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NCLEX/CGFNS REVIEW BULLETS 7

Home modifications to reduce the risk for falls includes use of sturdy and secure railings on all staircases and ample lighting. Bathroom safety equipment includes the use of a shower chair, handrails in the shower and near the toilet, and keeping a mat in the tub to prevent slipping.

Nursing care after bone biopsy includes monitoring the site for swelling, bleeding, and hematoma formation. The biopsy site is elevated for 24 hours to reduce edema. The vital signs are monitored every 4 hours for 24 hours. The client usually requires mild analgesics; more severe pain usually indicates that complications are arising.

A radiograph is a photographic image of a part of the body on a special film, which is used to diagnose a wide variety of conditions. The radiograph itself is painless; any discomfort would arise from repositioning a painful part for filming. The nurse may want to premedicate a client who is at risk for pain. Any radiopaque objects such as jewelry or other metal must be removed. The client is asked to breathe in deeply, and then hold the breath while the chest radiograph is taken. The client is not required to void before the procedure, but may do so to enhance comfort during the procedure.

No activity or dietary restrictions must be followed after a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. No hazards to the client or staff exist from the minimal amount of radioactivity of the isotope. The client would not experience nausea or flushing because contrast dye is not used for this procedure. In addition, those sensations would likely be experienced at the time of dye injection, not after it.

A comminuted fracture is a complete fracture across the shaft of a bone, with splintering of the bone into fragments. A compound fracture, also called an open or complex fracture, is one in which the skin or mucous membrane has been broken, and the wound extends to the depth of the fractured bone. A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. A greenstick fracture is an incomplete fracture, which occurs through part of the cross section of a bone. One side of the bone is fractured, and the other side is bent.

When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is outside a hospital, and a physician is called if the client is hospitalized. The nurse should remain with the client and provide realistic reassurance.

The procedure for casting involves washing and drying the skin and placing a stockinette material over the area to be casted. A roll of padding is then applied smoothly and evenly. The plaster is rolled onto the padding, and the edges are trimmed or smooth ed as needed with a

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special cast knife. A plaster cast gives off heat as it dries and may feel warm to the client. A plaster cast can tolerate weight-bearing once it is dry, which varies from 24 to 72 hours, depending on the nature and thickness of the cast.

The traction setup is checked routinely to assure that the ropes are in the grooves of the pulleys; ropes are not frayed; knots are tied securely; and weights are hanging freely from the ropes. Problems with any of these can interfere with maintenance of proper traction. If any problems are noted, they should be fixed immediately.

Buck’s extension traction is a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. It reduces muscle spasms and helps to immobilize the fracture. It does not completely immobilize the fracture. It does not lengthen the leg to prevent blood vessel damage. It also does not allow bony healing to begin.

Purulent drainage can indicate infection at the pin insertion site, and the nurse would reassess the client’s temperature as another indication of the presence of infection. A small amount of serous oozing is expected at pin-insertion sites. Serosanguineous drainage may be present in small amounts initially, but does not indicate infection. Sanguineous drainage also is of concern and should be brought to the attention of the physician.

Self-Care Deficit applies when the client is unable to perform activities of daily living (ADLs) independently. A major defining characteristic of Deficient Diversional Activity is expression of boredom by the client. Activity Intolerance applies when the client has a decreased tolerance for activity or exercise, which is reflected by excessive fatigue or change in vital signs with activity. Impaired Physical Mobility is present when the client has difficulty with coordination, range of motion, or muscle strength.

Buck’s extension traction is a type of skin traction. The nurse should inspect the skin of the limb in traction at least once every 8 hours for irritation or inflammation.

Exercise is indicated within therapeutic limits for the client in skeletal traction to maintain muscle strength and ROM. The client should not, however, do active ROM to the involved joints, because it would disrupt the pull of the traction force. The client may pull up on the trapeze, perform active ROM with uninvolved joints, and do isometric muscle-setting exercises (such as quadriceps- and gluteal-setting exercises). The client may also flex and extend the feet.

Signs and symptoms of infection under a casted area include odor or purulent drainage from the cast or the presence of “hot spots,” which are areas of the cast that are warmer than others. The physician should be notified if any of these occur. Signs of impaired arterial circulation in the distal limb include coolness and pallor of the skin and diminished arterial pulse. Edema indicates impaired venous return in the extremity.

A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and to promote venous drainage.

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Standard management of the client with deep vein thrombosis includes bed rest for a period as prescribed; limb elevation; relief of discomfort with warm moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. Ambulation is contraindicated, because the tail of the thrombus could dislodge and travel to the lungs as a pulmonary embolus. This is most likely to occur in the first 24 to 48 hours after clot formation.

Clients with chronic venous insufficiency are advised to avoid crossing the legs, sitting in chairs where the feet do not touch the floor, wearing garters or sources of pressure above the legs (such as girdles), and to avoid prolonged standing or sitting. The client should wear elastic hose for 6 to 8 weeks, and perhaps for life. The client should sleep with the foot of the bed elevated to promote venous return during sleep.

Successful resolution of the deep vein thrombosis is marked by the absence of original symptoms used to diagnose the problem (unilateral leg warmth, redness, edema, tenderness, enlarged calf).

Legal blindness implies that the person cannot perform work that requires visual ability. The person who is legally blind usually retains some perception of light and movement. Total blindness means the absence of all light perception. Low vision is a term that is used to refer to a legally blind person or persons with severe vision impairment who still have some visual ability.

Tonometry is an effective screen for the early detection of glaucoma. The normal intraocular pressure is 12 to 22 mm Hg. An intraocular pressure of 20 mm Hg is a normal finding.

As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Placenta previa is the sudden onset of painless uterine bleeding in the latter half of pregnancy. Abruptio placentae is characterized by abdominal pain and vaginal bleeding. Uterine atony relates to a uterus that is not firmly contracted.

The fourth stage of labor is the stage of physical recovery for the mother and infant. It lasts from the delivery of the placenta through the first 1 to 4 hours after birth. A potential complication after delivery is hemorrhage. The most significant source of bleeding is the site where the placenta was implanted. It is critical that the uterus remain contracted and that the nurse monitors vaginal blood flow every 15 minutes for the first 1 to 2 hours.

Vaginal bleeding in a pregnant client most often is caused by placenta previa or a placental abruption. Uterine tenderness accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax. Placental abruption is characterized by the presence of uterine pain and tenderness.

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It is not advisable to bathe a newborn or infant after a feeding because handling may cause regurgitation. Because bathing is thought to be relaxing to the newborn, before feeding may be the best time.

Because the placenta is implanted in the lower uterine segment that does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The nurse then has to assess the client carefully for signs of postpartum hemorrhage.

DIC is a state of diffuse clotting in which clotting factors are consumed. This leads to widespread bleeding. The presence of petechiae, oozing from injection sites, and hematuria is indicative of the presence of DIC. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area.

With a client in shock, the goal is to increase perfusion to the placenta. The initial nursing action would be to turn the mother on her side. This would increase blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels.

Chest tube drainage in the first 24 hours after thoracic surgery may total 500 to 1000 mL. Between 100 and 300 mL of drainage may accumulate during the first 2 hours.

After supratentorial surgery, the head of the bed is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This will promote venous return through the jugular veins, which will help prevent increases in intracranial pressure.

