NCLEX RN - NATIONAL COUNCIL LICENSURE EXAMINATION PEARSON TEST BANK QUESTIONS, ANSWERS, Exams of Nursing

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NCLEX RN - NATIONAL COUNCIL LICENSURE EXAMINATION PEARSON TEST

BANK QUESTIONS, ANSWERS & RATIONALES LATEST UPDATAED 2024 | A

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Isotonic IV fluids NS And lactated Ringers Are used as fluid replacement for fluid volume deficit Serum phenytoin 10 - 20 mcg/ml Normal glucose Infant 40 - 60mg/dl Normal resp for infant 30 - 60 Normal temp for infant 97.7-99. What is the antidote for norepinephrine? Phentolamine (Regitine) What is autonomic dysreflexia? Life-threatening condition in a client with high spinal cord injury Classic symptoms of autonomic dysreflexia? Severe hypotension, throbbing headache,diaphoresis,bradycardia,flushing and piloerection. Magnesium 1.5-2.5 mEq What is the therapeutic magnesium level to prevent seizures in a preeclamptic client? 4 - 7 mEq Absent or decreased deep-tendon reflexes Earliest sign of magnesium toxicity Calcium gluconate (antidote)

Magnesium toxicity Magnesium sulfate IV antidote? Calcium gluconate IV Acetaminophen N-acetylcysteine Most effective if given w/in 8hrs of ingesting acetaminophen Anticholinergics Physostigmine Arsenic Chelation therapy: 1.dimercarpol 2.penincillamine 3.calcium disodium edetate

4. Succimer Benzodiazepines Flumazenil Beta blockers (High dose) glucagon Calcium channel blockers Glucagon, calcium chloride, calcium gluconate Cholinergics Atropine,pralidoxime Cyanide Amyl nitrate Sodium thiosulfate Hyperbaric oxygen chamber Digitalis/digoxin Digoxin antibodies: digoxin immune fab, digifab,digibind Dnoxaparin

Protamine sulfate Ethylene glycol Ethanol Fomepizole Pyridoxine hydrochloride(vitamin b6) Heparin Protamine sulfate Is a process of learning a different culture to adapt to a new or changing environment. Acculturation. It is a subjective perspective of the person's heritage and a sense of belonging to a group Ethnic identity Include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, & spiritual measures (prayer). Low-risk therapies: Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans. High risk of obesity & diabetes mellitus Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products. Jehovah's Witnesses Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. Orthodox Judaism include whole medical systems, mind-body medicine, biologically based practices, manipulative & body-based practices, & energy medicine. Five categories of complementary and alternative medicine (CAM):

Focused, maintains strong control, makes decisions, & addresses all problems. Dominates group & commands, rather than seeks suggestions or input. Manager addresses problem (quality improvement) with taff, designs a plan without input, & wants all problems reported directly back to her Autocratic leader Participative & would likely meet with each staff person individually to determine staff member's perception of problem. Would also speak with the staff about any issues & ask the staff for input with developing a plan. Democratic leader Passive and nondirective. Would state what the problem was & inform staff that the staff needed to come up with a plan to "fix it." Laissez-faire leader Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck & hand vein distention, altered LOC, & decreased hematocrit. Overhydration or fluid overload & occurs when fluid intake or fluid retention Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, & tomatoes Common food sources of potassium: Muscle weakness, increased urinary output, & decreased specific gravity of the urine would be noted Hyponatremia Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide- based or magnesium-based antacids. Malnutrition is associated with alcoholism. Hypophosphatemia Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors. Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole grains, & carbonated beverages. Hyperphosphatemia Vomiting, diarrhea, conditions that increased respiration's or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy. Diuretics, & gastrointestinal suctioning.

Causes of a fluid volume deficit Decreased kidney function, heart failure, hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds & body cavities, & excessive ingestion of sodium. Causes of overhydration or fluid overload: Trauma, burns, sepsis, or metabolic or respiratory acidosis. Hyperkalemia causes: Cushing's syndrome or colitis & over use of laxatives. Hypokalemia causes: Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or diarrhea. Metabolic acidotic Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms experienced would include hypoventilation & tachycardia. Metabolic alkalosis Decreased pH and an increased CO2. Hypoventalation & COPD Respiratory acidotic Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea) occurs. Respiratory alkalotic Sample for PT & INR level to determine anticoagulation status & risk for bleeding Warfarin (Coumadin) aPTT monitors the effects. Anticoagulant used most often during hemodialysis. Monitors extent of anticoagulation checking PTT, which is appropriate measure heparin effect. Protamine sulfate is antidote. Heparin Dark green leafy vegetables good source iron, oranges are a good source of vitamin C, which enhances iron absorption.

