Escolar Documentos
Profissional Documentos
Cultura Documentos
To prepare for the exam (whether a subject exam or exit exam) use and have the
following materials/resources available:
6) HESI study notes compiled by faculty and previous ADN students (lab values,
meds, etc.)
7) HESI related powerpoints for remediation and instructional purposes, not from
evolve
1) Become an expert at the nursing process r/t questions, answers, and related
processes
6) Determine areas of weakness in previous HESI exams (via the statistical report
provided after taking the test)
8) Review the rationales on the Practest questions, case studies, and practice test
CD relentlessly (usually start with this first... essentially reverse engineer the
questions starting with the rationales and working backwards)
Super Condensed Portable HESI Study Guide 4
9) Memorize hints, meds, ranges, lab values, etc. as outlined in the HESI study
book (with an intent to not be caught off guard by material you haven't seen
before and to not forego any easy points)
10-A) Block off two weeks or more to constantly review the HESI book
11) Foregoing studying from other non-evolve resources such as the saunders
book temporarily (rationale: HESI test comes from HESI/Evolve related products,
normally).
12) Host/goto HESI review sessions with other students about to take the test
(rationale: If you can teach it, you get a better understanding=proficiency,
eventually)
http://www2.austin.cc.tx.us/adnlev2/Tutoring_Web/Documents/Testtaking.htm
http://portals.elsevier.com/portal/hesi/ProductAction?isbn=9780323055710
https://evolve.elsevier.com/productPages/s_994.html
https://evolve.elsevier.com/productPages/s_1641.html
http://search.barnesandnoble.com/Evolve-Reach-Comprehensive-Review-for-the-
NCLEX-RNExamination/Hesi/e/9781416047759
Super Condensed Portable HESI Study Guide 5
Do 5 HESI case Due 3 HESI case Due 6 HESI case Due 2 HESI case
studies studies studies studies
Note: “Fear” of the unknown only serves us from moving forward. Your self-discipline, commitment to
working hard and faith will help get you through this.
Super Condensed Portable HESI Study Guide 6
The HESI and NCLEX tests use the steps of the nursing process (assessment, nursing
diagnosis, planning, intervention, and evaluation) to evaluate how you critically think
about and apply your knowledge about nursing principles and skills during the care of
patients. Do the following before the test:
1) Review the nursing process and critical thinking. You need to be very familiar
with the stages of the process and the nursing actions associated with each stage,
and be prepared to identify whether a certain action is used in the planning or
evaluation phase of the nursing process.
3) Use an NCLEX study book to familiarize yourself with the type of questions to
expect and review the answers to understand why they are correct. Know the
common electrolyte values and signs of abnormal levels, common drugs. Don't
read things into the questions or assume things that are not part of the question.
After you read the test question only, close your eyes. Think about what the
question said and what you know about it, and only then, look at the answers.
Practice the questions with same time limit used in the NCLEX testing: 90
seconds per question.
1. Reading too much into the questions. Look at what is there, what you know. Unless it
is specified, don't assume that you know the patient's gender, age, diagnoses, situation
or where the interaction is occurring (home, street, nursing unit).
4. Becoming anxious. If you are feeling overwhelmed, discouraged, tired: STOP for a
minute or two. Do deep breathing or relaxation or visualization. Use positive,
affirmational self talk- NO negativity! You need your mental energy to concentrate, just
like you do in the hospital when patient care situations get tough, like severe bleeding or
a code.
5. Be sure to print out the test analysis at the end to have as proof of completion of the
test and to help guide future review work.
Initial = Assess
Essential = Safety
Deadly Words
All
Wholly
Every
Total
Alone
Sole
Lone
Nothing
Always
Forever
Entire
Whole
Completely
Each
Only
Any nobody
Never
None
Everywhere
Dangerous Words– are words are strong words. These are words that are strong
but not as absolute as the “deadly” words.
If you see these words look carefully at the answer. There is a strong chance it is
incorrect:
Super Condensed Portable HESI Study Guide 8
Main
Paramount
Primarily
Inevitable
Eliminate
Regardless
Impossible
Too
Chief
Avoid
Major
Shall
Will rarely
Lack
Safe Words – Are qualified answers or hedging words make answers correct. These
words are usually “safe” to choose:
Usually
Frequently
Potentially
Sometimes
Some
Occasionally
Essentially
Generally
Maybe
Commonly
Seldom
Normally
Almost
Probably
May
Partial
Might
Should
Few
Nearly
Could
Average
Often
Client
Problem/Behavior
UMBRELLA ANSWERS
Problem solving applies to nursing
Assess signs & symptoms
Determining the nursing diagnosis
Evaluating the outcome criteria
OPPOSITES ANSWERS
“High blood pressure”, “Low blood pressure”
“Increase IV drip”, “Stop IV”
“Turn to the left”, “Turn to the right”
When there are two answers that are opposite, the two automatically eliminates the other
two choices but the downside is which of the two opposite answers is correct.
Do not choose these answers, eliminate both, leaving the other two choices to be the
correct answers.
INITIALLY = Assess
ESSENTIAL = Safety
Super Condensed Portable HESI Study Guide 10
Maslow’s Hierarchy
Self-Esteem
Self-actualization
Safety
Physiology
Use Maslow’s Hierarchy to answer your questions. Physiology needs will always be
your first choice when answering a question with the exception of Psychological
questions.
Priority
“What actions take priority”
“What should the nurse do first”
“What should the nurse do initially”
“What is essential for the nurse to do?”
COMMUNICATION
Advising is always incorrect:
“What you really ought to know…..?”
“You shouldn’t have left……..?”
“If I were you I……?”
“What you really should do…..?”
ABSOLUTES
Wrong Answers Right Answers
Qualified answers or heading words make answers correct. These words are usually are
“safe” to choose. “Safe” words are words such as: usually, almost.
HESI: Pharmacology
Half-Life: Time it takes to excrete half the amt of drug from body. Shorter half-life
drugs are given more often – approx. 5 half-lives and drug removed from
body.
Teratogen: Substances that cause birth defects. 1st Trimester all major organs forming.
Weeks 3-8 are most critical. Drugs cross placenta easier in the 3 rd
trimester however. Known Teratogens: Thalomid, Lithium, Coumadin,
Accutane, Dilantin, Tetracycline
Hemolytic Reaction: Happens when patient received wrong blood type (cells lyse and
gluconate (clump together). Often apparent within the first 50 mL of
administration. S/S: Fever, chills, Low back pain, Chest Tightness,
Anxiety. STOP INFUSION IMMEDIATELY!
Therapeutic index: Relationship between the desired effect and toxicity. Therapeutic
effect is the “desired effect”.
Tolerance: Increased amounts of a drug are needed to produce the same effect.
Polypharmacy: Multiple drugs taken at the same time for multiple conditions. This
increases the risk of drug interactions.
Cross Sensitivity: When allergic to one drug, a similar type drug will cause the same
sensitivity. EX: Penicillin and Cephalosporin’s.
Cell-Cycle Specific: Anti-neoplastic drug only works in a “specific” cycle of the tumor-
cell reproduction.
Cell-Cycle nonspecific: Anti-neoplastic drug that works in any cycle of the tumor-cell
cycle.
Redman Syndrome: Caused by infusion VANCOMYCIN too quickly. Must infuse over
60 minutes. S/S: Sudden drop in BP, Rash on face, neck, chest,
Tachycardia, Fever and chills. Caused by a sudden release of Histamine.
Treat by slowing infusion and give Benadryl.
Anterograde Amnesia: a form of amnesia, or memory loss, where new events are not
transferred to long-term memory.
Reye’s Syndrome: Fatal complication if a patient, ages 0-16, is given ASA whilst
experiencing a viral infection
Heparin - Protamine
Coumadin - Vitamin K
Morphine - Narcan
Valium - Flumazicon
Tylenol - Mucomist
Digoxin - Digibind
MRSA - Vancomycin
Selected Values
BUN 10 – 20 PCO2 35 - 45
AST 7 – 27 HCO3 22 - 28
Na 135 – 145
K+ 3.5 – 5.3
Chloride 95 – 105
DRUG TABLES:
Alzheimer’s
Super Condensed Portable HESI Study Guide 15
Analgesics
ROUTE ADMINISTRATION
*ORAL *preferred method
*drug level peak 1-2 hours
*IV BOLUS (OR) IV PUSH *most rapid onset (5 minutes) with shortest duration
(1hour)
*management of acute pain
ROUTE ADMINISTRATION
PATIENT-CONTROLLED *pain control allowing the client to prevent or manage
ANALGESIA (PCA) pain
*physician prescribes drug, dose, lockout interval, &
maximum dose
*pump records all data related to interactions by the
nurse, physician, client
*risk of drug overdose if someone other than the client
regulates the dosage
CONTINUOUS *client who cannot take oral medications & require long
SUBCUTANEOUS NARCOTIC term pain management (parental narcotics)
INFUSION *provides a continuous level of analgesia
(CSI) *sites are inspected every 8 hours
*sites rotated every 7 days
Super Condensed Portable HESI Study Guide 18
Infants
Number 1 cause of injury or death is suffocation followed by Motor Vehicle Accident
then Homicide.
Sudden Infant Death Syndrome
Infection is the most significant cause of illness in infants and children.
Children
Obesity – Healthy people objectives have addressed youth fitness and obesity
Defined by using BMI which is a ratio of weight to height
Risks for childhood obesity were related to obesity in the parents
Obesity rates higher populations such as Native American, Hispanic, and
African Americans groups. Lower socioeconomic groups in urban settings
have been associated with higher rates
Chronic Health Problems- improved medical technology has increased the number of
children surviving with chronic health problems. Examples: Down Syndrome, spina
bifida, cerebral palsy, asthma, diabetes, congenital heart disease, cancer, hemophilia,
broncopulmonary dysplasia, and AIDS
Good nutrition is essential for healthy growth and development and influences disease
prevention in later life.
Women
The women’s health movement was pivotal in bringing national recognition to women’s
health issues.
Super Condensed Portable HESI Study Guide 19
Men
Men are physiologically the more vulnerable gender, shorter life span and higher infant
mortality rate
Life expectancy of men in the US is one of the lowest in the developed countries
Men engage in more risk-taking behaviors than women
Men tend to avoid diagnosis and treatment of illnesses that may result in serious health
problems
Elderly
Steadily growing population
Increase in chronic conditions, demand for services, and strained health care budgets
More older adults live in the community
Nurses address the chronic health concerns of elders with a focus on maintaining or
improving self-care and preventing complications to maintain the highest possible
quality of life.
Assessing the elderly incorporates physical, psychological, social, and spiritual domains.
Individual and community focused interventions involve all three levels of prevention
through collaborative practice.
Health care reform measures seek to make changes in the cost, quality, and access of the
present system.
The integration of primary care and public health is necessary for the future health of the
nation
To achieve the specific health goals of programs such as healthy People 2010, primary
care and public health must work within the community for community-based care.
The most sustainable individual and system changes come when people who live n the
community have actively participated.
Nurses are more than able to fill the gap between personal care and public health because
they have skills in assessment, health promotion, and disease and injury prevention;
Super Condensed Portable HESI Study Guide 20
Home visits provide opportunities to identify both barriers and supports for reaching
family health promotion goals.
Home visits afford the opportunity to gain a more accurate assessment of the family
structure and behavior in the natural environment.
Home visits also provide opportunities to observe the home environment and to identify
both barriers and supports to reducing health risks and reaching family health goals.
Parish nurses: nurses who respond to health and wellness needs within the faith context
of population of faith communities and are partners with the church in fulfilling the
mission of health ministry.
Parish nurse coordinator: a parish nurse who has completed a certificate program
designed to develop the nurse as a coordinator of a parish nursing service.
Parish nurse services respond to health, healing, and wholeness within the context of the
church. Although the emphasis is on health promotion and disease prevention throughout
the life span, the spiritual dimension of nursing is central to the practice.
The parish nurse partners with the wellness committee and volunteers to plan programs
and consider health-related concerns within faith communities
To promote a caring faith community, usual functions of the parish nurse include personal
health counseling, health teaching, facilitating linkages and referrals to congregation and
community resources, advocating and encouraging support resources, and providing
pastoral care.
Parish nurses collaborate to plan, implement, and evaluate health promotion activities
considering the faith community’s beliefs, rituals, and polity. Healthy People 2010
guidelines are basic to the partnering for the programs.
Nurses working in the parish nursing specialty must seek to attain adequate educational
and skill preparation for the accountability to those served and to those who have
entrusted the nurse to serve
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To sustain oneself as a parish nurse healer, the nurse takes heed to heal and nurture self
while supporting individuals, families, and congregation communities in their healing
process.
Hospice: palliative system of health care for terminally ill people; takes place in the
home with family involvement under the direction and supervision of health
professionals, especially the visiting nurse. Hospice care takes place in the hospital when
sever complications of terminal illness occur or when family becomes exhausted or does
not fulfill commitments.
Professional Preparedness
Requires nurses and other personnel to be aware of and understand the disaster plans
at their workplace and community- participate in mock drills
Adequately prepared nurses will function in leadership capacity and assist towards
smoother recovery phase
Fieldwork, shelter management requires creativeness and willingness
American Red Cross provides training for health professionals to adapt existing skills
to disaster setting
Personal Preparedness
Nurses who are disaster victims themselves and provide care to others will experience
considerable stress.
American Red Cross and Federal Emergency Management Agency (FEMA) are two
well known authorities on disaster preparedness, response, and recovery
Three levels
1st level – Personal Preparedness
2nd level- Professional Preparedness
3rd level- Community Preparedness
Most states and counties have an Office of Emergency Management (OEM) that is
responsible for developing and coordinating emergency response plans within their
defined area. The state office supports local OEMs and other state agencies that
participate in disaster response. It provides planning and training services to local
governments, including financial and technical assistance. During an actual
emergency or disaster, the state OEM coordinates a state response and recovery
program if necessary. County OEMs are in charge of creating a comprehensive, all-
hazard plan that should address realistic dangers to the community and list
available resources.
**Nurses need to review the disaster history of community, including how past
disasters have affected the health care delivery system, how their particular
Super Condensed Portable HESI Study Guide 23
organizations fit into the plan, and what role they and their organizations are
expected to play in a disaster.
Personal Preparedness
Entails plan for keeping oneself ready for disaster, both mentally and physically
Individuals not personally prepared will have less to give to family, community,
job, and other disaster victims
Nurses can be disaster victims- personal preparation needed to attend to patients
Checklist helpful to prepare
Professional Preparedness
Requires nurses and other personnel to be aware of and understand the disaster plans
at their workplace and community- participate in mock drills
Adequately prepared nurses will function in leadership capacity and assist towards
smoother recovery phase
Fieldwork, shelter management requires creativeness and willingness
American Red Cross provides training for health professionals to adapt existing skills
to disaster setting
Community Preparedness
Level of preparedness only as high as people/ organizations in the community make it
Well-prepared communities have written disaster plans, conduct drills, have adequate
warning system, and backup evacuation plan
Office of Emergency Management- state/ county office coordinating regional plans
Understanding past disasters can influence planning for future, liabilities in resources
Response
Scope- magnitude of the event, units affected and responding ,e.g., single-family,
local, state, major, federally declared
Single family – affects an individual or single family- occurs within the
jurisdiction of a single Red Cross chapter
Local Disaster- Affects more than one family, occurs within the jurisdiction of a
single Red Cross chapter
State Disaster- Affects multiple families, occurs within the jurisdiction of one or
More Red Cross chapters within a single state
Major Disaster- has one or more of the following characteristics
-coordinated response of multiple Red Cross units
- affects more than a single state
- creates national news
- result in emergency or disaster declaration by the President etc.
Plans for triage must begin as soon as rescue workers arrive- highest priority
given to life-threatening injuries with high probability of survival- nurse’s
accurate assessment info will help match available resources to population’s
emergency needs
Recovery
The recovery stage of disaster occurs as all involved agencies pull together to restore the
economic and civic life of the community. For example: the government takes the lead
in rebuilding efforts whereas the business community tries to provide economic support.
Get community back to normal, deal with emotional matters and after effects
Assess what might be going on in community using primary, secondary and tertiary care
Terrorism
Role of the Nurse:
Help people cope with the aftermath of terrorism
Allay public concerns and fears of bioterrorism
Identify the feelings that you and others may be experiencing
Assist victims to think positively and move to the future
Prepare nursing personnel to be effective in a crisis situation
Nurses are concerned with anthrax and small pox and should have awareness of these
diseases
Tertiary Prevention- Participate in home visits to uncover dangers that may cause
additional injury to victim or cause other problems (e.g. house fires from faulty wiring).
Triage: the process of separating casualties and allocating treatment on the basis of the
victims’ potentials for survival.
- Highest priority is always given to victims who have life threatening injuries but
who have a high probability of survival once stabilized
- Second priority is given to victims with injures that have systemic complications
that are not yet life threatening and could wait 45 – 60 minutes for treatment
- Last priority is given to those victims with local injuries without immediate
complications and who can wait several hours for medical attention.
Research studies using the tracer or sentinel method to identify clients’ outcomes and
client satisfaction surveys can be used to measure outcome standards.
From data, strengths and weaknesses in nursing care delivery can be determined.
The most common measurement methods are direct physical observations and
interviews.
Primary Care- refers to organized community efforts designed to prevent disease and
promote health (education).
Secondary Care- an intermediate level of health care that includes diagnosis and
treatment. Screening.
Levels of Prevention
Federal Agencies
Many federal agencies are involved in government health care functions. The agency
most directly involved with the health and welfare of Americans is the U.S. Department
of Health and Human Services
The Health Resources and Services Administration of the USDHHS contains the Bureau
of Health Professions, this bureau includes separate divisions for nursing, medicine,
dentistry, public health, and allied health professions
The Division of Nursing administers nurse education legislation, interprets trends and
nursing needs of the nation’s health care delivery system, and serves as a liaison with the
nursing community and with international, state, regional, and local health interests
Nurses can apply for support for research, projects, or training from a variety of agencies
within the federal government besides the NINR of the Division of Nursing.
Other federal agencies: Dept. of Commerce, Dept. of Defense, Dept. of Labor (includes
OSHA), Dept. of Agriculture (includes WIC), Dept. of Justice, Food and Drug
Administration.
The amount of financial assistance the voluntary agency receives depends on the
community it serves. With Medicare, the private nonprofit agency emerged as an
alternative agency to the public-supported program. These agencies included
rehabilitation agencies, based in either rehabilitation facilities or skilled facilities.
Nurses use assessment skills to detect potential and actual exposure pathways and
outcomes for clients cared for in the acute, chronic, and healthy communities of practice.
Super Condensed Portable HESI Study Guide 29
Risk communication is an important skill and must acknowledge the outrage factor
experienced by communities with environmental hazards.
Vulnerable populations- are those groups who have an increased risk to develop adverse
health outcomes, vulnerable populations often experience multiple cumulative risks and
they are particularly sensitive to the effects of those risks.
Vulnerable populations often are more likely than the general populations to suffer from
health disparities.
Examples of areas that show health disparities across populations groups are infant
mortality, childhood immunization rates, and disease-specific mortality rates.
Example Crude birth rate Number of live births during 1 year X1000
Midyear population
Evaluating Outcomes
Outcomes can be measured by looking at changes from before and after the intervention
to solve the problems. Changes in the following can be used to see the outcomes of the
interventions:
- Demographics
- Socioeconomic factors
- Environmental factors
- Individual and community health status
- Use of health services
In the example of infant malnutrition, one would look for the number of cases of infant
malnutrition in the community before providing education to other health providers about
assessment of infant development. A time period for evaluation would be chosen and
perhaps 1 year later (the time frame). The number of cases of infant malnutrition would
be measured to see if a change had occurred and there were fewer cases.
Community assessment
Most nurses are familiar with the nursing process as it applies to individually
focused nursing care. Using it to promote community health makes this same
nursing process community focused.
Community assessment- the process of critically thinking about the community and
involves getting to know and understand the community as partner. The community
assessment phase involves a logical, systematic approach to the initial phase of the
nursing process. Community assessment helps as follows:
- To identify community needs
- To clarify problems
- To identify strengths and resources
Super Condensed Portable HESI Study Guide 31
Data gathering is the process of obtaining existing, readily available data. The following
data usually describe the demography of a community
- Age of residents
- Gender distribution of residents
- Socioeconomic characteristics
- Racial distributions
- Vital statistics, including selected mortality and morbidity data
Identify needs, problems, strengths, resources and apply what you know.
Windshield survey- are the motorized equivalent of simple observation. They involve
the collection of data that “will help define the community, the trends, stability, and
changes that will affect the health of the community”
School Nurse:
- Primary -The school nurse monitors the children for all of their state-mandated
immunizations for school entry.
- Secondary- School nurse is involved in screening children for illnesses and
providing direct nursing care
- Tertiary – The school nurse cares for children with long-term health needs,
including asthma and disabling conditions
School nurses carry out catheterizations, suctioning, gastrostomy tube feedings, and other
skills in school.
The concern for health promotion of adolescents is safety because of their propensity to
take part in risky behavior.
To effectively reach a population group you must connect with someone in the
community and establish trust.
Occupational Exposure
Super Condensed Portable HESI Study Guide 32
Medicaid- Financial assistance to states and counties to pay for medical services for poor
older adults, the blind, the disabled, and families with dependent children.
Outreach worker: a health worker who makes a special, focused effort to find people
with specific health problems for the purpose of increasing their access to health services
- evaluate effectiveness find out if successful and use ways to measure success
Epidemiologic triangle – agent, host, and environment – changes in one of the elements
of the triangle can influence the occurrence of disease by increasing or decreasing a
person’s risk for disease. Risk is the probability that an individual will experience an
event.
Agent: an animate or inanimate factor that must be present or lacking for a disease or
condition to develop
Host: a living species (human or animal) capable of being infected or affected by an
agent
Environment- all that is internal or external to a given host or agent and that is
influenced and influences the host and/or agent
Agent- an animate or inanimate factor that must be present or lacking for a disease or
condition to develop
- causive – example: E. coli
- Infectious agents (bacteria, viruses, fungi, parasites)
- Chemical agents (heavy metal, toxic chemicals, pesticides)
- Physical agents (radiation, heat, cold, machinery)
Environment- all that is internal or external to a given host or agent and that is
influences the host and or agent
- anything external
- climate (temperature, rainfall)
- Plant and animal life (agents or reservoirs or habitats for agents)
- Human population distribution (crowding, social support)
- Socioeconomic factors (education, resources, access to care)
- Working conditions (levels of stress, noise, satisfaction)
Relationship between the above 3 cause disease, try to break the connection, if a
break then there will be no disease.
Family assessment
Ecomap- represents the family’s interactions with other groups and organizations,
accomplished by using a series of circles and lines.
- It is represented by a circle in the middle of the page
- Other groups and organizations are then indicated by circles
- Lines representing the flow of energy are drawn between the family circle and the
circles representing other groups and organizations
- An arrowhead at the end of each line indicates the direction of the flow of energy
(into or out of the family)
- The weight of the line indicates the intensity of the energy
Community Level
- Develop policy
- Conduct community resource mapping
- Collaborate with community to develop systematic response to violence
- Develop media campaign
- Develop resources such as transition housing and shelters
High school students and middle school students- steer away from violence and
teach to work on their own skills and build their self-esteem.
Super Condensed Portable HESI Study Guide 35
RESPIRATORY SYSTEM:
1. List 4 common symptoms of pneumonia the nurse might note on a physical exam.
- Tachypnea, fever with chills, productive cough, bronchial breath sounds.
3. What symptoms of pneumonia might the nurse expect to see in an older client?
- Confusion, lethargy, anorexia, rapid respiratory rate.
4. What should the O2 flow rate be for the client with COPD?
- 1-2 liters per nasal cannula, too much O2 may eliminate the COPD client’s stimulus to breathe, a
COPD client has hypoxic drive to breathe.
7. When examining a client with emphysema, what physical findings is the nurse likely to
see?
- Barrel chest, dry or productive cough, decreased breath sounds, dyspnea, crackles in lung fields.
8. What is the most common risk factor associated with lung cancer?
- Smoking
13. What precautions are required for clients with TB when placed on respiratory isolation?
- Mask for anyone entering room; private room; client must wear mask if leaving room.
Super Condensed Portable HESI Study Guide 36
RENAL SYSTEM:
2. During the oliguric phase of renal failure, protein should be severely restricted. What is the
rationale for this restriction?
- Toxic metabolites that accumulate in the blood (urea, creatinine) are derived mainly from protein
catabolism.
4. What is the highest priority nursing diagnosis for clients in any type of renal failure?
- Alteration in fluid and electrolyte balance.
5. A client in renal failure asks why he is being given antacids. How should the nurse reply?
- Calcium and aluminum antacids bind phosphates and help to keep phosphates from being
absorbed into blood stream thereby preventing rising phosphate levels, and must be taken with
meals.
6. List 4 essential elements of a teaching plan for clients with frequent urinary tract infections.
- Fluid intake 3 liters/day; good handwashing; void every 2-3 hours during waking hours; take all
prescribed medications; wear cotton undergarments.
7. What are the most important nursing interventions for clients with possible renal calculi?
- Strain all urine is the MOST IMPORTANT intervention. Other interventions include accurate intake
and output documentation and administer analgesics as needed.
8. What discharge instructions should be given to a client who has had urinary calculi?
- Maintain high fluid intake 3-4 liters per day. Follow-up care (stones tend to recur). Follow
prescribed diet based in calculi content. Avoid supine position.
9. Following transurethral resection of the prostate gland (TURP), hematuria should subside
by what post-op day?
- Fourth day
10. After the urinary catheter is removed in the TURP client, what are 3 priority nursing
actions?
- Continued strict I&O; continued observations for hematuria; inform client burning and frequency
may last for a week.
11. After kidney surgery, what are the primary assessments the nurse should make?
- Respiratory status (breathing is guarded because of pain); circulatory status (the kidney is very
vascular and excess bleeding can occur); pain assessment; urinary assessment most importantly,
assessment of urinary output.
CARDIOVASCULAR SYSTEM:
- Described as squeezing, heavy, burning, radiates to left arm or shoulder, transient or prolonged.
7. Describe the nurse’s discharge instructions to a client with venous peripheral vascular
disease.
- Keep extremities elevated when sitting, rest at first sign of pain, keep extremities warm (but do
NOT use heating pad), change position often, avoid crossing legs, wear unrestrictive clothing.
9. What lab values should be monitored daily for the client with thrombophlebitis who is
undergoing anticoagulant therapy?
- PTT, PT, Hgb, and Hct, platelets.
11. Differentiate between the symptoms of left-sided cardiac failure and right-sided cardiac
failure.
- Left-sided failure results in pulmonary congestion due to back-up of circulation in the left ventricle.
Right-sided failure results in peripheral congestion due to back-up of circulation in the right
ventricle.
14. What life style changes can the client who is at risk for hypertension initiate to reduce the
likelihood of becoming hypertensive?
- Cease cigarette smoking if applicable, control weight, exercise regularly, and maintain a low-
fat/low-cholesterol diet.
15. What immediate actions should the nurse implement when a client is having a myocardial
infarction?
- Place the client on immediate strict bedrest to lower oxygen demands of heart, administer oxygen
by nasal cannula at 2-5 L/min., take measures to alleviate pain and anxiety (administer prn pain
medications and anti-anxiety medications).
Super Condensed Portable HESI Study Guide 38
16. What symptoms should the nurse expect to find in the client with hypokalemia?
- Dry mouth and thirst, drowsiness and lethargy, muscle weakness and aches, and tachycardia.
17. Bradycardia is defined as a heart rate below ___ BPM. Tachycardia is defined as a heart
rate above ___ BPM.
- bradycardia 60 bpm; tachycardia 100 bpm
18. What precautions should clients with valve disease take prior to invasive procedures or
dental work?
- Take prophylactic antibiotics.
GASTROINTESTINAL SYSTEM:
5. List 4 nursing interventions for post-op care of the client with a colostomy.
- Irrigate daily at same time; use warm water for irrigations; wash around stoma with mild
soap/water after each colostomy bag change; pouch opening should extend at least 1/8 inch
around the stoma.
7. What are the common food intolerances for clients with cholelithiasis?
- Fried/spicy or fatty foods.
9. In a client with cirrhosis, it is imperative to prevent further bleeding and observe for
bleeding tendencies. List 6 relevant nursing interventions.
- Avoid injectons, use small bore needles for IV insertion, maintain pressure for 5 minutes on all
venipuncture sites, use electric razor, use soft-bristle toothbrush for mouth care, check stools and
emesis for occult blood.
10. What is the main side effect of lactulose, which is used to reduce ammonia levels in clients
with cirrhosis?
- Diarrhea.
ENDOCRINE SYSTEM:
4. List 5 important teaching aspects for clients who are beginning corticosteroid therapy.
- Continue medication until weaning plan is begun by physician, monitor serum potassium, glucose,
and sodium frequently; weigh daily, and report gain of >5lbs./wk; monitor BP and pulse closely;
teach symptoms of Cushing’s syndrome
10. Name the necessary elements to include in teaching the new diabetic.
- Teach the underlying pathophysiology of the disease, its management/treatment regime, meal
planning, exercise program, insulin administration, sick-day management, symptoms of
hyperglycemia (not enough insulin)
11. In less than ten steps, describe the method for drawing up a mixed dose of insulin (regular
with NPH).
- Identify the prescribed dose/type of insulin per physician order; store unopened insulin in
refrigerator. If opened, may be kept at room temperature for up to 3 months. Draw up regular
insulin FIRST. Rotate injection sites. May reuse syringe by recapping and storing in refrigerator.
12. Identify the peak action time of the following types of insulin: rapid-acting regular insulin,
intermediate-acting, long-acting.
- Rapid-acting regular insulin: 2-4 hrs. Immediate-acting: 6-12 hrs. Long-acting: 14-20 hrs.
13. When preparing the diabetic for discharge, the nurse teaches the client the relationship
between stress, exercise, bedtime snacking, and glucose balance. State the relationship
between each of these.
- Stress and stress hormones usually increase glucose production and increase insulin need;
exercise can increase the chance for an insulin reaction, therefore, the client should always have
a sugar snack available when exercising (to treat hypoglycemia); bedtime snacking can prevent
insulin reactions while waiting for long-acting insulin to peak.
14. When making rounds at night, the nurse notes that an insulin-dependent client is
complaining of a headache, slight nausea, and minimal trembling. The client’s hand is cool
and moist. What is the client most likely experiencing?
Super Condensed Portable HESI Study Guide 40
- Hypoglycemia/insulin reaction.
15. Identify 5 foot-care interventions that should be taught to the diabetic client.
- Check feet daily & report any breaks, sores, or blisters to health care provider, wear well-fitting
shoes; never go barefoot or wear sandals, never personally remove corns or calluses, cut or file
nails straight across; wash daily with mild soap & warm water.
MUSCULOSKELETAL SYSTEM:
1. Differentiate between rheumatoid arthritis and degenerative joint disease in terms of joint
involvement.
- Rheumatoid arthritis occurs bilaterally. Degenerative joint disease occurs asymmetrically.
4. What measures should the nurse encourage female clients to take to prevent
osteoporosis?
- Estrogen replacement after menopause, high calcium and vitamin D intake beginning in early
adulthood, calcium supplements after menopause, and weight-bearing exercise.
6. What is the priority nursing intervention used with clients taking NSAIDs?
- Administer or teach client to take drugs with food or milk.
9. Describe nursing care for the client who is experiencing phantom pain after amputation.
- Be aware that phantom pain is real and will eventually disappear. Administer pain medication;
phantom pain responds to medication.
10. A nurse discovers that a client who is in traction for a long bone fracture has a slight fever,
is short of breath, and is restless. What does the client most likely have?
- Fat embolism, which is characterized by hypoxemia, respiratory distress, irritability, restlessness,
fever and petechiae.
11. What are the immediate nursing actions if fat embolization is suspected in a
fracture/orthopedic client?
- Notify physician STAT, draw blood gas results, assist with endotracheal intubation and treatment of
respiratory failure.
13. List 3 nursing interventions for the prevention of thromboembolism in immobilized clients
with musculoskeletal problems.
