bending of the affected side's fingers is begun immediately with gradual increase in arm movement over the next few postoperative days. Postoperative arm and shoulder exercises are initiated slowly with the goal of full range of motion of the affected side within 4-6 weeks of the mastectomy. an important goal is restoring function in the client's affected arm. Measures to promote function are initiated immediately after surgery. Elevating the affected arm to heart level (eg, on a pillow) is crucial to reduce fluid retention and prevent lymphedema in the affected arm. Hand and arm exercises are implemented gradually, beginning with finger flexion and extension. These activities maintain muscle tone, prevent contractures, and improve lymph and blood circulation, which promote function and also prevent lymphedema. The return of full range of motion in the affected arm is desired within 4-6 weeks. Additional nursing care for clients after a mastectomy includes keeping the client in semi-Fowler position and placing a sign over the bed that specifies, "No blood pressure, venipuncture, or injections on left arm," as these actions could cause lymphedema.

Question 356

Oculocephalic reflex

Answer 356

(doll's eyes) is an expected finding that indicates an intact brain stem. - eyes roll in opposite direction when turning from side to side - The test is not performed if spinal trauma is suspected.

Question 357

Meniere disease

Answer 357

endolymphatic hydrops) results from excess fluid accumulation in the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. The vertigo can be severe and is associated with nausea and vomiting. Clients report feeling being pulled to the ground (drop attacks).

Question 358

Murmurs indicate

Answer 358

turbulent blood flow across diseased or malformed cardiac valves. They are often described as musical, blowing, or swooshing sounds that occur between normal heart sounds. They may be auscultated at the aortic, pulmonic, tricuspid, or mitral areas.

Question 359

arterial bruit is

Answer 359

a turbulent blood flow sound heard in a peripheral artery.

Question 360

pericardial friction rub is

Answer 360

a high-pitched, scratchy sound during S1 or S2 at the apex of the heart. It is best heard with the client sitting and leaning forward and at the end of expiration. It occurs when inflamed surfaces of the heart rub against each other.

Question 361

S3 gallop is

Answer 361

an extra heart sound that occurs closely after S2. It is a low-pitched sound heard in early diastole that is similar to the sound of a horse's gallop. The mitral area is located at the fifth intercostal space, medial to the mid-clavicular line. is made when blood from the atrium is pumped into a noncompliant ventricle. S3 is heard after S2 (ventricular gallop). It can present as a normal finding in young adults. In older clients, S3 is a significant finding as it often indicates heart failure or volume overload. This client may be receiving excessive IV fluids that are causing volume overload.

Question 362

Painful genital lesions can be indicative of

Answer 362

an outbreak of genital herpes simplex virus (HSV) and are a priority assessment finding to report to the health care provider. - Herpes in pregnant women can be transmitted to the infant in utero (congenital HSV), perinatally, or postnatally as a result of direct contact with virus particles shed from the infected vulva, vagina, cervix, or perineum. - Neonatal HSV infection has serious morbidity (eg, permanent neurologic sequelae) and mortality. Immediate antiviral therapy (eg, acyclovir) should be initiated to treat the active infection. - Vaginal birth is not recommended in the presence of active lesions; cesarean birth helps reduce the risk of transmission to the newborn

Question 363

Hyperosmolar hyperglycemic state

Answer 363

a serious complication usually associated with type 2 diabetes. - With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit. Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dL (33.3 mmol/L). - This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma. - Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent

Question 364

urolithiasis

Answer 364

urinary stones

Question 365

Bladder exstrophy is

Answer 365

a congenital disorder in which the bladder was not developed in the abdominal cavity during fusion in the embryo and is exposed externally. The priority before surgical repair is to prevent injury. Placing a protective film of plastic (Saran wrap) over the exposed bladder will keep the tissue moist and help prevent infection.

Question 366

Clients with cystic fibrosis require

Answer 366

- bronchodilators prior to chest physiotherapy; - a diet high in fat, calories, and proteins; - pancreatic enzyme supplements with all meals and snacks; - physical activity. - Clients should also be monitored for atypical signs of respiratory infection (eg, anorexia, weight loss, decreased activity levels).

Question 367

when suctioning a pt

Answer 367

Risks associated with suctioning include hypoxemia, microatelectasis, and cardiac dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of oxygen removed and mucosal trauma, suction is applied when removing, not inserting, the catheter into the artificial airway. - If secretions are thick and difficult to remove, increasing hydration, not suctioning time, is indicated. Aerosols of sterile normal saline or mucolytics such as acetylcysteine (Mucomyst) administered by nebulizer can also be used to thin the thick secretions, but water should not be used. Aerosol therapy may induce bronchospasm in certain individuals and can be relieved by use of a bronchodilator (albuterol). - Preoxygenation with 100% oxygen for 30 seconds before suctioning, unless otherwise specified, is the recommended practice to reduce suctioning-associated risks for hypoxemia, microatelectasis, and cardiac dysrhythmias. - limiting suction time to 10-15 seconds

Question 368

umbilical cord

Answer 368

The cord should be opaque or whitish-blue with two arteries and one vein and covered with Wharton's jelly. The presence of only one umbilical artery and vein is associated with heart or kidney malformation. The cord should also be assessed for bleeding. It will become dry and darker within 24 hours and detach from the body within 2 weeks.

Question 369

Pertussis

Answer 369

(whooping cough) is a very contagious communicable disease caused by the Bordetella pertussis bacteria. These organisms attach to the small hairs in the airway and release a toxin that causes swelling and irritation. Pertussis is spread from person to person by coughing, sneezing, and close contact. As a result, an affected client should be placed in standard (universal) and droplet isolation precautions when hospitalized. At first, symptoms similar to the common cold and a mild fever occur, but eventually these clients develop a characteristic violent, spasmodic cough. Coughing is so severe that the person is forced to inhale afterward, resulting in a distinctive, high-pitched "whooping" sound. Coughing episodes may continue until a thick mucus plug is expectorated and are sometimes followed by vomiting (posttussive emesis). Treatment consists of antibiotics and supportive measures. Humidified oxygen and adequate fluids will help loosen the thick mucus. Suction as needed is important in infants. Respiratory status should be monitored for obstruction. The client should be positioned on the left side to prevent aspiration if vomiting occurs. Vaccination against whooping cough is available, but some individuals will still develop the disease, although in a milder form.

Question 370

The correct order of assessment in infants includes the following:

Answer 370

1. Auscultation - performed first while the infant is quiet. This allows the nurse to clearly hear heart and lung sounds and also efficiently count the heart rate and respirations 2. palpation and percussion - performed together in a head-to-toe direction when the infant is still relatively calm. This allows the nurse to assess the abdominal muscles while the area is still relaxed 3. Traumatic procedures (eg, eyes, ears, mouth [while crying]) should be performed near the end of the assessment 4, General reflexes (eg, grasping, Babinski) can be tested as the corresponding body part (eg, hands, feet) is examined. 5. The last step in an infant assessment is testing the Moro reflex as by that time the infant is usually awake and moving around. The expected response to a sudden dropping or jarring motion is a reflexive startle and crying

Question 371

RACE

Answer 371

Rescue (remove clients from immediate danger) Alarm (activate the fire alarm, call "code red," alert nearby appropriate personnel) Confine (close the doors and windows) Extinguish the fire or evacuate clients—first horizontally, then vertically

Question 372

Raynaud phenomenon

Answer 372

vasospastic disorder resulting in an episodic vascular response related to cold temperatures or emotional stress. It most commonly affects women age 15-40. Vasospasms induce a characteristic color change in the appendages (eg, fingers, toes, ears, nose). When vasoconstriction occurs, the affected appendage initially turns white from decreased perfusion, followed by a bluish-purple appearance due to cyanosis. Clients usually report numbness and coldness during this stage. When blood flow is subsequently restored, the affected area becomes reddened and clients experience throbbing or aching pain, swelling, and tingling. Acute vasospasms are treated by immersing the hands in warm water. Client teaching regarding prevention of vasospasms includes: - Wear gloves when handling cold objects - Dress in warm layers, particularly in cold weather. - Avoid extremes and abrupt changes in temperature. - Avoid vasoconstricting drugs (eg, cocaine, amphetamines, ergotamine, pseudoephedrine). - Avoid excessive caffeine intake - Refrain from use of tobacco products - Implement stress management strategies (eg, yoga, tai chi) If conservative management is unsuccessful, clients may be prescribed calcium channel blockers to relax arteriole smooth muscle and prevent recurrent episodes.

Question 373

Guillain-Barré syndrome (GBS)

Answer 373

GBS is an acute, immune-mediated polyneuropathy that is most often accompanied by ascending muscle weakness and absent deep-tendon reflexes. Many clients have a history of antecedent respiratory tract or GI infection. Lower-extremity weakness progresses over hours to days to involve the thorax, arms, and cranial nerves. However, neuromuscular respiratory failure is the most life-threatening complication. Early signs indicating impending respiratory failure include: - Inability to cough - Shallow respirations - Dyspnea and hypoxia - Inability to lift the head or eye brows Assessing the client's pulmonary function by serial spirometry is also recommended. Measurement of forced vital capacity (FVC) is the gold standard for assessing ventilation; a decline in FVC indicates impending respiratory arrest requiring endotracheal intubation.

Question 374

Signs and symptoms of delirium tremens include

Answer 374

agitation, fever, tachycardia, hypertension, and diaphoresis.

Question 375

Nursing interventions to reduce aspiration risk for clients receiving enteral tube feedings include:

Answer 375

- Assess client for gastrointestinal intolerance to feedings every 4 hours by monitoring gastric residual and assessing for abdominal distension, abdominal pain, bowel movements, and flatus - Assess feeding tube placement at regular intervals - Keep head of the bed at ≥30 degrees, with 30-45 degrees being optimal to reduce gastroesophageal reflux and aspiration risk unless otherwise indicated - Keep endotracheal cuff inflated at appropriate pressure (about 25 cm H20) for intubated clients, as low cuff pressure increases the risk for aspirating oropharyngeal secretions and/or gastric contents - Suction any secretions that may have collected above the endotracheal tube before deflating the cuff if deflation is necessary - Use caution when giving sedatives and frequently monitor for over-sedation, which can slow gastric emptying and reduce gag reflex - Avoid bolus tube feedings for clients at high risk for aspiration

Question 376

Pediculosis capitis

Answer 376

(head lice) is a contagious parasitic infestation that is often seen in school-age children. The female louse lays eggs (nits) on the hair shaft close to the scalp that hatch in 7-10 days. The adult louse cannot survive away from the host's head for >48 hours. However, the nits can live away from the host (eg, on hairbrushes, carpets, hats) for up to 10 days. The infestation can spread between children when they share lice-infested items. Treatment involves applying a pediculicide (usually permethrin 1% cream) to the head and removing nits with a nit comb or by hand. After diagnosis, it is advised to use the nit comb at least every 2-3 days for 2 weeks. Carpets, rugs, and upholstered furniture must be vacuumed frequently to remove any lice or nits that might be present. The client's bedding should be washed in hot water and dried on the hottest dryer setting. Non-washable items can be sealed in a plastic bag for 2 weeks to kill lice. All hairbrushes, combs, and ornaments should be soaked in boiling water for 10 minutes or lice-killing products for 1 hour

Question 377

Pediatric administration of rectal suppositories

Answer 377

is similar to the adult technique, with a few key modifications due to the small size of a child's colon and varying developmental needs. Age-appropriate explanations and/or distractions should be implemented to reduce distress. Toddlers and infants may benefit from distraction with a toy; preschoolers and older children can be instructed to take deep breaths or count during the procedure. Basic steps for suppository administration include the following: - Apply clean gloves and position the client appropriately based on age and size (eg, infant supine with knees and feet raised, older child side-lying with knees bent) - Lubricate the tip of the suppository with water-soluble jelly. Petroleum-based products can reduce absorption. Insert the suppository past the internal sphincter using the fifth finger if the child is under 3 years. Use of the index finger may cause injury to the colon or sphincters in children younger than age 3 years. - Angle suppository and guide it along the rectal wall. The suppository should remain in contact with the rectal mucosa (and not be buried inside stool) to ensure systemic absorption. - Hold the buttocks together for several minutes, or until the urge to defecate has passed, to prevent immediate expulsion). - If a bowel movement occurs within 10-30 minutes, observe for the presence of the suppository.