Iron deficiency anemia foods in diet: May lack B12 in diet. Vegans Include fruits & vegetables Low sodium foods: Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish & shellfish. Smoked foods, High Sodium foods: Water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. Clear liquid diet: Pulling, Vegetable juice, Pureed vegetables, plain ice cream, sherbet, breakfast drinks, milk, pudding & custard, soups that are strained, refined cooked cereals, & strained vegetable juices. Full liquid diet: Pork products rich in this vitamin. Other good food sources include nuts, whole grain cereals, & legumes. High Thiamine foods On the left side, with the head lower than the feet. This position used to minimize effect of air traveling as a bolus to lungs by trapping it in right side of heart. Suspects air embolism. Should immediately place client in which position? Assess for known allergies to eggs to prevent anaphylaxis. Fat emulsion (lipids) Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, & coma when severe. If has these symptoms, blood glucose level should be checked immediately. Hyperglycemia: Temperature and weight: Temperature monitored to detect infection, potential complication of therapy. Infection also could result in sepsis because catheter in blood vessel. Weight monitored for effectiveness nutritional therapy & detect hypervolemia.

Parenteral nutrition; PN monitor Burns, exacerbation Crohn's disease, persistent nausea & vomiting due to chemotherapy. Had extensive surgery, multiple fractures, are septic, have advanced cancer or AIDS. (Electronic infusion pump used to administer) Parenteral nutrition; Patients needing 10% dextrose in water until new PN solution becomes available. Parenteral nutrition; If PN bag empty hang IV dislodged from vein & is lying in subcutaneous tissue. Pallor, coolness, & swelling are results of IV fluid being deposited in tissue. Corrective action is remove catheter & start new IV line at another site. Infiltrated IV Discomfort at site, redness, warmth, & swelling proximal to catheter. If phlebitis occurs, discontinue IV line & insert new IV line at different site. Apply warm moist compresses to area speed resolution of inflammation. Notify (HCP). Document occurrence, actions taken, & client response. Phlebitis at IV site: Produces a rash, redness, & itching. An allergic reaction at IV site: Characterized by ecchymosis, swelling, & leakage at IV insertion site, as well as hard & painful lumps at site. Hematoma Dyspnea, a swollen tongue, & cyanosis. Hypersensitivity reaction: Taught minor activity restrictions apply with this type of catheter. Protect site during bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as needed because catheter is for long-term use. PICC line Before beginning administration IV solution, assess whether chest radiograph reveals central catheter is in proper place. Portable chest X-ray. Central venous catheter insertion:

Characterized by chills, fever, malaise, headache, nausea, vomiting, backache, & tachycardia. Systemic infection Characterized by tachycardia, dyspnea, hypotension, cyanosis, decreased LOC, anxiety, feelings of impending doom, chest pain, & hypotension. Place left side in Trendelenburg's position. Lying left side may prevent air from flowing into pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases amount of blood pulled into vena cava during inspiration. Air embolism Occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, & development of shock Septicemia Necessary for proper blood clotting. Insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, & mucous membranes. Platelets Order of priority is to rescue patient in immediate danger. Next activate fire alarm. Close all doors & fire extinguished. Fire event Transmitted by droplet infection. Precautions include private room or cohort client & use of standard precaution mask. Meningococcal pneumonia Best results sitting head of bed elevated 45 to 90 degrees. Semi-Fowler's or high Fowler's position. Mouthpiece should be covered completely & tightly while inhales slowly, with constant flow through unit. Breath should be held for 5 seconds before exhaling slowly. Incentive spirometer Placed in left Sims position so enema solution can flow by gravity in natural direction of colon. Cleansing enema Preconventional stage, morals are thought to be motivated by punishment & reward. Kohlberg's theory of moral development