Super Condensed Portable HESI Study Guide 41
- Passive range of motion exercises, elastic stockings, and elevation of foot of bed 25 degrees to
increase venous return.
NEUROSENSORY/NEUROLOGICAL SYSTEMS:
1. What are the classifications of the commonly prescribed eye drops for glaucoma?
- Parasympathominetics for pupillary constriction. Beta-adrenergic receptor-blocking agents to
inhibit formation of aqueous humor. Carbonic anhydrase inhibitors to reduce aqueous humor
production, and prostaglandin agonists to increase aqueous humor outflow.
3. Write 4 nursing interventions for the care of the blind person and 4 nursing interventions
for the care of the deaf person.
- Care of the blind: announce presence clearly, call by name, orient carefully to surroundings, guide
by walking in front of client with his/her hand in your elbow. Care of deaf: reduce distraction
before beginning conversation, look and listen to client, give client full attention if they are a lip
reader, face client directly.
11. When a comatose client on IV hyperalimentation begin to receive tube feedings instead?
- When peristalsis resumes as evidenced by active bowel sounds, passage of flatus or bowel
movement.
12. What is the most important principle in a bowel management program for a neurologic
client?
- Establishment of REGULARITY
- A disruption of blood supply to a part of the brain, which results in sudden loss of brain function.
14. A client with a diagnosis of CVA presents with symptoms of aphasia, right hemiparesis, but
no memory or hearing deficit. In what hemisphere has the client suffered a lesion?
- Left
19. A neighbor calls the neighborhood nurse stating that he was knocked hard to the floor by
his very hyperactive dog. He is wondering what symptoms would indicate the need to visit
an emergency room. What should the nurse tell him to do?
- Call his physician now and inform him/her of the fall. Symptoms needing medical attention would
include vertigo, confusion or any subtle behavioral change, headache, vomiting, ataxia
(imbalance), or seizure.
20. What activities and situations should be avoided that increase ICP?
- Change in bed position, extreme hip flexion, endotracheal suctioning, compression of jugular
veins, coughing, vomiting, or straining of any kind.
21. How do Hyperosmotic agents (osmotic diuretics) used to treat intracranial pressure act?
- Dehydrate the brain and reduce cerebral edema by holding water in the renal tubules to prevent
reabsorption, and by drawing fluid from the extravascular spaces into the plasma.
23. Headache and vomiting are symptoms of many disorders. What characteristics of these
symptoms would alert the nurse to refer a client to a neurologist?
- Headache which is more severe upon awakening and vomiting not associated with nausea are
symptoms of a brain tumor.
24. How should the head of the bed be positioned for post-craniotomy clients with
infratentorial lesions?
- Infratentorial – FLAT; Supratentorial – elevated
27. What types of drugs are used in the treatment of myasthenia gravis?
- Anticholinesterase drugs, which inhibit the action of cholinesterase at the nerve endings to
promote the accumulation of acetylcholine at receptor sires, which should improve neuronal
transmission to muscles.
HEMATOLOGY/ONCOLOGY:
Super Condensed Portable HESI Study Guide 43
4. What actions should the nurse take if a hemolytic transfusion reaction occurs?
- Turn off transfusion. Take temperature. Send blood being transfused to lab. Obtain urine sample.
Keep vein patent with normal saline.
11. Describe the method of collecting the trough and peak blood levels of antibiotics.
- Collection of trough: draw blood 30 minutes prior to administration of antibiotic. Collection of peak:
draw blood 30 minutes after administration of antibiotic.
13. List 4 nursing interventions for care of the client with Hodgkin’s disease.
- Protect from infection. Observe for anemia. Encourage high-nutrient foods. Provide emotional
support to client and family.
14. List 4 topics you would cover when teaching an immunosuppressed client about infection
control.
- Handwashing technique. Avoid infected persons. Avoid crowds. Maintain daily hygiene to
prevent spread of microorganisms.
REPRODUCTIVE SYSTEM:
1. What are the indications for a hysterectomy in the client who has fibromas?
- Severe menorrhagia leading to anemia, severe dysmenorrhea requiring narcotic analgesics,
severe uterine enlargement causing pressure on other organs, severe low back and pelvic pain.
Super Condensed Portable HESI Study Guide 44
3. What are the most important nursing interventions for the postoperative client who has had
a hysterectomy with an A&P repair?
- Avoid rectal temps and/or rectal manipulation; manage pain; and encourage early ambulation.
4. Describe the priority nursing care for the client who has had radiation implants.
- Do not permit pregnant visitors or pregnant caretakers in room. Discourage visits by small
children. Confine client to room. Nurse must wear radiation badge. Nurse limits time in room.
Keep supplies and equipment within client’s reach.
5. What screening tool is used to detect cervical cancer? What are the American Cancer
Society’s recommendations for women ages 30 to 70 with three consecutive normal
results?
- Pap smear. Women ages 30 to 70 with 3 consecutive normal results may have pap smear every 2
to 3 years.
6. Cite 2 nursing diagnoses for a client undergoing a hysterectomy for cervical cancer.
- Altered body image related to uterine removal. Pain related to postoperative incision.
7. What are the 3 most important tools for early detection of breast cancer? How often should
these tools be used?
- Breast self-exam monthly; mammogram baseline at age 35 followed by exams every 1 to 2 years
in 40s and every year after age 50; physical examination by a professional skilled in examination
of the breast.
9. Name 3 priorities to include in a discharge plan for the client who has had a mastectomy.
- Arrange for Reach-to-Recovery visit. Discuss the grief process with the client. Have physician
discuss with the client the reconstruction options.
13. Which STD is characterized by remissions and exacerbations in both males and females?
- Herpes Simplex Type II
BURNS:
3. Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of
the burned client.
- Stage I (Emergent phase): Replacement of fluids is titrated to urine output. Stage II (Acute
phase): Maintain patent infusion site in case supplemental IV fluids are needed; heparin lock is
helpful; may use colloids. Stage III (Rehabilitation phase): No extra fluids needed, but high-protein
drinks are recommended.
6. Nutritional status is a major concern when caring for a burned client. List 3 specific dietary
interventions used with burned clients.
- High-calorie, high-protein, high-carbohydrate diet. Medications with juice or milk. NO “free” water.
Tube feeding at night. Maintain accurate, daily calorie counts. Weigh client daily.
7. Describe the method of extinguishing each of the following burns: thermal, chemical and
electrical.
- Thermal: remove clothing, immerse in tepid water. Chemical: flush with water or saline. Electrical:
separate client from electrical source.
PSYCHIATRIC NURSING
1. After the 4th group meeting, the informal leader makes a statement that she believes she
can help the group more than the assigned facilitator and has better credentials. Identify
the group dynamics and stage of development.
- The informal leader is “testing,” which is a behavior indicative of a new group trying to establish
trust. This group is still in the orientation phase of development.
2. On an in-patient psychiatric unit, clients are expected to get up at a certain time, attend
breakfast at a certain time, and come for their medication at the correct time. What form of
therapy is incorporated into this unit? - Milieu.
Super Condensed Portable HESI Study Guide 46
3. The wife of a man killed in a motor vehicle accident has just arrived at the emergency room
and is told of her husband’s death. What nursing actions are appropriate for dealing with
this crisis?
- Take woman to a quiet room, ask her if there are family, friends, or clergy you can call for her.
Assess her need for medication and discuss with physician. Stay with her, be firm and directive,
and assess previous successful coping strategies.
4. A 10 yr. old is admitted to the children’s unit of the psychiatric facility after stabbing his
sister. His behavior is extremely aggressive with the other children on the unit. Using a
behavior modification approach with positive reinforcement, design a treatment plan for
this child.
- Assess what activities he enjoys. Set up a token system – when he displays non-aggressive
behavior, he earns a token good towards participating in the activity selected. He loses a token
when he becomes aggressive.
5. The 10 yr. old, his sister, mother, and the mother’s live in boyfriend are asked to attend a
therapy meeting. Who is the “client” that will be treated during this session?
- The entire family.
6. A 66 yr. old woman is admitted to the psychiatric unit with agitated depression. She has
not responded to antidepressants in the past. What would be the medical treatment of
choice for this client?
- Electroconvulsive therapy (ECT).
7. Describe the nurse’s role in preparing clients for electroconvulsive therapy (ECT).
- Give accurate, non-judgmental information about the treatment. Explore client’s concerns.
Administer the following as ordered: Atropine sulfate to dry oral secretions, a quick-acting
barbiturate to induce anesthesia such as Brevital Sodium, and a muscle relaxant such as
Anectine. Check emergency equipment and O2 are available.
8. Describe the nursing interventions used to care for a client during and after
electroconvulsive therapy.
- Maintain patent airway. Check vital signs every 15 minutes until alert. Remain with client
following treatment until conscious. Reorient, if confused.
ANXIETY DISORDERS:
2. Identify the defense mechanism used by a person who feels guilty about masturbating as a
child, and develops a hand-washing compulsion as an adult.
- Undoing.
5. A Vietnam veteran is plagued by nightmares and is found trying to strangle his roommate
one night. List, in order of priority, the appropriate nursing interventions.
- Protect roommate from harm. Stay with client. If the client is agitated, administer anti-anxiety
medications as ordered. Arrange for private room. Place client on homicidal precautions at night.
6. A client displays a phobic response to flying. Describe the desensitization process, which
would probably be implemented.
Super Condensed Portable HESI Study Guide 47
- Talk about planes. Look at pictures of planes. Make plans to accompany client during a visit to
airport. Accompany client into a plane. Allow the client to board a plane alone. Accompany the
client on a short flight while listening to a relaxation tape.
7. A client is in the middle of an extensive ritual, which focuses on food during lunch.
However, the client is scheduled for group therapy, which is about to start. What action
should the nurse take?
- Allow client to complete the ritual. Discuss with the group leader the possibility of allowing the
client to enter the group late. Arrange for client to begin lunch either so that the ritual can be
completed prior to scheduled activities.
SOMATOFORM DISORDERS:
3. An air traffic controller suddenly suddenly develops blindness. All physical findings are
negative. The client’s history reveals an increased anxiety about job performance and fear
about job security. What type of disorder is this? What purpose is the blindness serving?
What nursing interventions are indicated?
- Conversion reaction. Decreases the anxiety about job. Assist with ADL, encourage expression of
anger, teach relaxation techniques, and assist with the identification of anxiety related to job
security and performance.
4. A 42 yr. old secretary has visited 7 different doctors in the last year with a complaint of
chest pain, heart palpitations, and shortness of breath. She is certain she is having a heart
attack in spite of the physician’s reassurance that all tests are normal. What type of
disorder is this? What nursing actions are indicated?
- Hypochondriacal disorder. Decrease anxiety, teach relaxation techniques, explore relationship
between the symptoms and past experiences with heart disease. Focus interactions away from
bodily concerns.
5. Five years ago, a woman was involved in a motor vehicle accident that killed her friend who
was a passenger in the car she was driving. Since that time, she has been unable to work
because of sever back pain. The pain in unrelieved by prescribed medications. What type
of disorder is this? What are the contributing causes? Describe the nursing care.
- Somatization disorder. Unresolved grief, anxiety. Evaluate pain medication use and/or abuse.
Document duration and intensity of pain. Assist client to identify precipitating factors related to
request for medication.
DISSOCIATIVE DISORDERS:
- Traumatic event such as a threat of death or injury, an intolerable life situation, or a natural
disaster.
PERSONALITY DISORDERS:
EATING DISORDERS:
3. An anorectic client has her friend bring her several cookbooks so she can plan a party
when she is discharged. What nursing intervention is appropriate in addressing this
behavior?
- Discuss activities that don’t involve food, which may take place after discharge. Discuss the
cookbooks with the treatment team and, if the treatment plan indicates, take books from client.
5. What might the initial treatment include for a client admitted to the hospital with a
diagnosis of bulimia nervosa?
- Blood work to evaluate electrolyte status; replenish electrolytes and fluids as indicated; carefully
monitor for evidence of vomiting.
AFFECTIVE DISORDERS:
2. A client, who has been withdrawn and tearful, comes to breakfast one morning smiling and
interacting with her peers. Prior to breakfast, she gave her roommate her favorite necklace.
What actions should the nurse take and why?
Super Condensed Portable HESI Study Guide 49
- Assess for suicidal ideation, plan and means to carry out plan. Place on precautions as indicated.
A sudden change in mood and giving away possessions are two possible signs that a suicide plan
has been developed.
4. A client on your unit refuses to go to group therapy. What is the most appropriate nursing
interventions?
- Accompany client to the group; do not give client option. Client needs to be mobilized.
5. A client is standing on a table loudly singing the “Star Spangled Banner” encircled by
sheets, which have been set afire. In order of priority, describe appropriate nursing
actions.
- Remove client and other persons in the vicinity to a safe area and activate hospital fire plan.
When area is safe, place client in quiet environment with low stimulation and medicate as
indicated.
SCHIZOPHRENIC/PARANOID DISORDERS:
1. A client is sitting alone, talking quietly. There is no one around. What nursing action
should be taken?
- Quietly approach client and note the behavior. Assess content of the hallucinations, e.g., “I
noticed you talking. Are you hearing voices? Can you tell me about the voices you are hearing?”
2. A client dials 222-2222 and asks for his fiance, Candice Bergen. This is an example of what
type of thought disorder?
- Delusion of grandeur
3. A client has been sitting in the same position for 2 hours. He is mute. What type of
schizophrenia is this client experiencing? Describe appropriate nursing interventions for
this client?
- Catatonic: Spend time with client; assist with ADL; be alert to potential for violence toward
self/others; be aware of fluid and nutrition needs.
4. A client is very agitated. He believes that the CIA has tapped the phone, is sending
messages through the television, and that you are an agent who has been planted by the
agency. In order of priority, list the appropriate nursing actions to intervene in this
situation. What type of delusion is this client experiencing?
- Approach client and offer solitary activity to distract. Assess need for medication. Encourage
verbalization of feelings and promote outlet for expression. Paranoid disorder with delusions of
reference (CIA).
5. The nurse asks the client, “What brought you to the hospital?” The client’s response is,
“The bus.” What type of thinking is this client exhibiting?
- Concrete.
SUBSTANCE ABUSE:
1. Three days ago, a client was admitted to the medical unit for a GI bleed. His BP and pulse
rate gradually increased, and he developed a low-grade fever. What assessment data
should the nurse obtain? What kind of anticipatory planning should the nurse develop?
- Obtain a drug and alcohol consumption assessment including type, frequency, and time of last
dose/drink. Call the physician and report findings. Anticipate withdrawal/delirium tremens.
Provide a quiet, safe environment. Place on seizure precautions. Anticipate giving a medication
like Librium.
2. What physical signs might indicate that a client is abusing intravenous medications?
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3. What behaviors would indicate to the nurse manager that an employee has a possible
substance abuse problem?
- Change in work performance, withdrawal, increase in absences (especially Monday or Friday),
increase in number of times tardy, long breaks, late returning from lunch.
5. A client, in the third week of cocaine rehabilitation program, returns from an unsupervised
pass. The nurse notices that he is euphoric and is socializing with the other clients more
than he has in the past. What nursing actions are indicated?
- Notify the physician of observed behavior change. Get a urine drug screen as ordered. Confront
client with observed behavior change.
ABUSE:
5. What dynamics prevent a battered spouse from leaving the battering situation?
- A woman in a battering relationship usually lacks self-confidence and feels trapped. She is often
embarrassed to tell friends and family, so she becomes isolated and dependent upon the abuser.
feelings about the assault. Advise of potential for venereal disease, HIV, or pregnancy and
describe medical care available.
1. A 7 yr. old boy is disruptive in the classroom and is described by his parents as
“hyperactive.” What is the most probable psychiatric disorder? What are the signs and
symptoms of this disorder? What drug is usually prescribed for this disorder?
- Attention deficit disorder (ADD/ADHD). More prevalent in boys, failure to listen or follow
instructions. Difficulty playing quietly, disruptive, impulsive behavior, difficulty sitting still,
distractibility to external stimuli, excessive talking, shifts from one unfinished task to another, and
underachievement in school performance. Ritalin.
2. A 15 yr. old boy is threatening to drop out of school. His parents, both alcoholics, say they
can’t stop him. He has just been arrested for stealing a car and breaking into a house.
What is the most probable disorder? Develop nursing diagnoses and interventions for this
disorder.
- Conduct disorder.
A. Potential for violence related to…depending on client.
B. Disturbance in self-esteem related to…depending on client.
C. Ineffective family coping related to…depending on client.
D. Assess verbal/nonverbal cues for escalating behavior to decrease outbursts. Use a non-
authoritarian approach. Avoid asking “why” questions. Initiate a “show of force” for a child
who is out of control. Initiate suicide precautions when assessment indicates risk. Use “quiet
room” when external control is needed. Clarify expressions or jargon if meaning is unclear.
Redirect angry feelings to “safe” alternative such as pillow or punching bag. Implement
behavior modification therapy if indicated. Role-play new coping strategies.
PEDIATRIC NURSING
10. How can the nurse BEST evaluate the adequacy of fluid replacement in children?
- Monitor urine output.
12. What interventions should the nurse do FIRST in caring for a child who has ingested a
poison?
- Assess the child’s respiratory, cardiac, and neurological status.
14. What instructions should be given by phone to a mother who knows her child has ingested
a bottle of medication?
- Administer syrup of ipecac if the child is conscious. Bring any emesis or stool to the emergency
room. Bring the container in which the medicine was stored to the emergency room.
RESPIRATORY DISORDERS:
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2. What are the physical assessment findings for a child with asthma?
- Expiratory wheezing, rales, right cough, and signs of altered blood gases.
3. What nutritional support should be provided for the child with cystic fibrosis?
- Pancreatic enzyme replacement, fat-soluble vitamins, and a high carbohydrate, high protein,
moderate fat diet.
8. Why are IV fluids important for the child with an increased respiratory rate?
- The child is at risk for dehydration and acid/base imbalance.
9. Children with chronic otitis media are at risk for developing what problem?
- Hearing loss
CARDIOVASCULAR DISORDERS:
1. Differentiate between a right to left and left to right shunt in cardiac disease.
- A left to right shunt moves oxygenated blood back through the pulmonary circulation. A right to left
shunt bypasses the lungs and delivers unoxygenated blood to the systemic circulation causing
cyanosis.
6. What position would best relieve the child experiencing a “tet” spell?
- Knee-chest position, or squatting.
NEUROMUSCULAR DISORDERS:
2. Describe “scissoring.”
- A common characteristic of spastic cerebral palsy in infants. The legs are extended and crossed
over each other, the feet are plantar flexed.
6. State the 3 main goals in providing nursing care for a child experiencing a seizure.
- Maintain patent airway, protect from injury, and observe carefully.
RENAL DISORDERS:
1. Compare the signs and symptoms of acute glomerulonephritis (AGN) with nephrosis.
- AGN: gross hematuria, recent strep infection, hypertension, and mild edema. Nephrosis: severe
edema, massive proteinuria, frothy-appearing urine, anorexia.
4. What is the physiologic reason for the lab finding of hypoproteinemia in nephrosis?
- Hypoproteinemia occurs because the glomeruli are permeable to serum proteins.
9. Explain why hypospadias correction is done before the child reaches preschool age.
- Preschoolers fear castration, are achieving sexual identity, and acquiring independent toileting
skills.
GASTROINTESTINAL DISORDERS:
1. Describe feeding techniques for the child with cleft lip or palate.
- Lamb’s nipple, or prosthesis. Feed child upright with frequent bubbling.
3. What nursing actions are initiated for the newborn with suspected esophageal atresia with
TEF?
- NPO immediately and suction secretions.
4. Describe the post-op nursing care for an infant with pyloric stenosis.
- Maintain Iv hydration and provide small, frequent oral feedings of glucose and/or electrolyte
solutions within 4-6 hours. Gradually increase to full strength formula. Position on right side in
semi-Fowler’s position after feeding.
6. Describe the pre-op nursing care for a child with Hirschsprung’s disease.
- Check vital signs and take axillary temps. Provide bowel cleansing program and teach about
colostomy. Observe for bowel perforation; measure abdominal girth.
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HEMATOLOGICAL DISORDERS:
1. Describe what information families should be given when a child is receiving oral iron
preparations.
- Give oral iron on an empty stomach and with vitamin C. Use straws to avoid discoloring teeth.
Tarry stools are normal. Increase dietary sources of iron.
7. Nursing interventions and medical treatment for the child with leukemia are based on what
3 physiological problems?
- Anemia (decreased erythrocytes). Infection (neutropenia). Bleeding thrombocytopenia
(decreased platelets).
SKELETAL DISORDERS:
6. What discharge instructions should be included for a child with spica cast?
- Check circulatio. Keep cast dry. Do not stick anything under cast. Prevent cast soilage during
toileting or diapering. DO NOT TURN with abductor bar.
7. What are the signs and symptoms of congenital dislocated hip in infants?
- Unequal skin folds of the buttocks, ortalani sign, limited abduction of the affected hip, and unequal
leg lengths.
9. What instructions should the child with scoliosis receive about the Milwaukee brace?
- Wear the brace 23 hours per day. Wear t-shirt under brace. Check skin for irritation. Perform
back and abdominal exercises. Modify clothing. Encourage the child to maintain normal activities
as able.
10. What care is indicated for a child with juvenile rheumatoid arthritis?
- Prescribed exercise to maintain mobility, splinting of affected joints, and teaching medication
management and side effects of drugs.
RESPIRATORY FAILURE:
3. Identify the condition that exists when the PO2 is less than 50 mmHg and FiO2 is greater
than 60%.
- Hypoxemia
1. Define shock.
- Widespread, serious reduction of tissue perfusion which leads to generalized impairment of
cellular function.
- Release of endotoxins from bacteria which act on nerves in vascular space in periphery, causing
vascular pooling, reduced venous return, and decreased cardiac output, resulting in poor systemic
perfusion.
5. What intervention is used to restore cardiac output when hypovolemic shock exists?
- Rapid infusion of volume-expanding fluids
6. It is important to differentiate between hypovolemic and cardiogenic shock. How might the
nurse determine the existence of cardiogenic shock?
- History of MI with left ventricular failure or possible cardiomyopathy, with symptoms of pulmonary
edema.
10. Once circulating volume is restored, vasopressors may be prescribed to increase venous
return. List the main drugs that are used.
- Epinephrine (Bronkaid). Dopamine (Dopram). Dobutamine (Dobutrex). Norepinephrine
(Levophed). Isoproterenol (Isuprel).
12. List 4 measurable criteria that are the major expected outcomes of a shock crisis.
- BP mean of 80 to 90 mmHg. PO2 >50 mmHg. CVP above 6 cm of H2O. Urine output at least 30
cc/hr.
14. What is the effect of DIC on PT, PTT, platelets, FSPs (FDPs)?
- PT: prolonged. PTT: prolonged. Platelets: decreased. Fribin split products: increased.
RESUSCITATION:
1. What is the first priority when a client with an unwitnessed cardiac arrest is found?
- Begin CPR
3. What criteria should alert a client with known angina who takes nitroglycerin tablets
sublingually to call the EMS?
- Unrelieved chest pain after 3 nitroglycerin tabs in 15 minutes.
4. After calling out for help and asking someone to dial for emergency services, what is the
next action in CPR?
- According to American Heart Association guidelines published September 2000, you should call
for help first for unresponsive adults and then begin the ABC’s of CPR. For unresponsive infants
& children, CPR should be performed for 1 minute before placing a 911 call for help.
5. True or False: In feeling of presence of a carotid pulse, no more than 5 seconds should be
used.
- FALSE: palpate for at least 5 to 10 seconds, recognizing that arrythmias or bradycardia could be
occurring.
6. During one-rescuer CPR, what is the ratio of compressions to ventilations for an adult?
During one-rescuer CPR, what is the ratio of compressions to ventialations for a child?
- 15:2 X 4 cycles for adult. 5:1 for a child and neonate.
7. What is the FIRST drug most likely to be used for an in-hospital cardiac arrest?
- Epinephrine
9. True or False: A precordial thump is routine activity for an in-hospital cardiac arrest.
- FALSE: only indicated in pulseless VT or VF or when ventricular asystole on monitor responds to a
thump with a QRS complex.
10. How would the nurse assess the adequacy of compressions during CPR? How would the
nurse assess for adequacy of ventilations during CPR?
- Check for a pulse. Watch for chest excursion and auscultate bilaterally for breath sounds.
12. One should NEVER make blind sweeps into the mouth of a choking child or infant. Why?
- Because the object might be pushed further down into the throat.
13. Why do ACLS guidelines recommend a decreased reliance on the use of bicarbonate
during adult CPR?
- Because acidosis should be relieved with improved ventilation. Bicarbonate administration can
actually contribute to increased CO2.
5. Cite the ABG normals for the following: pH, pCO2, HCO3.
- pH: 7.35-7.45. pCO2: 35 to 45 mmHg. HCO3: 22-26 mEq/L
PERIOPERATIVE CARE:
2. Why is a client with liver disease at increased risk for operative complications?
- Impairs ability to detoxify medications used during surgery. Impairs ability to produce prothrombin
to reduce hemorrhage.
4. What items should the nurse assist the client in removing before surgery?
- Contact lenses, glasses, dentures, partial plates, wigs, jewelry, prosthesis, make-up and nail
polish.
5. How and why is the client positioned in the immediate postoperative period?
- Usually on the side or with head to side in order to prevent aspiration of any emesis.
10. During the intraoperative period, what activities should the operating room nurse do to
ensure safety during surgery?
- Ascertain correct sponge, needle, and instrument count. Position client to avoid injury. Apply
ground during electrocautery use. Strict use of surgical asepsis.
HIV INFECTION:
Super Condensed Portable HESI Study Guide 61
2. Vertical transmission (from mother to fetus) occurs how often if mother is treated during
pregnancy?
- Vertical transmission occurs 30 to 50% of the time.
PAIN:
1. What modalities are associated with the Gate control pain theory?
- Massage, heat and cold, acupuncture, TENS.
2. How does past experiences with pain influence current pain experience?
- The more pain experienced in childhood, the greater the perception of pain in adulthood or with
current pain experience.
4. What 6 factors should the nurse include when assessing the pain experience?
- Location, intensity, comfort measures, quality, chronology and subjective view of pain.
5. What mechanism is involved in the reduction of pain through the administration of NSAIDs
meds?
- NSAIDs act by a peripheral mechanism at the level of damaged tissue by inhibiting prostaglandin
synthesis and other chemical mediators involved in pain transmission.
10. Which route of administration for pain medications has the quickest onset and the shortest
duration?
- IV push or bolus.
11. List the 6 modalities that are considered non-invasive, non-pharmacologic pain relief
measures.
- Heat and cold applications. Transcutaneous electrical nerve stimulation (TENS). Massage.
Distraction. Relaxation techniques. Biofeedback techniques.
2. A client has been told of a positive breast biopsy report. She asks no questions and leaves
the healthcare provider’s office. She is overheard telling her husband, :the doctor didn’t
find a thing.” What coping style is operating at this stage of grief?
- Denial
3. Your client, an incest survivor, is speaking of her deceased father, the perpetrator. “He was
a wonderful man, so good and kind. Everyone thought so.” What would be the most
useful intervention at this time?
- Gently point out both the positive and negative aspects of her relationship wit her father. Try to
minimize the idealization of the deceased.
4. Your client feels responsible for his sister’s death because he took her to the hospital where she
died. “If I hadn’t taken her there, they couldn’t have killed her.” It has been one month since her
death. Is this response indicative of a normal or complicated grief reaction?
- This is a normal expression of anger and guilt, which occurs. Try to minimize the rumination of
these thoughts.
5. Mrs. Green lost her husband 3 years ago. She has not disturbed any of his belongings and
continues to set a place at the table for him nightly. Is this response indicative of a normal
or complicated grief reaction?
- This is a dysfunctional grief reaction. Mrs. Green has never moved out of the denial stage of her
grief work.
ELECTROCARDIOGRAM:
5. If the U wave is most prominent, what condition might the nurse suspect?
- Hypokalemia
6. Describe the calculation of the heart rate using an EKG rhythm strip.
- Count the number of the R-R intervals in the 30 large squares and multiply by 10
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7. What is the most important assessment data for the nurse to obtain on a client with
arrythmia?
- Ability of the client to tolerate the arrhythmia
GERONTOLOGICAL NURSING:
2. What symptoms might the nurse expect to see in an older person who has had an overload
of changes as well as a respiratory infection?
- Confusion.
5. List 5 nursing interventions to promote adequate bowel functioning for older persons.
- Determine what is normal GI functioning for each individual, increase fiber and bulk in the diet,
provide adequate hydration, encourage regular exercise, and encourage eating, small, frequent
meals.
6. How can a female nurse increase the older client’s ability to hear her speak?
- Lower the pitch or tone of her voice.
8. Describe the following conditions which occur in the elderly: Presbyopia, Arcus senilis,
Presbycusis.
- Presbyopia – decreased ability of the eye to accommodate for close work.
- Arcus senilis – glossy white ring encircling the periphery of the cornea
- Presbycusis – decrease in hearing acuity, auditory threshold, pitch and tone discrimination, and
speech intelligibility.
11. What are the 2 factors that cause decrease in excretion of drugs by the kidneys?
- Decrease in glomerular filtration and slowed organ functioning.
OB-MATERNITY
2. Ovulation occurs how many days before the next menstrual period?
Super Condensed Portable HESI Study Guide 64
- 14 days.
5. Name the major discomforts of the first trimester and one suggestion for amelioration of
each.
- Nausea and vomiting: crackers before rising. Fatigue: teach the need for rest periods/naps and 7-
8 hours sleep at night.
6. If the first day of a woman’s last normal menstrual period was May 28, what is the
estimated delivery date (EDD) using Nagele’s rule?
- Count back 3 months and add 7 days: March 7 (always give February 28 days).
7. At twenty weeks gestation, the fundal height would be ______ , the fetus would weigh
approximately _______ and look like _____ .
- At the umbilicus; 300-400 grams; a baby with hair, lanugo and verniz, but without subcutaneous
fat.
10. State three principles relative to the PATTERN of weight gain in pregnancy.
- Total gain should average 24-30 lbs. Gain should be consistent throughout pregnancy. An
average of 0.9 lb/week should be gained in the 2nd & 3rd trimester.
11. During pregnancy a woman should add ____ calories to her diet, and drink ____ of
milk/day.
- 300 calories; 1 quart of milk
12. Fetal heart rate can be auscultated by Doppler at ____ weeks gestation.
- 10-12 weeks
13. Describe the schedule for prenatal visits for a low-risk pregnant woman.
- Once a month until 28 weeks, then once every week until delivery.
4. List 3 necessary nursing actions prior to an ultrasound exam for a woman in the first
trimester of pregnancy.
- Have client fill bladder. Do not allow client to void. Position supine with uterine wedge.
7. What is the most important determinant of fetal maturity for extrauterine survival?
- L/S ratio (lung maturity, lung surfactant development)
9. Name the 4 periodic changes of the fetal heart rate, their causes, and one nursing treatment
for each.
- Acceleration: caused by burst of sympathetic activity; they are reassuring and require no
treatment. Early decelerations: caused by head compression, are benign and caution the nurse to
monitor for labor progress and fetal descent. Variable decelerations: caused by cord compression;
change of position should be tried first. Late decelerations: are caused by UPI (uteroplacental
insufficiency) and should be treated by placing client on her side and administering O2.
10. What is the most important indicator of fetal autonomic nervous system integrity/health?
- Fetal heart rate variability
12. State the most important action to take when a cord prolapse is determined.
- Examiner should position mother to relieve pressure on the cord with fingers until emergency
delivery is accomplished.
15. Normal fetal scalp pH in labor is ____ and values below ____ indicate true acidosis.
- 7.25-7.35 normal pH; 7.2 indicates true acidosis.
INTRAPARTUM:
1. List five prodromal signs of labor the nurse might teach the client.
- lightening, braxton-hicks contractions increase, bloody show, loss of mucous plug, burst of energy,
and nesting behaviors.
- Nitrazine testing: paper turns dark blue or black. Demonstration of fluid “ferning” under
microscope.
4. Are psychoprophylactic breathing techniques prescribed for use by the stage and phase of
labor?
- No, clients should use these techniques according to their discomfort level and change techniques
when one is no longer working for relaxation.
