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Terms in this set (114)

Systemic inflammatory response syndrome (SIRS)
Occurs when the body undergoes a major insult (trauma, infection, burns, hemorrhage, multiple transfusions)

The HR, RR, temperature, and WBC are increased

S/s:
∙ Temp: >100.4 or <96.8
∙ HR: >90
∙ RR: 20/min or pCO2 <3 mmHg
∙ WBC: >12,000 or <4,000
Sepsis
SIRS + infectious source like pneumonia or UTI
Septic Shock
Severe sepsis + hypotension despite fluid resuscitation
Multiple Organ Dysfunction (MODS)
Septic shock + multiple organ system damage (acute respiratory distress syndrome, acute kidney injury, low platelets)
The nurse has received report on the following clients. Which client should the nurse assess first?
1. Client with 4 hours postoperative colon resection who has a blood pressure of 90/74
4. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min

Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and early shock.

Kussmaul breathing would be EXPECTED in a client with diabetic ketoacidosis!
Kussmaul breathing
Regular but rapid, deep respirations
Bishop Score
System for assessment + rating of cervical favorability and induction of labor

A score >8 in nulliparous women usually indicates that induction will be successful
Malignant Hyperthermia
Rare but life-threatening inherited muscle abnormality that is triggered by inhaled anesthetic drugs + the muscle relaxant succinylcholine used to induce general anesthesia
What diseases are African American women at higher risks for?
∙ Cervical cancer - higher among Hispanics, American Indians, + African americans
∙ HTN
∙ Ischemic stroke
What drugs are commonly associated with orthostatic hypotension?
∙ Most antihypertensive meds
∙ Antipsychotics
∙ Diuretics
∙ Vasodilators
∙ Narcotics
Heart Auscultation
Aortic: 2nd ICS to the right sternal border

Pulmonic: 2nd ICS to the left sternal border

Erb's point: 3rd ICS to the left sternal border

Triscupid: 5th ICS to the left sternal border

Mitral: 5th ICS at the mid-clavicular line AKA apical pulse!
Necrotizing enterocolitis
Life-threatening complication in premature infants due to underdeveloped intestine + gut immunity

∙ Measuring abdominal girth daily is important to assess for worsening distention
The nurse is caring for a 68 year old male client following a laparoscopic cholecystectomy 8 hours ago. The client has not urinated since surgery. Which would be the most appropriate initial intervention?
Help the client out of bed.

Urinary retention after surgery is common and often made worse by existing benign prostatic hyperplasia in older men (up to 50% of men over 60 have an enlarged prostate).
Grapefruit
Drugs that are metabolized by the same pathway would not be metabolized, resulting in higher drug levels and serious side effects

Calcium channel blockers + grapefruit = severe hypotension

Statins + grapefruit = myopathy
What vaccines contain live viruses and are contraindicated in pregnancy?
∙ The influenza NASAL spray
∙ Measles mumps and rubella (MMR)
∙ Varicella
Inactivated vaccines
∙ Tetanus, diphtheria, and pertussis (Tdap)
∙ Influenza
Lead toxicity
Leads to severe complications of neurological system like developmental delays, cognitive impairment + seizures.
Nitrazine pH test strip
Indicates whether membranes have ruptured
∙ Blue is positive result and indicates rupture
∙ Yellow or green is negative and membranes are intact
Allen's Test
Done to determine the patency of the ulnar artery usually done before collecting ABG to assure adequate circulation

1. Make a tight fist
2. Occlude the radial and ulnar arteries using firm pressure
3. Open the fist; palm will be white if both arteries are occluded
4. Release the pressure and the palm should turn pink within 15 seconds indicating potency (positive Allen's test)
When do preterm infants require iron supplementation?
By age 2-3 months, when maternal iron stores are depleted
Delirium
Suddent onset with fluctuating mental status and inattention with altered LOC (confusion), lethargy
Amnesia
Affects short and long term memory loss, either induced by a drug or as a result of trauma or underlying physical/psychological disease
Toxic megacolon
Common, life-threatening complication of inflammatory bowel disease often seen in ulcerative colitis