Should not try anticipate newborn infant needs but allow newborn infant to signal needs. If newborn infant is not allowed to signal a need, newborn will not learn how to control environment. Delayed or prolonged response to newborn infant's signal would inhibit development trust & lead to mistrust of others Erikson's psychosocial development theory Child has the ability to think abstractly and logically. Formal operations stage of Piaget's cognitive developmental theory Child begins to understand the environment. Paiget's sensorimotor stage Child is able to classify, order, and sort facts. Paiget's concrete operational stage Child learns to think in terms of past, present, & future. Paiget's preoperational stage 20 to 40 breaths/minute Normal respiratory rate in a 12-month-old 90 to 130 beats/minute Normal apical heart rate in a 12-month-old 90/56 mm Hg Average blood pressure in a 12-month-old Diamond-shaped & located on top of head. Soft & flat in normal infant, & it normally closes by 12- 18 months of age Anterior fontane Decreased lean body mass & age-associated decreased glomerular filtration rate. older client is at risk for medication toxicity because Stand feet together & arms at sides, close eyes & hold position; normally client can maintain posture & balance. Positive Romberg's sign is a vestibular neurological sign found when client exhibits loss balance when closing eyes. Romberg's test

Rhythmic respirations with periods of apnea. Periods apnea followed by deep rapid breathing Cheyne-Stokes respirations Physical obstruction to transmission of sound waves Conductive hearing loss occurs as result pathological process in inner ear, defect in 8th cranial nerve, or defect of sensory fibers that lead to cerebral cortex. Sensorineural hearing loss Abnormal heart sound & described as gentle, blowing, swooshing sound. Heart murmur Described as a scratchy, leathery heart sound. Pericardial friction rub Tests the six cardinal positions of gaze Assess for muscle weakness in eyes Visual acuity & cranial nerve II (optic). Snellen eye chart Close eyes & then lightly touching areas of face & testing corneal reflexes assess cranial nerve V (trigeminal). Testing sensory function tested insupine position. Flexes head (gently moves head to chest) & there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if passively flexes hip & knee in response to neck flexion & reports pain in vertebral column. Positive Brudzinski's sign Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned by one umbilical vein. Arteries carry deoxygenated blood & waste products from fetus, umbilical vein carries oxygenated blood & provides oxygen & nutrients to fetus. Fetal circulation Connects umbilical vein to inferior vena cava Ductus venosus

Is temporary opening between right & left atria. Foramen ovale Joins the aorta & pulmonary artery Ductus arteriosus Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement, Braxton Hicks contractions, & positive pregnancy test for presence of HCG. Probable signs of pregnancy Fetal heart rate detected by electronic device (Doppler transducer), active fetal movements palpable by examiner, & outline fetus by radiography or ultrasonography. Positive signs of pregnancy Pregnancy avoided for 1-3 months. Vaccine administered subcutaneous route.Exposure immunosuppressed individuals avoided. Hypersensitivity reaction can occur if client has allergy to eggs. Rubella virus vaccine Postpartum Three classic signs are hypertension, generalized edema, & proteinuria. Classic signs of preeclampsia Can trigger disseminated intravascular coagulation (DIC). Evidence of bleeding, such as in gums, petechiae, & purpura should be reported to HCP if noted on assessment. Severe preeclampsia Considered a risk factor for disseminated intravascular coagulation (DIC). Dead fetus syndrome Isoniazid plus rifampin (Rifadin) will be required for 9 months. Pregnant client tuberculosis is suspected; sputum culture obtained & identifies Mycobacterium tuberculosis When the cervix is dilated completely & ends with birth of the neonate. Second Stage of Labor begins Occur if umbilical cord becomes compressed, reducing blood flow between placenta & the fetus. Variable decelerations

Result from pressure on fetal head during a contraction. Early decelerations Fetal heart rate assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. Minimal vaginal examinations would be done because of risk of infection. Assessment finding following an amniotomy should be conducted first Acute abdominal pain present. Uterine tenderness with abruption, especially central abruption & trapped blood behind placenta. Abdomen feels hard/boardlike on palpation as blood penetrates myometrium & causes uterine irritability. Premature separation placenta from uterine wall after 20th week gestation, before fetus delivered. Associated conditions; hypertension, smoking, alcohol/ cocaine abuse. Overdistention uterus; multiple gestation, polyhydramnios. In addition, short umbilical cord, physical trauma, increased maternal age & parity are risk factors. Painful vaginal bleeding, abdominal pain, & back pain identify signs/symptoms of abruptio placentae. Abruptio placentae Symptoms increase in fundal height, hard board-like abdomen, persistent abdominal pain, late decelerations in fetal heart rate, or decreasing baseline variability. Concealed bleeding Prenatal Improperly implanted placenta lower uterine segment. Manual pelvic exam contraindicated vaginal bleeding apparent until diagnosis made & placenta previa ruled out. Digital exam cervix can lead to hemorrhage. Diagnosis by ultrasound. Hemoglobin/Hematocrit level monitored, external electronic fetal heart rate monitoring initiated; crucial evaluating status fetus, risk for severe hypoxia. Soft abdomen & painless, bright red vaginal bleeding in second/third trimester pregnancy symptom. (Sudden onset painless vaginal bleeding) Placenta previa Oxygen administered, 8 to 10 L/min, by face mask. Oxygen used decrease hypoxia. Kept on bed rest with head of bed slightly elevated reduce dyspnea. Morphine sulfate may be prescribed, not initial nursing action. IV also required, & vital signs need to be monitored, but these actions would follow administration of oxygen. Pulmonary embolism is suspected Infection of bladder. Should consume 3000 mL of fluids per day if not contraindicated. Cystitis