5. Identify two reasons to withhold anesthesia and analgesia until the mid-active phase of
Stage 1 labor.
- if given too early, can retard labor; if given too late, can cause fetal distress
6. Hyperventilation often occurs to the laboring client. What results from hyperventilation
and what actions should the nurse take to relieve the condition?
- Respiratory alkalosis occurs which is caused by blowing off CO2 and is relieved by breathing into
a paper bag or cupped hands.
12. List four nursing actions for the 2nd stage of labor.
- make sure cervix is completely dilated before pushing is allowed. Assess FHR with each
contraction. Teach woman to hold breath for no longer than 5 seconds. Teach pushing technique.
14. When should the postpartum dosage of Pitocin be administered? Why is it administered?
- give immediately after placenta is delivered to prevent postpartum hemorrhage/atony.
17. If meconium was passed in utero, what action must the nurse take in the delivery room?
- arrange for immediate endotracheal tube observation to determine the presence of meconium
below the vocal cords (prevents pneumonitis/meconium aspiration syndrome)
21. What is the major cause of maternal death when general anesthesia is administered?
- Aspiration of gastric contents
25. Hypotension often occurs after the laboring client receives a regional block. What is one of
the first signs the nurse might observe?
- Nausea
26. State three actions the nurse should take when hypotension occurs in a laboring client.
- turn client to left side. Adminsiter O2 by mask at 10L/min. increase speed of intravenous infusion
(if it does not contain medication).
28. What actions can the nurse take to assist in preventing postpartum hemorrhage?
- massage the fundus (gently) and keep the bladder emptied.
29. To promote comfort, what nursing interventions are used for a 3 rd degree episiotomy, which
extends into the anal sphincter?
- ice pack, withc hazel compresses, and no rectal manipulation
30. What nursing interventions are used to enhance maternal-infant bonding during the 4 th
stage of labor?
- withhold eye prophylaxis up to 2 hours. Perform newborn admission/routine procedures in room
with parents. Encourage early initiation of breastfeeding. Darken room to encourage newborn to
open eyes.
32. List symptoms of a full bladder, which might occur in the 4th stage of labor.
- fundus above umbilicus, dextroverted (to the right side of abdomen), increased bleeding (uterine
atony).
33. What action should the nurse take first when a soft, boggy, uterus is palpated?
- perform fundal massage
35. How often should the nurse check the fundus during the 4 th stage of labor?
- q15 minutes X 4 (1 hour), q30 minutes X 2 hours if normal.
1. A nurse discovers a postpartum client with a boggy uterus, displaced above and to the
right of the umbilicus. What nursing action is indicated?
- Perform immediate fundal massage. Ambulate to the bathroom or use bedpan to empty bladder
because cardinal signs of bladder distention are present.
3. Upon admission to the postpartum room, 3 hours after delivery, a client has a temperature
of 99.5F. What nursing actions are indicated?
- Probably elevated due to dehydration and work of labor; force fluids and retake temperature in an
hour; notify physician if above 100.4F.
4. A client feels faint on the way to the bathroom. What nursing assessments should be
made?
- Assess BP sitting and lying, assess Hgb and Hct for anemia.
6. A breastfeeding mother complains of very tender nipples. What nursing actions should be
taken?
- Have her demonstrate infant position on breast (incorrect positioning often causes tenderness).
Leave bra open to air-dry nipples for 15 minutes 3X daily. Remove all “smothering” creams.
7. Three days postpartum, a lactating mother has full, warm, taut, tender breasts. What
nursing actions should be taken?
- She is engorged; have newborn suckle frequently; use measures to increase milk flow; warm
water, breast massage and supportive bra.
9. A woman has decided to take birth control pills as her contraceptive method. What should
she do if she misses taking the pill two consecutive days?
- Take two pills for two days and use an alternate form of birth control.
10. A woman asks why she is urinating so much in the postpartum period. The nurse bases
the response on what information.
- Up to 3,000 cc per day can be voided due to the reduction of the 40% plasma volume increase
during pregnancy.
11. A woman’s white blood count returns 17,000; she is afebrile and has no symptoms of
infection. What nursing action is indicated?
- Continue routine assessments; normal leukocytosis occurs during postpartal period because of
placental site healing.
12. What is the most common cause of uterine atony in the first 24 hours postpartum?
- full bladder
13. What is the purpose of giving docusate sodium (Colace) to the postpartum client?
Super Condensed Portable HESI Study Guide 69
- to soften the stool in mother’s with 3 rd and 4th degree episiotomies, hemorrhoids, or Cesarean
section delivery.
14. What should the fundal height be at three days postpartum for a woman who has had a
vaginal delivery?
- 3 fingerbreadths/cm below the umbilicus.
2. The nurse anticipates which newborn will be more at risk for problems in the transitional
period. State 3 predisposing factors to respiratory depression in the newborn.
- Cesarean delivery; magnesium sulfate given to mother in labor; asphyxia/fetal distress in labor.
3. What is the danger of heat loss to the newborn in the first few hours of life?
- Leads to depletion of glucose (very little glycogen storage in immature liver); begins to use brown
fat for energy producing ketones causing subsequent ketoacidosis and shock.
5. The nurse records a temperature below 97F on admission of the newborn. What nursing
actions should be taken?
- Place newborn in isolette or under radiant warmer and attach a temperature skin probe to regulate
isolette or radiant warmer temperature. Wrap newborn double if no isolette or warmer available
and put cap on head. Watch for signs of hypothermia and hypoglycemia.
6. True or False: the newborn’s head is usually smaller than the chest.
- FALSE: head is usually 2 cm larger unless severe molding occurred.
7. During the physical exam of the newborn, the nurse notes the cry is shrill, high-pitched,
and weak. What are the possible causes?
- CNS anomalies, brain damage, hypoglycemia, drug withdrawal.
8. The nurse notes a swelling over the back part of the newborn head. Is this normal newborn
variation?
- It depends on the exam. If it crosses suture lines and is a caput (edema), it is normal. If it does
not cross suture lines, it is a cephalhematoma with bleeding between the skull and periosteum.
This could cause hyperbilirubinemia. This is an abnormal variation.
10. Identify 3 ways t determine presence of congenital hip dislocation in the newborn.
- Hip click determination, asymmetrical gluteal folds, unequal limb lengths.
11. Should the normal newborn have a positive or negative Babinski reflex?
- Positive. The transient reflex is present until 12-18 months of age.
13. When suctioning the newborn with a bulb syringe, which should be suctioned first, the
mouth or the nose?
- Mouth; stimulating the nares can initiate inspiration which could cause aspiration of mucus in oral
pharynx.
14. A new mother asks the nurse if circumcision is medically indicated in the newborn. How
should the nurse respond?
- There is controversy concerning this issue, but we do know it causes pain and trauma to the
newborn, and the medical indication may be unfounded.
15. Normal blood glucose in the term neonate is ____. = 40-80 mg/dl.
16. Why does the newborn need vitamin K in the 1st hour after birth?
- Sterile gut at delivery lacks intestinal bacteria necessary for the synthesis of vitamin K; vitamin K is
needed in the clotting cascade to prevent hemorrhagic disorders.
19. A term newborn needs to take in _____ calories per pound per day. After the initial weight
loss is sustained, the newborn should gain _____ per day.
- 50 calories; 1 ouncce or 30 grams.
20. List 5 signs and symptoms new parents should be taught to report immediately to a doctor
or clinic.
- Lethargy; temperature >100F, vomiting, green stools, refusal of 2 feeds in a row.
HIGH-RISK DISORDERS:
1. What instructions should the nurse give the woman with a threatened abortion?
- Maintain strict bedrest for 24-48 hrs. Avoid sexual intercourse for two weeks.
2. Identify the nursing plans and interventions for a woman hospitalized with hyperemesis
gravidarum.
- Weight daily; uring ketone checks 3X daily; progressive diet; check FHR q8h; monitor for
electrolyte imbalances.
3. Describe discharge counseling for a woman after hydatidiform mole evacuation by D&C.
- Prevent pregnancy for one year. Return to clinic/MD for monthly hCG levels for 1 yr. Post-op D&C
instructions; call if bright red vaginal bleeding or foul smelling vaginal discharge occurs, or
temperature spike over 100.4F.
4. What condition should the nurse suspect if a woman of childbearing age presents to an
emergency room with bilateral or unilateral abdominal pain with or without bleeding?
- Ectopic pregnancy
6. What specific information should the nurse include when teaching human papillomavirus
detection & treatment?
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- Detection of dry; wart-like growths on vulva or rectum. Need for pap smear in the prenatal period.
Treatment with laser ablation (cannot use Podophyllin in pregnancy). Associated with cervical
carcinoma in mother and respiratory papillomatosis in neonate.
9. All pregnant women should be taught preterm labor recognition. Describe the warning
symptoms of preterm labor.
- More than 5 contractions/hour, cramps, low, dull backache; pelvic pressure; change in vaginal
discharge.
12. What is the major side effect of beta-adrenergic (Terbutaline, Ritodrine) tocolytic drugs?
- Tachycardia
13. What special actions should the nurse take in the intrapartum period if preterm labor is
unable to be arrested?
- Monitor the FHR continuously and limit drugs, which cross placental barriers to prevent fetal
depression or further compromise.
14. A prolonged latent phase for a multipara is ____ and for a nullipara is ____. Multiparas
average cervical dilatation is ____cm/hr in the active phase and nulliparas average cervical
dilatation is ____cm/hr in the active phase.
- >14 hours, >20 hours, 1.5 cm/her; 1.2 cm/hr.
15. What are the major goals of nursing care related to pregnancy-induced hypertension with
preeclampsia?
- Maintenance of uteroplacental perfusion; prevention of seizures; prevention of complications such
as HELLP syndrome, DIC and abruption.
16. Magnesium sulfate is used to treat PIH. A) What is the purpose for administration of
magnesium sulfate? B) What is the main action of magnesium sulfate? C) The antidote for
magnesium sulfate? D) List the 3 main assessment findings indicating toxic effects of
magnesium sulfate.
- A) Prevent seizures by decreasing CNS irritability B) Central nervous system depression (seizure
prevention) C) Calcium Gluconate D) Reduced urinary output, reduced respiratory rate, and
decreased reflexes.
17. What are the major symptoms of pregnancy induced hypertension (preeclampsia)?
- Increase in BP of 30mmHg systolic and 15 mmHg diastolic over previous baseline; hyperflexia;
proteinuria (albuminuria); CNS disturbances; headache, and visual disturbances; epigastric pain.
18. What is the priority nursing action after spontaneous or artificial rupture of membranes?
- Assessment of the fetal heart rate.
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19. What is the most common complication of oxytocin augmentation or induction of labor?
List 3 actions the nurse should take if such a complication occurs.
- Tetany. Turn off Pitocin. Turn pregnant woman to side. Administer O2 by face mask.
20. List the symptoms of water intoxification from the antidiuretic hormone (ADH) effect of
Pitocin (oxytocin).
- Nausea and vomiting, headache, and hypotension.
23. What interventions should the nurse implement to prevent further CNS irritability in the PIH
client?
- Darken room, limit visitors, maintain close 1:1 nurse/client ratio, place in private room, plan
nursing interventions all together so client is disturbed as little as possible.
24. A woman on Orinase (oral hypoglycemic) asks the nurse if she can continue this
medication in pregnancy. How should the nurse respond?
- No, oral hypoglycemic medications are teratogenic to the fetus. Insulin will be used.
26. When should the nurse hold the dose of magnesium sulfate and call the physician?
- When the client’s respirations are <12/minute, DTRs are absent, or urinary output is <100cc/4
hours
27. State 3 priority nursing actions in the postdelivery period for the client with PIH.
- Monitor for signs of blood loss. Continue to assess BP and DTRs q4 hours. Monitor for uterine
atony.
28. When are the 2 most difficult times for control for the pregnant diabetic?
- Late in the 3rd trimester and in the postpartum period when insulin needs to drop sharply (the
diabetogenic effects of pregnancy drop precipitously).
30. List 3 conditions clients with diabetes mellitus are more prone to develop.
- PIH, hydramnios; infection
33. The goal for diabetic management during labor is euglycemia. How is it defined?
- 60-100 mg/dl.
- Diaphragm with spermicide. Avoid birth control pills that contain estrogen and IUDs, which are an
infection risk.
35. List the symptoms of cardiac decompensation in the laboring client with cardiac disease.
- Tachycardia, tachypnea, dry cough, rales in lung bases, dyspnea, and orthopnea.
36. What interventions can the nurse implement to maintain cardiac perfusion in a laboring
cardiac client?
- Position client in a semi or high-Fowler’s position. Prevent Valsalva’s maneuvers. Position client
in a supine or R/T for regional anesthesia. Avoid stirrups because of possible popliteal vein
compression and decreased venous return.
37. Gentle counterpressure against the perineum during an emergency delivery prevents ____
and ____.
- Maternal lacerations, fetal cerebral trauma.
38. When may a vaginal birth after Cesarean (VBAC) be considered by a woman with a
previous c-section?
- If a low uterine transverse incision was performed and can be documented AND if the original
complication does not recur, i.e., CPD.
39. Prior to anesthesia for C-section delivery, the mother may be given an antacid or a gastric
antisecretory drug (histamine receptor antagonist). State the reasons why these drugs are
given.
- Antacid buffers alkalize the stomach secretions. If aspiration occurs, less lung damage ensues.
An antisecretory drug reduces gastric acid, reducing the risk of gastric aspiration.
40. Clients who have had a C-section are prone to what post-op complications?
- Paralytic ileus, infection, thromboembolism, respiratory complications, and impaired maternal
infant bonding.
2. What are the common side effects of antibiotics used to treat puerperal infection?
- GI adverse reactions: nausea, vomiting, diarrhea, and cramping. Hypersensitivity reactions:
rashes, urticaria, and hives
1. List the major CNS danger signals, which occur in the neonate.
- Lethargy, high-pitched cry, jitteriness, seizures, and bulging fontanels.
2. A baby is delivered blue, limp, and with a heart rate <100. The nurse dries the infant,
suctions the oropharynx and gently stimulates the infant while blowing O2 over the face.
The infant still does not respond. What is the next nursing action?
- Begin oxygenation by bag and mask at 30-50 breaths/minute. Assist physician in setting up for
intubation procedure.
8. In order to prevent problems with oxygenating the newborn, what parameters can the nurse
observe?
- PO2 50-90, SVO2 60-80 mmHg.
10. A premature baby is born and develops hypothermia. State the major nursing
interventions to treat hypothermia.
- Place under radiant warmer or in incubator with temperature skin probe over liver. Warm all items
touching the newborn. Place plastic wrap over neonate.
11. Nurses often weigh diapers in order to determine exact urine output in the high-risk
neonate. Explain this procedure.
- Diaper is weighed in grams before applying. Weigh diaper after wetting. Calculate and record
each gram or added weight as one cc of urine.
12. What factors does the nurse look for in determining the newborn’s ability to take in
nourishment by nipple/mouth?
- Good suck, coordinated suck-swallow, takes less than 20 minutes to feed, gaining 20-30 gm/day.
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13. What complications are associated with total parenteral nutrition (TPN)?
- Hyperglycemia, electrolyte imbalance, dehydration, and infection.
14. In order to prevent rickets in the preterm newborn, what supplement is given?
- Calcium and vitamin D.
18. Write one nursing diagnosis generated from the data pertinent to hyperbilirubinemia.
- Potential for injury related to predisposition of bilirubin for fat cells in brain.
21. Neonates who are “sick” are prone to receive too much stimulation in the form of invasive
procedures and handling too little developmentally-appropriate stimulation and affection.
How might such an infant respond?
- Failure to thrive, lack of crying.
22. How should the nurse determine the length of a tube needed for oral gavage feeding of a
newborn?
- From the bridge of the nose, to the earlobe, to a point halfway between the xiphoid and the
umbilicus.
23. What are the 2 best ways to test for correct placement of the gavage tube in the infant’s
stomach?
- Aspiration of stomach contents with pH testing, and auscultation of air bubble injected into
stomach.
24. What characteristics would the nurse expect to see in a neonate with fetal alcohol
syndrome?
- Microcephaly, growth retardation, short palpebral fissures, and maxillary hypophysia.
In ARDS, a common laboratory finding is lowered PO2. However, these clients are not very
responsive to high concentrations of oxygen.
Think about the physiology of the lungs by remembering PEEP: Positive End Expiratory Pressure
is the instillation and maintenance of small amounts of air into the alveolar sacs to prevent them
from collapsing each time the client exhales. The amount of pressure can be set with the
ventilator and is usually around 5 to 10 cm of water.
Before drawing arterial blood gases from the radial artery, perform the Allen test to assess
collateral circulation. Make the client’s hand blanch by obliterating both the radial and ulnar
pulses. Then release the pressure over the ulnar artery only. If flow through the ulnar artery is
good, flushing will be seen immediately. The Allen test is then positive, and the radial artery can
be used for puncture. If the Allen test is negative, repeat on the other arm. If this test is also
negative, seek another site for arterial puncture. The Allen test ensures collateral circulation to the
hand if thrombosis of the radial artery should follow the puncture.
If the client does not have O2 to his/her brain, the rest of the injuries do not matter because death
will occur. However, they must be removed from any source of imminent danger, such as a fire.
Early signs of shock are agitation and restlessness resulting from cerebral hypoxia.
If cardiogenic shock exists with the presence of pulmonary edema, i.e., from pump failure, position
client to REDUCE venous return (HIGH FOWLER’s with legs down) in order to decrease venous
return further to the left ventricle.
Severe shock leads to widespread cellular injury and impairs the integrity of the capillary
membranes. Fluid and osmotic proteins seep into the extra vascular spaces, further reducing
cardiac output. A vicious cycle of decreased perfusion to ALL cellular level activities ensues. All
organs are damaged, and if perfusion problems exist, the damage can be permanent.
All vasopressors/vasodilator drugs are potent and dangerous and require weaning on and off. Do
not change infusion rates simultaneously.
A client is brought into the hospital suffering shock symptoms as a result of a bee sting. What is
the first priority? Maintaining an open airway (the allergic reaction damages the lining of the
airways causing edema). Also, keep the client warm without constricting clothing; keep legs
elevated (not Trendelenburg because the weight of the lower organs restricts breathing).
Volume expanding fluids are usually given to clients in shock. However, if the shock is
cardiogenic, pulmonary edema may result.
You are caring for a woman who was in severe automobile accident several days ago. She has
several fractures and internal injuries. The exploratory laparotomy was successful in controlling
the bleeding. However, today you find that this client is bleeding from her incision, short of breath,
has a weak thready pulse, has cold and clammy skin, and hematuria.
- What do you think is wrong with the client, and what would you expect to do about it?
- These are typical signs and symptoms of DIC crisis. Expect to administer IV heparin to block the
formation of thrombin (Coumadin does not do this). However, the client described is already past
the coagulation phase and into the hemorrhagic phase. Her management would be administration
of clotting factors along with palliative treatment of the symptoms as they arise. (Her prognosis is
poor).
NCLEX-RN questions on CPR often deal with prioritization of actions. Question: What actions are
required for each of the following situations?
- A 24-year old motorcycle accident vistim with a ruptured artery if the leg is pulseless and apneic.
- A 36-year old first time pregnant woman who arrests during labor.
- A 17-year old with no pulse or respirations who is trapped in an overturned car, which is starting to
catch fire.
- A 40-year old businessman who arrests two days after a cervical laminectomy.
It is important for the nurse to stay current with the American Heart Association’s guidelines for
Basic Life Support (BLS) by being certified every two years as required.
If one rescuer is performing CPR, 1 15:2 ratio of compression to ventilations is performed for 4
cycles, then reassess for breathing and pulse. If two rescuers are performing CPR, a 15:2 ratio is
now recommended for compressions to ventilations. Perform for 15 cycles with a 100/min
compression rate. When trading off, start with compressions.
Initiate CPR with BLS guidelines immediately, then move on to Advanced Cardiac Life Support
(ACLS) guidelines.
When significant arterial acidosis is noted, try to reduce PCO2 by increasing ventilation, which will
correct arterial, venous, and tissue acidosis. Bicarbonate may exacerbate acidosis b producing
CO2. Thus, the ACLS guidelines have recommended bicarbonate NOT be used unless
hyperkalemia and/or preexisting acidosis is documented.
Infants/prematures may have problems with the following that can predispose to arrest: Beware of
the “H’s” – hypoxia, hypoglycemia, hypothermia, increased H+ (metabolic and/or respiratory
acidosis), hypercoagulability (if polycythemia exists).
Changes is osmolarity cause shifts in fluid. The osmolarity of the extracellular fluid (ECF) is
almost entriely due to sodium. The osmolarity of intracellular fluid (ICF) is related to many
particles, with potassium being the primary electrolyte. The pressures in the ECF and the ICF are
almost identical. If either ECF or ICF change in concentration, fluid shifts from the area of lesser
concentration to the area of greater concentration.
Normal saline is an isotonic solution and is used for irrigations, such as bladder irrigations or IV
flush lines with intermittent IV medication.
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Use only isotonic (neutral) solutions in irrigations, infusions, etc., unless the specific aim is to shift
fluid into intracellular or extracellular spaces.
Check the IV tubing container to determine the drip factor because drip factors vary. The most
common drip factors are 10, 12, 15, and 60 drops per milliliter. A microdrip is 60 drops per
milliliter.
Flushing a saline lock requires approximately 1 ½ times the amount of fluid that the tubing will hold
in order to efficiently flush the tubing. REMEMBER to use sterile technique to prevent
complications such as infiltration, emboli and infection.
A pH of less than 6.8 or more than 7.8 is NOT COMPATIBLE WITH LIFE.
The acronym ROME can help you remember: Respiratory, Opposite, Metabolic, Equal.
Since the T waves represents repolarization of the ventricle, this is a critical time in the heartbeat.
This action represents a resting and regrouping stage so that the next heartbeat can occur. If
defibrillation occurs during this phase, the heart can be thrust into a life-threatening dysrhythmia.
Observe the client for tolerance of the current rhythm. This information is the most important data
the nurse can collect on the client with an arrythmia.
REMEMBER to monitor the client as well as the machine! If the EKG monitor shows a severe
dysrhythmia, but the client is sitting up quietly watching a TV without any sign of distress, assess
to determine if the leads are attached properly.
Marking the operative site is required for procedures involving right/left distinctions, multiple
structures (fingers, toes), or levels (spinal procedures). Site marking should be done with the
involvement of the client.
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Wound dehiscence is separation of the wound edges and is more likely to occur with vertical
incisions. It usually occurs after the early postoperative period, when the client’s own granulation
tissue is “taking over” the wound, after absorption of the sutures has begun. Evisceration of the
wound is protrusion of intestinal contents (in an abdominal wound) and is more likely in clients
who are older, diabetic, obese, or malnourished and have prolonged paralytic ileus.
NCLEX-RN items will focus on the nurse’s role in terms of the entire perioperative process.
Sample: A 43-year old mother of 2 teenage daughters enters the hospital to have her gallbladder
removed in a same-day surgery using a scope instead of an incision. What nursing needs will
dominate each phase of her short hospital stay?
- Preparation phase: Education about postoperative care, NPO, assist with meeting family needs.
- Operative phase: Assessment, management of the operative suite.
- Post-anesthesia phase: Pain management, post-anesthesia precautions.
- Post-operative phase: Prevent and assess for complications, pain management, dietary
restrictions, activity.
HIV clients with tuberculosis require respiratory isolation. Tuberculosis is the only real risk to non-
pregnant caregivers that is not related to a break in universal precautions (i.e., needle sticks, etc.).
STANDARD PRECAUTIONS:
- Wash hands, even if gloves have been worn to give care
- Wear gloves (latex) for touching blood or body fluids, or any non-intact body surface.
- Wear gowns during any procedure that might generate splashes (changing clients with diarrhea).
- Use masks and eye protection during activity which might disperse droplets (suctioning).
- Do not recap needles, dispose of in puncture-resistant containers.
- Use mouth piece for resuscitation efforts.
- Refrain from giving care if you have open skin lesions.
Caregivers who are pregnant may choose not to care for a client with Cytomegalovirus (CMV).
The focus of NCLEX-RN questions is likely to be assessment of early signs of the disease and
management of complications associated with HIV.
For narcotic induced respiratory depression, administer Naloxone 0.1mg to 0.4mg IV every 2-3
minutes as needed, until 1.0mg is achieved.
Narcotic analgesics are prepared for pain relief because they bind to the various opiate receptor
sites in the CNS. Morphine is often the preferred narcotic (REMEMBER: it causes respiratory
depression).
Other agonists are meperidine and methadone. Narcotic antagonists block the attachment of
narcotics to the receptors, such as Narcan (naloxone). Once Narcan has been given, additional
narcotics cannot be given until the Narcan effects have passed.
Do not take away the coping style used in a crisis state…DENIAL. It is a useful and needed tool
at the initial stage for some. Support, do not challenge, unless it hinders/blocks treatment –
endangering the patient.
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RESPIRATORY SYSTEM
Fever can cause dehydration from excessive fluid loss in diaphoresis. Increased temperature
also increases metabolism and the demand for oxygen.
Bronchial breath sounds are heard over areas of density or consolidation. Sound waves are
easily transmitted over consolidated tissue.
Hydration – enables liquification of mucous trapped in the bronchioles and alveoli, facilitating
expectoration. Essential for the client experiencing fever. Important because 300 to 400 ml of
fluid are lost daily by the lungs through evaporation.
Irritability and restlessness are early signs of cerebral hypoxia – the client is not getting enough
oxygen to the brain.
Pneumonia preventatives:
- Elderly: flu shots; pneumonia immunizations; avoiding sources of infection and indoor pollutants
(dust, smoke, and aerosols); do not smoke.
- Immunosuppressed and debilitated persons: infection avoidance, sensible nutrition, adequate
intake, balance of rest and activity.
- Comatose and immobile persons: elevate head of bed to feed; turn frequently.
Compensation occurs over time in clients with chronic lung disease, and arterial blood gases
(ABGs) are altered. It is imperative that baseline data are obtained on the client.
Productive cough and comfort can be facilitated by Semi-Fowler’s or high Fowler’s positions,
which lessen pressure on the diaphragm from abdominal organs. Gastric distention becomes a
priority in these clients because it elevates the diaphragm and inhibits lung expansion.
Pink puffer: Barrel chest is indicative of emphysema and is caused by use of accessory muscles to
breathe, which causes the person to work harder to breathe, but the amount of O2 taken in in
adequate to oxygenate the tissues.
Blue bloater: insufficient oxygenation occurs with chronic bronchitis and leads to generalized
cyanosis and often right-sided heart failure.
Cells of the body depend on oxygen to carry out their functions. Inadequate arterial oxygenation
is manifested by cyanosis and slow capillary refill (<3 seconds). A chronic sign is clubbing of the
fingernails, and a late sign is clubbing of the fingers.
Caution must be used in administering O2 to COPD client. The stimulus to breathe is hypoxia
(hypoxic drive) not the usual hypercapnia, the stimulus to breathe for healthy persons. Therefore,
if too much oxygen is given, the client may stop breathing!
Health Promotion:
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- Eating consumes energy needed for breathng. Offer mechanically soft diets, which do not require
as much chewing and digestion. Assist with feeding if needed.
- Prevent secondary infections – avoid crowds, contact with persons who have infectious diseases,
and respiratory irritants (tobacco smoke).
- Teach client to report any change in characteristics of sputum.
- Encourage client to hydrate well and to obtain immunizations needed (flu and pneumonia).
Look and listen. If breath sounds are clear, but the client is cyanotic and lethargic, adequate
oxygenation is not occurring.
The key to respiratory status assessment of breath sounds as well as visualization of the client.
Breath sounds are better “described,” not named, e.g., sounds should be described as “crackles,”
“wheeze,” “hihg-pitched whistling sound,” rather than “rales,” “rhonchi,” etc., which may not mean
the same thing to each clinical professional.
Watch for NCLEX-RN questions that deal with oxygen delivery. In adults, O2 must bubble through
some type of water solution so it can be humidified if given at >4 L/min or delivered directly to the
trachea. If given at 1 to 4 L/min or by mask or nasal prongs, the oropharynx and nasal pharynx
provide adequate humidification.
With cancer of the larynx, the tongue and mouth often appear white, gray, dark brown, or black,
and may appear patchy.
Tracheostomy care involves cleaning the inner cannula, suctioning, and applying a clean dressing.
Air entering the lungs is humidified along the naso-bronchial tree. This natural humidifying
pathway is gone for the client who has had a laryngectomy. If the air is not humidified before
entering the lungs, secretions tend to thicken and become crusty.
A laryngectomy tube has a larger lumen and is shorter than the tracheostomy tube. Observe the
client for any signs of bleeding or occlusion, which are the greatest immediate postoperative risks
(first 24 hours).
Fear of choking is very real for laryngectomy clients. They cannot cough as before because the
glottis is gone. Teach the “glottal stop” technique to remove secretions (take a deep breath,
momentarily occlude the tracheostomy tube, cough, and simultaneously remove the finger from
the tube).
TB SKIN TEST: a positive TB skin test is exhibited by an induration 10mm or greater in diameter
48 hours after skin test. Anyone who has received a BCG vaccine will have a positive skin test
and must be evaluated using a chest x-ray.
Teaching is very important with the TB client. Drug therapy is usually long term (9 months or
longer). It is essential that the client take the medications as prescribed for the entire time.
Skipping doses or prematurely terminating the drug therapy can result in a public health hazard.
TEACHING POINTS –
- Rifampin: Reduces effectiveness of oral contaceptives; should use other birth control methods
during treatment; gives body fluids orange tinge; stains soft contacts.
- Isoniazid (INH): Increases Dilantin levels.
- Ethambutal: Vision check before starting therapy and monthly; may have to take 1 to 2 years
longer.
- Teach rationale for combination drug therapy to increase compliance. Resistance develops more
slowly if several anti-TB drugs given, instead of just one drug at a time.
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Some tumors are so large that they fill entire lobes of the lung. When removed, large spaces are
left. Chest tubes are not usually used with these clients because it is helpful if the mediastinal
cavity, where the lung used to be, fills up with fluid. This fluid helps prevent a shift of the
remaining chest organs to fill the empty space.
If the chest tube remains disconnected, do not clamp! Immediately place the end of the tube in a
container of sterile saline or water until a new drainage system can be connected.
If the chest tube is accidentally removed from the client, the nurse should apply pressure
immediately with an occlusive dressing and notify the healthcare provider.
Chest Tube NCLEX-RN content: Fluctuations (tidaling) in the fluid will occur if there is no external
suction. These fluctuating movements are a good indicator that the system is intact and should
move upward with each inspiration and downward with each expiration. If fluctuations cease,
check for kinked tubing, accumulation of fluid in the tubing, occlusions, or change in the client’s
position, since expanding lung tissue may be occluding the tube opening. Remember, when
external suction is applied the fluctuations cease. Most hospitals DO NOT MILK chest tubes as a
means of clearing or preventing clots – it is too easy to remove chest tubes. Mediastinal tubes
may have orders to be stripped because of location, compared to larger thoracic cavity tubes.
RENAL SYSTEM
Normally, kidney excrete approximately 1ml of urine per kg of body weight per hour, which is about
1 to 2 liters in a 24-hour period.
Electrolytes are profoundly affected by kidney problems. There must be a balance between
extracellular fluid and intracellular fluid to maintain homeostasis. A change in the number of ions
or in the amount of fluid will cause a shift in one direction or the other. Sodium and chloride are
the primary extracellular ions. Potassium and phosphate are the primary intracellular ions.
In some cases, persons in ARF may not experience the oliguric phase but may progress directly to
diuretic phase during which the urine output may be as much as 10 liters per day.
Body weight is a good indicator of fluid retention and renal status. Obtain accurate weights on all
clients with renal failure – done on the same scale at the same time every day.
- Tachycardia
Watch for signs of hyperkalemia: dizziness, weakness, cardiac irregularities, muscle cramps,
diarrhea, and nausea.
Potassium has a critical safe range (3.5 to 5.0 mEg/L) because it affects the heart, and any
imbalance must be corrected by medications or dietary modification. Limit high potassium foods
(bananas, avocados, spinach, fish) and salt substitutes, which are high in potassium.
