NCLEX Review, Fourth Set

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Pearson Vue

Correction of DHD in infants less than 6 months of age involves the use of...

a Pavlik harness. Prevents hip extension or adduction and is worn continuously for about 3-6 months.

The infant grows rapidly, so the straps of the Pavlik harness should be checked every...

1-2 weeks for needed adjustments because vascular or nerve damage can occur with improper positioning.

In congenital clubfoot (talipes equinovarus), the affected foot is usually...

smaller and shorter than the unaffected foot.

Treatment of congenital clubfoot begins with the...

application of casts; cast is changed and affected limb is manipulated weekly for the first 6-12 weeks; surgical correction involves pin fixation and releast of tight joints and tendons followed by casting for 2-3 months.

The pregnant client should avoid external heat exposure, such as hot tubs and saunas, because these have been identified factors that increase the risk of...

neural tube defects.

Spina bifida: Meningocele

defect contains the meninges and spinal fluid; child has no neurological deficit

Spina bifida: Myelomeningocele

defect contains the meninges, nerve tissue, and spinal fluid; child has serious neurological deficit

Preoperative care of a client with myelomeningocele includes...

prevent injury to and or drying of the sac; sac should covered with a sterile, nonadherent dressing moistened with sterile normal saline; dressings changed every 2-4 hours

Newborn with myelomeningocele should be placed...

prone with the hips slightly flexed and elevated (low Trendelenburg) to prevent stretching of involved nerves.

Complications of myelomeningocele

hydrocephalus, UTI, meningitis, pressure sores, contractures

Symptoms of meningitis in the infant include...

temperature instability, poor feeding, high-pitched cry, and bulging fontanels.

Symptoms of meningitis in the child include...

fever, projectile vomiting, headache, and visual disturbances.

Symptoms of CHD in the infant include...

cyanosis with feeding, clubbing of the fingers and toes, dyspnea, failure to gain weight, fatigue, respiratory congestion

Early signs of CHF include...

tachycardia while sleeping, profuse sweating (especially on the scalp), fatigue, irritability, respiratory distress, and weight gain.

Acyanotic defects include...

patent ductus arteriosus, atrial septal defect, ventricular septal defect, and coarctation of the aorta

Cyanotic defects include...

transposition of the major vessels, truncus arteriosus, and Tetralogy of Fallot

Coarctation of the aorta (COA)

narrowing within the aorta that alters blood flow to the extremities

Symptoms of COA include...

elevated BP and bounding pulses in the upper extremities and dimished BP and weak or absent pulses in the lower extremities

Older children with COA might complain of...

dizziness, headache, fainting, and nosebleed, which can indicate that the BP is higher than usual.

Tetralogy of Fallot (TOF)

pulmonic stenosis, VSD, overriding aorta, right ventricular hypertrophy

Symptoms of TOF in infant include...

history of acute cyanosis and heart murmur at birth that worsens over first year of life; acute episodes of cyanosis and anoxia referred to as blue spells or tet attacks, occur during crying or feeding

Symptoms of TOF in child include...

noticeable cyanosis, clubbing of fingers, growth retardation

When oxygen is compromised in the child with TOF, the child assumes...

a squatting position.

Nursing care for the child with a tet attack includes placing the child in...

knee chest position and administering supplemental oxygen.

Phenylketonuria (PKU)

genetic disorder in which child is unable to metabolize phenylalanine into tyrosine; essential to formation of melanin (responsible for hair, skin, and eye color) and hormones epinephrine and thyroxine

Clinical manifestations of PKU include...

irritability, frequent vomiting, failure to thrive, and seizures; older children have bizarre behaviors such as head banging, screaming, arm biting, and other psychotic behaviors

Screening test for PKU

Guthrie blood test; side of heel; most reliable if newborn has ingested source of protein

Treatment of PKU

low-phenylalanine diet continued through adolescence; partial breast feeding allowed if monitored; solid food such as cereal, fruits, and vegetables added according to recommended schedule; most high-protein foods restricted; artificial sweeteners containing aspartame should be avoided

Galactosemia

infant appears normal at birth, but within a few days of ingesting a formula containing lactose, she begins to vomit and lose weight

Symptoms of galactosemia

jaundice, cirrhosis, portal hypertension, cataracts by 1-2 months of age, lethargy and hypotonia with brain damage

Treatment of galactosemia

eliminate all milk- and lactose-containing foods, including breast milk; fee a soy-protein formula

Symptoms of acute otitis media (AOM)

high fever (103 degrees-104 degrees F), anorexia, vomiting, and pain; rubbing or pulling at affected ear or rolling head side to side

If rupture of eardrum occurs...

pain and fever subside.

