THERAPEUTIC PROCEDURES
SELECTED TOPICS ON COMMON NURSING PROCEDURES
UNIVERSAL PRECAUTIONS
HANDWASHING
BARRIER METHOD
STERILIZATION AND DISINFECTION
IMMUNIZATION
ENVIRONMENTAL CONTROL AND SANITATION
ISOLATION
SURGICAL ASEPSIS
MAINTENANCE OF STERILE FIELD
MEDICAL AND SURGICAL ASEPTIC TECHNIQUES
THERAPEUTIC EXERCISES
ISOMETRIC
ISOTONIC
ROM
CHEST PHYSIOTHERAPY
BREATHING
COUGHING\POSTURAL DRAINANGE
PERCUSSION AND VIBRATION
INCENTIVE SPIROMETER
SUCTIONING
TRACHEOSTOMY CARE
OXYGEN THERAPY
Chest Physiotherapy
It is the combination of percussion, vibration, and postural drainage
Percussion is done for 1-2 minutes. If the patient has tenacious secretions, this can be performed for 3-5 minutes
Vibration is done during 5 exhalations
Postural drainage is done for 15-20 minutes usually performed 3-4 times a day.
Instruct the client to increase fluid intake to liquefy secretions
This procedure should not be performed in clients who are pregnant, with chest injuries, dizzy, with pulmonary embolism and abdominal surgery.
This procedure is done before meal or 90 minutes after a meal
Oxygen Therapy
Indicated to clients who needs additional oxygen, those clients who have reduced lung diffusion of oxygen through the respiratory membrane, heart failure leading to inadequate transport of oxygen.
Humidify the oxygen first before you administer.
Check for bubbles in the humidifier to promote adequate flow of oxygen
Check for kinks in the tubing
Position: semi-fowlers/ high fowlers position
Place cautionary readings: “NO smoking: Oxygen is in used”
Instruct the client not to use woolen blankets as this may create static electricity
pulmonary function tests
tidal volume- 500
residual volume- 1200
expiratory reserve volume –1200
inspiratory reserve volume – 3100
Vital Capacity- tidal volume + IRV + ERV = 4800
Total Lung Capacity – Tidal Volume + IRV +ERV +RV =6000
Forced Residual Capacity – ERV + RV
incentive spirometry – hold 2-6 sec; 4-5 times/H
endotracheal tube- reposition Q8H; cuff 20 mm Hg, humidification and aerosol, deflate cuff occasionaly
visualization –
X ray
Lung Scxan – 20-40mins isotopes in body for 8 H
laryngoscopy
Bronchoscopy
Thoracentesis- consent, VS and baseline X-ray + post Procedural
Tracheostomy Care
tie new trache tie before removing the old tie to prevent accidental dislodgement
use precut gauze and perform care OD at least.
soak iiner cannula in antiseptic soak with hydrogen peroxide, rinse well
suction prn, oral care prn
Oxygen Delivery Equipment
cannula – 2-6 LPM – 24-45%
Mask – 5-8 LPM – 40-60%
parial rebreather – 6-10 LPM – 60-90%
non rebreather – 10-15 LPM – 95-100%
tent – 4-8 LPM – 30-50 %
Venturi mask –
2-3 LPM – 24-28%
4 LPM – 30%
6 LPM – 35%
8 LPM – 45%
14LPM – 55%
Suctioning
PURPOSE: To obtain sputum sample.
NURSING ALERT:
Hyperoxygenate the patient before and after the procedure.
Apply intermittent suction on withdrawal of the catheter.
Do not suction the patient for more than 15 seconds.
Thoracentesis
PURPOSE: Aspiration of fluid and /or air from the pleural space.
NURSING ALERT:
Check the consent.
Position: Sitting on the side of the bed with feet on a chair, leaning over a bedside table. If the patient unable to sit, the patient may lie in his/her side with hands on the side resting on opposite shoulder.
Instruct the patient not to cough, breath deeply or move during the procedure.
After the procedure: Position the patient on the unaffected side/puncture site up.
Check for bleeding at the puncture site and monitor the respiratory function.
Notify the physician if signs of pneumothorax, air embolism and pulmonary edema occur.
ENEMA
They act by distending the intestines that increases peristalsis and expulsion of feces and flatus.
Enemas serve the following purpose:
Relief of constipation
Relief of flatulence
Lowers down body temperature
Evacuates feces in preparation for diagnostic procedures
Administration of medications
Take note of the general principles of Enema:
Tube: lubricate and insert 3-4 inches
Position: adult- left lateral; infants and children- dorsal recumbent
Administration- administer the enema in a minimum of 15 minutes duration.
Conatainer’s Height- 12 inches above the rectum
Temperature- 42°C or less
types:
carminative – expel flatus – 60 –180 ml.
retention oil – 1 –3 hours(LUBRICANTS)
BULK FORMERS-METAMUCIL-12 HOURS-INC.OFI
wetting/stool softeners- Colace(days)
Chemical hypertonic irritant-increases peristalsis-castor oil, Bisacodyl, Cascara)-SUPPOSITORIES-30 MIN
Saline- Epson salts, milk of mg(rapid)/mg citrate
return flow – haris flushing , colon irrigation
fleet – commercial
oil 1-3 H retention
others – 5 to 10 mins.
cleansing- irritating( hypertonic osmotic))
high 1000 ml
low 500 ml
T = 40-43 ‘ C ( 105 – 110 ‘ F
CHILDREN 37.7 ( 100 ‘ F)
APPROXIMATELY 30 CM ( 12 INCHES) BUT HIGH IN CLEANSING ( 30 – 45 CM. ) 12 TO 18 CM.
INSERT 7 – 10 CM ( 3-4 INCH)-ADULT
5 – 7.5 CM. –CHILD
2.5 – 3.5 – INFANT
IF FEELING OF FULLNESS – CLAMP – 30 SECS
amount
18 mos – 50-200 ml
18 mos – 5 y – 200-300 ml
5 – 12 years – 300 – 500 ml
12 – above – 500 – 1000 ml.
rectal tubes
infants-10-12F
toddler – 14 –16F
school age – 16-18F
adult – 22 – 30F
ENEMAS- PRESCRIBED AMOUNT AND TIME
HYPERTONIC – 5-10MINS – VARIES
HYPOTONIC(TAP)-15-20MIN – 500-1000ML
ISOTONIC(SALINE)-15-20MIN- 50ML
SOAP SUDS- 10-15MIN- + 3-5 ML. SOAP
oil( MINERAL/COTTONSEED) – 30-60 MIN- 90-120ML.
COLOSTOMY CARE
ostomy – divert and drain fecal material
temporary ( trauma / inflammatory condition)
permanent ( Cancer / congenital or Birth defects
stoma – red , initial slight bleeding - normal, no redness or irritation 2 to 5 inches sorrounding the areano burning sensation
parts:
periostomal seal
adhesive square –
solid wafer disk skin barrier
liquid skin sealant
drainable end
pouch ( Can be washable)
pouch belt
face plate
ileostomy – no irrigation , wet fecal material , appliance all the time , meticulous skin care,prevent skin breakdown, constant flow not regulated, bag emptied half full
colostomy – solid , can irrigate , can be bowel trained , pouch may not be worn and emptied after every defecation
avoid gas forming foods and nuts , but can have any food at tolerated after 6 weeks… yogurt recommended
dry skin before applying appliance
karaya – barrier to prevent contamination with excreta
appliance can be up to 2 weeks
broadwell 48 – 72 hours to check for periostomal skin
24-48 hours if eroded / ulcerated
refer to enterostomal therapy nurse
with deodorant ( Charcoal filter Disk)
Catheterization, urinary
PURPOSE: To determine residual urine and obtain sterile specimen. It can be a straight catheter, suprapubic, indwelling catheter, and external device catheter.
NURSING ALERT:
Know the necessary facts:
Principles Male Female
Position Supine Dorsal recumbent
Length of tube 40 cm./ 15.75 in. 22cm./ 8.66 in.
French number or
Circumference #14- 16 #18
Length of tube to
be inserted 2-3 in. 6-9 in.
Balloon size 5-10 ml. (30 ml 5-10 ml
Can be used to
achieve hemostasis
of the prostatic area
following prostatectomy
Place to secure lower abdomen Inner thigh
The procedure is sterile
Maintain a close system
The draining bag must always be below the bladder
The catheter bag should not be allowed to lie on the floor
Do not allow the drainage spout to touch the collection receptacle or on the toilet bowl when draining it
CATHETER CHANGE
PLASTIC
– 1 WEEK
LATEX – 2-3 WEEKS
SILICONE – 2-3 MOS.
PVC – 4-6 WEEKS
CLOSED INTERMITTENT IRRIGATION
ASPIRATE FROM PORT
CBI -3 WAY FOLEY CAHETER
CATHETER IRRIGATION ONLY – 200 ML.
BLADDER IRRIGATION – 1000ML
CLAMPS ON BOTH SIDES – ALTERNATELY RELEASED
URINARY DIVERSIONS-URINARY STOMA
ILEAL CONDUIT- EXTERNAL POUCH
KOCK POUCH – SMALL DRESSING OVER STOMA; BLADDER WALL SUTURED TO THE ABDOMEN
SUPRAPUBIC CATHETER – INTERMITTENT ATHETERIZATION q 3-4 HOURS
NORMAL AMOUNT/ DAY
1-3 / 500-600ML
3-5 / 600-700ML
5-8 / 700-100OML
8-14 / 800 – 1400ML
14 – ADULT / 1500 – 2500
CAN HOLD 500 – 750 ML
Bladder training
Q2 hours and 30 mins void(Trigerring, Credes and valsalva)
NEUROGENIC BLADDER
Intermitent Catheterization – 2-3 hours if <150ml>for incontinence – kegels exercises
HEMODIALYSIS
DONE 3-5 HOURS – 2-3 TIMES A WEEK
AV FISTULA-NO BP,VENIPUNCTURE OR CONSTRICTIONS
PALPATE FOR A THRILL AND LISTEN FOR BRUIT Q8H
MONITOR FOR HEMORRHAGE
DISEQUILIBRIUM SYNDROME,HEPATITIS,HEMORRHAGE,MUSCLE CRAMPS,AIR EMBOLISM AND SEPSIS-
COMPLICATIONS
PERITONEAL DIALYSIS
TENCKOFF,GORE-TEX CATHETER
WEIGH BEFORE AND AFTER, WARM DIALYSATE
CHON LOSS, INFECTION, -PERITONITIS(CLOUDY OUTFLOW,BLEEDING) , FEVER , ABDL TENDERNESS AND N & V
PREVENT CONSTIPATION BY INCREASING FIBER IN DIET,MAINTAIN STERILE PROCEDURE,FOR PROBLEMS WITH OUT FLOW –REPOSITION
TYPES:
CAPD(4-6H INDWELLING),
AUTOMATED 30MINS EXCHANGES,
INTERMITTENT- 4X A WEEK – 10H/DAY,
CONTINOUS – 1 DAY INDWELLING
DRESSINGS
PROTECT FROM INJURY , BACTERIAL CONTAMINATION
PROVIDE HUMIDITY
INSULATION
ABSORB DRAINAGE
DEBRIDE THE WOUND
PREVENT HEMORRHAGE
SPLINT / IMMOBILIZE
COMFORT
GUAZE, SYNTHETIC , SECURING, TEGADERM
TYPES OF DRESSINGS
DRY TO DRY – TRAP NECROTIC DEBRIS AND EXUDATE
WET TO DRY ( SALINE AND ANTI MICROBIAL SOLUTION – SOFTEN DEBRIS AS IT DRIES, DILUTE EXUDATE
WET TO DAMP – WOUND DEBRIDED IF GAUZE REMOVED( VARIATION @ DRYING)
WET TO WET – KEEP MOIST – WOUND BATHED – MOISTURE DILUTES VISCIOUS EXUDATE
WOUND HEALING
HEMOSTASIS---FIBRIN----PHAGOCYTOSIS----( INFLAMMATION PHASE 3-4DAYS
FIBROBLAST—COLLAGEN---CAPILLARIES----GRANULATION TISSUE---ESCHAR---(PROLIFERATIVE 3 – 21 DAYS
MATURATION(PHASE 21 DAYS – 2 YEARS)
pressure ulcer dressings
dry gauze stage II-IV
tegaderm film/ hydrocolloid – SI - SII
Absorptive Dressing III
Hydrogel – II - III
WOUND CARE
PRIMARY
SECONDARY- INCREASED INFECTION INCREASED TIME INCREASED ESCHAR( PRESSURE SORES)
TERTIARY- ABD. DRAINAGE
EXUDATES – SUPPURATION
PUS – ABCESS( PYOGENIC BACTERIA)
SURGICAL DRAINS
PENROSE – OPEN ENDS
CLOSED WOUND DRAINAGE ( SUCTION) – DECREASE ENTRY OF MICROBES- HEMOVAC / JACK PRATT TO RESERVOIR
D/C 3-7 DAYS POST – OP
PACKAGE – FACILITATE GRANULATION
IRRIGATION LAVAGE - STERILE
CHEST TUBES AND DRAINAGE SYSTEMS
1-DRAINAGE
2-WATERSEAL
3-COLLECTION/SUCTION
SEALED PATENCY-AFTER 3 DAYS REEXPANDED
FLUCTUATIONS IN WATER SEAL CHAMBER
RUBBER TIPPED CLAMPS/ FORCEPS; VASELINIZED GAUZE;EXTRA BOTTLE
NUTRITIONAL SUPPORT
NGT-GAVAGE AND LAVAGE
TPN
Nasogastric Tube Insertion
Purposes:
Gastric Gavage- gastric feeding
Gastric Lavage- stomach irrigation
For decompression
Medication and supplemental fluid administration
Principles:
Position: High-Fowler’s position
Length of tube to be inserted: measured from the tip of the nose to the tip of the earlobe to the xiphoid process (approximately 50cm.
Lubricate the tip of the tube by a water soluble lubricant before insertion
Secure the NGT by taping to the bridge of the nose
Gastroenteral Feedings
This is the administration of formula through a tube placed into the GIT, either by Nasogastric route or surgically created slit on the abdominal wall.
Remember these principles:
Position: fowler’s or sitting position
Prior to feeding, assess the bowel sounds and residual content
Assess for tube placement and patency:
Introduce 5-20 ml of air into the NGT and auscultate. Gurgling sounds must be auscultated.
X-ray most accurate
Aspirate gastric content
Immerse the tip of the tube in water, no bubbles must be produced.
Height of feeding: 12 inches above the patient’s point of insertion
Instill 60 ml of water into the NGT after feeding to cleanse the lumen of the tube
TOTAL PARENTERAL NUTRITION
peripheral<>Anti-embolism Stocking
Helps prevents thrombophlebitis by promoting venous return from the legs
It usually requires a doctor’s order
The client’s extremeties must be properly measured to assure therapeutic effect
Apply stockings before getting out of bed. If the client forgot to wear the stockings, instruct himn or her to assume modified trendelenburg’s position for 15-20 minutes
The stockings must be removed every 8 hours for 20-30 minutes
Assess the skin integrity150ml>
DOSAGES AND CALCULATION
CONVERSIONS
MEDICATION DOSAGES
D/A X V = Q
INFUSIONS
TOTAL VOLUME X DROP FACTOR
TIME IN HOUR ( 60 MIN.)
THERAPEUTIC DOSE
CLARKS RULE
BSA COMPUTATION
IV INFUSION FOR BURNS
MEDICATION ADMINISTRATION
RIGHT DRUG
RIGHT DOSAGE
RIGHT ROUTE
RIGHT TIME
RIGHT PATIENT
RIGHT ATTITUDE
RIGHT DOCUMENTATION
PARENTERAL ADMINISTRATION
IM – G 18-21 ; 1 1/2 INCH, Z-TRACK
( RETRACT)
SC/SQ – G 24-26;1/2 – 1 INCH ; 45’ ; DO NOT RETRACT OR MASSAGE ( INSULIN AND HEPARIN)
INTRADERMAL- 10-15’; G26-27;1\2 INCH BEVEL UP
INTRAVENOUS – TOURNIQUET, STERILE PROCEDURE ; 10-25 ; RELEASE TOURNIQUET IF WITH BACKFLOW
IV THERAPY
backflow means patent line
solutions for specific diseases and contraindications of certain solutions
management and troubleshooting
check for phlebitis and infiltration
change line everyday
keep site sterile
BLOOD TRANSFUSION
line – PNSS
vital signs – baseline then Q15 x 4; Q30 x 2; then q h
4 –6 hours
blood typing and crossmatching
watch out for blood transfusion reactions
hemolytic
anaphylactic
febrile
hypervolemic
septic
Hygiene and comfort measures
BEDMAKING
- OD
PERINEAL CARE – FRONT TO BACK
OUTER TO INNER, ONE COTTONBALL PER STROKE
BEDBATHING AND ND SHAMPOO
FOOT, HAIR , SKIN AND NAIL CARE
ORAL CARE
EYE AND EAR CARE
THERAPEUTIC BATH
SALINE – 4 ML- 500 ML
OATMEAL/AVENO – SOOTHES SKIN IRRITATION, LUBRICATES
CORNSTARCH- IN COLD WATER – SOOTHES IRRITATION
Na CHO3 – 4 ml. – 500 ml H2O
cooling / relieves irritation
KMnO4 – tablets dissolved in H2O – clears and disinfects
Rotating Tourniquet
APPLY PRESSURE TO 3 LIMBS ONE AT A TIME RELEASE / ROTATE EVERY 5 MINUTES. PRESSURE IN ONE EXTREMITY FOR ONLY 15 MINUTES
DO NOT RELEASE SIMULTANEOUSLY
PATIENT IN ORTHOPNEIC / FOWLERS POSITION
CPR and ACPLS Protocols
0-1 MINUTE ; CARDIAC IRRITABILITY
0-4 MINUTES; BRAIN DAMAGE NOT LIKELY
4-6 MINUTES; BRAIN DAMAGE POSSIBLE
6-10 MINUTES; BRAIN DAMAGE LIKELY
10 MINUTES-IRREVERSIBLE BRAIN DAMAGE
NURSING FILES
Sunday, August 18, 2013
Tuesday, June 25, 2013
FUNDAMENTALS BULLET
o
A blood pressure cuff that’s
too narrow can cause a falsely elevated blood pressure reading.
