In Abruptio Placenta, the placenta _______________ from the uterine wall ____________.
Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________.
Multi, 35 (HTN, trauma, cocaine)
How is the bleeding of Abruptio Placenta different from that in placenta previa?
pain and less voluminous in abruptio
If you are the nurse starting the IV on the client with Abruptia Placenta, what guage needle should you use?
18 (in preparation to give blood if necessary)
How often should you measure the vital signs, vaginal bleeding, fetal heart rate during Abruptio Placenta>?
Q5-15 minutes for bleeding and maternal VS, continuous fetal monitoring, deliver at earliest sign of fetal distress
Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa?
When taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER?
the suspected poison
An elderly client is a (high/low) risk for accidental poisoning? What about a school age child?
high - due to poor eyesight, high
Children at highest risk for seizure activity after ingestion are those who have swallowed _____________ and ______________.
Can impaired skin integrity ever be an appropriate nursing diagnosis when poisoning has occurred?
Yes, when lye or caustic agents have been ingested
What instructions do you give to a client taking tetracycline?
Take it on an empty stomach and avoid the sunlight (photosensitivity)
AIDS is trasmissible through what four routs?
blood, sexual contact, breast feeding, across placenta in utero
HIV is present in all body fluids?
Yes, but not transmitted by all, only blood, semen and breast milk
Name the 5 risk groups for AIDS
Homosexual/bisexual men, IV drug users, hemophiliacs, heterosexual partners of infected people, newborn children of infected women
Which 2 classes of drugs are given in combination for HIV sero-positivity?
NRTI's (nucleoside reverse transcriptease inhibitors) and PI's (protease inhibitors)
NRTI (nucleoside reverse transcriptease inhibitors)
an antiviral drug used against HIV (is incorporated into the DNA of the virus and stops the building process; results in incomplete DNA that cannot create a new virus; often used in combination with other drugs)
PI's (Protease inhibitors)
most potent of antiviral meds, inhibit cell protein synthesis that interferes with viral replication, does not cure but slows progression of AIDS and prolongs life, used prophylactically, used in AIDS to decrease viral load and opportunistic infections
What does the physician hope to achieve with NRTI's and PI's for HIV?
A delayed onset of AIDS for as long as possible (usually can delay onset for 10-15 years)
What is the most challenging aspect of combination of drug therapy for HIV disease?
The number of pills that must be taken in 24 hours can be overwhelming. The frequency also makes it hard to remember-an alarm wristwatch is used.
If the AIDS patient has leukopenia they will be on _____________ ________________.
protective (reverse) isolation
Without leukopenia the AIDS patient will be on ____________ precautions.
Standard precautions or blood and body fluid precautions
When the AIDS patient has a low platelet count, what is indicated?
bleeding precautions; No IM's, no rectal temperatures, other bleeding precautions
When do you need a mask with AIDS?
Not usually unless they have an infection caused by an airborne bug
If an AIDS patient's blood contaminates a counter top, with what di you clean?
1:10 solution of bleach and water
Is dietary protein limited in AGN?
Not usually, however if there is severe azotemia then it may be restricted
How can AGN be prevented?
By having all sore throats cultured for strep and treating any strep infections
What is the most important intervention in treating AGN?
Bedrest - they can walk if hematuria, edema and hypertension are gone.
What is the most common dietary restriction for AGN?
Moderate sodium restriction. Fluid restriction is #2 if edema is severe.
What happens to the kidney in AGN?
It becomes clogged with antigen-antibody complexes which then cause inflammation and loss of function.
What are the three adult stages of development called
early adulthood, middle adulthood and later adulthood
Intimacy vs. Isolation
Erikson's stage in which individuals form deeply personal relationships, marry, begin families
Generativity vs. Stagnation
Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service
Ego Integrity vs. Despair
(Erikson) People in late adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be relived
"Time is too short to start another life, though I wish I could," is an example of ___________.
"If I had to do it over again, I'd life my life just about the same," is an example of ____ ____________
If the patient had an AKA they should lie ____________ several times per day.
prone (to prevent flexion contracture
How do you prevent flexion contracture of the knee after BKA?
Remide the patient to straighten their knee constantly while standing
When a stump is wrapped, the bandage should be tightest _____________ and loosest _____________.
distally (far from the center), proximally (neareast to the point)
If after a right BKA, the client c/o pain in his right tow, he is experiencing _____________.
phantom limb sensation (which is normal)
Name ways to toughen a stump so it will not breakdown due to the wear of the prosthetic leg?
push the stump against the wall, hitting it with a pillow
An aneurysim is an abnormal _______________ of the wall of a(n) artery.
widening (it is also weakening)
Which vital signs are most important to measure in clients with aneurysm?
The pulse and blood pressure
An aneurysm will most affect which of the following, the blood pressure or the pusle?
the pulse (many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change.
What activity order is the client with an aneurysm supposed to have?
Bedrest. do not get these people up
If the client with aneurysm is physically unstable, should you encourage turning, coughing and deep breathing?
no, bedrest until the client is stable!
If an aneurysm is ruptured how would you know it?
decreased LOC (restlessness), tachycardia, hypotension - all signs of shock
Is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room?
Yes, if available you can get them into antishock trousers but not if this causes a delay in getting them to the operating room
The post op thoracic aneurysm is most likely to have which type of tube?
Chest tube, because the chest was opened
The post op abdominal aneurysm repair client is most likely to have which type of tube?
NG tube for decompression of bowel
If you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hours?
check the distal extremity (far from center) for color, temperature, pain and PULSE, also document
How do you tell if a client has angina or an MI?
the pain of the two is similar, the way to tell the difference is if nitro and rest relieve the pain. For angina, nitro and rest relieve the pain, for MI, nitro and rest do not relieve the pain
How many minutes should lapse between the nitro pills you take?
5 minutes - take one nitro tab every 5 minutes 3 times, if no relief, call MD
What is the action of nitro?
dilates coronary arteries to increase blood supply (O2 supply) and reduces preload.
What precaution must the nurse take when administering topical nitro paste?
wear gloves, nurse may get a dose of the med
The diagnosis is made when there is a weight loss of _______% or more of body weight.
15 (weigh < 85% of normal body weight), hospitalize if 30% weight loss
A major mental/emotional nursing diagnosis seen in anorexia nervosa is ___________.
Altered body image
What is the top priority in the care of the client with anorexia nervosa?
intake of enough food to keep them alive, have them gain weight
Name the 5 criteria that are recorded on an apgar scale
Cardiac status, respiratory effort, muscle tone, neuromuscular irritability, and color
On the HR criteria an infant scores a "1" if their HR is _________ than 0 and ____________ 100
greater, less than
Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.
Before the client with suspected appendicitis sees the physician what should be avoided?
pain meds, enemas, laxatives, food! NPO
To lessen pain place the client in ___________ position.
fowlers (a sitting position) (also use post op)