May present clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. Newborn infant with respiratory distress syndrome Bluish discoloration of hands & feet, is associated with immature peripheral circulation, & common in first few hours of life. Acrocyanosis Craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, & respiratory distress. Hypotonia, irritability, & poor sucking reflex. Fetal alcohol syndrome May exhibit hyperirritability, vomiting, diarrhea, or uncoordinated sucking & swallowing ability. Quiet environment with minimal stimuli & handling would help establish appropriate sleep-rest cycles in newborn as well. Fetal alcohol syndrome Used as prophylactic treatment for ophthalmia neonatorum, which is caused by bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law Erythromycin ophthalmic ointment Central nervous system depressant & relaxes smooth muscle, including uterus. Used to halt preterm labor contractions & used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, & elevated serum magnesium levels. MagnesiumSulfate Glucocorticoid, given increase production of surfactant to stimulate fetal lung maturation. Administered clients preterm labor at 28 to 32 weeks of gestation if labor can be inhibited for 48 hours. Betamethasone (Celestone) Opioid analgesic. Nalbuphine (Nubain) Given to Rh-negative clients to prevent sensitization. Rho(D) immune globulin (RhoGAM)

Prostaglandin given ripen & soften cervix & stimulate uterine contraction Dinoprostone (Cervidil vaginal insert) Respiratory Distress Syndrome serious lung disorder caused by immaturity & inability to produce surfactant, resulting in hypoxia & acidosis. Common premature infants & may be due to lung immaturity: result of surfactant deficiency. Mainstay treatment administration exogenous surfactant, administered by intratracheal route Beractant (Survanta) Opioid antagonist, which reverses effects of opioids & given for respiratory depression. Naloxone Appears burrows or fine, grayish red, threadlike lines. May be difficult to see if they are obscured by excoriation & inflammation. Multiple straight or wavy, threadlike lines beneath skin. Wear a gown & gloves for close contact. Scabies Clusters of fluid-filled vesicles Herpesvirus infection Contagious bacterial infection skin. Common during hot, humid summer months. May begin area broken skin, such as an insect bite or atopic dermatitis. Impetigo very contagious. Lesions usually located around mouth & nose, but may be on hands & extremities. Mupirocin(Bactroban) topical antibacterial agent active against impetigo. Impetigo Group bleeding disorders resulting from deficiency specific coagulation proteins Abnormal laboratory results indicate prolonged partial thromboplastin time. Female offspring of affected male & carrier female are at risk for hemorrhage once puberty is attained & menstrual cycles begin, depending on severity of hemophilia, hysterectomy or ablation may be performed Hemophilia Classified as antidote for acute iron toxicity. Deferoxamine (Desferal) Early sign slight change LOC, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late sign ICP include significant decrease LOC, bradycardia, decreased motor & sensory responses, alterations pupil size & reactivity, posturing, Cheyne-Stokes respirations, & coma.

