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The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL.

Dilantin are given to

clients with history of seizure disorder.

The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the level is below the
therapeutic range, the client may be noncompliant with the medication regimen. If the level is within
the therapeutic range, the client is most likely compliant with medication therapy. Drug is given to COPD

The normal therapeutic range for digoxin is 0.5 to 2.0 ng/ mL. A value of 1.0 is within therapeutic range,
and the nurse would administer the next dose as scheduled.

An International normalize ratio (INR) of 2.0 to 3.0 is appropriate for most clients. An INR of 3.0 to 4.5 is
recommended for clients with mechanical heart valves. If the INR is below the recommended range, the
warfarin sodium dose would be increased. If the INR is above the recommended range, the warfarin
sodium dose would be decreased. Since the value identified in this question is within the therapeutic
range, the nurse would administer the next dose of warfarin.

An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this
intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact.
Battery is the actual contact with ones body. Negligence involves actions below the standards of care.
Invasion of privacy occurs when the individuals private affairs are unreasonably intruded. In this
situation, the nurse can be charged with battery because the nurse administers a medication that the
client has refused.

Defamation takes place when something untrue is said (slander) or written (libel) about a person,
resulting in injury to that persons good name and reputation. An assault occurs when a person puts
another person in fear of a harmful or an offensive contact. Negligence involves the actions of
professionals that fall below the standard of care for a specific professional group. Although the
physician may be aware of the biopsy results, the physician decides when it is best to share such a
diagnosis with the client.

If the physician writes an order that requires clarification, it is the nurses responsibility to contact the
physician for clarification. If there is no resolution regarding the order because the order remains as it
was written, after the physician has been contacted or because the physician cannot be located, the
nurse should then contact the nurse manager or supervisor for further clarification as to what the next
step should be. Under no circumstances should the nurse proceed to carry out the order until
clarification is obtained.

Nurses need their own liability insurance for protection against malpractice law suits. Nurses
erroneously assume that they are protected by an agencys professional liability policies. Usually when a
nurse is sued, the employer is also sued for the nurses actions or inactions. Even though this is the
norm, nurses are encouraged to have their own malpractice insurance.

A Good Samaritan Law is passed by a state legislature to encourage nurses and other health care
providers to give care to a person when an accident, emergency, or injury occurs, without fear of being
sued for the care provided. Called immunity from suit, this protection usually applies only if all of the
conditions of the law are met, such as the heath care provider receives no compensation for the care
provided, and the care given is not willfully and wantonly negligent.

In a fire emergency, the steps to follow use the acronym RACE. The first step is to remove the victim.
The other steps are: activate the alarm, contain the fire, then evacuate as needed. This is a universal
standard that can be applied to any type of fire emergency. The nurse first removes the victim from
the area. Pulling the nearest fire alarm would be the next step. The nurse next contains the fire and
then extinguishes the fire.

Generally there are only two instances in which the informed consent of an adult client is not needed.
One instance is when an emergency is present and delaying treatment for the purpose of obtaining
informed consent would result in injury or death to the client. The second instance is when the client
waives the right to give informed consent.

The client with hyperphosphatemia should avoid foods that are naturally high in phosphates. These
include fish, eggs, milk products, vegetables, whole grains, and carbonated beverages. Coffee, tea, and
cocoa are not high in phosphates.

The nurse manager needs to attend to the client assignments first. Client care is the priority. In addition,
the nursing staff needs assignments so that they can begin client assessments and begin delivering client
care. The nurse manager should next check the crash cart (which is normally done every shift) to ensure
that needed equipment is available in the event of an emergency. The nurse manager could also
delegate this task to another registered nurse while client assignments are being planned. The nurse
manager would next begin the problem-solving process related to finding a charge nurse for the next
shift. Since this activity directly affects client care, this would be done before reading the stack of mail.

Arriving late to work is an unacceptable behavior. Although the nurses behavior has caused unrest with
other staff members, the primary concern is that this behavior affects client care. The nurse manager
needs to confront the nurse, discuss the lateness, and initiate problem-solving measures that ensure
that the behavior does not continue.

The nurse needs to stay with the client and consult with the nurse manager about the situation. It may
be necessary for the nurse manager to contact the supervisor to obtain an additional staff member to
care for the client. Since the client has a head injury, a major concern is the development of increased
intracranial pressure (ICP). The application of restraints may agitate the client, causing further
restlessness and thus increasing ICP. A nursing assistant is not trained to monitor for increased ICP. It is
inappropriate to ask a family member to sit with the client.

If a conflict arises, it is most appropriate to try to resolve the conflict directly. In this situation, the nurse
has attempted to explain the reasons for being uncomfortable with the surgeon but was unable to
resolve the conflict. The nurse would then most appropriately use the organizational channels of
communication and discuss the issue with the nurse manager, who would then proceed to resolve the
conflict. The nurse manager may attempt to discuss the situation with the surgeon or seek assistance
from the nursing supervisor.

External disasters occur in the community, and many victims may be brought to the emergency room for
care. In this situation, the nurse manager would initially contact the nursing supervisor about the need
for additional staffing and to discuss activation of the disaster plan. The nurse manager should ask, not
demand that nurses from the night shift stay until all of the victims are treated. The nurse manager
would not ask emergency medical services to take the victims to another hospital or close the
emergency room temporarily to incoming clients. These decisions are made by administration.

If a nurse feels that an assignment is more difficult than the assignment delegated to other nurses on
the unit, the nurse would most appropriately discuss the assignment with the nurse manager of the
neurological unit. The nurse may or may not have a more difficult assignment than the other nursing
staff. However, this action will assist in either identifying the rationale for the assignment or
determining if the assignment is actually more difficult. A nurse would not refuse an assignment.
Specific situations may be present in which a nurse should not take care of a specific client, for example,
if a pregnant nurse is assigned to care for a client with rubella or a client with an internal radiation
implant. In these situations, the nurse would also discuss the assignment with the nurse manager. The
nurse would not return to the cardiac unit; this would be client abandonment, and this action does not
address the conflict directly.

The signs of hypoglycemia and hyperglycemia can be difficult to distinguish. Weakness, headache, and
blurred vision can occur in either blood glucose alteration. A blood glucose reading will assist in
confirming the diagnosis so that the appropriate action can be taken.