One of the complications of cranial surgery is meningitis. Signs of meningeal irritation include nuchal rigidity, which is characterized by a stiff neck and soreness, and is especially noticeable when the neck is flexed. Pupils that are equal and reactive at 4 mm in size are normal. Mild headache relieved by codeine sulfate is an expected finding at this time. Disorientation to date is not of most concern when the client has been hospitalized for cranial surgery.

The normal serum osmolality is 285 to 295 mOsm/kg H2O. A higher value indicates dehydration; a lower value indicates overhydration. After craniotomy, the goal is to keep the serum osmolality on the high side of normal, which would help to control cerebral edema. Because a serum osmolality of 280 mOsm/kg H2O is low, the client is overhydrated and is at risk for cerebral edema. The nurse should report this finding. Each of the other options represents fluid balance measurements that are normal or expected findings.

Codeine sulfate is the narcotic analgesic of choice for clients after craniotomy. It is often combined with a non-narcotic analgesic, such as acetaminophen (Tylenol) for added effect. It does not alter the respiratory rate or mask neurological signs, as other narcotics do. Side effects of codeine sulfate include gastrointestinal upset and constipation. The medication can lead to physical and psychological dependence with prolonged use.

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The postcraniotomy client may find that loud noises, such as a loud television, are irritating. It is helpful to the client if the family keeps noise within normal ranges or softer. Seizures are a potential complication that can occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of doses administered. The family should learn seizure precautions and accompany the client while ambulating if dizziness occurs. The suture line is kept dry until sutures are removed to prevent infection.

Dexamethasone is an adrenocorticosteroid administered after craniotomy to control cerebral edema. It is given by IV push, and single doses are administered over a 1-minute period. Dexamethasone doses are changed to the oral route after 24 to 72 hours and are tapered in dose until discontinued.

Sensation is tested by using sharp and dull objects and having the client discriminate between them. The nurse starts at the shoulder level and works downward in a systematic manner to test sensation.

Crutchfield tongs are a type of skeletal traction, which have weights attached to the tongs. The weights exert pulling pressure on the longitudinal axis of the cervical spine and gradually realign the spine. The nurse and other personnel must not remove the weights to administer care. The client with Crutchfield tongs is placed on a Stryker frame or Roto-rest bed. The nurse ensures that weights hang freely, and the amount of weight matches the current order. The nurse also inspects the integrity and position of the ropes and pulleys.

The placenta is implanted low in the uterus in placenta previa, and a vaginal examination could cause the disruption of the placenta and initiate severe hemorrhage.

Adjusting to paralysis is difficult both physically and psychosocially for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client’s feelings while continuing to meet the client’s physical needs and encouraging independence.

The client with a Halo vest may not drive because the device impairs the range of vision. The Halo device alters balance and can cause fatigue because of its weight. The client should clean the skin daily under the vest to protect the skin from ulceration and should use powder or lotions sparingly or not at all. The client should use straws for drinking and have food cut into small pieces to facilitate chewing.

After SCI, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by Hematest positive NGT drainage or stool. This indicates development of an important complication and should be reported immediately. A single episode of diarrhea is not a cause for alarm, although the nurse should continue to watch for a pattern.

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The client who has had a SCI experiences significant losses in most areas of daily living. It is important for the nurse to understand that the client may be looking for new areas of control as a result of feelings of helplessness.

The client should use a mirror to inspect the skin twice a day (morning and evening) to assess for redness, edema, and breakdown. To prevent pressure ulcers from developing, the paraplegic client should shift weight in the wheelchair every 2 hours and use a pressure-relief pad. While the client is in bed, the bottom sheet should be free of wrinkles and wetness.

ROM to the hands is helpful to prevent contractures but does not actively strengthen muscle groups needed for self-mobilization with paraplegia. Other activities that are more effective in moving larger muscle groups include push-ups from a prone position, sit-ups from a sitting position, extending the arms while holding weights, and squeezing rubber balls or crumpling newspaper.

The client with SCI is at risk for autonomic dysreflexia if the injury is above the level of T7. It is characterized by severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. It is very important that the nurse recognize this complication so that quick action may be taken to remove the noxious stimulus.

Episodes of autonomic dysreflexia can be caused by stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas. Linens are kept free of wrinkles, and bed clothing is kept loose around the client to prevent mechanical irritation of the skin. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and a Foley catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. A bowel movement every 5 days is too infrequent.

Key nursing actions are (in order of priority) to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. The nurse also can clearly label the client’s chart, identifying the risk for autonomic dysreflexia. The client and family should be taught to recognize, and later manage, the signs and symptoms of this syndrome.

The client with Parkinson’s disease experiences bradykinesia and can be taught to rock back and forth to initiate movement. The client should avoid sitting in soft, deep chairs, because they are difficult to get up from. The client should buy clothes with Velcro fasteners and slide locking buckles to support independence in getting dressed. The client should exercise in the morning when energy levels are highest.

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Trigeminal neuralgia is characterized by spasms of pain that start suddenly and last for seconds to minutes. The pain is often characterized as stabbing or is similar to an electric shock. It is accompanied by spasms of facial muscles, which cause twitching of parts of the face or mouth, or closure of the eye.

The paroxysms of pain that accompany this neuralgia are triggered by stimulation of the terminal branches of the trigeminal nerve. Symptoms can be triggered by pressure from washing the face, brushing the teeth, shaving, eating, and drinking. Symptoms also can be triggered by thermal stimuli such as a draft of cold air.

The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as that for the client undergoing craniotomy. This client requires hourly neurological assessment, as well as monitoring of cardiovascular and respiratory status. Suctioning is done very cautiously and only when necessary to avoid increasing the intracranial pressure (ICP).

Bell’s palsy is a one-sided facial paralysis from compression of the facial nerve (CN VII). Facial droop occurs from paralysis of the facial muscles, increased lacrimation, painful sensations in the eye, face, or behind the ear, and speech or chewing difficulties.

Clients with Bell’s palsy should be reassured that they have not experienced a stroke and that symptoms often disappear spontaneously in 3 to 5 weeks. The client is given supportive treatment for symptoms.

Prevention of muscle atrophy with Bell’s palsy is accomplished with the use of facial massage, facial exercises, and electrical stimulation of the nerves. Local application of heat to the face may improve blood flow and provide comfort. Exposure to cold or drafts is avoided.

Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, it has been triggered by vaccination or surgery.

Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or GI infection in the 1 to 4 weeks before the onset of neurological deficits. Occasionally, it has been triggered by vaccination or surgery.

To manage constipation effectively, the client should take in a high-fiber diet, bulk formers, and stool softeners. A fluid intake of 2000 mL per day is recommended. The client should initiate the bowel program on an every-other-day basis. This should be done approximately 45 minutes after the largest meal of the day, to use the gastrocolic reflex. A glycerin suppository, bisacodyl suppository, or digital stimulation may be used to initiate the process. Laxatives and enemas should be avoided whenever possible because they lead to dependence.

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Venography is similar to arteriography, except it evaluates the venous system. A radiopaque dye is injected into selected veins to evaluate patency and blood-flow characteristics. Allergies to shellfish or iodine must be noted, because this could mean that the client would be allergic to the contrast dye. The client signs an informed consent because it is an invasive procedure. Peripheral pulses are assessed so comparisons can be made after the procedure. The client is usually given clear liquids for 3 to 4 hours before the procedure to help with dye excretion afterward.