Clients with renal failure retain sodium. With water retention, the sodium becomes diluted and
serum levels may appear near normal. With excessive water retention, the sodium levels appear
decreased dilution). Limit fluid and sodium intake in ARF clients.
During oliguric phase, minimize protein intake. When the BUN and creatinine return to normal,
aRF is determined to be resolved.
Accumulation of waste products from protein metabolism is the primary cause of uremia. Protein
must be restricted in CRF clients. However, if protein intake is inadequate, a negative nitrogen
balance occurs causing muscle wasting. The glomerular filtration rate (GFR) is most often used
as an indicator of level of protein consumption.
Protein intake is restricted until blood chemistry shows ability to handle protein catabolites: urea,
creatinine. Ensure high calorie intake so protein is spared for its own work: give hard candy, jelly
beans, flavored carbohydrate powders.
As kidneys fail, medications must often be adjusted. Of particular importance is digoxin toxicity
since digitalis preparations are excreted by the kidneys. Signs of toxicity in adults include nausea,
vomiting, anorexia, visual disturbances, restlessness, headache, cardiac arrythmias, and pulse
<60 beats per minute (bradycardia).
The major difference between dailysate for hemodialysis and peritoneal dialysis is the amount of
glucose. Peritoneal dialysis dialysate is much higher in glucose. For this reason, if the dialysate
is left in the peritoneal cavity too long, hyperglycemia may occur.
The key to resolving UTI with most antibiotics is to keep the blood level of the antibiotic constant.
It is important to tell the client to take the antibiotics round-the-clock and not skip doses so that a
consistent blood level can be maintained for optimal effectiveness.
Percutaneous nephrostomy: A needle/catheter is inserted through the skin into the calyx of the
kidney. The stone may be dissolved by percutaneous irrigation with a liquid which will dissolve the
stone, or ultrasonic sound waves (lithotripsy) can be directed through the needle/catheter to break
up the stone which then can be eliminated through the urinary tract.
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Bladder spasms frequently occur after TURP. Inform the client that the presence of the oversized
balloon on the catheter (30 to 45 cc inflate) will cause a continuous feeling of needing to void. The
client should not try to avoid around the catheter since this can precipitate bladder spasms.
Medications to reduce or prevent spasms should be given.
Instillation of hypertonic or hypotonic solution into a body cavity will cause a shift in cellular fluid.
Use only sterile saline for bladder irrigation after TURP since the irrigation must be isotonic to
prevent fluid and electrolyte imbalance.
Inform the client prior to discharge that some bleeding is expected after TURP. Large amounts of
blood or frank bright bleeding should be reported. However, it is normal for the client to pass small
amounts of blood during the healing process as well as small clots. He should rest quietly and
continue drinking large amounts of fluid.
CARDIOVASCULAR SYSTEM
Angina is caused by myocardial ischemia. Which cardiac medications would be appropriate for
acute angina?
- Digoxin – Not appropriate – Increases the strength and contractility of the heart muscle; the
problem in angina is that the muscle is not receiving enough oxygen. Digoxin will not help.
- Nitroglycerin – Appropriate – Causes dilation of the coronary arteries, allowing more oxygen to get
to the heart muscle.
- Atropine – Not appropriate – Increases heart rate by blocking vagal stimulation, which suppresses
the heart rate. Does not address the lack of O2 to the heart muscle.
- Propanolol (Inderal) – Not appropriate – for acute angina attack; however, is appropriate for long-
term management of stable angina because it acts as a beta-blocker to control vasoconstriction.
Blood pressure is created by the difference in the pressure of the blood as it leaves the heart and
the resistance it meets flowing out to the tissues. Therefore, any factor that alters cardiac output
or peripheral vascular resistance will alter blood pressure. Diet and exercise, smoking cessation,
weight control, and stress management can control many factors that influence the resistance
blood meets as it flows from the heart.
Remember the risk factors for hypertension: heredity, race, age, alcohol abuse, increased salt
intake, obesity, and use of oral contraceptives.
The number one cause of CVA with hypertensive clients is non-compliance with medication
regime. Hypertension is often symptomless, and antihypertensive medications are expensive and
have side effects. Studies have shown that the more clients know about their antihypertensive
medications, the more likely they are to take them – teaching is important.
Decreased blood flow results in diminished sensation in the lower extremities. Any heat source
can cause severe burns before the client actually realizes the damage is being done.
A client is admitted with severe chest pain and states that he feels a terrible, tearing sensation in
his chest. He is diagnosed with a dissecting aortic aneurysm. What assessment should the nurse
obtain in the first few hours?
- Vital signs q1 hour
- Neurological vital signs
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- Respiratory status
- Urinary output
- Peripheral pulses
During aortic aneurysm repair, the large arteries are clamped for a period of time and kidney
damage can result. Monitor daily BUN and creatinine levels. Normal BUN is 10 to 20 mg/dl and
normal creatinine is 20:1. When this ratio increases or decreases, suspect renal problems.
Heparin prevents conversion of fibrinogen to fibrin and prothrombin to thrombin, thereby inhibiting
clot formation. Since the clotting mechanism is prolonged, do not cause tissue trauma which may
lead to bleeding when giving heparin subcutaneously. Do not massage area or aspirate; give in
the abdomen between the pelvic bones; 2 inches from umbilicus; rotate sites.
HEPARIN:
- Antagonist: Protamine Sulfate
- LAB: PTT or APTT determines efficacy
- Keep 1.5 to 2.5 times normal control
COUMADIN:
- Antagonist: Vitamin K
- LAB: PT determines efficacy
- Keep 1.5 to 2.5 times normal control
INR: Desirable therapeutic level usually 2 to 3 seconds (reflects how long it takes a blood sample
to clot).
A holter monitor offers continuous observation of the client’s heart rate. To make assessment of
the rhythm strips, most meaningful, teach the client to keep a record of:
- Medication times and doses
- Chest pain episodes – type and duration
- Valsalva maneuver (straining at stool, sneezing, coughing)
- Sexual activity
- Exercise
Restricting sodium reduces salt and water retention, thereby reducing vascular volume and
preload.
DIGITALIS:
- Side effects of digitalis are increased when the client is hypokalemic.
- Has a negative chronotropic effect, i.e., it shows the heart rate. Hold the digitalis if the pulse rate
is <60, >120, or has markedly changed rhythm.
- Bradycardia, tachycardia, or dysrhythmias may be signs of digitalis toxicity: these signs include
nausea, vomiting, and headache in adults.
- If withheld, consult with physician.
Infective endocarditis damage to heart valves occurs with the growth of vegetative lesions on
valve leaflets. These lesions pose a risk of embolization; erosion/perforation of the valve leaflets;
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Acute and Subacute Infective Endocarditis - There are 2 types of infective endocarditis:
- Acute, which often affects individuals with previously normal hearts and healthy valves, and
carries a high mortality rate
- Subacute, which typically affects individuals with preexisting conditions, such as rheumatic heart
disease, mitral valve prolapse, or immunosuppression. Intravenous drug abusers are at risk for
both acute and subacute bacterial endocarditis. When this population develops Subacute
Infective Endocarditis, the valves on the right side of the heart (tricuspid and pulmonic) are
typically affected due to the introduction of common pathogens which colonize on the skin (S.
epidermis and Candida) into the venous system.
With mitral valve stenosis, blood is regurgitated back into the left atrium from the left ventricle. In
early period, there may be no symptoms; but, as the disease progresses, the client will exhibit
excessive fatigue, dyspnea on exertion, orthopnea, dry cough, hemoptysis, or pulmonary edema.
There will be a rumbling apical diastolic murmur, and atrial fibrillation is common.
GASTROINTESTINAL SYSTEM
Stress can cause or exacerbate ulcers. Teach stress reduction methods and encourage those
with a family history of ulcers to obtain medical surveillance for ulcer formation.
The GI tract usually accounts for only 100 to 200 ml fluid loss per day, although it filters up to 8
liters per day. Large fluid losses can occur if vomiting and/or diarrhea exists.
Opiate drugs tend to depress gastric motility. However, they should be given with care, and those
receiving them should be closely monitored because a distended intestinal wall accompanied by
decreased muscle tone may lead to intestinal perforation.
Diverticulosis is the presence of pouches in the wall of the intestine. There is usually do
discomfort, and the problem goes unnoticed unless seen on radiological examination (usually
prompted by some other condition).
Diverticulitis is an inflammation of the diverticula (punches), which can lead to perforation of the
bowel.
A client admitted with complaints of severe lower abdominal pain, cramping, and diarrhea is
diagnosed with diverticulitis. What are the nutritional needs of this client throughout recovery?
- Acute phase – NPO graduating to liquids.
- Recovery phase – no fiber or foods that irritate the bowel.
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- Maintenance phase – high-fiber diet, with bulk-forming laxatives to prevent pooling of foods in the
pouches where they can become inflamed. Avoid small, poorly digested foods such as popcorn,
nuts, seeds, etc.
Bowel obstructions:
- Mechanical: due to disorders outside the bowel (hernia, adhesions), due to disorders within the
bowel (tumors, diverticulitis), or due to blockage of the lumen in the intestine (intussusception, gall
stone).
- Non-mechanical: paralytic ileus, which does not involve any actual physical obstruction, but results
from inability of the bowel itself to function.
Blood gas analysis will show alkalotic state if the bowel obstruction is high in the small intestine
where gastric acid is secreted. If the obstruction is in the lower bowel where base solutions are
secreted, the blood will be acidic.
A client admitted with complaints of constipation, thready stools and rectal bleeding over the past
few months is diagnose with a rectal mass. What are the nursing priorities for this client?
- NPO
- NG tube (possibly an intestinal tube such as a Miller-Abbott)
- IV fluids
- Surgical preparations of bowel (if obstruction is complete)
- Teaching (preoperative, nutrition, etc.)
Cancer of the colon is the most common cancer in the US when considering men and women
together. An early sign is the rectal bleeding. Encourage patients 50 years of age or older, or
those with increased risk factors, to be screened yearly with fecal occult blood testing. Routine
colonoscopy at 50 is also recommended.
Fetor hepaticus is a distinctive breath odor of chronic liver disease. It is characterized by a fruity
or musty odor which results from the damaged liver’s inability to metabolize and detoxify
mercaptan which is produced by the bacterial degradation of metionine, a sulfurous amino acid.
For treatment of ascities, paracentesis and peritoneovenous shunts (LaVeen and Denver shunts)
may be indicated.
Esophageal varices may rupture and cause hemorrhage. Immediate management includes
insertion of an esophagogastric balloon tamponade – a Blakemore-Sengstaken or Minnesota
tube. Other therapies include vasopressors, vitamin K, coagulation factors, and blood
transfusions.
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Ammonia is not broken down as usual in the damaged liver; therefore, the serum ammonia level
rises.
PROVIDE AN ENVIRONMENT CONDUCIVE TO EATING for clients who are anorexic and/or
nauseated:
- Remove strong odors immediately; they can be offensive and increase nausea.
- Encourage client to sit up for meals; this can decrease the propensity to vomit.
- Serve small, frequent meals.
Liver tissue is destroyed by hepatitis. Rest and adequate nutrition are necessary for regeneration
of liver tissue being destroyed by the disease. Since many drugs are metabolized in the liver, drug
therapy must be scrutinized carefully. Caution the client that recovery takes many months, and
previously taken medications should not be resumed without the healthcare provider’s directions.
Acute pancreatic pain is located retroperitoneally. Any enlargement of the pancreas causes the
peritoneum to stretch tightly. Therefore, sitting up or leaning forward will reduce the pain.
Following an endoscopic retrogade cholangiopancreatography (ERCP), the client may feel sick.
The scope is placed in the gallbladder and the stones are crushed and left to pass on their own.
These clients may be prone to pancreatitis.
ENDOCRINE SYSTEM
Thyroid storm is a life-threatening event that occurs with uncontrolled hyperthyroidism due to
Grave’s disease. Symptoms include fever, tachycardia, agitation, anxiety, and hypertension.
- Primary nursing interventions include maintaining an airway and adequate aeration.
- Propylthiouracil (PTU) or methimazole (Tapazole) are antithyroid drugs used to treat thyroid storm.
Propanolol (Inderal) may be given to decrease excessive sympathetic stimulation.
Normal serum calcium is 9.0 to 10.5 mEq/L. The best indicator of parathyroid problems is a
decrease in the client’s calcium compared to the preoperative value.
If two or more parathyroid glands have been removed, the chance of tetany increases
dramatically:
- Monitor serum calcium levels (9.0 to 10.5 mg/dl is normal range)
- Check for tingling of toes, fingers, and around the mouth.
- Check for Chvostek’s sign (tap over the parotid gland and which for twitching of lip = positive)
- Check Trousseau’s sign (carpopedal spasm after inflating BP cuff above systolic pressure =
positive).
Many people take steroids for a variety of conditions. NCLEX-RN questions often focus on the
need to teach clients the importance of precisely following the prescribed regimen. They should
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be cautioned against suddenly stopping the medications and be informed that it is necessary to
taper off taking steroids.
Teach clients to take steroids with meals to prevent gastric irritation. They should never skip
doses. If they have nausea or vomiting for more than 12 to 24 hours, they should contact the
physician.
Why do diabetics have trouble with wound healing? High blood glucose contributes to damage of
the smallest vessels, the capillaries. This damage causes permanent capillary scarring, which
inhibits the normal activity of the capillary. This phenomenon causes disruption of capillary
elasticity and promotes problems such as diabetic retinopathy, poor healing or breaks in the skin,
cardiovascular abnormalities, etc.
The body’s response to illness/stress is to produce glucose. Therefore, any illness results in
hyperglycemia.
MUSCULOSKELETAL SYSTEM
A client comes to the clinic complaining of morning stiffness, weight loss, and swelling of both
hands and wrists. Rheumatoid arthritis is suspected. Which methods of assessment might the
nurse use and which methods would the nurse not use?
- Use inspection, palpation, and strength testing.
- Do not use range of motion (this activity promotes pain because ROM is limited).
In the joint, the normal cartilage becomes soft, fissures and pitting occur, and the cartilage thins.
Spurs form and inflammation sets in. The result is deformity marked by immobility, pain, and
muscle spasm. The prescribed treatment regimen is corticosteroids for the inflammation; splinting,
immobilization, and rest for joint deformity; and NSAIDS for the pain.
Synovial tissues line the bone of the joints. Inflammation of this lining causes destruction of tissue
and bone. Early detection of rheumatoid arthritis can decrease the amount of bone and joint
destruction. Often the disease will go into remission. Decreasing the amount of bone and joint
destruction will reduce the amount of disability.
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What activity recommendations should the nurse provide a client with rheumatoid arthritis?
- Do not exercise painful, swollen joints.
- Do not exercise any joint to the point of pain.
- Perform exercises slowly and smoothly; avoid jerky movements.
NCLEX-RN questions often focus on the fact that avoiding sunlight is key in management of lupus
erythematosus – this is what differentiates it from other connective tissue diseases.
Degenerative joint disease (DJD) and osteoarthritis are often described as the same disease, and
indeed they both result in hypertrophic changes in the joints. However, they differ in that
osteoarthritis is an inflammatory disease and DJD is characterized by non-inflammatory
degeneration of the joints.
Postmenopausal, thin, Caucasian women are at highest risk for development of osteoporosis.
Encourage exercise, a diet high in calcium, and supplemental calcium. While TUMS is an
excellent source of calcium, it is also high in sodium and hypertensive or edematous individuals
should seek another source for supplemental calcium.
The main cause of fractures in the elderly, especially women, is osteoporosis. The main fracture
sites seem to be hip, vertebral bodies, and Colles’ fracture of forearm.
NCLEX-RN questions focus on safety precautions. Improper use of assistive devices can be very
risky. When using a non-wheeled walker, the client should lift and move the walker forward, then
take a step into it. The client should avoid scooting the walker or shuffling forward into it which
takes more energy and is less stable than a single movement.
What type of fracture is more difficult to heal, an extra capsular fracture (below the neck of the
femur) or an intracapsular fracture (in the neck of the femur)?
- The blood supply enters the femur below the neck of the femur. Therefore, an intra-capsular
fracture is much more harder to heal and has a greater likelihood of necrosis since it is cut off from
the blood supply.
The risk of a fat embolism, a syndrome in which fat globules migrate into the bloodstream and
combine with platelets to form emboli, is greatest in the first 36 hours after a fracture. It is more
common in clients with multiple fractures, fractures of long bones, and fractures of the pelvis. The
initial symptom of a fat embolism is confusion due to hypoxemia (check blood gases for PO2).
Assess for respiratory distress, restlessness, irritability, fever, and petechiae. If an embolus is
suspected, notify physician STAT, draw blood gases, administer oxygen, and assist with
endotracheal intubation.
In clients with hip fractures, thromboembolism is the most common complication. Prevention
includes passive range of motion exercises, elastic stocking use, elevation of the foot of the bed
25 degrees to increase venous return, and low-dose hepatin therapy.
Clients with fractures, casts, or edema to the extremities need frequent neurovascular assessment
distal to the injury. Skin color, temperature, sensation, capillary refill, mobility, pain and pulses
should be assessed.
Assess the “5 Ps” of neurovascular functioning: pain, paresthesia, pulse, pallor and paralysis.
Orthopedic wounds have a tendency to ooze more than other wounds. A suction drainage device
usually accompanies the client to the postoperative floor. Check drainage often.
Fractures of bone predispose the client to anemia, especially if long bones are involved. Check
hemtocrit every 3 to 4 days to monitor erythropoiesis.
Instruct the client not to lift the leg upward from a lying position or to elevate the knee when sitting.
This upward motion can pop the prosthesis out of the socket.
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Immobile clients are prone to complications: skin integrity problems, formation of urinary calculi
(may limit milk intake), and venous thrombosis (may be on prophylactic anticoagulants).
The residual limb should be elevated on one pillow. If the residual limb (stump) is elevated too
high, the elevation can cause contracture.
NEUROSENSORY SYSTEM
Glaucoma is often painless and symptom-free. It is usually picked up as part of a regular eye
exam.
Eye drops are used to cause pupil constriction since movement of the muscles to constrict the
pupil also allows aqueous humor to flow out, thereby decreasing the pressure in the eye.
Pilocarpine is often used. Caution client that vision may be blurred 1 to 2 hours after
administration of pilocarpine and adaptation to dark environments is difficult because of pupillary
constriction (desired effect of the drug).
There is an increased incidence of glaucoma in the elderly population. Older clients are prone to
problems associated with constipation. Therefore, the nurse should assess these clients for
constipation and postoperative complications associated with constipation, and implement a plan
of care directed at prevention, and, if necessary, treatment for constipation.
The lens of the eye is responsible for projecting light, which enters onto the retina so that images
can be discerned. Without the lens, which becomes opaque with cataracts, light cannot be filtered
and vision is blurred.
When the cataract is removed, the lens is gone, making prevention of falls important. If the lens is
replaced with an implant, vision is better than if a contact lens is used (some visual distortion) or if
glasses are used (greater visual distortion – everything has a curved shape).
The ear consists of three parts: the external ear, middle ear, and the inner ear. Inner ear
disorders, or disorders of the sensory fibers going to the CNS., often are neurogenic in nature and
may not be helped with a hearing aid. External and middle ear problems (conductive) may result
from infection, trauma or wax buildup. These types of disorders are treated more successfully with
hearing aids.
NCLEX-RN questions often focus on communicating with older adults who are hearing impaired.
- Speak in a low-pitched voice, slowly, and distinctly.
- Stand in front of the person with the light source behind the client.
- Use visual aids if available.
NEUROLOGICAL SYSTEM
Use of the Glasgow Coma Scale eliminates ambiguous terms to describe neurologic status such
as lethargic, stuporous, or obtunded.
Almost every diagnosis in the NANDA format is applicable, as severely neurologically impaired
persons require total care.
Clients with an altered state of consciousness are fed by enteral routes since the likelihood of
aspiration with oral feedings is great. Residual feeding is the amount of previous feeding still in
the stomach. The presence of 100 ml residual in adults usually indicates poor gastric emptying
and the feeding should be held.
Paralytic ileus is common in comatose clients. Gastric tube aids in gastric decompression.
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Any client on bedrest/immobilized must have range of motion exercises often and very frequent
position changes. Do not leave the client in any one position for longer than 2 hours. Any position
that decreases venous return is dangerous, i.e., sitting with dependent extremities for long
periods.
If temperature elevates, take quick measures to decrease it since fever increases cerebral
metabolism and can increase cerebral edema.
Restlessness may indicate a return to consciousness but can also indicate anoxia, distended
bladder, covert bleeding, or increasing cerebral anoxia. Do not over-sedate, and report any
symptoms of restlessness.
The forces of impact influence the type of head injury. They include acceleration injury, which is
caused by the head in motion, and deceleration injury, which occurs when the head stops
suddenly. Helmets are a GREAT preventive measure for motorcyclists and bicyclists.
Even subtle behavior changes, such as restlessness, irritability, or confusion, may indicate
increased ICP.
CSF leakage carries the risk of meningitis and indicates a deteriorating condition. Because of
CSF leakage, the usual signs of increased ICP may not occur.
Try not to use restraints; they only increase restlessness. AVOID narcotics since they mask level
of responsiveness.
Physical assessment should concentrate on respiratory status, especially in clients with injury at
C-3 to C-5, as cervical plexus innervates diaphragm.
It is imperative to reverse spinal shock as quickly as possible. Permanent paralysis can occur if a
spinal cord is compressed for 12 to 24 hours.
A common cause of death after spinal cord injury is urinary tract infection. Bacteria grow best in
alkaline media, so keeping urine diluted ad acidic is prophylactic against infection. Also, keeping
the bladder emptied assists in avoiding bacterial growth in urine, which is stagnated in the bladder.
Benign tumors continue to grow and take up space in the confined area of the cranium causing
neural and vascular compromise for the brain, increased intracranial pressure, and necrosis of
brain tissue – even benign tumors must be treated as they may have malignant effects.
Symptoms involving motor function usually begin in the upper extremities with weakness
progressing to spastic paralysis. Bowel and bladder dysfunction occurs in 90% of the cases. MS
is more common in women. Progression is not “orderly.”
Drug therapy for MS clients: ACTH, cortisone, Cytoxan, and other immunosuppressive drugs.
Nursing implications for administration of these drugs should focus on prevention of infection.
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In clients with Myasthenia Gravis, be alert for changes in respiratory status – the most severe
involvement may result in respiratory failure.
Bedrest often relieves symptoms. Bladder and respiratory infections are often a recurring
problem. Need for health promotion teaching.
Myasthenic crisis is associated with a positive edrophonium (Tensilon) test, while a cholinergic
crisis is associated with a negative test.
NCLEX-RN questions often focus on the features of Parkinson’s disease – tremors (a coarse
tremor of fingers and thumb on one hand which disappears during sleep and purposeful activity –
also called “pill rolling”), rigidity, hypertonicity, and stooped posture. Focus: SAFETY!
An important aspect of Parkinson’s treatment is drug therapy. Since the pathophysiology involves
an imbalance between acetylcholines and dopamine, symptoms can be controlled by
administering dopamine precursor (Levodopa).
Atrial flutter/fibrillation has a high incidence of thrombus formation following arrythmias due to
turbulence of blood flow through all valves/heart chambers.
A woman who had a stroke two days ago has left-sided paralysis. She has begun to regain some
movement in her left side. What can the nurse tell the family about the client’s recovery period?
- The quicker movement is recovered, the better the prognosis is for more or full recovery. She will
need patience and understanding from her family as she tries to cope with the stroke. Mood
swings can be expected during the recovery period, and bouts of depression and tearfulness are
likely.
Steroids are administered after a stroke to decrease cerebral edema and retard permanent
disability. H2 inhibitors are administered to prevent peptic ulcers.
HEMATOLOGY/ONCOLOGY
Physical symptoms occur as a compensatory mechanism when the body is trying to make up for a
deficit somewhere in the system. For instance, cardiac output increases when hemoglobin levels
drop below 7g/dl.
ONLY use normal saline to flush IV tubing or to run with blood. NEVER add medications to blood
products. TWO registered nurses should simultaneously check the physician’s prescription,
client’s identity, and blood bag label.
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A 24-year old is admitted with large areas of ecchymosis on both upper and lower extremities.
She is diagnosed with acute myeologenous leukemia. What are the expected laboratory findings
for this client and what is the expected treatment?
- Lab: Decreased Hgb, decreased Hct, decreased platelet count, altered WBC (usually quite high).
- Treatment: Prevention of infection; prevention and/or control of bleeding; high protein, high calorie
diet; assistance with ADL; drug therapy.
Infection in the immunosuppressed person may not be manifested with an elevated temperature.
It is imperative, therefore, that the nurse performs a total and thorough assessment of the client
frequently.
Hodgkin’s is one of the most curable of all adult malignancies. Emotional support is vital. Career
development is often interrupted for treatment. Chemotherapy renders many male clients sterile.
May bank sperm prior to treatment, if desired.
REPRODUCTIVE SYSTEM
Menorrhagia (profuse or prolonged menstrual bleeding) is the most important factor relating to
benign uterine tumors. Assess for signs of anemia.
What is the anatomical significance of a prolapsed uterus? When the uterus is displaced, it
impinges on other structures in the lower abdomen. The bladder, rectum, and small intestine can
protrude through the vaginal wall.
Laser therapy or cryosurgery is used to treat cervical cancer when the lesion is small and
localized. Invasive cancer is treated with radiation, conization, hysterectomy, or pelvic
exenteration (a drastic surgical procedure where the uterus, ovaries, fallopian tubes, vagina,
rectum, and bladder are removed in an attempt to stop metastasis). Chemotherapy is not useful
with this type of cancer.
Pap smears should begin within 3 years of having intercourse or no later than age 21, whichever
comes first. Should be done annually until age 30 and then may be done every 2 to 3 years if a
woman has 3 consecutive normal results. After age 70 may stop if woman has 3 consecutive
normal and no abnormal pap smears in last 10 years. Women at high risk should have annual
screenings.
Ovarian cancer is the leading cause of death from gynecologic cancers in the US. Growth is
insidious, so it is not recognized until it is at an advanced stage.
The major emphasis in nursing management of cancers of the reproductive tract is early detection.
The presence or absence of hormone receptors is paramount in selecting clients for adjuvant
therapy.
Men whose testes have not descended into the scrotum or whose testes descended after age 6
are at high risk for developing testicular cancer. The most common symptom is the appearance of
a small, hard lump about the size of a pea on the front or side of the testicle. Manual testicular
examination should be done after a shower by gently palpating the testes and cord to look for a
small lump. Swelling may also be a sign of testicular cancer.
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STDs in infants and children usually indicate sexual abuse and should be reported. The nurse is
legally responsible to report cases of child abuse. Chlamydia is the most reported communicable
disease in the United States.
Pelvic inflammatory disease (PID) involves one more of the pelvic structures. The infection can
cause adhesions and eventually result in sterility. Manage the pain associated with PID with
analgesics and warm sitz baths. Bedrest in a semi-Fowler’s position may increase comfort and
promote drainage. Antibiotic treatment is necessary to reduce inflammation and pain.
A client comes to the clinic with a chancre on his penis. What is the usualy treatment?
- IM dose of penicillin (such as Benzathine penicillin G 2.4 million units).
- Obtain sexual history, including the names of his sex partners, so that they can receive treatment.
BURNS
Massive volumes of IV fluids are given. It is not uncommon to give over 1,000 cc/hr during various
phases of burn care. Hemodynamic monitoring must be closely observed to be sure the client is
supported with fluids but is not overloaded.
Infection is a life-threatening risk for those with burns. Dressing changes are VERY PAINFUL!
Medicate client prior to procedure.
Pre-existing conditions that might influence burn recovery are age, chronic illness, diabetes,
cardiac problems, etc.), physical disabilities, disease, medications used routinely, and drug and/or
alcohol abuse.
PEDIATRIC NURSING
Be aware that a girl’s growth spurt during adolescence begins earlier than boys (as early as 10
years old).
Temper tantrums are common in the toddler, i.e., considered “normal,” or average behavior.
Be aware that adolescence is a time when the child forms his/her identity and that rebellion
against family values is common for this age group.
Normal growth and development knowledge is used to evaluate interventions and therapy. For
example, “What behavior would indicate that thyroid hormone therapy for a 4-month-old is
effective?” You must know what milestones are accomplished by a 4-month-old. One correct
answer would be “has steady head control” which is an expected milestone for a 4-month-old and
indicates that replacement therapy is adequate for growth.
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Use facts and principles related to growth and development in planning teaching interventions.
For example: “What task could a 5-year-old diabetic boy be expected to accomplish by himself?”
One correct answer would be to pick the injection sites. This is possible for a preschooler to do
and gives the child some sense of control.
School-age children are in Erikson’s stage of industry, meaning they like to do and accomplish
things. Peers are also becoming important for this age child.
Following immunization, what teaching should the nurse provide to the parents?
- Irritability, fever (<102F), redness and soreness at injection site for 2 to 3 days are normal side
effects of DPT and IPV administration.
- Call health care provider if seizures, high fever, or high-pitched crying occur.
- A warm washcloth on the thing injection site and “bicycling” the legs with each diaper change will
decrease soreness.
- Acetaminophen (Tylenol) is administered orally 4 to 6 hours (10 to 15 mg/Kg).
Children with German measles pose a serious threat to their unborn siblings. The nurse should
counsel all expectant mothers, especially those with young children, to be aware of the serious
consequences of exposure to German measles during pregnancy.
Common childhood problems are encountered by nurses caring for children in the community or
hospital settings. The child’s age directly influences the severity and management of these
problems.
Teach proper cooking and storage to preserve potency, i.e., cook vegetables in small amount of
liquid. Store milk in opaque container.
Use of syrup of ipecac is no longer recommended by the American Academy of Pediatrics. Teach
parents that it is NOT recommended to induce vomiting in any way as it may cause more damage.
RESPIRATORY DISORDERS
Child needs 150% of the usual calorie intake for normal growth and development.
Do not examine the throat of a child with epiglottis due to the risk of completely obstructing the
airway, i.e., do not put a tongue blade or any object in the throat.
In planning and providing nursing care, a patent airway is always a priority of care, regardless of
age!
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Respiratory disorders are the primary reason most children and their families seek medical care.
Therefore, these disorders are frequently tested on the NCLEX-RN. Knowing the normal
parameters for respiratory rates and the key signs of respiratory distress in children is essential!
The nurse should be sure a PT and PTT have been determined prior to a tonsillectomy. More
importantly, the nurse should ask if there has been a history of bleeding, prolonged/excessive, or if
there is a history of any bleeding disorders in the family.
When calculating a pediatric dosage, the nurse must often change the child’s weight from pounds
to kilograms.
HINT: weight expressed in kilograms should always be a smaller number than weight expressed in
pounds.
CARDIOVASCULAR DISORDERS
CHF is a common complication of congenital heart disease. It reflects the increased workload of
the heart resulting from shunts or obstructions. The two objectives in treating CHF are to reduce
the workload of the heart and increase cardiac output.
When frequent weighings are required, weigh client on the same scale at same time of day so that
accurate comparisons can be made.
NEUROMUSCULAR DISORDERS
The nursing goal in caring for children with Down syndrome is to help the child reach his/her
OPTIMAL level of functioning.
Feed infant or child with cerebral palsy using nursing interventions aimed at preventing aspiration.
Position child upright and support the lower jaw.
Baseline data on the child’s USUAL behavior and level of development is essential so changes
associated with increased ICP can be detected EARLY.
Do not pump shunt unless specifically prescribed. The shunt is made up of delicate valves, and
pumping changes pressures within the ventricles.
Do NOT use tongue blade, padded or not, during a seizure. It can cause traumatic damage to
mouth/oral cavity.
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Monitor hydration status and IV therapy carefully. With meningitis, there may be inappropriate
ADH secretions causing fluid retention (cerebral edema) and dilutional hyponatremia.
Most postoperative clients with infratentorial tumors are prescribed to lie flat and turn to either
side. A large tumor may require that the child NOT be turned to the operative side.
RENAL DISORDERS
Surgical correction for hypospadias is usually done before preschool years due to achieving
sexual identity, castration anxiety and toilet training.