∙ S/s: abdominal pain/distention, bloody diarrhea, fever, signs of shock
Tx of Bradycardia with one of these symptoms (hypotension, signs of shock, acute mental changes, acute heart failure, chest discomfort)
1. Treat with IV atropine
2. If that doesn't work, transcutaneous pacing or IV dopamine or epinephrine
Duchenne muscular dystrophy (DMD)
The replacement of muscle fibers with connective tissue that affect muscles of the lower extremities first
∙ Lack of protein caused dystrophin needed for muscle stabilization
∙ Gower sign (using hand to rise from a squat or chair)
∙ X linked (carried by females and affects males)
∙ Diet should reduce risk for constipation from immobility (fluids, whole grains, fruits, vegetables)
∙ No cure, most children wheelchair bound by adolescence and die from age 20-30 from respiratory failure
∙ Remove throw rugs
An experience nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of PRBCs to be hung over 3 hours. Which statement by the graduate nurse indicates correct rationale for asking the client to void prior to starting the transfusion?
If a transfusion rxn occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs.

An acute hemolytic transfusion rxn is life-threatening caused by blood incompatibility. The transfusion should be stopped and a fresh urine specimen should be collected and sent to the lab to analyze for hemolyzed RBCs. Asking the client to void prior to starting the transfusion helps ensure that any urine specimen collected after a rxn is reflective of the body's physiological processes after the blood transfusion.
Which client should the charge nurse assign to the room closest to the nurse's station?
Client with gastroenteritis and dementia who wanders.

This client presents the greatest safety risk, which includes potential for falls and fluid and electrolyte imbalances.
The nurse is assessing a 70 year old client with a long hx of type 2 diabetes mellitus for sudden, severe nausea, diaphoresis, dizziness, and fatigue in the ER. Which hospital protocol would be the most appropriate to follow initially?
Myocardial infarction

Women, the elderly, and clients with a hx of diabetes may not have classic heart attack symptoms.

Instead they can present with: N/V, indigestion, diaphoresis, dizziness, and fatigue.
The nurse is caring for an intubated client whose oxygen saturation begins to drop. What action should the nurse take first?
Auscultate the lung sounds bilaterally.

Proper placement of the endotracheal tube is essential for adequate ventilation in intubated clients. If the tube becomes displaced in the hypopharnyx, hypoxemia can result.
Kawasaki Disease
Systemic vasculitis of childhood that presents with >5 days of fever, nonexudative conjunctivitis, lymphadenopathy, mucositis, hand + foot swelling and a rash.

∙ Tx: IV immunoglobulin and aspirin to prevent coronary artery aneurysms
Neonatal abstinence syndrome
A neonate born to an opioid dependent mother experiences opioid withdrawal within 24-48 hours with irritability, jitteriness, high-pitched cry, sneezing, diarrhea, vomiting and poor feeding.
Bell's Palsy
Inflammation of cranial nerve VII (7, facial) facial muscle weakness.

∙ Inability to close eyes + drooping of eyelids
∙ Loss of nasolabial folds + drooping of lower lip

Wear a patch at night to protect exposed eye, chew on unaffected side, maintain good oral hygiene.
The nurse cares for a client with type 1 diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?
Take the BP sitting and standing.

Autonomic neuropathy is nerve damage to the autonomic nervous system, the system responsible for involuntary body functions such as BP, HR, perspiration, sexual function and digestion.
Risk factors for colorectal cancer
Family hx of inflammatory bowel disease, obesity, diet high in red meat, smoking, alcohol
Amyotrophic lateral sclerosis (ALS, Lou Gehrig disease)
Causes progressive motor neuron degeneration that leads to progressive muscle weakness, twitching + muscle spasms, difficulty swallowing, difficulty speaking and respiratory failure
∙ No cure, survive only 3-5 years
Left to right heart shunts
(patent ductus arteriosus, atrial septal defect, ventricular septal defect)
Result in pulmonary congestion, causing increased work of breathing and decreased lung compliance

∙ S/s: tachypnea, tachycardia, diaphoresis, heart murmur or extra heart sounds, increased metabolic rate with poor weight gain
Right to left heart shunts
(Tetralogy of Fallot, transposition of the great vessels)
Impede pulmonary blood flow and cause cyanosis

∙ Expect low O2 (65%-85%) in TOF until defect is surgically repaired
∙Clubbing of fingers
∙ Poor oxygenation can cause polycythemia
A home health nurse is visiting a client who underwent right-sided mastectomy with lymph node removal. The client is concerned about swelling in her arm on the affected side. Which instructions should the nurse discuss with the client?
Lymphedema is the accumulation of lymph fluid in the soft tissue.