Hypoglycemia is immediately treated with 10 to 15 grams of carbohydrate. Glucose tablets or glucose
gel may be administered. Other items used to treat hypoglycemia include 1/2 cup of fruit juice, 1/2 cup
of regular (nondiet) soft drink, 8 oz of skim milk, 6 to 10 hard candies, 4 cubes or 4 teaspoons of sugar, 6
saltines, 3 graham crackers, or 1 tablespoon of honey or syrup.

Most minor burns can be handled at home by the parents. For minor burns, exposure to cool running
water is the best treatment. This stops the burning process and helps to alleviate pain. Ice is
contraindicated, because it may add more damage to already injured skin.

When a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. Pain
can be alleviated by applying an ice pack and elevating the site.

When a Salem sump tube is connected to suction, the air vent permits a free, continuous flow of
secretions. The air vent should never be clamped or tied off, connected to suction, or used for irrigation.
The nurse manager should handle this problem directly with the nurse who is performing this action and
should initially review the skills checklist of the nurse who is tying the knots to assess if this skill has ever
been performed and validated.

When cord compression is suspected, the woman is immediately repositioned. The clients hips can be
elevated to shift the fetal presenting part toward her diaphragm, thus relieving cord compression. A
hands-and-knees position can reduce compression on the cord that is entrapped behind the fetus.
Several position changes may be required before the fetal pattern improves or resolves.

If a nonreassuring fetal heart pattern occurs (tachycardia, bradycardia, decreased variability, and late
decelerations), the nurse would intervene to increase fetal oxygenation. The oxytocin infusion is
stopped immediately. The infusion rate of the nonadditive IV solution is increased. The client is
positioned in a side-lying position, and oxygen via a snug facemask is administered at 8 to 10 liters per
minute. The physician is notified of the adverse reactions, the nursing interventions that have been
implemented, and the clients response to the interventions. The maternal blood pressure is monitored

If physical abuse or neglect is suspected, the priority nursing action is to assess the client, treat any
physical injuries, and ensure that the client is safe. The nurse also notifies the physician and the social
worker to investigate the situation. All states in the United States and other Western countries have
laws requiring health care professionals to report suspected elder abuse. Calling the police is a
premature action. Telling the son that he cannot visit with his mother could initiate aggressive behavior
in the son. Although the nurse may be involved in obtaining psychiatric assistance for the son, this is not
the priority action.

Severe leg pain, once traction has been established, indicates a problem. A client who complains of
severe pain may need realignment or may have traction weights ordered that are too heavy. The nurse
realigns the client, and if that is ineffective, then calls the physician. The nurse never removes traction
weights unless specifically prescribed by the physician. The client should be medicated only after an
attempt has been made to determine and treat the cause.

With a tracheainnominate artery fistula, a malpositioned tube causes its distal tip to push against the
lateral wall of the tracheostomy. Continued pressure from the tracheostomy tube causes necrosis and
erosion of the innominate artery. This situation is a life-threatening complication. The tracheostomy
tube is immediately removed. Direct pressure is then applied to the innominate artery at the stoma
site. The client is then prepared for immediate surgical repair. An IV line will need to be initiated, but
this is not the immediate action.

The nurse should monitor the clients heart rate and pulse oximetry during suctioning to assess the
clients tolerance of the procedure. Oxygen desaturation below 90% indicates hypoxemia. If hypoxia
occurs during suctioning, the nurse terminates the suctioning procedure. Using the 100% oxygen
delivery system, the client is reoxygenated until baseline parameters are achieved. The size of the
catheter should not exceed half the size of the tracheal lumen. In adults, the standard catheter size is 12
to 14 French. Adequate catheter size facilitates efficient removal of secretions without causing

In most situations, clamping of chest tubes is contraindicated, and agency policy and procedure must
be followed with regard to clamping a chest tube. When the client has a residual air leak or
pneumothorax, clamping the chest tube may precipitate a tension pneumothorax because the air has
no escape route. If the tube becomes disconnected, it is best to immediately reattach it to the
drainage system or to submerge the end in a bottle of sterile water or saline to reestablish a water
seal. If sterile water or saline is not readily available, it is preferable to leave the tube open because
the risk of tension pneumothorax outweighs the consequences of an open tube. The physician may
need to be notified, but this is not the immediate action. The client would not be instructed to inhale.

Surface foreign bodies are often removed simply by irrigating the eye with sterile normal saline. The
nurse would not use clamps because this action will risk causing further injury to the eye. Applying an
eye patch would not provide relief for the problem. Visual acuity tests are not the priority at this time,
and might not be feasible because the client most likely has excessive blinking and tearing as well at this

Keratoplasty is done by removing damaged corneal tissue and replacing it with corneal tissue from a
human donor (live or cadaver). Preoperative preparation of the recipients eye can include obtaining a
culture and sensitivity with conjunctival swabs, instilling antibiotic ophthalmic medication, and cutting
the eyelashes. Some ophthalmologists order a medication such as 2% pilocarpine to constrict the pupil
before surgery.

Discharge instructions to a client after a keratoplasty includes telling the client that sutures are usually
left in place for as long as 6 months. After the sutures are removed and complete healing has occurred,
prescription glasses or contact lenses will be prescribed.

Enucleation is removal of the eye, leaving the eye muscles and remaining orbital contents intact.

Topical glucocorticoids can be absorbed in sufficient amounts to produce systemic toxicity. Primary
concerns are growth retardation (in children), and adrenal suppression in all age groups. Systemic
toxicity is more likely under extreme conditions, such as with prolonged therapy in which extensive
surfaces are treated with high doses of high potency agents in conjunction with occlusive dressings.

Isotretinoin (Accutane) is prescribed for a clietn to treat severe cystic acne. It is usually administered
two times daily for a period of 15 to 20 weeks. The usual adult dosage is 0.5 to 1 mg/kg/day. If
needed, a second course may be administered, but not until 2 months have elapsed after completing
the first course.

Saquinavir (Invirase) is an antiviral medication. It is administered within 2 hours after a full meal. If
the medication is taken without food in the stomach, it may result in no antiviral activity.

Anastrozole (Arimidex) is prescribed for a postmenopausal client with breast cancer. The most
dangerous adverse reaction to anastrozole is thromboembolism. Common reactions include nausea,
chest pain, edema, and shortness of breath. A variety of gastrointestinal tract or nervous system effects
may also occur.