A blackened appearance on an ulcerated area indicates necrosis and developing gangrene, which must be reported to the physician. Pressure dressings or dry sterile dressings will not help the serious circulatory problem presented here. Turning up the heat in the room may be partially helpful, but again will not address the concern addressed in the question.

Raynaud’s phenomenon is a condition in which the small arteries and arterioles constrict in response to various stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, stress, and trauma, or jarring movements of the fingertips.

Raynaud’s phenomenon is a condition in which the small arteries and arterioles constrict in response to various stimuli. Raynaud’s phenomenon is frequently seen associated with collagen disorders such as rheumatoid arthritis, scleroderma, and lupus erythematosus. Other factors that may contribute to the disorder include occupationally related trauma or pressure to the fingertips such as seen in typists, pianists, use of hand held vibrating tools, and exposure to heavy metal.

Intermittent claudication is a classic symptom of peripheral vascular disease, also known by other names, including peripheral arterial disease and chronic arterial insufficiency. It is described as a cramplike pain that occurs with exercise and is relieved by rest.

The classic manifestations of peripheral arterial disease include color changes (pallor, rubor, cyanosis), temperature changes, and trophic changes in the affected extremity. The pedal pulse diminishes and becomes absent as the disease progresses. Progression of pain from intermittent claudication to rest pain indicates a severe degree of occlusion and a critical state of ischemia.

Causes of autonomic dysreflexia include bladder distention, bowel distention from constipation or fecal impaction, and stimulation of the skin from pain, pressure, or changes in temperature. The client and family should learn the triggering factors, methods of preventing them from occurring, and how to manage an episode.

Signs and symptoms of spinal shock include loss of skeletal muscle movement, loss of bowel and bladder tone, and loss of autonomic reflexes below the level of the injury. Sexual function also is lost. The limbs have a flaccid paralysis, and bowel and bladder retention occurs. The client in spinal shock has special needs, and it is important for the nurse to recognize this condition.

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Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure (ICP) and trigger bleeding or rupture of the aneurysm.

Kegel exercises are extremely important to strengthen the muscle tone of the perineal area. Postpartum exercises can begin soon after birth. The initial exercises should be simple, with progression to increasingly strenuous exercises. Postpartum exercises will not result in stress urinary incontinence.

The most accurate method for determining the amount of lochial flow is to weigh the perineal pads before and after use. Once these two weights are noted, the amount of lochial flow can be accurately determined. Each gram increase in the weight is roughly equivalent to 1 mL of blood loss. To obtain an accurate estimate of lochial flow, the time factor must be incorporated into the analysis.

One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. It uses five criteria to measure the infant’s adaptation. Heart rate: absent, 0; less than 100, 1; greater than 100, 2. Respiratory effort: absent, 0; slow or irregular weak cry, 1; good, crying lustily, 2. Muscle tone: limp or hypotonic, 0; some extremity flexion, 1; active, moving, and well flexed, 2. Irritability or reflexes (measured by bulb suctioning): no response, 0; grimace, 1; cough, sneeze, or vigorous cry, 2. Color: cyanotic or pale, 0; acrocyanotic, cyanosis of extremities, 1; pink, 2.

The normal respiratory rate for a newborn infant is 30 to 60 breaths/minute.

The anterior fontanel is diamond shaped and located on the top of the head. It should be flat and soft and may range in size from almost nonexistent to 4 to 5 cm across. It normally closes by age 18 to 24 months.

A caput succedaneum indicates swelling of the soft tissues of the head and scalp that may extend across suture lines. It is most pronounced after a long labor, is evident within 24 hours after birth, and resolves within a few days.

cephalhematoma is an edema resulting from bleeding below the periosteum of the cranium.

Gastroschisis is an abdominal wall defect. Embryonal weakness in the abdominal wall causes herniation of the gut on one side of the umbilical cord during early development. The viscera are located outside the abdominal cavity and are not covered with a sac.

Omphalocele is a defect in which the vicera is outside the abdominal cavity but inside a translucent sac covered with peritoneum and amniotic membrane

Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum.

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Esophageal atresia and tracheoesophageal fistula (TEF) are congenital malformations in which the esophagus terminates before it reaches the stomach and/or a fistula is present that forms an unnatural connection with the trachea.

Congenital diaphragmatic hernia is an herniation of abdominal contents through an opening of the diaphram.

Clinical manifestations associated with CDH include diminished or absent breath sounds on the affected side; bowel sounds heard over the chest; cardiac sounds heard on the right side of the chest; respiratory distress developing soon after birth including dyspnea, cyanosis, nasal flaring, tachypnea, retractions; and a scaphoid abdomen.

clinical manifestation of esophageal atresia and tracheoesophageal fistula is excessive oral secretions.

clinical manifestation of gastroesophageal reflux is hiccupping and splitting up after a meal.

characteristic of a hiatal hernia includes coughing, wheezing and short periods of apnea.

Morning sickness is common during the first trimester of pregnancy and is associated with increased levels of human chorionic gonadotropin (hCG) and changes in carbohydrate metabolism. It most often occurs on arising, although a few women experience it throughout the day. Self-care measures include eating a dry cracker or toast before getting out of bed, eating small frequent meals, avoiding fatty or spicy foods, and rising slowly from a lying or sitting position to avoid orthostatic hypotension.

Urinary frequency is present in the first trimester and late in the third trimester because of the pressure placed on the bladder by the enlarged uterus. Self-care measures for urinary frequency include emptying the bladder frequently (every 2 hours) and continuing to drink at least 2000 mL of fluid a day.

Ankle edema is a common occurrence and is caused by decreased venous return from the feet because of gravity. It is a minor discomfort as long as hypertension and proteinuria are not present. Self-care measures for ankle edema include elevating the feet at hip level during the day, taking frequent rest periods, wearing supportive stockings or hose, and avoiding standing in one position or place for long periods.

Heartburn is associated with regurgitation of gastric acid contents into the esophagus. Self-care for heartburn includes eating small frequent meals, avoiding fatty or spicy foods, remaining upright for 30 minutes after eating, and drinking approximately 2000 mL of fluid per day.

To assess and evaluate the presence of pitting edema, the nurse uncovers the woman’s lower leg, presses the fingertips of the index and middle finger against the shin, and holds the pressure for 2 to 3 seconds.

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When evaluating the presence of pitting edema, the nurse presses the fingertips of the index and middle fingers against the shin and holds pressure for 2 to 3 seconds. An indentation of approximately 1 inch deep would be indicative of 4+ edema. A slight indentation would indicate 1+ edema. An indentation of approximately ¼ inch deep indicates 2+ edema. An indentation of approximately 1/2 inch deep indicates 3+ edema.

When evaluating the deep tendon reflex, the normal response should be an extension and thrusting of the foot upward. A 1+ response indicates a diminished response; 2+ indicates normal; 3+ indicates increased, brisker than average; and 4+ indicates a very brisk hyperactive response.

To detect the presence of clonus, the nurse places one hand under the women’s knee and bends the knee slightly. The nurse then places the other hand on the ball of the foot, encourages the women to relax her leg and foot, and sharply dorsiflexes the foot. Clonus is present if the foot jerks or taps against the nurse’s hand.

Discomfort and pain associated with true labor contractions typically begins in the lower abdomen and back and then radiates over the entire abdomen.