Symptom of increased ICP Confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate & biopsy. Leukemia Malignancy lymph nodes. Presence of giant, multinucleated cells (Reed-Sternberg cells) is classic characteristic of this disease. Hodgkin's disease Never be administered in the presence of oliguria or anuria. Checks amount urine output before administration. potassium chloride Also known as congenital aganglionosis or megacolon. Pellet or ribbon-like stools: foul- smelling is clinical manifestation of disorder. Delayed passage or absence of meconium stool in neonatal period also a sign. Bowel obstruction in neonatal period, abdominal pain & distention, & failure to thrive also clinical manifestations. Hirschsprung's disease Projectile vomiting, irritability, hunger & crying, constipation, & signs dehydration including decrease urine output. Pyloric stenosis Invagination of section of intestine into distal bowel. Most common cause of bowel obstruction children aged 3 months to 6 years. Severe abdominal pain; crampy & intermittent, child draw in knees to chest. Vomiting may be present, but not projectile. Bright red blood & mucus passed through rectum & commonly described as currant jelly- like stools Intussusception Preoperative period, child observed presence loose teeth to decrease risk aspiration during surgery. Bleeding during surgery controlled via packing & suction as needed. Frequent swallowing, restlessness, fast/thready pulse, & vomiting bright red blood are signs of bleeding. Bad mouth odor normal after tonsillectomy & may be relieved by drinking more liquids. Tonsillectomy (Surgical removal tonsils) condition eyes not aligned because lack coordination of extraocular muscles. May in child when complains frequent headaches, squints, tilts head to see. Other manifestations include

crossed eyes, closing one eye to see, diplopia, photophobia, loss of binocular vision, or impairment of depth perception. Strabismus Decreased wheezing in child with asthma may be interpreted incorrectly as positive sign when may actually signal inability move air. "Silent chest" is an ominous sign during an asthma episode. Child with asthma Highly communicable disorder. Not transmitted airborne route. Usually transferred by hands. Use contact & standard precaution during care (wearing gloves & gown) reduce nosocomial transmission of RSV. Isolated private room or room with another infant with RSV infection. Cool humidified oxygen delivered relieve dyspnea, hypoxemia, & insensible water loss from tachypnea. Respiratory syncytial virus (RSV) Acute stage: fever, conjunctival hyperemia, red throat, swollen hands, rash, & enlargement cervical lymph nodes. Subacute stage, cracking lips & fissures, desquamation skin on tips of fingers & toes, joint pain, cardiac manifestation, & thrombocytosis. Convalescent stage, appear normal, but signs inflammation may be present. Kawasaki disease Narrowing or stricture of aortic valve. Signs of exercise intolerance, chest pain, & dizziness when standing for long periods. Aortic stenosis Failure fetal ductus arteriosus (artery connecting aorta & pulmonary artery) to close. Characteristic machinery-like murmur is present, & infant may show signs of heart failure Patent ductus arteriosus Abnormal opening between the atria Atrial septal defect Abnormal opening between the right and left ventricles. Ventricular septal defect Gross hematuria & proteinuria: urine may be small in volume, specific gravity elevated, & urine may appear dark & smoky; cola-colored/brown-colored. Foamy urine from proteinuria. Hypertension common. Blood urea nitrogen levels may be elevated. Moderately elevated high urinary specific gravity. Common experiences excess fluid

volume & fatigue. Intervention; fluid restriction, monitoring weight, I&O. Diet high calorie but low protein. Placed bed rest, encouraged rest, because direct correlation between proteinuria & hematuria & increased activity level. Glomerulonephritis Symptoms include increased serum lipids, edema, increased excretion of protein in the urine, & decreased serum albumin levels. Kidney disorder characterized massive proteinuria, hypoalbuminemia (hypoproteinemia), & edema. Child with edema from nephrotic syndrome high risk skin breakdown. Skin surfaces cleaned & separated with clothing to prevent irritation & resultant skin breakdown. Child will be anorexic. Nephrotic syndrome Weight gain; periorbital & facial edema most prominent in morning; leg, ankle, labial, or scrotal edema; decreased urine output & urine dark & frothy; abdominal swelling; blood pressure normal or slightly decreased. Massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, & pallor. Nephrotic syndrome Condition which one or both testes fail descend through inguinal canal into scrotal sac. Surgical correction may be necessary. Vigorous activities restricted 2 weeks after surgery help healing & prevent injury. Cryptorchidism: orchiopexy surgery Congenital defect involving abnormal placement urethral orifice of penis. Urethral orifice located below glans penis along ventral surface. Should not be circumcised because dorsal foreskin tissue used for surgical repair of hypospadias. Hypospadias Congenital defect abnormal placement urethral orifice of penis. Urethral opening located anywhere on dorsum of penis. Anatomical characteristic facilitates entry bacteria into urine. Epispadias Chronic disability characterized by impaired muscle movement & posture Cerebral palsy Inflammation brain occurs as a result of viral illness or central nervous system infection. Encephalitis Infectious process central nervous system.