Cytarabine (Cytosar-U) is being prescribed to a nonlymphocytic anemia patient. The major toxic effect
of cytarabine is bone marrow depression, resulting in hematologic toxicity. Signs of hematologic
toxicity include fever, sore throat, signs of local infection, easy bruising, or unusual bleeding from any
site. If these signs occur, the physician is notified. Anorexia, nausea, and a transient headache can
occur as side effects of the medication but do not necessarily warrant physician notification, unless
they are persistent in nature.

Docetaxel (Taxotere) is an antineoplastic medication. Frequent side effects include alopecia,
hypersensitivity reaction, fluid retention, nausea, vomiting, diarrhea, fever, myalgia, and nail changes.
Before receiving docetaxel, the client is premedicated with an oral corticosteroid (dexamethasone
(Decadron) 16 mg per day for 5 days, beginning day 1 before docetaxel therapy) to reduce the severity
of fluid retention or prevent a hypersensitivity reaction.

Paclitxel is being prescribed to a client with ovarian cancer. Side effects of paclitaxel (Taxol) include
alopecia, pain in the joints and muscles, diarrhea, nausea, vomiting, peripheral neuropathy,
hypotension, mucositis, pain and redness at the injection site, cardiac disturbances (bradycardia), and an
abnormal electrocardiogram. Fatigue is an occasional side effect.

Stavudine (Zerit) is prescribed for a client with advanced human immunodeficiency virus. Peripheral
neuropathy, characterized by numbness, tingling, or pain in the hands or feet can occur frequently
with this medication and is an adverse reaction.

Ritonavir (Norvir) oral solution is prescribed to a client with HIV virus. The drug is preferably
administered with food. It may be mixed with chocolate milk or a dietary supplement to improve the
taste. The client is also instructed to consume the dose within 1 hour of mixing.

Propofol (Diprivan) is an anesthetic agent that is used to provide continuous sedation for a client
receiving mechanical ventilation. An adverse effect of the medication is hypotension. It can also cause
respiratory depression and bradycardia. Facial flushing can occur as an occasional side effect.

An adverse reaction of gemcitabine hydrochloride, an antineoplastic medication, is severe bone marrow
depression, evidenced by anemia, thrombocytopenia, and leukopenia. The medication may be
discontinued or the dosage may be modified if bone marrow depression occurs. The normal platelet
count is 150,000 to 450,000/mm3. The nurse would contact the physician if a platelet count of
90,000/mm3 were noted. The normal range for the total bilirubin is 8.4 to 10.2 mg/dL. The normal BUN
is 7 to 25 mg/dL. The normal range for the alkaline phosphatase is 42 to 128 units/L.

IGIV is an immune serum that increases antibody titer and antigen-antibody reaction, providing passive
immunity against infection. Anaphylactic reactions, although rare, can occur, and so the nurse ensures
that epinephrine is readily available when administering this medication. Protamine sulfate is the
antidote for heparin. Vitamin K is the antidote for oral anticoagulants. Acetylcysteine is used to treat
acetaminophen overdose.

Lepirudin (Refludan) is an anticoagulant used for clients with heparin-induced thrombocytopenia and
associated thromboembolitic disease to prevent additional thromboembolitic complications. For the
postoperative client, the initial dose is administered as soon as possible after surgery but not more
than 24 hours after surgery.

Letrozole (Femara) is an aromatase inhibitor that is used to treat advanced breast cancer in
postmenopausal women whose disease has progressed after antiestrogen therapy. The most frequent
side effects include skeletal pain, and back, arm, and leg pain. Less frequent side effects include nausea,
headache, fatigue, constipation, vomiting, and dyspnea.

Amprenavir (Agenerase) is an antiretroviral agent, classified as a protease inhibitor, used to treat HIV

Indinavir (Crisxivan) is an antiretroviral agent. This medication can cause kidney stones; therefore, the
client is instructed to increase fluid intake to at least 1.5 liters per day. The client is also instructed to
report sharp back pain or the presence of blood in the urine. The client is instructed to take the
medication 1 hour before or 2 hours after a large meal. If the medication needs to be taken with food,
the client should consume a light meal, such as dry toast, juice, or a bowl of cereal with milk.
Unexplained weight loss needs to be reported to the physician.

Lamivudine is an antiretroviral agent that is administered in combination with zidovudine to delay the
appearance of zidovudine resistance. Lamivudine is well absorbed orally either with or without food.
Peripheral neuropathy can occur with its use, and the client is instructed to notify the physician if
burning, numbness, or tingling of the hands, arms, feet, or legs occurs. Pancreatitis, evidenced by
nausea, vomiting, and abdominal pain is also an adverse reaction to the medication, requiring
physician notification.

Levalbuterol (Xopenex) is a bronchodilator. This medication stimulates the beta receptors in the lungs,
relaxes bronchial smooth muscle, increases vital capacity, and decreases airway resistance. Central
nervous system (CNS) stimulation can occur with the use of this medication. The client is instructed to
avoid caffeine-containing products such as coffee, tea, colas, and chocolate, because these products can
cause further CNS stimulation.

Moxifloxacin (Avelox) is a fluoroquinolone. Increased sensitivity of the skin to sunlight can occur, and
the client is instructed to avoid excessive sunlight and artificial ultraviolet light. The client should wear
sunscreen and protective clothing when outdoors. The client should also drink fluids liberally and
avoid the use of antacids, because antacids will decrease absorption of the medication. The
medication can cause inflamed and ruptured tendons, so that the client is instructed to notify the
physician if inflammation or tendon pain occurs.

Nelfinavir (Viracept) is an antiviral medication used in the treatment of HIV infection when antiretroviral
therapy is warranted. It is available in both tablet and powder form. The powder form is prepared by
mixing the dose with a small amount of water, milk, formula, soy milk, or dietary supplements. The
powder is not mixed with acidic foods or juices such as apple juice or applesauce, orange juice, or
grapefruit juice.

Antacids are generally not administered with other medications because of their interactive effects.
Additionally, antacids delay the absorption of other medications

The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce
the intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken,
oatmeal, and pasta are considered to be low-calcium foods.

Sodium should not be limited for the client with hypercalcemia unless contraindicated for another
reason, such as cardiac disease. When sodium is retained, then calcium is lost through the kidneys.