Question 378

nonimmune pregnant woman to rubella

Answer 378

In a pregnant client, a serum sample is collected at the first prenatal visit to determine immunity to the rubella virus. A positive immune response indicates immunity to the rubella virus, attributed to either past infection or vaccination. A negative, or nonimmune, response indicates that the client is susceptible to rubella disease and requires vaccination. An equivocal response indicates partial immunity to rubella and is treated clinically the same as nonimmune status. Measles-mumps-rubella (MMR) is a live attenuated vaccine. Live vaccines are contraindicated in pregnancy due to the theoretical risk of contracting the disease from the vaccine. Maternal rubella infection can be teratogenic for the fetus. The fetal effects of congenital rubella syndrome include congenital cataracts, deafness, heart defects (patent ductus arteriosus), and cerebral palsy. The best time to administer an MMR vaccine to a nonimmune client is in the postpartum period just prior to discharge. The MMR vaccine can safely be administered to breastfeeding clients.

Question 379

macrolytic anemia

Answer 379

is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12 supplement is recommended when dietary intake is inadequate.

Question 380

inferior vena cava filter

Answer 380

is a device that is inserted percutaneously, usually via the femoral vein. The filter traps blood clots from lower extremity vessels (eg, embolus from deep venous thrombosis) and prevents them from migrating to the lungs and causing a pulmonary embolism (PE). It is prescribed when clients have recurrent emboli or anticoagulation is contraindicated. Clients should be questioned about and report any metallic implants (eg, vascular filters/coils) to the health care team prior to radiologic imaging, specifically MRI. Physical activity should be promoted, and clients should avoid crossing their legs to promote venous return from the legs. Leg pain, numbness, or swelling may indicate impaired neurovascular status distal to the insertion site and should be reported immediately

Question 381

hepatisis B

Answer 381

Viral hepatitis is a disease of the liver characterized by inflammation, necrosis, and cirrhosis. One of the most common viral strains that causes hepatitis is hepatitis B. The transmission of hepatitis B is primarily through contact with blood, semen, and vaginal secretions (mnemonic: B for body fluids), commonly through unprotected sexual intercourse and intravenous illicit drug use (Options 1, 3, and 5). Infants born to infected mothers are also at risk for vertical transmission of hepatitis B. Although kissing, sneezing, sharing drinks/utensils, and breastfeeding are not known routes of transmission, hepatitis B could possibly be transmitted through saliva entering the bloodstream via sharing a toothbrush or receiving a bite. Hepatitis B has an insidious onset of illness, and clients may be asymptomatic carriers. Early symptoms are often nonspecific (eg, malaise, nausea, vomiting, abdominal pain). Hepatitis B may produce jaundice, weight loss, clay-colored stools, and thrombocytopenia in late stages of illness. An effective vaccine is widely available for hepatitis B.

Question 382

intermittent claudication

Answer 382

or ischemic muscle pain that can be due to peripheral artery disease (PAD). PAD impairs circulation to the client's extremities. The nurse should first check for the adequacy of blood flow to the lower extremities by palpating for the presence of posterior tibial and dorsalis pedis pulses and their quality. Poor circulation to the extremities can place the client at increased risk for development of arterial ulcers and infection. The quality of circulation to the extremities will guide the treatment plan for this client; management will include risk factor modification for cardiovascular disease, drug therapy, and possibly surgical revascularization.

Question 383

lymphedema

Answer 383

is the accumulation of lymph fluid in the soft tissue. It can occur as a result of lymph node removal or radiation treatment. When the axillary nodes cannot return lymph fluid to central circulation, the fluid can accumulate in the arm, hand, or breast. The client's arm may feel heavy or painful, and motor function may be impaired. The presence of lymphedema increases the client's risk for infection or injury of the affected limb. Interventions to manage lymphedema include: - Decongestive therapy (massage technique to mobilize fluid) - Compression sleeves or intermittent pneumatic compression sleeve - Compression sleeves are graduated with increased distal pressure and less proximal pressure. - Clothing should also be less constrictive at the proximal arm and over the chest. - Elevation of arm above the heart - Isometric exercises - Avoidance of venipunctures (eg, IV catheter insertion, blood draw), blood pressure measurements, and injections (eg, vaccinations) on the affected limb - Injury prevention (limb less sensitive to temperature changes) - Infection prevention (limb more prone to infection through skin breaks)

Question 384

bed position used with hypotension

Answer 384

trendelenburg not reverse trendelenburg

Question 385

administering eye drops

Answer 385

If applicable, the nurse requests that the client remove contact lenses. The nurse then dons clean gloves and uses aseptic technique to administer ophthalmic medications (eg, eye drops, lubricant) that lubricate the eye and treat eye conditions (eg, glaucoma, infection). The Joint Commission disallows the use of abbreviations for right eye (OD), left eye (OS), and both eyes (OU). The nurse must verify the prescription if the health care provider (HCP) uses these abbreviations. The general procedure for the administration of ophthalmic medications includes the following steps in sequence: 1. Remove dried secretions with moistened (warm water or normal saline) sterile gauze pads by wiping from the inner to outer canthus to keep eyelid and eyelash debris from entering the eye and to prevent transfer of debris into the lacrimal (tear) duct 2. Place client in the supine or sitting position with head tilted back toward side of the affected eye to prevent excess medication from flowing into the lacrimal duct and minimize systemic absorption through the nasal mucosa 3. Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4 in) above the conjunctival sac, which keeps the dropper away from the eye globe and avoids contamination 4. Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the conjunctival sac 5. Instruct client to look upward and then instill drops of medication into the conjunctival sac. This minimizes the blink reflex and retracts the cornea up and away from the conjunctival sac to avoid instillation onto the cornea 6. Instruct client to close the eyelid and move the eye around (if able). Then apply pressure to the lacrimal duct for 30-60 seconds if medication has systemic effects (eg, beta blocker, timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into the lacrimal duct, and reduce possible systemic absorption 7. Remove excess medication from each eye with a new tissue or gauze pad to prevent cross-contamination 8. Wait 5 minutes before instilling a different medication into the same eye

Question 386

Wernicke encephalopathy,

Answer 386

Clients with chronic alcohol abuse suffer from poor nutrition related to improper diet and altered nutrient absorption. Poor thiamine intake and/or absorption can lead to Wernicke encephalopathy, a serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Clients are prescribed thiamine to prevent this condition.

Question 387

diabetic foot care

Answer 387

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet due to the chronic complication of peripheral neuropathy. Peripheral neuropathy results from damage to the nerves in the extremities. Clients may be unable to feel injuries if they occur and must take extra measures in caring for their feet. Clients should be taught to wear closed-toed, leather-based shoes to prevent injury. Careful, daily attention to foot care can prevent long-term complications. The following instructions can be used in teaching diabetic foot care: - Proper footwear – Wear shoes that are comfortable, supportive, and well-fitting (preferably leather). Avoid high-heeled, open-heeled, and open-toed shoes. Wear clean, absorbent (eg, cotton) socks. - Daily hygiene and inspection – Use a mild soap and warm water; dry feet thoroughly, especially between toes. Apply lanolin lotion to prevent drying (but not between toes). Inspect for any break in skin integrity using a mirror or a second person to visualize the bottom of the feet. Trim toenails straight across; file edges along contour of the toes. - Injury avoidance – Do not walk barefoot, use hot water or heating pads, wear restrictive shoes or clothing, or cross the legs for extended periods (Options 3 and 4). - Report problems – Do not self-treat corns, calluses, or ingrown toenails. Cleanse cuts or abrasions with mild soap and water; report non-healing or infected injuries to the health care provider immediately

Question 388

acrocyanosis

Answer 388

peripheral cyanosis that is considered normal during the first day of life or up to 7-10 days after birth if the infant becomes cold. It manifests as a bluish discoloration of the hands and feet and sometimes the skin around the mouth. It results from poor perfusion of blood to the periphery of the body as an initial mechanism to reduce heat loss and stabilize temperature. Initial nursing management is to keep the newborn warm by placing skin-to-skin with the mother or under a radiant warmer. The nurse should also frequently assess axillary temperature to ensure that the newborn is properly retaining body heat. Stable body temperature is generally reached within 6-12 hours after birth. However, if peripheral cyanosis is present with central cyanosis of the mucous membranes or trunk, along with signs of grunting, nasal flaring, retractions, or an abnormal breathing rate (<30 or >60/min), the infant may be experiencing respiratory distress and requires immediate further assessment and intervention

Question 389

oxygen prescribed for COPD

Answer 389

The prescribed concentration of oxygen, usually 24%-28% for clients with COPD, should be maintained. Oxygen is prescribed to raise the PaO2 to 60-70 mm Hg and the saturations from 90%-93%. A flow rate of 2 L/min provides approximately 28% oxygen concentration, and 6 L/min provides approximately 44%. Higher rates usually do not help and can even be dangerous in clients with COPD as they can decrease the drive to breathe. The client should notify the care provider about excessive shortness of breath as additional treatment may be indicated.

Question 390

chicken pox

Answer 390

(varicella). transmitted primarily by airborne spread of secretions from the nasopharyngeal secretions of an infected individual and through direct contact of open lesions. It is most contagious 1–2 days before the rash until shortly after onset of rash (until all lesions are crusted over). Supportive care is usually adequate, and most children recover fully. Children who are immunocompromised are at risk for complications. Contact and airborne precautions are used. A mask will help prevent the spread of infection until the child is placed in an isolation negative airflow room.

Question 391

where is bubbling in chest tube

Answer 391

The suction control chamber (Section A) maintains and controls suction to the chest drainage system; continuous, gentle bubbling indicates that the suction level is appropriate. The amount of suction is controlled by the amount of water in the chamber and not by wall suction. Increasing the amount of wall suction would cause vigorous bubbling but does not increase suction to the client as excess suction is drawn out through the vent of the suction control chamber. Vigorous bubbling would increase water evaporation and therefore decrease the negative pressure applied to the system. The nurse should check the water level and add sterile water, if necessary, to maintain the prescribed level.

Question 392

Posttraumatic stress disorder

Answer 392

(PTSD) is a reaction to a traumatic or catastrophic event that is typically life-threatening to oneself or others. There are 3 categories of PTSD symptoms: - Reexperiencing the traumatic event Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (rapid, pounding heart; gastrointestinal distress; diaphoresis) - Avoiding reminders of the trauma Examples include avoidance of activities, places, thoughts, or other triggers that could be trauma reminders, feeling detached and emotionally numb, loss of interest in life, lack of future goals, and amnesia related to important details of the event - Increased anxiety and emotional arousal Examples include insomnia, irritability, outbursts of anger and/or rage, difficulty concentrating, hypervigilance, and feeling jumpy

Question 393

pleural friction rub

Answer 393

Pleurisy is characterized by stabbing chest pain that usually increases on inspiration or with cough. It is caused by inflammation of the visceral pleura (over the lung) and the parietal pleura (over the chest cavity). The pleural space (between the 2 layers) normally contains about 10 mL of fluid to help the layers glide easily with respiration. When inflamed, they rub together, causing pleuritic pain. A pleural friction rub is auscultated in the lateral lung fields over the area of inflammation. The sound is produced by the 2 layers rubbing together and can indicate pleurisy, a complication of pneumonia. It is characterized by squeaking, crackling, or the sound heard when the palm is placed over the ear and the back of the hand is rubbed with the fingers. Complications of pneumonia are more prevalent in elderly clients with underlying chronic disease.

Question 394

thoracic arotic aneurysm

Answer 394

horacic aortic aneurysm can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate that the aneurysm has increased in size and may need further diagnostic evaluation and treatment.

Question 395

postpartum endometritis

Answer 395

uterine infection Clients develop fever, chills, tachycardia, uterine tenderness, and foul-smelling lochia. Postpartum endometritis is usually caused by polymicrobial infection and is treated with broad-spectrum antibiotics. If the health care provider prescribes blood cultures, they must be obtained prior to initiating antibiotic therapy as the medication may alter laboratory results. After the results of the blood culture are obtained, the antibiotic prescribed may be changed for appropriate treatment.

Question 396

AV canal defect is often seen with

Answer 396

trisomy 21 (down syndrome) - needs to be repaired surgically when infants grows and can tolerate the procedure - usually loud murmur, requires no immediately reaction as long as vitals are stable

Question 397

to prevent surgical wound dehenise

Answer 397

The edges of a surgical wound may fail to approximate or they may separate due to a partial or total separation of the skin and tissue layers. This condition is known as dehiscence and is a complication of wound healing. Factors associated with dehiscence include conditions that impair circulation, tissue oxygenation, and wound healing (eg, diabetes, smoking, obesity, advanced age, malnutrition, infection, steroid use) and cause mechanical stress on the wound (eg, straining to cough, vomit, defecate). Interventions to prevent surgical wound dehiscence include: - Administering stool softeners such as docusate (Colace) to prevent straining during defecation and alleviate constipation caused by postoperative immobility and opioid pain medications - Administering antiemetics such as ondansetron (Zofran) as needed to prevent straining that can occur with vomiting - Applying an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing and moving - Monitoring blood sugar to maintain tight glycemic control (<140 mg/dL fasting glucose, <180 mg/dL random glucose) to help prevent infection and promote wound healing - Splinting the abdomen by holding a pillow or folded blanket against the abdomen to support the wound when coughing and moving

Question 398

aphasia

Answer 398

refers to impaired communication due to a neurological condition (eg, stroke, traumatic brain injury). The term aphasia is interchangeable with dysphasia, although aphasia is used more commonly. Receptive aphasia refers to impaired comprehension of speech and writing. A client with receptive aphasia may speak full sentences, but the words do not make sense. The nurse should speak clearly, ask simple "yes" or "no" questions, and use gestures and pictures to increase understanding. Expressive aphasia refers to impaired speech and writing. A client with expressive aphasia may be able to speak short phrases but will have difficulty with word choice. The nurse should listen without interrupting and give the client time to form words. A client may have one type of aphasia or a combination of both, and the severity will vary with the individual.