o
When preparing a single
injection for a patient who takes regular and neutral protein Hagedorn insulin,
the nurse should draw the regular insulin into the syringe first so that it
does not contaminate the regular insulin.
o
Rhonchi are the rumbling sounds
heard on lung auscultation. They are more pronounced during expiration than
during inspiration.
o
Gavage is forced feeding,
usually through a gastric tube (a tube passed into the stomach through the
mouth).
o
According
to Maslow’s hierarchy of needs, physiologic
needs (air, water, food, shelter, sex, activity, and comfort) have the highest
priority.
o
The safest and surest way to
verify a patient’s identity is to check the identification band on his wrist.
o
In the therapeutic environment,
the patient’s safety is the primary concern.
o
Fluid oscillation in the tubing
of a chest drainage system indicates that the system is working properly.
o
The nurse should place a
patient who has a Sengstaken-Blakemore tube in semi-Fowler position.
o
The nurse can elicit
Trousseau’s sign by occluding the brachial or radial artery. Hand and finger spasms that occur during
occlusion indicate Trousseau’s sign and suggest hypocalcemia.
o
For blood transfusion in an
adult, the appropriate needle size is 16 to 20G.
o
Intractable pain is pain that
incapacitates a patient and can’t be relieved by drugs.
o
In an emergency, consent for
treatment can be obtained by fax, telephone, or other telegraphic means.
o
Decibel is the unit of
measurement of sound.
o
Informed consent is required
for any invasive procedure.
o
A patient who can’t write his
name to give consent for treatment must make an X in the presence of two
witnesses, such as a nurse, priest, or physician.
o
The Z-track I.M. injection
technique seals the drug deep into the muscle, thereby minimizing skin
irritation and staining. It requires a needle that’s 1" (2.5 cm) or
longer.
o
In the event of fire, the
acronym most often used is RACE. (R) Remove the patient. (A) Activate the
alarm. (C) Attempt to contain the fire by closing the door. (E) Extinguish the
fire if it can be done safely.
o
A registered nurse should
assign a licensed vocational nurse or licensed practical nurse to perform
bedside care, such as suctioning and drug administration.
o
If a patient can’t void, the
first nursing action should be bladder palpation to assess for bladder
distention.
o
The patient who uses a cane
should carry it on the unaffected side and advance it at the same time as the affected extremity.
o
To fit a supine patient for
crutches, the nurse should measure from the axilla to the sole and add 2"
(5 cm) to that measurement.
o
Assessment begins with the
nurse’s first encounter with the patient and continues throughout the patient’s
stay. The nurse obtains assessment data through the health history, physical
examination, and review of diagnostic studies.
o
The appropriate needle size for
insulin injection is 25G and 5/8" long.
o
Residual urine is urine that
remains in the bladder after voiding. The amount of residual urine is normally
50 to 100 ml.
o
The five stages of the nursing
process are assessment, nursing diagnosis, planning, implementation, and
evaluation.
o
Assessment is the stage of the
nursing process in which the nurse continuously collects data to identify a
patient’s actual and potential health needs.
o
Nursing diagnosis is the stage
of the nursing process in which the nurse makes a clinical judgment about
individual, family, or community responses to actual or potential health
problems or life processes.
o
Planning is the stage of the
nursing process in which the nurse assigns priorities to nursing diagnoses,
defines short-term and long-term goals and expected outcomes, and establishes
the nursing care plan.
o
Implementation is the stage of
the nursing process in which the nurse puts the nursing care plan into action,
delegates specific nursing interventions to members of the nursing team, and
charts patient responses to nursing interventions.
o
Evaluation is the stage of the
nursing process in which the nurse compares objective and subjective data with
the outcome criteria and, if needed, modifies the nursing care plan.
o
Before administering any “as
needed” pain medication, the nurse should ask the patient to indicate the
location of the pain.
o
Jehovah’s Witnesses believe
that they shouldn’t receive blood components donated by other people.
o
To test visual acuity, the
nurse should ask the patient to cover each eye separately and to read the eye
chart with glasses and without, as appropriate.
o
When providing oral care for an
unconscious patient, to minimize the risk of aspiration, the nurse should
position the patient on the side.
o
During assessment of distance
vision, the patient should stand 20′ (6.1 m) from the chart.
o
For a geriatric patient or one
who is extremely ill, the ideal room temperature is 66° to 76° F (18.8° to
24.4° C).
o
Normal room humidity is 30% to 60%.
o
Hand washing is the single best method of
limiting the spread of microorganisms. Once gloves are removed after routine
contact with a patient, hands should be washed for 10 to 15 seconds.
o
To perform catheterization, the
nurse should place a woman in the
dorsal recumbent position.
o
A positive Homans’ sign may
indicate thrombophlebitis.
o
Electrolytes in a solution are
measured in milliequivalents per liter (mEq/L). A milliequivalent is the number
of milligrams per 100 milliliters of a solution.
o
Metabolism occurs in two
phases: anabolism (the constructive phase) and catabolism (the destructive
phase).
o
The basal metabolic rate is the
amount of energy needed to maintain essential body functions. It’s measured
when the patient is awake and resting, hasn’t eaten for 14 to 18 hours, and is
in a comfortable, warm environment.
o
The basal metabolic rate is
expressed in calories consumed per hour per kilogram of body weight.
o
Dietary fiber (roughage), which
is derived from cellulose, supplies bulk, maintains intestinal motility, and
helps to establish regular bowel habits.
o
Alcohol is metabolized
primarily in the liver. Smaller amounts are metabolized by the kidneys and
lungs.
o
Petechiae are tiny, round,
purplish red spots that appear on the skin and mucous membranes as a result of
intradermal or submucosal hemorrhage.
o
Purpura is a purple
discoloration of the skin that’s caused by blood extravasation.
o
According to the standard precautions recommended
by the Centers for Disease Control and Prevention, the nurse shouldn’t recap
needles after use. Most needle sticks result from missed needle recapping.
o
The nurse administers a drug by
I.V. push by using a needle and syringe to deliver the dose directly into a
vein, I.V. tubing, or a catheter.
o
When changing the ties on a
tracheostomy tube, the nurse should leave the old ties in place until the new
ones are applied.
o
A nurse should have assistance
when changing the ties on a
tracheostomy tube.
o
A filter is always used for
blood transfusions.
o
A four-point (quad) cane is
indicated when a patient needs more stability than a regular cane can provide.
o
A good way to begin a patient
interview is to ask, “What made you seek medical help?”
o
When caring for any patient,
the nurse should follow standard precautions for handling blood and body
fluids.
o
Potassium (K+) is the most
abundant cation in intracellular fluid.
o
In the four-point, or
alternating, gait, the patient first
moves the right crutch followed by the left foot and then the left crutch
followed by the right foot.
o
In the three-point gait, the
patient moves two crutches and the affected leg simultaneously and then moves
the unaffected leg.
o
In the two-point gait, the
patient moves the right leg and the left crutch simultaneously and then moves
the left leg and the right crutch simultaneously.
o
The vitamin B complex, the water-soluble vitamins that are essential for metabolism,
include thiamine (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), and
cyanocobalamin (B12).
o
When being weighed, an adult
patient should be lightly dressed and shoeless.
o
Before taking an adult’s
temperature orally, the nurse should ensure that the patient hasn’t smoked or
consumed hot or cold substances in the previous 15 minutes.
o
The nurse shouldn’t take an
adult’s temperature rectally if the patient has a cardiac disorder, anal
lesions, or bleeding hemorrhoids or has recently undergone rectal surgery.
o
In a patient who has a cardiac
disorder, measuring temperature rectally may stimulate a vagal response and
lead to vasodilation and decreased cardiac output.
o
When recording pulse amplitude
and rhythm, the nurse should use these descriptive measures: +3, bounding pulse
(readily palpable and forceful); +2, normal pulse (easily palpable); +1,
thready or weak pulse (difficult to detect); and 0, absent pulse (not
detectable).
o
The intraoperative period
begins when a patient is transferred to the operating room bed and ends when the patient is
admitted to the postanesthesia care unit.
o
On the morning of surgery, the
nurse should ensure that the informed consent form has been signed; that the
patient hasn’t taken anything by mouth since midnight, has taken a shower with antimicrobial soap, has
had mouth care (without swallowing the water), has removed common jewelry, and
has received preoperative medication as prescribed; and that vital signs have
been taken and recorded. Artificial limbs and other prostheses are usually
removed.
o
Comfort measures, such as positioning
the patient, rubbing the patient’s back, and providing a restful environment,
may decrease the patient’s need for analgesics or may enhance their
effectiveness.
o
A drug has three names: generic
name, which is used in official publications; trade, or brand, name (such as
Tylenol), which is selected by the drug company; and chemical name, which
describes the drug’s chemical composition.
o
To avoid staining the teeth,
the patient should take a liquid
iron preparation through a straw.
o
The nurse should use the
Z-track method to administer an I.M. injection of iron dextran (Imferon).
o
An organism may enter the body
through the nose, mouth, rectum, urinary or reproductive tract, or skin.
o
In descending order, the levels
of consciousness are alertness, lethargy, stupor, light coma, and deep coma.
o
To turn a patient by
logrolling, the nurse folds the patient’s arms across the chest; extends the
patient’s legs and inserts a pillow between them,
if needed; places a draw sheet under the patient; and turns the patient by
slowly and gently pulling on the draw sheet.
o
The diaphragm of the
stethoscope is used to hear high-pitched sounds, such as breath sounds.
o
A slight difference in blood
pressure (5 to 10 mm Hg) between the right and the left arms is normal.
o
The nurse should place the
blood pressure cuff 1" (2.5 cm) above the antecubital fossa.
o
When instilling ophthalmic
ointments, the nurse should waste the first bead of ointment and then apply the ointment from the inner
canthus to the outer canthus.
o
The nurse should use a leg cuff
to measure blood pressure in an obese patient.
o
If a blood pressure cuff is
applied too loosely, the reading will be falsely elevated.
o
Ptosis is drooping of the
eyelid.
o
A tilt table is useful for a
patient with a spinal cord injury, orthostatic hypotension, or brain damage
because it can move the patient gradually from a horizontal to a vertical
(upright) position.
o
To perform venipuncture with
the least injury to the vessel, the nurse should turn the bevel upward when the
vessel’s lumen is larger than the needle and turn it downward when the lumen is
only slightly larger than the needle.
o
To move a patient to the edge
of the bed for transfer, the nurse should follow these steps: Move the
patient’s head and shoulders toward the edge of the bed. Move the patient’s
feet and legs to the edge of the bed (crescent position). Place both arms well
under the patient’s hips, and straighten the back while moving the patient
toward the edge of the bed.
o
When being measured for
crutches, a patient should wear shoes.
o
The nurse should attach a
restraint to the part of the bed frame that moves with the head, not to the
mattress or side rails.
o
The mist in a mist tent should never become so
dense that it obscures clear visualization of the patient’s respiratory pattern.
o
To administer heparin
subcutaneously, the nurse should follow these steps: Clean, but don’t rub, the
site with alcohol. Stretch the skin taut or pick up a well-defined skin fold.
Hold the shaft of the needle in a dart position. Insert the needle into the skin at a right (90-degree) angle.
Firmly depress the plunger, but don’t aspirate. Leave the needle in place for
10 seconds. Withdraw the needle gently at the angle of insertion. Apply
pressure to the injection site with an alcohol pad.
o
For a sigmoidoscopy, the nurse
should place the patient in the knee-chest position or Sims’ position,
depending on the physician’s preference.
o
Maslow’s hierarchy of needs
must be met in the following order: physiologic (oxygen, food, water, sex,
rest, and comfort), safety and security, love and belonging, self-esteem and
recognition, and self-actualization.
o
When caring for a patient who
has a nasogastric tube, the nurse should apply a water-soluble lubricant to the
nostril to prevent soreness.
o
During gastric lavage, a nasogastric
tube is inserted, the stomach is flushed, and ingested substances are removed
through the tube.
o
In documenting drainage on a
surgical dressing, the nurse should include the size, color, and consistency of
the drainage (for example, “10 mm of brown mucoid drainage noted on dressing”).
o
To elicit Babinski’s reflex,
the nurse strokes the sole of the patient’s foot with a moderately sharp
object, such as a thumbnail.
o
A positive Babinski’s reflex is
shown by dorsiflexion of the great toe and fanning out of the other toes.
o
When assessing a patient for
bladder distention, the nurse should check the contour of the lower abdomen for
a rounded mass above the symphysis pubis.
o
The best way to prevent
pressure ulcers is to reposition the bedridden
patient at least every 2 hours.
o
Antiembolism stockings
decompress the superficial blood vessels, reducing the risk of thrombus
formation.
o
In adults, the most convenient
veins for venipuncture are the basilic and median cubital veins in the antecubital space.
o
Two to three hours before
beginning a tube feeding, the nurse should aspirate the patient’s stomach
contents to verify that gastric emptying is adequate.
o
People with type O blood are
considered universal donors.
o
People with type AB blood are
considered universal recipients.
o
Hertz (Hz) is the unit of
measurement of sound frequency.
o
Hearing protection is required
when the sound intensity exceeds 84 dB. Double hearing protection is required
if it exceeds 104 dB.
o
Prothrombin, a clotting factor,
is produced in the liver.
o
If a patient is menstruating
when a urine sample is collected, the nurse should note this on the laboratory
request.
o
During lumbar puncture, the
nurse must note the initial intracranialpressure and the color of the
cerebrospinal fluid.
o
If a patient can’t cough to
provide a sputum sample for culture, a heated aerosol treatment can be used to
help to obtain a sample.
o
If eye ointment and eyedrops
must be instilled in the same eye, the eyedrops should be instilled first.
o
When leaving an isolation room,
the nurse should remove her gloves before her mask because fewer pathogens are
on the mask.
o
Skeletal traction, which is
applied to a bone with wire pins or tongs, is the most effective means of
traction.
o
The total parenteral nutrition
solution should be stored in a refrigerator and removed 30 to 60 minutes before
use. Delivery of a chilled solution can cause pain, hypothermia, venous spasm,
and venous constriction.
o
Drugs aren’t routinely injected
intramuscularly into edematous tissue because they may not be absorbed.
o
When caring for a comatose
patient, the nurse should explain each action to the patient in a normal voice.
o
Dentures should be cleaned in a
sink that’s lined with a
washcloth.
o
A patient should void within 8
hours after surgery.
o
An EEG identifies normal and abnormal
brain waves.
o
Samples of feces for ova and
parasite tests should be delivered to the laboratory without delay and without
refrigeration.
o
The autonomic nervous system
regulates the cardiovascular and respiratory systems.
o
When providing tracheostomy care,
the nurse should insert the catheter gently into the tracheostomy tube. When
withdrawing the catheter, the nurse should apply intermittent suction for no
more than 15 seconds and use a slight twisting motion.
o
A low-residue diet includes
such foods as roasted chicken, rice, and pasta.
o
A rectal tube shouldn’t be
inserted for longer than 20 minutes because it can irritate the rectal mucosa
and cause loss of sphincter control.
o
A patient’s bed bath should
proceed in this order: face, neck, arms, hands, chest, abdomen, back, legs,
perineum.
o
To prevent injury when lifting
and moving a patient, the nurse should primarily use the upper leg muscles.
o
Patient preparation for
cholecystography includes ingestion of a contrast medium and a low-fat evening
meal.
o
While an occupied bed is being
changed, the patient should be covered with a bath blanket to promote warmth
and prevent exposure.
o
Anticipatory grief is mourning
that occurs for an extended time when the patient realizes that death is
inevitable.
o
The following foods can alter
the color of the feces: beets (red), cocoa (dark red or brown), licorice
(black), spinach (green), and meat
protein (dark brown).
o
When preparing for a skull
X-ray, the patient should remove all jewelry and dentures.
o
The fight-or-flight response is
a sympathetic nervous system response.
o
Bronchovesicular breath sounds
in peripheral lung fields are abnormal and suggest pneumonia.
o
Wheezing is an abnormal,
high-pitched breath sound that’s accentuated on expiration.
o
Wax or a foreign body in the
ear should be flushed out gently by irrigation with warm saline solution.
o
If a patient complains that his
hearing aid is “not working,” the nurse should check the switch first to see if
it’s turned on and then check the batteries.
o
The nurse should grade hyperactive
biceps and triceps reflexes as +4.
o
If two eye medications are
prescribed for twice-daily instillation, they should be administered 5 minutes
apart.
o
In a postoperative patient,
forcing fluids helps prevent constipation.
o
A nurse must provide care in accordance
with standards of care established by the American Nurses Association, state
regulations, and facility policy.
o
The kilocalorie (kcal) is a
unit of energy measurement that represents the amount of heat needed to raise
the temperature of 1 kilogram of water 1° C.
o
As nutrients move through the
body, they undergo ingestion, digestion, absorption, transport, cell
metabolism, and excretion.
o
The body metabolizes alcohol at
a fixed rate, regardless of serum concentration.
o
In an alcoholic beverage, proof
reflects the percentage of
alcohol multiplied by 2. For example, a 100-proof beverage contains 50%
alcohol.
o
A living will is a witnessed
document that states a patient’s desire for certain types of care and
treatment. These decisions are based on the patient’s wishes and views on
quality of life.
o
The nurse should flush a
peripheral heparin lock every 8 hours (if it wasn’t used during the previous 8
hours) and as needed with normal saline solution to maintain patency.
o
Quality assurance is a method
of determining whether nursing actions and practices meet established
standards.
o
The five rights of medication
administration are the right patient, right drug, right dose, right route of
administration, and right time.
o
The evaluation phase of the
nursing process is to determine whether nursing interventions have enabled the
patient to meet the desired goals.
o
Outside of the hospital
setting, only the sublingual and translingual forms of nitroglycerin should be
used to relieve acute anginal
attacks.
o
The implementation phase of the
nursing process involves recording the patient’s response to the nursing plan,
putting the nursing plan into action, delegating specific nursing
interventions, and coordinating the patient’s activities.
o
The Patient’s Bill of Rights
offers patients guidance and protection by stating the responsibilities of the
hospital and its staff toward patients and their families during
hospitalization.
o
To minimize omission and
distortion of facts, the nurse should record information as soon as it’s
gathered.
o
When assessing a patient’s
health history, the nurse should record the current illness chronologically,
beginning with the onset of the problem and continuing to the present.