The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurses
primary responsibility to follow up with each staff member regarding the performance of the task and
the outcomes related to implementing the task. Not all staff members have the education, knowledge,
and ability to make judgments about tasks being performed. The nurse would document that the task
was completed but this would not be done until follow-up was implemented and outcomes were
identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

The client with a thoracic burn and smoke inhalation requires aggressive pulmonary measures to
prevent atelectasis and pneumonia. These include turning and repositioning, using humidified oxygen,
providing incentive spirometry, and suctioning on an as-needed basis. The client should not be left lying
in a single position and should not have the head of bed flat. These could promote the development of
complications by limiting chest expansion.

Wound dehiscence is the disruption of the surgical incision or wound. When dehiscence occurs, the
nurse immediately places the client in low-Fowlers position and instructs the client to lie quietly. These
actions will minimize protrusion of the underlying body tissues. The nurse then covers the abdominal
wound with a sterile dressing moistened with sterile saline. The physician is then notified and the nurse
documents the occurrence and the nursing actions implemented.

Adult diabetes mellitus can be diagnosed either by symptoms (polydipsia, polyuria, polyphagia), or by
laboratory values. Diabetes mellitus is diagnosed by an abnormal glucose tolerance test, or when
random plasma glucose levels are greater than 200 mg/dL, or fasting plasma glucose levels are greater
than 140 mg/dL on two separate occasions.

Hemorrhage is a potential complication following tonsillectomy and adenoidectomy. If the client vomits
large amounts of altered blood or bright red blood, or if the pulse rate or temperature rises and the
client is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror,
gauze, curved hemostats, and a waste basin for examination of the surgical site. The nurse would also
gather additional assessment data, but the immediate nursing action would be to contact the surgeon.

The client with hypertension is at risk for cardiovascular complications, such as angina pectoris,
myocardial infarction, and heart failure. Thyroid preparations increase metabolic rate, oxygen demands,
and demands on the heart. The client should know to report the onset of chest pain immediately.
Lethargy, constipation, and weight gain are symptoms of hypothyroidism, which should improve with
medication therapy such as levothyroxine sodium.

Pulmonary embolism is a life-threatening emergency. Nasal oxygen is administered immediately to
relieve hypoxemia, respiratory distress, and central cyanosis. IV infusion lines are needed to administer
medications or fluids. A perfusion scan, among other tests, may be performed. The ECG is monitored for
the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and arterial blood gases
may be drawn. However, the immediate nursing action is to administer oxygen.

Fludrocortisone acetate (Florinef) is a long-acting oral medication with mineralocorticoid and moderate
glucocorticoid activity. It is prescribed for the long-term management of Addisons disease.
Mineralocorticoids cause renal resorption of sodium and chloride ions, and the excretion of potassium
and hydrogen ions. These actions help restore electrolyte balance in the body.

The client with diabetic neuropathy of the lower extremities has diminished ability to feel sensations in
the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system

A traumatic open pneumothorax is an emergency. Stopping the flow of air through the opening in the
chest wall is a life saving measure. In such an emergency, anything may be used that is large enough to
fill the chest wound including a towel, a handkerchief, or the heel of the hand. If conscious, the victim is
instructed to inhale and strain against a closed glottis. This action assists in reexpanding the lung and
ejecting the air from the thorax. In the hospitalized client who experiences an open pneumothorax, the
opening is plugged by sealing it with gauze impregnated with petrolatum.

The client with severe osteoporosis as a result of hyperparathyroidism is at great risk for injury as a
result of pathological fractures from bone demineralization. The client may or may not have a risk for
impaired urinary elimination, depending on other elements in the client history, and whether or not the
client is at risk for stone formation from high serum calcium levels. The client may also have a risk for
constipation from the disease process, but this would be a lesser priority than client safety. A risk for
ineffective health maintenance may be a concern but is not the priority.

Clients with myxedema or hypothyroidism have decreased metabolic demands from reduced metabolic
rate. For this reason they often experience weight gain. The diet should be low in calories overall and
yet be representative of all food groups.

Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this disorder then is one that is high
in calcium but low in phosphorus, because these two electrolytes have inverse proportions in the body.

Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the
presence of an air leak. The nurse would assess the chest tube system for the presence of an external air
leak if constant bubbling were noted in this chamber. If no external air leak is present, the physician is
notified immediately because an air leak may be present in the pleural space. Leaking and trapping of air
in the pleural space can result in a tension pneumothorax.

The client taking NPH insulin obtains peak medication effects 6 to 12 hours after administration. At the
time that the medication peaks, the client is at risk of hypoglycemia if food intake is insufficient. The
nurse would teach the client to watch for signs and symptoms of hypoglycemia, including anxiety,
confusion, difficulty concentrating, blurred vision, cold sweating, headache, increased pulse, shakiness,
and hunger.

Before doing a fingerstick for blood glucose measurement, the client should first wash the hands. Warm
water should be used to stimulate the circulation to the area. The finger is punctured near the side, not
the center, since there are fewer nerve endings along the side of the finger. The puncture is only deep
enough to obtain an adequately sized drop of blood; excessively deep punctures can lead to pain and
bruising. The arm should be allowed to hang dependently, and the finger can be milked to promote
obtaining a good size blood drop.

Diabetic clients should take in approximately 15 grams of carbohydrate every 1 to 2 hours when unable
to tolerate food due to illness.

The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to a
lowered pH. Once fluid replacement and insulin therapy are started, the potassium level drops quickly.
This occurs because potassium is carried into the cells along with glucose and insulin, and also because
potassium is excreted in the urine once rehydration has occurred. Thus, the nurse must plan to monitor
the results of serum potassium levels carefully, and report hypokalemia

In the immediate postoperative period following a radical neck dissection, the nurse assesses for stridor
(a coarse, high-pitched sound on inspiration when auscultating over the trachea). This finding is
reported immediately, because it indicates airway obstruction.

Variances are actual deviations or detours from the critical paths. Variances can be positive or negative,
avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the
client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs
when untoward events prevent a timely discharge. Variance analysis occurs continually in order to
anticipate and recognize negative variance early, so that appropriate action can be taken

In functional nursing, a task approach method is used to provide care to clients.

The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are deep and nonlabored.
They occur as the body tries to eliminate carbon dioxide to compensate for lactic acidosis. As
ketoacidosis improves, this pattern of respiration resolves. The nurse monitors the clients respiratory
status as part of the clients overall status.

The client is likely to have tachycardia due to efforts by the body to compensate for the effects of
anemia. The client with anemia is likely to complain of fatigue, because of decreased ability of the body
to carry oxygen to tissues to meet metabolic demands. Increased respiratory rate is not an associated
finding, although some clients may have shortness of breath.