The placenta provides an exchange of nutrients and waste products between the mother and fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

The FHR can first be heard with a fetoscope at 18 to 20 weeks of gestation. If a Doppler ultrasound device is used, the FHR can be detected as early as 10 weeks of gestation.

The FHR should be approximately 110 to 160 beats/minute throughout pregnancy. Because the FHR is elevated from the normal range, the nurse would contact with the physician.

An infant born to an HIV-positive mother is at risk for developing the disease. Characteristically, the newborn is asymptomatic at birth, but signs and symptoms usually become obvious during the first year of life.

Low or oddly placed ears are associated with a variety of congenital defects and should be reported immediately. Although the findings would be documented, the most appropriate action would be to notify the physician.

Pelvic-tilt exercises decrease strain to muscles of the abdomen and lower back caused by the added weight of the abdomen and the shift in the center of gravity. An abdominal support should only be worn if recommended by the physician. Relaxing abdominal muscles will add to the problem. Wearing high-heeled shoes will add to the strain on the muscles and will exaggerate the shift in the center of gravity.

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Rho(D) immune globulin IGIM (RhoGAM) is administered at 28 weeks of gestation to a woman as described, with a second injection within 72 hours of delivery. This prevents sensitization, which could jeopardize a future pregnancy. For subsequent pregnancies or abortions, the injections must be repeated, because immunity is passive.

Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four servings of folic acid–rich foods per day.

A reactive nonstress test (normal/negative) indicates a healthy fetus. It is described as two or more fetal heart rate (FHR) accelerations of at least 15 beats/minute, lasting at least 15 seconds from the beginning of the acceleration to the end, in association with fetal movement, and during a 20-minute period. A nonreactive nonstress test (abnormal) is described as no accelerations or accelerations of less than 15 beats/minute or lasting less than 15 seconds for a 40-minute observation. An unsatisfactory test cannot be interpreted because of the poor quality of the FHR.

A contraction stress test assesses placental oxygenation and function, determines fetal ability to tolerate labor, determines fetal well-being, and is performed if the nonstress test is abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract either by the administration of a dilute dose of oxytocin (Pitocin) or by having the mother use nipple stimulation until three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been achieved. Frequent maternal blood pressure readings are done, and the client is monitored closely while increasing doses of oxytocin are given.

Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. Women are advised to count fetal movements for 30 to 60 minutes, 3 times a day (usually after meals when the fetus is more active). The client lies down on the left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. Most women count four movements in 1 hour. The midwife or health care provider is notified if 10 movements are not felt in a 12-hour period.

HIV is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and transmission from an infected woman to her fetus. Women in the high-risk category for HIV infection include those with persistent and recurrent sexually transmitted diseases or a history of multiple sexual partners, and those who have used IV drugs.

Infected house cats transmit toxoplasmosis through feces. Handling litter boxes can transmit the disease to the maternity client. Hands should be washed throughout the day when items that could be contaminated are handled.

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An intervention to prevent sickle cell crisis during labor includes administering oxygen. During the labor process, the client is at high risk for being unable to meet the oxygen demands of labor and is at high risk for sickle cell crisis.

To further to assess and plan for the newborn’s care, the newborn’s blood type and direct Coombs' must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn. If the newborn’s blood type is Rh negative, or if the newborn’s blood type is Rh positive with a negative direct Coombs' test, then no concern is needed for Rh incompatibility. If the newborn’s blood type is Rh positive and the direct Coombs' is positive, then Rh incompatibility exists.

The initial nursing action when a client has a seizure (eclampsia) is to maintain an open airway.

An empty bladder contributes to a woman’s comfort during the examination. Drinking water to fill the bladder and warming sonogram gel may be performed before a sonogram but are not applicable to performing Leopold maneuvers. Often the Leopold maneuvers are performed to aid the examiner in locating the fetal heart tones.

The goal of labor augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-minute period. The uterus should return to resting tone between contractions with no evidence of fetal distress. Acute hypoxia is a common cause of fetal tachycardia. The dosage of oxytocin should be decreased in the presence of fetal tachycardia from excessive uterine activity. The nurse should also assure that the uterus maintains an adequate resting tone between contractions.

Accelerations are transient increases in the fetal heart rate (FHR). Accelerations are normally caused by fetal movement or often accompany contractions. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve.

Variable decelerations, present on a fetal heart monitor, suggest cord compression. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because they suggest uteroplacental insufficiency during a contraction. Short-term variability refers to the difference between successive heartbeats, identifying that the natural pacemaker activity of the fetal heart is working properly.

Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen transfer to the fetus during uterine contractions. This causes hypoxemia; therefore oxygen is necessary,

Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain.

Relaxation techniques include specific relaxation exercises and conditioned responses, such as distraction from the discomfort of labor. The woman is an active participant in the use of these techniques, which focus in relaxing uninvolved muscles while the uterus contracts.

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When the membranes rupture in the birth setting, the nurse immediately assesses the FHR to detect changes associated with prolapse or compression of the umbilical cord.

Large quantities of alcohol have been associated with an increased risk of liver cancer. However, according to the client’s statement, the client understood that no alcohol may be consumed. Thus the client requires reinforcement that alcohol is the substance associated with liver cancer; however, clarification is needed that it is an excessive intake that is associated with liver cancer.

Decreased aldosterone secretion results in a fluid volume deficit. Clients are encouraged to maintain an oral intake of 3000 mL/day to avoid dehydration. Clients require a high sodium diet to replace losses. Snacks between meals are encouraged, to prevent hypoglycemia. Clients with Addison’s disease require hormone-replacement therapy with corticosteroids.

Addisonian crisis is a serious, life-threatening response to acute adrenal insufficiency that is most commonly precipitated by a major stressor. The client with addisonian crisis may have any of the signs or symptoms of Addison’s disease, but the primary problems are sudden profound weakness; severe abdominal, back, and leg pain; hyperpyrexia followed by hypothermia; peripheral vascular collapse; coma; and renal failure.

Typical discharge instructions after AICD implantation include reporting to the physician symptoms indicating dysrhythmias, such as fainting, blackouts, rapid pulse, weakness, or nausea. The physician may want to be called each time the device discharges. At a minimum, the client should keep a log recording the date, time, symptoms, and activity before the shock, the number of shocks delivered, and how the client felt afterward. The physician will use this information in managing the ongoing medication regimen. The community emergency medical system should be notified about the device, so they are prepared if they are called to the home. Contingency plans for health care should be made before travel. The family also should become trained in cardiopulmonary resuscitation (CPR).

No special restrictions are imposed after a bone scan. The client is encouraged to drink large amounts of water for 24 to 48 hours to flush the radioisotope from the system. No hazards to the client or staff exist from the minimal amount of radioactivity of the isotope.

A hepatitis A vaccine is available for administration to protect against the infection. In addition, a standard immunoglobulin for passive immunization can be given prophylactically or after exposure. The immunoglobulin for passive immunization provides protection from infection for approximately 2 months. Hepatitis A is transmitted via the fecal-oral route

Outcomes indicating that peritonitis has resolved include an afebrile condition, absence of rebound tenderness, clear appearance of dialysate, absence of bacteria in dialysate, normal WBC count, and no redness or swelling at the catheter site.

Medical management of hyperparathyroidism includes increasing urinary calcium excretion with diuretics.