o
When assessing a patient’s
health history, the nurse should record the current illness chronologically,
beginning with the onset of the problem and continuing to the present.
o
A nurse shouldn’t give false
assurance to a patient.
o
After receiving preoperative
medication, a patient isn’t competent to sign an informed consent form.
o
When lifting a patient, a nurse
uses the weight of her body instead of the strength in her arms.
o
A nurse may clarify a
physician’s explanation about an operation or a procedure to a patient, but must refer questions
about informed consent to the physician.
o
When obtaining a health history
from an acutely ill or agitated patient, the nurse should limit questions to
those that provide necessary information.
o
If a chest drainage system line
is broken or interrupted, the nurse should clamp the tube immediately.
o
The nurse shouldn’t use her
thumb to take a patient’s pulse rate because the thumb has a pulse that may be
confused with the patient’s pulse.
o
An inspiration and an expiration count as
one respiration.
o
Eupnea is normal respiration.
o
During blood pressure
measurement, the patient should rest the arm against a surface. Using muscle
strength to hold up the arm may raise the blood pressure.
o
Major, unalterable risk factors
for coronary artery disease include heredity, sex, race, and age.
o
Inspection is the most
frequently used assessment technique.
o
Family members of an elderly
person in a long-term care facility should transfer some personal items (such
as photographs, a favorite chair, and knickknacks) to the person’s room to
provide a comfortable atmosphere.
o
Pulsus alternans is a regular
pulse rhythm with alternating weak and strong beats. It occurs in ventricular
enlargement because the stroke volume varies with each heartbeat.
o
The upper respiratory tract
warms and humidifies inspired air and plays a role in taste, smell, and
mastication.
o
Signs of accessory muscle use
include shoulder elevation, intercostal muscle retraction, and scalene and
sternocleidomastoid muscle use during respiration.
o
When patients use axillary
crutches, their palms should bear the brunt of the weight.
o
Activities of daily living
include eating, bathing, dressing, grooming, toileting, and interacting
socially.
o
Normal gait has two phases: the stance phase,
in which the patient’s foot rests on the ground, and the swing phase, in which
the patient’s foot moves forward.
o
The phases of mitosis are
prophase, metaphase, anaphase, and telophase.
o
The nurse should follow
standard precautions in the routine care of all patients.
o
The nurse should use the bell
of the stethoscope to listen for venous hums and cardiac murmurs.
o
The nurse can assess a
patient’s general knowledge by asking questions such as “Who is the president
of the United States ?
o
Cold packs are applied for the
first 20 to 48 hours after an injury; then heat is applied. During cold
application, the pack is applied
for 20 minutes and then removed for 10 to 15 minutes to prevent reflex dilation
(rebound phenomenon) and frostbite injury.
o
The pons is located above the
medulla and consists of white matter (sensory and motor tracts) and gray matter
(reflex centers).
o
The autonomic nervous system
controls the smooth muscles.
o
A correctly written patient
goal expresses the desired patient behavior, criteria for measurement, time
frame for achievement, and conditions under which the behavior will occur. It’s
developed in collaboration with the patient.
o
Percussion causes five basic
notes: tympany (loud intensity, as heard over a gastric air bubble or puffed
out cheek), hyperresonance (very loud, as heard over an emphysematous lung),
resonance (loud, as heard over a normal lung), dullness (medium intensity, as
heard over the liver or other solid organ), and flatness (soft, as heard over
the thigh).
o
The optic disk is yellowish
pink and circular, with a distinct border.
o
A primary disability is caused
by a pathologic process. A secondary disability is caused by inactivity.
o
Nurses are commonly held liable
for failing to keep an accurate count of sponges and other devices during
surgery.
o
The best dietary sources of
vitamin B6 are liver, kidney, pork, soybeans, corn, and whole-grain cereals.
o
Iron-rich foods, such as organ
meats, nuts, legumes, dried fruit, green leafy vegetables, eggs, and whole
grains, commonly have a low water content.
o
Collaboration is joint
communication and decision making betweennurses and physicians. It’s designed
to meet patients’ needs by integrating the care regimens of both professions
into one comprehensive approach.
o
Bradycardia is a heart rate of
fewer than 60 beats/minute.
o
A nursing diagnosis is a
statement of a patient’s actual or potential health problem that can be
resolved, diminished, or otherwise changed by nursing interventions.
o
During the assessment phase of
the nursing process, the nurse collects and analyzes three types of data:
health history, physical examination, and laboratory and diagnostic test data.
o
The patient’s health history
consists primarily of subjective data, information that’s supplied by the
patient.
o
The physical examination
includes objective data obtained by inspection, palpation, percussion, and
auscultation.
o
When documenting patient care,
the nurse should write legibly, use only standard abbreviations, and sign each
entry. The nurse should never destroy or attempt to obliterate documentation or
leave vacant lines.
o
Factors that affect body
temperature include time of day, age, physical activity, phase of menstrual
cycle, and pregnancy.
o
The most accessible and
commonly used artery for measuring a patient’s pulse rate is the radial artery. To take the pulse rate, the
artery is compressed against the radius.
o
In a resting adult, the normal
pulse rate is 60 to 100 beats/minute. The rate is slightly faster in women than
in men and much faster in children than in adults.
o
Laboratory test results are an objective form of
assessment data.
o
The measurement systems most
commonly used in clinical practice are the metric system, apothecaries’ system,
and household system.
o
Before signing an informed
consent form, the patient should know whether other treatment options are
available and should understand what will occur during the preoperative,
intraoperative, and postoperative phases; the risks involved; and the possible
complications. The patient should also have a general idea of the time required
from surgery to recovery. In addition, he should have an opportunity to ask
questions.
o
A patient must sign a separate
informed consent form for each procedure.
o
During percussion, the nurse
uses quick, sharp tapping of the fingers or hands against body surfaces to
produce sounds. This procedure is done to determine the size, shape, position,
and density of underlying organs and tissues; elicit tenderness; or assess
reflexes.
o
Ballottement is a form of light
palpation involving gentle, repetitive bouncing of tissues against the hand and
feeling their rebound.
o
A foot cradle keeps bed linen
off the patient’s feet to prevent skin irritation and breakdown, especially in
a patient who has peripheral vascular disease or neuropathy.
o
Gastric lavage is flushing of
the stomach and removal of ingested substances through a nasogastric tube. It’s
used to treat poisoning or drug overdose.
o
During the evaluation step of
the nursing process, the nurse assesses the patient’s response to therapy.
o
Bruits commonly indicate life-
or limb-threatening vascular disease.
o
O.U. means each eye. O.D. is
the right eye, and O.S. is the left eye.
o
To remove a patient’s
artificial eye, the nurse depresses the lower lid.
o
The nurse should use a warm
saline solution to clean an artificial eye.
o
A thready pulse is very fine
and scarcely perceptible.
o
Axillary temperature is usually
1° F lower than oral temperature.
o
After suctioning a tracheostomy
tube, the nurse must document the color, amount, consistency, and odor of secretions.
o
On a drug prescription, the
abbreviation p.c. means that the drug should be administered after meals.
o
After bladder irrigation, the
nurse should document the amount, color, and clarity of the urine and the
presence of clots or sediment.
o
After bladder irrigation, the
nurse should document the amount, color, and clarity of the urine and the
presence of clots or sediment.
o
Laws regarding patient
self-determination vary from state to state. Therefore, the nurse must be
familiar with the laws of the state in which she works.
o
Gauge is the inside diameter of
a needle: the smaller the gauge, the larger the diameter.
o
An adult normally has 32
permanent teeth.
o
After turning a patient, the
nurse should document the position used, the time that the patient was turned,
and the findings of skin assessment.
o
PERRLA is an abbreviation for
normal pupil assessment findings: pupils equal, round, and reactive to light with accommodation.
o
When percussing a patient’s
chest for postural drainage, the nurse’s hands should be cupped.
o
When measuring a patient’s
pulse, the nurse should assess its rate, rhythm, quality, and strength.
o
Before transferring a patient
from a bed to a wheelchair, the
nurse should push the wheelchair’s footrests to the sides and lock its wheels.
o
When assessing respirations,
the nurse should document their rate, rhythm, depth, and quality.
o
For a subcutaneous injection,
the nurse should use a 5/8" 25G needle.
o
The notation “AA & O × 3”
indicates that the patient is awake, alert, and oriented to person (knows who
he is), place (knows where he is), and time (knows the date and time).
o
Fluid intake includes all
fluids taken by mouth, including foods that are liquid at room temperature,
such as gelatin, custard, and ice cream; I.V. fluids; and fluids administered
in feeding tubes. Fluid output includes urine, vomitus, and drainage (such as
from a nasogastric tube or from a wound) as well as blood loss, diarrhea or
feces, and perspiration.
o
After administering an
intradermal injection, the nurse shouldn’t massage the area because massage can
irritate the site and interfere with results.
o
When administering an
intradermal injection, the nurse should hold the syringe almost flat against
the patient’s skin (at about a 15-degree angle), with the bevel up.
o
To obtain an accurate blood
pressure, the nurse should inflate the manometer to 20 to 30 mm Hg above the
disappearance of the radial pulse before
releasing the cuff pressure.
o
The nurse should count an
irregular pulse for 1 full minute.
o
A patient who is vomiting while
lying down should be placed in a lateral position to prevent aspiration of
vomitus.
o
Prophylaxis is disease
prevention.
o
Body alignment is achieved when
body parts are in proper relation to their natural position.
o
Trust is the foundation of a
nurse-patient relationship.
o
Blood pressure is the force
exerted by the circulating volume of blood on the arterial walls.
o
Malpractice is a professional’s
wrongful conduct, improper discharge of duties, or failure to meet standards of
care that causes harm to another.
o
As a general rule, nurses can’t
refuse a patient care assignment; however, in most states, they may refuse to
participate in abortions.
o
A nurse can be found negligent
if a patient is injured because the nurse failed to perform a duty that a
reasonable and prudent person would perform or because the nurse performed an
act that a reasonable and prudent
person wouldn’t perform.
o
States have enacted Good
Samaritan laws to encourage professionals to provide medical assistance at the
scene of an accident without fear of a lawsuit arising from the assistance.
These laws don’t apply to care provided in a health care facility.
o
A physician should sign verbal
and telephone orders within the time established by facility policy, usually 24
hours.
o
A competent adult has the right
to refuse lifesaving medical treatment; however, the individual should be fully
informed of the consequences of his refusal.
o
Although a patient’s health
record, or chart, is the health care facility’s physical property, its contents
belong to the patient.
o
Before a patient’s health
record can be released to a third party, the patient or the patient’s legal
guardian must give written consent.
o
Under the Controlled Substances
Act, every dose of a controlled drug that’s dispensed by the pharmacy must be
accounted for, whether the dose was administered to a patient or discarded
accidentally.
o
A nurse can’t perform duties
that violate a rule or regulation established by a state licensing board, even
if they are authorized by a health care facility or physician.
o
To minimize interruptions
during a patient interview, the nurse should select a private room, preferably
one with a door that can be closed.
o
In categorizing nursing
diagnoses, the nurse addresses life-threatening problems first, followed by
potentially life-threatening concerns.
o
The major components of a
nursing care plan are outcome criteria (patient goals) and nursing
interventions.
o
Standing orders, or protocols,
establish guidelines for treating a specific disease or set of symptoms.
o
In assessing a patient’s heart,
the nurse normally finds the
point of maximal impulse at the fifth intercostal space, near the apex.
o
The S1 heard on auscultation is
caused by closure of the mitral and tricuspid valves.
o
To maintain package sterility,
the nurse should open a wrapper’s top flap away from the body, open each side
flap by touching only the outer part of the wrapper, and open the final flap by
grasping the turned-down corner and pulling it toward the body.
o
The nurse shouldn’t dry a
patient’s ear canal or remove wax with acotton-tipped applicator because it may
force cerumen against the tympanic membrane.
o
A patient’s identification
bracelet should remain in place until the patient has been discharged from the
health care facility and has left the premises.
o
The Controlled Substances Act
designated five categories, or schedules, that classify controlled drugs
according to their abuse potential.
o
Schedule I drugs, such as
heroin, have a high abuse potential and have no currently accepted medical use
in the United States.
o
Schedule II drugs, such as
morphine, opium, and meperidine (Demerol), have a high abuse potential, but
currently have accepted medical uses. Their use may lead to physical or
psychological dependence.
o
Schedule III drugs, such as
paregoric and butabarbital (Butisol), have a lower abuse potential than
Schedule I or II drugs. Abuse of Schedule III drugs may lead to moderate or low
physical or psychological dependence, or both.
o
Schedule IV drugs, such as
chloral hydrate, have a low abuse potential compared with Schedule III drugs.
o
Schedule V drugs, such as cough
syrups that contain codeine, have the lowest abuse potential of the controlled
substances.
o
Activities of daily living are
actions that the patient must perform every day to provide self-care and to
interact with society.
o
Testing of the six cardinal
fields of gaze evaluates the function of all extraocular muscles and cranial
nerves III, IV, and VI.
o
The six types of heart murmurs
are graded from 1 to 6. A grade 6 heart murmur can be heard with the
stethoscope slightly raised from the chest.
o
The most important goal to
include in a care plan is the patient’s goal.
o
Fruits are high in fiber and
low in protein, and should be omitted from a low-residue diet.
o
The nurse should use an
objective scale to assess and quantify pain. Postoperative pain varies greatly
among individuals.
o
Postmortem care includes
cleaning and preparing the deceased patient for family viewing, arranging
transportation to the morgue or funeral home, and determining the disposition
of belongings.
o
The nurse should provide honest
answers to the patient’s questions.
o
Milk shouldn’t be included in a
clear liquid diet.
o
When caring for an infant, a
child, or a confused patient, consistency in nursing personnel is paramount.
o
The hypothalamus secretes
vasopressin and oxytocin, which are stored in the pituitary gland.
o
The three membranes that
enclose the brain and spinal cord
are the dura mater, pia mater, and arachnoid.
o
A nasogastric tube is used to remove fluid and gas from
the small intestine preoperatively or postoperatively.
o
Psychologists, physical
therapists, and chiropractors aren’t authorized to write prescriptions for
drugs.
o
The area around a stoma is
cleaned with mild soap and water.
o
Vegetables have a high fiber
content.
o
The nurse should use a
tuberculin syringe to administer a subcutaneous injection of less than 1 ml.
o
For adults, subcutaneous
injections require a 25G 1" needle; for infants, children, elderly, or
very thin patients, they require a 25G to 27G ½" needle.
o
Before administering a drug,
the nurse should identify the patient by checking the identification band and asking the patient to state
his name.
o
To clean the skin before an
injection, the nurse uses a sterile alcohol swab to wipe from the center of the
site outward in a circular motion.
o
The nurse should inject heparin
deep into subcutaneous tissue at a 90-degree angle (perpendicular to the skin)
to prevent skin irritation.
o
If blood is aspirated into the
syringe before an I.M. injection, the nurse should withdraw the needle, prepare
another syringe, and repeat the procedure.
o
The nurse shouldn’t cut the
patient’s hair without written consent from the patient or an appropriate
relative.
o
If bleeding occurs after an
injection, the nurse should apply pressure until the bleeding stops. If
bruising occurs, the nurse should monitor the site for an enlarging hematoma.
o
When providing hair and scalp
care, the nurse should begin combing at the end of the hair and work toward the
head.
o
The frequency of patient hair
care depends on the length and texture of the hair, the duration of
hospitalization, and the
patient’s condition.
o
Proper function of a hearing
aid requires careful handling during insertion and removal, regular cleaning of
the ear piece to prevent wax buildup, and prompt replacement of dead batteries.
o
The hearing aid that’s marked
with a blue dot is for the left ear; the one with a red dot is for the right
ear.
o
A hearing aid shouldn’t be
exposed to heat or humidity and shouldn’t be immersed in water.
o
The nurse should instruct the
patient to avoid using hair spray while wearing a hearing aid.
o
The five branches of
pharmacology are pharmacokinetics, pharmacodynamics, pharmacotherapeutics,
toxicology, and pharmacognosy.
o
The nurse should remove heel
protectors every 8 hours to inspect the foot for signs of skin breakdown.
o
Heat is applied to promote
vasodilation, which reduces pain caused by inflammation.
o
A sutured surgical incision is
an example of healing by first intention (healing directly, without
granulation).
o
Healing by secondary intention
(healing by granulation) is closure of the wound when granulation tissue fills
the defect and allows reepithelialization to occur, beginning at the wound
edges and continuing to the center, until the entire wound is covered.
o
Keloid formation is an
abnormality in healing that’s characterized by overgrowth of scar tissue at the
wound site.
o
The nurse should administer
procaine penicillin by deep I.M. injection in the upper outer portion of the
buttocks in the adult or in the midlateral thigh in the child. The nurse
shouldn’t massage the injection site.
o
An ascending colostomy drains
fluid feces. A descending colostomy drains solid fecal matter.
o
A folded towel (scrotal bridge)
can provide scrotal support for the patient with scrotal edema caused by
vasectomy, epididymitis, or orchitis.
o
When giving an injection to a
patient who has a bleeding disorder, the nurse should use a small-gauge needle
and apply pressure to the site for 5 minutes after the injection.
o
Platelets are the smallest and
most fragile formed element of
the blood and are essential for coagulation.
o
To insert a
nasogastric tube, the nurse instructs the patient to tilt the head
back slightly and then inserts the tube. When the nurse feels the tube curving
at the pharynx, the nurse should tell the patient to tilt the head forward to
close the trachea and open the esophagus by swallowing. (Sips of water can
facilitate this action.)
o
Families with loved ones in
intensive care units report that their four most important needs are to have
their questions answered honestly, to be assured that the best possible care is
being provided, to know the patient’s prognosis, and to feel that there is hope
of recovery.
o
Double-bind communication
occurs when the verbal message contradicts the nonverbal message and the
receiver is unsure of which message to respond to.
o
A nonjudgmental attitude
displayed by a nurse shows that she neither approves nor disapproves of the
patient.
o
Target symptoms are those that
the patient finds most distressing.
o
A patient should be advised to
take aspirin on an empty stomach, with a full glass of water, and should avoid
acidic foods such as coffee, citrus fruits, and cola.
o
For every patient problem,
there is a nursing diagnosis; for every nursing diagnosis, there is a goal; and
for every goal, there are interventions designed to make the goal a reality.