Spinal cord compression should be suspected in a client with metastatic disease, particularly when a
new and sudden onset of back pain occurs. Spinal cord compression causes back pain before
neurological changes occur. Spinal cord compression is an oncological emergency, and the physician
should be notified.

The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The
best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, and oysters.

Iron preparations can be very irritating to the stomach and are best taken after a meal. The tablet is
swallowed whole, not chewed. Because the client might experience constipation, the client should
increase fluids and fiber in the diet to counteract this side effect of therapy.

For most hematological laboratory studies, including CBC, no special care is needed either before or
after the test. There is no reason to fast after midnight, drink extra liquids, or avoid red meat prior to the
laboratory test being drawn.

Before bone marrow aspiration, the site is cleansed with an antiseptic solution such as povidone-iodine.
This helps reduce the number of bacteria on the skin, and decreases the risk of infection from the

When delegating nursing assignments, the nurse needs to consider the skills and educational levels of
the nursing staff. The nursing assistant can most appropriately give a shower, a bed bath, ambulate a
client with a walker, take an oral temperature. The LPN can administer the rectal suppository to the
client requiring the enema. The LPN is skilled in wound irrigations and dressing changes, and this client
would most appropriately be assigned to this staff member.

After ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be
instructed to avoid drinking with a straw for 2 to 3 weeks, traveling by air, and coughing excessively.
Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Swimming is
also avoided. Clients need to avoid moving the head rapidly, bouncing, and bending over for 3 weeks.

Exacerbation of Mnires disease is characterized by severe vertigo. The nurse instructs the client to
make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid
restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Activities such as
reading and watching TV will worsen the vertigo. Clients are advised to stop smoking because of its
vasoconstrictive effects.

The client who is thrombocytopenic is at risk for bleeding. The family should observe the puncture site
for bleeding for several days after the procedure, since the client is at high risk. Acetaminophen may be
given for discomfort, and aspirin should be avoided because it could aggravate bleeding

The client who has had surgical resection of the stomach or small intestine may develop pernicious
anemia as a complication. This results from decreased production of intrinsic factor (gastrectomy) or
decreased surface area for vitamin B12 absorption (intestinal resection). The client then requires
vitamin B12 injections for life. Decreased iron intake leads to iron deficiency anemia, which is often
easily treated with iron supplements.

Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic
membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also
have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of
the head.

The RN would plan to care for the client who is scheduled for surgery at 1:00 p.m. first. There are several
items that need to be addressed preoperatively, including client preparation (physically and
emotionally) and physician orders that need to be carried out. This preparation takes time. Additionally,
many times the operating room makes late changes in the schedule, depending on room and physician
availability, and requests an earlier surgical time. Therefore, it is best to ensure that this client is

Abdominal pain is the most prominent symptom of acute pancreatitis. The main focus of nursing care is
aimed at reducing discomfort and pain by the use of measures that decrease gastrointestinal tract
activity, thereby decreasing pancreatic stimulation.

A diagnosis of gout is made on the basis of clinical manifestations, hyperuricemia, and the presence of
uric acid crystals in the synovial fluid of the inflamed joint. Blood studies show an increased serum uric
acid level of more than 7 mg/100 mL. The erythrocyte sedimentation rate and the white blood cell count
may be elevated during an acute episode. T

Probenecid is a uricosuric medication. The client should be instructed to avoid alcohol, because it
increases the urate levels and to avoid medications that contain aspirin. Increased fluid intake is
encouraged to maintain an adequate urine output and prevent hematuria, renal colic, and stone
development. The client is instructed to administer the medication with milk or meals to prevent gastric
distress and is also told to limit high-purine foods.

Calcium supplements should not be taken with whole grain cereals, rhubarb, spinach, or bran,
because these foods decrease the absorption of the calcium. Most supplements should be taken on an
empty stomach (1 hour before meals or at bedtime) to promote absorption, but food might be
necessary if gastric irritation develops. The client should be instructed to drink water while taking the
supplements to prevent renal stones. Side effects include constipation, gastric irritation, a chalky
taste, nausea, and gastric bleeding.

Blood glucose levels for an adult normally range between 60 and 120 mg/dL. A level of 33 mg/dL
indicates hypoglycemia. Metabolic disorders can be an etiological factor of delirium.

The Romberg test is an assessment for cerebellar functioning related to balance. The client stands
with feet together and arms at the side and then closes the eyes. Slight swaying is normal, but loss of
balance indicates a problem and a positive Romberg test.

For the first 12 hours following a laparotomy, the NG tube drainage may be dark brown to dark red. The
drainage should then change to a light yellowish brown color. The presence of bile may cause a greenish
tinge. The physician should be notified at once of the possibility of hemorrhage if the dark red color
continues or if bright red blood is observed. Due to the presence of small amounts of blood and the
action of gastric secretions, coffee ground granules might be seen in the NG tube drainage.

The diagnosis of HIV is difficult to accept. Clients can exhibit a variety of reactions that are not
necessarily a direct result of ineffective coping skills. The nurse must also know that persons with HIV
are living well beyond 1 year. Ignoring the problem will not eliminate the clients difficulty in
understanding the disease process. The nurse must focus on the knowledge deficit of a disease process
and other psychosocial interventions.

Sheet grafts are often used to graft burns in visible areas. Sheet grafts are done on cosmetically
important areas, such as the face and hands, to avoid the meshed pattern that occurs with meshed

The incidence of invasive cervical cancer in situ peaks around age 45 and occurs twice as often in African
American women than in other races. A classic symptom is painless vaginal bleeding; it can be
accompanied by watery, blood-tinged vaginal discharge that can become dark and foul smelling as the
disease progresses. A Papanicolaou smear is the initial diagnostic test performed.

Organisms present in the synovial fluid are characteristic of a septic joint condition. Urate crystals are
found in gout. Bloody synovial fluid is seen with trauma. Cloudy synovial fluid is diagnostic of
rheumatoid arthritis.

Trigeminal neuralgia affects cranial nerve V, causing sudden bursts of electric currentlike pain in the

In atrial fibrillation with rapid ventricular response, the atrial chambers quiver, do not contract
normally, and fill the ventricles with blood during the last part of diastole. This results in the loss of an
important atrial contribution to cardiac output, called the atrial kick. Loss of the atrial kick and the
rapid ventricular rate causes a reduction of cardiac output by as much as 25%.