GASTROINTESTINAL DISORDERS
Typical parent/family reaction to a child with an obvious malformation such as cleft lip/palate are
quilt, disappointment, grief, sense of loss, and anger.
Children with cleft lip/palate and those with pyloric stenosis both have a nursing diagnosis
“alteration in nutrition; less than body requirements.”
- Cleft lip/palate is related to decreased ability to suck.
- Pyloric stenosis is related to frequent vomiting.
Nutritional needs and fluid and electrolyte balance are key problems for children with GI disorders.
The younger the child, the more vulnerable they are to fluid and electrolyte imbalances and
greater is the need for caloric intake required for growth.
HEMATOLOGICAL DISORDERS
Inherited bleeding disorders (hemophilia and sickle cell anemia) are often used to test knowledge
of genetic transmission patterns. Remember:
- Autosomal recessive: Both parents must be heterozygous, or carriers of the recessive trait, for the
disease to be expressed in their offspring. With each pregnancy, there is a 1:4 chance of the
infant having the disease. However, all children of such patterns CAN get the disease – NOT 25%
of them. This is the transmission for sickle cell anemia, cystic fibrosis, and phenylketonuria (PKU).
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- X-linked recessive trait: The trait is carried on the X chromosome, therefore, usually affects male
offspring, e.g., hemophilia. With each pregnancy of a woman who is a carrier there is a 25%
chance of having a child with hemophilia. If the child is male, he has a 50% chance of having
hemophilia. If the child is female, she has a 50% chance of being a carrier.
Hydration is very important in treatment of sickle cell disease because it promotes hemodilution
and circulation of red cells through the blood vessels.
Important terms:
- Heterozygous gene (HgbAS) sickle cell trait
- Homozygous gene (HbSS) sickle cell disease
- Abnormal hemoglobin (HGBS) disease and trait
Supplemental iron is not given to clients with sickle cell anemia. The anemia is not caused by iron
deficiency. Folic acid is given only to stimulate RBC synthesis.
Have epinephrine and oxygen readily available to treat anaphylaxis when administering l-
asparaginase.
Prednisone is frequently used in combination with antineoplastic drugs to reduce the mitosis of
lymphocytes. Allopurinol, a xanthine-oxidase inhibitor, is also administered to prevent renal
damage from uric acid build up during cellular lysis.
An infant with hypothyroidism is often described as a “good, quiet baby” by the parents.
Nutrasweet (aspartame) contains phenylalanine and should not therefore, be given to a child with
phenylketonuria.
Diabetes mellitus (DM) in children was typically diagnosed as insulin dependent diabetes (Type I)
until recently. A marked increase in Type II DM has occurred recently in the US, particularly
among Native-American, African-American, and Hispanic children and adolescents. Adolescence
frequently causes difficulty with management since growth is rapid and the need to be like peers
makes compliance difficult. Remember to consider the child’s age, cognitive level of development,
and psychosocial development when answering NCLEX-RN questions.
There has been an increase in the number of children diagnosed with Type II diabetes. The
increasing rate of obesity in children is thought to be a contributing factor. Other contributing
factors include lack of physical activity and a family history of Type II diabetes.
SKELETAL DISORDERS
Fractures in older children are common as they fall during play and are involved in motor vehicle
accidents.
Spiral fractures (caused by twisting) and fractures in infants may be related to child abuse.
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Fractures involving the epiphyseal plate (growth plate) can have serious consequences in terms of
growth of the affected limb.
Skin traction for fracture reduction should not be removed unless prescribed by healthcare
provider.
Pin sites can be sources of infection. Monitor signs of infection. Cleanse and dress pin sites as
prescribed.
Skeletal disorders affect the infant’s or child’s physical mobility, and typical NCLEX-RN questions
focus on appropriate toys or activities for the child who is on bedrest and/or immobilized.
Children do not like injections and will deny pain to avoid “shots.”
A brace does not correct the curve of a child with scoliosis, it only stops or slows the progression.
Corticosteroids are used short term in low doses during exacerbations. Long-term use is avoided
due to side effects and their adverse effect on growth.
MATERNITY NURSING
From ovulation to the beginning of the next menstrual cycle is usually exactly 14 days. In other
words, ovulation occurs 14 days before the next menstrual period.
Sperm lives approximately 3 days and eggs live about 24 hours. A couple must avoid unprotected
intercourse for several days before the anticipated ovulation and for 3 days after ovulation in order
to prevent pregnancy.
Because some women experience implantation bleeding or spotting, they do not know they are
pregnant.
Look for signs of maternal-fetal bonding during pregnancy. For example: talking to fetus in utero,
massaging abdomen, nicknaming fetus are all healthy psychosocial activities.
For many women, BATTERING (emotional or physical abuse) begins during pregnancy. Women
should be assessed for abuse in private, away from the male partner, by a nurse who knows local
resources and how to determine the safety of the client.
Practice determining gravidity and parity: A woman who is 6 weeks pregnant has the following
maternal history:
- Has a 2 yr. old healthy daughter.
- Had a miscarriage at 10 weeks, 3 years ago.
- Had an elective abortion at 6 weeks, 5 years ago. With this pregnancy, she is a gravida 4, para 1
(only 1 delivery after 20 weeks gestation).
Practice calculating EDB (estimated date of birth). If the first day of a women’s last normal
menstrual period was October 17, what is her EDB using Nagele’s rule? July 24. Count back 3
months and add 7 days (always give February 28 days).
values may look “good,” but in reality represent pregnancy-induced hypertension and a depleted
vascular space.
Hgb/Hct data can be used to evaluate nutritional status. Example: a 22-year old primigravida at
12 weeks gestation has a high Hgb of 9.6 g/dl and a Hct of 31%. She has gained 3 pounds during
the first trimester. A weight gain of3.5 to 5 pounds during the first trimester is recommended and
this client is anemic. Supplemental iron and a diet higher in iron are needed.
Foods high in iron: fish and red meats; cereal and yellow vegetables; green leafy vegetables and
citrus fruits; egg yolks and dried fruits.
As pregnancy advances, the uterus presses on abdominal vessels (vena cava and aorta). Teach
the woman that a side-lying position increases perfusion to uterus, placenta, and fetus. Recent
research indicates that the knee-chest position is best for increasing perfusion and that the side-
lying position (either left or right side-lying) is the second most desirable position to increase
perfusion. Prior to this research, the left side-lying position was usually encouraged.
Fetal well-being is determined by assessing fundal height, fetal heart tones/rate, fetal movement
and uterine activity (contractions). Changes in fetal heart rate are the first and most important
indicator of compromised blood flow to the fetus, and these changes require action! Remember,
the normal FHR is 110 to 160 bpm.
Danger signs during pregnancy. Teach clients to immediately report any of the following danger
signs. Early intervention can optimize maternal and fetal outcome.
Signs of infection:
- Chills
- Dysuria
- Temperature over 100.4 F
- Pain in abdomen
- Fluid discharge from vagina (anything other than normal leukorrhea)
- Change in fetal movement and/or increased FHR
Most providers prescribe prenatal vitamins to ensure that the client receives an adequate intake of
vitamins. However, only the healthcare provider can prescribe prenatal vitamins. It is the nurse’s
responsibility to teach about proper diet and taking prescribed vitamins, if prescribed by the
healthcare provider.
It is recommended that pregnant women drink one quart of milk/day. This will ensure that the daily
calcium needs are met an help to alleviate the occurrence of leg cramps.
In some states, the screening for neural tube defects through either maternal serum AFP levels or
amniotic fluid AFP levels is mandated by state law. This screening test is highly associated with
both false positives and false negatives.
When an amniocentesis is done in early pregnancy, the bladder must be full to help support the
uterus and to help push the uterus up in the abdomen for easy access. When an amniocentesis is
done in late pregnancy, the bladder must be empty to avoid puncturing the bladder.
Early decelerations, caused by head compression and fetal descent, usually occur between 4 and
7 cm and in the 2nd stage. Check for labor progress if early decelerations are noted.
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If cord prolapse is detected, the examiner should position the mother to relieve pressure on the
cord (i.e., knee-chest position) or push the presenting part off the cord until IMMEDIATE Cesarean
delivery can be accomplished.
Late decelerations indicate uteroplacental insufficiency and are associated with conditions such as
postmaturity, preeclampsia, diabetes mellitus, cardiac disease, and abruptio placentae.
When deceleration patterns (late or variable) are associated with decreased or absent variability
and tachycardia, the situation is OMINOUS (potentially disastrous) and requires immediate
intervention and fetal assessment.
The danger of nipple stimulation lies in controlling the “dose” of oxytocin stimulated from the
posterior pituitary. The chance of hyper-stimulation or tetany (contractions over 90 seconds or
contractions with less than 30 seconds in between) is increased.
Percutaneous umbilical blood sampling (PUBS) can be done during pregnancy under ultrasound
for prenatal diagnosis and therapy. Hemoglobinopathies, clotting disorders, sepsis, and some
genetic testing can be done using this method.
The most important determinant of fetal maturity for extra-uterine survival is the L/S ratio (2:1 or
higher).
True labor:
- Pain in lower back that radiates to abdomen
- Accompanied by regular, rhythmic contractions
- Contractions that intensify with ambulation
- Progressive cervical dilation and effacement
False labor:
- Discomfort is localized in abdomen
- No lower back pain
- Contractions decrease in intensity and/or frequency with ambulation
Slight elevation is often due to dehydration and the work of labor. Anything higher indicates
infection and must be reported immediately.
Admission procedures:
- vulvar/perineal shave (may not be done)
- enema: may be refused by woman due to pre-labor diarrhea or recent, large bowel movement. An
enema should not be administered to a client in active labor. If head is floating, watch for cord
prolapse.
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Breathing techniques such as deep chest, accelerated, and cued are not prescribed by the stage
and phase of labor, but by the discomfort level of the laboring woman. If coping is decreasing,
switch to a new technique.
Hyperventilation results in respiratory alkalosis due to blowing off too much CO2. Symptoms
include:
- Dizziness
- Tingling of fingers
- Stiff mouth
- Have woman breathe into her cupped hands or a paper bag in order to rebreathe CO2.
Determine cervical dilation before allowing client to push. Cervix should be completely dilated (10
cm) before the client begins pushing. If pushing starts too early, the cervix can become
edematous and never fully dilate.
Give the oxytocin after the placenta is delivered because the drug will cause the uterus to
contract. If the oxytocic drug is administered before the placenta is delivered, it may result in a
retained placenta, which predisposes the client to hemorrhage and infection.
Methergine is NOT given to clients with hypertension due to its vasoconstrictive action. Pitocin is
given with caution to those with hypertension.
FULL BLADDER is one of the most common reasons for uterine atony and/or hemorrhage in the
first 24 hours after delivery. If the nurse finds the fundus soft, boggy, and displaced above and to
the right of the umbilicus, what action should be taken first? First, perform fundal massage; then
have the client empty her bladder. Recheck fundus q15 minutes X 4 (1 hour); q30 minutes X 2
hours.
If narcotic analgesics (codeine, meperidine) are given, raise side rails and place call light within
reach. Instruct client not to get out of bed or ambulate without assistance. Caution client about
drowsiness as a side effect.
A 1st degree tear involves only the epidermis. A 2 nd degree tear involves dermis, muscle, and
fascia. A 3rd degree tear extends into the anal sphincter, and a 4 th degree extends up the rectal
mucosa. Tears cause pain and swelling. Avoid rectal manipulations.
If it was documented that the fetus passed meconium in utero or the nurse noted LATE passage of
meconium in delivery room, the neonate MUST be attended by a pediatrician, neonatologist,
and/or nurse practitioner to determine, through endotracheal tube observation and suction, the
presence of meconium below the cords. It can result in pneumonitis/meconium aspiration
syndrome, which will necessitate a sepsis workup including a chest x-ray early in the transitional
newborn period.
Do not wait until a 1 minute Apgar is assigned to begin resuscitation of the compromised neonate.
IV administration of analgesics is preferred to IM for the client in labor because the onset and peak
occurs more quickly and duration of the drug is shorter.
IV administration:
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IM administration:
- Onset: within 30 minutes
- Peak: 1 to 3 hours after injection
- Duration: 4 to 6 hours
Agonist narcotic drugs (Demerol, morphine) produce narcosis and have a higher risk for
maternal/fetal respiratory depression. Antagonist drugs (Stadol, Nubain) have less respiratory
depression but MUST be used with caution in a mother with preexisting narcotic dependency
since withdrawal symptoms occur immediately.
Pudendal block and subarachnoid (saddle block) are used only for second stage of labor.
Peri/epidural may be used for all stages of labor.
The first sign of block effectiveness is usually warmth and tingling of ball/big toe of foot.
Nerve block anesthesia (spinal or epidural) during labor blocks motor as well as nerve fibers.
Vasodilation below the level of the block results in blood pooling in the lower extemities and
maternal hypotension. Approximately 20 minutes prior to nerve block anesthesia, the client should
be hydrated with 500 to 1000 cc of lactated ringers IV. Monitor maternal vital signs and FHR q5 to
15 minutes. If hypotension occurs – turn the client to her side, administer O2 at 10 L/min by
facemask, and increase IV rate.
NORMAL PUERPERIUM
Normal leukocytosis of pregnancy averages 12,000 to 15,000 mm3. The first 10 to 12 days post-
delivery, values of 25,000 mm3 are common. Elevated WBC and the normal elevated ESR may
confuse interpretation of acute postpartal infections. For example, if the nurse assesses a client’s
temperature to be 101 F on the client’s second postpartum day, what assessments should be
made before notifying the physician? Assess fundal height and firmness, perineal integrity, check
for a positive Homan’s sign and other symptoms, i.e., burning on urination, pain in leg, excessive
tenderness of uterus.
Client/family teaching is a common area for NCLEX-RN questions. Remember, when teaching the
first step is to assess the client’s (parent’s) level of knowledge and identify their readiness to learn.
Client teaching regarding lochia changes, perineal care, breastfeeding, sore nipples are commonly
tested content.
After the 1st PP day, the most common cause of uterine atony is retained placental fragments. The
nurse must check for presence of fragments in lochial tissue.
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Women can tolerate blood loss, even slightly excessive blood loss, in the postpartal period due to
the 40% increase in plasma volume during pregnancy. In postpartal period can void up to 3,000
cc/day to reduce this volume increase that occurred during pregnancy.
Client should void within 4 hours of delivery. Monitor closely for urine retention. Suspect retention
if voiding is frequent and <100 cc per voiding.
Women often have a syncopal spell (faint) on the first ambulation after delivery (usually related t
ovasomotor changes, orthostatic hypotension). The astute nurse will check for client’s Hgb and
Hct for anemia and the blood pressure, sitting and lying for orthostatic hypotension.
Kegel exercises: increase integrity of introitus and improve urine retention. Teach client to
alternate contraction and relaxation of the pubococcygeal muscles.
Assess for thromboembolism: Examine legs of PP client daily for pain, warmth, and tenderness or
a swollen vein which is tender to touch. Client may or may not exhibit a positive Homan’s sign
(dorsiflexion of foot causes compression of tibial veins and pain if thrombus is present).
“Postpartum blues” are usually normal, especially 5 to 7 days after delivery (unexplained
tearfulness, feeling “down,” and a decreased appetite). Encourage use of support persons to help
with housework for first two postpartum weeks. Refer to community resources.
Remember RhoGAM is given to a Rh-negative mother who delivers a Rh-positive fetus and has a
negative direct Coombs. If the mother has a positive Coombs, there is no need to give RhoGAM
since the mother is already sensitized.
Because Rh Immune Globulins suppress the immune system, the client who receives both
RhoGAM and the Rubella vaccine should be tested for rubella immunity at 3 months.
These neurological reflexes are transient, and, as such, disappear usually within the first year of
life. In the pediatric client, prolonged presence of these reflexes can indicate CNS defects.
Anticipate NCLEX-RN questions regarding normal newborn reflexes. Physical assessment
questions focus on normal characteristics of the newborn and the differentiation of conditions such
as caput succedaneum and cephalhematoma.
The umbilical cord should always be checked at birth. It should contain 3 vessels, 1 vein which
carries oxygenated blood to the fetus and 2 arteries which carry unoxygenated blood back to the
placenta. This is the opposite of normal circulation in the adult. Cord abnormalities usually
indicate cardiovascular or renal anomalies.
Postnatally, the fetal structures of foramen ovale, ductus arteriosus and ductus venosus should
close. If they do not, cardiac and pulmonary compromise will develop.
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Suctioning the mouth first and then the nose. Stimulating the nares can initiate inspiration which
could cause aspiration of mucus in oral pharynx.
Circumcision has become controversial since there is no real medical indication for the procedure
and it does not cause trauma and pain to the newborn. It was once thought to decrease the
incidence of penile and cervical cancer, but some researchers say this is unfounded.
HYPOTHERMIA (heat loss) leads to depletion of glucose and, therefore, the use of brown fat
(special fat deposits fetus puts on in last trimester which are important to thermoregulation) for
energy, resulting in ketoacidosis and possible shock. Prevent by keeping neonate warm!
Physiologic jaundice (normal inability of the immature liver to keep up with normal RBC
destruction) occurs at 2 to 3 days of life. If it occurs before 24 hours or persists beyond 7 days, it
becomes pathologic. Typically, NCLEX-RN questions ask about normal problem of physiologic
jaundice which occurs 2 to 3 days after birth due to the liver’s inability to keep up with RBC
destruction and bind bilirubin. Remember, unconjugated bilirubin is the culprit.
Do not feed a newborn when the respiratory rate is over 60. Inform the physician and anticipate
gavage feedings in order to prevent further energy utilization and possible aspiration.
A 7 lb. 8 oz. baby would need 50 calories X 7 lbs = 350 calories plus 25 calories (1/2 lb. or 8 oz.) =
375 calories per day. Most infant formulas contain 20 calories/ounce. Dividing 375 by 20 = 18.75
ounces of formula needed per day.
Teach parents to take infant’s temperature BOTH axillary and rectally. While axillary is
recommended, some pediatricians will request a rectal temperature (core).
- AXILLARY: Place thermometer under arm and hold thermometer in place 5 minutes.
- RECTALLY: Use thermometer with BLUNT end. Insert thermometer ¼ to ½ inch and hold in place
for 5 minutes. Hold feet and legs firmly.
HIGH-RISK DISORDERS
Clients with prior traumatic delivery, history of D&C, multiple abortions (spontaneous or induced),
or daughters of DES mothers may experience miscarriage or preterm labor related to
INCOMPETENT CERVIX. The cervix may be surgically repaired prior to pregnancy, or DURING
gestation. A CERCLAGE (McDonald’s suture) is placed around the cervix to constrict the internal
os. The cerclage may be removed prior to labor if labor is planned or left in place if cesarean birth
is planned.
Suspect ectopic pregnancy in any woman of childbearing age who presents at an emergency
room, clinic, or office with unilateral or bilateral abdominal pain. Most are misdiagnosed with
appendicitis.
A client who is 32 weeks gestation calls the healthcare provider because she is experiencing dark,
red vaginal bleeding. She is admitted to the emergency room where the nurse determines the
FHR to be 100 bpm. The client’s abdomen is rigid and boardlike, and she is complaining of
severe pain. What action should the nurse take first? First, the nurse must use knowledge base
to differentiate between abruptio placentae (this client) from placenta previa (painless bright red
bleeding occurring in the third trimester). The nurse should immediately notify the healthcare
provider and no abdominal or vaginal manipulation or exams should be done. Administer O2 per
face mask. Monitor for bleeding at IV sites and gums due to the increased risk of DIC.
Emergency Cesarean section is required since uteroplacental perfusion to the fetus is being
compromised by early separation of the placenta from the uterus.
Clients with abruptio placentae or placenta previa (actual or suspected) should have NO
abdominal or vaginal manipulation. NO Leopold’s maneuvers. NO vaginal exams. NO rectal
exams, enemas, or suppositories. NO internal monitoring.
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Toxoplasmosis is usually related to exposure to cats, gardening (where cat feces may be found),
or eating raw meat.
Rubella is teratogenic to the fetus during the FIRST trimester, causing congenital heart disease
and/or congenital cataracts. All women should have their titers checked during pregnancy. If a
women’s titer’s are low, she should receive the vaccine AFTER delivery and be instructed not to
get pregnant within 3 months. Breastfeeding mothers may take the vaccine.
Although Metronidazole (Flagyl) is the treatment of choice for some vaginal infections, its use is
contraindicated in the first trimester of pregnancy, and its use during the second trimester is
controversial. Medications usually recommended for the non-pregnant client with STDs may be
CONTRAINDICATED for the pregnant client due to effect on the fetus.
The outcome of adolescent pregnancy depends on prenatal care. NUTRITION is a key factor
since the adolescent’s physiological needs for growth are already increased, plus the additional
stress of pregnancy.
Although the toxic side effects of magnesium sulfate are well known and watched for, it is just as
important to get serum blood levels of magnesium sulfate above 4 mg/dl in order to prevent
convulsions and reach therapeutic range.
Hold next dose of magnesium sulfate and notify healthcare provider if any toxic symptoms occur
(<12 respirations/minute, urine output <100 cc/4 hours, absent DTRs, Magnesium sulfate > 8
mg/dl).
When administering magnesium sulfate. ALWAYS have antidote available (calcium gluconate, 20
ml vial of 10% solution).
Tachycardia is the major side-effect of tocolytic drugs, which are bete adrenergic agents such as
terbutaline (Brethine) or ritodrine (Yutopar) used to stop preterm labor. Teach the client to take her
pulse prior to administration and withhold medication if pulse is not within the prescribed
parameters (usually whitheld if pulse >120 to 140). If administration is via a continuous pump,
teach client to monitor pulse periodically.
In 1978, the FDA banned the use of oxytocin for ELECTIVE inductions. The healthcare provider
must provide, for the record, the medical reason for oxytocin use.
Dystocia frequently requires the use of oxytocin for augmentation or induction of labor. Uterine
tetany is a harmful complication and careful monitoring is required. The desired effect is
contractions q2 to 3 minutes, with duration of contractions no longer than 90 seconds.
Continuously monitor FHR and uterine resting tone. If tetany occurs, turn off Pitocin, turn client to
a side-lying position, and administer O2 by facemask. Check output (should be at least 100 cc/4
hours). Oxytocin’s most important side effects is its antidiuretic (ADH) effect, which can cause
water intoxification. Using IV fluids containing electrolytes decreases the risk of water
intoxification.
The uterus is most sensitive to becoming tetanic at the beginning of infusion. The client must
ALWAYS be attended and contractions monitored. Contractions should last NO longer than 90
seconds to prevent fetal hypoxia.
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Women with previous uterine scars are prone to uterine rupture especially if oxytocin or forceps
are used. If a woman complains of a sharp pain accompanied by the abrupt cessation of
contractions, suspect uterine rupture, a MEDICAL EMERGENCY. Immediate surgical delivery is
indicated to save the fetus and the mother.
Rarely are antihypertensive drugs used in the preeclamptic client. They are given only in the
event of diastolic blood pressure over 110 mmHg. (CVA danger). Drug of choice is Hydralazine
HCL (Apresoline).
Altough delivery is often described as the “cure” for preeclampsia, the client can convulse up to 48
hours after delivery.
The major goal of nursing care for a client with preeclampsia is to maintain uteroplacental
perfusion and prevent seizures. This requires the administration of magnesium sulfate. Withhold
administration of magnesium sulfate if signs of toxicity exist: respirations <12/minute, absence of
DTRs, and urine output <30 ml/hour.
Nursing care during labor and delivery for the client with cardiac disease is focused on prevention
of cardiac embarrassment, maintenance of uterine perfusion, and alleviation of anxiety.
Should these clients experience preterm labor, the use of beta-adrenergic agents such as
terbutaline (Brethine) and ritodrine HCL (Yutopar) are contraindicated due to the chance of
myocardial ischemia.
Normal diuresis, which occurs in the postpartum period, can pose serious problems to the new
mother with cardiac disease because of the increased cardiac output.
Coumadin may NOT be taken during pregnancy due to its ability to cross the placenta and affect
the fetus. HEPARIN is the drug of choice; it does NOT cross the placental membrane.
Recent research has found that Helicobacter pylori, (the bacterium that causes stomach ulcers)
infection is another possible causative factor in hyperemesis. Other pregnancy and non-
pregnancy risk factors for hyperemesis gravidarum include first pregnancy, multiple fetuses, age
under 24, history of this condition in other pregnancies, obesity, and high fat diets.
Women who suffer from hyperemesis gravidarum are often deficient in thiamin, riboflavin, vitamin
B6, vitamin A, and retinol-binding proteins.
GLUCOSE SCREEN: Client does NOT have to fast for this test. 50 gm of glucose is given and
blood is drawn after one hour. If the blood glucose is greater than 135 mg/dl, the na three-hour
glucose tolerance test (GTT) is done.
High incidence of fetal anomalies occurs in pregnant diabetic women. Therefore, fetal surveillance
is very important. Ultrasound exam. Alpha-fetoprotein (to determine neural tube anomalies).
Non-stress and contraction stress tests.
Oral hypoglycemics are not taken in pregnancy due to potential teratogenic effects on fetus.
Insulin is used for therapeutic management.
When a woman is admitted in labor with diagnosis of diabetes mellitus. She is more prone to
preeclampsia, hemorrhage and infection. Delivery is often scheduled between 37 to 38 weeks
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gestation to avoid the end of the 3 rd trimester of pregnancy because this is a VERY difficult time to
maintain diabetic control.
It is useful to discontinue long-acting insulin administration on the day before the delivery is
planned since insulin requirements are less in labor and drop precipitously after delivery.
If a woman is medicated, the responsible adult accompanying her must sign the necessary
consent forms. State laws differ as to the acceptability of a friend signing the consent form rather
than a relative.
Babies delivered abdominally miss out on the vaginal squeeze and are born with more fluid in the
lungs, predisposing the newborn to transient tachypnea (TTN) and respiratory distress.
The preferable low-transverse uterine incision usually results in less postoperative pain, less
bleeding, and less incidents of ruptured uterus. The classical, vertical incision on the uterus may
involve part of the fundus, resulting in more postoperative pain, bleeding, and an increased
chance of uterine rupture.
Due to the exploration and cleansing of the uterus just after delivery of the placenta, the amount of
lochia may be scant in the recovery room. However, pooling in the vagina and uterus while on
bedrest may result in blood running down the client’s leg when she first ambulates. Cesarean
birth clients have the same lochial changes, placental site healing, and aseptic needs as do
vaginal birth clients.
A laparotomy of any kind, including cesarean birth, predisposes the client to postoperative
paralytic ileus. When the bowel is manipulated in surgery, it ceases preistalsis, which may persist.
Symptoms include: absent bowel sounds, abdominal distention, tympany on percussion, nausea
and vomiting, and of course, obstipation (intractible constipation). Early ambulation is an effective
nursing intervention.
Nurse must be especially supportive of postpartum client with infection because it usually implies
isolation from newborn until organism is identified and treatment begun. Arrange phone calls to
nursery and window viewing. Involve family, spouse, significant others in teaching, and encourage
other family members to continue neonatal attachment activities.
Most common iatrogenic cause of UTI is urinary catheterization. Encourage clients to void
frequently and not ignore the urge. IV antibiotic are usually administered to clients with
pyelonephritis.
Remember, the risk of postpartum infections increases for clients who experienced problems
during pregnancy (e.g., anemia, diabetes) or experienced trauma during labor and delivery.
Clients taking anticoagulants can usually expect to have heavy menstrual periods.
In most cases, a mother who is on antibiotic therapy can continue to breastfeed unless the
healthcare provider thinks the neonate is at risk for sepsis by maternal contact. Sulfa drugs are
used cautiously in lactating mothers because they can be transferred to the infant in breast milk.
Many times mastitis can be confused with a blocked milk sinus, which is treated by nursing closer
to the lump and by rotating the baby on the breast. Breastfeeding is not contraindicated for
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women with mastitis, unless pus is in the breast milk, or the antibiotic of choice is harmful to the
infant. If either of these occurs, milk production can still be fostered by manual expression.
During medical emergencies such as bleeding episodes, clients need calm, direct explanations
and assurance that all is being done that can be done. If possible, allow support person at
bedside. Risk-management principles state that the suit-prone client is one who feels things are
being hidden from her or that adequate attention is NOT being give to HER problem.
Risk factors for hemorrhage include: dystocia, prolonged labor, over distended uterus, abruptio
placentae, and infection.
What immediate nursing actions should be taken when a postpartum hemorrhage is detected?
- Perform fundal massage
- Notify the healthcare provider if the fundus does not become firm with massage
- Count pads to estimate blood loss
- Assess and record vital signs
- Increase IV fluids (additional IV line may be indicated)
- Administer oxytocin infusion as prescribed
To avoid metabolic problems brought on by cold stress, the first step and number one priority, in
management of the newborn is to prevent loss of body heat, followed by ABCs. Neonates
produce heat by non-shivering thermogenesis, by burning brown fat. The neonate is easily
stressed by hypothermia and develops acidosis from hypoxia. Prevent chilling (keep under
radiant warmer or in isolette). If cold, the first signs exhibited are prolonged acrocyanosis, skin
mottling, tachycardia, and tachypnea. If cold stressed, warm slowly over 2 to 4 hours since rapid
warming may produce apnea. The neonate needs glucose, he/she has little glycogen storage and
needs to be fed.
The lower the score on the Silverman-Anderson index of Respiratory Distress, the better the
respiratory status of the neonate. A score of 10 indicates that a newborn is in severe respiratory
distress. This is the exact opposite of the method used for Apgar scoring.
WATCH the newborn Hct; it is difficult to oxygenate either an anemic newborn (lack of oxygen-
carrying capacity) or a newborn with polycythemia (Hct >80%, thich, sluggish circulation).
The PO2 should be maintained between 50 to 90 mmHg. PO2 <50 signifies hypoxia, PO2 > 90
signifies oxygen toxicity problems.
Antibiotic dosage is based on the neonate’s weight in kilograms. Peak and trough drug levels are
drawn to evaluate if therapeutic drug levels have been achieved. Closely monitor the neonate for
adverse effects of ALL drugs.
Sepsis can be indicated by both a temperature increase and a temperature decrease.
Drugs used to treat neonatal infections can be ototoxic and nephrotoxic. Close monitoring of
therapeutic levels and observation for side effects are required.
Renal immaturity in the preterm infant makes the monitoring of IV fluid administration and drug
therapy crucial. Closely monitor BUN and creatinine levels when administering the “mycin”
antibiotics to treat infections in the neonate.
If tube passes into trachea, newborn can make NO noise, i.e., no crying. Newborn may gag,
cough, or become cyanotic.
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To assess for skin jaundice, apply with thumb over bony prominences to blanch skin. After
removing thumb, area will look yellow before normal skin color reappears. The best areas for
assessment are the nose, forehead, and sternum. In dark-skinned infants, observe conjunctival
sac and oral mucosa.
Lab tests measure total and direct (conjugated, excretable, non-fat soluble) bilirubin levels. The
dangerous bilirubin is the unconjugated, indirect (fat-soluble), which is measured by subtracting
the direct from the total bilirubin.
Maintenance of hydration is crucial for all infants. The preterm infant is already at risk for fluid and
electrolyte imbalances due to increased body surface area from extended body positioning and
larger body area in related to body weight. Phototherapy treatment for hyperbilirubinemia (level >
12 mg/dl) increases the risk for dehydration.
PSYCHIATRIC NURSING
The purpose of therapeutic interaction with clients is to allow them the autonomy to make choices
when appropriate. Keep statements value free, advice free, and reassurance free. Remember,
JUST THE FACTS! NO OPINIONS!
What action should the nurse take in a “psychiatric situation” when the client describes a physical
problem? Assess, assess, assess! If the client with paranoid schizophrenia on the psychiatric unit
complains of chest pain, take his/her blood pressure. If the OB client who has delivered a dead
fetus complains of perineal pain – look at the perineal area (she may have a hematoma). Just
because the focus of the client’s situation is on his/her psychological needs, it does not mean that
the nurse can ignore physiological needs.
Remember, nurses are “nice” people, but they are also therapeutic.