The keys to answering examination questions correctly are identifying the problem
presented, formulating a goal for the problem, and selecting the intervention
from the choices provided that will enable the patient to reach that goal.
o
Fidelity means loyalty and can
be shown as a commitment to the profession of nursing and to the patient.
o
Administering an I.M. injection
against the patient’s will and without legal authority is battery.
o
An example of a third-party
payer is an insurance company.
o
The formula for calculating the
drops per minute for an I.V. infusion is as follows: (volume to be infused ×
drip factor) ÷ time in minutes = drops/minute
o
On-call medication should be
given within 5 minutes of the call.
o
Usually, the best method to
determine a patient’s cultural or spiritual needs is to ask him.
o
An incident report or unusual
occurrence report isn’t part of a patient’s record, but is an in-house document
that’s used for the purpose of correcting the problem.
o
Critical pathways are a
multidisciplinary guideline for patient care.
o
When prioritizing nursing
diagnoses, the following hierarchy should be used: Problems associated with the
airway, those concerning breathing, and those related to circulation.
o
The two nursing diagnoses that
have the highest priority that the nurse can assign are Ineffective airway
clearance and Ineffective breathing pattern.
o
A subjective sign that a sitz
bath has been effective is the
patient’s expression of decreased pain or discomfort.
o
For the nursing diagnosis
Deficient diversional activity to be valid, the patient must state that he’s
“bored,” that he has “nothing to do,” or words to that effect.
o
The most appropriate nursing diagnosis for
an individual who doesn’t speak English is Impaired verbal communication
related to inability to speak dominant language (English).
o
The family of a patient who has
been diagnosed as hearing impaired should be instructed to face the individual
when they speak to him.
o
Before instilling medication
into the ear of a patient who is up to age 3, the nurse should pull the pinna
down and back to straighten the
eustachian tube.
o
To prevent injury to the cornea
when administering eyedrops, the nurse should waste the first drop and instill
the drug in the lower conjunctival sac.
o
After administering eye
ointment, the nurse should twist the medication tube to detach the ointment.
o
When the nurse removes gloves
and a mask, she should remove the gloves first. They are soiled and are likely
to contain pathogens.
o
Crutches should be placed
6" (15.2 cm) in front of the patient and 6" to the side to form a tripod arrangement.
o
Listening is the most effective
communication technique.
o
Before teaching any procedure
to a patient, the nurse must assess the patient’s current knowledge and
willingness to learn.
o
Process recording is a method
of evaluating one’s communication effectiveness.
o
When feeding an elderly
patient, the nurse should limit high-carbohydrate foods because of the risk of
glucose intolerance.
o
When feeding an elderly
patient, essential foods should be given first.
o
Passive range of motion
maintains joint mobility. Resistive exercises increase muscle mass.
o
Isometric exercises are
performed on an extremity that’s in a cast.
o
A back rub is an example of the
gate-control theory of pain.
o
Anything that’s located below
the waist is considered unsterile; a sterile field becomes unsterile when it
comes in contact with any unsterile item; a sterile field must be monitored
continuously; and a border of 1" (2.5 cm) around a sterile field is
considered unsterile.
o
A “shift to the left” is
evident when the number of immature cells (bands) in the blood increases to
fight an infection.
o
A “shift to the right” is
evident when the number of mature cells in the blood increases, as seen in
advanced liver disease and
pernicious anemia.
o
Before administering
preoperative medication, the nurse should ensure that an informed consent form
has been signed and attached to the patient’s record.
o
A nurse should spend no more
than 30 minutes per 8-hour shift providing care to a patient who has a
radiation implant.
o
A nurse shouldn’t be assigned
to care for more than one patient who has a radiation implant.
o
Long-handled forceps and a
lead-lined container should be available in the room of a patient who has a radiation implant.
o
Usually, patients who have the
same infection and are in strict isolation can share a room.
o
Diseases that require strict
isolation include chickenpox, diphtheria, and viral hemorrhagic fevers such as Marburg disease.
o
For the patient who abides by
Jewish custom, milk and meat shouldn’t be served at the same meal.
o
Whether the patient can perform
a procedure (psychomotor domain of learning) is a better indicator of the
effectiveness of patient teaching than whether the patient can simply state the
steps involved in the procedure (cognitive domain of learning).
o
According to Erik Erikson,
developmental stages are trust versus mistrust (birth to 18 months), autonomy
versus shame and doubt (18 months to age 3), initiative versus guilt (ages 3 to
5), industry versus inferiority (ages 5 to 12), identity versus identity
diffusion (ages 12 to 18), intimacy versus isolation (ages 18 to 25),
generativity versus stagnation (ages 25 to 60), and ego integrity versus
despair (older than age 60).
o
When communicating with a
hearing impaired patient, the nurse should face him.
o
An appropriate nursing
intervention for the spouse of a patient who has a serious incapacitating
disease is to help him to mobilize a support system.
o
Hyperpyrexia is extreme
elevation in temperature above 106° F (41.1° C).
o
Milk is high in sodium and low
in iron.
o
When a patient expresses
concern about a health-related issue, before addressing the concern, the nurse
should assess the patient’s level of knowledge.
o
The most effective way to
reduce a fever is to administer an antipyretic, which lowers the temperature
set point.
o
When a patient is ill, it’s
essential for the members of his family to maintain communication about his
health needs.
o
Ethnocentrism is the universal
belief that one’s way of life is superior to others’.
o
When a nurse is communicating
with a patient through an interpreter, the nurse should speak to the patient
and the interpreter.
o
In accordance with the
“hot-cold” system used by some Mexicans, Puerto Ricans, and other Hispanic and
Latino groups, most foods, beverages, herbs, and drugs are described as “cold.”
o
Prejudice is a hostile attitude
toward individuals of a particular group.
o
Discrimination is preferential
treatment of individuals of a particular group. It’s usually discussed in a
negative sense.
o
Increased gastric motility
interferes with the absorption of oral drugs.
o
The three phases of the therapeutic
relationship are orientation, working, and termination.
o
Patients often exhibit
resistive and challenging behaviors in the orientation phase of the therapeutic
relationship.
o
Abdominal assessment is
performed in the following order: inspection, auscultation, palpation, and
percussion.
o
When measuring blood pressure
in a neonate, the nurse should select a cuff that’s no less than one-half and
no more than two-thirds the length of the extremity that’s used.
o
When administering a drug by
Z-track, the nurse shouldn’t use the same needle that was used to draw the drug
into the syringe because doing so could stain the skin.
o
Sites for intradermal injection
include the inner arm, the upper chest, and on the back, under the scapula.
o
When evaluating whether an answer
on an examination is correct, the nurse should consider whether the action
that’s described promotes autonomy (independence), safety, self-esteem, and a
sense of belonging.
o
When answering a question on
the NCLEX examination, the student should
consider the cue (the stimulus for a thought) and the inference (the thought)
to determine whether the inference is correct. When in doubt, the nurse should
select an answer that indicates the need for further information to eliminate
ambiguity. For example, the patient complains of chest pain (the stimulus for
the thought) and the nurse infers that the patient is having cardiac pain (the
thought). In this case, the nurse hasn’t confirmed whether the pain is cardiac.
It would be more appropriate to make further assessments.
o
Veracity is truth and is an
essential component of a therapeutic relationship between a health care
provider and his patient.
o
Beneficence is the duty to do
no harm and the duty to do good.
There’s an obligation in patient care to do no harm and an equal obligation to
assist the patient.
o
Nonmaleficence is the duty to
do no harm.
o
Frye’s ABCDE cascade provides a
framework for prioritizing care by identifying the most important treatment
concerns.
o
A = Airway. This category
includes everything that affects a patent airway, including a foreign object,
fluid from an upper respiratory infection, and edema from trauma or an allergic
reaction.
o
B = Breathing. This category
includes everything that affects the breathing pattern, including
hyperventilation or hypoventilation and abnormal breathing patterns, such as
Korsakoff’s, Biot’s, or Cheyne-Stokes respiration.
o
C = Circulation. This category
includes everything that affects thecirculation, including fluid and
electrolyte disturbances and disease processes that affect cardiac output.
o
D = Disease processes. If the
patient has no problem with the airway, breathing, or circulation, then the
nurse should evaluate the disease processes, giving priority to the disease
process that poses the greatest immediate risk. For example, if a patient has
terminal cancer and hypoglycemia, hypoglycemia is a more immediate concern.
o
E = Everything else. This
category includes such issues as writing an incident report and completing the
patient chart. When evaluating needs, this category is never the highest
priority.
o
When answering a question on an NCLEX examination, the basic rule is “assess
before action.” The student should evaluate each possible answer carefully.
Usually, several answers reflect the implementation phase of nursing and one or
two reflect the assessment phase. In this case, the best choice is an
assessment response unless a specific course of action is clearly indicated.
o
Rule utilitarianism is known as
the “greatest good for the greatest number of people” theory.
o
Egalitarian theory emphasizes that equal access to goods and
services must be provided to the less fortunate by an affluent society.
o
Active euthanasia is actively
helping a person to die.
o
Brain death is irreversible
cessation of all brain function.
o
Passive euthanasia is stopping
the therapy that’s sustaining life.
o
A third-party payer is an
insurance company.
o
Utilization review is performed
to determine whether the care provided to a patient was appropriate and
cost-effective.
o
A value cohort is a group of
people who experienced an out-of-the-ordinary event that shaped their values.
o
Voluntary euthanasia is
actively helping a patient to die at the patient’s request.
o
Bananas, citrus fruits, and
potatoes are good sources of potassium.
o
Good sources of magnesium
include fish, nuts, and grains.
o
Beef, oysters, shrimp,
scallops, spinach, beets, and greens are good sources of iron.
o
Intrathecal injection is administering
a drug through the spine.
o
When a patient asks a question
or makes a statement that’s emotionally charged,
the nurse should respond to the emotion behind the statement or question rather
than to what’s being said or asked.
o
The steps of the trajectory-nursing
model are as follows:
– Step 1: Identifying the trajectory
phase
– Step 2: Identifying the problems and
establishing goals
– Step 3: Establishing a plan to meet
the goals
– Step 4: Identifying factors that
facilitate or hinder attainment of the goals
– Step 5: Implementing interventions
– Step 6: Evaluating the effectiveness
of the interventions
o
A Hindu patient is likely to
request a vegetarian diet.
o
Pain threshold, or pain
sensation, is the initial point at which a patient feels pain.
o
The difference between acute
pain and chronic pain is its duration.
o
Referred pain is pain that’s
felt at a site other than its origin.
o
Alleviating pain by performing
a back massage is consistent with the gate control theory.
o
Romberg’s test is a test for
balance or gait.
o
Pain seems more intense at
night because the patient isn’t distracted by daily activities.
o
Older patients commonly don’t
report pain because of fear of treatment, lifestyle changes, or dependency.
o
No pork or pork products are
allowed in a Muslim diet.
o
Two goals of Healthy People
2010 are:
– Help individuals of all ages to
increase the quality of life and the number of years of optimal health
– Eliminate health disparities among
different segments of the population.
o
A community nurse is serving as
a patient’s advocate if she tells a malnourished patient to go to a meal
program at a local park.
o
If a patient isn’t following
his treatment plan, the nurse should first ask why.
o
Falls are the leading cause of
injury in elderly people.
o
Primary prevention is true
prevention. Examples are immunizations, weight control, and smoking cessation.
o
Secondary prevention is early
detection. Examples include purified protein derivative (PPD), breast
self-examination, testicular self-examination, and chest X-ray.
o
Tertiary prevention is
treatment to prevent long-term complications.
o
A patient indicates that he’s
coming to terms with having a chronic disease when he says, “I’m never going to
get any better.”
o
On noticing religious artifacts and literature on
a patient’s night stand, a culturally aware nurse would ask the patient the
meaning of the items.
o
A Mexican patient may request
the intervention of a curandero, or faith healer, who involves the family in
healing the patient.
o
In an infant, the normal
hemoglobin value is 12 g/dl.
o
The nitrogen balance estimates
the difference between the intake and use of protein.
o
Most of the absorption of water
occurs in the large intestine.
o
Most nutrients are absorbed in the small intestine.
o
When assessing a patient’s
eating habits, the nurse should ask, “What have you eaten in the last 24
hours?”
o
A vegan diet should include an
abundant supply of fiber.
o
A hypotonic enema softens the
feces, distends the colon, and stimulates peristalsis.
o
First-morning urine provides
the best sample to measure glucose, ketone, pH, and specific gravity values.
o
To induce sleep, the first step
is to minimize environmental stimuli.
o
Before moving a patient, the
nurse should assess the patient’s physical abilities and ability to understand
instructions as well as the amount of strength required to move the patient.
o
To lose 1 lb (0.5 kg) in 1
week, the patient must decrease his weekly intake by 3,500 calories
(approximately 500 calories daily). To lose 2 lb (1 kg) in 1 week, the patient
must decrease his weekly caloric intake by 7,000 calories (approximately 1,000
calories daily).
o
To avoid shearing force injury,
a patient who is completely immobile is lifted on a sheet.
o
To insert a catheter from the
nose through the trachea for suction, the nurse should ask the patient to
swallow.
o
Vitamin C is needed for
collagen production.
o
Only the patient can describe
his pain accurately.
o
Cutaneous stimulation creates
the release of endorphins that block the transmission of pain stimuli.
o
Patient-controlled analgesia is
a safe method to relieve acute pain caused by surgical incision, traumatic
injury, labor and delivery, or cancer.
o
An Asian American or European
American typically places distance between himself and others when communicating.
o
The patient who believes in a
scientific, or biomedical, approach to health is likely to expect a drug,
treatment, or surgery to cure illness.
o
Chronic illnesses occur in very
young as well as middle-aged and very old people.
o
The trajectory framework for
chronic illness states that preferences about daily life activities affect
treatment decisions.
o
Exacerbations of chronic
disease usually cause the patient to seek treatment and may lead to
hospitalization.
o
School health programs provide
cost-effective health care for low-income families and those who have no health
insurance.
o
Collegiality is the promotion of collaboration,
development, and interdependence among members of a profession.
o
A change agent is an individual
who recognizes a need for change or is selected to make a change within an
established entity, such as a hospital.
o
The patients’ bill of rights
was introduced by the American Hospital Association.
o
Abandonment is premature
termination of treatment without the patient’s permission and without
appropriate relief of symptoms.
o
Values clarification is a
process that individuals use to prioritize their personal values.
o
Distributive justice is a
principle that promotes equal treatment for all.
o
Milk and milk products,
poultry, grains, and fish are good sources of phosphate.
o
The best way to prevent falls
at night in an oriented, but restless, elderly patient is to raise the side
rails.
o
By the end of the orientation
phase, the patient should begin to trust the nurse.
o
Falls in the elderly are likely
to be caused by poor vision.
o
Barriers to communication
include language deficits, sensory deficits, cognitive impairments, structural
deficits, and paralysis.
o
The three elements that are
necessary for a fire are heat, oxygen, and combustible material.
o
Sebaceous glands lubricate the
skin.
o
To check for petechiae in a
dark-skinned patient, the nurse should assess the oral mucosa.
o
To put on a sterile glove, the
nurse should pick up the first glove at the folded border and adjust the
fingers when both gloves are on.
o
To increase patient comfort, the nurse should let the
alcohol dry before giving an intramuscular injection.
o
Treatment for a stage 1 ulcer
on the heels includes heel protectors.
o
Seventh-Day Adventists are
usually vegetarians.
o
Endorphins are morphinelike substances
that produce a feeling of well-being.
o
Pain tolerance is the maximum
amount and duration of pain that an individual is willing to endure.
MATERNAL & CHILD CARE
o
Unlike false labor, true labor
produces regular rhythmic contractions, abdominal discomfort, progressive
descent of the fetus, bloody show, and progressive effacement and dilation of
the cervix.
o
To help a mother break the
suction of her breast-feeding infant, the nurse should teach her to insert a
finger at the corner of the infant’s mouth.
o
Administering high levels of
oxygen to a premature neonate can cause blindness as a result of retrolental
fibroplasia.
o
Amniotomy is artificial rupture
of the amniotic membranes.
o
During pregnancy, weight gain
averages 25 to 30 lb (11 to 13.5 kg).
o
Rubella has a teratogenic
effect on the fetus during the first trimester. It produces abnormalities in up
to 40% of cases without interrupting the pregnancy.
o
Immunity to rubella can be
measured by a hemagglutination inhibition test (rubella titer). This test identifies
exposure to rubella infection and determines susceptibility in pregnant women.
