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.
Cleft palate repair places the infant at risk for airway compromise.
The client is at risk for swelling and bleeding, which can easily obstruct the oral and/or nasal airway.
As the nurse, your priority is to maintain an adequate airway, ensure sufficient oxygenation
Be prepared for possible intubation
A fine maculopapular rash indicates a hypersensitivity reaction.
You must assess the client to ensure that an anaphylactic reaction is not in progress.
This can impact the client’s airway; therefore, this client is the priority concern
SubQ injection sites include the abdomen, thigh, upper arm, and lower lateral back.
Heparin is preferred in the abdomen
The appropriate need should be a 25-27 gauge
Aspiration is not necessary for SubQ injections and should be avoided
The nurse should advise the “Parent” to provide the school nurse with an inhaler, spacer, prescription, and directions for use, NOT the teacher, should the child have an acute asthmatic episode at school.
Diseases requiring airborne, precautions include, but are not limited to:
Measles
SARs
Varicella
Disseminated herpes zoster
TB
When a client is admitted for another physical problem, the nurse many times becomes the case finder and must be alert for subtle symptoms of an alcohol related problem.
The client experiencing tremors, elevated body temperature, nocturnal leg cramps, and reporting pain are all symptoms associated with an alcohol related problem.
Increasing pain and pressure for a patient with a cast may be indicative of compartment syndrome and can be a medical emergency
A health care proxy is not authorized to make financial decisions for the client. A durable power of attorney for finances, which is a person who has been authrozied to conduct financial transactions are allowed to make those decisions if the client is incapacitated.
Before notifying the health care provider, the nurse should obtain the blood glucose to determine if hypoglycemia is the cause of the client’s symptoms
Rebound hypoglycemia can occur when the TPN is stopped abruptly.
COAL: Cane Opposite Affected Leg
Toe-touch weight bearing is when the affected side is used for balance not for anything else.
Crutches should not go all the way up to the axilla
Hypernatremia can lead to neurologic changes, such as seizures, loss of consciousness, lethary, and hyperreflexia
A childe experiencing hypernatremia will be oliguric, it is important to weigh all diapers
Compressions with two rescueres is 30:2 while for an infant is 15:2
A newly admitted client with a lymphoms in the upper neck could be putting pressure on the client’s airway and should be assessed first.
In Hodgkin lymphoma, cancer cells develop in the lymph nodes and glands, primarily in the neck region
It is expected to see enlarged nodes on the neck
The nodes will be firm, painless, and freely movable upon palpation
Alzheimer disease is commonly characterized by progressive deterioriation of cognitive functioning.
The nurse must ensure safety and decrease sensory overload, which can increase anxiety and confusion.
Orienting to the unit will help, but the client must first have decreased anxiety
The first priority in a case of increasing intracranial pressure is to notify the physician so definitive treatment can be started
Fibrinolytic therapy is only given in the first few hours after a stroke, not 24 hours later.
Mannitol is a specific hypertonic solution which quickly pulls excess water from tissues to decrease dangerous swelling in the body
Raising the head of bed at 30 degrees will help use gravity to promote venous outflow and reduce pressure in the brain
The client displays decreased ability to problem solve, psychomotor deficits, and social isolation = depression. A regular daily routine of scheduled activities provides structure and decreases the amount of problem solving required
Participating in activities will increase self-esteem and assist the client to engage with others
Allowing the client time to get acclimated is a do nothing answer
Taking deep breaths hyperoxygenates the clients lungs and prevents anoxia during suctioning of a laryngectomy tube
The nurse is expected to receive and transcribe health care provider prescriptions when appropriate
RA is a chronic, autoimmune, inflammatory disorder marked by symmetrical joint symptoms and often is accompanied by extraarticular findings
Joint pain and morning stiffness that lasts longer than 60 min to several hrs
OA is a noninflammatory, localized disease that is often asymmetric, affecting joints on one side of the body as opposed to pairs.
Joint stiffness upon arising that recedes after 30 min
Stiffness occurs after periods of unchanged position or rest
Gout, is characterized by urate crystal deposits.
Joint pain, swelling, touch sensitivity that typically occurs at night
Progressive joint degeneration from OA
Cartilage becomes softer and less elastic
Cartilage at joint edges develops osteophytes and joint surfaces become uneven which affects stress distribution and causes reduced motion
Osteomyelitis is an infection invading the bone
The nurse anticipates the client’s surgical incision will be located in the inner aspect of the upper lip and gingiva, which allows access to the nasal cavity
For transsphenoidal approach tp hypophysectomy
Cushing disease is related to altered hormone secretion due to excess glucocorticodis
The posterior pituitary gland function may be disrupted due to manipulation during surgery
Resulting in transisent diabetes insipidus of several days duration
CSF leak may occur due to surgical entry into the sella turcica through the sphenoid sinuses
This can also lead to infection of the meninges, or meningitis
Stool softener is indicated for care for this client
Analgesic medications may cause constipation and straining at stool
The client should avoid straining to defecate because increased pressure on the surgical site may cause a CSF leak
Saline rinses and coo mist vaporizer may be prescribed; tooth brushing is usually avoided until the incision is well healed
Serum lithium levels should be monitored frequently,
Early signs of toxicity include N/V, diarrhea, tremors and twitching
Late signs are ataxia, confusion, seizures, coma
When a CVAD becomes disconnected the nurse should immediately clamp the CVAD to prevent further air from entering the client’s circulation