Physical changes in the client's appearance can occur with Cushing's syndrome. Such changes include
hirsutism, moon face, buffalo hump, acne, and striae. These changes cause a body image disturbance.

A fasciotomy is a treatment for compartment syndrome.

The client with unilateral neglect must learn to scan the environment and gradually come to a
realization of the affected side

Alcohol can precipitate an attack of pancreatitis. Coffee and cola products, which contain caffeine,
stimulate the pancreas. Carbohydrates actually should be encouraged, since they are less stimulating to
the pancreas. Since smoking can overstimulate the pancreas, teaching is effective when the client will
try to stop smoking.

Hypercalcemia is a phenomenon associated with multiple myeloma. Due to the hypercalcemia,
pathological fractures are possible. Ambulation is important, because immobility increases the
likelihood of hypercalcemia. Most clients with multiple myeloma will not tolerate aerobic exercise
because of their anemia.

Even if testicular cancer is detected in an early stage, the client newly diagnosed with testicular cancer
might be afraid he will be sexually handicapped, and feelings of sexual inadequacy may occur. An
appropriate nursing diagnosis would be Ineffective Role Performance.

Ventilators need to be assessed routinely by the respiratory therapist. Ventilators are machines, and
machines can fail.

The normal white blood cell count is 5,000 to 10,000/mm3. Chemotherapy agents cause medication-
induced leukopenia, and treatment focuses on this side effect.

A fractured femur may require up to 20 weeks for healing in an adult. Full weight-bearing is permitted as
soon as bony union is present. Ambulation with a cane requires at least partial to full weight-bearing
status. Full weight-bearing is usually restricted until there is radiographic evidence of bony union of the
fracture fragments. Callus formation is too weak, and the fracture site may refracture with full weight-
bearing. The stage of fracture healing dictates the amount of weight-bearing, not range of motion,
muscle strength, or pain.

Perforation of the gastrointestinal wall is a potential complication of any endoscopic procedure. Signs
of perforation include abdominal pain, bleeding, and fever. Temperature elevation does not usually
accompany internal hemorrhage. The temperature may be elevated in both severe dehydration and
with a nosocomial infection, but the potential complication that can occur with this procedure is
perforation of the intestine.

Clients who test positive for HIV antibody are at risk for opportunistic infection. The normal CD4+ T
cell count is between 500 mcg/L and 1600 mcg/L. As the CD4+ T cell count falls, the clients risk for
infection increases. Clients with HIV infection or acquired immunodeficiency syndrome are commonly
afflicted with diarrhea, not constipation.

Clients with chronic illness often experience feelings of anger and depression. Manifestations of chronic
hepatitis include profound fatigue, resulting in an inability to pursue normal daily activities. Ineffective
coping involves inappropriate use of defense mechanisms (alcohol consumption). It can also include the
inability to meet role expectations (working). The destructive use of alcohol will contribute to the
clients illness and rehabilitation time, and further prolong fatigue and the inability to work.

Nocturnal attacks of reflux from hiatal hernias are common, especially if the person has eaten near
bedtime. Large meals, alcohol, and smoking can also precipitate attacks. Therefore, if the client did more
entertaining earlier in the day, attacks might be decreased or eliminated.

The client with Addisons disease is experiencing deficits of mineralocorticoids, glucocorticoids, and
androgens. Aldosterone deficiency affects the ability of the nephrons to conserve sodium, so the client
experiences sodium and fluid volume deficit. The client needs to manage this problem with daily
hormone replacement and increased fluid and sodium intake. Clients are instructed to weigh themselves
daily as a means of monitoring fluid volume balance. Glucocorticoids and mineralocorticoids are
essential components of the stress response. Additional doses of hormone replacement therapy are
needed with any type of physical or psychological stressor. This information needs to be conveyed to the
client and also requires that the client wear a Medic-Alert bracelet, so that health care professionals are
aware of this problem if the client were to experience a medical emergency.

The client with ulcerative colitis is most likely anemic due to chronic blood loss in small amounts that
occur with exacerbations of the disease. These clients often have bloody stools and are therefore at
increased risk for anemia

If a transfusion reaction is suspected, the transfusion is stopped and then normal saline is infused,
pending further physician orders. This maintains a patent IV access line and aids in maintaining the
clients intravascular volume. The IV line would not be removed, because then there would be no IV
access route. Normal saline is the solution of choice over solutions containing dextrose, because saline
does not allow red blood cells to clump.

A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such
as ramipril, is the appearance of a persistent, dry cough. The cough generally does not improve while
the client is taking the medication. Clients are advised to notify the physician if the cough becomes very
troublesome to them.

Nitroglycerin is a coronary vasodilator used in the management of coronary artery disease. The client is
generally advised to apply a new patch each morning and leave it in place for 12 to 14 hours as per
physician directions. This prevents the client from developing tolerance (as happens with 24-hour use).
The client should avoid placing the system in skin folds, hairy areas, or excoriated areas. The client can
apply a new patch if it falls off, because the dose is released continuously in small amounts through the

Verapamil is a calcium channelblocking agent that can be used to treat rapid-rate supraventricular
tachydysrhythmias, such as atrial flutter or atrial fibrillation. The client must be attached to a cardiac
monitor to evaluate the effectiveness of the medication. A noninvasive blood pressure monitor is also
helpful, but is not as essential as the cardiac monitor.

The client should take in increased fluids (2000 to 3000 mL/day) to make secretions less viscous. This
can help the client to expectorate secretions. This is standard advice given to clients receiving any of the
adrenergic bronchodilators, such as albuterol, unless the client has another health problem that could
be worsened by increased fluid intake.

The client taking a potassium-wasting diuretic such as chlorothiazide needs to be monitored for
decreased potassium levels.

Amiloride is a potassium-sparing diuretic used to treat edema or hypertension. A daily dose should be
taken in the morning to avoid nocturia. The dose should be taken with food to increase bioavailability.
Sodium should be restricted if used as an antihypertensive. Increased blood pressure is not a reason
to hold the medication, although it may be an indication for its use.

When ranitidine is given as a single daily dose, it should be taken at bedtime. This allows for
prolonged effect, and the greatest protection of gastric mucosa around the clock.

Urinary retention is a side effect of benztropine mesylate. The nurse needs to observe for dysuria,
distended abdomen, infrequent voiding of small amounts, and overflow incontinence.