Question 399

Femoral-popliteal bypass surgery

Answer 399

involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow. The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselines. The client's nonpalpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately.

Question 400

extrasation

Answer 400

is the infiltration of a drug into the tissue surrounding the vein. Norepinephrine (Levophed) is a vasoconstrictor and vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue. Pain, blanching, swelling, and redness are signs of extravasation. Norepinephrine should be infused through a central line when possible. However, it may be infused at lower concentrations via a large peripheral vein for up to 12 hours until central venous access is established. The nurse should implement the following interventions to manage norepinephrine extravasation: - Stop the infusion immediately and disconnect the IV tubing - Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while aspirating. - Elevate the extremity above the heart to reduce edema - Notify the health care provider and obtain a prescription for the antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to counteract the effects of some adrenergic agonists (eg, norepinephrine, dopamine)

Question 401

insulin pump

Answer 401

is a small, battery-operated device about the size of a pager. The infusion set holds a syringe (reservoir) filled with rapid-acting insulin (175-315 units) and delivers the drug from the pump to the client through a needle or catheter that is usually secured to the abdomen with an adhesive patch. The pump delivers insulin in 2 ways: - As a steady, measured, and continuous dose (basal rate) 24 hours a day - As an intermittent dose (bolus) administered manually at mealtime to cover carbohydrate intake and as a supplemental dose to correct pre- or postprandial hyperglycemia. CSII therapy delivers the insulin more accurately than injections, so the client experiences fewer swings in blood glucose levels and hypoglycemic episodes, as compared with the administration of insulin using a needle and syringe, or pen

Question 402

agoraphobia

Answer 402

Individuals with agoraphobia have fear and anxiety about being in (or anticipating) certain situations or physical spaces. The fear they experience is out of proportion to any actual danger. These individuals are also highly concerned about having trouble escaping or getting help in the event of a panic attack or panic symptoms. The primary psychological need in agoraphobia is to avoid panic, and individuals with this condition will engage in various behaviors to lessen anxiety and avoid specific situations. In severe agoraphobia, the individual may become homebound, not going to public places for fear of experiencing a panic attack that may cause them to become embarrassed or perform an uncontrollable act. The person with agoraphobia will often feel the need to be accompanied by a relative or friend when facing situations. Agoraphobic individuals most typically fear being in the following situations: Outside the home alone In a crowd or standing in line Traveling in a bus, train, car, ship, or airplane On a bridge or in a tunnel Open spaces (eg, parking lots, marketplaces) Enclosed spaces (eg, theaters, concert halls, stores)

Question 403

Postpartum psychosis

Answer 403

is a rare but serious perinatal mood disorder. Research suggests a multifactorial etiology, including genetic predisposition and hormone fluctuation after birth. Risk factors include history of bipolar disorder and previous discontinuation of mood-stabilizing medications (eg, lithium). Signs appear within 2 weeks after birth and include hallucinations, delusions, paranoia, severe mood changes, delirium, and feelings that someone will harm the baby. Postpartum psychosis is a psychiatric emergency requiring hospitalization, pharmacologic intervention, and long-term supportive care. Women exhibiting signs of postpartum psychosis are at increased risk of suicide and infanticide, and their assessment should take priority to ensure the safety of mother and baby.

Question 404

Desquamation

Answer 404

(skin peeling) of the hands and feet is an expected finding in KD. Parents should be informed that the peeling itself is not painful but that the new skin underneath may be red and sore.

Question 405

Angina pectoris

Answer 405

defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to cardiac muscle may cause angina, including the following: - Physical exertion (eg, exercise, sexual activity): Increases heart rate and reduces diastole (time of maximum blood flow to the myocardium) - Intense emotion (eg, anxiety, fear): Initiates the sympathetic nervous system and increases cardiac workload - Temperature extremes: Usually cold exposure and hypothermia (vasoconstriction); occasionally hyperthermia (vasodilation and blood pooling) - Tobacco use and second-hand smoke inhalation: Replaces oxygen with carbon monoxide; nicotine causes vasoconstriction and catecholamine release - Stimulants (eg, cocaine, amphetamines): Increase heart rate and cause vasoconstriction - Coronary artery narrowing (eg, atherosclerosis, coronary artery spasm): Decreases blood flow to myocardium

Question 406

pneumonia s/s

Answer 406

- Crackles - Fine or coarse crackling sounds caused by air passing through alveoli and small airways obstructed with mucus - Fever, chills, productive cough, dyspnea, and pleuritic chest pain - Increased vocal/tactile fremitus - Transmission of palpable vibrations (fremitus) is increased when transmitted through consolidated versus normal lung tissue. - Bronchial breath sounds in peripheral lung fields - High-pitched, harsh sounds conducted through consolidated lung tissue, which are abnormal when heard in an area distant from where normally heard (ie, trachea); this finding can be an early sign of pneumonia. - Unequal chest expansion - Decreased expansion of affected lung on palpation - Dullness - Percussion of medium-pitched sounds over consolidated lung tissue (pneumonia) or fluid-filled space (eg, pleural effusion, a complication of pneumonia)

Question 407

Hyperresonance is

Answer 407

percussed over a hyperinflated lung (eg, asthma, emphysema) or air in the pleural space (eg, pneumothorax).

Question 408

Human papillomavirus (HPV)

Answer 408

one of the most common sexually transmitted infections, is associated with genital warts and cervical cancer. There are many different strains of HPV, with types 16 and 18 causing nearly all cases of cervical cancer. HPV infection is often asymptomatic, and genital warts due to HPV are typically painless. Prevention includes vaccination against HPV before sexual activity begins and safe sex practices/abstinence. The recommended age for vaccination in both boys and girls is age 11-12, but the vaccine can be given as early as age 9 and up to age 26. Clients with HPV and their partners should be educated that the virus can still be spread through skin-to-skin contact, even with the use of condoms. Safe sex practices decrease the risk of disease transmission but do not prevent it entirely.

Question 409

Discharge Teaching points for a pt who had DVT include the following:

Answer 409

emphasizes minimization of risk factors (eg, venous stasis, blood hypercoagulability, endothelial damage) and interventions to promote blood flow and venous return and prevent reoccurrence (eg, exercise, smoking cessation). - Drink plenty of fluids and limit caffeine and alcohol intake to avoid dehydration, which predisposes to blood hypercoagulability and venous thromboembolism - Elevate legs on a footstool when sitting and dorsiflex the feet often to reduce venous hypertension, edema, and promote venous return - Resume walking/swimming exercise program as soon as possible after getting home to promote venous return through contraction of calf and thigh muscles - Change position frequently to promote venous return, circulation, and prevent venous stasis. - Stop smoking to prevent endothelial damage and vasoconstriction as this promotes clotting. - Avoid restrictive clothing (eg, Spanx, tight jeans) that interferes with circulation and promotes clotting. - The nurse would suggest consultation with a nutritionist or a weight loss program to overweight/obese clients as excess weight contributes to venous insufficiency and hypertension by compressing large pelvic vessels. Traveling does not need to be avoided. During extended travel (>4 hours), clients are instructed to use preventative measures (eg, wear knee-high compression stockings, exercise calf and foot muscles every 30 minutes, take frequent breaks and walk briefly every hour, recline in seat, remove objects around the feet and legs to allow maximal movement, drink ample fluids to avoid dehydration). Clients should avoid sitting in any cross-legged position and should never cross the legs at the knees or ankles as this compresses the veins and limits venous return.

Question 410

Thrombotic thrombocytopenic purpura

Answer 410

onsists of hemolytic anemia with fragmentation of erythrocytes, signs of intravascular hemolysis, thrombocytopenia, decreased renal function, and fever. Regardless of the cause of the low platelets, the concern in this case is the critically low (below 10,000/mm3 (10 x 109/L) platelet count, which puts this client at risk for internal bleeding, especially within the brain. Change in level of consciousness is the most clinically significant finding requiring an emergency response

Question 411

Spinal immobilization is not a benign procedure. An acronym to help determine the need for spinal immobilization is NSAIDs:

Answer 411

N - Neurological examination. Focal deficits include numbness and decreased strength. S - Significant traumatic mechanism of injury A - Alertness. The client may be disoriented or have an altered level of consciousness (Option 2). I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option 1). D - Distracting injury. Another significant injury could distract the client from spinal pain. S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present

Question 412

how to sort pts during mass casualty event

Answer 412

During mass casualty events, the goal is the greatest good for the greatest number of people. Clients are triaged using various systems (eg, Simple Triage and Rapid Transport/Treatment [START]; Sort, Assess, Lifesaving interventions, Treatment/Transport [SALT]) and placed into 4 categories: Immediate (red tag): Life-threatening injuries with good prognoses after minimal intervention (eg, airway obstruction, open long-bone fractures, second- or higher-degree burns covering 15%-40% body surface area) Delayed (yellow tag): Requiring treatment within hours (eg, stable abdominal wounds, soft-tissue injuries) Minimal (green tag): Requiring treatment within a few days (eg, minor burns or fractures, small lacerations) Expectant (black tag): Extensive injuries, poor prognosis regardless of treatment (eg, C1-C2 spinal cord injuries)

Question 413

gout

Answer 413

is an inflammatory condition caused by ineffective metabolism of purines, which causes uric acid accumulation in the blood. Uric acid crystals typically form in the joints. Kidney stones can also develop, increasing the risk of kidney damage. Clients with medical risk factors (eg, obesity, hypertension, dyslipidemia, insulin resistance) and other lifestyle factors (eg, poor diet, alcohol consumption, sedentary lifestyle) have increased risk for future gout attacks. Improvements in uric acid control are often seen when weight loss is accompanied by dietary modifications Suggested modifications include: - Increasing fluid intake (2 L/day) to help eliminate excess uric acid - Implementing a low-purine diet, particularly avoiding organ meats (eg, liver, kidney, brain) and certain seafood (eg, sardines, shellfish) - Limiting alcohol intake, especially beer - Following a healthy, low-fat diet, as excess dietary fats impair urinary excretion of urates

Question 414

mitral stenosis will hear

Answer 414

A diastolic murmur

Question 415

aortic regurgitation will hear

Answer 415

A diastolic murmur

Question 416

A systolic ejection murmur is heard in

Answer 416

pulmonic stenosis. Right ventricular hypertrophy will develop if this defect is not repaired. In adults, systolic ejection murmur is usually due to aortic stenosis.

Question 417

nosocomial infection

Answer 417

occurs in a hospital (hospital-acquired) or other health care setting and is not the reason for the client's admission. Many nosocomial infections are caused by multidrug resistant organisms. These infections occur 48 hours or more after admission or up to 90 days after discharge. Clients at greater risk include young children, the elderly, and those with compromised immune systems. Other risk factors include long hospital stays, being in the intensive care unit, the use of indwelling catheters, failure of health care workers to wash their hands, and the overuse of antibiotics. The most common nosocomial infection is urinary tract infection, followed by surgical site infections, pneumonia, and bloodstream infections.

Question 418

drawing up regular insulin and NPH

Answer 418

Neutral protamine Hagedorn (NPH) insulin and regular insulin may be safely mixed and administered as a single injection. Regular insulin should be drawn into the syringe before intermediate-acting insulin to decrease the risk of cross-contaminating multidose vials (mnemonic – RN: Regular comes before NPH).