In a woman, a titer greater than 1:8 indicates immunity.
o
When used to describe the
degree of fetal descent during labor, floating means the presenting part isn’t
engaged in the pelvic inlet, but is freely movable (ballotable) above the
pelvic inlet.
o
When used to describe the
degree of fetal descent, engagement means when the largest diameter of the
presenting part has passed through the pelvic inlet.
o
Fetal station indicates the
location of the presenting part in relation to the ischial spine. It’s
described as –1, –2, –3, –4, or –5 to indicate the number of centimeters above
the level of the ischial spine; station –5 is at the pelvic inlet.
o
Fetal station also is described
as +1, +2, +3, +4, or +5 to indicate the number of centimeters it is below the
level of the ischial spine; station 0 is at the level of the ischial spine.
o
During the first stage of
labor, the side-lying position usually provides the greatest degree of comfort,
although the patient may assume any comfortable position.
o
During delivery, if the
umbilical cord can’t be loosened and slipped from around the neonate’s neck, it
should be clamped with two clamps and cut between the clamps.
o
An Apgar score of 7 to 10 indicates
no immediate distress, 4 to 6 indicates moderate distress,
and 0 to 3 indicates severe
distress.
o
To elicit Moro’s reflex, the
nurse holds the neonate in both hands and suddenly, but gently, drops the
neonate’s head backward. Normally, the neonate abducts and extends all
extremities bilaterally and symmetrically, forms a C shape with the thumb and
forefinger, and first adducts and then flexes the extremities.
o
Pregnancy-induced hypertension
(preeclampsia) is an increase in blood pressure of 30/15 mm Hg over baseline or
blood pressure of 140/95 mm Hg on two occasions at least 6 hours apart
accompanied by edema and albuminuria after 20 weeks’ gestation.
o
Positive signs of pregnancy include ultrasound evidence, fetal
heart tones, and fetal movement felt by the examiner (not usually present until
4 months’ gestation
o
Goodell’s sign is softening of
the cervix.
o
Quickening, a presumptive sign
of pregnancy, occurs between 16 and 19 weeks’ gestation.
o
Ovulation ceases during
pregnancy.
o
Any vaginal bleeding during
pregnancy should be considered a complication until proven otherwise.
o
To estimate the date of delivery using Nägele’s rule, the nurse counts
backward 3 months from the first day of the last menstrual period and then adds
7 days to this date.
o
At 12 weeks’ gestation, the
fundus should be at the top of the symphysis pubis.
o
Cow’s milk shouldn’t be given
to infants younger than age 1 because it has a
low linoleic acid content and its protein is difficult for infants to digest.
o
If jaundice is suspected in a
neonate, the nurse should examine the infant under natural window light. If
natural light is unavailable, the nurse should examine the infant under a white light.
o
The three phases of a uterine
contraction are increment, acme, and decrement.
o
The intensity of a labor
contraction can be assessed by the indentability of the uterine wall at the
contraction’s peak. Intensity is graded as mild (uterine muscle is somewhat
tense), moderate (uterine muscle is moderately tense), or strong (uterine
muscle is boardlike).
o
Chloasma, the mask of
pregnancy, is pigmentation of a circumscribed area of skin (usually over the
bridge of the nose and cheeks) that occurs in some pregnant women.
o
The gynecoid pelvis is most
ideal for delivery. Other types
include platypelloid (flat), anthropoid (apelike), and android (malelike).
o
Pregnant women should be
advised that there is no safe level of alcohol intake.
o
The frequency of uterine
contractions, which is measured in minutes, is the time from the beginning of
one contraction to the beginning of the next.
o
Vitamin K is administered to
neonates to prevent hemorrhagic disorders because a neonate’s intestine can’t synthesize vitamin K.
o
Before internal fetal
monitoring can be performed, a pregnant patient’s cervix must be dilated at
least 2 cm, the amniotic membranes must be ruptured, and the fetus’s presenting
part (scalp or buttocks) must be at station –1 or lower, so that a small
electrode can be attached.
o
Fetal alcohol syndrome presents
in the first 24 hours after birth and produces lethargy, seizures, poor sucking
reflex, abdominal distention, and respiratory difficulty.
o
Variability is any change in the fetal heart rate (FHR) from its
normal rate of 120 to 160 beats/minute. Acceleration is increased FHR;
deceleration is decreased FHR.
o
In a neonate, the symptoms of heroin withdrawal may begin several
hours to 4 days after birth.
o
In a neonate, the symptoms of methadone withdrawal
may begin 7 days to several weeks after birth.
o
In a neonate, the cardinal
signs of narcotic withdrawal include coarse, flapping tremors; sleepiness;
restlessness; prolonged, persistent, high-pitched cry; and irritability.
o
The nurse should count a
neonate’s respirations for 1 full minute.
o
Chlorpromazine (Thorazine) is
used to treat neonates who are addicted to narcotics.
o
The nurse should provide a
dark, quiet environment for a neonate who is experiencing narcotic withdrawal.
o
In a premature neonate, signs
of respiratory distress include nostril flaring, substernal retractions, and
inspiratory grunting.
o
Respiratory distress syndrome
(hyaline membrane disease) develops in premature infants because their
pulmonary alveoli lack surfactant.
o
Whenever an infant is being put
down to sleep, the parent or caregiver should position the infant on the back.
(Remember back to sleep.)
o
The male sperm contributes an X
or a Y chromosome; the female ovum contributes an X chromosome.
o
Fertilization produces a total
of 46 chromosomes, including an XY combination (male) or an XX combination
(female).
o
The percentage of water in a
neonate’s body is about 78% to 80%.
o
To perform nasotracheal
suctioning in an infant, the nurse positions the infant with his neck slightly
hyperextended in a “sniffing” position, with his chin up and his head tilted
back slightly.
o
Organogenesis occurs during the
first trimester of pregnancy, specifically, days 14 to 56 of gestation.
o
After birth, the neonate’s
umbilical cord is tied 1" (2.5 cm) from the abdominal wall with a cotton
cord, plastic clamp, or rubber band.
o
Gravida is the number of
pregnancies a woman has had, regardless of
outcome.
o
Para is the number of
pregnancies that reached viability, regardless of whether the fetus was
delivered alive or stillborn. A fetus is considered viable at 20 weeks’
gestation.
o
An ectopic pregnancy is one
that implants abnormally, outside the
uterus.
o
The first stage of labor begins
with the onset of labor and ends with full cervical dilation at 10 cm.
o
The second stage of labor
begins with full cervical dilation and ends with the neonate’s birth.
o
The third stage of labor begins
after the neonate’s birth and ends with expulsion of the placenta.
o
In a full-term neonate, skin
creases appear over two-thirds of the neonate’s feet. Preterm neonates have
heel creases that cover less than two-thirds of the feet.
o
The fourth stage of labor (postpartum stabilization) lasts up to
4 hours after the placenta is delivered. This time is needed to stabilize the
mother’s physical and emotional state after the stress of childbirth.
o
At 20 weeks’ gestation, the
fundus is at the level of the umbilicus.
o
At 36 weeks’ gestation, the
fundus is at the lower border of the rib cage.
o
A premature neonate is one born
before the end of the 37th week of gestation.
o
Pregnancy-induced hypertension
is a leading cause of maternal death in the United States .
o
A habitual aborter is a woman
who has had three or more consecutive spontaneous abortions.
o
Threatened abortion occurs when
bleeding is present without cervical dilation.
o
A complete abortion occurs when
all products of conception are expelled.
o
Hydramnios (polyhydramnios) is
excessive amniotic fluid (more than 2,000 ml in the third trimester).
o
Stress, dehydration, and
fatigue may reduce a breast-feeding mother’s milk supply.
o
During the transition phase of
the first stage of labor, the cervix is
dilated 8 to 10 cm and contractions usually occur 2 to 3 minutes apart and last
for 60 seconds.
o
A nonstress test is considered
nonreactive (positive) if fewer than two fetal heart rate accelerations of at
least 15 beats/minute occur in 20 minutes.
o
A nonstress test is considered
reactive (negative) if two or more fetal heart rate accelerations of 15
beats/minute above baseline occur in 20 minutes.
o
A nonstress test is usually
performed to assess fetal well-being in a pregnant patient with a prolonged
pregnancy (42 weeks or more), diabetes, a history of poor pregnancy outcomes,
or pregnancy-induced hypertension.
o
A pregnant woman should drink
at least eight 8-oz glasses (about 2,000 ml) of water daily.
o
When both breasts are used for
breast-feeding, the infant usually doesn’t empty the second breast. Therefore,
the second breast should be used first at the next feeding.
o
A low-birth-weight neonate
weighs 2,500 g (5 lb 8 oz) or less at birth.
o
A very-low-birth-weight neonate
weighs 1,500 g (3 lb 5 oz) or
less at birth.
o
When teaching parents to
provide umbilical cord care, the nurse should teach them to clean the umbilical
area with a cotton ball saturated with alcohol after every diaper change to
prevent infection and promote drying.
o
Teenage mothers are more likely
to have low-birth-weight neonates because they seek prenatal care late in
pregnancy (as a result of denial) and are more likely than older mothers to
have nutritional deficiencies.
o
Linea nigra, a dark line that
extends from the umbilicus to the
mons pubis, commonly appears during pregnancy and disappears after pregnancy.
o
Implantation in the uterus
occurs 6 to 10 days after ovum fertilization.
o
Placenta previa is abnormally low implantation of the
placenta so that it encroaches on
or covers the cervical os.
o
In complete (total) placenta
previa, the placenta completely covers the cervical os.
o
In partial (incomplete or
marginal) placenta previa, the placenta covers only a portion of the cervical
os.
o
Abruptio placentae is premature separation of a normally
implanted placenta. It may be partial or complete, and usually causes abdominal
pain, vaginal bleeding, and a boardlike abdomen.
o
Cutis marmorata is mottling or
purple discoloration of the skin. It’s a transient vasomotor response that
occurs primarily in the arms and legs of infants who are exposed to cold.
o
The classic triad of symptoms
of preeclampsia are hypertension, edema, and
proteinuria. Additional symptoms of severe preeclampsia include hyperreflexia,
cerebral and vision disturbances, and epigastric pain.
o
Ortolani’s sign (an audible
click or palpable jerk that occurs with thigh abduction) confirms congenital
hip dislocation in a neonate.
o
The first immunization for a
neonate is the hepatitis B vaccine, which is administered in the nursery
shortly after birth.
o
If a patient misses a menstrual
period while taking an oral contraceptive exactly as prescribed, she should
continue taking the contraceptive.
o
If a patient misses two
consecutive menstrual periods while taking an oral contraceptive, she should
discontinue the contraceptive and take a pregnancy test.
o
If a patient who is taking an
oral contraceptive misses a dose, she should take the pill as soon as she
remembers or take two at the nextscheduled interval and continue with the
normal schedule.
o
If a patient who is taking an
oral contraceptive misses two consecutive doses, she should double the dose for
2 days and then resume her normal schedule. She also should use an additional
birth control method for 1 week.
o
Eclampsia is the occurrence of seizures that aren’t caused by a
cerebral disorder in a patient who has pregnancy-induced hypertension.
o
In placenta previa, bleeding is
painless and seldom fatal on the first occasion, but it becomes heavier with
each subsequent episode.
o
Treatment for abruptio
placentae is usually immediate cesarean delivery.
o
Drugs used to treat withdrawal
symptoms in neonates include phenobarbital (Luminal), camphorated opium
tincture (paregoric), and diazepam (Valium).
o
Infants with Down syndrome
typically have marked hypotonia, floppiness, slanted eyes, excess skin on the
back of the neck, flattened bridge of the nose, flat facial features, spadelike
hands, short and broad feet, small male genitalia, absence of Moro’s reflex,
and a simian crease on the hands.
o
The failure rate of a
contraceptive is determined by the experience of 100 women for 1 year. It’s
expressed as pregnancies per 100 woman-years.
o
The narrowest diameter of the
pelvic inlet is the anteroposterior (diagonal conjugate).
o
The chorion is the outermost extraembryonic membrane
that gives rise to the placenta.
o
The corpus luteum secretes
large quantities of progesterone.
o
From the 8th week of gestation
through delivery, the developing cells are known as a fetus.
o
In an incomplete abortion, the
fetus is expelled, but parts of the placenta and membrane remain in the uterus.
o
The circumference of a
neonate’s head is normally 2 to 3 cm greater than the circumference of the
chest.
o
After administering magnesium
sulfate to a pregnant patient for hypertension or preterm labor, the nurse
should monitor the respiratory rate and deep tendon reflexes.
o
During the first hour after
birth (the period of reactivity), the neonate is alert and awake.
o
When a pregnant patient has
undiagnosed vaginal bleeding, vaginal examination should be avoided until
ultrasonography rules out placenta previa.
o
After delivery, the first
nursing action is to establish the neonate’s airway.
o
Nursing interventions for a
patient with placenta previa include positioning the patient on her left side
for maximum fetal perfusion, monitoring fetal heart tones, and administering
I.V. fluids and oxygen, as ordered.
o
The specific gravity of a
neonate’s urine is 1.003 to 1.030. A lower specific gravity suggests
overhydration; a higher one suggests dehydration.
o
The neonatal period extends
from birth to day 28. It’s also called the first 4 weeks or first month of
life.
o
A woman who is breast-feeding
should rub a mild emollient cream or a few drops of breast milk (or colostrum)
on the nipples after each feeding. She should let the breasts air-dry to
prevent them from cracking.
o
Breast-feeding mothers should
increase their fluid intake to 2½ to 3 qt (2,500 to 3,000 ml) daily.
o
After feeding an infant with a
cleft lip or palate, the nurse should rinse the infant’s mouth with sterile
water.
o
The nurse instills erythromycin
in a neonate’s eyes primarily to prevent blindness caused by gonorrhea or
chlamydia.
o
Human immunodeficiency virus
(HIV) has been cultured in breast milk and can be transmitted by an
HIV-positive mother who breast-feeds her infant.
o
A fever in the first 24 hours postpartum
is most likely caused by dehydration rather than infection.
o
Preterm neonates or neonates who can’t maintain a skin
temperature of at least 97.6° F (36.4° C) should receive care in an incubator
(Isolette) or a radiant warmer. In a radiant warmer, a heat-sensitive probe
taped to the neonate’s skin activates the heater unit automatically to maintain
the desired temperature.
o
During labor, the resting phase
between contractions is at least 30 seconds.
o
Lochia rubra is the vaginal
discharge of almost pure blood that occurs during the first few days after
childbirth.
o
Lochia serosa is the serous
vaginal discharge that occurs 4 to 7 days after childbirth.
o
Lochia alba is the vaginal
discharge of decreased blood and increased leukocytes that’s the final stage of
lochia. It occurs 7 to 10 days after childbirth.
o
Colostrum, the precursor of
milk, is the first secretion from the breasts after delivery.
o
The length of the uterus
increases from 2½" (6.3 cm) before pregnancy to 12½" (32 cm) at term.
o
To estimate the true conjugate
(the smallest inlet measurement of the pelvis), deduct 1.5 cm from the diagonal
conjugate (usually 12 cm). A true conjugate of 10.5 cm enables the fetal head
(usually 10 cm) to pass.
o
The smallest outlet measurement
of the pelvis is the intertuberous diameter, which is the transverse diameter
between the ischial tuberosities.
o
Electronic fetal monitoring is
used to assess fetal well-being during labor. If compromised fetal status is
suspected, fetal blood pH may be evaluated by obtaining a scalp sample.
o
In an emergency delivery,
enough pressure should be applied
to the emerging fetus’s head to guide the descent and prevent a rapid change in
pressure within the molded fetal skull.
o
After delivery, a multiparous
woman is more susceptible to bleeding than a primiparous woman because her uterine muscles may be overstretched
and may not contract efficiently.
o
Neonates who are delivered by
cesarean birth have a higher incidence of respiratory distress syndrome.
o
The nurse should suggest
ambulation to a postpartum patient who has gas pain and flatulence.
o
Massaging the uterus helps to
stimulate contractions after the placenta is delivered.
o
When providing phototherapy to
a neonate, the nurse should cover the neonate’s eyes and genital area.
o
The narcotic antagonist
naloxone (Narcan) may be given to a neonate to correct respiratory depression
caused by narcotic administration to the mother during labor.
o
In a neonate, symptoms of
respiratory distress syndrome include expiratory grunting or whining, sandpaper breath sounds, and
seesaw retractions.
o
Cerebral palsy presents as
asymmetrical movement, irritability, and excessive, feeble crying in a long,
thin infant.
o
The nurse should assess a
breech-birth neonate for hydrocephalus, hematomas, fractures, and other
anomalies caused by birth trauma.
o
When a patient is admitted to
the unit in active labor, the nurse’s first action is to listen for fetal heart
tones.
o
In a neonate, long, brittle
fingernails are a sign of postmaturity.
o
Desquamation (skin peeling) is
common in postmature neonates.
o
A mother should allow her
infant to breast-feed until the infant is satisfied. The time may vary from 5 to 20 minutes.
o
Nitrazine paper is used to test
the pH of vaginal discharge to determine the presence of amniotic fluid.
o
A pregnant patient normally
gains 2
to 5 lb (1 to 2.5 kg) during the
first trimester and slightly less than 1 lb (0.5 kg) per week during the last
two trimesters.
o
Neonatal jaundice in the first
24 hours after birth is known as pathological jaundice and is a sign of erythroblastosis
fetalis.
o
A classic difference between
abruptio placentae and placenta previa is the degree of pain. Abruptio
placentae causes pain, whereas placenta previa causes painless bleeding.
o
Because a major role of the
placenta is to function as a fetal lung, any condition that interrupts normal
blood flow to or from the placenta increases fetal partial pressure of arterial
carbon dioxide and decreases fetal pH.
o
Precipitate labor lasts for
approximately 3 hours and ends with delivery of the neonate.
o
Methylergonovine (Methergine)
is an oxytocic agent used to prevent and treat postpartum hemorrhage caused by
uterine atony or subinvolution.
o
As emergency treatment for
excessive uterine bleeding, 0.2 mg of methylergonovine (Methergine) is injected
I.V. over 1 minute while the patient’s blood pressure and uterine contractions
are monitored.
o
Braxton Hicks contractions are
usually felt in the abdomen and
don’t cause cervical change. True labor contractions are felt in the front of
the abdomen and back and lead to progressive cervical dilation and effacement.
o
The average birth weight of
neonates born to mothers who smoke is 6 oz (170 g) less than that of neonates born to
nonsmoking mothers.
o
Culdoscopy is visualization of
the pelvic organs through the posterior vaginal fornix.
o
The nurse should teach a
pregnant vegetarian to obtain protein from alternative sources, such as nuts,
soybeans, and legumes.
o
The nurse should instruct a
pregnant patient to take only prescribed prenatal vitamins because
over-the-counter high-potency vitamins may harm the fetus.
o
High-sodium foods can cause
fluid retention, especially in pregnant patients.
o
A pregnant patient can avoid
constipation and hemorrhoids by adding fiber to her diet.
o
If a fetus has late
decelerations (a sign of fetal hypoxia), the nurse should instruct the mother
to lie on her left side and then administer 8 to 10 L of oxygen per minute by
mask or cannula. The nurse should notify the physician. The side-lying position
removes pressure on the inferior vena cava.
o
Oxytocin (Pitocin) promotes
lactation and uterine contractions.
o
Lanugo covers the fetus’s body
until about 20 weeks’ gestation. Then it begins to disappear from the face,
trunk, arms, and legs, in that order.
o
In a neonate, hypoglycemia
causes temperature instability, hypotonia, jitteriness, and seizures.
