QBANK notes

• Two areas that provide insight into the client’s risk of developing breast cancer include a history of liver disease, which decreases the production of male hormones, and a family history of breast cancer.

• Chest pain is a potential symptom of pneumonia, MI, and pulmonary embolism.

  • The crushing and radiating characteristics of the client’s chest pain are most consistent with MI

• Dyspnea and tachycardia can be expected for a client experiencing pneumonia, MI, and pulmonary embolism.  

  • Tachycardia can be expected due to sympathetic nervous system stimulation

• The client’s pale, sweaty skin is most likely associated with MI. Skin can be diaphoretic in a client with a PE as well, but is typically more flushed or cyantoic. A client with pneumonia is more likely to have hot, flushed skin, and sweating may be due to fever.

• Denial is about protecting self from reality. For example, “that lab result is just a mistake”

  • With displacement, the person takes feelings out on others. For example. “yelling at an uninvolved person after getting bad news

• Scleral Icterus is yellowing of the sclera of the eye. This is an abnormal finding, as the sclera should be white and clear. The newborn’s skin has yellow undertones when it is blanched. This can indicate jaundice which may not be noticable just by looking at the newborn’s skin. Facial bruising can increase hemolysis of rbcs, causing increased levels of bilirubin, which is difficult for the newborn to excrete.

  • A heart murmur auscultated at the left sternal border can indicate a patent foramen ovale, which typically closes spontaneously before 1 year of age.

• The client is at greatest risk for hyperbilirubinemia, due to a gestational age of less than 38 weeks and extensive bruising.

  • Preterm birth is a risk factor for byperbilirubinemia

• The priority concern for the newborn with hyperbilirubinemia is the development of neurologic complications including encephalophaty and Kernicterus, which can lead to cerebral palsy, seizures, and death.

• Semi-Fowler position for a new tracheostomy facilittes respirtion, promotes drainage, prevents edema, and prevents strain on the suture line. Having the clients head turned to one side will also promote drainage; this is the optimal position

• An early sign of acute compartment syndrome is a sudden inability of pain medication to relieve pain

  • Compartment syndrome is a painful and dangerous condition caused by pressure buildup from internal bleeding or swelling of tissuese

• An acute attack of vertigo for a client diagnosed with Meniere disease feels like the room is violently spinning

  • Vertigo and dizziness may cause the client to fall

  • Lying down will prevent injury, and lying on a firm surface and placing pillows on either side of the head will prevent movement of the head, which aggravates vertigo

  • Medications used to tx s/sx include diuretics, antihistamines, antiemetics, and tranquilizers

• If a trachesotomy that was created 18hrs ago was expelled the nurse should use a manual resuscitation bag to ventilate the client while another staff member contacts the resuscitation team

  • Inserting the outer cannula in a new (UNDER 72HR) tracheostomy, it may cause tissue damage because the tract is not matured.

Medications:

• Providing morphine and nitroglycerin are indicated to reduce the chest pain and the shortness of breath, by reducing preload and pulmonary congestion

• IV nitroprusside can causes dizziness, hypotension, and headache

• Inhaled corticosteriods can take up to 3 weeks to achieve maximum effect

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