Question 419

Amniotomy

Answer 419

refers to the artificial rupture of membranes (AROM) and may be performed by the health care provider to augment or induce labor. After AROM, there is a risk of umbilical cord prolapse if the fetal head is not applied firmly to the cervix. A prolapsed cord can cause fetal bradycardia due to cord compression. The nurse should assess the fetal heart rate before and after the procedure The nurse should note the amniotic fluid color, amount, and odor. Amniotic fluid should be clear/colorless and without a foul odor. Yellowish-green fluid can indicate the fetal passage of meconium in utero, and a strong, foul odor may indicate infection. Once the membranes are ruptured, there is an increased risk for infection. The nurse should monitor the client's temperature at least every 2 hours after AROM

Question 420

The appropriate timing of self breast examine is determined by the client's menstrual cycle:

Answer 420

- Women with regular menstrual periods should perform BSE 5-7 days after menstruation. Self-examination before menstruation is not recommended due to the risk of finding benign cystic lesions that usually resolve with menstruation. - Women with irregular menses should perform BSE on the same day each month - Women taking oral contraceptives should perform BSE when a new package is initiated - Women who are postmenopausal should perform BSE on the same day each month

Question 421

Scleroderma is

Answer 421

an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. This is a progressive disease without a cure, and treatment is aimed at managing complications. Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal.

Question 422

Acanthosis nigricans is

Answer 422

a skin disorder characterized by the presence of symmetric, hyperpigmented velvety plaques located in flexural and intertriginous regions of skin (axilla, neck). Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans. Both indicate insulin resistance (diabetic dermopathy). The client should be referred to the primary health care provider for evaluation of undiagnosed diabetes mellitus and/or metabolic syndrome.

Question 423

when to use a A 14-gauge (large-bore) needle

Answer 423

used to administer fluids and drugs in a prehospital or emergency setting, or for hypovolemic shock.

Question 424

Phenylketonuria

Answer 424

is one of a few genetic inborn errors of metabolism. Individuals with PKU lack the enzyme (phenylalanine hydroxylase) required for converting the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine accumulates, irreversible neurologic damage can occur. A low-phenylalanine diet is essential in the treatment of PKU. Phenylalanine cannot be entirely eliminated from the diet as it is an essential amino acid and necessary for normal development. The diet must meet nutritional needs while maintaining phenylalanine levels within a safe range (2-6 mg/dL for clients age <12). There is no known age at which the diet can be discontinued safely, and lifetime dietary restrictions are recommended for optimal health. Management of the client with PKU includes: - Monitoring serum levels of phenylalanine - Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet - Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet - Encouraging the consumption of natural foods low in phenylalanine (most fruits and vegetables)

Question 425

Marfan syndrome

Answer 425

is an autosomal dominant disorder affecting the connective tissues of the body. Abnormalities are mainly seen in the cardiovascular, musculoskeletal, and ocular systems. Clients with Marfan syndrome are very tall and thin, with disproportionately long arms, legs, and fingers. Cardiovascular manifestations of Marfan syndrome include abnormalities of the aorta and cardiac valves, including aneurysms, tears (dissection), and leaky heart valves that may require replacement or repair. Therefore, competitive or contact sports are discouraged due to the risk of cardiac injury and sudden death The client may also experience crowding of the teeth from a very high-arched palate. Preventive antibiotics prior to dental work may be needed to provide prophylaxis against infective endocarditis, especially in clients with an artificial valve replacement. However, this is not a priority. These clients have an increased risk for scoliosis, especially during the adolescent years of increased growth; therefore, the child should be monitored regularly for curvature of the spine. This is not a priority. Ocular problems (eg, lens dislocation [ectopia lentis], retinal detachment, cataracts, glaucoma) can be common for the child with Marfan syndrome. Annual eye examinations with an ophthalmologist are important to monitor for developing issues

Question 426

EKG with burns

Answer 426

Burn injuries cause tissue damage that leads to increased vascular permeability and fluid shifts (eg, second and third spacing). In the emergent phase after a burn (first 24-72 hours), fluid, proteins, and intravascular components leak into the surrounding interstitium, causing decreased intravascular oncotic pressure and decreased intravascular volume, and resulting in fluid shifts and hypovolemia. Potassium, the predominant intracellular cation, is released when cellular damage occurs, resulting in hyperkalemia (potassium >5.0 mEq [5.0 mmol/L]). Clients with hyperkalemia experience muscle weakness, ECG changes (tall, peaked T waves, shortened QT interval), and cardiac arrhythmias

Question 427

Wound evisceration

Answer 427

is the protrusion of internal organs through the wall of an incision. It typically occurs 6-8 days after surgery and is more common in clients who have had abdominal surgery, those with poor wound healing, and those who are obese. It is considered a medical emergency. - The nurse should remain with the client while calling for help. The health care provider should be notified immediately and supplies brought to the room by another staff member. - The wound should be covered with sterile normal saline dressings. - While the nurse remains in the room, the client should be positioned in low Fowler's position with the knees bent. This position lessens abdominal tension on the suture line and can prevent further evisceration. - The client should be prepared for immediate return to surgery.

Question 428

if IV Infiltrates

Answer 428

- Discontinuing the IV line immediately and starting a new IV, preferably on the opposite extremity - Continuing to monitor the infiltration site for swelling or other abnormalities (eg, redness, warmth, coolness) - Elevating the affected extremity to decrease swelling - Notifying the health care provider if severe complications (eg, cellulitis, tissue necrosis, nerve damage) develop - Applying a cold or warm, moist compress based on the solution infiltrated. Heat is avoided when extravasation of a vesicant (ie, drug capable of causing tissue necrosis) occurs.

Question 429

celiac disease teaching points

Answer 429

- All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. Rice, corn, and potatoes are gluten free and are allowed on the diet. - Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced. - Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. - Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of nutritional deficiencies and intestinal cancer (lymphoma). - Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet

Question 430

alanine aminotransferase /aspartate aminotransferase

Answer 430

ALT/AST are used to diagnose hepatic disorders - ALT and AST are enzymes released when hepatocytes are destroyed as part of the hepatitis pathology. Hepatitis is diagnosed when these enzymes are ≥2-3 times the normal value. The hepatitis C virus usually causes chronic infection - elevated in - Besides viral hepatitis, liver injury can occur with excessive chronic alcohol intake, some over-the-counter medications (eg, acetaminophen), and certain herbal and dietary supplements). - IV illicit drug use increases the risk for hepatitis B and C infection