Premature, postmature, small-for-gestational-age, and large-for-gestational-age
neonates are susceptible to this disorder.
o
Neonates typically need to
consume 50 to 55 cal per pound of body weight daily.
o
Because oxytocin (Pitocin)
stimulates powerful uterine contractions during labor, it must be administered
under close observation to help prevent maternal and fetal distress.
o
During fetal heart rate
monitoring, variable decelerations indicate compression or prolapse of the
umbilical cord.
o
Cytomegalovirus is the leading
cause of congenital viral infection.
o
Tocolytic therapy is indicated
in premature labor, but contraindicated in fetal death, fetal distress, or
severe hemorrhage.
o
Through ultrasonography, the
biophysical profile assesses fetal well-being by measuring fetal breathing
movements, gross body movements, fetal tone, reactive fetal heart rate
(nonstress test), and qualitative amniotic fluid volume.
o
A neonate whose mother has
diabetes should be assessed for
hyperinsulinism.
o
In a patient with preeclampsia,
epigastric pain is a late symptom and requires immediate medical intervention.
o
After a stillbirth, the mother
should be allowed to hold the neonate to help her come to terms with the death.
o
Molding is the process by which
the fetal head changes shape to facilitate movement through the birth canal.
o
If a woman receives a spinal
block before delivery, the nurse should monitor the patient’s blood pressure
closely.
o
If a woman suddenly becomes hypotensive during
labor, the nurse should increase the infusion rate of I.V. fluids as
prescribed.
o
The best technique for
assessing jaundice in a neonate is to blanch the tip of the nose or the area
just above the umbilicus.
o
During fetal heart monitoring, early
deceleration is caused by compression of the head during labor.
o
After the placenta is
delivered, the nurse may add oxytocin (Pitocin) to the patient’s I.V. solution,
as prescribed, to promote postpartum involution of the uterus and stimulate
lactation.
o
Pica is a craving to eat nonfood
items, such as dirt, crayons, chalk,
glue, starch, or hair. It may occur during pregnancy and can endanger the
fetus.
o
A pregnant patient should take
folic acid because this nutrient is required for rapid cell division.
o
A woman who is taking clomiphene
(Clomid) to induce ovulation should be informed of the possibility of multiple
births with this drug.
o
If needed, cervical suturing is
usually done between 14 and 18 weeks’ gestation to reinforce an incompetent
cervix and maintain pregnancy. The suturing is typically removed by 35 weeks’ gestation.
o
During the first trimester, a
pregnant woman should avoid all drugs unless doing so would adversely affect
her health.
o
Most drugs that a
breast-feeding mother takes appear in breast milk.
o
The Food and Drug Administration
has established the following five categories of drugs based on their potential
for causing birth defects: A, no evidence of risk; B, no risk found in animals,
but no studies have been done in women; C, animal studies have shown an adverse
effect, but the drug may be beneficial to women despite the potential risk; D,
evidence of risk, but its benefits may outweigh its risks; and X, fetal
anomalies noted, and the risks clearly outweigh the potential benefits.
o
A patient with a ruptured
ectopic pregnancy commonly has sharp pain in the lower abdomen, with spotting
and cramping. She may have abdominal rigidity; rapid, shallow respirations;
tachycardia; and shock.
o
A patient with a ruptured
ectopic pregnancy commonly has sharp pain in the lower abdomen, with spotting and cramping. She may have abdominal
rigidity; rapid, shallow respirations; tachycardia; and shock.
o
The mechanics of delivery are
engagement, descent and flexion, internal rotation, extension, external
rotation, restitution, and expulsion.
o
A probable sign of pregnancy,
McDonald’s sign is characterized by an ease in flexing the body of the uterus
against the cervix.
o
Amenorrhea is a probable sign
of pregnancy.
o
A pregnant woman’s partner
should avoid introducing air into the vagina during oral sex because of the possibility of air
embolism.
o
The presence of human chorionic
gonadotropin in the blood or urine is a probable sign of pregnancy.
o
Radiography isn’t usually used
in a pregnant woman because it may harm the developing fetus. If radiography is
essential, it should be performed only after 36 weeks’ gestation.
o
A pregnant patient who has had
rupture of the membranes or who is experiencing vaginal bleeding shouldn’t
engage in sexual intercourse.
o
Milia may occur as pinpoint
spots over a neonate’s nose.
o
The duration of a contraction
is timed from the moment that the uterine muscle begins to tense to the moment
that it reaches full relaxation. It’s measured in seconds.
o
The union of a male and a
female gamete produces a zygote, which divides into the fertilized ovum.
o
The first menstrual flow is
called menarche and may be anovulatory (infertile).
o
Spermatozoa (or their
fragments) remain in the vagina for 72 hours after sexual intercourse.
o
Prolactin stimulates and
sustains milk production.
o
Strabismus is a normal finding
in a neonate.
o
A postpartum patient may resume
sexual intercourse after the perineal or uterine wounds heal (usually within 4
weeks after delivery).
o
A pregnant staff member
shouldn’t be assigned to work with a patient who has cytomegalovirus infection
because the virus can be transmitted to the fetus.
o
Fetal demise is death of the
fetus after viability.
o
Respiratory distress syndrome
develops in premature neonates because their alveoli lack surfactant.
o
The most common method of
inducing labor after artificial rupture of the membranes is oxytocin (Pitocin)
infusion.
o
After the amniotic membranes
rupture, the initial nursing action is to assess the fetal heart rate.
o
The most common reasons for
cesarean birth are malpresentation, fetal distress, cephalopelvic
disproportion, pregnancy-induced hypertension, previous cesarean birth, and
inadequate progress in labor.
o
Amniocentesis increases the
risk of spontaneous abortion, trauma to the fetus or placenta, premature labor,
infection, and Rh sensitization of the fetus.
o
After amniocentesis, abdominal
cramping or spontaneous vaginal bleeding may indicate complications.
o
To prevent her from developing
Rh antibodies, an Rh-negative primigravida should receive Rho (D)
immune globulin (RhoGAM) after delivering an Rh-positive neonate.
o
If a pregnant patient’s test
results are negative for glucose but positive for acetone, the nurse should
assess the patient’s diet for inadequate caloric intake.
o
If a pregnant patient’s test
results are negative for glucose but positive for acetone, the nurse should
assess the patient’s diet for inadequate caloric intake.
o
Rubella infection in a pregnant
patient, especially during the first trimester, can lead to spontaneous
abortion or stillbirth as well as fetal cardiac and other birth defects.
o
A pregnant patient should take
an iron supplement to help prevent anemia.
o
Direct antiglobulin (direct
Coombs’) test is used to detect maternal antibodies attached to red blood cells
in the neonate.
o
Nausea and vomiting during the
first trimester of pregnancy are caused by rising levels of the hormone human
chorionic gonadotropin.
o
Before discharging a patient
who has had an abortion, the nurse should instruct her to report bright red
clots, bleeding that lasts longer than 7 days, or signs of infection, such as a
temperature of greater than 100° F (37.8° C), foul-smelling vaginal discharge,
severe uterine cramping, nausea, or vomiting.
o
When informed that a patient’s
amniotic membrane has broken, the nurse should check fetal heart tones and then
maternal vital signs.
o
The duration of pregnancy
averages 280 days, 40 weeks, 9 calendarmonths, or 10 lunar months.
o
The initial weight loss for a
healthy neonate is 5% to 10% of birth weight.
o
The normal hemoglobin value in
neonates is 17 to 20 g/dl.
o
Crowning is the appearance of
the fetus’s head when its largest diameter is encircled by the vulvovaginal
ring.
o
A multipara is a woman who has
had two or more pregnancies that progressed to viability, regardless of whether
the offspring were alive at birth.
o
In a pregnant patient,
preeclampsia may progress to eclampsia, which is characterized by seizures and
may lead to coma.
o
The Apgar score is used to assess the neonate’s vital
functions. It’s obtained at 1 minute and 5 minutes after delivery. The score is
based on respiratory effort, heart rate, muscle tone, reflex irritability, and
color.
o
Because of the anti-insulin
effects of placental hormones, insulin requirements increase during the third
trimester.
o
Gestational age can be
estimated by ultrasound
measurement of maternal abdominal circumference, fetal femur length, and fetal
head size. These measurements are most accurate between 12 and 18 weeks’
gestation.
o
Skeletal system abnormalities
and ventricular septal defects are the most common disorders of infants who are
born to diabetic women. The incidence of congenital malformation is three times
higher in these infants than in those born to nondiabetic women.
o
Skeletal system abnormalities
and ventricular septal defects are the most common disorders of infants who are
born to diabetic women. The incidence of congenital malformation is three times
higher in these infants than in those born to nondiabetic women.
o
The patient with preeclampsia
usually has puffiness around the eyes or edema in the hands (for example, “I
can’t put my wedding ring on.”).
o
Kegel exercises require
contraction and relaxation of the perineal muscles. These exercises help
strengthen pelvic muscles and improve urine control in postpartum patients.
o
Symptoms of postpartum depression range from mild
postpartum blues to intense, suicidal, depressive psychosis.
o
The preterm neonate may require
gavage feedings because of a weak sucking reflex, uncoordinated sucking, or
respiratory distress.
o
Acrocyanosis (blueness and
coolness of the arms and legs) is normal in neonates because of their immature
peripheral circulatory system.
o
To prevent ophthalmia
neonatorum (a severe eye infection caused by maternal gonorrhea), the nurse may
administer one of three drugs, as prescribed, in the neonate’s eyes:
tetracycline, silver nitrate, or erythromycin.
o
Neonatal testing for
phenylketonuria is mandatory in most states.
o
The nurse should place the
neonate in a 30-degree Trendelenburg position to facilitate mucus drainage.
o
The nurse may suction the
neonate’s nose and mouth as needed with a bulb syringe or suction trap.
o
To prevent heat loss, the nurse
should place the neonate under a radiant warmer during suctioning and initial
delivery-room care, and then wrap the neonate in a warmed blanket for transport
to the nursery.
o
The umbilical cord normally has
two arteries and one vein.
o
When providing care, the nurse
should expose only one part of an infant’s body at a time.
o
Lightening is settling of the
fetal head into the brim of the pelvis.
o
If the neonate is stable, the
mother should be allowed to breast-feed within the neonate’s first hour of
life.
o
The nurse should check the
neonate’s temperature every 1 to 2 hours until it’s maintained within normal
limits.
o
At birth, a neonate normally
weighs 5 to 9 lb (2 to 4 kg), measures 18" to 22" (45.5 to 56 cm) in
length, has a head circumference
of 13½" to 14" (34 to 35.5 cm), and has a chest circumference that’s
1" (2.5 cm) less than the head circumference.
o
In the neonate, temperature
normally ranges from 98° to 99° F (36.7° to 37.2° C), apical pulse rate
averages 120 to 160 beats/minute, and respirations are 40 to 60 breaths/minute.
o
The diamond-shaped anterior
fontanel usually closes between ages 12 and 18 months. The triangular posterior
fontanel usually closes by age 2 months.
o
In the neonate, a straight
spine is normal. A tuft of hair
over the spine is an abnormal finding.
o
Prostaglandin gel may be
applied to the vagina or cervix to ripen an unfavorable cervix before labor induction
with oxytocin (Pitocin).
o
Supernumerary nipples are
occasionally seen on neonates. Theyusually appear along a line that runs from
each axilla, through the normal nipple area, and to the groin.
o
Meconium is a material that
collects in the fetus’s intestines and forms the neonate’s first feces, which
are black and tarry.
o
The presence of meconium in the
amniotic fluid during labor indicates possible fetal distress and the need to
evaluate the neonate for meconium aspiration.
o
To assess a neonate’s rooting
reflex, the nurse touches a finger to the cheek or the corner of the mouth. Normally, the neonate turns
his head toward the stimulus, opens his mouth, and searches for the stimulus.
o
Harlequin sign is present when
a neonate who is lying on his side appears red on the dependent side and pale
on the upper side.
o
Mongolian spots can range from
brown to blue. Their color depends on how close melanocytes are to the surface
of the skin. They most commonly appear as patches across the sacrum, buttocks,
and legs.
o
Mongolian spots are common in
non-white infants and usuallydisappear by age 2 to 3 years.
o
Vernix caseosa is a cheeselike
substance that covers and protects the fetus’s skin in utero. It may be rubbed
into the neonate’s skin or washed away in one or two baths.
o
Caput succedaneum is edema that
develops in and under the fetal scalp during labor and delivery. It resolves
spontaneously and presents no danger to the neonate. The edema doesn’t cross
the suture line.
o
Nevus flammeus, or port-wine
stain, is a diffuse pink to dark bluish red lesion on a neonate’s face or neck.
o
The Guthrie test (a screening
test for phenylketonuria) is most reliable if it’s done between the second and
sixth days after birth and is performed after the neonate has ingested protein.
o
To assess coordination of
sucking and swallowing, the nurse should observe the neonate’s first
breast-feeding or sterile water bottle-feeding.
o
To establish a milk supply
pattern, the mother should breast-feed her infant at least every 4 hours.
During the first month, she should breast-feed 8 to 12 times daily (demand
feeding).
o
To avoid contact with blood and
other body fluids, the nurse should wear gloves when handling the neonate until
after the first bath is given.
o
If a breast-fed infant is
content, has good skin turgor, an adequate number of wet diapers, and normal
weight gain, the mother’s milk supply is assumed to be adequate.
o
In the supine position, a
pregnant patient’s enlarged uterus impairs venous return from the lower half of the body to the
heart, resulting in supine hypotensive syndrome, or inferior vena cava
syndrome.
o
Tocolytic agents used to treat
preterm labor include terbutaline (Brethine), ritodrine (Yutopar), and
magnesium sulfate.
o
A pregnant woman who has
hyperemesis gravidarum may require hospitalization to treat dehydration and
starvation.
o
Diaphragmatic hernia is one of
the most urgent neonatal surgical emergencies. By compressing and displacing
the lungs and heart, this disorder can cause respiratory distress shortly after
birth.
o
Common complications of early
pregnancy (up to 20 weeks’ gestation) include fetal loss and serious threats to
maternal health.
o
Fetal embodiment is a maternal
developmental task that occurs in the second trimester. During this stage, the
mother may complain that she never gets to sleep because the fetus always gives
her a thump when she tries.
o
Visualization in pregnancy is a
process in which the mother imagines what the child she’s carrying is like and
becomes acquainted with it.
o
Hemodilution of pregnancy is
the increase in blood volume that occurs during pregnancy. The increased volume
consists of plasma and causes an imbalance between the ratio of red blood cells
to plasma and a resultant decrease in hematocrit.
o
Mean arterial pressure of
greater than 100 mm Hg after 20 weeks of pregnancy is considered hypertension.
o
The treatment for supine
hypotension syndrome (a condition that sometimes occurs in pregnancy) is to
have the patient lie on her left side.
o
A contributing factor in
dependent edema in the pregnant patient is the increase of femoral venous
pressure from 10 mm Hg (normal) to 18 mm Hg (high).
o
Hyperpigmentation of the
pregnant patient’s face, formerly called chloasma and now referred to as melasma, fades after delivery.
o
The hormone relaxin, which is
secreted first by the corpus luteum and later by the placenta, relaxes the
connective tissue and cartilage of the symphysis pubis and the sacroiliac joint
to facilitate passage of the fetus during delivery.
o
Progesterone maintains the
integrity of the pregnancy by inhibiting uterine motility.
o
Ladin’s sign, an early
indication of pregnancy, causes softening of a spot on the anterior portion of
the uterus, just above the uterocervical juncture.
o
During pregnancy, the abdominal
line from the symphysis pubis to the umbilicus changes from linea alba to linea
nigra.
o
In neonates, cold stress
affects the circulatory, regulatory, and respiratory systems.
o
Obstetric data can be described
by using the F/TPAL system:
o
F/T: Full-term delivery at 38
weeks or longer
o
P: Preterm delivery between 20
and 37 weeks
o
A: Abortion or loss of fetus
before 20 weeks
o
L: Number of children living
(if a child has died, further explanation is needed to clarify the discrepancy
in numbers).
o
Parity doesn’t refer to the
number of infants delivered, only the number of deliveries.
o
Women who are carrying more
than one fetus should be encouraged to gain 35 to 45 lb (15.5 to 20.5 kg)
during pregnancy.
o
The recommended amount of iron
supplement for the pregnant patient is 30 to 60 mg daily.
o
Drinking six alcoholic
beverages a day or a single episode of binge drinking in the first trimester
can cause fetal alcohol syndrome.
o
Chorionic villus sampling is
performed at 8 to 12 weeks of pregnancyfor early identification of genetic
defects.
o
In percutaneous umbilical blood
sampling, a blood sample is obtained from the umbilical cord to detect anemia,
genetic defects, and blood incompatibility as well as to assess the need for
blood transfusions.
o
The period between contractions
is referred to as the interval, or resting phase. During this phase, the uterus
and placenta fill with blood and allow for the exchange of oxygen, carbon
dioxide, and nutrients.
o
In a patient who has hypertonic
contractions, the uterus doesn’t have an opportunity to relax and there is no
interval between contractions. As a result, the fetus may experience hypoxia or
rapid delivery may occur.
o
Two qualities of the myometrium
are elasticity, which allows it
to stretch yet maintain its tone, and contractility, which allows it to shorten
and lengthen in a synchronized pattern.
o
During crowning, the presenting
part of the fetus remains visible during the interval between contractions.
o
Uterine atony is failure of the
uterus to remain firmly contracted.
o
The major cause of uterine
atony is a full bladder.
o
If the mother wishes to
breast-feed, the neonate should be nursed as soon as possible after delivery.
o
A smacking sound, milk dripping from the side of the
mouth, and sucking noises all indicate improper placement of the infant’s mouth
over the nipple.
o
Before feeding is initiated, an
infant should be burped to expel air from the stomach.
o
Most authorities strongly
encourage the continuation of breast-feeding on both the affected and the
unaffected breast of patients with mastitis.
o
Neonates are nearsighted and
focus on items that are held 10" to 12" (25 to 30.5 cm) away.
o
In a neonate, low-set ears are
associated with chromosomal abnormalities such as Down syndrome.
o
Meconium is usually passed in
the first 24 hours; however, passage may take up to 72 hours.
o
Boys who are born with hypospadias
shouldn’t be circumcised at birth because the foreskin may be needed for constructive surgery.
o
In the neonate, the normal
blood glucose level is 45 to 90 mg/dl.
o
Hepatitis B vaccine is usually
given within 48 hours of birth.
o
Hepatitis B immune globulin is
usually given within 12 hours of birth.
o
HELLP (hemolysis, elevated
liver enzymes, and low platelets) syndrome is an unusual variation of
pregnancy-induced hypertension.