∙ Massage the area
∙ Compression sleeves
∙ Elevation of arm above the heart
∙ Isometric exercises
∙ Avoid venipuncture in that arm
A client with Alzheimer disease is found slumped over the lunch tray on the bedside table, coughing violently with emesis visible in the back of the throat. The client has a pulse of 135/min, respirations 32/min, and oxygen sat 85%. The client also has circumoral cyanosis and decreased level of consciousness. Place the nurse's action while awaiting arrival of the rapid response team in priority order.
1. Place client in high Fowler's position
2. Perform oropharyngeal suctioning
3. Administer 100% O2 by nonrebreather mask
4. Assess lung sounds
5. Notify the HCP
Vaccinations required for 6 months and 12 months
6 months: Hep B, DTaP, RV, Hib, IPV, PCV

12 months: MMR, VZV, Hep A, PCV, Hib
Prevention of ventilator-associated pneumonia
∙ Elevating HOB
∙ Avoid gastric over-distention (high residuals)
∙ Maintaining endotracheal cuff pressure of at least 20 cm H2O
∙ Daily assessments for extubation readiness
∙ Oral care with chlorhexidine
Who should take prophylactic antibiotics prior to dental procedures to prevent infective endocarditis?
Clients with any form of prosthetic material in their heart valves or who have unrepaired cyanotic congenital heart defect or prior hx of infective endocarditis
In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which actions should the nurse expect to implement?
∙ Administer K+ supplement when serum potassium is 3.5-5.0
∙ Monitor fingerstick or serum blood glucose every hour
∙ Start infusion of dextrose 5% water when blood glucose is <250 mg/dL
Endovascular abdominal aortic aneurysm repair
Minimal invasive procedure that places a sutureless aortic graft inside the aortic aneurysm via femoral artery

∙ Monitor groin puncture sites, peripheral pulses, urine output and kidney function

∙ Monitor for graft leakage: pain in the back, pelvis or groin, ecchymosis of the groin, scrotum, or penis, tachycardia, weak or absent peripheral pulses, decreasing hematocrit and Hgb, increased abdominal girth, decreased UO
Two days after surgical debridement for a pressure ulcer, the client develops new-onset confusion, a temp of 101 F, BP 74/48 mmHg, pulse 110/min, respirations 28/min, and oxygen sat 88% on room air. Place the prescribed interventions in the order the nurse would perform them.
Hypoxemia, hypotension and increased temp.

1. Adminster O2 using a non-rebreathing mask
2. Assess lung sounds
3. Increase 0.9% IV NS rate from 75ml/hr to 200 ml/hr
4. Administer acetaminophen every 6 hours as needed
5. Reasess a full set of VS
Pharmacologic nuclear stress test
Utilizes vasodilators (adenosine, dipyridamole) to stimulate exercise when clients are unable to tolerate continuous physical activity or if their target heart rate is not achieved by exercise alone