Remember, a nurse’s nonverbal communication may be more important that his/her verbal
communication.
A question concerning nurse-client confidentiality often appears on the NCLEX-RN. For the nurse
to tell a client she/he will not tell anyone about their discussion, puts the nurse in a difficult
position. Some information MUST be shared with other team members for the client’s safety (e.g.,
suicide plan) and optimal therapy.
Nausea is a common complaint after ECT. Vomiting by the unconscious client can lead to
aspiration. Because post-ECT clients are unconscious, the nurse must observe closely for the
possibility of aspiration, i.e., MAINTAIN A PATENT AIRWAY!
ANXIETY DISORDERS
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Common physiological responses to anxiety include increased heart rate and blood pressure;
rapid, shallow respirations; dry mouth, tight feeling in throat; tremors, muscle tension; anorexia;
urinary frequency; palmar sweating.
Anxiety is very contagious and is easily transferred from client to nurse AND from nurse to client.
FIRST, the nurse must assess his/her own level of anxiety and remain calm. A calm nurse assists
the client to gain control, decrease anxiety, and increase feelings of anxiety.
When a client described a phobia or expresses an unreasonable fear, the nurse should
acknowledge the feeling (fear) and refrain from exposing the client to the identified fear. After trust
is established, a desensitization process may be prescribed. Desensitization is the nursing
intervention for phobia disorders. The nurse should:
- Assist client to recognize factors associated with feared stimuli that precipitate a phobic response.
- Teach and practice with client alternative adaptive coping strategies such as the use of thought
substitution (replacing a fearful thought with a pleasant thought), and relaxation techniques. Role-
playing is useful when the client is in a calm state.
- Expose client progressively to feared stimuli, offering support with the nurse’s presence.
- Provide positive reinforcement whenever a decrease in phobic reaction occurs.
- NOTE: In all likelihood, the desensitization process will be overseen by a mental health
practitioner (NP psych CNS, or psychologist).
The nurse should place an anxious client where there are reduced environmental stimuli – a quiet
area of the unit, away from the nurse’s station.
The best time for interaction with a client is at the completion of the performed ritual. The client’s
anxiety is lowest at this time; therefore, it is an optimal time for learning.
Compulsive acts are used in response to anxiety, which may or may not be related to the
obsession. It is the nurse’s responsibility to help alleviate anxiety. Interfering will increase anxiety.
These acts should be allowed as long as the client’s acts are free of violence. The nurse should:
- Actively listen to the client’s obsessive themes
- Acknowledge effects that ritualistic acts have on the client
- Demonstrate empathy
- Avoid being judgmental
SOMATOFORM DISORDERS
Be aware of your own feelings when dealing with this type of client. It is a challenge to be non-
judgmental. The pain is real to the person experiencing it. These disorders cannot be explained
medically: they result from internal conflict. The nurse should:
- Acknowledge the symptom or complaint
- Reaffirm that diagnostic test results reveal no organic pathology
- Determine the secondary gains acquired by the client
DISSOCIATIVE DISORDERS
Avoid giving clients with dissociative disorders too much information about past events at one
time. The various types of amnesia, which accompany dissociative disorders, provide protection
from pain. Too much, too soon, may cause decompensation.
PERSONALITY DISORDERS
Personality disorders are long-standing behavioral traits that are maladaptive responses to anxiety
and cause difficulty in relating and working with other individuals. NCLEX-RN questions test
personality disorder content by describing management situations.
Persons with a personality disorder are usually comfortable with their disorder and believe that
they are right and the world is wrong. These individuals usually have very little motivation to
change. Think of them as a CHALLENGE.
EATING DISORDERS
People with Anorexia gain pleasure from providing others with food and watching them eat. These
behaviors reinforce their perception of self-control. Do not allow these clients to plan or prepare
food for unit-based activities.
People with Bulimia often use syrup of ipecac to induce vomiting which may cause cardiovascular
problems such as congestive heart failure (CHF). Because CHF is not usually seen in young
people, it is often overlooked. Assess for edema and listen to breath sounds.
Physical assessment and nutritional support are a priority; the physiological implications are great.
Nursing interventions should increase self-esteem and develop a positive body image. Behavior
modification is useful and effective. Family therapy is most effective since issues of control are
common in these disorders. (Therapy is usually long term).
MOOD DISORDERS
Depressed clients have difficulty hearing and accepting compliments because of their lowered
self-concept. Comment on signs of improvement by noting the behavior, e.g., “I noticed you
cobed your hair today” NOT, “You look nice today.”
The most important signs and symptoms of depression are a depressed mood with a loss of
interest or pleasure in life. The client has sustained a loss. Other symptoms include:
- Significant change in appetite often accompanied by a change in weight – either weight loss or
gain
- Insomnia or hyperinsomnia (usually sleeping during the day – often because the client is not
sleeping at night due to anxiety).
- Fatigue or a lack of energy
- Feelings of hopelessness, worthlessness, guilt, or over-responsibility
- Loss of ability to concentrate or think clearly
- Preoccupation with death or suicide
The nurse knows depressed clients are improving when they begin to take an interest in their
appearance or begin to perform self-care activities, which were previously of little or no interest.
The nurse should suspect an imminent suicide attempt if a depressed client becomes “better,”
e.g., happy or even elated. Be aware – a happy affect may signify that the client feels relieved
that a plan has been made and he/she is ready for the suicide attempt.
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When dealing with a depressed client, the nurse should assist with personal hygiene tasks and
encourage the client to initiate grooming activities even when he/she does not feel like doing so.
This helps promote self-esteem and a sense of control.
An important intervention for the depressed client is to sit quietly with the client. When answering
NCLEX-RN questions, remember that you are working at Utopia General and there is plenty of
time and staff to provide ideal nursing care. Do not let realities of clinical situations deter you from
choosing the best nursing intervention. The best intervention is to sit quietly with the client,
offering support with your presence.
There are always drug questions on the NCLEX-RN. Here are some tips: Know common side
effects for drug groups. For example:
- Anti-anxiety drugs = sedation, drowsiness
- Antidepressant drugs = anticholinergic effects, postural hypotension
- MAO inhibitors = hypertensive crisis
Monitor serum lithium levels carefully. The therapeutic range is between 0.5 and 1.5 mEq/L. the
therapeutic and toxic levels are very close in reading. Signs of toxicity are evident when lithium
levels are more than 1.5 mEq/L. Blood levels should be drawn 12 hours after LAST dose.
Manic clients can be very caustic toward authority figures. Be prepared for personal “put downs.”
Avoid arguing or becoming defensive.
What activities are appropriate for a manic client? = Noncompetitive physical activities, which
require the use of large muscle groups.
Where should a manic client be placed on the unit? = Make every attempt to reduce stimuli in the
environment. Place the client in a quiet part of the unit.
Two atypical antipsychotic drugs are also indicated for mania (risperidone and olanzapine).
There are five types of schizophrenia specified under the DSM-IV-TR. The DSM-IV-TR is a
diagnostic manual prepared by the American Psychiatric Association that provides diagnostic
criteria for all psychiatric disorders.
Observe for increased motor activity and/or erratic response to staff and other clients. The client
may be experiencing an increase in command hallucinations. When this occurs, there is an
increased potential for aggressive behavior. THINK PRN!
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When evaluating client behaviors, consider the medications the client is receiving. Exhibited
behaviors may be manifestations of schizophrenia or a drug reaction.
Do not argue with a client about their delusions. Logic does NOT work, it only increases the
client’s anxiety. Be matter-of-fact and divert delusional thought to reality. Trust is the basis for all
interactions with these clients. Be supportive and non-judgmental. Stress increases anxiety and
the need for delusions and hallucinations. Do not agree you hear voices (you should be the
client’s contact to reality), but acknowledge your observation of the client, for example, “You look
like you’re listening to something.”
Know the side effects of drugs commonly used to treat schizophrenia since client behavioral
changes may be due to drug reactions instead of schizophrenia.
SUBSTANCE ABUSE
Know what defense mechanisms are used by chemically dependent clients. Denial and
rationalization are the two most common coping styles used – their use must be confronted so
accountability for the client’s own behavior can be developed.
What basic needs have priority when working with chemically dependent clients? Nutrition is a
priority. Alcohol and drug intake has superseded the intake of food for these clients.
What behaviors are expected during withdrawal? In the alcoholic, delirium tremens (DT) occurs 12
to 36 hours after the last intake of alcohol. Know the symptoms (tachycardia, tachypnea,
diaphoresis, marked tremors, hallucinations, paranoia). In drug abuse, withdrawal symptoms are
specific to the type of drug.
What medications can the nurse expect to administer to chemically dependent clients? In treating
alcohol withdrawal, Librium or Ativan are commonly used. Antabuse is often used as s deterrent
to drinking alcohol. Client teaching should include the effects of consuming any alcohol while on
Antabuse. Encourage client to read all labels of over-the-counter medications and food products,
which may contain small amounts of alcohol.
What type of therapy is used with chemically dependent clients? Group therapy is effective as
well as support groups such as Alcoholics Anonymous, Narcotics Anonymous, etc.
Harm reduction is a community health strategy designed to reduce the harm of substance abuse
to families, individuals, community, and society.
- More compassionate drug treatment options including abstinence and drug substitution models.
- HIV related interventions such as needle exchanges
- Directed drug use management should the client wish to continue use
- Changes in laws concerning possession of paraphernalia
ABUSE
Select only one nurse to care for an abused child. Abused children have difficulty establishing
trust. The child will be less anxious with one consistent caregiver.
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Women who are abused may rationalize the spouse’s behavior and unnecessarily accept the
blame for his actions. The woman may or may not choose to press charges. Be sure to give her
the number of a shelter for “help line” for future occurrences, as well as develop a safety plan.
It is difficult for an elderly person to admit abuse for fear being placed in a nursing home or being
abandoned. Therefore, it is imperative to establish a trusting relationship with the elderly client.
Rape victims are at high risk for Post Traumatic Stress Disorder (PTSD). Immediate intervention
to diminish distress is vital. The nurse should also assess for and intervene for sequellae such as
unwanted pregnancy, sexually transmitted diseases, and HIV risk.
Questions on the NCLEX-RN regarding physical/sexual abuse usually focus on three aspects:
- Physical manifestations of abuse
- Client safety
- Legal responsibilities of the nurse – In children, the nurse is legally responsible to report all
suspected cases of abuse. In intimate partner abuse, it is the adult’s decision; the nurse should
be supportive of their decision. Remember to document objective factual assessment data and
the client’s exact words in cases of sexual abuse/rape.
Confusion in the elderly is often “accepted” as part of growing old. This confusion may be due to
dehydration with resulting electrolyte imbalance. Think “sudden change” when obtaining a history.
Such changes are usually due to a specific stressor, and treatment for the causative stressor will
usually result in correcting the confusion.
Confabulation is not lying. It is used by the client to decrease anxiety and protect the ego.
Providing consistent caregiver is a priority in planning nursing care for the confused older client.
Change increases anxiety and confusion.
May also use atypical antipsychotics such as resperidine, quetiapine, olanzapine, Clozaril is not a
front-line agent due to side-effects. May also give mood stabilizers and antianxiety medications as
indicated.
The basic difference between delirium and dementia is that delirium is acute, and reversible,
whereas dementia is gradual and permanent.
Children also experience depression, which often presents as headaches, stomachaches, and
other somatic complaints. Be sure to assess suicidal risks, especially in the adolescent.
The client’s lack of remorse or guilt about their antisocial behavior represents a malfunction of the
superego or conscience. The id functions on the basic instinct level and strives to meet immediate
needs. The ego is in touch with external reality and is the part of the personality that makes
decisions.
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GERONTOLOGICAL NURSING
Changes in the heart and lungs result in less efficient utilization of O2, which reduces an
individual’s capacity to maintain physical activity for long periods of time. Physical training for
older persons can significantly reduce blood pressure and increase aerobic capacity. NCLEX-RN
questions ask about teaching and designing rehab programs for the elderly – they should contain
something about exercise and nutrition.
Older persons often complain that they cannot get to sleep at night and do not sleep soundly even
after they fall asleep. This is because they have shorter stages of sleep, particularly shorter cycles
from stages 1 to 4 and REM sleep (stage 4 is deep sleep). They are easily awakened by
environmental stimuli. They often compensate by napping during the day, which leads to further
disruptions of night sleep. A common response is use of prescription sleeping pills which can
create still further problems of disorientation, etc.
Both systolic and diastolic blood pressure tend to increase with normal aging, but the elevation of
the systolic is greater. REMEMBER the physiologic of blood pressure, which is expressed as a
ratio of systolic to diastolic pressure. Systolic refers to the level of blood pressure during the
contraction phase whereas diastolic refers to the stage when the chambers of the heart are filling
with blood.
Dysrhythmias in the elderly are particularly serious since older persons cannot tolerate decreased
cardiac output, which can result in syncope, falls, and transient ischemic attacks (TIAs). Pulse
may be rapid, slow, or irregular.
Angina symptoms may be absent in the elderly or they may be confused with GI symptoms.
With aging, the muscles that operate the lings lose elasticity so that respiratory efficiency is
reduced. Vital capacity (the amount of air brought into the lungs at one time) decreases.
Breathing may become more difficult after strenuous exercise or after climbing up several flights of
stairs. The rate of decline has been found to be slower in more active persons. The nurse should
encourage older persons to remain physically active for as long as possible. Declining muscle
strength may impair cough efficiency. This fact makes older persons more susceptible to chronic
bronchitis, emphysema, and pneumonia.
Tooth loss is NOT a normal aging process. Good dental hygiene, good nutrition, and dental care
can prevent tooth loss.
Older persons appear to eat small quantities of food at mealtimes. This is because the digestive
system of older persons features a decrease in contraction time of the muscles and more time is
needed for the cardiac sphincter to open. Therefore, it takes more time for the food to be
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transmitted to the stomach. Thus, the sensation of fullness may occur before the entire meal is
consumed.
Older persons have a higher risk of developing renal failure because normal age-related changes
result in compromised renal functioning. The nurse should pay careful attention to urinary output
in older clients because it is the first sign of loss of renal integrity.
Kegel exercises consist of tightening and relaxing the vaginal and urinary meatus muscles. These
exercises have been very successful in reducing the incidence of incontinence. They must be
done consistently, and they can be done unobtrusively at home.
The elderly with incontinence may seek isolation, thereby predisposing themselves to loneliness.
15 to 30% of community-based elderly and almost 50% of elderly living in nursing homes suffer
from difficulties with bladder control. Older persons may be more sensitive to alcohol and caffeine
since these substances inhibit the production of antidiuretic hormone (ADH). An assessment of
sensitivity to bladder problems is essential when planning nursing care.
MEDICATION ALERT:
- As one ages, the total number of functioning glomeruli decreases until function has been reduced
by nearly 50%. This decrease in the filtration efficiency of the kidneys has grave implications for
persons who are taking medication. Of particular importance are penicillin, tetracycline, and
digoxin, which are primarily cleared from the blood stream by the kidneys. These drugs remain
active longer in an older person’s system. Therefore, they may be more potent, indicating a need
to adjust the dosage frequency of administration.
Alzheimer’s disease is the most common irreversible dementia of old age. It is characterized by
deficits in attention, learning, memory, and language skills. Discuss the problems family members
have in dealing with Alzheimer’s clients in relation to the following disease manifestations:
- Depression
- Night wandering
- Aggressive or passiveness
- Failure to recognize family members
Strokes from cerebral thrombosis are more common in older persons than are strokes from
cerebral hemorrhage. Clots tend to develop when patient is awake or just arousing.
Normal loss of brain cells is compounded by alcohol, smoking, and breathing polluted air. In
relation to such losses, the nurse should teach to shop at uncrowded times in stores that are
familiar to them, slow down well in advance of traffic signals, stay in the slower lane of the
freeway, avoid freeways during rush hours, and leave for appointments well ahead of time.
The most common endocrine disorders in the older adult are thyroid dysfunctions and diabetes.
Impaired mobility, impaired skin integrity, decreased peripheral circulation, and a lack of physical
activity place the elderly at risk for developing decubitus ulders.
Peripheral circulation decreases as one ages. Regular assessment of the feet is very important
because it increases the opportunity to discover and treat skin care problems early. These
problems could become more serious because of decreased circulation.
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Older persons have a dry, wrinkled skin because they lose subcutaneous fat and the second layer
of skin, the dermis, becomes less elastic.
Lower the tone of your voice when talking to an older person who is hearing-impaired. High-
pitched tones (i.e., women’s voices) are the first hearing to go, therefore, lowering the pitch of your
voice increases the likelihood that an older person with a hearing loss will be able to hear you
speak.
Presbycusis (age-related hearing loss) can result in decreased socialization, avoidance of friends
and family, decreased sensory stimulation, and hazardous conditions when driving.
Use frequent touch to decrease the sense of isolation and to compensate for visual and sensory
loss.
Older persons undergo a great many changes, which are usually associated with LOSS (loss of
spouse, friends, career, home, health, etc.). therefore, older persons are extremely vulnerable to
emotional and mental stress.
INTEGRITY VS. DESPAIR is Erikson’s final stage of growth and development. Reminiscing is a
means of setting one’s life in order (accepting life and self), which is the task of this stage of
Erikson’s development theory. The goal of this stage is to feel a sense of meaning in one’s life,
rather than to feel despair or bitterness that life was wasted. The major task of old age is to
redefine self in relation to a changed role. Those persons who had been in charge of situations
most of their lives may now fund themselves in dependent positions. The role adjustment is a
major task of old age.
Think about the following situations and discuss the nursing care for each.
- A nursing supervisor who has had a stroke and is sent to a long term facility for rehabilitation.
- An oil company executive retires after 42 years with the company to travel in his recreational
vehicle wit his wife and dog.
- Shortly after their 53rd wedding anniversary, a woman who has never worked outside the home
loses her husband to brain cancer.
There are many conditions that can imitate dementia in the older adult. A key role for the nurse is
to complete assessment to rule out other possible causes.
abruptio placentae
Premature separation of a normally positioned placenta in a pregnancy of at least 20 weeks' gestation either
before labor or during labor but before delivery. This serious complication of pregnancy, occurring in one of
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every 200 births and often resulting in hemorrhage, may lead to the death of the mother, the fetus, or both.
Also called ablatio placentae, accidental hemorrhage.
abuse
1. Behavior toward another that is offensive, harmful, or injurious. 2. Misuse or particularly excessive use of
a substance, service, or equipment; commonly refers to improper use of a drug or similar substance.
accommodation
1. The act or process of adapting to changes in the physiologic or psychological environment to maintain
homeostasis. 2. In ophthalmology: adjustment of the lens of the eye for various distances. 3. In sociology:
the use of compromise, arbitration, or negotiation to resolve conflicts between persons or groups that arise
from differences in customs or cultural norms. Also called adjustment.
active immunity
Acquired immunity caused by the production of antibodies, either after infection or as a result of vaccination.
acute nephritis
Acute inflammation of the kidney, possibly involving the glomerulus, tubules, and interstitial tissues.
Addison's disease
A life-threatening condition characterized by fatigue, hypotension, loss of appetite and weight, nausea or
vomiting, and increased hyperpigmentation of the skin and mucous membranes. It results from partial or
complete loss of glucocorticoid, mineralocorticoid, and androgenic function of the adrenal glands caused by
tuberculosis, an autoimmune process, or other disease. Also called Addisonism, Addison's syndrome,
chronic adrenocortical insufficiency.
Addisonian crisis
An emergency situation occurring with adrenal hypofunction and exposure to trauma, surgery, or other
severe physiologic stress that exhausts the body's stores of glucocorticoids.
adrenergic
1. Activated or transmitted by epinephrine, norepinephrine, or a similar substance. 2. Also called a
sympathomimetic, a drug that stimulates alpha or beta receptors (thus mimicking the effects of epinephrine
or norepinephrine) or acts primarily on receptors in the sympathetic nervous system that are stimulated by
dopamine.
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advance directive
Documented written or verbal instructions by the client about his wishes for life-sustaining medical care in
the event he becomes incapacitated (for example, living wills, durable powers of attorney for health care, or
any document that states the client's wishes).
agonist
1. In anatomy: any muscle in a state of contraction whose action is opposed by another muscle with which
it’s paired (called the antagonist). 2. In pharmacology: a drug that has an affinity for and stimulates
physiologic activity at cell receptors.
agoraphobia
An intense, irrational fear of being in open spaces or of venturing out from the home or other familiar setting.
The anxiety may be generalized to any setting beyond the home or may be specific for certain types of
situations and environments, such as open spaces or crowded places.
akinesia
1. Loss of the ability to move voluntarily. 2. The rest period after systole in the normal heart rhythm. 3. In
psychiatry: a neurotic condition characterized by symptoms of paralysis.
Allen's test
A test designed to evaluate a client's collateral circulation in the arm before an invasive arterial procedure
such as arterial blood gas analysis. While the client's radial and ulnar arteries are occluded, he clenches his
fist, causing the hand to blanch. The client then unclenches his fist while the pressure on the ulnar artery is
released (but the radial artery remains occluded). The hand should become pink, indicating a patent ulnar
artery.
amblyopia
Decreased visual acuity in one eye in the absence of detectable structural or pathologic changes.
amenorrhea
The absence or cessation of menstruation. Except in preadolescents and in pregnant and postmenopausal
women, amenorrhea may reflect dysfunction of the hypothalamus, pituitary gland, ovary, or uterus;
congenital absence or surgical removal of both ovaries or the uterus; or an adverse effect of medication.
amniocentesis
Withdrawal of a sample of amniotic fluid by transabdominal puncture and needle aspiration, usually
performed during the fifth month of pregnancy to detect such genetic disorders as Down syndrome, neural
tube defects, and Tay-Sachs disease; if the clinician suspects sex-linked genetic defects, the procedure may
be done to determine fetal gender.
amniotomy
Artificial rupture of the membranes.
analgesic
1. Having the ability to relieve pain. 2. A medication that relieves pain.
anaphylaxis
A systemic reaction to a previously encountered antigen.
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anastomosis
A surgical procedure in which two blood vessels, ducts, or other tubelike structures are joined to allow the
flow of substances between them. Types of anastomoses are end-to-end and side-to-side.
angina pectoris
Severe chest pain characterized by sensations of spasm, constriction, and crushing weight, classically
radiating from the area over the heart to the left shoulder and arm and possibly accompanied by a feeling of
choking or suffocation. Angina usually results from myocardial oxygen deprivation secondary to
atherosclerosis of the coronary arteries.
anorexia
Loss of appetite.
anorexia nervosa
An eating disorder, most common among adolescent girls, that is characterized by an aversion to eating, a
morbid fear of becoming obese despite significant weight loss, a disturbed body image that results in a
feeling of being fat even when extremely thin, and amenorrhea (in females).
antagonist
1. In pharmacology: a drug that nullifies the action of another drug. 2. In anatomy: a muscle whose effects
counteract the effects of another muscle. 3. In dentistry, a tooth that meets another in the opposite jaw
during chewing or clenching of the teeth.
anteroposterior-to-lateral
Direction referring from front to back and side to side.
anticholinergic
1. Of or relating to blockade of the impulses of parasympathetic or other cholinergic nerve fibers. 2. Any
agent with anticholinergic properties.
anticipatory guidance
Information about a disorder or about the normal growth and development expectations of a specific age-
group given at an appropriate time before an event in order to provide the client with support and strategies
for dealing with potential problems before they occur.
antiembolism stockings
Elasticized stockings prescribed for some postoperative or bedridden clients to enhance venous blood flow
from the lower extremities and thus prevent thromboembolism resulting from pooling of blood in the veins
and dilation of veins.
anuria
Absence of urine production.
aortic stenosis
An abnormal narrowing of the orifice of the aortic valve, which prevents normal flow of blood from the left
ventricle into the aorta. The constriction may result from a congenital malformation or pathologic fusion of
the valve cusps. Aortic stenosis causes decreased cardiac output and pulmonary vascular congestion.
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Apgar score
A numerical evaluation of a neonate's condition in which a rating of 0, 1, or 2 is assigned to each of five
criteria: heart rate, respiratory effort, muscle tone, reflex responses, and skin color. The five scores are then
combined: A score of 7 to 10 is considered normal, 4 to 7 indicates moderate distress, and 3 or less
indicates acute distress. The Apgar score is usually obtained at 1 minute and 5 minutes after birth.
aphasia
Loss or impairment of the ability to communicate through speech, written language, or signs, resulting from
brain disease or trauma.
aphthous stomatitis
A recurring disease of unknown cause marked by the eruption of ulcers on the mucous membranes of the
mouth. Also called canker sore.
appendicitis
Inflammation of the vermiform appendix. When acute, appendicitis commonly necessitates an
appendectomy to prevent perforation of the appendix and subsequent peritonitis.
apraxia
Complete or partial inability to perform purposeful movements in the absence of sensory or motor
impairment.
asepsis
The absence of living, disease-producing organisms. Medical asepsis refers to the removal or destruction of
disease organisms or infected material. Surgical asepsis refers to protection against infection before, during,
or after surgery by means of sterile technique.
asthma
A respiratory disorder characterized by recurrent attacks of paroxysmal dyspnea, bronchospasm, wheezing
on expiration, and coughing. Conditions that may trigger an asthma attack include inhalation of allergens or
pollutants, vigorous exercise, emotional stress, and infection.
ataxia
Impairment of the ability to coordinate voluntary muscle movement.
atopic dermatitis
A skin inflammation occurring in individuals with a genetic predisposition to allergies, characterized by
intense itching, maculopapular lesions, and excoriation (rash pattern varies with age but usually occurs on
the face).
audiometry
Evaluation of hearing using an audiometer. Various audiometric tests identify the lowest intensity of sound at
which a client can perceive an auditory stimulus, hear different frequencies, and differentiate speech
sounds. Pure tone audiometry evaluates the ability to hear frequencies, usually ranging from 125 to 8,000
Hz, and can determine whether a hearing loss results from a problem in the middle ear, inner ear, or
auditory nerve.
auditory hallucinations
Perceptual experiences occurring in the absence of actual external sensory stimuli (for example, hearing
voices telling one to do something).
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auscultatory gap
Absence of Korotkoff sounds between phases I (onset of faint, clear tapping sound that gradually intensifies)
and II (onset of swishing-like sound) while obtaining a blood pressure reading.
autograft
The surgical transfer of tissue (commonly skin) from one location of the body to another location in the same
individual.
autoimmune disorder
A disorder resulting from an inappropriate immune response that is directed against the self. Antigens
normally found in the internal cells stimulate the development of antibodies; these antibodies can’t
distinguish antigens of the internal cells from external antigens and act against the internal cells to cause
various reactions.
autoimmunity
A condition in which the immune system mounts an attack against the individual's own body tissues. One
theory proposes that autoimmunity reflects an inability of the immune system to distinguish between
autoantigens and foreign substances, caused by some change in the cellular components of the immune
system. Autoimmunity may lead to hypersensitivity and autoimmune disease.
autonomic dysreflexia
Reaction that may occur in clients with spinal cord injury above T6. Dysreflexia results in profuse
diaphoresis, pounding headache, blurred vision, and dramatically elevated blood pressure. This life-
threatening reaction may occur even from seemingly minor stimuli, such as lying on a wrinkled sheet or
having a full bladder.
bacterial meningitis
Inflammation of the meninges of the brain and spinal cord caused by bacteria such as Neisseria
meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, or Escherichia coli.
Battle's sign
Discoloration of the skin behind the ear after the fracture of a bone in the lower skull.
bipolar disorder
A mood disorder characterized by major depression and full manic episodes.
bradyarrhythmias
Irregularity in heart rate or rhythm characterized by slowness.
bradycardia
A slow but steady heartbeat at a rate of less than 60 beats per minute. Bradycardia is normal during sleep
and in well-conditioned athletes. In other circumstances, it may indicate an abnormal condition, such as
brain tumor or digitalis toxicity.
breast engorgement
Distention of the milk ducts and surrounding tissue as breast milk is formed, causing the breasts to become
fuller, larger, and firmer.
bronchiolitis
A lung inflammation that usually begins in the terminal bronchioles, occurring mainly in infants and
debilitated persons. Also called bronchopneumonia. Commonly, bronchiolitis results from upper respiratory
infection, specific infectious fevers, and other debilitating diseases.
bronchoscopy
Visual examination of the tracheobronchial tree using a bronchoscope.
Broviac catheter
Single-lumen silicone central venous catheter used for long-term venous access.
Brudzinski's sign
Flexion of the hips and knees in response to passive flexion of the neck; signals meningeal irritation.
bruit
An abnormal vascular "swishing" sound heard on auscultation as a result of turbulent blood flow through
dilated, irregular, torturous, or stenotic vessels.
buccal
Of or relating to the inside of the cheek; may also refer to a tooth surface or the gum next to the cheek.
bulimia
An eating disorder characterized by episodes of binge eating that may end in self-induced vomiting,
alternating with periods of normal eating or fasting. Depression and awareness of the abnormal behavior are
part of this illness.
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cardiac catheterization
A diagnostic procedure in which a cardiac catheter is inserted into a large vein (usually of an arm or leg) and
then threaded through the vein to the client's heart.
cardiac output
The volume of blood ejected by the heart per minute (normally ranging from 4 to 8 L). Cardiac output equals
the stroke volume (the difference between end-diastolic volume and end-systolic volume) multiplied by the
heart rate.
cardiogenic shock
A condition of low cardiac output that results from heart pump failure, such as in acute myocardial infarction,
heart failure, or severe cardiomyopathy.
cardiomyopathy
Primary noninflammatory disease of the myocardium.
catatonic
A stuporous or unresponsive state commonly characterized by an inability to move or talk.
catecholamine
Any of a group of compounds having a sympathomimetic action and composed of a catechol molecule and
the aliphatic portion of an amine. Some catecholamines are produced by the body and function as key
neurologic chemicals. Others are synthesized as drugs for use in the treatment of such disorders as
asthma, shock, and heart failure.
cauda equina
The aggregation of spinal roots, resembling the tail of a horse, that descend from the first lumbar vertebrae
and occupy the vertebral canal below the cord.
celiac disease
A chronic disease in which an individual can’t tolerate foods containing gluten or wheat protein. Signs and
symptoms include abdominal distention, vomiting, diarrhea, muscle wasting, and extreme lethargy.
cellulitis
An infection of deep subcutaneous tissue and sometimes muscle that may be associated with infection of an
operative or traumatic wound. Cellulitis is characterized by local heat, pain, redness, and swelling.
cerebral aneurysm
A saclike dilation of the wall of a cerebral artery, typically resulting from weakness of the wall. A cerebral, or
berry, aneurysm usually occurs in the circle of Willis and is prone to rupture.
cerebral contusion
A bruising of the brain tissue as a result of a severe blow to the head. A contusion disrupts normal nerve
function in the bruised area and may cause loss of consciousness, hemorrhage, edema, and even death.
cerebral palsy
A permanent disorder of motor function resulting from nonprogressive brain damage or a brain lesion.
Cerebral palsy usually appears before age 3.
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chelation therapy
Administration of agents that bind to metals; administered to aid in the removal of excess metals, such as
lead or iron in the body.
chemotherapy
Treatment of a disease using chemicals that exert a toxic effect on the pathogen or abnormal cell growth.
chest physiotherapy
An array of physical techniques, including postural drainage, chest percussion and vibration, and coughing
and deep-breathing maneuvers. Chest physiotherapy is used to loosen and help eliminate lung secretions,
reexpand lung tissue, and promote optimal use of respiratory muscles.
cholelithiasis
The presence or formation of gallstones in the gallbladder.
cholinergic
1. Of or relating to nerve fibers that are stimulated to free acetylcholine at a synapse. 2. An agent that frees
acetylcholine.
chronic bronchitis
A persistent respiratory disease marked by increased production of mucus by the glands of the trachea and
bronchi. This common disease is characterized by a cough (with expectoration) at least 3 months of the year
for more than 2 consecutive years.