Meningitis Congenital condition results in moderate to severe retardation. More likely to develop acute leukemia than average child Down syndrome Not able extend leg when thigh is flexed anteriorly at hip. Raise child's leg with knee flexed & then extend the leg at knee & assess for pain; resistance is noted or pain is felt, result is positive Kernig's sign. Kernig's sign Neck flexion causes adduction & flexion movements lower extremities children & adolescents Brudzinski's sign (extension) posturing characterized: rigid extension & pronation of arms & legs. Abnormal extension upper extremities with internal rotation of upper arms & wrists & extension of lower extremities with some internal rotation. Indicates damage in diencephalon, midbrain, or pons Decerebrate posturing (flexion) posturing; Abnormal flexion of upper extremities & extension of lower extremities with possible plantar flexion of feet. Indicates lesion in cerebral hemisphere or disruption of the corticospinal tracts. Decorticate posturing supportive care, monitoring & managing cerebral edema. Decrease stimuli environment quiet & dimmed lighting would decrease stress on cerebral tissue & neuron responses. Reye's syndrome Assess hip instability. Abducts thigh & applies gentle pressure forward over greater trochanter. A "clicking" sensation indicates dislocated femoral head moving into acetabulum. Ortolani maneuver confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. Detection of HIV in infants Contains neomycin. History of anaphylactic reaction neomycin considered a contraindication to IPV.

Inactivated polio vaccine (IPV) Administered subcutaneously outer aspect of upper arm (MMR) vaccine Transmitted airborne particles or direct contact with infectious droplets. Airborne droplet precautions required, & should wear masks. Private room if hospitalized, & door remains closed. Standard precautions used. Needs rest. consideration in rubeola is eye care. Child usually has photophobia, suggest parent keep child out of brightly lit areas. Rubeola (measles) Move safe area away from snake & rest to decrease venom circulation. Next jewelry & constricting clothing removed before swelling occurs. Immobilize extremity & maintain below heart level done next. Kept warm & calm. Stimulants alcohol/caffeinated beverages not given: may speed absorption of venom snakebite first priority intervention Infection dermis & underlying hypodermis: results in deep red erythema without sharp borders & spreads widely throughout tissue spaces. Skin is erythematous, edematous, tender, & sometimes nodular. Antibiotic therapy; after blood cultures obtained. Warm compresses to the affected area Cellulitis Lesions or patches appear as red, raised papules that may coalesce into large plaques covered by silvery scales. Affected areas include scalp, elbows, knees, shins, sacral area, & trunk. Incidence is lower in darker-skinned races & ethnic groups. Psoriasis Pigmented malignant lesions originating melanin-producing cells of epidermis. This skin cancer highly metastatic, & survival depends on early diagnosis & treatment Melanoma The skin is intact in stage I. stage II, skin not intact. Partial-thickness skin loss dermis. Shallow open ulcer with red-pink wound bed, without slough or intact, open or ruptured, serum-filled blister. Full-thickness skin loss occurs stage III. Exposed bone, tendon, muscle present stage IV Pressure ulcers Early signs Periorbital edema, edema face, tightness of a shirt or blouse collar. As worsens, experiences edema hands & arms. Cyanosis & mental status changes are late signs.

Superior vena cava syndrome Classic symptoms polydipsia, polyuria, & polyphagia Hyperglycemia Results from insufficient ADH production. Triad clinical symptoms including polyuria, polydipsia, excessive thirst often occurs in client with diabetes insipidus. Urine dilute, with specific gravity lower than 1.005, & urine osmolality low (50-200 mOsm/L). High serum osmolality (>300 mOsm/kg of water). There is (insufficient ADH production), which causes kidneys excrete large volumes of urine. Diabetes insipidus Decreased blood glucose levels produce autonomic nervous system symptoms, manifested as nervousness, irritability, & tremors. Usually feels hunger. Profuse sweating & shakiness would be noted Hypoglycemic reaction Caused by excessive amounts cortisol. Diet low carbohydrates & sodium but ample protein/potassium encouraged. Promotes weight loss, reduction edema & hypertension, control of hypokalemia, rebuilding of wasted tissue. Appearance buffalo hump develop but most physical changes resolve with treatment. Rounded moon-like face; prominent jowls; red cheeks; hirsutism upper lip, lower cheek, & chin. (Moon facies & truncal obesity) Cushing's syndrome Catecholamine-producing tumor. Severe Hypertension can precipitate stroke or sudden blindness. Monitor vital signs, particularly blood pressure. Normal range of urinary catecholamines is14 mcg/100 mL of urine, higher levels in pheochromocytoma. Pheochromocytoma Deficiency thyroid hormone. Puffy, edematous face, around eyes (periorbital edema), along with coarse facial features, dry skin, & dry, coarse hair & eyebrows. Feeling cold, hair loss, lethargy facial puffiness are signs. Hypothyroidism Goiter (increase size thyroid gland) & exophthalmos (bulging eyeballs). Nervousness, fatigue, weight loss, muscle cramps, heat intolerance. Tachycardia; shortness of breath; excessive sweating; fine muscle tremors; thin, silky hair & thin skin; infrequent blinking; & staring appearance. Hyperthyroidism