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Clients with hypoparathyroidism experience symptoms related to hypocalcemia ranging from mild paresthesias due to the tetany and possible seizures. Treatment for the disorder involves correction of the hypocalcemia and vitamin D deficiency with pharmacological intervention such as calcium chloride, vitamin D, and calcitriol (Rocaltrol). Nurses should encourage compliance with the prescription regimen as well as teach the client that treatment for this disorder is lifelong. In addition to pharmacological compliance, the client should maintain certain dietary guidelines (high calcium, low phosphorus) if the disease is to be controlled.

PTU is administered to clients in thyroid storm to block thyroid hormone synthesis of T3 and T4. Thyroid antibodies indicate whether an autoimmune disease is causing the client's symptoms. A thyroid scan provides information about whether excessive or diminished activity is present in the gland but provides no information about the degree of hormone synthesis. The TSH stimulation test differentiates primary from secondary hypothyroidism.

The client learns to void after creation of a neobladder by relaxing the external sphincter while increasing the intra-abdominal pressure (Valsalva maneuver). If the client cannot perform this procedure, then the client must learn to do intermittent catheterization of the neobladder.

In the absence of documented heart disease, the desired goal is to have a total cholesterol less than 200 mg/dL, low LDL levels of less than 130 mg/dL, and high HDL levels greater than 50 mg/dL. In the absence of documented heart disease or significant risk factors, the values identified in the question place the client at a low risk for heart disease.

The oropharynx (mouth) should be suctioned last to prevent introducing oral bacteria into the lung field. Allowing at least 30-second intervals between suctioning times will allow the client to equilibrate. Pressure beyond 120 mm Hg will damage the mucous membranes. The suction catheter should not be left in the trachea for more than 15 seconds, or the client will experience hypoxia.

MRI is a test that involves an external magnetic field to visualize soft tissues. Because of the magnetic field, this test is contraindicated in clients with pacemakers because it can reprogram the pacemaker.

Although esophageal varices are caused by portal pressure, rupture of the varices may be caused by increased intrathoracic pressure such as coughing and straining. This pressure may occur during heavy weight-lifting.

The term nephrotic syndrome refers to a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. The child experiences fatigue, anorexia, increased weight, abdominal pain, and a normal blood pressure.

Nicardipine hydrochloride (Cardene) is a calcium channel blocker that is used to treat chronic stable angina or primary hypertension. Before administering the medication, the nurse would check the client’s blood pressure and pulse rate.

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Epstein-Barr virus is transmitted by contact with infectious saliva, close intimate contact with an infectious individual, or contact with infected blood. The infectious period is unknown. Commonly, the virus is shed before clinical onset of the disease until 6 months or longer after recovery.

Early signs of lithium toxicity include vomiting, diarrhea, lethargy, and muscle twitching. Moderate toxicity results in ataxia, giddiness, tinnitus, blurred vision, clonic movements, and severe hypotension. Acute toxicity is characterized by seizures, oliguria, circulatory failure, and death.

Poor nutrition during pregnancy can negatively influence fetal growth and development. Although pregnancy poses some nutritional risk for the mother, not all clients are at high risk. Calcium is critical during the third trimester, but must be increased from the onset of pregnancy. Intake of dietary iron is usually insufficient for the majority of pregnant women, and iron supplements are routinely encouraged.

One of the earliest indicators of successful adaptation of the newborn infant is the Apgar score. Scoring ranges from 0 to 10. A score of 8 to 10 indicates that the infant is adjusting well to extrauterine life. A score of 5 to 7 often indicates an infant who requires some resuscitative intervention. Scores of less than 5 indicate infants who are having difficulty adjusting to extrauterine life and require vigorous resuscitation.

Kegel exercises strengthen the pelvic floor (pubococcygeal muscle). The increased tone of this muscle is beneficial during pregnancy and afterward.

Hemorrhoids are varicosities and are likely to be precipitated during pregnancy by the pressure of the growing fetus inside the abdominal cavity. Standing aggravates the problem. Dietary factors, such as fluids and bulk, and manual reduction are measures that should be included in the plan of care. Hormonal changes are not a factor in the development of hemorrhoids during pregnancy.

Oxygen is administered continuously during labor to the client with sickle cell anemia to provide adequate oxygenation and prevent sickling.

HELLP is a laboratory diagnosis for a variant of severe preeclampsia and is characterized by hemolysis (H), elevated liver enzymes (EL), and low platelets (LP). One of the signs of HELLP syndrome is a decrease in the platelet count.

When performing fundal massage, one hand is placed just above the symphysis pubis to support the lower uterine segment, while the fundus is gently but firmly massaged in a circular motion. Pushing on an uncontracted uterus could invert the uterus and cause massive hemorrhage.

Symptoms of infection are moistness, oozing, discharge, and a reddened base around the cord. If symptoms of infection occur, the mother should be instructed to notify a health care provider because antibiotics may be needed. If these symptoms occur, antibiotics are necessary.

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In term infants, jaundice first appears after 24 hours and disappears by the end of day 7. Jaundice is first noticed in the head, especially the sclera and mucous membranes. The newborn infant has a high rate of bilirubin production. The reabsorption of bilirubin from the neonatal small intestine is considerable.

Criteria for early discharge in the newborn infant include no evidence of significant jaundice within the first 24 hours after birth. The infant should have urinated and passed at least one stool, completed at least two successful feedings, and have normal vital signs for at least 12 hours. These criteria may vary depending on agency policy.

If the newborn infant is apneic or has gasping respirations after stimulation, or if the heart rate is below 90 beats/minute, positive-pressure ventilation by bag and mask can be given. The ventilation bag used for neonatal resuscitation should have a pressure gauge. Ventilations should be given at a rate of 40 to 60 breaths/minute at pressures of 15 to 20 cm H2O. An initial pressure of 30 to 40 cm H2O may be necessary to inflate collapsed alveoli.

After the placenta separates, it can usually be delivered if the mother bears down. The cord may be gently pulled to assist in the delivery of the placenta. Excess traction on the cord may cause it to break, making the placenta harder to deliver.

Complete uterine rupture results in massive blood loss; however, external bleeding may not be noted because most of the blood is lost into the peritoneal cavity. Signs of shock, as evidenced by a decrease in blood pressure, tachycardia, tachypnea, pallor, cool and clammy skin, anxiety, and pain, develop quickly. Cessation of uterine contractions occurs.

The nurse should report the time of the last food intake to the physician. General anesthesia may be used for an emergency cesarean delivery. Gastric contents are very acidic and can produce chemical pneumonitis if aspirated.

Situational Low Self-Esteem represents temporary negative feelings about self in response to an event.

Ineffective Coping implies that the person is unable to manage stressors adequately.

Dysfunctional Grieving implies prolonged unresolved grief leading to detrimental activities.

Deficient Knowledge indicates a lack of information or psychomotor skill concerning a condition or treatment.

Dystocia (antonym eutocia) is an abnormal or difficult childbirth or labour.

Abnormal labor patterns are assessed according to the nature of the cervical dilation and fetal descent. Progressive changes in the cervix are a reassuring pattern in labor

After a precipitate delivery, the mother may need help to process what has happened and time to assimilate it all. The mother may be exhausted, in pain, stunned by the rapid nature of the

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delivery, or simply following cultural norms. Providing support to the mother is the most appropriate and therapeutic action by the nurse.