Quinapril hydrochloride is an angiotensin-converting enzyme inhibitor used in the treatment of
hypertension. The client should be instructed to rise slowly from a lying to sitting position and to
permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect.
The medication does not need to be taken with meals. It may be given without regards to food. If
nausea occurs, the client should be instructed to consume a non-cola carbonated beverage and salted
crackers or dry toast. A full therapeutic effect may take place in 1 to 2 weeks.

Quinidine gluconate is an antidysrhythmic medication used as prophylactic therapy to maintain
normal sinus rhythm after conversion of atrial fibrillation and/or atrial flutter. It is contraindicated in
complete AV block, intraventricular conduction defects, abnormal impulses and rhythms due to
escape mechanisms, and in myasthenia gravis. It is used with caution in clients with preexisting
asthma, muscle weakness, infection with fever, and hepatic or renal insufficiency.

Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this
reason, the nurse monitors the client for signs and symptoms of bleeding, and implements the same
precautions that are used for a client receiving anticoagulant therapy. These include providing a soft
toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. Venipuncture
sites should be held for approximately 10 minutes. The medication does not have to be taken on an
empty stomach. The medication may cause hypoglycemia, but not hyperglycemia.

Diarrhea, nausea, vomiting, loss of appetite, and dizziness are all common side effects of quinidine. If
these should occur, the physician should be notified; however, the patient should not discontinue the
medication. A rapid decrease in medication levels of antidysrhythmics could precipitate dysrhythmia.

Benzonatate (Tessalon) is a locally acting antitussive. Its effectiveness is measured by the degree to
which it decreases the intensity and frequency of cough without eliminating the cough reflex.

Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with Carbamazepine
(Tegretol). Adverse reactions include blood dyscrasias. If the client developed a fever, sore throat,
mouth ulcerations, unusual bleeding or bruising, or joint pain, this might be indicative of a blood
dyscrasia and the physician should be notified.

Parlodel is an antiparkinson prolactin inhibitor used in the treatment of neuroleptic malignant
syndrome. Vitamin K is the antidote for warfarin (Coumadin) overdose. Protamine sulfate is the antidote
for heparin overdose. Vasotec is an angiotensin-converting enzyme (ACE) inhibitor and an
antihypertensive that is used in the treatment of hypertension.

Hematological reactions can occur in the client taking clozapine, and include agranulocytosis and mild
leukopenia. The white blood cell count should be assessed before treatment is initiated and should be
monitored closely during the use of this medication. The client should also be monitored for signs
indicating agranulocytosis, which may include sore throat, malaise, and fever.

The client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which
can be determined by questioning the client about allergies to iodine or shellfish.

The client undergoing LP is positioned lying on the side, with the legs pulled up against the abdomen
and with the head bent down toward the chest. This position helps widen the spaces between the

Caloric testing provides information about the vestibular portion of CN VIII, which aids in
differentiating between cerebellar and brainstem lesions. Usually ice-cold water is inserted into the
auditory canal after patency of the ear canal is determined. If brainstem function is intact, the eyes
move in a conjugate fashion slowly toward the irrigated side and then quickly move back to midline.
With brainstem death, this nystagmus pattern does not occur.

The correct technique for administering parenteral iron is deep in the gluteal muscle using Z-track
technique. This method minimizes the possibility that the injection will stain the skin a dark color.

Pernicious anemia can occur in a client who has not had gastric surgery, such as when the client has a
disease that involves the ileum, where vitamin B12 is absorbed. The nurse checks the client's history
for small bowel disorders to detect this risk factor.

Classic signs of pernicious anemia include weakness, mild diarrhea, and smooth, sore, red tongue. The
client may also have nervous system symptoms such as paresthesias, difficulty with balance, and
occasional confusion.

An urticaria reaction is characterized by a rash accompanied by pruritus. This type of transfusion
reaction is prevented by pretreating the client with an antihistamine, such as diphenhydramine.

Instructions to a femail client regarding the procedure for collecting a midstream urine sample includes
telling the client that he should cleanse the perineum from front to back with the antiseptic swabs that
are packaged with the specimen kit. The client should begin the flow of urine, collecting the sample
after starting the flow of urine. The specimen should be sent to the laboratory as soon as possible and
not allowed to stand. Improper specimen handling can yield inaccurate test results.

Sickle cell anemia is a severe anemia that predominantly affects African Americans. It is characterized by
the presence of only hemoglobin S.

The indirect Coombs' test detects circulating antibodies against red blood cells (RBCs), and is the
screening component of the order to type and screen a clients blood. This test is used in addition
to the ABO typing, which is normally done to determine blood type. The direct Coombs' test is used to
detect idiopathic hemolytic anemia, by detecting the presence of autoantibodies against the clients
RBCs. Eosinophil and monocyte counts are part of a complete blood count, a routine hematologic
screening test.

The most common sites for bone marrow aspiration in the adult are the iliac crest and the sternum.
These areas are rich in marrow and are easily accessible for testing.

Sickle cell disease often causes pain in the bones and joints, accompanied by joint swelling. Pain is a
classic symptom of the disease and may require large doses of narcotic analgesics when it is severe.

The priority items in the management of sickle cell crisis are hydration therapy and pain relief. To
achieve this, the client is given intravenous fluids to promote hydration and reverse the agglutination of
sickled cells in small blood vessels. Narcotic analgesics may be given to relieve the pain that
accompanies the crisis. Oxygen would be given, based on individual need. RBC transfusion also may be
done in selected circumstances such as aplastic crisis or when the episode is refractive to other therapy.
Genetic counseling is recommended, but not during the acute phase of illness.

Idiopathic autoimmune hemolytic anemia is treated with corticosteroids, particularly prednisolone
(Prelone). Other treatments that can be initiated as necessary include splenectomy, transfusions, and
sometimes immunosuppressive agents.

At age 15 months, the nurse would expect that the child could build a tower of two blocks. A 24-month-
old would be able to open a doorknob and unzip a large zipper. At age 30 months, the child would be
able to put on simple clothes independently.

Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or activity. Alternating
constipation and diarrhea with the presence of undigested food and mucus in the stools may also be

Following pyloromyotomy, the head of the bed is elevated and the infant is placed prone to reduce
the risk of aspiration.