Question 431

ectopic pregnancy

Answer 431

``` occurs when a fertilized egg implants and begins to grow outside the uterine cavity, most often in the fallopian tubes. The fetus cannot survive; it will grow and cause a rupture of the fallopian tube if left untreated. Clients with an ectopic pregnancy report sudden-onset abdominal pain. Shoulder pain (referred pain) is a classic sign of irritation of the diaphragm and is usually due to intraabdominal bleeding (eg, ectopic pregnancy, spleen rupture, liver laceration, intestinal perforation). Ruptured ectopic pregnancy is a surgical emergency due to blood loss and requires priority hemodynamic support (eg, IV fluids, blood transfusion). ``` can be life-threatening if diagnosis and treatment are delayed. A growing embryo implanting anywhere outside the uterus (eg, fallopian tube, abdominal cavity) results in an ectopic pregnancy. Rupture of an ectopic pregnancy can occur if the embryo outgrows its environment, resulting in hemorrhage. Any woman with amenorrhea (ie, delayed or absent menstrual period), pelvic or abdominal pain, and/or subsequent vaginal bleeding/spotting should be evaluated promptly for the possibility of ectopic pregnancy

Question 432

molar pregnancy

Answer 432

fetal parts are replaced by edematous, cystic chorionic villi. There is no viable pregnancy. Clients report intermittent dark brown vaginal discharge that contains vesicles. This is expected until the molar pregnancy is evacuated.

Question 433

nasoenteric tube

Answer 433

A nasoenteric tube is passed through the nares into the duodenum or jejunum when it is necessary to bypass the esophagus and stomach. Nasoenteric tubes have a decreased risk of aspiration compared with nasogastric tubes; however, a nasoenteric tube can become dislodged to the lungs, causing aspiration of enteral feedings. If a client with a feeding tube develops signs of aspiration pneumonia (diminished or adventitious lung sounds [eg, crackles, wheezing], dyspnea, productive cough), the feeding should be stopped immediately and tube placement checked (eg, measure insertion depth, obtain x-ray, assess aspirate pH) (Option 2). Some facilities use capnography to determine placement; if a sensor detects exhaled CO2 from the tube, it is in the client's airway and must be removed immediately.

Question 434

The management of anaphylactic shock includes:

Answer 434

1. Ensure patent airway, administer oxygen 2. Remove insect stinger if present 3. IM epinephrine is the drug of choice and should be given to this client. Epinephrine stimulates both alpha- and beta-adrenergic receptors and dilates bronchial smooth muscle (beta 2) and provides vasoconstriction (alpha 1). The IM route (mid anterior lateral thigh) is better than the subcutaneous route. Repeat dose every 5-15 minutes. 4. Place in recumbent position and elevate legs 5. Maintain blood pressure with IV fluids, volume expanders or vasopressors 6. Bronchodilator (inhaled beta agonist) such as albuterol is administered to dilate the small airways and reverse bronchoconstriction 7. Antihistamine (diphenhydramine) is administered to modify the hypersensitivity reaction and relieve pruritus 8. Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease airway inflammation and swelling associated with the allergic reaction 9. Anticipate cricothyrotomy or tracheostomy with severe laryngeal edema

Question 435

General interventions to maintain gastric suction using a Salem sump tube include:

Answer 435

- Place the client in semi-Fowler's position to help keep the tube from lying against the stomach wall; this is done to help prevent gastric reflux - Keep the air vent (blue pigtail) open and above the level of the client's stomach - Provide mouth care every 4 hours as this helps to maintain moisture of oral mucosa and promote client comfort - Turn off suction briefly during auscultation as the suction sound can be mistaken for bowel sounds - Inspect the drainage system for patency (eg, tubing kink or blockage).

Question 436

variable decelerations on fetal monitor=

Answer 436

cord compression/prolapse

Question 437

early decelerations on fetal monitor=

Answer 437

head compression

Question 438

accelerations on fetal monitor =

Answer 438

OK normal fetal oxygenation

Question 439

late decelerations on fetal monitor =

Answer 439

placental insufficiency Late decelerations indicate uteroplacental insufficiency and are a sign of fetal intolerance to labor. Interventions are directed at correcting the cause of late decelerations, and delivery may be necessary. Nursing actions to improve fetal perfusion and oxygenation include: - Discontinue uterotonic drugs (eg, oxytocin [Pitocin]) to reduce uterine activity—FIRST action - Change the maternal position to the left side to relieve compression of the inferior vena cava - Administer oxygen at 8-10 L/min via nonrebreather face mask - Give prescribed intravenous (IV) bolus of lactated Ringer's or normal saline - Notify the HCP

Question 440

nitrazine test

Answer 440

paper tests are used to assess for the presence of leaking amniotic fluid. The fern paper test is positive when a ferning pattern of dried amniotic fluid is visualized under a microscope. Nitrazine paper tests the pH of vaginal secretions (acidic with pH of 4.5-5.5). This test is positive when the pH strip turns blue, which indicates the presence of amniotic fluid (basic with pH of 7.0-7.5).

Question 441

Middle East respiratory syndrome (MERS)

Answer 441

is a viral respiratory illness caused by the coronavirus (MERS-CoV). Symptoms include fever, cough, and shortness of breath that often worsen and cause death in many of those afflicted. The incubation period is 5-6 days but can range from 2-14 days. How the virus spreads is not fully understood, but it is thought to spread via respiratory secretions. Because it has easily spread to those who care for infected persons, the Centers for Disease Control and Prevention recommends the use of standard, contact, and airborne precautions with eye protection when caring for clients with MERS.

Question 442

Essential nursing actions related to a needle liver biopsy include

Answer 442

checking coagulation, blood type, and crossmatch beforehand, positioning the client on the right side for hours afterward, and monitoring vital signs and for potential signs of shock.

Question 443

Cushing syndrome

Answer 443

is the result of prolonged exposure to excess corticosteroids, especially glucocorticoid steroids. The most common cause is the administration of corticosteroids, such as prednisone or hydrocortisone, for other conditions. However, pituitary adenomas can secrete adrenocorticotropic hormone (ACTH), which in turn causes the adrenal glands to produce too much cortisol. Clinical manifestations include: - Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities (eg, oligomenorrhea). - Metabolic complications include truncal obesity (subsequently causing peripheral insulin resistance), hypertension, and hyperglycemia (ie, excess cortisol stimulating gluconeogenesis). Fat accumulation in the face (ie, moon face) and the back of neck (ie, buffalo hump) is common - Dermatological changes are possible and include easy bruising, purple striae, and skin atrophy; these result from loss of collagen. - Proximal muscle weakness and bone loss (ie, osteoporosis) due to steroid catabolism on muscles and bone can develop in untreated clients. - hyperglycemia as a result of excess corticosteroids

Question 444

Adrenal insufficiency, or addisonian crisis

Answer 444

may occur after adrenalectomy and can be life-threatening. Addisonian crisis presents with a sudden drop in blood pressure, tachycardia, hypoglycemia, abdominal pain, and weakness. The adrenocortical insufficiency is treated with IV hydrocortisone (Solu-Cortef). Without early treatment, clients will develop vascular collapse and hypovolemic shock.

Question 445

Toxic epidermal necrolysis

Answer 445

is an acute skin disorder, most commonly associated with a medication reaction, that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion (ie, denuded skin). It is a severe form of Stevens-Johnson syndrome. The major cause of death related to toxic epidermal necrolysis is sepsis; therefore, infection prevention is critical. Basic supportive care includes: - Wound care: Sterile, moist dressings are applied to open areas of skin - Infection prevention: Strict sterile technique and reverse isolation decrease infection risk. The nurse should also monitor for any signs of infection (eg, fever) - Fluids and nutrition: Vital signs and urine output are monitored for signs of hypovolemia. Oral feeding should be initiated early to promote wound healing; a nasogastric tube may be necessary. - Hypothermia prevention: Maintain a room temperature of 85 F (29.4 C) or more, and use passive rewarming methods such as sterile, single-use warming blankets or digitally regulated warming pads - Pain management: Analgesics are administered around the clock and before painful procedures. - Eye care: Sterile, cool compresses are applied to relieve discomfort. Lubricants may relieve dryness and prevent corneal abrasion

Question 446

gastroduodenostomy

Answer 446

(Biliroth I) involves removal of the distal two-thirds of the stomach; the remaining stomach is anastomosed to the duodenum. This technique is used to treat stomach cancer and peptic ulcer disease that does not respond to more conservative treatment. Following a gastroduodenostomy, clients should be taught to consume frequent, low-carbohydrate meals with moderate amounts of fat and protein. Due to the decreased size of the stomach, fluids and meal sizes should be reduced to prevent dumping syndrome (the rapid emptying of stomach contents into the small intestine). Other common postoperative interventions, such as deep venous thrombosis prophylaxis (eg, sequential compression device, antiembolism stockings); turning, coughing, and deep breathing; and elevating the head of the bed to prevent aspiration from reflux, also apply

Question 447

abstinence syndrome in the neonate

Answer 447

Autonomic nervous system symptoms – stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and tachypnea. Treatment includes swaddling and keeping nasal passages clear Central nervous system symptoms – irritability, restlessness, high-pitched crying, abnormal sleep pattern, and hypertonicity/hyperactive primitive reflexes. Treatment includes medication and protecting the skin Gastrointestinal symptoms – poor feeding, vomiting, and diarrhea. These are treated with small, frequent feedings

Question 448

Cognitive behavioral therapy

Answer 448

- Education about the client's specific disorder - Self-observation and monitoring - the client learns how to monitor anxiety, identify triggers, and assess the severity - Physical control strategies – deep breathing and muscle relaxation exercises - Cognitive restructuring – learning new ways to reframe thinking patterns, challenging negative thoughts Behavioral strategies – focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events

Question 449

Exophthalmos

Answer 449

is a complication of hyperthyroidism (hypermetabolic state due to thyroid hormone overproduction) from Graves' disease. It is defined as a protrusion of the eyeballs caused by increased orbital tissue (connective, adipose, muscular) expansion and can be irreversible. The exposed cornea is at risk for dryness, injury, and infection. Nursing care for a client with exophthalmos includes: - Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area - Using artificial tears or other similar products to moisten the eyes to prevent corneal drying (causes abrasions/ulcers) - Taping the client’s eyelids shut during sleep if they do not close on their own Teaching the client the following: - Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate condition. - If recommended, anti-thyroid drugs should be taken to prevent further exacerbation of exophthalmos. - Smoking cessation is necessary as smoking increases the risk of Graves’ disease and associated eye problems. - Restrict salt intake to decrease periorbital edema. - Use dark glasses to decrease glare and prevent external irritants and infection. - Perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility.

Question 450

The Billroth II surgery (gastrojejunostomy)

Answer 450

removes the distal two-thirds of the stomach. Dumping syndrome is a complication of the surgically reduced gastric capacity. Dumping syndrome is the rapid emptying of hypertonic gastric contents into the duodenum and small intestine. This process leads to fluid shift from the intravascular space to the small intestine, leading to hypotension and activation of the sympathetic nervous system. Symptoms include abdominal pain, diarrhea, nausea and vomiting, dizziness, generalized sweating, and palpitations (tachycardia). The symptoms usually diminish over time, and dietary changes are helpful in controlling the symptoms. Dietary recommendations to promote delayed gastric emptying: - Small, frequent meals – reduces the amount of food in the stomach at any one time - Foods high in protein and fat – these take longer to digest and will remain in the stomach longer than carbohydrates - Drink fluids between meals (at least 30-45 min before or after meals) – fluids with meals would promote passage of stomach contents into the jejunum easily and worsen symptoms - Avoid meals high in carbohydrates – may trigger dumping syndrome as the carbohydrates are broken down into simple sugars - Diets high in fiber – delay the emptying of the stomach and prevent rapid absorption of simple sugars - Eat slowly in a relaxed environment - Avoid sitting up after a meal. Gravity increases gastric emptying. Lying down after meals would slow down gastric emptying and is preferred

Question 451

Placenta previa

Answer 451

Placenta previa is suspected in any client with PAINLESS VAGINAL BLEEDING after 20 weeks gestation. In placenta previa, the placenta is implanted over or very near the cervix. This placement, confirmed through ultrasound, may result in damage to placental blood vessels during dilation and effacement, leading to massive blood loss. Because of the risk of hemorrhage, the client should have a pelvic ultrasound using the abdominal (not vaginal) approach and blood drawn on admission for baseline hemoglobin or hematocrit levels and for a type and screen. The client should be monitored frequently for signs of hypovolemic shock. Fetal well-being should also be assessed constantly through electronic fetal monitoring. In the presence of profuse or constant bleeding, the client should be prepared for an emergency cesarean delivery. A type and screen to determine blood type and Rh status is appropriate due to the potential for excessive blood loss and need for blood transfusion. Fetal well-being is assessed via continuous electronic fetal monitoring to help determine appropriate timing for birth. Large-bore IV access is established in anticipation of fluid resuscitation and administration of blood products. The client should also be monitored frequently for any changes in bleeding via pad counts

Question 452

Oligohydramnios

Answer 452

a condition characterized by low amniotic fluid volume. This can occur due to fetal kidney anomalies (eg, renal agenesis or urine flow obstruction) or fluid leaking through the vagina (eg, undiagnosed ruptured membranes). Amniotic fluid is produced by the fetal kidney and serves 2 major purposes - to prevent cord compression and promote lung development Fluid volume also declines gradually after 41 weeks. Small uterine size for gestational age or a fetal outline that is easily palpated through the maternal abdomen should raise suspicion for oligohydramnios. Ultrasound confirms the diagnosis. Major complications of oligohydramnios are: - Pulmonary hypoplasia - due to the lack of normal alveolar distension by aspirated amniotic fluid. Therefore, additional neonatal personnel should attend the birth in anticipation of possible resuscitation - Umbilical cord compression - continuous (not intermittent) fetal monitoring should be applied to monitor for variable decelerations

Question 453

Hypomagnesemia

Answer 453

low blood magnesium level (normal 1.5-2.5 mEq/L), is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues: - Ventricular arrhythmias (torsades de pointes): This is the most serious concern (priority). - Neuromuscular excitability: Manifestations of low magnesium, similar to those found in hypocalcemia and demonstrated by neuromuscular excitability, include tremors, hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures.

Question 454

Hypospadias is

Answer 454