As the placenta separates, the uterus changes from a discoid to a globular shape. Other signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, and a firmly contracted uterus. The client may experience vaginal fullness, but not sudden abdominal pain.

The lower uterine segment does not contain the same intertwining musculature as the fundus of the uterus, making this site more prone to postpartum bleeding.

The client most at risk for abruptio placenta is the woman who smokes or uses alcohol, illegal drugs such as cocaine, or caffeine during pregnancy.

The normal fetal heart rate is 120 to 160 beats/minute. Signs of potential complications of labor include contractions consistently lasting 90 seconds or longer, contractions consistently occurring 2 minutes or less apart, fetal bradycardia, tachycardia, persistently decreased variability, or an irregular FHR.

Breath sounds are the best way to assess the onset of heart failure. The presence of crackles or rales or an increase in crackles is an indicator of fluid in the lungs caused by heart failure.

A positive reaction to a tuberculin skin test indicates exposure to tuberculosis infection. Because the response to tuberculin skin testing may be decreased in the immunosuppressed client, induration reactions more than 5 mm are considered positive. A reading of 6-mm induration is a positive result in a client who is HIV positive. A positive result indicates exposure to tuberculosis and possibly the development of tuberculin infection. Further diagnostic tests should be performed to confirm infection with tuberculosis.

The TNM classification system for staging tumors is widely used. T refers to the tumor size, with T0 indicating no primary tumor found and T1 to T4 referring to progressively larger tumors. TIS is used to indicate a carcinoma in situ. N refers to regional lymph node involvement. N0 indicates regional nodes were normal, and N1 to N4 indicates increasingly abnormal regional lymph nodes. M1 indicates that distant metastasis is present.

The complications associated with thoracic surgery include pulmonary edema, cardiac dysrhythmias, hemorrhage, hemothorax, hypovolemic shock, and thrombophlebitis. Signs of pulmonary edema include dyspnea, crackles, persistent cough, frothy sputum, and cyanosis. A urinary output of 45 mL/hour is an appropriate output. The nurse would become concerned if the output were below 30 mL/hour. Between 100 and 300 mL of drainage may accumulate during the first 2 hours after thoracic surgery. Normal arterial blood pH is 7.35 to 7.45. An arterial blood pH of 7.35 is not indicative of a complication.

The client with Raynaud’s disease suffers from body-image disturbance when physical changes begin to occur. Therapeutic nursing interventions are implemented to encourage verbalization

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about the body changes and to develop appropriate problem-solving techniques for coping with the changes.

Specific gravity is a measure of the concentration of particles in the urine. A normal range of urine specific gravity is approximately 1.005 to 1.030. Early in polycystic kidney disease, the ability of the kidneys to concentrate urine decreases. A urine specific gravity of 1.000 is lower than normal, indicating dilute urine.

Giving the client with chronic emphysema a high liter flow of oxygen could stop the hypoxic drive and cause apnea.

Assays of catecholamines are performed on single-voided urine specimens, 2- to 4-hour specimens, and 24-hour urine specimens. The normal range of urinary catecholamines is up to 14 mcg/100 mL of urine, with higher levels occurring in pheochromocytoma.

After a cerebrovascular accident, clients are often emotionally labile, confused, forgetful, and frustrated. Clients may use profanity, which is often termed “automatic language.”

The complications associated with severe scoliosis interfere with respiration. The lungs may not fully expand as a result of the severe curvature of the spine. Atelectasis and dyspnea are complications that can occur as a result of a decrease in lung expansion.

The purpose of a venogram is to assess the severity of venous obstruction. The test will locate obstructions and/or thrombi by x-ray films after a radiopaque dye is injected into a vein that has been previously emptied by gravity. This test is a diagnostic procedure and will not eliminate leg problems or determine whether the support stockings can be discontinued. Injections can cause discomfort.

The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, congestive heart failure (CHF), increased platelet aggregation, and cerebrovascular accident (CVA). Death can occur from shock, CVA, renal failure, dysrhythmias, and dissecting aortic aneurysm. Rales heard on auscultation are indicative of CHF.

In myxedema, the TSH level is elevated, and the T3 and T4 levels are decreased. Secretion of T3 and T4 is regulated by a hypothalamic-pituitary-thyroid gland feedback mechanism. TSH regulates the secretion of thyroid hormone from the thyroid gland. The circulating levels of thyroid hormone are the major factor regulating the release of TSH. If the thyroid levels are low, TSH release is increased, and if the thyroid levels are high, TSH is inhibited. In hyperthyroidism, T3 and T4 secretions are elevated because the normal regulatory controls of thyroid hormone are lost. Hypoparathyroidism is associated with a decrease in serum calcium and an increase in serum phosphate.

Cutting the blood glucose monitoring strips in half may affect the accuracy in reading the results.

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Hydrocortisone is the topical treatment of choice for cutaneous inflammation and pruritus associated with contact dermatitis. If a rash does not respond to this over-the-counter medication, it should be evaluated by a health care provider.

The client should be taught to take the pulse in the wrist or neck every day at the same time, preferably in the morning, and to rest a full 5 minutes before taking the pulse. The pulse is counted for 1 full minute by using a watch or clock that has an accurate second hand. The pulse is recorded every day in a log that indicates a description of the rate, rhythm, and date and time of day. If a change in rate or rhythm is noted, the physician should be notified.

Crutch tips should remain dry. Water could cause slipping by decreasing the surface friction of the rubber tip on the floor. If crutch tips get wet, the client should dry them with a cloth or paper towel. The client should use only crutches measured for the client. The tips should be inspected for wear, and spare crutches and tips should be available if needed.

The normal random blood glucose level is 70 to 115 mg/dL but may vary depending on the time of the last meal.

On removal of a chest tube, an occlusive dressing consisting of petrolatum gauze covered by a dry sterile dressing is usually placed over the chest tube site dressing. This is maintained in place until the physician states it may be removed. Monitoring and reporting respiratory difficulty and increased temperature are appropriate client activities on discharge. The client should avoid heavy lifting for the first 4 to 6 weeks after discharge to facilitate continued wound healing.

Postoperative care after a parathyroidectomy includes instructing the client that the weight of the client’s head must be supported when the client flexes the neck or moves the head. This decreases the stress on the suture line, which prevents bleeding.

Boiling the vegetables and discarding the water can decrease the potassium content of vegetables. Bananas and oranges are high in potassium and should be avoided. Meats contain some potassium and are high in protein and should be limited to 6 oz/day. Salt substitutes are often high in potassium and are to be avoided.

Plasmapheresis is a process that separates the plasma from the blood elements, so that plasma proteins that contain antibodies can be removed. It is used as an adjunct therapy in myasthenia gravis and may give temporary relief to clients with actual or impending respiratory failure. Usually three to five treatments are required. Improvement in vital (respiratory) capacity is an intended effect of this treatment.

The client with CAL should use energy-conservation techniques to conserve oxygen. These include sitting to perform many household chores or activities, and alternating activity with rest periods. The client should avoid raising the arms above the head, because use of the arms could increase dyspnea. The client should never hold the breath during an activity.

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When a client is placed in pelvic traction, the foot end of the bed is raised to prevent the client from being pulled down in bed by the traction. The head of the bed is usually kept flat, and the client is maintained in good body alignment. The girdle or belt should be applied snugly so it does not slip off of the client, and therefore the skin should be checked for pressure sores.

