Professional Documents
Culture Documents
org
• 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
1
• Verapamil is a calcium channel–blocking 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.
2
and in myasthenia gravis. It is used with caution in clients with
preexisting asthma, muscle weakness, infection with fever, and
hepatic or renal insufficiency.
• 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.
3
• Clinical manifestations suggestive of airway obstruction include tripod
positioning (leaning forward supported by the arms, chin thrust out, and
mouth open), nasal flaring, tachycardia, a high fever, and sore throat.
• Familiar objects provide a sense of security for the child in a strange hospital
environment. The child should be allowed to have a favorite toy or security
blanket while in the mist tent.
• Dietary changes such as salt and fluid restrictions that reduce the amount of
endolymphatic fluid are sometimes prescribed for clients with Ménière’s
disease.
• Following mastoidectomy, the nurse should monitor vital signs and inspect
the dressing for drainage or bleeding. The nurse should assess for signs of
facial nerve injury to cranial nerve VII and assess the client for pain,
dizziness, or nausea. The head of the bed should be elevated at least 30
degrees, and the client is instructed to lie on the unaffected side. The client
would probably have sutures and an outer ear packing and a bulky dressing,
which is removed on approximately the sixth postoperative day.
• Hearing loss can occur in a client with an inner ear disorder. However,
hearing loss is not the most common complaint of a client with an inner ear
disorder. Tinnitus is the most common complaint of clients with otological
4
disorders, especially disorders involving the inner ear. Symptoms of tinnitus
range from mild ringing in the ear, which can go unnoticed during the day, to
a loud roaring in the ear, which can interfere with the client’s thinking
process and attention span.
• The client with any renal disorder, such as renal failure, may become angry
and depressed because of the permanence of the alteration. Due to the
physical change and the change in lifestyle that may be required to manage
a severe renal condition, the client may experience Disturbed Body Image.
• Athletes often have sinus bradycardia because exercise increases the stroke
volume of the heart. Since the cardiac output is a product of stroke volume
and heart rate, fewer beats are needed per minute at rest to maintain the
normal cardiac output. The vital signs are normal for this client.
5
cause of the virus for chicken pox. In a Wood’s light examination, the skin is
viewed under ultraviolet light to identify superficial infections of the skin. A
patch test is a skin test that involves the administration of an allergen to the
skin’s surface to identify specific allergies.
• Assessment findings in frostbite include a white or blue color, and the skin
will be hard, cold, and insensitive to touch. As thawing occurs, the skin
becomes flushed, blisters or blebs develop, or tissue edema appears.
Gangrene develops in 9 to 15 days.
• Acute frostbite is ideally treated with rapid and continuous rewarming of the
tissue in a water bath for 15 to 20 minutes or until flushing of the skin occurs.
Slow thawing or interrupted periods of warmth are avoided because this can
6
contribute to increased cellular damage. Thawing can cause considerable
pain, and the nurse administers analgesics as prescribed.
• The client who suffers a spinal cord injury experiences spinal shock at the
time of the injury. The client loses all motor, bowel, bladder, and sexual
function, and loses all reflexes below the level of the injury. Spinal shock
resolves in 7 days to 3 months. Indications of resolving spinal shock include
hyperreflexia and positive Babinski reflex.
• As the first symptom, the client with Pneumocystis carinii infection usually
has a cough that begins as nonproductive and then progresses to productive.
Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.
• If the results of two ELISA tests are positive, the Western Blot is done to
confirm the findings. If the result of the Western Blot is positive, then the
client is considered to be positive for HIV, and infected with the HIV virus. The
CD4 count identifies the T-helper lymphocyte count and is performed to
determine progression and treatment.
• Renal biopsy is a definitive test that gives specific information about whether
the lesion is benign or malignant. An ultrasound discriminates between a
fluid-filled cyst and a solid mass. Renal arteriography outlines the renal
vascular system. While some types of cancer grow more quickly than others,
it is not possible to determine this by biopsy.
• Radiation therapy to the brain can cause cerebral edema. Clients may also
experience nausea and vomiting because of the effects of the radiation on
the brain’s chemoreceptor trigger zone. Because hair follicles are destroyed
7
by radiation, clients receiving radiation to the head may also experience hair
loss.
8
• Vaccines for hepatitis A using live activated and inactivated virus have been
tested and seem safe and effective. Havrix, a vaccine containing the inactive
virus of hepatitis A, is available and can replace gamma globulin for travelers.