Acute, life-threatening condition occurs in uncontrollable hyperthyroidism. Systolic hypertension, tachycardia, diarrhea, & fever as high as 106° F, abdominal pain, dehydration, extreme vasodilation, stupor rapidly progressing to coma, atrial fibrillation, & cardiovascular collapse. Fever, nausea, tremors. As condition progresses they become confused. Restless, anxious & experiences tachycardia. Thyroid storm Incretin mimetic used for type 2 diabetes mellitus only. Not recommended clients taking insulin. Exenatide (Byetta) Rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals approximately 30 minutes before meals & should be withheld if client does not eat. Hypoglycemia is a side effect of repaglinide & client should always be prepared by carrying a simple sugar with her or him at all times. Repaglinide(Prandin) Oral hypoglycemic given combination repaglinide, works decreasing hepatic glucose production. Common side effect metformin is diarrhea. Used with caution; kidney/liver disease, heart failure, chronic lung disease, history heavy alcohol consumption. Metformin (Glucophage) Insomnia, weight loss, & mild heat intolerance side effects. Taken on empty stomach enhance absorption. Dosing morning before breakfast. levothyroxine sodium (Synthroid) Treat hyperthyroidism, or Graves' disease. Excessive dosing may convert hyperthyroid state to hypothyroid state. If this occurs, dosage should be reduced. Adverse effect of PTU is agranulocytosis. Early signs adverse effect; fever & sore throat. Propylthiouracil (PTU) may decrease effect oral hypoglycemics, insulin, diuretics, & potassium supplements. Prednisone Severe & unrelenting, located epigastric area & radiating to back. NPO (nothing by mouth) status decrease activity of pancreas. Pain management typically administration opioids patient-controlled analgesia. Morphine or hydromorphone (Dilaudid) are typically used. Nasogastric tube insertion is done to provide suction secretions & administer medications as necessary. Acute pancreatitis

Avoid chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, & alcohol Gastroesophageal reflux disease (GERD Inability absorb vitamin B12. This leads to development of pernicious anemia. Chronic gastritis Nonbloody diarrhea usually not more than four to five stools daily. Over time, diarrhea episodes increase in frequency, duration, & severity. Crohn's disease Irregular flapping movements fingers & wrists when hands & arms are outstretched, with palms down, wrists bent up, & fingers spread. Asterixis Pain relieved by food intake. Burning, heavy, sharp, or "hungry" pain that often localizes in mid-epigastric area. 90 minutes to 3 hours after eating & often awakens client at night. Duodenal ulcer Weight loss or nausea & vomiting. exacerbated by intake of food. Pain occurs 30- 60 minutes after meal & rarely occurs at night Gastric ulcer Bowel protrudes through stoma, causing elongated & swollen appearance to stoma Prolapsed stoma Sunken & hidden stoma (Sinking in of stoma) Stoma retraction Frequent complication that occurs is fluid & electrolyte imbalance. I & O monitored. Ileostomy Narrow opening Stenosed Stoma Early manifestation occur 5- 30 mins after eating. Symptoms; vertigo, tachycardia, syncope, sweating, pallor, palpitations, & desire to lie down. Instruct maintain low Fowler position while eating & lie down for 30 mins after eating. Small, frequent meals best & avoid liquids with meals. Avoiding high-carbohydrate food sources also assist. Dumping syndrome