Traditional treatment of a UTI involves 7 to 10 days administration of oral antimicrobial therapy. It is important to take antibiotics, even if the client is feeling better. While taking these medications, the client should drink at least eight glasses of fluid per day to keep urine dilute. Voiding regularly will flush bacteria out of the bladder and urethra. Teaching the client to cleanse the perineal area from front to back helps to prevent urinary tract infection.

The cane is held on the stronger side to minimize stress on the affected extremity and provide a wide base of support. The cane is held 6 inches lateral to the fifth toe. The cane is moved forward with the affected leg. The client leans on the cane for added support while the stronger side swings through.

Older and immunocompromised clients may not have a positive reaction to the initial tuberculin skin test, even if they had prior exposure to the tubercle bacillus. If the test is negative (no reaction), the client may have a delayed reaction and should have a repeated tuberculin skin test in 1 to 2 weeks. The second test should reveal positive results if the client had prior exposure. The tuberculin skin test is read in 48 to 72 hours. Erythema or redness alone is not considered significant. The size of induration, if any, is what determines the significance of the test. A positive test does not indicate active disease. Persons with a positive reaction are followed up with a chest radiograph.

After restoring circulation to the affected limb, the nurse reinforces teaching that was done after the original surgery. This includes exercise and dietary recommendations, as well as instructions on foot care and prevention of injury to the limb. The client should check the condition of the leg and foot every day. Taking a baby aspirin every day does not ensure that further complications will not occur. Walking will be a component of the treatment plan.

Instructions to a client after a aorto-iliac bypass grafting about measures to improve circulation while in the hospital includes clot formation in the graft can result from any form of pressure that impairs blood flow through the graft, including bending at the hip or knee, crossing the knees or ankles, or use of the knee gatch or pillows. All of these actions are avoided in the postoperative period.

The presence of multiple organisms in a urine culture usually indicates that contamination has occurred. The urinary tract is normally sterile, and infection, if it occurs, is usually with one organism. A repeat of the urine culture is indicated.

Spinal shock that occurs after spinal cord injury lasts 3 to 6 weeks after the injury and is characterized by a flaccid neurogenic bladder with urinary retention. Intermittent catheterization used to empty the bladder should be carried out in a manner that prevents

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urinary tract infection (UTI). Cloudy or blood-tinged urine may indicate the onset of infection. Because fluid is lost through the skin, lungs, and bowel, intake does not normally equal output. Sensations of the need to void require an intact cord, which would not be present in this client. Cholinergic action stimulates bladder emptying, so anticholinergics would produce the undesirable effect of relaxation of the bladder in this client.

First-degree heart block indicates a delayed conduction somewhere between the junctional tissue and the Purkinje network, causing a prolonged PR interval. Lying still will not relieve the problem. A pacemaker is not necessary for first-degree heart block. Medication may be prescribed to treat this condition.

The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it, and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus the client would not be supporting the weaker leg with the walker during ambulation.

Within 2 or 3 days of surgery, a lung is generally fully re-expanded. The nurse notes an absence of fluctuation or bubbling in the water seal chamber or drainage from the chest tube. At this time, the client’s status is confirmed by chest x-ray. If the lung is fully re-expanded, the physician may remove the chest tube.

The irreversible stage of cardiogenic shock represents the point along the shock continuum when organ damage is so severe that the client does not respond to treatment and is unable to survive. Multiple organ failure has occurred, and death is imminent. As it becomes obvious that the client is unlikely to survive, the client’s family needs to be informed about the prognosis and outcome. Support to the grieving family members becomes an integral part of the nursing care plan.

The purpose of ECG monitoring is to record cardiac electrical activity during the depolarization and repolarization phases. The two types of single-lead monitoring are hardwire and telemetry. With a wireless battery-operated telemetry system, the client is afforded more freedom and mobility than with the hardwire system. The most common problems with ECG monitoring are related to client movement, electrical interference from equipment in the room, poor choice of monitoring leads, and poor contact between the skin and electrode.

Tracheostomy dressings should be changed whenever they get wet or damp. A soiled dressing promotes microorganism growth and enhances tissue irritation and skin breakdown. The oxygen collar may be cleaned if it becomes soiled between collar and tubing changes, which are done every 24 hours. Tracheostomy care should be done at least every 8 hours or per agency policy. It would not be beneficial to the client to limit fluids, because thicker secretions pose added problems with airway management.

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Before discharging a ventilator-dependent client to home, the nurse determines that the family is able to perform CPR, including mouth-to-tracheostomy ventilation. The CPR course designed for lay people in the community does not include this element of care. The electrical service to the home must be sufficient for the equipment that will be used. The ventilator should have a built-in converter to battery power if the electrical power should fail. Otherwise, a generator must be installed. The home itself should be free of drafts and provide adequate air circulation.

Back pain after AAA repair may indicate a problem with the repair. It should be reported to the physician immediately.

Disease processes, such as cirrhosis, damage the blood flow through the liver, resulting in hypertension in the portal venous system. The increased portal pressure causes esophageal varices, which are swollen and distended veins. Factors such as increased intrathoracic pressure or irritations can cause these varices to rupture with subsequent hemorrhage.

Cryosurgery entails freezing cervical tissue with nitrous oxide. It is performed in an outpatient setting. Cryosurgery may result in cramping and a vasovagal response that may cause faintness. A watery discharge is normal for a few weeks after the procedure.

The client who experiences epididymitis from a urinary tract infection should increase the intake of fluids to flush the urinary system. Because organisms can be forced into the vas deferens and epididymis from strain or pressure during voiding, the client should limit the force of the urinary stream. Condom use can help to prevent epididymitis that can occur as a result of STDs. Antibiotics are always taken until the full course of therapy is completed.

Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The client also is taught to rest, increase fluid intake, and use sitz baths for comfort. Antimicrobial therapy is always continued until the prescription is completely finished.

The client with respiratory disease may have Ineffective Coping related to the inability to tolerate activity and social isolation. The client demonstrates adaptive responses by increasing the activity to the highest level possible before symptoms are triggered, using relaxation or other learned coping skills, or enrolling in a pulmonary rehabilitation program.

The primary symptom in placenta previa is painless vaginal bleeding in the second or third trimester of pregnancy. Passage of the mucus plug appears pink or as blood-tinged mucus. A ruptured amniotic sac would include findings such as a watery vaginal drainage. Findings of abruptio placenta include dark red vaginal bleeding and abdominal pain.

Magnesium sulfate depresses the respiratory rate. If the respiratory rate is less than 12 breaths per minute, the continuation of the medication should be reassessed.

The symptoms of jitteriness and tachypnea (respiratory rate of 62 breaths per minute) in a 42-week-gestation newborn infant are indicative of hypoglycemia. Hypoglycemia may develop in a 42-week-gestation newborn infant because of the insufficient stores of glycogen, which may

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have been depleted during the post-term period. Insufficient amounts of glucose in the infant’s brain could possibly cause central nervous system damage.

A normal blood glucose level for newborn infants is 40 mg/dL and higher.

Rho(D) immune globulin is not administered if a client has experienced a severe reaction to its component, human globulin. Rho(D) immune globulin is indicated when Rh-negative clients are exposure to Rh-positive fetal blood cells in any way, including amniocentesis and abortion.

A person who lacks hope feels that life is too much to handle. By seeing no way out of the situation except death, the client meets the criteria for hopelessness.