Treatment of AOM

antibiotics (amoxicillin, sulfonamides, erythromycin, or cephalosporins); antipyrectics (ibuprofen or acetaminophen) for fever and pain

Complications of AOM

mastoiditis, meningitis, and hearing loss

Hearing evaluation is recommended for a child who has bilateral OM for a total of...

three months.

Symptoms of tonsillitis

difficulty swallowing and breathing, enlargement of the tonsils, inability to smell and taste, mouth breathing, snoring

Postoperative tonsillectomy

child should be observed for continual swallowing, which is an indication of bleeding

Postoperative tonsillectomy, foods that should be avoided include...

citrus foods, hot foods, and foods with rough textures, as well as foods that are red, orange, or brown in color

Upon discharge of a tonsillectomy, parents should be instructed to...

keep the child out of crowds for 1-2 weeks.

Symptoms of laryngotracheobronchitis (LTB) (croup)

upper respiratory infection and low-grade fever, restless and irritable, noticeable hoarseness and brassy cough

The symptoms of hoarseness, cough, and inspiratory stridor can be relieved by providing...

high humidity with cool mist; frequently offer fluids; steroids or epinephrine to reduce bronchial swelling

The American Academy of Pediatrics recommends that all children receive the H. influenza B conjugate vaccine beginning at...

two months of age as part of the routine childhood immunization series.

Symptoms of acute epiglottitis

awaken complaining of sore throat and pain on swallowing, drooling, muffled phonation, inspiratory stridor, and sitting in tripod position; cherry red epiglottitis

Only the MD should exam a child's throat with epiglottitis because...

visualization can precipitate immediate airway obstruction; tracheostomy set or endotracheal intubation set should be readily available

Symptoms of bronchiolitis

dyspnea, nonproductive cough, wheezing, nasal flaring, intercostal and sternal retractions, emphysema

Treatment of bronchiolitis

oral fluids may be withheld until respiratory function improves; cool mist vaporizers with or without supplemental oxygen and respiratory therapy with Virazole (ribavirin)

Ribavirin should be administered within

3 days of the infection; pregnant healthcare workers should avoid direct care of the client receiving aerosolized Virazole (ribavirin)

Symptoms of CF

meconium ileus, frequent upper respiratory infections, malabsorption, failure to gain weight, heat prostration; reoccurring nasal polyps and rectal prolapse

Diagnosis of CF

sweat test

The sweat test in CF will reveal...

elevated sodium and chloride levels

In CF, the absence of pancreatic enzymes results in...

malabsorption and steatorrhea or undigested fat in stools

Treatment of CF

antibiotics to treat respiratory infections and pancreatic enzyme replacement to improve absorption and decrease weight loss

Diet for a client with CF

high in carbohydrates, high in protein, moderate in fat; extra salt is allowed; supplemented vitamins A, D, E, and K

Pancreatic enzymes are given...

with each meal and snack, and are best tolerated when given in applesauce because it disguises the taste

Gastroenteritis or...

acute diarrheal disease

Treatment of gastroenteritis

determine cause, assess for signs of fluid and electrolyte imbalance, ensure adequate hydration, adequate diet

Treatment of gastroenteritis of children

clear liquids with progression to BRAT diet (bananas, rice, applesauce, and toast)

Treatment of formula for infants with gastroenteritis

half-strength soy formula, full-strength soy formula, and (if tolerated) a return to regular formula

Potassium replacement should be instituted only after...

assessing for the presence of urinary output.

Symptoms of pyloric stenosis

projectile vomiting and a palpable olive-shaped mass in the right upper quadrant

Intussusception

invagination or telescoping of one portion of the bowel into another; most common site is ileocecal valve or where large and small intestines join

Symptoms of intussusception

colicky abdominal pain, sausage-shaped mass in abdomen, passage of currant jelly stools

Treatment of intussusception

conservative measures of air pressure or water-soluble contrast, surgical intervention

Celiac

malabsorptive disorder of proximal small intestine caused by intolerance to gluten

Gluten is found in...

grain of wheat, oats, barley, and rye

Symptoms of celiac

malabsorption, steatorrhea, abdominal distention, muscle wasting (in buttocks and extremities)

Treatment of celiac

replacement of gluten-containing grains with corn, rice, and millet

Rheumatic fever is an autoimmune response to...