Radioactive dye is injected so a special camera can produce images of the heart to see if there is adequate coronary perfusion
∙ Do not eat, drink or smoke on the day of the test (NPO 4 hours before)
∙ Avoid caffeine + decaffeinated products 24 hours before test
∙ Do not take theophylline, diabetic meds, nitrates, dypiridamole and beta blockers 24 hours prior
Sjogren's syndrome
Chronic autoimmune disorder where moisture-producing exocrine glands of the body are attacked by WBC, commonly the salivary and lacrimal glands leading to dry eyes and dry mouth
Systemic lupus erythematosus
Autoimmune disorder (body's immune system attacks body tissues) that result inflammation + damage to body parts
∙ Common s/s: painful/swollen joints, extreme fatigue, skin rashes + kidney problems
∙ Treated with corticosteroids therefore susceptible to infection
∙ Physical + emotion stress can exacerbate SLE
∙ Avoid sunlight
Why should clients with HTN not take OTC medications?
They can increase BP
Ischemic stroke
Loss of brain tissue perfusion due to blockage in blood flow, elevated BP is expected (as long as it is <220/120) and may be a protective measure to maintain tissue perfusion and autocorrects within 24-48 hour
Care of a client with enteral feedings
Gastric residual volumes are checked q4h with continuous feeding or before each intermittent feeding and med administration to assess clients risk for aspiration
∙ Holding feeding for residual volume >100 isn't necessary as long as the client is asymptomatic
∙ Aspirated residual volume should be returned to the stomach!
∙ Gastric pH should be acidic (<5)
∙ Flush tube before + after bolus intermittent feeding with sterile water
Administering medications through feeding tube (nasogastric, gastrostomy)
∙ Determine if meds come in liquid forms
∙ Crush each med separately before administering
∙ Flush tube with sterile water before and after each med
∙ Don't mix with enteral feedings - creates thick consistency that clogs tube
Appropriate play
Toddler: Stacking blocks
Preschool: Providing crayons to draw noses on face masks
School age: Puzzles
Adolescent: Maintaining contact with peers
Performing a well-child assessment on a 2 month old sleeping client
1. Auscultate heart and lungs
2. Palpate fontanels
3. Percuss abdomen
(Palpation and percussion are performed together in a head-to-toe direction
4. Assess pupillary response
(Traumatic procedures should be performed near the end of assessment)
5. Moro reflex
Catatonia
∙ Immobility
∙ Mute
∙ Bizarre postures
∙ Extreme negativism
∙ Waxy flexibility
∙ Staring
∙ Stereotyped movements, prominent mannerisms, or grimacing

Clients with catatonic schizophrenia are unable to meet their own needs for fluids, food, movement, and elimination and need assistance in perform basic ADLs.
The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care?
Obtaining equipment and cold fluids for induction of therapeutic hypothermia.

Neurologic injury is the most common cause of mortality inclines who have had cardiac arrest. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours improves this, and is indicated in all clients who are comatose or do not follow commands after resuscitation.
Which pediatric respiratory prevention in the emergency department is a priority for nursing care?
Client with an acute asthma exacerbation but no wheezing

Inability to hear any breath sounds or wheezing in an acute asthma client is an ominous sign and requires emergency intervention.
How do you treat severe asthma exacerbations?
1. Oxygen
2. Short acting beta agonist (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes
3. Systemic corticosteroids (methylprednisone)
What is administered to treat anaphylactic shock?
Diphenhydramine, IM epinephrine, inhaled beta agonists, and methylprednisone
Tumor lysis syndrome
Rapid lysis of cells and the resulting release of intracellular potassium + phosphorus into bloodstream. Destruction of cellular nucleic acids leads to hyperuricemia. Phosphate binds to calcium producing calcium phosphate but lowers serum calcium levels. Calcium phosphate and uric acid deposit into the kidneys and cause renal injury.

Increase in uric acid, potassium, and phosphate levels with decreasing calcium levels.

Tx: IV hydration and allopurinol
Peripheral artery disease (PAD)
Risk factors: diabetes, HTN, tobacco use, older age, high cholesterol level, CAD, ischemic stroke

S/s: intermittent claudication, hair loss, cool dry shiny skin, decreased peripheral pulses, thick brittle nails, arterial ulcers that form at the most distal ends of the body - small, circular, deep ulcers
An elderly client with sepsis has a BP of 96/46 mmHg, pulse 100/min, and respirations 28/min. Pulse oximetry shows 95% on nasal oxygen at 3 L/min. The client remains hypotensive after 2 fluid challenges with NS. Two hours later the SPO2 is 86%. What is the nurse's first action?
1. Increase oxygen flow rate.
2. Notify the HCP of the drop in saturation.
3. Reposition the pulse oximeter sensor.

When pulse oximetry readings are altered, the nurse must determine if changes are associated with decreased perfusion, the effect of vasoactive drugs, excessive movement, or improper sensor placement and fit. The nurse can THEN take appropriate action.
Ankylosing spondylitis
Inflammatory spinal disease characterized by back pain and morning stiffness that improves with exercise/activity. Can limit chest wall expansion leading to hypoventilation.