a congenital defect in which the urethral opening is on the underside of the penis. Except in very mild cases, the condition is typically corrected around age 6-12 months by surgically redirecting the urethra to the penis tip. Circumcision is delayed so the foreskin can be used to reconstruct the urethra. If not corrected, clients may have toilet-training difficulties, more frequent urinary tract infections, and inability to achieve erections later in life. Postoperatively, the client will have a catheter or stent to maintain patency while the new meatus heals. Urinary output is an important indication of urethral patency. Fluids are encouraged, and the hourly output is documented. Absence of urinary output for an hour indicates that a kink or obstruction may have occurred

Question 455

pessary

Answer 455

is a vaginal device that provides support for the bladder. Clients can remain sexually active while wearing a pessary. They are fitted for the proper type and size by an HCP in the office. Surgery is not required for pessary placement; clients who are able can insert and remove the pessary themselves (Option 1). If a pessary or other treatment (eg, pelvic muscle exercises, estrogen replacement therapy) is ineffective, reconstructive surgery may be indicated.

Question 456

A RAIU test

Answer 456

involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue. The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones. A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves' disease). Important nursing considerations: - Notify the primary health care provider (PHCP) if computerized tomography scan or other recent x-ray using iodine contrast has been performed; the iodine may alter the test results. - Antithyroid or thyroid hormone medication should be held for 5-7 days before undergoing a RAIU test as these can also alter results. - All premenopausal women must take a pregnancy test before the procedure, as radioactive iodine could adversely affect the development of the fetal thyroid gland. Important aspects of client education: - Maintain nothing by mouth (NPO) status for 2-4 hours prior to the procedure. Eating may resume 1-2 hours after swallowing the iodine; a normal diet can be restarted when the test ends. - Remove dentures and jewelry/metal around the neck to allow clear visualization during the scan. - Drink plenty of fluids after the procedure to clear RAI from the system. Notify the PHCP if you are allergic to any medications (eg, iodine). However, a RAIU test is generally safe (even in the presence of an iodine allergy) due to the diminutive amount of iodine used. - You will be awake during the procedure but there should be no discomfort. - Do not breastfeed immediately after this procedure, and ask your PHCP when breastfeeding may resume.

Question 457

"worst headache of my life."

Answer 457

A subarachnoid intercerebral bleed is an emergent, serious presentation often described as the "worst headache of my life." The onset is usually abrupt due to rupture of the vessel. Subarachnoid hemorrhage has a high mortality from recurrent bleeding and is an emergency

Question 458

Trigeminal neuralgia

Answer 458

(tic douloureux) presents with paroxysms of unilateral excruciating facial pain along the distribution of the trigeminal nerve (CN V) that are often triggered by touch, talking, or hot/cold air or intake. Carbamazepine (Tegretol) is the drug of choice; the condition is not life-threatening

Question 459

myopia

Answer 459

nearsightedness Children report headaches, dizziness, and difficulty seeing objects clearly. Their performance in school is often affected, especially in subjects such as arithmetic and reading. Rubbing of the eyes may be observed, as well as frequent blinking or squinting when attempting to view distant objects. Treatment includes the use of biconcave lenses or laser surgery.

Question 460

pursed-lip breathing

Answer 460

helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease (COPD). Clients with COPD are taught to use this technique when experiencing dyspnea as it increases ventilation and decreases work of breathing. Regular practice (eg, 5–10 minutes 4 times daily) enables the client to do pursed lip breathing when short of breath, without conscious effect. Clients are taught the following steps: - Relax the neck and shoulders - Inhale for 2 seconds through the nose with the mouth closed - Exhale for 4 seconds through pursed lips. If unable to exhale for this long, exhale twice as long as inhaling

Question 461

Wilms tumor

Answer 461

(nephroblastoma) is a kidney tumor that usually occurs in children age <5. Most often it involves only one kidney, and the prognosis is good if the tumor has not metastasized. Wilms tumor is usually diagnosed after caregivers observe an unusual contour in the child's abdomen. Once the diagnosis is suspected or confirmed, the abdomen should not be palpated, as this can disrupt the encapsulated tumor. It is important to post the sign "DO NOT PALPATE ABDOMEN" at the bedside. It is also essential that the child be handled carefully during bathing.

Question 462

D-dimer is a

Answer 462

laboratory test that measures the amount of cross-linked fibrin fragments resulting from clot degradation. It is ordered for clients with suspected pulmonary embolism

Question 463

Romberg test

Answer 463

part of a focused neurologic examination, assesses clients' perceptions of their head in space (vestibular function) and body in space (proprioception). It is used to determine the reason for loss of coordination (ataxia). Clients are asked to stand with the feet together and hands at the sides of the body. They are then asked to close their eyes while ability to maintain balance is assessed. A loss of balance is considered to be a positive Romberg sign and indicates that ataxia is sensory in nature rather than cerebellar. Clients demonstrating a positive Romberg test are likely to have ataxia, or be prone to lose balance, and would require assistance with ambulation.

Question 464

appendix pain on which side

Answer 464

Continuous; begins in the periumbilical region and then moves to the right lower quadrant centering at McBurney's point (one-third of the distance from the right anterior superior iliac spine to the umbilicus)

Question 465

hepatitis A

Answer 465

The transmission of hepatitis A occurs most commonly through the fecal-oral route through poor hand hygiene and improper food handling by infected persons. It is seen primarily in developing countries. After infection, the hepatitis A virus reproduces in the liver and is secreted in bile. Therefore, hand hygiene (especially after toileting and before meals) is the most important intervention to reduce the occurrence of hepatitis A infection (Option 4). Vaccination against hepatitis A is recommended for all children at age 1 and for adults at risk of contracting the virus (health care workers, men who have sex with men, drug users, those who travel to areas with a high prevalence, those with clotting disorders, and those with liver disease).

Question 466

Pressure ulcers are staged from I to IV to classify the degree of tissue damage and determine the most appropriate and effective wound treatments.

Answer 466

Stage I pressure ulcers have intact skin with non-blanchable redness. Stage II pressure ulcers have partial-thickness skin loss (abrasion, blister, or shallow crater) involving the dermis or epidermis. The wound bed is red or pink and may be shiny or dry. Stage III has full-thickness loss. Subcutaneous fat is visible, but not tendon, muscle, or bone; tunneling may be present. Stage IV has full-thickness skin loss with visible tendon, muscle, or bone. Slough or char (scabbing, dead tissue) may be present; undermining and tunneling may be present. Ulcers are described as "unstageable" if the base is covered by necrotic tissue or eschar.

Question 467

A low-pressure limit alarm on the ventilator is

Answer 467

triggered when the amount of positive pressure necessary to deliver a breath to the client is decreased. A decrease in resistance to airflow occurs due to complications that arise in the client (eg, loss of airway), artificial airway (eg, cuff leak), and/or ventilator system (eg, tubing disconnect). All of these conditions impair airway and ventilation

Question 468

Measles/Rubella isolation

Answer 468

- airborne - negative pressure room - N95 respirator - wear gown gloves and goggles as needed for blood splash - postexposure vaccination within 72 hours of exposure recommend for people who cannot show immunity (unvaccinated, susceptible family members)

Question 469

crackles immediately after birth

Answer 469

- normal - indicate fluid in the lungs and expected immediately after birth - but wheezes, stridor, or persistence of crackles after the first few hours are abnormal

Question 470

ptosis found immediately after birth

Answer 470

concerning!! - eyelids should sit above the pupils symmetrically with irises showing - ptosis (drooping of the eyelid below the level of the pupil) could indicate paralysis of the oculomotor nerve - at time of birth there should be no cranial nerve abnormalities

Question 471

aortic dissection

Answer 471

occurs when the arterial wall intimal layer tears and allows blood between the inner (intima) and middle (media) layers - more likely associated with back pain, described as the "worst ever," "tearing," or "ripping" pain - HTN contributing factor - uncontrolled hypertension can cause cardiac tamponade or aterial rupture which can be fatal - emergency tx: lowering bp or surgery

Question 472

peak flow meter

Answer 472

hand-held device used to measure peak expiratory flow rate and most helpful to pt with asthma - exhale as quickly and forcibly as possible - measures the volume of air that can be exhaled in one breath

Question 473

otalgia

Answer 473

ear pain - common after adentonsillectomy due to irritation of the 9th cranial nerve (glossopharyngeal) in the throat, causes referred pain in the ears, expected finding

Question 474

meconium ileus in a neonate classic sign for

Answer 474

cystic fibrosis

Question 475

floppy muscle tone in neonate typical for

Answer 475

down's syndrome

Question 476

spina bifida

Answer 476

defect in which the spinal cord contents can protrude through the vertebrae that did not close - mildest form is spina bifida occulta, most often at the 5th lumbar or first sacral vertebrae - a tuft of hair or a hemangioma may be seen over the site - different than lanugo (fine downy hair on the back that gradually falls out) - term infant will have minimal lanugo - to reduce chance of spina bifida increase folic acid during pregnancy - infant will need surgical repair - depending on the location of the defect, the infant can have bowel and bladder incontinence, hydrocephalus, and sensory loss

Question 477

congenital dermal melanocytosis

Answer 477

Mongolian spots - flat, bluish discolorted areas on the lower back/butt on infants - most common in African American, Asians, Hispanics, and native Americans - benign and usually resolves on its on

Question 478

caput succedaneum

Answer 478

localized soft tissue edema of the scalp from the prolonged pressure of the head against th emother's cervix during labor - feels "spongy" and crosses the suture line (Caput Succedaneum = Crosses Suture) - resolves within the first week of life

Question 479

Vernix caseosa

Answer 479

protective substance secreted by the sebaceous glands that covers the fetus during pregnancy - described as white and cheesy, most likely seen in the axillary or genital area - very little seen in full term infants

Question 480

hypothyroidism during pregnancy

Answer 480

places pts at increased risk for other complications of pregnancy (preeclampsia, placental abruption, preterm labor) - symptoms may be fatigue, cold intolerance, constipation, dry skin, and brittle hair/nails - Levothyroxine (synthroid) 1st line med for tx during pregnancy; pt may experience relief of symptoms around 3-4 weeks, may take up to 8 weeks after initiation to see a full effect, med should not be stopped during pregnancy - take med in the morning on empty stomach, 4 hours before or after prenatal vitamin

Question 481

Cushing's triad

Answer 481

- related to increase ICP - early signs include change in level of consciousness - later signs include bradycardia, increased systolic bp with widening pulse pressure (difference between systolic and diastolic), and slowed irregular respirations (Cheyne-stokes) - cushings triad is a later sign that does not appear until the ICP is increased for some time - indicates brain stem compression

Question 482

extravasation

Answer 482

infiltration of a drug into the tissue surrounding the vein | - pain, blanching, swelling, and redness are signs of extravasation

Question 483

norepinephrine (Levophed) extravasation

Answer 483

- norepinephrine is a vasoconstrictor and a vesicant that can cause skin breakdown and/or necrosis if absorbed into the tissue Interventions: - stop infusion immediately and disconnect the IV tubing - use a syringe to aspirate the drug from the IV catheter and remove the catheter while aspirating - elevate the extremity above the heart to reduce edema - notifiy the health care provider and obtain a prescription for the antidote Phentolamine (Regitine), a vasodilator that is injected Subcutaneoulsy to counteract the effect of some adrenergic agonists

Question 484

arteriovenous malformation

Answer 484

tangle of veins and arteries that is believed to form during embryonic development, the tangled vessels do not have a capillary bed which causes them to become weak and dilated - treatment depends on the location, but blood pressure control is crucial - theses pts are at high risk for having an intracranial bleed as the veins can easily rupture because they alack a muscular layer around their lumen - any neurological changes, sudden severe headache, n/v should be evaluated immediately as these are usually the first symptoms of a hemorrhage

Question 485

area of pain with pancreatitis

Answer 485

sudden onset of unrelenting, severe pain in the left upper quadrant or midepigastric area of the abdomen that often radiates to the back - pain improves with leaning forward and worsens with lying flat - pain is often made worse with a high fat meal - n/v common due to severe pain

Question 486

asthma

Answer 486

disease characterized by airway hyper-reactivity and chronic inflammation, resulting in bronchial muscle spasm, mucosal edema, and hypersecreation of mucus - the airways narrow, resulting in increased airway resistance, air trapping, and lung hyperinflation S/S: - accessory muscle use r/t increased working of breathing and diaphragm fatigue - chest tightness r/t air trapping - diminished breath sounds r/t hyperinflation - high pitched, sibilant wheezing on expiration caused by increased airway resistance (as condition gets worse wheezing can be heard on inspiration and expirations) - tachypnea which causes respiratory alkalosis - cough from inflamed airways and hypersecretion of mucus

Question 487

Nursing interventions for a newborn immediately after delivery include:

Answer 487

- Standard precautions - The unbathed newborn is covered in maternal blood and bodily fluid. Standard precautions (eg, gloves) are implemented when contact with blood or bodily fluid is anticipated. - Maintain a clear airway - Suction the pharynx first followed by the nasal passages to prevent aspiration if the newborn gasps with nasal suctioning. - Thermoregulation (97.5-99 F) reduces oxygen and stored calorie consumption. Hypothermia predisposes the newborn to metabolic acidosis, hypoxia, and shock. - A radiant warmer is used while performing assessments and interventions. Use pre-warmed linens, an infant stocking cap, and a thermal skin sensor for monitoring. Skin-to-skin contact aids in thermoregulation. - Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral thigh) within 6 hours of birth to prevent bleeding due to absence of vitamin K-producing intestinal bacteria. - Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria gonorrhoeae is legally required; application may be delayed up to 1 hour after delivery. - Initial bathing of the newborn is limited to removing blood, bodily fluids, or meconium. Vernix caseosa, a waxy, white coating, protects the skin and should not be vigorously removed

Question 488

Abdominal paracentesis

Answer 488

used to remove ascitic fluid from the peritoneal cavity in end-stage liver disease (cirrhosis). - The client should be positioned in high Fowler's or sat upright to facilitate the flow of fluid to the bottom of the peritoneal cavity, where the needle will be inserted. - The client should void prior to the procedure to decrease the risk of bladder puncture

Question 489

In the event of an air embolus, position the pt with

Answer 489