o
Maternal serum
alpha-fetoprotein is detectable at 7 weeks of gestation and peaks in the third
trimester. High levels detected between the 16th and 18th weeks are associated
with neural tube defects. Low levels are associated with Down syndrome.
o
An arrest of descent occurs
when the fetus doesn’t descend through the pelvic cavity during labor. It’s
commonly associated with cephalopelvic disproportion, and cesarean delivery may
be required.
o
A late sign of preeclampsia is
epigastric pain as a result of severe liver edema.
o
In the patient with
preeclampsia, blood pressure returns to normal during the puerperal period.
o
To obtain an estriol level, urine is
collected for 24 hours.
o
An estriol level is used to
assess fetal well-being and maternal renal functioning as well as to monitor a
pregnancy that’s complicated by diabetes.
o
A pregnant patient with vaginal
bleeding shouldn’t have a pelvic examination.
o
In the early stages of
pregnancy, the finding of glucose in the urine may be related to the increased
shunting of glucose to the developing placenta, without a corresponding
increase in the reabsorption capability of the
kidneys.
o
A patient who has premature
rupture of the membranes is at significant risk for infection if labor doesn’t
begin within 24 hours.
o
Infants of diabetic mothers are
susceptible to macrosomia as a result of increased insulin production in the
fetus.
o
To prevent heat loss in the
neonate, the nurse should bathe one part of his body at a time and keep the
rest of the body covered.
o
A patient who has a cesarean
delivery is at greater risk for infection than the patient who gives birth
vaginally.
o
The occurrence of thrush in the
neonate is probably caused by contact with the organism during delivery through
the birth canal.
o
The nurse should keep the sac
of meningomyelocele moist with normal saline solution.
o
If fundal height is at least 2
cm less than expected, the cause may be growth retardation, missed abortion,
transverse lie, or false pregnancy.
o
Fundal height that exceeds
expectations by more than 2 cm may be caused by multiple gestation,
polyhydramnios, uterine myomata, or a large baby.
o
A major developmental task for
a woman during the first trimester of pregnancy is accepting the pregnancy.
o
Unlike formula, breast milk
offers the benefit of maternal antibodies.
o
Spontaneous rupture of the
membranes increases the risk of a prolapsed umbilical cord.
o
A clinical manifestation of a
prolapsed umbilical cord is variable decelerations.
o
During labor, to relieve supine
hypotension manifested by nausea and vomiting and paleness, turn the patient on her left side.
o
If the ovum is fertilized by a
spermatozoon carrying a Y chromosome, a male zygote is formed.
o
Implantation occurs when the
cellular walls of the blastocyte implants itself in the endometrium, usually 7
to 9 days after fertilization.
o
Implantation occurs when the
cellular walls of the blastocyte implants itself in the endometrium, usually 7
to 9 days after fertilization.
o
Heart development in the embryo
begins at 2 to 4 weeks and is complete by the end of the embryonic stage.
o
Methergine stimulates uterine
contractions.
o
The administration of folic
acid during the early stages of gestation may prevent neural tube defects.
o
With advanced maternal age, a
common genetic problem is Down syndrome.
o
With early maternal age,
cephalopelvic disproportion commonly occurs.
o
In the early postpartum period,
the fundus should be midline at the umbilicus.
o
A rubella vaccine shouldn’t be
given to a pregnant woman. The vaccine can be administered after delivery, but
the patient should be instructed to avoid becoming pregnant for 3 months.
o
A 16-year-old girl who is pregnant
is at risk for having a low-birth-weight neonate.
o
The mother’s Rh factor should
be determined before an amniocentesis is performed.
o
Maternal hypotension is a
complication of spinal block.
o
After delivery, if the fundus
is boggy and deviated to the right side, the patient should empty her bladder.
o
Before providing a specimen for
a sperm count, the patient should avoid ejaculation for 48 to 72 hours.
o
The hormone human chorionic
gonadotropin is a marker for pregnancy.
o
Painless vaginal bleeding
during the last trimester of pregnancy may indicate placenta previa.
o
During the transition phase of
labor, the woman usually is irritable and restless.
o
Because women with diabetes
have a higher incidence of birth anomalies than women without diabetes, an
alpha-fetoprotein level may be ordered at 15 to 17 weeks’ gestation.
o
To avoid puncturing the
placenta, a vaginal examination shouldn’t
be performed on a pregnant patient who is bleeding.
o
A patient who has postpartum
hemorrhage caused by uterine atony should be given oxytocin as prescribed.
o
Laceration of the vagina,
cervix, or perineum produces bright red bleeding that often comes in spurts.
The bleeding is continuous, even when the fundus is firm.
o
Hot compresses can help to
relieve breast tenderness after breast-feeding.
o
The fundus of a postpartum
patient is massaged to stimulate contraction of the uterus and prevent
hemorrhage.
o
A mother who has a positive
human immunodeficiency virus test result shouldn’t breast-feed her infant.
o
Dinoprostone (Cervidil) is used
to ripen the cervix.
o
Breast-feeding of a premature
neonate born at 32 weeks’ gestation can be accomplished if the mother expresses
milk and feeds the neonate by gavage.
o
If a pregnant patient’s rubella
titer is less than 1:8, she should be immunized after delivery.
o
The administration of oxytocin
(Pitocin) is stopped if the contractions are 90 seconds or longer.
o
For an extramural delivery (one
that takes place outside of a normal delivery center), the priorities for care
of the neonate include maintaining a patent airway,
supporting efforts to breathe, monitoring vital signs, and maintaining adequate
body temperature.
o
Subinvolution may occur if the
bladder is distended after delivery.
o
The nurse must place
identification bands on both the mother and the neonate before they leave the
delivery room.
o
Erythromycin is given at birth
to prevent ophthalmia neonatorum.
o
Pelvic-tilt exercises can help
to prevent or relieve backache during pregnancy.
PEDIATRICS BULLET
o
A child with
HIV-positive blood should receive inactivated poliovirus vaccine (IPV) rather
than oral poliovirus vaccine (OPV) immunization.
o
To achieve postural
drainage in an infant, place a pillow on the nurse’s lap and lay the infant
across it.
o
A child with cystic fibrosis should
eat more calories, protein, vitamins, and minerals than a child without the
disease.
o
Infants subsisting on
cow’s milk only don’t receive a sufficient amount of iron (ferrous sulfate),
which will eventually result in iron deficiency anemia.
o
A child with an
undiagnosed infection should be placed in isolation.
o
An infant usually
triples his birth weight by the end of his first year.
o
Clinical signs of a
dehydrated infant include lethargy, irritability, dry skin decreased tearing,
decreased urinary output, and increased pulse.
o
Appropriate care of a
child with meningitis includes frequent assessment of neurologic signs (such as
decreasing levels of consciousness, difficulty to arouse) and measuring the
circumference of the head because subdural effusions and obstructive
hydrocephalus can develop.
o
Expected clinical
findings in a newborn with cerebral palsy include
reflexive hypertonicity and criss-crossing or scissoring leg movements.
o
Papules, vesicles, and
crust are all present at
the same time in the early phase of chickenpox.
o
Topical corticosteroids
shouldn’t be used on chickenpox lesions.
o
A serving size of a food
is usually 1 tablespoon for each year of age.
o
The characteristic of
fifth disease (erythema infectiosum) is erythema on the face, primarily the
cheeks, giving a “slapped face” appearance.
o
Adolescents may brave
pain, especially in front of peers. Therefore, offer analgesics if pain is
suspected or administer the medication if the client asks for it.
o
Signs that a child with
cystic fibrosis is responding to pancreatic enzymes are the absence of
steatorrhea, improved appetite, and absence of abdominal pain.
o
Roseola appears as
discrete rose-pink macules that first appear on the trunk and that fade when
pressure is applied.
o
A ninety degree-ninety
degree traction is used for fracture of a child’s femur or tibia.
o
One sign of
developmental dysplasia is limping during ambulation.
o
Circumcision wouldn’t be
performed on a male child with hypospadias because the foreskin may be needed
during surgical reconstruction.
o
Neonatal abstinence
syndrome is manifested in central nervous system hyperirritability (for
example, hyperactive Moro reflex) and gastrointestinal symptoms (watery
stools).
o
Classic signs of shaken
baby syndrome are seizures, slow apical pulse difficulty breathing, and retinal
hemorrhage.
o
An infant born to an
HIV-positive mother will usually receive AZT (zidovudine) for the first 6 weeks
of life.
o
Infants born to an
HIV-positive mother should receive all immunizations of schedule.
o
Blood pressure in the
arms and legs is essentially the same in infants.
o
When bottle-feeding a
newborn with a cleft palate, hold the infant’s head in an upright position.
o
Because of circulating
maternal antibodies that will decrease the immune response, the measles, mumps,
and rubella (MMR) vaccine shouldn’t be given until the infant has reached 1
year of age.
o
Before feeding an infant
any fluid that has been warmed, test a drop of the liquid on your own skin to
prevent burning the infant.
o
A newborn typically wets
6 to 10 diapers per day.
o
Although microwaving
food and fluids isn’t recommend for infants, it’s commonplace in the United States . Therefore the family should be toughs to test the
temperature of the food or fluid against their own skin before allowing it to
be consumed by the infant.
o
The most adequate diet
for an infant in the first 6 months of life is breast milk.
o
An infant can usually
chew food by 7 months, hold spoon by 9 month, and drink fluid from a cup by 1
year of age.
o
Choking from mechanical
obstruction is the leading cause of death (by suffocation) for infants younger
than 1 year of age.
o
Failure to thrive is a
term used to describe an infant who falls below the fifth percentile for weight
and height on a standard measurement chart.
o
Developmental theories
include Havighurst’s age periods and developmental tasks; Freud’s five stages
of development; Kohlberg’s stages of moral development; Erikson’s eight stages
of development; and Piaget’s phases of cognitive development.
o
The primary concern with
infusing large volumes of fluid is circulatory overload. This is especially
true in children and infants, and in clients with renal disease.
o
Certain hazards present increased risk of harm to children and
occur more often at different ages. For infants, more falls, burns, and
suffocation occur; for toddlers, there are more burns, poisoning, and drowning
for preschoolers, more playground equipment accidents, choking, poisoning, and
drowning; and for adolescents, more automobile accidents,
drowning, fires, and firearm accidents.
o
A child in Bryant’s
traction who’s younger than age 3 or weighs less than 30 lb (13.6 kg) should
have the buttocks slightly elevated and clear or the bed. The knees should be
slightly flexed, and the legs should be extended at a right angle to the body.
The body provides the traction mechanism.
o
In an infant, a bulging
fontanel is the most significant sign of increasing intracranial pressure.
PSYCHIATRICS BULLET
o
According to Kübler-Ross, the five stages of death and dying are denial, anger,
bargaining, depression, and acceptance.
o
Flight of ideas is an alteration in thought
processes that’s characterized by skipping from one topic to another, unrelated
topic.
o
La belle indifférence is the lack of concern for a
profound disability, such as blindness or paralysis that may occur in a patient
who has a conversion disorder.
o
Moderate anxiety decreases a
person’s ability to perceive and concentrate. The person is selectively inattentive (focuses
on immediate concerns), and the perceptual field narrows.
o
A patient who has a phobic
disorder uses self-protective
avoidance as an ego defense mechanism.
o
In a patient who has anorexia nervosa, the highest treatment priority is
correction of nutritional and electrolyte imbalances.
o
A patient who is taking lithium must undergo
regular (usually once a month) monitoring of the blood lithium level because
the margin between therapeutic and toxic levels is narrow. A normal laboratory
value is 0.5 to 1.5 mEq/L.
o
Early signs and symptoms of alcohol withdrawal include anxiety, anorexia,
tremors, and insomnia. They may begin up to 8 hours after the last alcohol
intake.
o
Al-Anon is a support group for
families of alcoholics.
o
The nurse shouldn’t administer chlorpromazine
(Thorazine) to a patient who has ingested alcohol because it may cause
oversedation and respiratory depression.
o
Lithium toxicity can occur when sodium and fluid
intake are insufficient, causing lithium retention.
o
An alcoholic who achieves
sobriety is called a recovering alcoholic because no cure for alcoholism
exists.
o
According to Erikson, the school-age child (ages 6
to 12) is in the industry-versus-inferiority
stage of psychosocial development.
o
When caring for a depressed
patient, the nurse’s first priority
is safety because of the increased risk of suicide.
o
Echolalia is parrotlike repetition of another person’s
words or phrases.
o
According to psychoanalytic theory, the ego is the part of the
psyche that controls internal demands and interacts with the outside world at
the conscious,
preconscious, and unconscious levels.
o
According to psychoanalytic theory, the superego is the part of
the psyche that’s composed of morals, values, and ethics. It continually
evaluates thoughts and actions, rewarding the good and punishing the bad.
(Think of the superego as the “supercop” of the
unconscious.)
o
According to psychoanalytic theory, the id is the part of the
psyche that contains instinctual
drives. (Remember i for instinctual and d for drive.)
o
Denial is the defense mechanism used
by a patient who denies the reality of an event.
o
In a psychiatric setting, seclusion is used to
reduce overwhelming environmental stimulation, protect the patient from
self-injury or injury to others, and prevent damage to hospital property. It’s
used for patients who don’t respond to less restrictive interventions.
Seclusion controls external behavior until the patient can assume self-control
and helps the patient to regain self-control.
o
Tyramine-rich food, such as aged cheese, chicken
liver, avocados, bananas, meat tenderizer, salami,
bologna, Chianti wine, and beer may cause severe hypertension in a patient who
takes a monoamine oxidase inhibitor.
o
A patient who takes a monoamine oxidase inhibitor
should be weighed biweekly
and monitored for suicidal tendencies.
o
If the patient who takes a monoamine oxidase inhibitor
has palpitations,
headaches, or severe orthostatic hypotension, the nurse should withhold the drug and
notify the physician.
o
Common causes of child abuse
are poor impulse control by the parents and the lack of knowledge of growth and
development.
o
The diagnosis of Alzheimer’s disease is
based on clinical findings of two or more cognitive deficits, progressive worsening of memory,
and the results of a neuropsychological test.
o
Memory disturbance is a classic sign of Alzheimer’s disease.
o
Thought blocking is loss of the train of
thought because of a defect in mental processing.
o
A compulsion is an irresistible urge to perform an irrational act,
such as walking in a clockwise circle before leaving a room or washing the
hands repeatedly.
o
A patient who has a chosen
method and a plan to commit suicide in the next 48 to 72 hours is at high risk for suicide.
o
The therapeutic serum level for
lithium is 0.5 to 1.5
mEq/L.
o
Phobic disorders are treated with desensitization therapy,
which gradually exposes a patient to an anxiety-producing stimulus.
o
Dysfunctional grieving is absent or prolonged grief.
o
During phase I of the nurse-patient relationship
(beginning, or orientation, phase), the nurse obtains an initial history and the nurse
and the patient agree to a contract.
o
During phase II of the nurse-patient
relationship (middle, or working, phase), the patient discusses his problems, behavioral changes
occur, and self-defeating behavior is resolved or reduced.
o
During phase III of the nurse-patient relationship
(termination, or resolution, phase), the nurse terminates the therapeutic relationship and gives
the patient positive feedback on his accomplishments.
o
According to Freud, a person between ages 12 and 20 is in the genital stage, during
which he learns independence, has an increased interest in members of the
opposite sex, and establishes an identity.
o
According to Erikson, the identity-versus-role confusion stage occurs
between ages 12 and 20.
o
Tolerance is the need for increasing
amounts of a substance to achieve an effect that formerly was achieved with
lesser amounts.
o
Suicide is the third leading cause of
death among white teenagers.
o
Most teenagers who kill themselves made a previous
suicide attempt and left telltale signs of their plans.
o
In Erikson’s stage of generativity versus despair,
generativity (investment of the self in the interest of the larger community)
is expressed through procreation, work, community service, and creative
endeavors.
o
Alcoholics Anonymous recommends a 12-step program to achieve
sobriety.
o
Signs and symptoms of anorexia nervosa include amenorrhea, excessive weight loss, lanugo (fine body hair),
abdominal distention, and electrolyte disturbances.
o
A serum lithium level that
exceeds 2.0 mEq/L is considered toxic.
o
Public Law 94-247 (Child Abuse and Neglect Act of
1973) requires reporting of suspected cases of child abuse to child protection
services.
o
The nurse should suspect sexual abuse in a young
child who has blood in the feces or urine, penile or vaginal discharge, genital trauma that
isn’t readily explained, or a sexually transmitted disease.
o
An alcoholic uses alcohol to cope with the stresses of life.
o
The human personality operates on three levels:
conscious, preconscious,
and unconscious.
o
Asking a patient an open-ended
question is one of the best ways to elicit or clarify information.
o
The diagnosis of autism is often made when a
child is between ages 2 and 3.
o
Defense mechanisms protect the personality by
reducing stress and anxiety.
o
Suppression is voluntary exclusion of stress-producing
thoughts from the consciousness.
o
In psychodrama, life situations are
approximated in a structured environment, allowing the participant to recreate
and enact scenes to gain insight and to practice new skills.
o
Psychodrama is a therapeutic technique that’s
used with groups to
help participants gain new perception and self-awareness by acting out their
own or assigned problems.
o
A patient who is taking disulfiram (Antabuse)
must avoid ingesting products that contain alcohol, such as cough syrup, fruitcake,
and sauces and soups made with cooking wine.
o
A patient who is admitted to a
psychiatric hospital involuntarily loses the right
to sign out against medical advice.
o
“People who live in glass
houses shouldn’t throw stones” and “A rolling stone gathers no moss” are
examples of proverbs
used during a psychiatric interview to determine a patient’s ability to think
abstractly. (Schizophrenic patients think in concrete terms and might interpret
the glass house proverb as “If you throw a stone in a glass house, the house
will break.”)
o
Signs of lithium toxicity include
diarrhea, tremors, nausea, muscle weakness, ataxia, and confusion.
o
A labile affect is characterized by rapid shifts of
emotions and mood.
o
Amnesia is loss of memory from an
organic or inorganic cause.
o
A person who has borderline personality
disorder is demanding and judgmental in interpersonal relationships and will attempt to split staff by
pointing to discrepancies in the treatment plan.
o
Disulfiram (Antabuse) shouldn’t be taken
concurrently with metronidazole
(Flagyl) because they may interact and cause a psychotic reaction.