∙ Promote extension of spine with proper posture, daily stretching
∙ Breathing exercises
∙ Manage pain with moist heat, NSAIDS, inflammatory meds
A postoperative client who is receiving enteral feedings via a nasoenteric tube becomes dyspneic with a productive cough, and the nurse auscultates crackles and diminished breath sounds in lung bases. Which action is appropriate at this time?
Check marked insertion depth of the tube.

Nasoenteric tubes can become dislodged, causing the tube to enter the stomach or lungs. Feedings should be stopped immediately and tube placement checked if client develops signs of aspiration.
Cauda equina syndrome
Disorder that results from injury to the lumbosacral nerve roots (L4-L5) causing motor and sensory deficits

S/s: lower back pain, inability to walk, saddle anesthesia, and bowel and bladder incontinence

Medical emergency
Abdominal aortic aneurysm
Blood filled bulge in the abdominal aorta caused by leaking in the vessel wall due to increased pressure

S/s: acute abdominal pain radiating to the back, hemorrhagic shock
Peritonsillar abscess
Serious complication that results from tonsillitis

S/s: muffled voice, trismus (inability to open mouth), pooling of saliva, and deviation of the uvula to one side
A client on fall precautions is found on the floor by the bed when the UAP makes hourly rounds. Place the actions the RN should take in appropriate order.
1. Assess for presence of adequate pulse
2. Inspect the client for injuries
3. Get help and move the client to the bed
4. Notify the client's HCP
5. Complete an incident report

The need for immediate resuscitation should be assessed first
Sickle Cell Crisis
Priority is to give IV fluids before oxygen to reduce blood viscosity and restore perfusion.

∙ Elevated bilirubin due to hemoglobin breakdown
∙ Elevated reticulocytes in response to the anemia
∙ Low hemoglobin
∙ Hyperkalemia from bursting of RBC

Splenic sequestration crisis: occurs when large number of "sickled" cells get trapped in the spleen, causing splenomegaly - life-threatening can lead to hypovolemic shock
Myasthenia gravis
Autoimmune disease that involves reductions of acetylcholine receptors in the skeletal muscles

∙ Administer anti cholinesterase drugs before meals
∙ Semi-solid foods are preferred
∙ Should receive flu and pneumonia vaccine
When admitting a client who had an anterior wall ST-elevation myocardial infarction the cardiac step-down unit, which intervention should the nurse perform first?
2. Attach the cardiac monitor to the client
3. Auscultate heart and breath sounds

Dysrhythmias are the most frequent complication following MI, most commonly V-fib
The nurse cares for a client diagnosed with type I diabetes who came to an emergency department with the acute complication of diabetic ketoacidosis. After checking the blood glucose, which prescription should the nurse implement first?
3. Prepare an insulin drip for IV infusion as prescribed
4. Start an IV line and infuse NS as prescribed

Hyperglycemia causes osmotic diuresis and clients are severely dehydrated
Which nursing instruction is the highest priority when teaching a 38-year-old female client newly diagnosed with stress incontinence?
1. Coaching related to Kegal exercises
2. Importance of voiding every 2 hours

The highest priority is to prevent skin breakdown and UTIs through bladder trading.
Risk factors for breast cancer
Non-modifiable risks:
∙ Female sex and age >50
∙ First degree relative with hx or breast cancer
∙ BRCA and BRCA2 genetic mutations
∙ Personal hx of endometrial or ovarian cancer
∙ Menarche before age 12 or menopause after age 55

Modifiable risk factors:
∙ Hormone therapy/taking oral contraceptives
∙ Postmenopausal weight gain and obesity as fat cells store estrogen
∙ Hx of smoking + alcohol consumption
∙ Dietary fat intake
∙ Sedentary lifestyle
A client presents to the emergency department with alcohol intoxication. Assessment shows nystagmus, ataxia, and confusion. The client's breath smells of alcohol. Which prescription from the HCP should the nurse implement first?
2. D5 1/2 NS
4. Thiamine

Clients with alcoholism can have hypoglycemia. They can also have thiamine deficiency r/t to poor nutrient intake and alcohol-induced suppression of thiamine absorption. Thiamine deficiency can lead to Wernicke encephalopathy and left untreated can lead to death or Korsakoff psychosis.
Which steps should the nurse take to decompress the stomach for a client with abdominal distention + vomiting after insertion of a large-bore NG tube?
∙ Use an adaptor to connect main NG lumen to suction tubing
∙ Leave the blue pigtail air vent open to air
∙ Flush the tubing with water regularly
The nurse in an outpatient clinic cares for a client with Addison's disease who has been taking hydrocortisone 20 mg/day for the last 8 years. Which client data is most important to report to the HCP?
1. Development of moon face
3. Low-grade fever of 100 F
4. Weight gain of 6 lb in 3 months