the head of the bed should be lowered (Trendelenburg) and the client positioned on the left side; this will cause the air to rise to the right atrium. The health care provider should be notified immediately and the nurse should remain with the client

Question 490

pt position for Chest tube insertion

Answer 490

Chest tube insertion should be performed with the client's arm raised above the head on the affected side. If possible, the head of the bed should be raised 30-60 degrees to reduce risk of injury to the diaphragm

Question 491

After a liver biopsy, the client should positioned

Answer 491

the client should lie on the right side for a minimum of 2 hours (to apply pressure and splint the puncture site) and then supine for an additional 12-14 hours. The risk for bleeding is increased due to the high vascularity of the liver, but correct positioning reduces this risk.

Question 492

During a lumbar puncture, the client is positioned

Answer 492

side-lying, with the head, back, and knees flexed. A small pillow may be placed between the legs and under the head for comfort and to maintain the spine in a horizontal position. Following the procedure, the client will be positioned according to the health care provider's prescription (usually supine or with head of the bed elevated 30 degrees).

Question 493

Hirsutism

Answer 493

is a condition in women that consists of male-pattern hair growth on the face, lower abdomen, chest, and back. Common causes are polycystic ovary syndrome and Cushing's syndrome.

Question 494

Allen's test with arterial blood draws

Answer 494

The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The patency of the ulnar artery can be confirmed with a positive modified Allen's test. The modified Allen's test includes the following steps: - Instruct the client to make a tight fist (if possible) - Occlude the radial and ulnar arteries using firm pressure - Instruct the client to open the fist; the palm will be white if both arteries are sufficiently occluded - Release the pressure on the ulnar artery; the palm should turn pink within 15 seconds as circulation is restored to the hand, indicating patency of the ulnar artery (positive Allen's test) If the Allen's test is positive, the arterial blood gas can be drawn; if negative and the palm does not return to a pink color, an alternate site (eg, brachial artery, femoral artery) must be used.

Question 495

Mononucleosis

Answer 495

caused by the Epstein-Barr virus. - typically seen in adolescence from the sharing of drinks, kissing, or other direct exposure to saliva. - Symptoms may include fatigue, fever, sore throat, splenomegaly, hepatomegaly, and swollen lymph nodes. - Antibiotic treatment is inappropriate for a viral infection. Inadvertent intake of antibiotics (amoxicillin) can cause a rash. - Treatment for mononucleosis is management of symptoms and includes hydration, rest, control of pain, and reducing fever as necessary. Sore throat is treated with saline gargles or anesthetic troches. - Complications include airway obstruction (eg, stridor, difficult breathing) from swollen lymph nodes around the neck and severe abdominal pain (splenic rupture). These should be reported to the health care provider (HCP) immediately.

Question 496

Tenderness over the lateral epicondyle

Answer 496

seen with tennis elbow.

Question 497

hypocalcemia

Answer 497

- Trousseau's sign (carpal spasm with blood pressure cuff inflation) indicates hypocalcemia. - known risk after a thyroidectomy as the parathyroid gland can be inadvertently removed during the surgery due to its very small size. - Acute hypocalcemia can cause tetany, laryngeal stridor, seizures, and cardiac dysrhythmias.

Question 498

cold stress in neonates

Answer 498

Clinical manifestations of cold stress include: - Neurological - altered mental status (irritability or lethargy) - Cardiovascular - bradycardia - Respiratory - tachypnea early, followed by apnea and hypoxia - Gastrointestinal - high gastric residuals, emesis, hypoglycemia - Musculoskeletal - hypotonia, weak suck and cry Neonates are unable to generate heat by shivering due to their lack of muscle tissue and immature nervous systems; they therefore produce heat by increasing their metabolic rates through nonshivering thermogenesis. Brown adipose tissue (BAT), developed during the third trimester, is metabolized for thermogenesis when available. Once BAT is depleted, nonshivering thermogenesis is less effective and the neonate may experience cold stress, possibly leading to death. Preterm neonates have fewer stores of BAT and are at higher risk for cold stress. Frequent temperature monitoring is the best method to assess if an infant is cold. In cold stress, metabolism increases to generate heat, causing a greater demand for oxygen and glucose and the release of norepinephrine. If adequate oxygenation is not maintained, hypoxia and acidemia occur. Hypoglycemia develops when available glucose is depleted, and repletion of glucose is impaired by gastrointestinal immotility and poor oral intake.

Question 499

left-to-right-sided heart shunt

Answer 499

Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: - Tachypnea - Tachycardia, even at rest - Diaphoresis during feeding or exertion - Heart murmur or extra heart sounds - Signs of congestive heart failure - Increased metabolic rate with poor weight gain

Question 500

measuring NG tube

Answer 500

Ensure proper measurement prior to inserting a large-bore NG tube by measuring from the tip of the nose, extending the tube to the earlobe, and then down to the xiphoid process. Mark the distance with a small piece of tape that can be easily removed.

Question 501

Positive end-expiratory pressure

Answer 501

(PEEP) applies a given pressure at the end of expiration during mechanical ventilation. It counteracts small airway collapse and keeps alveoli open so that they can participate in gas exchange. PEEP is usually kept at 5 cm H2O (3.7 mm Hg). However, a higher level of PEEP is an effective treatment strategy for acute respiratory distress syndrome (ARDS), a type of progressive respiratory failure that causes damage to the type II surfactant-producing pneumocytes that then leads to atelectasis, noncompliant lungs, poor gas exchange, and refractory hypoxemia. High levels of PEEP (10-20 cm H2O [7.4-14.8 mm Hg]) can cause overdistension and rupture of the alveoli, resulting in barotrauma to the lung. Air from ruptured alveoli can escape into the pulmonary interstitial space or pleural space, resulting in a pneumothorax and/or subcutaneous emphysema.

Question 502

vaccines when pregnant

Answer 502

- Inactivated vaccines (eg, inactivated influenza; tetanus, diphtheria, and pertussis) may be given during pregnancy to protect pregnant clients from illness and provide the fetus with passive immunity. - Live virus vaccines are contraindicated in pregnancy. - The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine; and varicella vaccine contain live viruses and are contraindicated in pregnancy

Question 503

Insertion of a foley catheter female

Answer 503

1. Perform hand hygiene 2. After ensuring privacy, position client in the dorsal recumbent position and drape 3. Open the catheterization kit on a clean bedside table or between client's legs 4. Touching only the outside 1" border, place sterile drape under the client's hips 5. Apply sterile gloves 6. Apply fenestrated drape over perineum 7. Organize remaining items in the kit. Place top tray on a sterile field and ensure the clamp on the catheter is closed. 8. Open antiseptic swabs with stick end up or pour antiseptic solution over cotton balls 9. Squirt lubricant into tray 10. Remove protective sheath from catheter and place the tip in lubricant 11. Using the nondominant hand, spread the labia to expose the urethral meatus 12. Use the antiseptic swab (or cotton ball with forceps) to cleanse the perineum. Wipe in the direction from clitoris to anus. Always use a new swab or cotton ball with each swipe. Cleanse far labial fold, near labial fold and finally the meatus. 13. Using the dominant hand, pick up catheter and insert until urine is visualized (usually about 3"), then advance another 1-2". If obstruction occurs, do not force the catheter. 14. Let go of the labia but hold the catheter securely in place with the nondominant hand. 15. Inflate the balloon according to manufacturer instructions (most manufacturers now warn against testing the balloon prior to insertion) 16. Anchor indwelling catheter and secure drainage bag to the bed frame

Question 504

uterine hyperstimulation

Answer 504

More than 5 contractions in 10 minutes or a resting tone of more than 20 mm Hg indicates uterine hyperstimulation by the oxytocin (Pitocin). If the fetal heart rate (FHR) tracings are reassuring, the client is placed/maintained in a side-lying position and a bolus of IV fluid is given. If these measures do not reduce uterine activity, the oxytocin dose is reduced. However, if the FHR tracing shows a non-reassuring pattern (late decelerations, fetal bradycardia, tachycardia, and decreased variability), interventions are performed in the following order: - Stop oxytocin immediately – this will stop uterine stimulation and should be the nurse's first action - Reposition or maintain the side-lying position – this is a simple and effective measure to decrease aortocaval compression and increase placental blood flow - Apply oxygen at 10 L/min via face mask – only if steps 1 and 2 do not reduce abnormalities. Administering oxygen will be more helpful if there is adequate placental perfusion of the oxygenated blood. Maternal repositioning should therefore be performed before oxygen administration. - Give IV fluid bolus - Consider giving terbutaline subcutaneously per unit protocol or standing prescriptions - Notify the health care provider - Document the findings

Question 505

subdural hematoma

Answer 505

- typically a slower venous bleed, and symptoms appear 24-48 hours later. - Signs and symptoms are similar to those of increased intracranial pressure and include change in level of consciousness, projectile vomiting, ataxia, ipsilateral (unilateral) pupil dilation, and seizures. - Brain herniation can occur if the condition is not recognized and treated

Question 506

Aspects of care for Muslim clients include:

Answer 506

- Facilitating client to face Kaaba in the holy city of Mecca, generally northeastward from North America, during prayer - Ritual daily prayers occur 5 times a day, and dying clients may pray more often. - Modesty - Care providers should be the same sex as the client whenever possible. The female client may require a hijab (traditional head covering) and/or gown to cover most of the body. - Providing foods that are halal (lawful), or acceptable for consumption (eg, no pork) - Kosher and vegetarian meals are acceptable if a specific halal menu is unavailable. - During Ramadan, the sick and dying are not required to fast with other Muslims from dawn until sunset. If the client chooses to fast, meals and medications should be rescheduled accordingly.

Question 507

dehiscence

Answer 507

The edges of a surgical wound may fail to approximate or they may separate due to a partial or total separation of the skin and tissue layers. This condition is known as dehiscence and is a complication of wound healing. Factors associated with dehiscence include conditions that impair circulation, tissue oxygenation, and wound healing (eg, diabetes, smoking, obesity, advanced age, malnutrition, infection, steroid use) and cause mechanical stress on the wound (eg, straining to cough, vomit, defecate). Interventions to prevent surgical wound dehiscence include: - Administering stool softeners such as docusate (Colace) to prevent straining during defecation and alleviate constipation caused by postoperative immobility and opioid pain medications - Administering antiemetics such as ondansetron (Zofran) as needed to prevent straining that can occur with vomiting - Applying an abdominal binder to provide hemostasis, support the incision, and reduce mechanical stress on the wound when coughing and moving - Monitoring blood sugar to maintain tight glycemic control (<140 mg/dL fasting glucose, <180 mg/dL random glucose) to help prevent infection and promote wound healing - Splinting the abdomen by holding a pillow or folded blanket against the abdomen to support the wound when coughing and moving

Question 508

Breast cancer

Answer 508

the unregulated growth of abnormal breast tissue cells and the second most common cause of cancer deaths among women. When palpated, the breast lump is usually described as hard, irregularly shaped, non-mobile, and nontender. Mammography usually detects breast cancer. Non-modifiable breast cancer risk factors include: - Female sex and age ≥50 - First-degree relative (mother or sister) with history of breast cancer - BRCA1 and BRCA2 genetic mutations - Personal history of endometrial or ovarian cancer - Menarche before age 12 or menopause after age 55 Modifiable breast cancer risk factors include: - Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause) - Postmenopausal weight gain and obesity as fat cells store estrogen - History of smoking and alcohol consumption - Dietary fat intake - Sedentary lifestyle

Question 509

ventricular tachycardia

Answer 509

pts with VT can be pulseless or have a pulse. Treatment is based on this important initial assessment. VT with a pulse should be further assessed for clinical stability or instability. Signs of instability include hypotension, altered mental status, signs of shock, chest pain, and acute heart failure. The unstable client in VT with a pulse is treated with synchronized cardioversion. The stable client in VT with a pulse is treated with antiarrhythmic medications (eg, amiodarone, procainamide, sotalol).

Question 510

The transmission of hepatitis A occurs through

Answer 510

the fecal-oral route via poor hand hygiene and improper food handling. Therefore, this infection is seen primarily in developing countries

Question 511

Repair of abdominal aortic aneurysms

Answer 511

can be done via femoral percutaneous placement of a stent graft (endovascular aneurysm repair) or via an open surgical incision of the aneurysm and placement of a synthetic graft. With either procedure, postoperative monitoring for graft leakage or separation is a priority. Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum, or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back, or groin; and decreased urinary output

Question 512

Bronchiolitis

Answer 512

is a common viral illness of childhood that is usually caused by RSV. It typically begins with viral upper respiratory symptoms (eg, rhinorrhea, congestion) that progress to lower respiratory tract symptoms such as tachypnea, cough, and wheezing. Bronchiolitis is a self-limited illness and supportive care is the mainstay of treatment. Most children can be managed in the home environment. Breastfeeding should be continued and additional fluids offered if there is a risk of dehydration due to frequent coughing and vomiting. Parents should be instructed to use saline nose drops and then suction the nares with a bulb syringe to remove secretions prior to feedings and at bedtime

Question 513

Mitral valve regurgitation

Answer 513

is the result of a disrupted papillary muscle(s) or ruptured chordae tendineae, allowing a backflow of blood from the left ventricle through the mitral valve into the left atrium. This backflow can lead to dilation of the left atrium, reduced cardiac output, and pulmonary edema. Clients are often asymptomatic but are instructed to report any new symptoms indicative of heart failure (eg, dyspnea, orthopnea, weight gain, cough, fatigue). This client should be assessed first due to possible heart failure, which would require immediate intervention.

Question 514

Cleansing enemas

Answer 514

(eg, normal saline, soapsuds, tap water) relieve constipation by stimulating intestinal peristalsis. When administering an enema, appropriate interventions include: - Place the client in a left lateral position with the right knee flexed (ie, Sims position) to promote flow of the enema into the colon - Hang the enema bag no more than 12 in above the rectum to avoid overly rapid administration. - Lubricate the enema tubing tip and gently insert 3-4 in into the rectum. - Direct the tubing tip toward the umbilicus (ie, anteriorly) during insertion to prevent intestinal perforation - Encourage the client to retain the enema for as long as possible (eg, 5-10 minutes) - Open the roller clamp on the tubing to allow the solution to flow in by gravity. If the client reports abdominal cramping, use the roller clamp to slow the rate of administration

Question 515

The following is a quick assessment formula to calculate the expected number of teeth during the first 24 months:

Answer 515

