Health Promotion and Maintenance
Adults diagnosed with type 2 diabetes are recommended to have a yearly dilated eye exam to enable assessment of the blood vessels of the retina.
The recommendation for youth diagnosed with type 2 diabetes is a comprehensive dilated exam at the time of diagnosis and an annual dilated exam at the time of diagnosis and annual dilated exams thereafter
Adults between 40 and 60 years should have a glaucoma test every 2 years.
Formula-fed infant excretes pale yellow to light brown stools. They are firmer in consistency than those of the breastfed infant.
Stools of infants fed with breast milk are seedy, and the color and consistency are mustard-like with a sweet-sour smell
Bowel control is usually achieved before bladder control
Voluntary control of anal and urethral sphincters begins at about 18 to 24 months
The cardinal sign of impaction is continuous oozing of liquid stool, with no normal stool.
Oozing occurs as the liquid portion of feces higher in the intestines seeps around the mass.
For septic shock, administering NS at 500 ml/hr is priority to improve the client’s hemodynamic status
Glycemic control is important in sepsis care
Immunizations with live virus vaccines (Measles, mumps, rubella, varicella, and smallpox) are contraindicated during pregnancy because of possible teratogenic effects on the fetus
Inactivated vaccines such as (tetanus, hep B, and influenza) are safe for women who have a risk for developing these diseases.
Women who have not been previously vaccinated against pertussis receive the vaccine during the third or late second trimester
A 4 year old child should receive 4 doses of the IPV
The first dose at 2 months, a second at 4 months, the third dose between 6 and 18 months, and the fourth dose between 4 and 6 years of age
The child should receive 4 doses of PVC13. The first dose at 2 months, a second dose at 4 months, the third dose at 6 months, and the fourth dose between 12 and 15 months
The child should receive 4 doses of HiB. The first dose at 2 months, second dose at 4 months, and the third dose at 6 months, and the fourth dose between 12 and 15 months
The child should receive 2 doses of MMR, the first dose at 12 to 15 months and the second dose between 4 and 6 years of age
For bleeding from the circumcision site, the nurse applies gentle pressure with a sterile gauze pad to stop the bleeding in a short period of time.
The client diagnosed with seasonal affective disorder should use phototherapy beginning in the Fall and continue use until Spring
One intervention to help reduce symptoms is to increase exposure to sunlight
There are devices that mimic natural sunlight, which should be used until the amount of natural sunlight increases with the changing season
The client diagnosed with PKU lacks the enzyme necessary to convert phenylalanine to tyrosine.
Phenylalnine is a type of protein.
PKU results in phheylalnine accumulating in the tissues and that leads to mental deficiencies.
Clients diagnosed with PKU are fed a formula that is low in phenylalanine but contains minerals and vitamins required by the client
Cataract symptoms include blurred vision, photosensitivity, halos around lights, and difficulty seeing at night.
Vision can also seem “cloudy”
Macular degeneration symptoms include blurred vision and reduced central vision
Open angle glaucome symptoms include blurred vision, distorted vision, seeing halos around lights, and tunnel vision.
Nausea may being as early as 4 weeks after the last menstrual period, and usually improves by the end of the 14th week of pregnancy. Nausea is associated with an increase of hCG levels in early pregnancy.
Eating a dry carbohydrate upon waking up in the morning may help decrease nausea
Maintaining a weight within normal limits decreases insulin resistance, which may lower blood glucose levels. Women diagnosed with PCOS are predisposed to weight gain. If the client is overweight, a 10% loss in body weight can result in a more regular menstrual cycle, which can improve one’s chance of becoming pregnant. An example of a 10% weight loss would be if a 150b woman lost 15 lb.
Initial treatment when a DVT has occurred includes bed rest, with the affected leg elevated to decrease interstital swelling and to promote venous return from the leg
Explaining that the memory loss is a result of ECT.
The nurse should have prepared the client by explaining the procedure and associated temporary memory loss and confusion
Asking if the client has had memory problems is a yes/no question is non therapeutic.
Many twins or higher multiples are born prematurely because the uterus becomes overly distended.
Intermittent low back pain is a sign of labor.
Although the urine is dark related to the obstructive process, kidney function is usually not affected in pancreatic cancer
Severe anorexia and dramatic weight loss occur with pancreatic cancer
The nurse should make sure the bladder of the cuff is over the brachial artery in order to compress it during measurement
The nurse should be sure to place the cuff 2.5cm above the antecubital space
The nurse should position the client’s arm at the level of the heart to ensure an accurate reading
For clients with heavy menses, hormonal contraceptives such as birth control pills, injections, patches, and implants significantly reduce menstrual flow and associated cramping, improving the client’s quality of life.
If the client is not physically comfortable, the health assessment will not go as well as it could.
This is the priority. Remember how you conduct the client interview is just as important as the questions you ask
Major health problems can be assessed after physical and psychological comfort are established.