Chvostek's sign
A spasm of the facial muscles elicited by light taps on the facial nerve. This spasm signals tetany and is
seen in clients with hypocalcemia.
circumcised
Involving the removal of the foreskin of the penis.
circumferential
Area encircling or concerning the periphery of an object or body part.
cirrhosis
A chronic, degenerative liver disease in which the lobes are covered with fibrous tissue, the liver
parenchyma degenerates, and the lobules are infiltrated with fat.
clarification
Communication technique used to help the client identify inconsistencies in his statements.
clinical depression
Syndrome characterized by persistent sadness and dysphoria accompanied by disturbances in sleep and
appetite, lethargy, and an inability to experience pleasure.
clubfoot
A congenital foot deformity in which the foot is twisted out of shape or position.
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cognitive development
Ability to learn from experience, gain and maintain knowledge, respond to new situations, and solve
problems.
colonoscopy
Examination of the colon using a flexible endoscope to visualize internal body areas or to remove tissue
samples or small growths.
communicable disease
A disease that may be transmitted directly or indirectly from one person to another.
compartment syndrome
A neurovascular complication commonly associated with fractures of the limb; constricting or occlusive
dressings, sutures, or casts; poor positioning; and any injury causing ischemia, swelling, or bleeding into the
tissues that ultimately can lead to permanent dysfunction and deformity. It’s characterized by increasing limb
pain unrelieved by analgesics, pallid or dusky skin color changes, absent pulse or edema distal to the injury
site, decreased active and passive muscle movement distal to the injury site, pain with passive muscle
stretching, and sensory changes.
compliance
1. Adherence to a therapeutic regimen. 2. A tissue's or organ's ability to yield to pressure without disruption,
commonly used to describe the distensibility of an air- or fluid-filled organ.
compulsion
A ritualistic, repetitive, and involuntary defensive behavior.
concussion
A violent shock or jarring, such as from an explosion or a blow. Concussion of the brain is characterized by
loss of consciousness. Severe concussion may also cause impairment of brain stem functions.
consolidation
Solidification of the lungs that occurs with pneumonia.
contracture
Abnormal flexion and fixation of a joint, possibly permanent, which is typically caused by muscle wasting
and atrophy or by loss of normal skin elasticity such as from extensive scar tissue.
controlled substance
Any substance that is strictly regulated or outlawed because of its potential for abuse or addiction.
conversion disorder
A disorder in which the client attempts to resolve a psychological conflict through the loss of a specific
physical function -- for example, by paralysis, blindness, or inability to swallow.
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Corrigan's pulse
Short, forceful, bounding pulse typically associated with aortic insufficiency.
couvade
The experience of physical symptoms associated with pregnancy, such as nausea, vomiting, and backache,
by the husband of a pregnant woman; the response often results from stress, anxiety, and empathy for the
pregnant woman.
crackles
Short, explosive or popping sounds usually heard during inspiration. They may be coarse (loud and low in
pitch) or fine (less intense and high in pitch) and resemble the sounds heard when rolling hair between the
fingers near the ear.
Crohn's disease
A chronic inflammatory bowel disease of unknown cause, usually involving the terminal ileum, with scarring
and thickening of the bowel wall. Signs and symptoms include frequent episodes of diarrhea, severe
abdominal pain, nausea, fever, chills, anorexia, and weight loss.
croup
An acute viral infection of the respiratory tract that causes acute upper airway obstruction. Characterized by
stridor, a barking cough, and hoarseness, it primarily affects infants and young children ages 3 months to 3
years and follows an upper respiratory tract infection.
crowning
Appearance of the presenting part of the fetus at the perineum and seen when the vulva are separated.
crystalloid fluid
Clear solutions (usually in reference to I.V. solutions) containing electrolytes and water.
Cushing's syndrome
A metabolic disorder caused by chronic, excessive production of adrenocortical hormones or by prolonged
high-dose glucocorticoid therapy. It’s characterized by such signs and symptoms as hypertension, diabetes
mellitus, dusky complexion with purple striae, muscle wasting, weakness, and sudden development of fat
around the face, neck, and trunk.
cyanosis
Bluish discoloration of the skin and mucous membranes resulting from an excessive amount of
deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule such as in
methemoglobin.
cyanotic
Referring to the bluish or bluish black discoloration of the skin and mucous membranes that results from
excessive concentration of unoxygenated hemoglobin in the blood.
cystic fibrosis
An inherited disorder of the exocrine glands that affects multiple organ systems, causing such conditions as
chronic pulmonary disease, pancreatic deficiency, sweat gland dysfunction, malabsorption, and liver
obstruction.
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cystoscopy
Direct visualization of the urinary tract by inserting a cystoscope in the urethra.
debridement
Removal of dead or damaged tissue or foreign material from a wound to prevent the growth of
microorganisms and further damage and to promote healing.
deceleration
A drop in baseline fetal heart rate as indicated by the fetal monitor. Early deceleration is a drop in fetal heart
rate that coincides with uterine contraction. Variable deceleration is a drop in fetal heart rate that doesn't
occur at a consistent point during contractions. Prolonged deceleration is a drop in fetal heart rate that
occurs for an extended period of time.
dehiscence
The partial or complete separation of a wound's edges.
dehydrated
Having insufficient water in the body or tissues.
delusions
False ideas or beliefs accepted as real by the client.
delusions of grandeur
Distorted or false idea or belief that one has exceptional powers, wealth, skill, influence, or destiny.
depolarization
Neutralization of electrical polarity; reversal of the resting potential in excitable cell membranes when
stimulated. An example is the reduction of the ion differential of sodium and potassium across the nerve
cells at the neuromuscular junction.
diabetes insipidus
A metabolic disorder marked by extreme polyuria and polydipsia and resulting from deficient secretion or
production of antidiuretic hormone (ADH) or inability of the renal tubules to respond to ADH. (Rarely,
excessive water intake causes signs and symptoms.) The condition may be acquired (secondary to disease
or drug therapy), inherited, idiopathic, or nephrogenic.
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diabetes mellitus
A chronic disorder of carbohydrate metabolism characterized by hyperglycemia and glycosuria resulting
from inadequate production or utilization of insulin.
diabetic ketoacidosis
An acute, life-threatening form of metabolic acidosis that may arise as a complication of uncontrolled
diabetes mellitus. Accumulation of ketone bodies leads to urinary loss of water, potassium, ammonium, and
sodium, resulting in hypovolemia, electrolyte imbalances, an extremely high blood glucose level and,
commonly, coma. Signs and symptoms include flushed, hot, dry skin; confusion; nausea; diaphoresis;
restlessness; and fruity breath odor.
dislocated
Displacement of any body part, primarily a bone from its normal position in a joint.
diuretic
1. Tending to increase the formation and excretion of urine. 2. An agent that promotes the formation and
excretion of urine.
diverticulitis
Inflammation of one or more diverticula, or saclike herniations, in the muscular layer of the colon.
diverticulosis
The presence of saclike herniations through the muscular layer of the colon without accompanying
inflammation. Most clients with this condition have few signs or symptoms except for occasional rectal
bleeding.
drip factor
An indication of the number of drops needed to obtain one milliliter of solution delivered by a manufacturer's
I.V. tubing based on the drop size.
dumping syndrome
A condition of nausea, weakness, profuse sweating, and dizziness occurring in clients who have had a
subtotal gastrectomy. Signs and symptoms arise soon after eating when the contents of the stomach empty
too rapidly into the duodenum. Also called postgastrectomy syndrome. Eating small, frequent, high-
protein, high-calorie meals may help prevent discomfort and ensure adequate nutrition.
dysphagia
Difficulty swallowing, commonly resulting from obstructive or motor disorders of the esophagus. Obstructive
disorders, such as an esophageal tumor or lower esophageal ring, interfere with the ability to swallow solids;
motor disturbances such as achalasia impair swallowing of solids and liquids.
dyspnea
Shortness of breath, difficulty breathing, or labored breathing resulting from certain heart conditions, anxiety,
or strenuous exercise.
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dystonic reaction
Severe tonic contractions of the muscles in the neck, mouth, and tongue; dystonic reaction is a common
adverse reaction to antipsychotic drugs.
dysuria
Painful or difficult urination, which is usually caused by a bacterial infection or an obstruction in the urinary
tract.
echolalia
Parrotlike and inappropriate repetition of another's words.
ectopic pregnancy
Implantation of the fertilized ovum outside the uterine cavity. Types of ectopic pregnancy are abdominal
pregnancy, interstitial pregnancy, and tubal pregnancy.
effacement
Shortening of the vaginal portion of the cervix and thinning of its walls during labor due to stretching and
dilation caused by the fetus. Full effacement obliterates the constrictive neck of the uterus. The extent of
effacement is expressed as a percentage of full effacement.
elbow restraints
Type of restrictive device attached to the client's body at the elbow to restrict movement or access to
another body part; may be applied after cleft palate repair to reduce the risk of injury to the suture line.
electrocardiogram interpretation
Analysis of the waveforms seen on an electrocardiogram
electromyogram (EMG)
A record of the electrical activity of skeletal muscles, obtained by surface electrodes or needle electrodes
and devices that amplify, transmit, and record the signals. The technique is helpful in diagnosing
neuromuscular disorders, pinpointing motor nerve lesions, and measuring electrical potentials induced by
voluntary muscle contraction.
electromyography
Diagnostic test that records the electrical activity of selected skeletal muscle groups at rest and during
voluntary contraction. It involves percutaneous insertion of a needle electrode into a muscle with
measurement of the muscle's electrical discharge through an oscilloscope.
endocarditis
An abnormal condition of the endocardium and heart valves marked by vegetations on the valves and
endocardium. It may occur as a primary disorder or arise in association with another disease.
endotracheal intubation
Passage of a wide-bore tube through the mouth or nose into the trachea. It may be used to maintain a
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patent airway, administer anesthesia, aspirate secretions, prevent aspiration of foreign material into the
tracheobronchial tree of an unconscious or paralyzed person, or administer positive pressure ventilation that
can’t be given effectively by a mask.
enteral
Referring to administration by mouth, rectum, or directly into the intestinal system.
enteral feedings
Delivery of nutrients directly into the GI tract through a feeding tube.
enteric precautions
A category-specific type of infection precautions established by the Centers for Disease Control and
Prevention involving infections transmitted by intestinal secretions. These have since been replaced with
standard precautions and transmission-based precautions.
enuresis
Involuntary passage or release of urine after the age when bladder control would have been normally
achieved.
epiglottis
The lidlike, cartilaginous structure that overhangs the larynx and prevents food from entering the larynx and
trachea during swallowing.
epiglottitis
Inflammation of the epiglottis. Acute epiglottitis, a severe form of the condition that primarily affects children,
causes stridor, fever, sore throat, croupy cough, and a reddened, swollen epiglottis.
epilepsy
A group of neurologic disorders marked by uncontrolled electrical discharge from the cerebral cortex and
typically manifested by seizures with clouding of consciousness. Epilepsy is most commonly of unknown
cause (idiopathic) but is sometimes associated with head trauma, intracranial infection, brain tumor,
vascular disturbances, intoxication, or chemical imbalance.
episiotomy
Surgical incision into the perineum to enlarge the vaginal opening for delivery. It’s performed to prevent
traumatic tearing of the perineum, to hasten or promote delivery, or to prevent stretching of perineal muscles
and connective tissue.
Erikson
Psychosocial development theorist who described eight developmental stages across the life span, each of
which is characterized by a conflict between two opposing forces.
erythroblastosis fetalis
Hemolytic anemia of the neonate caused by placental transmission of maternally formed antibodies against
the incompatible antigens of fetal blood. It results from maternal-fetal blood group incompatibility, specifically
involving the rhesus (Rh) factor and the ABO blood groups, and is characterized by accelerated destruction
of red blood cells and resulting jaundice. In Rh factor incompatibility, the hemolytic reaction appears only
when the mother is Rh-negative and the infant is Rh-positive. Isoimmunization rarely occurs with the first
pregnancy, but the risk increases with each succeeding pregnancy.
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eschar
A thick scab or dry crust that appears after a thermal or chemical burn.
esophageal atresia
A congenital anomaly involving closure of the esophagus at some point, often ending in a blind pouch.
evaporation
The change of a liquid to a vapor at a temperature below the boiling point of the liquid. Evaporation occurs
at the surface of the liquid, hastened by an increase in temperature and a decrease in atmospheric
pressure.
evisceration
1. Pushing out or removal of the viscera, especially through a surgical incision. 2. In ophthalmology:
excision of the contents of the eyeball (except the sclera).
exacerbation
An increase in the seriousness of a disease or disorder or in its signs and symptoms.
extrapyramidal
1. Describing the tissues and structures of the brain located outside the pyramidal tract and not running
through the medullary pyramid -- excluding the motor neurons, motor cortex, and corticospinal and
corticobulbar tracts. 2. Of or relating to the function of these tissues and structures.
extravasation
Escape, usually of blood, lymph, or I.V. solution, from a vessel into surrounding tissues.
failure to thrive
Condition in which an infant's height and weight fall below the third percentile on a standard growth chart;
also called reactive attachment disorder.
fantasy play
Type of play involving imaginary playmates typically associated with preschoolers.
febrile seizure
Typically, a tonic-clonic seizure of relatively short duration (usually less than 1 minute) occurring with an
acute illness and fever.
fifth disease
A contagious, relatively benign disease caused by the Parvovirus B19; most commonly occurs in children
ages 2 to 12 and is characterized by a red rash on the cheeks. Also called erythema infectiosum.
fontanel
A soft spot, such as the spaces covered by tough membranes remaining between the bones of an infant's
skull.
full-term
Pregnancy that has continued for a period of 38 to 42 weeks.
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fundus
The base of an organ; the portion of a hollow organ farthest from its mouth, such as the fundus of the
uterus.
gastritis
Inflammation of the stomach and stomach lining.
gastroenteritis
Inflammation of the lining of the stomach and intestines that accompanies numerous GI disorders;
characterized by anorexia, weakness, abdominal pain, nausea, and diarrhea.
gastrostomy
Opening created into the stomach.
gestational diabetes
The development of diabetes during pregnancy, usually during the second trimester.
glaucoma
A group of eye diseases characterized by abnormally elevated pressure within the eye due to obstruction of
the outflow of aqueous humor.
glomerulonephritis
Inflammation of the glomeruli in the kidneys.
gout
A group of disorders associated with inborn errors of metabolism that affect purine and pyrimidine use;
results in increased production of uric acid or interferes with its excretion. Manifested by hyperuricemia,
recurrent acute inflammatory arthritis, deposition of urate crystals in the joints of the extremities, and uric
acid urolithiasis.
granulation tissue
Tissue that develops during collagen production; capillaries form as budlike structures from nearby vessels,
penetrating the wound, growing into loops, and providing a nutritional source for the newly generated tissue;
the loops give the tissue a "granular" appearance.
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Graves' disease
A disorder of the thyroid gland characterized by pronounced thyrotoxicosis usually associated with an
enlarged thyroid gland, exophthalmos, or pretibial myxedema.
gravida
A pregnant woman.
gynecomastia
Enlargement and development of the mammary glands in men, usually temporary and benign.
hallucinations
Sensory perceptions that don't result from external stimuli and that occur during wakefulness.
heart failure
Inability of the heart to pump an adequate amount of blood to the tissues.
hemarthrosis
Bleeding into a joint cavity.
hematuria
The presence of blood in the urine.
hemicolectomy
Surgical removal of one-half of the colon.
hemiparesis
Paralysis on one side of the body or a part of it that indicates an injury to the motor area of the brain.
hemiplegia
Paralysis of one side of the body.
hemogram
Written recording of the blood count differential.
hemolytic reaction
Type of blood transfusion reaction occurring when the donor's blood is incompatible with the recipient's
blood; the most serious type of transfusion reaction.
hemophilia
A bleeding disorder characterized by a failure of the blood clotting mechanism. It’s an inherited condition
occurring almost exclusively in males.
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hemoptysis
The coughing or spitting up of blood caused by hemorrhage in the lungs or bronchi. Minor amounts of blood
may appear in the sputum of individuals with bronchitis or upper respiratory tract infections.
hepatic encephalopathy
A serious complication of liver failure affecting a client's neurologic status; believed to result from the
accumulation of toxins, such as ammonia, in the blood.
hepatojugular reflux
Distention of the neck veins when manual pressure is applied over the right upper quadrant of the abdomen;
it suggests heart failure.
hepatomegaly
Enlargement of the liver.
heterozygous
Having two different genes at corresponding loci on homologous chromosomes.
hiatal hernia
Protrusion of part of the stomach through the esophageal opening in the diaphragm.
homonymous hemianopia
Blindness or visual deficit in one-half of the field of vision of both eyes. Either the right halves or the left
halves of each eye are affected.
hopelessness
State of severe despair associated with feelings of inadequacy and isolation, an inability to act on one's
behalf, and a belief that the situation is highly unlikely to improve.
hospice
A system of family-centered care using a multidisciplinary approach designed to assist the chronically ill
person to maintain a satisfactory lifestyle through the terminal phases of dying.
hydatidiform mole
A usually benign neoplasm that occurs at the end of a degenerating pregnancy and arises from enlarged
chorionic villi and the proliferation of trophoblastic tissue.
hydramnios
Presence of an excess volume of amniotic fluid during pregnancy.
hydrotherapy
Treatment involving the use of water, such as tub or shower baths and whirlpools.
hyperemesis gravidarum
Severe and prolonged vomiting during pregnancy to such a degree that weight loss and an imbalance of
fluids and electrolytes occur.
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hyperphosphatemia
Elevated serum level of phosphorus above 2.6 mEq/L or 4.5 mg/dl.
hypersomnolence
Excessive sleepiness.
hyperthermia
A severe elevation in body temperature.
hyperthyroidism
Disorder involving overproduction of thyroid hormone, leading to a metabolic imbalance.
hypertonic
1. A solution that has greater osmotic pressure compared to another solution; a fluid in which cells shrink. 2.
In reference to muscles or arteries, having a greater than normal degree of tension.
hypertrophic cardiomyopathy
Primary disease of the cardiac muscle characterized by disproportionate, asymmetrical thickening of the
interventricular septum, particularly in the anterior-superior region. Also called idiopathic hypertrophic
subaortic stenosis.
hyperventilate
To increase the rate or depth of one's inspirations or expirations, or both; may occur with anxiety.
hypochondriasis
Preoccupation with the fear that one has a serious illness despite medical reassurance to the contrary; fear
interferes with psychosocial functioning.
hypoglycemia
Low serum glucose levels.
hypospadias
A congenital abnormality in males in which the urethral opening is on the underside, rather than at the tip, of
the penis; in females, the defect is manifested by a urethral opening into the vagina.
hypotonic
1. A solution that has a decreased osmotic pressure compared to another solution; a fluid in which cells
swell. 2. In reference to muscles or arteries, having a less than normal degree of tension.
hypoxia
A decreased level of oxygen in inspired air.
iatrogenic
Introduced inadvertently by a medical practitioner or resulting from a diagnostic procedure or treatment.
impetigo
A contagious, inflammatory skin infection that usually occurs on the face. Characterized by the appearance
of small, itchy blisters that rupture and form a crusty scab; usually caused by streptococcal or
staphylococcal bacteria or a combination of both types of organisms.
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incentive spirometer
A device that requires the client to deep breathe, hold the breath for approximately 3 seconds, and then
exhale in an effort to expand the lungs.
incompatibility
Unsuitability for combination, often due to antagonistic action.
induration
Area of hardened tissue.
infection
The invasion and multiplication of pathogenic organisms within the body.
informed consent
Permission obtained from a client to perform a specific test or procedure after the client has been fully
informed about the test or procedure.
intermittent claudication
Pain that occurs with activity or exercise but that is relieved with rest. This pain results from the body's
inability to supply arterial blood (blood rich in nutrients) to the tissues that experience an increase in demand
during exercise or activity.
interpretation
The deep analysis of the meaning and significance of what a client is saying and doing in an effort to gain
insight into his behavior.
intertrigo
Dermatitis that occurs at moist, warm sites where skin surfaces rub together, such as the armpits, the inner
surfaces of the thighs, and between the buttocks; caused by an overgrowth of normal flora.
intracranial pressure
Pressure exerted by the brain tissue, cerebrospinal fluid, and blood.
intradermal injection
Injection of any substance into the skin between the dermis and epidermis. The technique is typically used
to produce a local drug effect (such as in local anesthesia for procedures such as suturing wounds) or
during allergy testing. Also called intracutaneous injection.
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intraosseous infusion
Administration of fluid, blood, or drugs into the bone marrow cavity of a long bone; typically used in children
for emergency situations when I.V. access is difficult or unavailable.
intussusception
Telescoping or invagination of a portion of the bowel into an adjacent portion; most commonly seen in
infants.
irritability
Excitability or excessive responsiveness to a stimulus.
isotonic
Of or relating to a solution that has the same osmotic pressure as another solution; a solution in which cells
neither swell nor shrink.
juvenile hypothyroidism
A condition involving a deficiency of thyroid hormone secretion in children.
Kawasaki disease
A febrile, multisystem disorder affecting the small to medium-size vessels, primarily of the lymph nodes,
most commonly in children before puberty; usually follows exposure to an infection. Also called
mucocutaneous lymph node syndrome.
Kegel exercises
Exercises involving alternate contraction and relaxation performed to strengthen the perineal muscles.
kernicterus
A neurologic syndrome resulting from deposition of unconjugated bilirubin in the brain cells and
characterized by severe neural symptoms.
Kernig's sign
Elicitation of resistance and hamstring muscle pain when the examiner attempts to extend the knee while
the hip and knee are both flexed 90 degrees.
Kussmaul's respirations
Abnormally deep, gasping type of respirations resulting from air hunger; associated with severe diabetic
acidosis and coma.
laminectomy
Surgical removal of the bony arches of one or more vertebrae; performed to relieve spinal cord compression
or to remove a displaced intervertebral disk.
lead poisoning
Poisoning caused by the ingestion or absorption of lead or one of its salts. Signs and symptoms include loss
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of appetite and weight, anemia, constipation, insomnia, headache, dizziness, irritability, a blue line at the
margin of the gums, and peripheral neuropathy.
lethargy
A feeling or condition of sluggishness, apathy, or inactivity.
lipodystrophy
Any disturbance in fat metabolism.
living will
A witnessed document indicating a client's desire to be allowed to die a natural death rather than be kept
alive by heroic, life-sustaining measures. The will applies to decisions that will be made after a terminally ill
client is incompetent and has no reasonable possibility of recovery.
lochia
The vaginal discharge present during the first several weeks after delivery.
lochia alba
A creamy white, brown, or colorless discharge consisting mainly of serum and white blood cells; typically
stops flowing at about 6 weeks postpartum.
lochia rubra
Present during the first 3 to 4 postpartal days; it’s bloody and may contain mucus, tissue, debris, and small
clots.
lochia serosa
A pink or brownish discharge persisting for 5 to 7 days postpartum.
Logan bar
Apparatus used to protect the surgical incision after cleft lip repair.
Logan bow
A wire U-shaped apparatus taped to both cheeks of an infant or toddler following cleft lip repair to protect the
surgical site.
lumbar puncture
Fluid withdrawal from the subarachnoid space of the lumbar region of the spinal canal, usually between the
third and fourth lumbar vertebrae, for diagnostic or therapeutic purposes. Also called spinal tap.
lymphangiography
A diagnostic radiographic evaluation of lymphatic system filling after injection of a contrast medium into a
lymphatic vessel of each foot or hand.
lymphedema
Edema of an arm or leg caused by the buildup of interstitial fluid as a result of lymphatic inflammation or
obstruction or a lymph node disorder.
mammogram
A radiograph of the breast; used for diagnostic purposes.
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mammography
Radiography of the mammary gland to identify benign and malignant neoplastic processes.
mastectomy
The surgical resection of a breast; usually performed to remove a malignant tumor.
mastitis
Inflammation of the mammary gland; usually caused by streptococcal or staphylococcal infection and
infrequent breast-feeding.
meconium
A dark, greenish black material that occurs in the intestines of a fetus that forms the first stools of a neonate.
The fluid is thick and sticky and is composed of intestinal gland secretions, some amniotic fluid, and
intrauterine debris.
megaloblastic anemia
A hematologic disorder that is characterized by the production and peripheral proliferation of megaloblasts.
Ménière's disease
A labyrinthine dysfunction that produces severe vertigo, sensorineural hearing loss, and tinnitus.
metabolic acidosis
A condition resulting from excessive accumulation of acid or depletion of bicarbonate.
metabolic alkalosis
A clinical state marked by decreased amounts of acid or increased amounts of base bicarbonate.
milieu
A therapeutic environment, typically used as part of inpatient psychiatric therapy.
mitral stenosis
Obstruction of blood flow from the left atrium to the left ventricle due to thickening and contracting of the
mitral valve leaflets; consequently, left atrial volume and pressure rise and the chamber dilates. Greater
resistance to blood flow causes pulmonary hypertension, right ventricular hypertrophy, and right-sided heart
failure.
muscular dystrophy
A group of degenerative genetic diseases characterized by weakness and the progressive atrophy of
skeletal muscles with no evidence of nervous system involvement.
myalgia
Diffuse muscle pain or tenderness associated with many infectious diseases.
myasthenia gravis
An abnormal muscle weakness and fatigability, especially in the muscles of the face and throat, resulting
from a defect in the conduction of nerve impulses at the myoneural junction.
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mycoplasmal pneumonia
A contagious respiratory disease caused by Mycoplasma pneumoniae, characterized by a sore throat, dry
cough, fever, malaise, and myalgia.
myeloma
Osteolytic neoplasm consisting of a protrusion of cells typical of the bone marrow.
myelomeningocele
The protrusion of a hernial sac containing a portion of the spinal cord, its meninges, and cerebrospinal fluid
through a congenital defect in the vertebral column.
myxedema
A disorder that results from hypofunction of the thyroid. Signs and symptoms include enlarged tongue,
slowed speech, moon face, drowsiness, cold intolerance, hair loss, and anemia.
myxedema coma
A rare, serious form of hypothyroidism that usually results from lack of treatment or mistreatment, severe
stress (from infection, exposure to cold, or trauma), or the use of sedatives or anesthetics in a client being
treated for hypothyroidism.
nebulizer
A device that employs a baffle to produce a fine aerosol spray consisting of particles less than 30
micrometers in diameter.
necrotizing enterocolitis
GI disorder commonly associated with premature infants and characterized by diffuse or patchy intestinal
necrosis and sometimes accompanied by sepsis.
neglect
A form of abuse involving the failure to protect a person from injury or meet the person's physical, emotional,
or medical needs.
nephrectomy
The surgical removal of a kidney, usually done to remove a tumor, drain an abscess, or treat
hydronephrosis.
nephrotic syndrome
A clinical classification including all kidney diseases characterized by marked proteinuria, hypoalbuminemia,
and edema.
neurotransmitter
Any one of a group of substances that act on a target nerve cell to excite or inhibit transmission of nerve
impulses; substances include norepinephrine, acetylcholine, and dopamine.
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nystagmus
Involuntary, rapid movements of the eyeball that may be horizontal, rotatory, vertical, or mixed.
obsessive-compulsive disorder
A disorder characterized by obsessive thoughts and compulsive behaviors that represent recurring efforts to
control overwhelming anxiety, guilt, or unacceptable impulses that persistently enter the consciousness.
oliguria
A diminished flow of urine in relation to fluid intake; usually less than 400 ml in 24 hours. Also called
hypouresis.
ophthalmia neonatorum
Eye infection occurring at birth or in the first month; most commonly caused by gonorrhea or chlamydia.
opioids
Opium-derived or synthetically produced drugs that alter pain perception, induce mental changes, promote
deep sleep, depress respirations, constrict pupils, and decrease GI motility.
orthostatic hypotension
Abnormally low blood pressure that occurs when a person stands up. Also called postural hypotension.
osmolality
The concentration or osmotic pressure of a solution; expressed in osmoles of solute per kilogram of solvent.
osmolarity
The osmotic pressure of a solution expressed in osmoles of solute per liter of solution.
osteomalacia
Delayed or poor mineralization of bone; the adult equivalent of rickets. This condition is associated with
anorexia, fracture, pain, weakness, and weight loss.
osteomyelitis
Inflammation of bone that results from a local or general infection of bone and bone marrow. The bacterial
infection is caused by trauma or surgery, by direct extension from a nearby infection, or by introduction from
the bloodstream.
osteoporosis
A disorder in which bone mass is reduced and fractures occur after minimal trauma. It occurs most
commonly in postmenopausal women, sedentary or immobilized individuals, and persons on long-term
steroid or heparin therapy.
otorrhea
A discharge from the ear, which may be serous, sanguineous, or purulent if the external or middle ear is
infected.
ototoxicity
Harmful effect on the function of the eighth cranial nerve or hearing organs; most commonly associated with
prescribed drugs.
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Paget's disease
A common bone disease that usually affects middle-aged and elderly people. It’s marked by inflammation of
the bones, softening and thickening of the bones, excessive bone destruction, and unorganized bone repair;
the result is bowing of the long bones. The cause is unknown.
palilalia
Repetition of words or phrases with increasing rapidity.
pancreatitis
Acute or chronic inflammation of the pancreas.
paralysis
An abnormal condition characterized by the loss or impairment of motor function or the impairment of
sensory function.
paralytic ileus
A decrease in or absence of bowel motility that may occur following abdominal surgery or may be caused by
numerous other conditions, most commonly by peritonitis.
paranoid schizophrenia
Disorder involving disordered thinking with delusional thought content characterized by preoccupation with
delusions or auditory hallucinations, lack of organized speech, disorganized or catatonic behavior, or flat or
inappropriate affect.
paraplegia
An abnormal condition characterized by the loss of sensation and motor function in the lower limbs, which
may result in either complete or incomplete paralysis.
parenteral
Not in or through the digestive system, but rather by injection through some other route, such as
subcutaneously, I.V., I.M., or intradermally.
paresthesia
Abnormal or heightened touch sensations, such as burning, numbness, prickling, and tingling, that
commonly occur without external stimulus.
perceptions
Awareness of objects and the ability to differentiate between them.
pericarditis
Inflammation of the pericardium; may be caused by trauma, neoplasm, infection, uremia, myocardial
infarction, or collagen disease.
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perineum
1. The pelvic floor and its associated structures; located between the symphysis pubis and the coccyx and
on the sides by the ischial tuberosities. 2. The body area between the thighs; bounded by the anus and
scrotum in males and by the anus and vulva in females.
peristaltic waves
Alternating involuntary contraction and relaxation of the smooth muscle fibers of a structure in a wavelike
fashion to propel the contents forward; commonly associated with the GI tract.
peritoneal dialysis
A procedure performed to remove toxins, drugs, or other wastes normally excreted by the kidney; transfers
these substances across the peritoneum by intermittently introducing and removing a dialysate from the
peritoneal cavity.
peritonitis
An inflammation of the peritoneum; can be produced by bacteria or irritating substances introduced into the
abdominal cavity by a penetrating wound or perforation of an organ.
pernicious anemia
A megaloblastic anemia characterized by decreased gastric production of hydrochloric acid from the parietal
cells of the stomach essential for vitamin B12 absorption; results in vitamin B12 deficiency.
phagocytosis
The process by which cells engulf and digest solid substances, such as microorganisms and cell debris.
phenylketonuria (PKU)
An inborn metabolic disorder caused by absence or deficiency of phenylalanine hydroxylase, the enzyme
responsible for the conversion of phenylalanine to tyrosine; results in accumulation of phenylalanine and its
metabolites, causing mental retardation and other neurologic problems, light pigmentation, eczema, and a
distinctive mousy odor.
pheochromocytoma
A chromaffin-cell tumor of the adrenal medulla that secretes an excessive amount of the catecholamines
epinephrine and norepinephrine, which results in severe hypertension, increased metabolism, and
hyperglycemia.
phototherapy
The treatment of disease by the use of light, especially ultraviolet light or other concentrated rays; used to
treat acne, psoriasis, and hyperbilirubinemia.
pituitary dwarfism
A condition characterized by a deficiency in secretion of the growth hormone from the anterior pituitary
gland.
placenta accreta
Abnormal adherence of the placenta to the uterine wall.
placenta previa
Implantation of the placenta so that it adjoins or covers the internal os of the uterine cervix. The most
common symptom is painless hemorrhage in the last trimester.