o
In rare cases,
electroconvulsive therapy causes arrhythmias and death.
o
A patient who is scheduled for
electroconvulsive therapy should receive nothing by mouth after midnight to prevent aspiration while
under anesthesia.
o
Electroconvulsive therapy is
normally used for patients who
have severe depression
that doesn’t respond to drug therapy.
o
For electroconvulsive therapy
to be effective, the patient usually receives 6 to 12 treatments at a rate of 2 to 3 per week.
o
During the manic phase of
bipolar affective disorder, nursing care is directed at slowing the patient
down because the patient may die as a result of self-induced exhaustion or
injury.
o
For a patient with Alzheimer’s disease, the
nursing care plan should focus on safety measures.
o
After sexual assault, the
patient’s needs are the primary concern, followed by medicolegal considerations.
o
Patients who are in a
maintenance program for narcotic
abstinence syndrome receive 10 to 40 mg of methadone (Dolophine) in a single daily dose and
are monitored to ensure that the drug is ingested.
o
Stress management is a short-range goal of
psychotherapy.
o
The mood most often experienced
by a patient with organic brain syndrome is irritability.
o
Creative intuition is controlled by the right side of the brain.
o
Methohexital (Brevital) is the general anesthetic
that’s administered to patients who are scheduled for electroconvulsive
therapy.
o
The decision to use restraints
should be based on the patient’s safety needs.
o
Diphenhydramine (Benadryl) relieves
the extrapyramidal adverse effects of psychotropic drugs.
o
In a patient who is stabilized
on lithium (Eskalith)
therapy, blood lithium levels should be checked 8 to 12 hours after the
first dose, then two or three times weekly during the first month. Levels
should be checked weekly to monthly during maintenance therapy.
o
The primary purpose of psychotropic drugs
is to decrease the patient’s symptoms, which improves function and increases
compliance with therapy.
o
Manipulation is a maladaptive method of
meeting one’s needs because it disregards the needs and feelings of others.
o
If a patient has symptoms of lithium toxicity, the
nurse should withhold one
dose and call the physician.
o
A patient who is taking lithium (Eskalith) for
bipolar affective disorder must maintain a balanced diet with adequate salt
intake.
o
A patient who constantly seeks approval
or assistance from staff members and other patients is demonstrating dependent behavior.
o
Alcoholics Anonymous advocates total abstinence
from alcohol.
o
Methylphenidate (Ritalin) is the drug of choice for
treating attention deficit hyperactivity disorder in children.
o
Setting limits is the most
effective way to control manipulative behavior.
o
Violent outbursts are common in a patient who
has borderline personality disorder.
o
When working with a depressed
patient, the nurse should explore meaningful losses.
o
An illusion is a misinterpretation of an actual
environmental stimulus.
o
Anxiety is nonspecific; fear is
specific.
o
Extrapyramidal adverse effects are
common in patients who take antipsychotic drugs.
o
The nurse should encourage an
angry patient to follow a physical exercise program as one of the ways to
ventilate feelings.
o
Depression is clinically significant if
it’s characterized by exaggerated feelings of sadness, melancholy, dejection,
worthlessness, and hopelessness that are inappropriate or out of proportion to
reality.
o
Free-floating anxiety is anxiousness with
generalized apprehension and pessimism for unknown reasons.
o
In a patient who is
experiencing intense anxiety, the fight-or-flight reaction (alarm reflex) may
take over.
o
Confabulation is the use of imaginary
experiences or made-up information to fill missing gaps of memory.
o
When starting a therapeutic
relationship with a patient, the nurse should explain that the purpose of the
therapy is to produce a positive change.
o
A basic assumption of psychoanalytic theory is that
all behavior has meaning.
o
Catharsis is the expression of deep
feelings and emotions.
o
According to the pleasure
principle, the psyche seeks pleasure and avoids unpleasant experiences,
regardless of the consequences.
o
A patient who has a conversion
disorder resolves a psychological conflict through the loss of a specific
physical function (for example, paralysis, blindness, or inability to swallow).
This loss of function is involuntary, but diagnostic tests show no organic
cause.
o
Chlordiazepoxide (Librium) is the
drug of choice for treating alcohol withdrawal symptoms.
o
For a patient who is at risk
for alcohol withdrawal, the nurse should assess the pulse rate and blood
pressure every 2 hours for the first 12 hours, every 4 hours for the next 24
hours, and every 6 hours thereafter (unless the patient’s condition becomes
unstable).
o
Alcohol detoxification is most successful when
carried out in a structured environment by a supportive, nonjudgmental staff.
o
The nurse should follow these
guidelines when caring for a patient who
is experiencing alcohol withdrawal: Maintain a calm environment, keep
intrusions to a minimum, speak slowly and calmly, adjust lighting to prevent
shadows and glare, call the patient by name, and have a friend or family member
stay with the patient, if possible.
o
The therapeutic regimen for an alcoholic
patient includes folic acid, thiamine, and multivitamin supplements as well as
adequate food and fluids.
o
A patient who is addicted to
opiates (drugs derived from poppy seeds, such as heroin and morphine) typically
experiences withdrawal symptoms within 12 hours after the last dose. The most severe
symptoms occur within 48 hours and decrease over the next 2 weeks.
o
Reactive depression is a response to a specific
life event.
o
Projection is the unconscious assigning
of a thought, feeling, or action to someone or something else.
o
Sublimation is the channeling of
unacceptable impulses into socially acceptable behavior.
o
Repression is an unconscious defense
mechanism whereby unacceptable or painful thoughts,
impulses, memories, or feelings are pushed from the consciousness or forgotten.
o
Hypochondriasis is morbid anxiety about one’s
health associated with various symptoms that aren’t caused by organic disease.
o
Denial is a refusal to acknowledge
feelings, thoughts, desires, impulses, or external facts that are consciously
intolerable.
o
Reaction formation is the avoidance of anxiety
through behavior and attitudes that are the opposite of repressed impulses and drives.
o
Displacement is the transfer of
unacceptable feelings to a more acceptable object.
o
Regression is a retreat to an earlier
developmental stage.
o
According to Erikson, an older
adult (age 65 or older) is in the developmental stage of integrity versus despair.
o
Family therapy focuses on the family as a
whole rather than the individual. Its major objective is to reestablish
rational communication between family members.
o
When caring for a patient who
is hostile or angry, the nurse should attempt to remain calm, listen
impartially, use short sentences, and speak in a firm, quiet voice.
o
Ritualism and negativism are typical toddler behaviors.
They occur during the developmental stage identified by Erikson as autonomy
versus shame and doubt.
o
Circumstantiality is a disturbance in associated
thought and speech patterns in which a patient gives unnecessary, minute
details and digresses into inappropriate thoughts that delay communication of
central ideas and goal achievement.
o
Idea of reference is an incorrect belief that the
statements or actions of others are related to oneself.
o
Group therapy provides an
opportunity for each group member to examine interactions, learn and practice
successful interpersonal communication skills, and explore emotional conflicts.
o
Korsakoff’s syndrome is believed to be a chronic
form of Wernicke’s
encephalopathy. It’s marked by hallucinations, confabulation, amnesia,
and disturbances of orientation.
o
A patient with antisocial
personality disorder often engages in confrontations with authority figures,
such as police, parents, and school officials.
o
A patient with paranoid
personality disorder exhibits suspicion, hypervigilance, and hostility toward
others.
o
Depression is the most common psychiatric
disorder.
o
Adverse reactions to tricyclic
antidepressant drugs include tachycardia, orthostatic hypotension, hypomania,
lowered seizure threshold, tremors, weight gain, problems with erections or orgasms,
and anxiety.
o
The Minnesota
Multiphasic Personality Inventory consists of 550 statements for the subject to
interpret. It assesses personality and detects disorders, such as depression
and schizophrenia, in adolescents and adults.
o
Organic brain syndrome is the
most common form of mental
illness in elderly patients.
o
A person who has an IQ of less
than 20 is profoundly retarded and is considered a total-care patient.
o
Reframing is a therapeutic
technique that’s used to help depressed patients to view a situation in alternative ways.
o
Fluoxetine (Prozac), sertraline (Zoloft), and
paroxetine (Paxil) are serotonin reuptake inhibitors used to treat depression.
o
The early stage of Alzheimer’s disease lasts 2
to 4 years. Patients have inappropriate affect, transient paranoia, disorientation to time,
memory loss, careless dressing, and impaired judgment.
o
The middle stage of Alzheimer’s disease lasts 4
to 7 years and is marked by profound personality changes, loss of independence,
disorientation, confusion, inability to recognize family members, and nocturnal
restlessness.
o
The last stage of Alzheimer’s disease occurs
during the final year of life and is characterized by a blank facial
expression, seizures, loss of appetite, emaciation, irritability, and total dependence.
o
Threatening a patient with an
injection for failing to take an oral drug is an example of assault.
o
Reexamination of life goals is a
major developmental task during middle adulthood.
o
Acute alcohol withdrawal causes
anorexia, insomnia, headache, and restlessness and escalates to a syndrome
that’s characterized by agitation, disorientation, vivid hallucinations, and
tremors of the hands, feet, legs, and tongue.
o
In a hospitalized alcoholic,
alcohol withdrawal delirium most commonly occurs 3 to 4 days after admission.
o
Confrontation is a communication technique in
which the nurse points out discrepancies between the patient’s words and his
nonverbal behaviors.
o
For a patient with
substance-induced delirium, the time of drug ingestion can help to determine whether
the drug can be evacuated from the body.
o
Treatment for alcohol
withdrawal may include administration of I.V. glucose for hypoglycemia, I.V.
fluid containing thiamine and other B vitamins, and antianxiety, antidiarrheal,
anticonvulsant, and antiemetic drugs.
o
The alcoholic patient receives thiamine to help prevent
peripheral neuropathy and Korsakoff’s syndrome.
o
Alcohol withdrawal may precipitate seizure activity because alcohol
lowers the seizure threshold in some people.
o
Paraphrasing is an active listening
technique in which the nurse restates what the patient has just said.
o
A patient with Korsakoff’s
syndrome may use confabulation (made up information) to cover memory lapses or
periods of amnesia.
o
People with obsessive-compulsive disorder
realize that their behavior is unreasonable, but are powerless to control it.
o
When witnessing psychiatric
patients who are engaged in a threatening confrontation,
the nurse should first separate the two individuals.
o
Patients with anorexia nervosa
or bulimia must be observed during meals and for some time afterward to ensure
that they don’t purge what they have eaten.
o
Transsexuals believe that they were born
the wrong gender and may seek hormonal or surgical treatment to change their
gender.
o
Fugue is a dissociative state in
which a person leaves his familiar surroundings, assumes a new identity, and
has amnesia about his previous identity. (It’s also described as “flight from himself.”)
o
In a psychiatric setting, the
patient should be able to predict the nurse’s behavior and expect consistent
positive attitudes and approaches.
o
When establishing a schedule
for a one-to-one interaction with a
patient, the nurse should state how long the conversation will last and then
adhere to the time limit.
o
Thought broadcasting is a type of delusion in which
the person believes that his thoughts are being broadcast for the world to hear.
o
Lithium should be taken with food. A
patient who is taking lithium shouldn’t restrict his sodium intake.
o
A patient who is taking lithium
should stop taking the drug and call his physician if he experiences vomiting, drowsiness, or muscle
weakness.
o
The patient who is taking a monoamine oxidase inhibitor
for depression can include cottage cheese, cream cheese, yogurt, and sour cream
in his diet.
o
Sensory overload is a state in which sensory
stimulation exceeds the individual’s capacity to tolerate or process it.
o
Symptoms of sensory overload
include a feeling of distress and hyperarousal with impaired thinking and
concentration.
o
In sensory deprivation, overall
sensory input is decreased.
o
A sign of sensory deprivation
is a decrease in stimulation from the environment or from within oneself, such
as daydreaming, inactivity, sleeping excessively, and reminiscing.
o
The three stages of general
adaptation syndrome are alarm, resistance, and exhaustion.
o
A maladaptive response to
stress is drinking alcohol or smoking excessively.
o
Hyperalertness and the startle
reflex are characteristics of posttraumatic stress disorder.
o
A treatment for a phobia is
desensitization, a process in which the patient is slowly exposed to the feared
stimuli.
o
Symptoms of major depressive
disorder include depressed mood, inability to experience pleasure, sleep
disturbance, appetite changes, decreased libido, and feelings of worthlessness.
o
Clinical signs of lithium
toxicity are nausea, vomiting, and lethargy.
o
Asking too many “why” questions
yields scant information and may overwhelm a psychiatric patient and lead to
stress and withdrawal.
o
Remote memory may be impaired
in the late stages of dementia.
o
According to the DSM-IV,
bipolar II disorder is characterized by at least one manic episode that’s
accompanied by hypomania.
o
The nurse can use silence and
active listening to promote interactions with a depressed patient.
o
A psychiatric patient with a
substance abuse problem and a major psychiatric disorder has a dual diagnosis.
o
When a patient is readmitted to
a mental health unit, the nurse should assess compliance with medication orders.
o
Alcohol potentiates the effects
of tricyclic antidepressants.
o
Flight of ideas is movement
from one topic to another without
any discernible connection.
o
Conduct disorder is manifested
by extreme behavior, such as hurting people and animals.
o
During the “tension-building”
phase of an abusive relationship, the abused individual feels helpless.
o
In the emergency treatment of
an alcohol-intoxicated patient, determining the blood-alcohol level is
paramount in determining the amount of medication that the patient needs.
o
Side effects of the
antidepressant fluoxetine
(Prozac) include
diarrhea, decreased libido, weight
loss, and dry mouth.
o
Before electroconvulsive
therapy, the patient is given the skeletal muscle relaxant succinylcholine (Anectine)
by I.V. administration.
o
When a psychotic patient is
admitted to an inpatient facility, the primary concern is safety, followed by the
establishment of trust.
o
An effective way to decrease
the risk of suicide is to make a suicide contract with the patient for a specified period of time.
o
A depressed patient should be
given sufficient portions of his favorite foods, but shouldn’t be overwhelmed
with too much food.
o
The nurse should assess the
depressed patient for suicidal
ideation.
o
Delusional thought patterns commonly
occur during the manic
phase of bipolar disorder.
o
Apathy is typically observed in patients
who have schizophrenia.
o
Manipulative behavior is characteristic of a patient
who has passive–
aggressive personality disorder.
o
When a patient who has
schizophrenia begins to
hallucinate, the nurse should redirect the patient to activities that are focused on the here
and now.
o
When a patient who is receiving
an antipsychotic drug exhibits
muscle rigidity and tremors, the nurse should administer an antiparkinsonian drug (for
example, Cogentin or Artane) as ordered.
o
A patient who is receiving lithium (Eskalith)
therapy should report diarrhea, vomiting, drowsiness, muscular weakness, or
lack of coordination to the physician immediately.
o
The therapeutic serum level of lithium
(Eskalith) for maintenance is 0.6 to 1.2 mEq/L.
o
Obsessive-compulsive disorder
is an anxiety-related disorder.
o
Al-Anon is a self-help group for
families of alcoholics.
o
Desensitization is a treatment for phobia, or irrational
fear.
o
After electroconvulsive therapy, the patient
is placed in the lateral position, with the head turned to one side.
o
A delusion is a fixed false belief.
o
Giving away personal
possessions is a sign of suicidal ideation. Other signs include writing a
suicide note or talking about suicide.
o
Agoraphobia is fear of open spaces.
o
A person who has paranoid personality disorder projects
hostilities onto others.
o
To assess a patient’s judgment,
the nurse should ask the patient what he would do if he found a stamped,
addressed envelope. An appropriate response is that he would mail the envelope.
o
After electroconvulsive therapy, the patient
should be monitored for post-shock amnesia.
o
A mother who continues to
perform cardiopulmonary resuscitation after a physician pronounces a child dead
is showing denial.
o
Transvestism is a desire to wear clothes
usually worn by members of the opposite sex.
o
Tardive dyskinesia causes excessive blinking and
unusual movement of the tongue, and involuntary sucking and chewing.
o
Trihexyphenidyl (Artane) and benztropine (Cogentin) are
administered to counteract extrapyramidal adverse effects.
o
To prevent hypertensive crisis,
a patient who is taking a monoamine oxidase inhibitor should avoid consuming
aged cheese, caffeine, beer, yeast, chocolate, liver, processed foods, and
monosodium glutamate.
o
Extrapyramidal symptoms include parkinsonism,
dystonia, akathisia (“ants in the
pants”), and tardive dyskinesia.
o
One theory that supports the
use of electroconvulsive
therapy suggests that it “resets” the brain circuits to allow normal function.
o
A patient who has obsessive-compulsive disorder usually
recognizes the senselessness of his behavior but is powerless to stop it
(ego-dystonia).
o
In helping a patient who has
been abused, physical safety is the nurse’s first priority.
o
Pemoline (Cylert) is used to treat attention
deficit hyperactivity disorder (ADHD).
o
Clozapine (Clozaril) is contraindicated in
pregnant women and in patients who have severe granulocytopenia or severe
central nervous system depression.
o
Repression, an unconscious process, is the
inability to recall painful or unpleasant thoughts or feelings.
o
Projection is shifting of unwanted
characteristics or shortcomings to others (scapegoat).
o
Hypnosis is used to treat psychogenic
amnesia.
o
Disulfiram (Antabuse) is
administered orally as an aversion therapy to treat alcoholism.
o
Ingestion of alcohol by a patient who is taking disulfiram (Antabuse) can
cause severe reactions, including nausea and vomiting, and may endanger the
patient’s life.
o
Improved concentration is a sign that lithium is
taking effect.
o
Behavior modification,
including time-outs, token economy, or a reward system, is a treatment for
attention deficit hyperactivity disorder.
o
For a patient who has anorexia nervosa, the
nurse should provide support at mealtime and record the amount the patient
eats.
o
A significant toxic risk associated with clozapine (Clozaril) administration is blood dyscrasia.
o
Adverse effects of haloperidol (Haldol)
administration include drowsiness; insomnia; weakness; headache; and
extrapyramidal symptoms, such as akathisia, tardive dyskinesia, and dystonia.
o
Hypervigilance and déjà vu are signs of posttraumatic stress
disorder (PTSD).
o
A child who shows dissociation has probably
been abused.
o
Confabulation is the use of fantasy to fill
in gaps of memory
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