Age of child (in months) – 6 = Expected number of teeth A 12-month-old should have approximately 6 teeth, and by age 30 months all primary teeth (20) should have erupted.

Question 516

rheumatic fever

Answer 516

RF is an acute inflammatory disease of the heart. It is a complication that occurs 2-3 weeks after a streptococcal pharyngitis. RF is caused by a delayed-onset autoimmune reaction involving anti-streptococcal antibodies that cross-react with the antigens in the heart and other organs. Recurrent, untreated streptococcal pharyngitis will lead to faster onset and increased severity of rheumatic heart disease due to increased autoimmune activity. RF affects the heart, skin, joints, and central nervous system. The presence of 2 major criteria or 1 major and 2 minor criteria and evidence of a preceding streptococcal infection indicate a high probability of RF

Question 517

Cystic fibrosis

Answer 517

an inherited autosomal recessive disorder of the exocrine glands that results in physiologic alterations in the respiratory, gastrointestinal, and reproductive systems. It is theorized that the chloride transport alternation and resulting thickened mucus inhibit normal ciliary action and cough clearance, and the lungs become clogged with mucus. The thickened mucus harbors bacteria. Over time, airways develop chronic colonization and frequent respiratory infections result. Bronchial hygiene therapy, such as manual chest physiotherapy, is used. For physiotherapy, various positions are used, and this should be performed before meals to avoid a full stomach and resultant regurgitation or vomiting In cystic fibrosis (CF), a protein responsible for transporting sodium and chloride is defective and causes the secretions from the exocrine glands to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the gastrointestinal (GI) tract. The thick secretions block pancreatic ducts, resulting in a deficient amount of pancreatic enzymes entering the bowel to aid in digestion and nutrient absorption. Clients require multiple vitamin supplements and supplemental pancreatic enzymes that are administered with meals. To meet the growth needs of clients with CF, a diet high in calories, fat, and protein is required.

Question 518

"huff" cough

Answer 518

Coughing is an important lung defense mechanism. Clients with chronic obstructive pulmonary disease (COPD) have weakened muscles and narrowed airways that are prone to collapse when under increased pressure. They are therefore unable to generate the high pressure needed to create the explosive rush of air to cough effectively. The low-pressure "huff" cough, which uses a series of mini-coughs, is more effective in mobilizing and expectorating secretions in clients with COPD. When this technique is done correctly, there is less airway collapse, less energy and oxygen consumption, and greater secretion removal. The steps are as follows: 1. Position upright – maximizes lung expansion and gas exchange 2. Inhale through the nose using abdominal breathing and prolong the exhalation through pursed lips for 3 breaths – deflates excess air from lungs 3. Hold breath for 2–3 seconds following an inhalation, keeping the throat open – opens glottic structures and prevents a high-pressure cough 4. Deeply inhale and, while leaning forward, force the breath out gently using the abdominal muscles while making a "ha" sound (huff cough); repeat 2 more times (eg, "ha, ha, ha") – keeps airways open while moving secretions up and out of the lungs. 5. Inhale deeply using abdominal breathing and give one forced huff cough – the last, increased force ("ha") usually results in mucus being expectorated from the larger airways

Question 519

Intrauterine fetal demise

Answer 519

(ie, stillbirth) is the birth of an infant who is not alive.

Question 520

hiatal hernia

Answer 520

Conditions that increase intraabdominal pressure (eg, pregnancy, obesity, ascites, tumors, heavy lifting) and weaken the muscles of the diaphragm may allow a portion of the stomach to herniate through an opening in the diaphragm, causing a hiatal hernia. A sliding hernia occurs when a portion of the upper stomach squeezes through the hiatal opening in the diaphragm. A paraesophageal hernia (rolling hernia) occurs when the gastroesophageal junction remains in place but a portion of upper stomach folds up along the esophagus and forms a pocket. Paraesophageal hernias are a medical emergency. Although hiatal hernias may be asymptomatic, many clients experience signs and symptoms commonly associated with gastroesophageal reflux disease (GERD), including heartburn, dysphagia, and pain caused by increased intraabdominal pressure or supine positioning. Interventions to reduce herniation include the following: - Diet modification—avoid high-fat foods and those that decrease lower esophageal sphincter pressure (eg, chocolate, peppermint, tomatoes, caffeine). Eat small, frequent meals, and decrease fluid intake during meals to prevent gastric distension. Avoid consumption of meals close to bedtime and nocturnal eating - Lifestyle changes—smoking cessation, weight loss - Avoid lifting or straining - Elevate the head of the bed to approximately 30 degrees—this can be done at home using pillows or 4 - 6 inch blocks under the bed

Question 521

Right-sided heart failure

Answer 521

Right-sided heart failure results from pulmonary hypertension, right ventricular myocardial infarction, or left-sided heart failure. The right ventricle cannot effectively pump blood to the lungs, which results in incomplete emptying of the right ventricle. The resulting decrease in forward blood flow causes blood to back up into the right atrium and then into venous circulation, resulting in venous congestion and increased venous pressure throughout the systemic circulation. Clinical manifestations of right-sided heart failure include: - Peripheral and dependent edema (eg, sacrum, legs, hands), especially in the lower extremities - Jugular venous distension - Increased abdominal girth due to venous congestion of the gastrointestinal tract (eg, hepatomegaly, splenomegaly) and ascites. Nausea and anorexia may also occur as a result of increased abdominal pressure and decreased gastrointestinal circulation - Hepatomegaly due to hepatic venous congestion.

Question 522

Myelomeningocele

Answer 522

occurs when the neural tube fails to fuse properly during fetal development. An outpouching of spinal fluid, spinal cord, and nerves covered by only a thin membrane occurs, typically in the lumbar area. The newborn is at high risk for infection at this area. A priority nursing intervention is to cover the area with a sterile, moist dressing to decrease the risk of infection until surgical repair can occur.

Question 523

varicella immunization

Answer 523

is administered to prevent infection of varicella zoster, commonly known as chickenpox. Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary.

Question 524

at what age can you take the flu vaccine

Answer 524

after 6 mo

Question 525

Coffee-ground emesis indicates

Answer 525

active gastric bleeding, which places the client at risk for rapid decompensation (eg, hypovolemic shock). Treatment includes volume replacement, nasogastric tube insertion, and possible endoscopic intervention.

Question 526

Volkmann contracture

Answer 526

occurs as a result of compartment syndrome associated with distal humerus fractures. Swelling of antecubital tissue causes pressure within the muscle compartment, restricting arterial blood flow (brachial artery). The resulting ischemia leads to tissue damage, wrist contractures, and an inability to extend the fingers. A Volkmann contracture is a medical emergency that can cause permanent damage to the extremity if left untreated. Any restrictive dressing should be removed immediately, and the health care provider (HCP) must be notified for possible surgical intervention (eg, fasciotomy).

Question 527

birth weight at 6 mo and 12 mo

Answer 527

birth weight doubling by age 6 months and tripling by age 12 months

Question 528

Cauda equina syndrome

Answer 528

a disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain, inability to walk, saddle anesthesia (ie, motor weakness/loss of sensation to inner thighs and buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to prevent permanent damage

Question 529

Morning sickness interventions

Answer 529

- Eating several small meals during the day (ie, high in protein or carbohydrates and low in fat) - Drinking fluids (preferably clear, cold, carbonated beverages) between, rather than with, meals - Having a high-protein snack before bedtime and on awakening - Consuming foods/drinks with ginger (eg, ginger tea, ginger lollipops, ginger chews) - Consuming foods high in vitamin B6 (eg, nuts, seeds, legumes)

Question 530

Refeeding syndrome

Answer 530

potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphorous, potassium, and/or magnesium (mnemonic PPM). Other findings may include fluid overload, sodium retention, hyperglycemia, and thiamine deficiency. Actions to prevent refeeding syndrome include the following: - Obtaining baseline electrolytes - Initiating nutrition support cautiously with hypocaloric feedings - Closely monitoring electrolytes - Increasing caloric intake gradually

Question 531

Chronic pancreatitis

Answer 531

is an inflammatory disease that causes the tissue of the pancreas to become fibrotic, impairing pancreatic endocrine and exocrine functions. Chronic pancreatitis is most commonly caused by alcohol abuse, but may also result from biliary tract disease (eg, cholelithiasis), autoimmune processes, or cystic fibrosis. Lifestyle modification is a key component of treatment and includes cessation of alcohol and smoking as well as dietary modifications. Clients with pancreatitis often cannot secrete lipase in sufficient quantities to digest consumed fats. Therefore, clients should follow a low-fat diet, with the degree of fat restriction based on the severity of disease. Due to lack of endogenous lipase, oral supplementation of pancreatic enzymes is often required before meals. To avoid exacerbating gastric discomfort, the client should avoid spicy and gas-forming foods. Low-fat food choices include lean meats (eg, fish, chicken), nonfat dairy products, vegetables/fruits prepared without added fat, and low-fat carbohydrates (eg, green peas)

Question 532

Signs of meningitis in an infant include:

Answer 532

- Fever or hypothermia - Poor feeding, vomiting - Altered level of consciousness (eg, restlessness, irritability, lethargy) - Increased intracranial pressure (bulging fontanelle [late sign], opisthotonic positioning [arching of the back with hyperextension of the neck])

Question 533

To relieve choking in a responsive infant, the rescuer should:

Answer 533

- Hold the infant face down on the forearm with the infant's head slightly lower than the body. The rescuer's forearm is supported on the thigh to avoid compressing the infant's soft throat tissue and fontanelles. - Forcefully perform 5 back slaps between the infant's shoulder blades with the heel of the hand. - Using both forearms, turn the infant face up on the forearm with the head slightly lower than the body. - Forcefully provide 5 chest thrusts in a downward motion over the lower half of the breastbone using 2-3 fingers. - Repeat the cycle until the object is expelled or the infant becomes unresponsive.

Question 534

Tumor lysis syndrome

Answer 534

(TLS), an oncologic emergency, occurs when cancer treatment successfully kills cancer cells, resulting in release of intracellular components (eg, potassium, phosphate, nucleic acids). Clients with TLS develop significant imbalances of serum electrolytes and metabolites. TLS may result in the following life-threatening conditions: - Hyperkalemia (eg, >5.0 mEq/L) may progress to lethal dysrhythmias (eg, ventricular fibrillation) - Large amounts of nucleic acids (normally converted to uric acid and excreted by the kidneys) overwhelm the kidneys, leading to hyperuricemia and acute kidney injury from uric acid crystal formation - Hyperphosphatemia (eg, >4.4 mg/d) can cause acute kidney injury and dysrhythmias TLS is best prevented by aggressive hydration and prophylactic allopurinol for hyperuricemia.

Question 535

decorticate posturing

Answer 535

In a cerebrovascular accident (CVA), blood flow in the brain is compromised due to either bleeding or occlusion of a blood vessel. After a CVA, mental status may continue to decline, especially within the first 24-48 hours. The nurse should immediately notify the health care provider of decorticate (flexion) posturing, which is characterized by arms rigidly flexed at the elbow, hands raised to the chest, and legs extended. This posturing suggests worsening cerebral impairment (eg, increased intracranial pressure) that may be reversible with proper interventions.

Question 536

Elevated intracranial pressure

Answer 536

Elevated ICP is a life-threatening condition that decreases cerebral blood flow, risking brain ischemia, infarction, or herniation. Late manifestations of severely increased ICP, impending brainstem herniation, and possible brain death include changes in vital signs (eg, Cushing triad) and pupil response. Cushing triad is a neurologic emergency characterized by bradycardia, irregular respirations, and hypertension with a widening pulse pressure. The body attempts to increase perfusion to the brain by increasing blood pressure, which causes systolic hypertension with a widening pulse pressure. Other late signs may include motor abnormalities (eg, posturing) and cranial nerve deficits (eg, loss of cough and gag reflexes).

Question 537

Fetal tachycardia

Answer 537

is defined as a baseline heart rate above 160 beats per minute. Tachycardia can be an early indicator of fetal hypoxia and acidosis. Other common causes include infection, maternal fever, maternal dehydration, maternal hypotension, and drug side effects. Maternal temperature should be taken to assess for fever, and blood pressure should be assessed to rule out hypotension. Certain medications can lead to fetal tachycardia (eg, terbutaline, bronchodilators, decongestants), and the nurse should review the medication administration record to determine whether potential causative medications were administered recently

Question 538

Enteral tube feeding is the preferred route for providing nutrition to clients who cannot intake oral nutrition (eg, dysphagia, prolonged intubation). The nurse assesses tube feeding tolerance by monitoring for signs of potential complications:

Answer 538

- Diarrhea: May occur if tube feeding formula is too concentrated (hyperosmolar) or administered too rapidly. The presence of hyperosmolar feedings in the intestines causes the osmotic movement of water into the intestinal lumen, resulting in diarrhea. - Fluid overload: Manifested as rapid weight gain and peripheral edema; due to excess water flushes or too-dilute (hypo-osmolar) formula - Nausea and vomiting: Due to delayed gastric emptying or rapid administration

Question 539

Common causes of metabolic acidosis include:

Answer 539

Metabolic acidosis is due to an increase in the production or retention of acid or the depletion of bicarbonate via the kidneys or gastrointestinal (GI) tract. In metabolic acidosis there is a decrease in pH (<7.35) and HCO3- (<22 mEq). - GI bicarbonate losses (eg, diarrhea) - Ketoacidosis (eg, diabetes, alcoholism, starvation) - Lactic acidosis (eg, sepsis, hypoperfusion) - Renal failure (eg, hemodialysis with inaccessible arteriovenous shunt) - Salicylate toxicity

Question 540

Megaloblastic anemia

Answer 540

caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products, including eggs, milk, and milk products, from the diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin B12. Individuals who practice any form of vegetarianism are at risk for vitamin B12 deficiency. A vegan diet, with its elimination of all animal products, poses the highest risk. A vitamin B12 supplement is recommended when dietary intake is inadequate.

Question 541

Pyrosis

Answer 541

heart burn, occurs during pregnancy from an increase in the hormone progesterone. Progesterone causes the esophageal sphincter to relax, leading to pyrosis. Interventions to reduce heartburn include: - Upright position after meals to reduce gastroesophageal reflux - Small, frequent meals rather than 3 large meals a day - Keeping the head of the bed elevated using pillows - Drinking smaller amounts of fluid while eating - Eliminating dietary triggers, including fried and fatty foods, caffeine/chocolate, spicy foods, carbonated drinks, and peppermint

Question 542

Pap screening for cervical cancer

Answer 542

- begins at age 21. - Women age 21-65 are screened every 3 years. - Women age >65 with previous normal results do not need testing. - Women who have had a hysterectomy with cervical removal do not require Pap testing