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pneumonia
An acute infection of the lung parenchyma that commonly impairs gas exchange.
pneumothorax
A collection of air in the pleural space; may result from an open chest wound that permits the entrance of air
or from the rupture of a vesicle on the surface of the lung. Common types of pneumothorax are open,
closed, and tension.
polydipsia
Chronic, excessive thirst.
polymyositis
The simultaneous inflammation of a number of voluntary muscles.
polyneuritis
Degeneration of peripheral nerves primarily supplying the distal muscles of the extremities. It results in
muscle weakness, with sensory loss and atrophy, and decreased or absent deep tendon reflexes.
polyphagia
Voracious or excessive eating before becoming satiated.
polyuria
The excessive excretion of urine from the kidneys.
postterm neonate
A neonate born after the onset of the 43rd week of pregnancy.
preeclampsia
An abnormal condition characterized by the development of hypertension during pregnancy, accompanied
by edema or proteinuria, usually after the 20th week of gestation.
pressure ulcer
Localized area of skin breakdown occurring secondary to prolonged pressure. Necrotic tissue develops
because the vascular supply to the area is diminished.
preterm neonate
A neonate born before the beginning of the 38th week of pregnancy.
primigravid
A woman who is pregnant for the first time.
Prinzmetal's angina
A variant of angina pectoris, a form of unstable angina, in which the attacks occur during rest. Attacks are
indicated by an ST-segment elevation on an electrocardiogram.
productive cough
A mechanism by which the body clears the airway passages of secretions that normal mucociliary action
doesn't remove; usually sudden, forceful, noisy expulsion of air from the lungs that contains sputum or blood
(or both).
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projection
False attribution of one's unacceptable feelings, impulses, or thoughts onto another.
pruritus
Itching; an unpleasant sensation that leads to rubbing or scratching the skin in an effort to obtain relief.
Scratching the skin may lead to secondary infection.
pseudoparkinsonism
The development of a Parkinson-like disorder (neuromuscular disorder involving progressive muscle rigidity,
akinesia, and involuntary tremors) due to psychotropic drug therapy.
puerperal
1. Of or pertaining to the period from the end of childbirth until involution of the uterus is complete (usually 3
to 6 weeks). 2. Of or pertaining to a woman (puerpera) who has just given birth to an infant.
pulmonary edema
An abnormal condition in which extravascular fluid is accumulated in lung tissues and alveoli.
pulse pressure
The numeric difference between the systolic and diastolic pressures, usually 30 to 40 mm Hg.
purulent
Containing or forming pus.
pyelonephritis
Inflammation of the kidney and its pelvis.
pyuria
The presence of pus in the urine, commonly a sign of urinary tract infection.
quickening
The first notable fetal movement in utero, usually occurring at 16 to 20 weeks' gestation.
radical mastectomy
Surgical removal of an entire breast, pectoral muscles, axillary lymph nodes, and all fat, fascia, and adjacent
tissues; usually used in the treatment of breast cancer.
reaction formation
Substitution of behavior, thoughts, or feelings that are completely opposed to one's own unacceptable
behavior, thoughts, or feelings.
rectal route
Use of the rectum to administer medication
reflection
A technique in which the listener interprets the feelings of the client and repeats them back to the client;
encourages the client to clarify his feelings.
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repolarization
Part of the cardiac conduction cycle in which the cell returns to its resting state, a more negatively charged
state. Calcium ions move into the cell and potassium ions move out, followed by the extrusion of sodium
and calcium ions from the cell and the restoration of potassium ions into the cell by the sodium potassium
pump.
respiratory acidosis
Caused by reduced alveolar ventilation; is marked by increased partial pressure of arterial carbon dioxide,
excess carbonic acid, and increased plasma hydrogen-ion concentration. Hypoventilation inhibits the
excretion of carbon dioxide, which consequently produces excessive carbonic acid and thus lowers blood
pH.
respiratory alkalosis
Caused by both respiratory and nonrespiratory factors, this condition is marked by decreased partial
pressure of arterial carbon dioxide, decreased hydrogen-ion concentration, and increased blood pH.
Extreme anxiety can precipitate hyperventilation associated with respiratory alkalosis.
resuscitation
A method used to support a client's breathing and circulation until the body can do so on its own or the client
is mechanically supported. It involves maintaining an open airway, providing artificial ventilation through
rescue breathing, and promoting artificial circulation through external cardiac compression.
Reye's syndrome
Acute encephalopathy and fatty infiltration of the internal organs following acute viral infections, such as
influenza B, chickenpox (varicella), the enteroviruses, and the Epstein-Barr virus; has also been associated
in children with administration of aspirin and other salicylates.
Rh incompatibility
In hematology: two blood groups that are antigenically different and, therefore, aren't compatible because
one group lacks the Rh factor.
rheumatic fever
An inflammatory disease sometimes occurring if group A beta-hemolytic streptococcal infection is
inadequately treated.
rheumatoid arthritis
A chronic, systemic collagen disease marked by inflammation, stiffness, and pain in the joints and related
structures that result in crippling deformities.
ritodrine therapy
A prescribed treatment that uses the beta-receptor agonist ritodrine to halt preterm labor.
Romberg’s sign
A swaying (or falling) when a person stands with feet together and eyes closed. It’s an indication that the
person has lost a sense of position. Also called rombergism.
rooting reflex
A response in neonates to the cheek being touched or stroked. The infant turns the head toward the
stimulated side and begins to suck. The reflex usually disappears by 3 to 4 months of age.
Super Condensed Portable HESI Study Guide 150
Russell traction
An orthopedic device that combines suspension and traction to align and immobilize the legs; used to treat
diseases of the hip and knee and fractured femurs as well as hip and knee contractures.
scabies
A contagious skin disease caused by the itch mite, Sarcoptes scabiei.
scoliosis
An appreciable lateral curvature of the spine resulting from numerous causes, including congenital
malformations of the spine, muscle paralysis, poliomyelitis, sciatica, and unequal leg length.
sensory perceptions
Awareness of one's surroundings through the use of vision, hearing, taste, touch, and smell.
serosanguineous
Of a discharge containing both serum and blood.
shock
An abnormal physiologic state characterized by reduced cardiac output, circulatory insufficiency,
tachycardia, hypotension, restlessness, pallor, and diminished urinary output. Shock may be caused by a
variety of conditions, including trauma, infection, hemorrhage, poisoning, myocardial infarction, and
dehydration.
simple fracture
An uncomplicated, closed bone fracture in which the skin isn't broken.
skin turgor
Skin characteristic determined by pinching a small area of skin on the medial arm or anterior chest and
noting how quickly it returns to its position when released.
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somatoform pain
Development of the symptom of pain as a result of psychological stress.
spinal shock
Loss of autonomic reflex, motor, and sensory activity below the level of a lesion. Signs of spinal shock
include flaccid paralysis, loss of deep tendon and perianal reflexes, and loss of motor and sensory function.
standard precautions
Infection control guidelines established by the Centers for Disease Control and Prevention requiring all
health care personnel to use gloves, gowns, and goggles to prevent contact with a client's blood or body
fluids and to adhere to strict safety measures when handling needles, scalpels, and other sharp instruments.
status asthmaticus
A severe and prolonged asthma attack in which bronchospasm fails to respond to oral medication,
sometimes resulting in hypoxia, cyanosis, and unconsciousness.
Stokes-Adams attack
Episode of confusion and light-headedness accompanying syncope with or without seizures due to
inadequate cerebral perfusion secondary to heart block.
stoma
1. A minute pore, orifice, or surface opening. 2. An artificial, surgically created opening of an internal organ
on the body surface, such as for a colostomy or tracheostomy. 3. A new opening surgically created between
two structures, such as for a gastroenterostomy or pancreaticogastrostomy.
stomatitis
An inflammation of the mouth that may result from bacterial, viral, or fungal infection; exposure to chemicals
or drugs; vitamin deficiency; or a systemic inflammatory disease.
stridor
A high-pitched respiratory sound, usually heard during inspiration, caused by an obstruction of the trachea
or larynx.
stroke
A condition of sudden onset in which a cerebral blood vessel is occluded by an embolus or cerebrovascular
hemorrhage. The resulting ischemia of brain tissue that is normally perfused by the affected vessel may lead
to permanent neurologic damage.
subdural hematoma
A condition involving the collection of blood between the dura mater and the brain.
sublingual
Under the tongue.
supratentorial
Located above the tentorium of the brain.
suspension
A liquid that contains solid particles that aren't dissolved; stirring or shaking the liquid maintains the
dispersal.
sympathomimetics
Group of drugs that mimic the effects of impulses conveyed by adrenergic postganglionic fibers of the
sympathetic nervous system.
synchronized cardioversion
Delivery of an electrical shock to the client in conjunction with the R wave on his ECG, just as the heart
muscle contracts. Delivery is timed to avoid the T wave because an electrical discharge at this time may
cause ventricular fibrillation.
synergistic effect
Administration of two drugs producing the same qualitative effect together to produce a greater response
than either drug alone.
tachycardia
A condition characterized by a regular but accelerated action of the heart, usually l00 to 150 beats per
minute.
tactile fremitus
Vibration in the chest wall that can be felt when a hand is applied to the thorax while the patient is speaking.
It's most commonly due to consolidation of a lung or a part of a lung but may also be caused by congestion,
inflammation, or infection.
tardive dyskinesia
A neurological syndrome marked by slow, rhythmical, automatic movements that occur as an adverse effect
of extended phenothiazine use.
tension pneumothorax
A condition in which air enters the pleural space through a tear in lung tissue but can't exit through the same
vent, thereby trapping air in the pleural space with each inspiration and producing positive pleural pressure.
This in turn causes the ipsilateral lung to collapse.
tenting
An indication of decreased skin turgor, as exhibited by a fold of skin remaining or holding in the pinched
position after being released.
teratogenic
Causing harm to the developing fetus.
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tetany
Hyperexcitability of nerves and muscles as a result of a lessened concentration of extracellular ionized
calcium; symptoms include convulsions, muscle twitching and cramps, and sharp flexion of the wrist and
ankle joints.
tetralogy of Fallot
A combination of congenital cardiac defects consisting of pulmonic stenosis, interventricular septal defect,
dextroposition of the aorta so that it overrides the interventricular septum and receives venous as well as
arterial blood, and right ventricular hypertrophy.
thrombocytopenia
A reduction in the number of blood platelets; usually caused by destruction of erythroid tissue in bone
marrow. The condition may be a result of neoplastic disease or an immune response to a drug.
thrombophlebitis
Inflammation of a vein, often involving clot formation. Common causes include chemical irritation, blood
hypercoagulability, immobilization, infection, postoperative venous stasis, prolonged sitting or standing,
trauma to the vessel wall, or a long period of I.V. catheterization.
tonic-clonic seizure
Paroxysmal, uncontrolled discharge of central nervous system neurons extending to the entire brain and
characterized by stiffening (tonic phase) and then rapid synchronous muscle jerking and hyperventilation
(clonic phase). Also called a major or grand mal seizure.
tonsillectomy
The surgical removal of the palatine tonsils.
tracheoesophageal fistula
Abnormal opening between the esophagus and trachea that may lead to aspiration.
tracheostomy
The surgical creation of an opening through the neck into the trachea; used to relieve upper airway
obstruction and aid breathing.
traction
1. The action of pulling a part of the body along the long axis. 2. In orthopedics: the act of exerting force
through a system of weights and pulleys to align, immobilize, or relieve pressure in a limb, bone, or group of
muscles.
transdermal
Method or route of topical drug administration; provides continuous drug delivery through the skin to achieve
a constant, steady blood concentration level.
transsphenoidal adenohypophysectomy
Surgery involving the pituitary gland, most commonly performed to remove a pituitary tumor. The physician
enters from the inner aspect of the upper lip through the sphenoid sinus.
Super Condensed Portable HESI Study Guide 154
transsphenoidal hypophysectomy
Microsurgery in which an incision is made at the junction of the gums and upper lip. A surgical microscope is
advanced and a special surgical instrument is used to excise all or part of the pituitary gland.
Trendelenburg's position
Position in which the client's head is lower than the trunk; typically, the body and legs are elevated on an
incline.
Trousseau's sign
An assessment technique for evaluating neuromuscular irritability (tetany) associated with hypocalcemia.
When Trousseau's sign is positive, the client develops a carpopedal spasm (adducted thumb, flexed wrist
and metacarpophalangeal joints, and extended interphalangeal joints) after a blood pressure cuff is applied
to the client's upper arm and inflated to a pressure above systolic pressure for approximately 1 to 4 minutes.
tuberculosis
An acute or chronic infection from exposure to Mycobacterium tuberculosis or another strain of
mycobacteria characterized by pulmonary infiltrates and formation of granulomas with caseation, fibrosis,
and cavitation.
type 1 diabetes
An endocrine disorder involving disturbances in carbohydrate, protein, and fat metabolism, usually occurring
before age 30 and requiring the use of exogenous insulin and dietary management. Also called insulin-
dependent diabetes mellitus.
type 2 diabetes
An endocrine disorder involving disturbances in carbohydrate, protein, and fat metabolism; characterized by
insulin resistance with varying degrees of insulin secretory defects. May be treated with diet, exercise, and
oral antidiabetic agents. Exogenous insulin is sometimes necessary.
ulcerative colitis
A chronic, recurrent ulceration of the colon of unknown cause in which there is abdominal cramping, rectal
bleeding, and diarrhea containing blood, pus, and mucus.
urinary incontinence
Inability to prevent urine discharge.
urticaria
A vascular reaction caused by dilation and increased permeability of the capillaries. Symptoms include the
development of transient wheals with pale centers and well-defined erythematous margins.
Super Condensed Portable HESI Study Guide 155
variability
Differing rhythmicity or changes in condition; often used to describe fetal heart rate reflected on the fetal
heart rate tracing as a slight irregularity or jitteriness.
vaso-occlusive crisis
The most common type of sickle cell crisis resulting from blood vessel obstruction by rigid, tangled sickle
cells leading to tissue anoxia and possibly necrosis. Also called a painful crisis or infarctive crisis.
vastus lateralis
The largest of the four muscles that make up the quadriceps femoris; located on the outside of the thigh,
extending from the hip joint to the common quadriceps tendon and inserted in the patella; extends the leg.
venography
A radiographic test using a contrast medium to identify thrombi or obstruction in the veins of the lower
extremities or the kidneys.
ventricular tachycardia
A life-threatening arrhythmia that occurs when the ventricles produce several premature ventricular
contractions in succession; usually due to a problem with the heart's conduction system and increased
myocardial contractility.
vertigo
A sensation of movement in which the client feels himself revolving in space (subjective vertigo) or his
surroundings revolving about him (objective vertigo); may result from diseases of the inner ear or from
disturbances of the vestibular pathways in the central nervous system.
vesicle
1. Any small anatomic sac that contains liquid. 2. A small blister that contains clear fluid.
wet-to-dry dressings
Type of wound covering (dressing) in which gauze moistened with normal saline is applied wet to the wound
and removed once the gauze becomes dry and adheres to the wound bed; used for debridement.
Wilms' tumor
A rapidly growing malignant kidney tumor that occurs most commonly in children younger than age 5,
although it sometimes develops before birth. Rare cases occur later in life. Also called adenomyosarcoma.
Z-track
An I.M. injection technique in which the client's skin is pulled in such a way that the needle track is sealed off
after the injection. The technique is done to minimize subcutaneous irritation and discoloration.
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peroperative screening.
cleanse below the antecubital space w/alcohol
and allow to dry. inflate BP cuff to 40mm Hg
and leave inflated during test.puncure skin 2.5
Describe Ivy method:
mm deep. start timing on stopwatch. blot blood
q 30 sec until bleeding stops. the time required
for bleeding to stop is recorded.
when pt is taking anticoagulants or ASA. Pt
When should Ivy test method not be should stop these meds 3-7 days prior to test w/
done? more popular than Duke method Drs permission. ASA therapy will prolong
bleeding time.
Describe Duke method: earlobe is used. no food or fluid restriction.
thrombocytopenia (decreased platelet count
<50,000), platelet function abnormality,
What can disorders can increase vascular abnormalities, severe liver dx,
bleeding times (prolonged time)? disseminated intravascular coagulation (DIC)
aplastic anemia, factor deficiencies (V, VII, XI)
Christmas disease, hemophilia, leukemia
What drugs may increase bleeding salicylates, (ASA, others) warfarin (Coumadin)
time? dextran, streptokinase (fibrinolytic agent)
What are adult reference values for Ivy
3-7 minutes
method?
What are adult reference values for
1-3 minutes
Duke method?
What is urea? Urea is an end product of protein metabolism.
If both BUN and Creatinine levels are
kidney disease
elevated, nurse should suspect what?
What should nurse do w/Dr's
Encourage fluids.
permission if pt's BUN is 26-35?
serum calcium (Ca) normal range for
adult: 4.5-5.5 mEq/L, 9-11 mg.dL
Adults
newborn: 3.7-7.0 mEq/L, 7.4-14.0 mg/dL
serum calcium (Ca) normal range:
Infant: 5.0-6.0 mEq/L, 10-12 mg/dL Child: 4.5-
newborn, infant, child
5.8 mEq/L, 9-11.5 mg/dL
what is total serum calcium? ionized and nonionized calcium level together.
How does pH affect calcium acidosis-more Ca ionized alkalosis-most of Ca
ionization? is bound to protein and cannot be ionized.
What does a calcium deficit cause? tetany symptoms, unless acidosis is present
What can a calcium excess cause? cardiac dysrhythmias
What can a 24-urine specimen for
parathyroid disorders
calciuria determine?
In hyperparathyroidism, increased. it is decreased in
Super Condensed Portable HESI Study Guide 165
What should nurse promote if pt is active and passive exercises. this will prevent
bedridden? ca loss from bone.
What happens when pt is
thiazide diuretic inhibit ca excretion and
hypercalcemic and is taking a thiazide
promote hypercalcemia.
diuretic?
What is normal Chloride serum level
95-105 mEq/L
for adult?
What is normal serum Chloride level newborn: 94-113 mEq/L infant: 95-110 mEq/L
for newborn, infant and child? child: 98-105 mEq/L
Where is chloride found, extracellular
It is found in the extracellular fluid.
or intracellular?
maintain body water balance, osmaolality of
What roles does chloride play? body fluids (with sodium), and acid-base
balance.
vomiting, gastric suction, diarrhea, low serum
K+ or Na (or both), Low Na diet, continuous
What causes decreased levels of IV D5/W, adrenal gland insufficiency, heat
chloride? exhaustion, acute infections, burns, excess
diaphoresis, metabolic alkalosis, chronic resp
acidosis, CHF
What drugs may decrease chloride
thiazide and loop diuretics, bicarbonates
value?
dehydration, high serum Na level, adrenal
gland hyperfunction, multiple myeloma, head
What causes increased levels of
injury, eclampsia, cardiac decompensation,
chloride?
excessive IV saline (0.9% NaCl) kidney
dysfunction
ammonium chloride, cortisone preparations,
What drugs may increase chloride
ion exchange resins, acetazolamide (Diamox),
level?
prolonged use of triamterene (Dyrenium)
hyperexcitability of the nervous system and
What should nurse look for in
muscles, tetany, slow and shallow breathing,
hypochloremia?
hypotension
What should nurse tell Dr can happen
a chloride deficit can occur.
with continuous IV D5/W?
What should nurse encourage the pt drink fluids containing sodium and chloride
who is Cl deficient to do? (ex. broth, tomato juice) NO PLAIN WATER)
What other labs should nurse look at if serum K+ and Na levels. Cl is frequently lost
pt's Cl is decreased? with Na and K+.
What are sx of overhydration when pt Na holds water. Sx of overhydration: constant,
is receiving several L of normal saline irritating cough, dyspnea, neck&hand vein
for Na and Cl replacement? engorgement, chest rales.
What are sx of hyperchloremia? Sx similar to acidosis; weakness, lethargy and
Super Condensed Portable HESI Study Guide 167
for adult?
What is normal serum Chloride level newborn: 94-113 mEq/L infant: 95-110 mEq/L
for newborn, infant and child? child: 98-105 mEq/L
Where is chloride found, extracellular
It is found in the extracellular fluid.
or intracellular?
maintain body water balance, osmaolality of
What roles does chloride play? body fluids (with sodium), and acid-base
balance.
vomiting, gastric suction, diarrhea, low serum
K+ or Na (or both), Low Na diet, continuous
What causes decreased levels of IV D5/W, adrenal gland insufficiency, heat
chloride? exhaustion, acute infections, burns, excess
diaphoresis, metabolic alkalosis, chronic resp
acidosis, CHF
What drugs may decrease chloride
thiazide and loop diuretics, bicarbonates
value?
dehydration, high serum Na level, adrenal
gland hyperfunction, multiple myeloma, head
What causes increased levels of
injury, eclampsia, cardiac decompensation,
chloride?
excessive IV saline (0.9% NaCl) kidney
dysfunction
ammonium chloride, cortisone preparations,
What drugs may increase chloride
ion exchange resins, acetazolamide (Diamox)
level?
prolonged use of triamterene (Dyrenium)
hyperexcitabillity of the nervous system and
What s&s should nurse look for in
muscles, tetany slow and shallow breathing,
hypochloremia?
hypotensions
Why should nurse inform Dr when pt
a chloride deficit could occur.
is receiving IV D5/W continuously?
what should nurse encourage to do drink fluids containing sodium and chloride
with hypochloremia? (broth, tomato juice) NO PLAIN WATER!
Why should nurse check serum
chloride is frequently lost with sodium and
potassium and sodium levels in pt that
potassiu.
is hypochloremic?
What should nurse look for when pt is Sx of overhydration. Sodium holds water. Sx
receiving several L of NS for sodium include: constant irritating cough, dyspnea,
and chloride replacement? neck and hand vein engorgement, chest rales.
similar to acidosis, (weakness, lethargy and
What are s&s of hyperchloremia?
deep, rapid, vigorous breathing)
avoid drinking or eating salty foods and to use
What should nurse instruct pt do when
a salt substitute (avoid calcium chloride and
hyperchloremic?
potassium chloride substitutes)
Why should nurse notify dr when pt NS increases chloride level more. check for
Super Condensed Portable HESI Study Guide 169
function.
serum: 0.5-1.5 mg/dL Females may have
What are normal reference values for
slightly lower values d/t less muscle mass.
adult serum and urine creatinine?
urine: 1-2 g/24 hr
newborn: 0.8-1.4 mg/dL infant: 0.7-1.7 mg/dL
What are normal reference values for 2-6yo: 0.3-0.6 mg/dL older child: 0.4-1.2
newborn, infant, 2-6 yo, older child mg/dL elderly: may have decreased values d/t
and elderly? decreased muscle mass and decreased
creatinine production.
Question Answer Hint
Albumin normal levels 3.5 - 5.0 mg/dl
Decreased: cystic fibrosis, chronic
glomerulonephritis, alcoholic cirrhosis,
Hodkin's disease, malnutrition, nephrotic
Albumin Increased serum values?
syndrome, multiple myeloma, inflammatory
bowel disease, leukemia, collagen-vascular
diseases
Aldosterone Increased in which Increased: hyperaldosterism (primary or
pathologies secondary).
Aldosterone Decreased in which Decreased: adrenal insufficiency,
pathologies panhypopituitarism.
Increased: acute pancreatitis, pancreatic duct
obstruction, alcohol ingestion, mumps,
Amylase Increased in which
parotitidis, renal disease, cholecystitis, peptic
pathologies
ulcers, intestinal obstruction, mesenteric
thrombosis, postop abdominal surgery
Amylase Decreased in which Decreased: Liver damage, pancreatic
pathologies destruction (pancreatitis, cystic fibrosis)
Bilirubin Normal Serum values Total: 0.2 - 1.2 mg/dl
Increased total: hepatic damage (hepatitis,
toxins, cirrhosis), biliary obstruction,
Bilirubin Increased in which
hemolysis, fasting. Increased direct
pathologies
(conjugated): biliary obstruction / cholestasis,
drug induced cholestasis.
BUN Normal Serum values 7-20 mg/dl
Increased: renal failure, pre-renal azotemia,
shock, volume depletion, postrenal
BUN Increased in which pathologies
(obstruction), GI bleeding, stress, drugs
(aminoglycosides, vanco etc).
Decreased: starvation, liver failure, pregnancy,
BUN decreased serum values
infancy, nephrotic syndrome, overhydration.
Calcium serum values 8.8 - 10.3 mg/dl
Super Condensed Portable HESI Study Guide 172
What are some age-appropriate toys mobiles rattles squeaking toys picture books
for hospitalized infants? balls colored blocks activity boxes
Birth weight quadruples by _____. 30 months
Achieves 50% of adult height by ___. 2 years
Anterior fontanel closes by _____. 12 - 18 months
A child should be able to throw a ball
18 months
overhand at _____.
The nurse tells a mother that her child
24 months
should be able to kicks a ball at _____.
A child should be able to feeds self
2 years
with spoon and cup at _____.
Day time toilet training can usually be
2 years of age
started around _____.
A child should be able to speak two to
2 years (24 months)
three word sentences at _____.
A child should be able to speak three
to four word sentences at _____ of 3 years
age.
A child should be able to states his/her
2.5 to 3 years
own first and last name by _____.
Is temper tantrums common among
Yes
toddlers (1 to 3 years)?
What is the import developmental task
of a toddler according to Erikson's Developing a sense of autonomy.
theory?
What are some age-appropriate toys board and mallet push/pull toys toy telephone
for the hospitalized toddler? stuffed animals storybooks with pictures
Toddlers benefit from being taken to the
What can the nurse do to promote the
hospital playroom, as mobility is very
developemental task of a toddler?
important to their development.
What are the average weight and
Each year gain about 5 lbs and grows 2.5 to 3
height gain for preschool children (3 to
inches.
5 years old)?
A child can use sissors at _____ of
4 years
age.
A child should be able to ties shoelaces
5 years
at _____ of age.
Visual acuity approaches 20/20 at
Preschool age (3 to 5 years)
_____.
A preschool child thinking is _____
egocentric; concrete
and _____.
Super Condensed Portable HESI Study Guide 175
When teaching adolescent needs, the here and now i.e., how will this affect me
focus should be on _____. today?
Infants: After 6 months, their cognitive
Infants' concept of bodily injury:
development allows them to remember pain.
Toddlers' concept of bodily injury Toddlers: Fear intrusive procedures.
Preschoolers' concept of bodily injury Preschoolers: Fear body mutilation.
School ages' concept of bodily injury: School age: Fear loss of control of their body.
Adolescent: Major concern is change in body
Adolescents' concept of bodily injury:
image.
MMR VACCINE Generally
administered at _____ months of age
12 to 15; 4 to 6; 11 to 12
and repeated at _____ years or by
_____ years.
In times of measles epidemic, it is
possible to give measles protection at 6 months; 15 months
_____ and repeat the MMR at _____.
Measles vaccine is contraindicated for
persons with history of anaphylactic
reaction to _____ or _____, those with neomycin; eggs; immunodeficiency; pregnant
known altered _____ and _____
women.
MMR vaccine may be given to those
with HIV and breastfeeding women. T True
or F
MMR vaccines are administer _____
subcutaneously
at separate sites.
A child may have a light transient ___
2 weeks after administration of MMR rash
vaccine.
DTaP Vaccine administration begins at
age ____, administer three doses at 2 months; 2 months
_____ intervals.
DTaP Vaccine: Booster doses given at
15; 18 months; 4 to 6 years.
_____ to _____; and at _____.
DTaP Vaccine: administer _____
intramuscularly
(separate site from other vaccine).
DTaP Vaccine is not given to children
past the ______ birthday; they receive
_____ which contains full strength 7th; Td
protection against tetanus and lesser
strength diphtheria protection.
When pertussis vaccine is DT (full strength diphtheria and tetanus without
Super Condensed Portable HESI Study Guide 179
and _____.
Question Answer Hint
Which action should the nurse
Give one hour before or two hours after a meal.
implement when administering a
Average transit time from stomach to
prescription drug that should be given
duodenum is 2 hours.
on an empty stomach?
The nurse is caring for a client who is
unable to void. The plan of care
establishes an objective for the client
Drinks 240ml of fluid five times during the
to ingest 1000ml of fluid between 7am
shift.
and 3pm. Which client response
should the nurse document that
indicates a sucessful outcome?
A client with metastatic cancer is
preparing to make decisions about end It will identify someone that can make
of life issues. When the nurse explains decisions for your health care if you are in a
a durable power of attorney for health coma or vegetative state.
care, which description is accurate?
The nurse is caring for a client who is
the daughter of a local politician.
When the nurse approaches a man who
is reading the names on the hall doors,
he identifies himself as a reporter for Confidentiality
the local newspaper and requests
information about the client's status.
Which standard of nursing practice
should the nurse use to respond?
A client with acute hemorrhagic
anemia is to receive four units of
packed RBC's (red blood cells) as
Ensure the accuracy of the blood type match.
rapidly as possible. Which intervention
is most important for the nurse to
implement?
A male client who had abdominal
surgery has a nasogastric tube to Apply a water soluble lubricant to the lips, oral
suction, oxygen per nasal cannula, and mucosa, and nares. Petroleum based products
complains of dry mouth. Which action are flammable.
should the nurse implement?
A client with chronic renal failure
selects a scramble egg for his Commend the client for selecting a high
breakfast. Which action should the biologic value protein.
nurse take?
The nurse is administering meds Flush the tube with water. NGT should be
through a NG tube which is connected flushed before, after, and in between each med
to suction. After ensuring correct tube adminstered.
Super Condensed Portable HESI Study Guide 183
employment is termed?
A legal term meaning the accused is
not criminally responsible for the
insanity
unlawful act committed due to mental
illness?
Forgetting to give a medication or
giving the wrong medication is an negligence/malpractice
example of?
An act contrary to a criminal statute.
Wrongs punishable by the state,
crime
committed against the state, with
intent usually present.
Legal hearing that is held to determine
a person's capability to make
competency hearing
responsible decisions about self,
dependent, or property?
Persons declared incompetent have the
vote make contracts or wills drive a car sue or
legal status of a minor, i.e., they
be sued hold a professional license
cannot? (5)
If a person is incompetent, a _____ is
appointed. Declaring a person
guardian state
incompetent can be initiated by the
____ or family.
An admission whereby any adult may
apply for another. However, medical
emergency admmission
or judicial approval is required to
detain anyone beyond 24 hours.
Emergency admissions allow persons
held against their will to file a ____
habeas corpus
_____ to try and get the court to hear
their case and release them.
With emergency admissions, the court
determines the ____ and alleged sanity
unlawful restraint of a person.
Question Answer Hint
1 km = _ m 1,000
1 m = _ cm 100
1 cm = _ mm 10
1 L = _ ml 1000
1 ml = _ cm3 1
1 kg = _ g 1000
1 g =_ mg 1,000
Super Condensed Portable HESI Study Guide 195
relationships learned?
When does socialization with peers
School age
become important?
When do molars erupt? School age (6 year molars)
Whose growth spurt develops 1st? As
Girls-10 years old. Boys at 14.
early as what age?
Adult-like thinking begins at what
15
age?
When does growth end? Girl-15, boys-17
What is Erickson’s theory for
Developing sense of identity
adolescents (12 to 19)?
After 6 months what is the baby’s
They can remember the pain
concept of bodily injury?
What is the toddler’s concept of bodily
Fear of intrusive procedures
injury?
What is the preschooler’s concept of
Fear of body mutilation
bodily injury?
What is the school age childs concept
Fear of loss of control over their body
of bodily injury?
What is the adolescent’s concept of
Change in body image
bodily injury?
When can you start using the numeric
9 and up
pain scale?
Using the FLACC pain assessment tool, that
How can a non verbal child be
looks at the face, leg movement, activity, cry,
assessed for pain?
and consolability
What are the best nondrug measures to
Pacifiers, holding, rocking
reduce pain in infants?
What are the best nondrug measures to
reduce pain in toddlers and Distraction
preschoolers?
What are the best nondrug measures to
reduce pain in school age and Guided imagery
adolescents?
At what age can you teach a child how
5 years old
to use PCA?
12-15 months and then 1 other time between 4
When is MMR vaccine given?
and 12 years old
During a measles epidemic when can
6 months and then again at 15 months
you give the MMR?
What are contraindications for MMR? Allergy to neomycin or eggs
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