In a client taking corticosteroids, it is imperative to notify the HCP if s/s of infection occur b/c the anti-inflammatory properties of these drugs can mask infection that can spread quickly in this type of immunocompromised client.
A 62-year old client was admitted to the telemetry unit after having an acute MI 3 days ago. The client reports to the nurse that the left calf is very tender and feels warm to the touch. Which assessment by the nurse is priority?
1. Ask the client how long the leg has been tender and warm.
3. Check VS including pulse oximetry.
4. Complete neurovascular assessment on lower extremities.

These are all assessments that the nurse should collect to report to the HCP but are not as high of a priority or as relevant to the specific situation the client is currently experiencing.
Sepsis neonatorum
Sepsis in a newborn is life-theatening

S/s: fever, lethargy, refusal to feed

Broad-spectrum antibiotics should be started immediately after obtaining blood, urine, and cerebrospinal fluid cultures
Hirschsprung disease
Lack of specialized nerve cells in portions of the distal large intestine therefore the internal sphincter can't relax.

∙ Can't pass meconium
∙ Distended abdomen
∙ Bilious emesis
∙ Thin, ribbon like stools
The nurse is providing discharge teaching for a client who suffered full-thickness burns. Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury?
1. I should avoid using lotion to prevent infection.
4. I will wear pressure garments to minimize scars.

The rehabilitation phase begins after the clients wounds are fully healed.

∙ Massaging with water-based lotion alleviates itching and minimizes scarring
∙ Pressure garments prevent hypertrophic scars and promote circulation
Otitis media
Inflammation or infection of the middle ear from dysfunction of the Eustachian tube that typically occurs in children under age 2

Eustachian tubes in young children are shorter, straighter, and fairly horizontal which results in ineffective drainage and protection form respiratory secretions.

∙ Avoid exposure to tobacco smoke due to respiratory inflammation
∙ Discontinue pacifier use after 6 months of age
∙ Obtain all routine immunizations
Initial interventions in emergency management of chest pain
1. Assess ABC
2. Position client upright
3. Apply O2 if hypoxic
4. Obtain baseline vitals including O2 sat
5. Auscultate heart + lung sounds
6. Obtain 12-lead electrocardiogram
7. Insert 2-3 large-bore IV catheters
8. Assess pain using PQRST
9. Medicate for pain as prescribed
10. Initiate continuous ECG monitoring
11. Obtain baseline blood work + chest x-ray
Psoriasis
Chronic autoimmune disease that causes a rapid turnover of epidermal cells

Disease management:
∙ Avoid stress, trauma, infection
∙ Topical therapy (corticosteroids, moisturizers)
∙ Phototherapy
∙ Systemic meds - methotrexate and infliximab
Advanced directives
Used to document a client's wishes, but it is not a medical order. If a client doesn't want CPR, a DNR order should be used.

∙ Two witnesses are required for completion of the advance directive form, cannot be health care providers involved in the care or individuals named as health care proxies in the document
∙ Copy should be given to everyone listed as health care proxies
Growth hormone replacement therapy
Option for children who are not growing according to accepted standards

∙ Start as soon as delays are noted and continue bone growth stops, around 14 in girls and 16 in boys
∙ Despite replacement therapy, child may still be shorter than their peers
∙ SubQ injections
Small-bowel obstruction
∙ Rapid onset of N/V
∙ Colicky intermittent abdominal pain
∙ Abdominal distention

Tx: place client NPO, insert nasogastric tube, administer IV fluids and pain control
Large-bowel obstruction
∙ Gradual onset of symptoms
∙ Cramping abdominal pain
∙ Constipation + lack of flatus
Quadriplegia (tetraplegia)
The lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs usually due to cervical spinal cord injury

Priority assessment is airway + oxygenation
Electrical cardioversion
Procedure in which an electric current is used to reset the heart's rhythm back to its regular pattern

If client is in atrial fibrillation for more than 48 hours, anticoagulation therapy is needed 3-4 weeks before cardioversion as it can dislodge an atrial thrombus and cause a stroke.