Abdominal exercises should not be started after abdominal surgery until 3 to 4 postoperative weeks to allow healing of the incision.

Coagulation failure, particularly disseminated intravascular coagulopathy (DIC), is a common result of an amniotic fluid embolus. Manifestations are internal and external hemorrhage clinically determined by bleeding at the site of any trauma (pressure, needle prick, or incision), and petechiae resulting from slight to moderate touch.

A postpartum woman who saturates a Peripad in 15 minutes or less is considered to be hemorrhaging, which in this case is caused by lack of coagulation at the placental site.

A pulsating rope-like object seen in the vagina indicates the presence of the umbilical cord. Each contraction will press the presenting part downward against the bony pelvis, applying pressure to the prolapsed cord, compressing it between the presenting part and the bony pelvis. The compression will shut off the fetal circulation at the point of compression, leading to impaired fetal tissue perfusion and hypoxia of the fetus.

Situational Low Self-Esteem represents temporary negative feelings about self in response to an event. This is a normal response to cesarean section.

Pregnancy taxes the circulating system of every woman because both the blood volume and cardiac output increase approximately 30%. This is especially important to monitor in the client whose heart may not tolerate this normal increase.

HIV has a strong affinity for surface marker proteins on lymphocytes. This affinity of HIV for T lymphocytes leads to significant cell destruction. Angiotensin is produced in the kidney and plays a role in blood pressure control.

HIV infection in a pregnant woman may cause both maternal and fetal complications. Fetal compromise can occur because of premature rupture of the membranes, preterm birth, or low birth weight. Potential maternal effects include an increased risk of opportunistic infections. Individuals in the later stages of HIV are further susceptible to other invasive conditions, such as tuberculosis and a wide variety of bacterial infections.

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The anterior fontanel is normally 2.5 to 5 cm in width and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could be indicative of increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated.

Clients with Cushing’s syndrome experience weight gain with truncal obesity. The extremities appear thin with the presence of muscle wasting and weakness. The skin is often described as being thin and translucent. A butterfly rash across the cheeks of the face is seen in systemic lupus erythematosus. Polydipsia and polyphagia are seen in diabetes mellitus. Weight loss and peripheral edema may be seen in a number of conditions.

Situations that precipitate sickle cell crisis include hypoxia, vascular stasis, low environmental and/or body temperature, acidosis, strenuous exercise, anesthesia, dehydration, and infections.

The client undergoing radiation therapy should avoid washing the site until instructed to do so. The client should then wash with mild soap and warm or cool water, and pat the area dry. No lotions, creams, alcohol, or deodorants should be placed on the skin over the treatment site. Lines or ink marks that are placed on the skin to guide the radiation therapy should be left in place. The affected skin should be protected from temperature extremes, direct sunlight, and chlorinated water (as from swimming pools).

Prevention of recurrence of urinary stones is accomplished by drinking at least 3 L of fluid per day; voiding every 2 hours; following an acid ash diet if the stones are calcium oxalate stones; and notifying the physician promptly if symptoms of UTI occur.

The client with polycystic kidney disease should report any signs and symptoms of urinary tract infection so that treatment may begin promptly. The client should also report increases in blood pressure, because control of hypertension is essential. The client may experience heart failure as a result of hypertension, and thus any symptoms of heart failure, such as shortness of breath, also are reported.

The goal of therapy in nephrotic syndrome is to heal the leaking glomerular membrane. This would then control edema by stopping loss of protein in the urine. Fluid balance and albumin levels are monitored to determine effectiveness of therapy.

Stair climbing may be restricted or limited for several weeks after spinal fusion with instrumentation. The nurse assures that resources are in place before discharge so that the client may sleep and perform all activities of daily living on a single living level.

The skin under a casted area may be discolored and crusted with dead skin layers. The client should gently soak and wash the skin for the first few days. The skin should be patted dry, and a lubricating lotion should be applied. Clients often want to scrub the dead skin away, which irritates the skin. The client should avoid overexposing the skin to the sunlight.

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Expected outcomes for Impaired Physical Mobility for the client in traction include absence of thrombophlebitis (measurable by negative Homans' sign), active baseline ROM to uninvolved joints, clear lung sounds, intact skin, and bowel movement every other day.

After three unsuccessful defibrillation attempts, CPR should be done for 1 minute, followed by three more shocks, each delivered at 360 joules.

Typical discharge activity instructions for the first 6 weeks include lifting nothing heavier than 5 pounds, not driving, and avoiding any activities that cause straining. The client is taught to use the arms for balance, but not weight support, to avoid the effects of straining. These limitations are to allow sternal healing, which takes approximately 6 weeks.

Clients can resume sexual activity on the advice of a physician, which generally occurs when the client can walk one block and climb two flights of stairs without discomfort. Suggestions to minimize potential problems include waiting for 2 hours after meals or alcohol consumption, making sure one feels well rested, using a comfortable position, and keeping the room at a mild (not chilly) temperature.

Expected outcomes for the client with pulmonary edema include improved cardiac output as evidenced by stable vital signs, and urine output of at least 30 mL/hour.

The client’s blood gas results indicate respiratory acidosis. Symptoms of respiratory acidosis include headache, irritability, muscle twitching, behavioral changes, confusion, lethargy, and coma.

When the carboxyhemoglobin levels are greater than 25% (acute toxicity), the respiratory center becomes depressed because of inadequate oxygenation, and hypoxia occurs.

A long-range approach to the prevention of pulmonary edema is to minimize any pulmonary congestion. During recumbent sleep, fluid (which has seeped into the interstitium by day with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed elevated helps prevent circulatory overload.

Complications after pleural biopsy include hemothorax, pneumothorax, and temporary pain from intercostal nerve injury. The nurse notes indications of these complications, such as dyspnea, excessive pain, pallor, or diaphoresis. Mild pain is expected, because the procedure itself is painful.

The nurse teaches the client that the pain of fractured ribs generally lasts for about 5 to 7 days. Full healing takes about 6 weeks, after which full activity may be resumed.

Coughing and deep breathing will effectively promote lung expansion and clearance of mucus. Using an incentive spirometer is helpful, but it is most effective if the client uses it independently without coaching. The nurse may not need to suction the client if the client is not intubated

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Prinzmetal’s angina results from spasm of the coronary vessels. The risk factors are unknown, and it is relatively unresponsive to nitrates. Beta blockers may worsen the spasm.

Exercise is most effective when done at least 3 times a week for a client with angina pectoris. Other positive habits include limiting salt and fat in the diet, using stress-management techniques, and knowing when and how to use medications.

Nosebleeds may occur during the winter because of decreased humidity in the home. The use of a humidifier helps to alleviate this problem.

If pulse oximeter values fall below a preset norm, which is usually 90% to 91%, the client should be instructed to take several deep breaths. This is especially true of a client without a respiratory history who is still under the effects of sedation. If the client did have a respiratory disease history, it might be an indication that supplemental oxygen should be put in place or increased if already in place.

A Gram stain classifies the organism as gram-negative or gram-positive, and may be done immediately by the laboratory. This gives initial information about the type of organism when initiation of antibiotic therapy is a high priority. The specimen is then incubated on a culture medium for at least 24 hours more to identify the specific organism(s). The sensitivity test gives the physician precise information about which antibiotics the organism is sensitive to.

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