Group A beta hemolytic streptococcal infection; affects skin, joints, brain, serous surfaces, and heart; damange to valves of heart (mitral)

In rheumatic fever, appearance of...

hemorrhagic lesions (Aschoff bodies) found in all affected tissues

Symptoms of rheumatic fever

carditis (heart) includes presence of apical systolic murmur, aortic regurgitation, tachycardia, cariomegaly, complaints of chest pain, development of mitral stenosis; polymigratory arthritis (joints) red, swollen, painful joints (larger, knees, elbows, hips, shoulders, wrists); erythema marginatum (skin) red macule with clear center found on trunk and proximal extremities; subcutaneous nodules (serous surfaces) small, painless swellings, bony prominences of feet, hands, elbows, vertebrae, scalp, scapulae; Syndeham's chorea (brain) aimless, jerking movements of extremities; involuntary facial grimacing; speech disturbances; emotional lability; muscle weakness

Minor symptoms of rheumatic fever

fever, arthralgia, elevated ESR, positive C-reactive protein

Supporting evidence of preceding Group A beta hemolytic streptococcal infection includes...

positive throat culture and positive ASLO titer

Treatment of rheumatic fever

eradicating hemolytic streptococcal infection, prevent cardiac damage, make child comfortable, prevent recurrences of Group A beta hemolytic infection

Kawasaki's disease is an...

acute systemic vasculitis; dilation of coronary arteries, which results in aneurysm formation

Symptoms of Kawasaki's disease

high fever that lasts five or more days and fails to respond to antipyretics or antibiotics, redness or bulbar conjunctiva, inflammation of pharynx and oral mucosa, red cracked lips, "strawberry tongue," swelling of cervical lymph nodes; swelling in weight-bearing joints; increased platelet counts and increased coagulation

One of the most notable symptoms of Kawasaki's disease

desquamation that begins at fingertips and toes and gradually spreads, leaving soles and palms red and swollen

Diagnosis of KD

no specific; diagnosis based on symptoms and lab work that reveals decreased number of RBC, increased number of immature WBC, increased ESR

Treatment of KD

IV immunoglobulin and aspirin

Signs of MI in infant or young child

abdominal pain, vomiting, restlessness, inconsolable crying, pallor, and shock

Signs of CHF in infant or child

respiratory distress, tachycardia, and decreased urinary output

Symptoms of aspirin toxicity

tinnitus, dizziness, headache, confusion

The nurse should instruct the parents to discontinue aspirin and notify the MD if the child is...

exposed to influenza or chickenpox

Treatment of scoliosis

use of Milwaukee brace or Boston brace and exercise; surgical correction with Harrington rods and Luque wires

A client treated surgically with Harrington rods should be...

logrolled when turning

Legg-calve-perthes disease

aseptic necrosis of the head of the femur

Symptoms of legg-calve-perthes disease

soreness, aching, stiffness, and appearance of limp on affected side; pain and joint dysfunction most evident on arising or at end of day

Treatment of legg-calve-perthes disease

bed rest, non-weight-bearing activity; abduction brace, leg casts, leather harness sling

Clinical manifestations of muscular dystrophy

delayed walking; wide-based waddling gait; lordosis; weak, hypertrophied leg muscles; use of Gower's maneuver to stand erect

Children with Duchenne muscular dystrophy lose the ability to walk by...

9-12 years of age.

Gower's maneuver

child places his hands on his knees and moves his hands up his legs until he's standing erect

Wims tumor (nephroblastoma)

renal cancer; confined to one side; firm and nontender; encapsulated, responsive to chemotherapy

With a wilms tumor the nurse should not...

palpate the abdomen

Symptoms of leukemia

anemia, fatigue, lethargy, fever, joint and bone pain, pallor, petechiae, enlargement of spleen, liver, and kidneys

Acute lymphoid leukemia is most prevelant in...

males 1-5 year of age

Treatment of leukemia

cytotoxic drugs and possible bone marrow transplantation

Osteogenic sarcoma

most common site is epiphyseal plate of long bones, particularly the femur

Managment of osteosarcoma

amputation of affected extremity and intensive chemotherapy

Salicylate, or aspirin overdose, results in...

an acid/base imbalance.

Symptoms of salicylate overdose

nausea, vomiting, dehydration, tinnitus, hyperpnea, hyperpyrexia, bleeding, convulsions, coma

Treatment of salicylate overdose

removal through emesis, lavage, activate charcoal; sodium bicarbonate transfusions to correct metabolic acidosis, vitamin K to control bleeding, diazepam to control seizures

Initial drug levels for acetaminophen overdose are drawn...