If 4 weeks of anticoagulation is not an option, transesophageal echocardiogram (TEE) has to be performed
Trigeminal neuralgia
Sudden, sharp pain along the trigeminal nerve, primarily in the maxillary and mandibular branches. Triggers can include washing the face, chewing food, brushing teeth, yawning or talking.

∙ Drug of choice: carbamazepine (agranulocytosis and infection risk) report fever or sore throat
∙ Use small, soft-bristled toothbrush
∙ Avoid rubbing or facial massage
∙ Soft diet with high calorie content, and chew on unaffected side
∙ Use lukewarm water and avoid beverages or food too hot or cold
Raynaud's phenomenon
Usually triggered by cold exposure.

During a typical episode, fingers constrict and blood flow is impaired, causing the skin to turn pale then blue then to feel numb and cold. As blood flow returns, the skin turns red and a throbbing or tingling sensation is often felt.
Aphasia
Inability to express thoughts and comprehend language due to brain dysfunction and includes both verbalizing and writing
Ventricular septal defect
Left to right shunting

Left side has higher pressure and goes into the right ventricle increasing workload of right side causing pulmonary HTN. Eventually, blood does not go into the lungs, but instead the pressure on the right side increases that results in shunt reversal. This causes more blood to be shunted to the left ventricle, followed by the left atrium, and then back into the lungs (heart failure!)

∙ Tachypnea due to pulmonary volume overload
∙ Diaphoresis indicates infant is exending too much energy during feeding
∙ Assess for congestive heart failure
∙ Holosystolic murmur
Coarctation of the aorta
Obstructive congenital heart defect resulting in decreased cardiac output

∙ Stronger pulses in the upper extremities and diminished pulses in the lower extremities
Nursing interventions for a blood transfusion reaction
S/s: chills, fever, low back pain, flushing + itching

1. Stop transfusion immediately and disconnect tubing at the catheter hub
2. Maintain IV access with NS, using new tubing to prevent hypotension and vascular collapse
3. Notify HCP + blood bank
4. Monitor VS
5. Recheck labels, numbers, and client's blood type
6. Treat client's symptoms according to HCP's prescription
7. Collect blood + urine specimens to evaluate for hemolysis
8. Return blood and tubing set to the blood bank for additional testing
9. Complete necessary facility paperwork to document rxn
The parent of an 11-month child calls pediatric outpatient clinic and tells the nurse that the child was exposed to measles 2 days ago during a family trip to a theme park. What is the best response by the nurse?
Bring the baby into the clinic for the measles, mumps, rubella (MMR) vaccine.

CDC recommends first dose of MMR vaccine be given to children age 12-15 months, however is safe for children <12 months.

Could provide protection if administered within 72 hours of child's initial measles exposure. Immunoglobulin, if administered within 6 days of exposure is also used as post-exposure prophylaxis.
Dumping syndrome
Surgical reduction of gastric capacity can be complicated by dumping syndrome, in which rapid emptying of stomach contents cause fluid shifts + hypotension.

∙ Eat foods high in protein, fat, + fiber
∙ Avoid carbohydrates
∙ Drink fluids BETWEEN meals (30-45 min before)
∙ Lie down after meals
∙ Small, frequent meals
A client is diagnosed with DKA. The client reports frequent urination, thirst, and weakness. The nurse assesses a temp of 102.4, fruity breath, deep labored respirations with a rate of 30/min and dry mucous membranes. What is the priority ND at this time?
1. Deficient fluid volume related to osmotic diuresis
3. Ineffective breathing pattern related to the presence of metabolic acidosis

Hyperglycemia associated with DKA leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. This condition requires rapid correction through infusion of isotonic fluids and poses greatest risk.
Retroperitoneal hemorrhage
PCI via the femoral approach places the client at increased risk for retroperitoneal hemorrhage.