Immunomodulator that reduces degree inflammation in colon, reducing diarrhea Infliximab (Remicade): Used in Crohn's disease antiemetic treat postoperative nausea/vomiting, also N&V associated with chemotherapy. Ondansetron (Zofran) Pancreatic enzyme used as digestive aid for pancreatitis. Reduce amount fatty stools (steatorrhea). Also help improve nutritional status Pancrelipase (Pancrease MT) Gastric protectant administered 1 hour before meals & bedtime. Timed to allow it to form protective coating over ulcer before food intake stimulates gastric acid production & mechanical irritation. Sucralfate (Carafate) Antiulcer agent. Intended effect is relief of pain from gastric irritation, often called heartburn by clients Omeprazole (Prilosec) Promote carbon dioxide elimination; facilitates maximal expiration with obstructive lung disease. Allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Pursed-lip breathing preoxygenate before suction & limit suction pass to 10 seconds Suctioning Paradoxical chest movement Suffered flail chest earliest sign is increased respiratory rate, can begin from 1 to 96 hours after initial insult to body. Followed by increasing dyspnea, air hunger, retraction accessory muscles, & cyanosis. Acute respiratory distress syndrome Common initial symptom chest pain; sudden in onset. Next common symptom dyspnea, accompanied by increased respiratory rate. Other symptoms PE include apprehension, restlessness, tachycardia, cough, & cyanosis. Pulmonary embolism

Sitting up & leaning on overbed table, sitting up & rest elbows on knees, standing & leaning against wall. Emphysema positions that help breathing First pulmonary manifestations cough with expectoration mucoid sputum. Sputum cultures performed every 2-4 weeks after initiation drug therapy. Return work when three sputum cultures are negative; considered noninfectious at that point. Tuberculosis Antitubercular medication. Side effect peripheral neuritis. Symptoms; numbness, tingling, paresthesias in extremities. Minimized w/pyridoxine (vitamin B6) intake. Report yellow eyes/skin immediately. Hepatotoxic. Monitor liver enzyme first 3 months therapy. Children HIV infection who demonstrate positive Mantoux tuberculin skin test result, minimum 12 months treatment recommended. Isoniazid Used caution impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or history seizures. Medication may increase blood glucose levels. Terbutaline: is an bronchodilator Treat bronchial asthma. Used with caution impaired hepatic function. Liver function laboratory tests should be performed and monitored with treatment. Zafirlukast (Accolate) administered empty stomach unless it causes GI upset, & then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before. Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently. rifampin (Rifadin) causes optic neuritis, decreases visual acuity & ability discriminate between color red & green. Ethambutol (Myambutol) Single daily dose (bronchodilator) early in morning. Enables maximal benefit during daytime activities. Additionally, causes insomnia. Take in at least 2 L of fluid per day; decrease viscosity of secretions. Limit intake Coffee, cola, & chocolate Theophylline (Theo-24) antiinflammatory for long-term control asthma. Anaphylactic reactions can occur with administration. Swelling lips & tongue are indication of adverse reaction

omalizumab (Xolair) Used treatment of pulseless ventricular tachycardia & ventricular fibrillation Defibrillation Regular rhythm, with rate 60 to 100 beats/min. PR & QRS normal 0.12 to 0.20 second & 0.04 to 0.10 seconds. Normal sinus rhythm Characterized absence P waves, wide QRS complexes (longer than 0.12 sec) & typically rate between 140-180 impulses/min. Rhythm is regular. Restorative coughing techniques sometimes used unstable V tachycardia. Cough cardiopulmonary resuscitation (CPR), if prescribed, by inhaling deeply & coughing forcefully every 1-3 seconds. Cough CPR may terminate the dysrhythmia or sustain cerebral & coronary circulation for short time until other measures can be implemented. Ventricular tachycardia Life-threatening dysrhythmia results from irritable ectopic focus that takes over pacemaker for heart. Low cardiac results can lead quickly to cerebral & myocardial ischemia. Feeling of impending doom. Ventricular tachycardia Loss P waves & fibrillatory waves before each QRS complex. aia quiver, which can lead to thrombus formation Atrial fibrillation energy level used defibrillation attempts is 360 joules. monophasic defibrillator machine maintenance first patent airway, & then oxygen administration, assessment of vital signs & LOC, & dysrhythmia detection. Nursing responsibilities after cardioversion Irregular chaotic undulations varying amplitudes. Ventricular fibrillation has no measurable rate & no visible P waves or QRS complexes & results from electrical chaos in ventricles. Ventricular fibrillation Induced by exercise & relieved by rest or nitroglycerin tablets. Triggered by a predictable amount effort or emotion