A single dose of this vaccine is given intramuscularly. For maximum antibody
titer, a booster dose is recommended 6 to 12 months after the initial
injection. The hepatitis B vaccine (Engerix-B, Recombivax-HB) provides active
immunity to hepatitis B.
• In Bell’s palsy, the client experiences weakness on an entire half of the face.
The client is unable to close the eye on the affected side and experiences
paralysis of the ipsilateral facial muscles. The client also experiences pain,
drooling, decreased taste, and increased tearing. Tinnitus, vertigo, and
deafness are not associated with Bell’s palsy but can be seen in Ménière’s
disease. Muscle spasms in the jaw and cheek area are most likely associated
with trigeminal neuralgia.
• Therapeutic management for the client with Bell’s palsy includes providing
moist heat packs to the affected area. The client is instructed to eat small
meals and soft foods frequently, and to protect the affected eye by using an
eye patch. The client is also instructed to use artificial tears four times daily
and to manually close the affected eye from time to time.
• For the first 24 hours postoperatively, the nurse should elevate the stump as
prescribed to decrease swelling and promote comfort. Stumps with
compromised circulation must not be elevated. A lower extremity stump is
elevated at intervals, because elevation for long periods of time can cause
flexion contractures of the hip. To prevent flexion hip contractures, the client
should be positioned on the abdomen for a 30-minute period every 4 to 6
hours.
• In general, only the area in the treatment field is affected by radiation. Skin
reactions, fatigue, nausea, and anorexia may occur with radiation to any site,
whereas other side effects occur only when specific areas are involved in
treatment. A client receiving radiation to the neck is most likely to experience
a sore throat.
9
mucosa. Jaundice is best seen in the sclera, the junction of the hard and soft
palate, and over the palms.
• Usually, one tooth erupts for each month of age past 6 months up to 30
months of age. Proper dental care includes adequate cleaning, removal of
plaque, use of fluoride, and good nutrition. The child should not be allowed to
have a bottle in bed. A diet that is low in sweets and high in nutritious food
promotes dental health.
• The normal respiratory rate for a 3 year old is 20 to 30 breaths per minute.
The nurse would document the findings.
• The normal apical rate for a newborn infant is 120 to 160 beats per minute
• A toddler has the skills required to feed himself or herself. The mother should
be instructed not to feed a child who can feed herself and to never force-feed
the child. To increase nutritious intake, the mother is instructed to limit juice
intake to 6 ounces per day, and milk intake to 16 to 24 ounces per day.
Additionally, the mother should limit the child to 2 nutritious snacks per day
and should only provide the snacks at the toddler’s request.
• McBurney’s point is usually the location of greatest pain in the child with
appendicitis. McBurney’s point is midway between the right anterior superior
iliac crest and the umbilicus.
10
• Clinical manifestations of iron deficiency anemia will vary with the
degree of anemia but usually include extreme pallor with a
porcelain-like skin, tachycardia, lethargy, and irritability.
• High fevers and severe illnesses are reasons to delay immunization, but only
until the child has recovered from the acute stage of the illness. Minor
illnesses such as a cold, otitis media, or mild diarrhea without fever are not
contraindications to immunization.
• HBV is one of the safest vaccines. The most common reactions are soreness
at the injection site and mild to moderate fever. Acetaminophen (Tylenol)
may be used to relieve discomfort, but aspirin should be avoided. The only
11
contraindication to HBV is a previous anaphylactic reaction to either the HBV
immunization or to Baker’s yeast.
• Care to the child with rubella involves contact isolation. Contact isolation
requires the use of masks, gowns, and gloves for contact with any infectious
material. Contaminated articles are also bagged and labeled per agency
protocol. Goggles are not necessary to care for the child with German
measles.
• Asymmetry of the gluteal skin folds when the infant is placed prone and the
legs are extended against the examining table is noted in hip dysplasia.
Asymmetric abduction of the affected hip, when the client is placed supine
with the knees and hips flexed, would also be an assessment finding in hip
dysplasia in infants beyond the newborn period. An apparent short femur on
the affected side is noted as well as limited range of motion.
• SGA infants are at risk for developing hypocalcemia. The normal range for
total serum calcium is 7.0 mg/dL to 8.5 mg/dL.
12