4 hours after the drug is ingested, but treatment should begin before the lab value is back

Treatment of acetaminophen overdose

IV acetylcysteine; plasma levels of 300 mcg/ml occuring 4 hours after ingestion or 50 mcg/ml occuring 12 hours after ingestion are associated with hepatotoxicity

Lead poisoning results in...

irreversible damage to the brain

Lead poisoning affects the...

hematopoietic, renal, and neurological systems

Low-dose lead exposure symptoms

impulsivity, hyperactivity, distractibility

High-dose lead exposure symptoms

mental retardation, paralysis, blindness, convulsions, and death

Treatment of lead poisoning

Chelation therapy with calcium disodium edetate (EDTA), calcium disodium versenate (Versenate), British anti-Lewisite (BAL/Dimercaprol), and Succimer (orally)

The client receiving Versenate should be assessed for signs of...

cerebral edema

Treatment of cerebral edema

IV mannitol or dexamethasone

Symptoms of iron poisoning

vomiting of blood and blood in stools; if left untreated, restless, hypotensive, tachypneic, cyanotic; hepatic injury, coma, death within 48-96 hours after ingestion if left untreated

Treatment of iron poisoning

emesis or gastric lavage; severe cases require chelation therapy with deferoxamine

CF affects the...

exocrine glands

The child with Syndeham's chorea has...

facial grimacing, jerking movements of the extremities, and rapidly changing mood.

ABCD assessment

airway, breathing, circulation, deficits

Only relief of airway obstruction and care of sucking wounds would take priority over the immediate control of...

bleeding.

Deficits include...

fractures, burns, wounds, and neurological injuries

Symptoms of partial obstruction of airway

noisy breathing and coughing

Clients who need airway management

scores less than 8 on GCS, maxiofacial injuries, aspirated, inhalation injuries from burns

A client with a partially obstructed airway should be encouraged to...

cough forcefully.

Always provide C spine immobilization before...

opening the airway of any client with undeteremined or suspected neck injuries

RR adults

12-20

RR children

15-30

RR infants

28-50

Tourniquets or inflated blood pressure cuffs are applied to an extremity only if...

hemorrhage cannot be controlled by direct pressure; should be loosened periodically

Infusion of LR helps...

restore circulation and allows time for blood typing and screening.

Resuscitative efforts continue until the client has a serum lactic acid level lower than...

2.5 mmol/L within 24 hours after the injury and there are no further signs of hemorrhage.

To test for responsiveness, note AVPU

alertness, verbal stimuli, pain, unresponsiveness

Rapid head-to-toe approach for trauma after ABCD, includes DCAP--BTLS

deformities, contusions, abrasions, punctures or penetrations, burns, tenderness, lacerations, swelling

Coup (site of impact) injuries occur in the...

frontal area of the brain.

Contrecoup injuries occur...

away from the site of impact (frontal and temporal areas of the brain).

The use of opiates for a client with a head injury is...

contraindicated because they cause CNS depression.

Flail chest

unequal chest movement

Blood tends to collect in these areas

anterior abdomen, flanks, back, genitalia, and rectum

Cullen's sign

ecchymosis around umbilicus; indicates retroperitoneal bleeding

Turner's sign

ecchymosis on either flank; indicate retroperitoneal bleeding

Ballance's sign

with client lying on left side, right flank is percussed, resonance indicates rupture of spleen

Kehr's sign

pain in left shoulder is seen in client with ruptured spleen

Pain in right shoulder indicates...

lacerations of the liver

Do not try to insert an NG if there is...

suspected skull fracture.

Vomiting is never induced in a client who has ingested...

corrosive or petroleum distillates.

Management of a client with a sting includes...

removing stinger and washing area with soap and water; discourage from scratching because it releases histamine; oral antihistamines and analgesics

In anaphylaxis or severe allergic reaction, give...

epinephrine and massage the site to speed absorption

Venomous snake bites is a medical emergency and the client should...

lie down; constricting items should be removed; affected area immobilized below the level of the heart; antivenin given (most effective when given within 12 hours of snake bite)

Corticosteroids are contraindicated in the first...

6-8 hours after bite because they can interfere with action of antivenin.

Symptoms of antivenin allergic reaction

feeling of facial fullness, itching, rash, and apprehension; followed by tachycardia, dyspnea, hypotension, and shock

Nerve agents

Tabun; Sarin; Soman; VX

Symptoms of nerve agents

salivation; lacrimation; urination; defecation; gastric emptying; pinpoint pupils (everything looks dark); seizures

Treatment of nerve agents

atropine (will not reverse miosis); Pralidoxime chloride; benzodiazepines for seizure control

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