S/s: back pain, hypotension, flank ecchymosis (Grey-Turner sign), hematoma formation + diminished distal pulses can be early signs of bleeding and require immediate intervention.
Autism spectrum disorders
Neurodevelopmental disorders characterized by impaired social interaction + behavior

∙ Provide brief, concrete, and developmentally appropriate communication - children with ASD respond to pictures
∙ Reduce stimulation
∙ Limit physical contact - physical touch + eye contact may activate a stress response
While the nurse and UAP are turning an intubated and heavily sedated client during a bath, the client coughs and expels an endotracheal tube. What is the priority nursing action?
Deliver rescue breathing with a bag-valve mask attached to 100% oxygen

Accidental extubation is a medical emergency. The nurse should immediately provide ventilation and call for assistance to prepare for reintubation.
A client comes to the ER with crushing substernal chest pain. Which interventions should the nurse complete?
∙ Administer morphine
∙ Check BP + HR
∙ Draw blood specimen
∙ Obtain a 12-lead ECG

The nurse should rapidly assess (VS, heart and lung sounds, pain) and intervene (2 large-bore IV lines, morphine, oxygen, nitro, aspirin) for the client with acute chest pain. Upright positioning, obtain 12 lead ECG, chest x-ray and blood work (cardiac markers) and place client on continuous cardiac monitoring.
How to prevent dental caries
Dental caries form when bacteria digests carbohydrates in the mouth, producing acids that break down tooth enamel and cause mineral loss

Cariogenic: refined simple sugars like dried fruit + candy, sugary beverages - fruit juices and soda

Cariostatic (inhibitory effect): dairy products, whole grains, fruit + vegetables, sugar free gum containing xylitol

∙ Rinse mouth with water after meals or snacks
∙ Drink tap water rather than bottled as it has fluoride added
∙ Finish meals with high-protein food
Acute angle-closure glaucoma
Requires immediate medical intervention, IOP increases rapidly and drastically

∙ Sudden onset of severe eye pain
∙ Reduced central vision
∙ Blurred vision
∙ Ocular redness
∙ Report of seeing halos around lights
Open-angle glaucoma
Glaucoma disorders are characterized by IOP due to decreased outflow of aqueous humor, resulting in compression of the optic nerve that can lead to permanent blindness
∙ Gradual loss of peripheral vision
∙ Difficulty adjusting to different lighting
A client admitted to the cardiac care unit with markedly elevated BP + heart failure is receiving a continuous infusion of nitroprusside. Thirty minutes later, the client appears pale with cold, clammy skin and reports being lightheaded. Which is the priority nursing action?
1. Auscultate the client's lungs
3. Measure the client's blood pressure

Auscultation of lung sounds is a common assessment for the client in HF but in this client the signs + symptoms indicate hypotension and make checking the BP a higher priority.
Care for chest and leg incisions from CABG
∙ Wash daily with soap + water
∙ Itching, tingling + numbness around incision is to be expected due to damage to local nerves
∙ Report any redness, swelling, and increase in drainage
∙ Wear supportive elastic hose on legs
Heparin-induced thrombocytopenia
There are 2 forms of heparin induced thrombocytopenia

First form: platelets >100,000 normalizes within a few days

Second form: platelets <40,000 life-threatening! Immediate heparin discontinuation
Agoraphobia:
Social Anxiety:
Agoraphobia is abnormal fear of being helpless in an embarrassing or unescapable situation that is characterized by avoidance of open or public places

Social anxiety is the fear of interaction with other people that brings on self-consciousness, feelings of being negatively judged + evaluated, and as a result leads to avoidance
Pyloric Stenosis
Hypertrophy of the pyloric sphincter that eventually causes complete obstruction
∙ Nonbilious projectile vomiting followed by hunger
∙ Olive-shaped RUQ mass
∙ Weight loss
∙ Dehydration
∙ Electrolyte imbalance (metabolic alkalosis)
Autonomic Dysreflexia
Life-Threatening condition in a client with a T6 or above spinal cord injury.

S/s: severe HTN, headache, nausea, diaphoresis, bradycardia, flushing, and piloerection

Correct the cause: check bowel or bladder distention, remove tight clothing, raise the HOB, check BP if there is a headache
Diverticulitis
When the diverticula is infected or inflamed, care focuses on allowing the colon to rest and inflammation to resolve

NPO status, IV fluids, pain relief via IV meds, preventing increased intraabdominal pressure, preventing intestinal motility (avoid laxatives + enemas)
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