Mumps generally affects salivary glands but can involve multiple organs. The most common
complication is septic meningitis, with the virus being identified in the cerebrospinal fluid. Common
signs include nuchal rigidity, lethargy, and vomiting. The child should be seen by the physician.

Carditis is the inflammation of all parts of the heart, primarily the mitral valve.

Hypernatremia occurs when the sodium level is greater than 145 mEq/L. Clinical manifestations include
intense thirst; oliguria; agitation and restlessness; flushed skin; peripheral and pulmonary edema; dry,
sticky mucous membranes; and nausea and vomiting.

The two primary pathophysiological alterations associated with hemolytic disease are anemia and
hyperbilirubinemia. The red blood cell count is decreased, because the red blood cell production
cannot keep pace with the red blood cell destruction. Hyperbilirubinemia results from the red blood
cell destruction accompanying this disorder, as well as from the normally decreased ability of the
infants liver to conjugate and excrete bilirubin efficiently from the body. Hypoglycemia is associated
with hypertrophy of pancreatic islet cells and increased levels of insulin.

Live measles vaccine is produced by chick embryo cell culture, so the possibility of an anaphylactic
hypersensitivity in children with egg allergies should be considered. If there is a question of
sensitivity, children should be tested before the administration of MMR vaccine. If a child tests
positive for sensitivity, the killed measles vaccine may be given as an alternative.

Meperidine hydrochloride is contraindicated for ongoing pain management for a client admitted to the
hospital with a diagnosis of sickle cell crisis, because of the increased risk of seizures associated with its
use. Management of severe pain generally includes the use of strong narcotic analgesics, such as
morphine sulfate or hydromorphone (Dilaudid). These medications are usually most effective when
given as a continuous infusion or at regular intervals around the clock.

Dietary sources of iron that are easy for the body to absorb include meat, poultry, and fish. Vegetables,
fruits, cereals, and breads are also dietary sources of iron but contain less iron and are harder for the
body to absorb.

Intravenous immune globulin (IVIG) will increase the platelet count. It is thought to act by interfering
with the attachment of antibody-coded platelets to receptors on the macrophage cells of the
reticuloendothelial system. Corticosteroids can be prescribed to enhance vascular stability and decrease
the production of antiplatelet antibodies.

Koplik spots appear approximately 2 days before the appearance of the rash of rubeola. These are small,
blue-white spots with a red base found on the buccal mucosa. The spots last approximately 3 days, after
which time they slough off

A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral

Ductus arteriosus is described as an artery that connects the aorta and the pulmonary artery during
fetal life. It generally closes spontaneously within a few hours to several days after birth. When
patent, it allows abnormal blood flow from the high- pressure aorta to the low-pressure pulmonary
artery, resulting in a left-to-right shunt.

Discharge instruction to the parents of a child who has had heart surgery includes the child may return
to school the third week after hospital discharge, but should go for half days for the first few days. The
child should avoid crowds of people for 1 week after discharge, including day care centers and churches.
Play outside should be avoided for several weeks, although inside play is allowed. If any difficulty with
breathing occurs, the parents should notify the physician.

A toddler derives comfort and security from familiar routines and people. The new sights, sounds, and
smells are a source of anxiety during hospitalization.

The crisis of Autonomy vs Shame and Doubt is related to the developmental task of gaining control of
self and environment as exemplified by toilet training. Initiative vs Guilt is the crisis of the preschool
and early school-aged child. Initiative vs Inferiority is the crisis of the 6- to 12-year-old, and Trust vs
Mistrust is the crisis of the infant.

The Somogyi effect is a rebound hyperglycemia that occurs as a result of the secretion of counter
regulatory hormones such as epinephrine, growth hormone, and corticosteroids. The 3:00 a.m. blood
glucose level is low, followed by a high level a few hours later, demonstrating the rebound effect.

Children suspected of having acute rheumatic fever are tested for the presence of recent streptococcal
infection antibodies. An increased antibody level, evidenced by an elevated or rising antistreptolysin-O
(ASO) titer, will assist in confirming the diagnosis. An increased erythrocyte sedimentation rate would
occur in acute rheumatic fever. A leukocyte count and hemoglobin count will not confirm the diagnosis
of acute rheumatic fever.

A diarrhea stool has an alkaline pH that can cause skin breakdown. A damp washcloth is an ineffective
way to clean the skin. The mother should be taught to thoroughly clean the skin, using a mild soap.

Spina bifida occurs during fetal growth and development and has genetic predispositions. Parents who
have children with congenital defects blame themselves for the childs defects. Parents, at times, have
difficulty bonding with their newborn because they are grieving the loss of their perfect baby.
Integrating the new baby with special needs into the parents life is a stressful adjustment.

Complications from pertussis include pneumonia, atelectasis, otitis media, convulsions, and
subarachnoid bleeding. Decreased breath sounds are indicative of both pneumonia and atelectasis.

Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of
a chronic tissue hypoxia and polycythemia.

In hemophilia A, the partial thromboplastin time is prolonged. The white blood cell count,
sedimentation rate, and clot retraction time are unrelated to the diagnosis of hemophilia A.

The stools of a child with celiac disease are characteristically malodorous, pale, fatty, large (bulky), and
soft (loose). Excessive flatus is common, and bouts of diarrhea may occur.

Rehydration is the initial step in resolving diabetic ketoacidosis (DKA.) Normal saline is the initial IV
rehydration fluid. Regular insulin will be administered by continuous IV infusion. Dextrose solutions
are added to the treatment regime when the blood glucose levels reach an acceptable level. IV
potassium may be required, depending on the potassium levels, but would not be part of the initial
treatment. Glucagon hydrochloride is used to treat severe hypoglycemia.

If a child is being treated with propylthiouracil, the increased risk for neutropenia and hepatotoxicity
exists. Contact sports should be limited to decrease the possibility of injury and damage to the liver. If
the child develops a sore throat or fever, the physician should be notified, because these signs could
indicate neutropenia. A yellow discoloration of the skin could indicate the presence of liver damage or
hepatitis, and if this occurs, it is not normal and the physician must be notified.

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.

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

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.

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 clients feelings while continuing to
meet the clients 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.

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

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 clients 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 Parkinsons 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

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).

Bells 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 Bells 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 Bells 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-Barr 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-Barr 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.

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.

Raynauds 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.

Raynauds phenomenon is a condition in which the small arteries and arterioles constrict in response
to various stimuli. Raynauds 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.

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.