has a sudden onset and involves fluctuating mental status and inattention with disorganized thinking and/or altered level of consciousness.
Dementia has a slow onset, usually with normal attention.
involves loss of interest in previously pleasurable activities.
Anemia is a common complication of pregnancy, sometimes due to iron deficiency
During the second half of pregnancy, the fetus begins to store iron in preparation for extrauterine life and depletes maternal iron stores.
Hemoglobin <11 g/dL (110 g/L) in the first or third trimester
or <10.5 g/dL (105 g/L) in the second trimester is considered low.
can usually be relieved through lifestyle and dietary changes, including eating small and frequent meals, drinking cold fluids between meals, having a high-protein snack before bedtime and on awakening, and consuming foods/drinks containing ginger and vitamin B6.
.Interventions that meet the psychosocial (ie, sense of initiative) and cognitive (ie, preoperational thinking) needs of preschool-age children during preprocedural education include
allowing parents to remain with the client during the procedure, emphasizing that the procedure is not punishment, encouraging the child to ask questions, and utilizing toys to communicate about the procedure.
The primary intervention for trigeminal neuralgia includes pain control and limiting pain triggers. The drug of choice is carbamazepine
Triggers can include washing the face, chewing food, brushing teeth, yawning, or talking. Carbamazepine is associated with agranulocytosis (leukopenia) and infection risk. Clients should be advised to report any fever or sore throat.
Incorrect placement of a subclavian central venous catheter can result in an iatrogenic pneumothorax or hemothorax. The priority is to check the results of the chest x-ray to verify that the catheter tip has been placed correctly in the superior vena cava.
Other appropriate actions include attaching a filter to the IV tubing, monitoring baseline and fingerstick BG levels every 6 hours, and programming the electronic infusion device to ensure an accurate and consistent hourly infusion rate.
continuous IV drug infusions
monitored by the RN
The fundus rises above the symphysis pubis at approximately
12 weeks gestation
fundus reaches umbilicus
20-22 weeks gestation
fundus reaches the xyphoid process
at 36 weeks gestation
After 20 weeks gestation, the fundal height in centimeters correlates closely to
the weeks of gestation.
at 16 weeks
fundus is halfway between pubic symphysis and umbilicus
The nurse should educate clients about risk factors. Nonmodifiable risk factors (eg, those the client cannot control)
include African American ethnicity, having a first-degree relative with prostate cancer, and increasing age (>50)
Clients can lower the risk for prostate cancer by avoiding modifiable (ie, those the client can control) risk factors, which include:
-Diet high in red meat, animal fat, high-fat dairy products, and refined carbohydrates -Low fiber intake-Obesity
is an inherited disorder that results in impaired exocrine gland function and is characterized by thickened secretions that affect the pulmonary, gastrointestinal, and reproductive systems.
When planning care, the nurse should monitor for priority concerns of cystic fibrosis
including development of respiratory infections, chronic hypoxemia, nutritional deficiencies, and abnormal growth (failure to thrive).
Status epilepticus is a serious condition that could result in brain damage and death.
Quickly stopping the seizure is the first nursing priority as long as there is an adequate airway and the client is breathing. IV or rectal benzodiazepines (lorazepam or diazepam) are used to rapidly control seizures.
The development of hives, angioedema, wheezing, and respiratory distress in a client receiving IV vancomycin indicates anaphylaxis. The infusion must be stopped immediately and IM epinephrine administered.
Red man syndrome is a rate-related infusion reaction to IV vancomycin that is characterized by flushing, erythema, and pruritus, typically on the face, neck, and chest.-airway over anything
Clinical manifestations of an asthma exacerbation include:
-Accessory respiratory muscle use related to increased work of breathing and diaphragm fatigue -Chest tightness related to air trapping -Cough from airway inflammation and increased mucus production-Diminished breath sounds related to hyperinflation-High-pitched expiratory wheezing caused by narrowing airways ; wheezing may be heard on both inspiration and expiration as asthma worsens-Tachypnea related to inability to take a full, deep breath
Clients with obstructive lung disease (eg, asthma, chronic obstructive pulmonary disease)
develop prolonged expiratory phase as a physiologic response to hyperinflation and trapped air.
Myasthenia gravis is a chronic neurologic autoimmune disease in which acetylcholine receptors are blocked, causing muscle weakness.
Infection, undermedication, and stress can lead to a myasthenic crisis, which is characterized by oropharyngeal and respiratory muscle weakness and respiratory failure
Clients taking rifampin or rifapentine (Priftin) as part of antitubercular combination therapy should be taught to prevent pregnancy with non-hormonal contraceptives (NO oral contraceptives)
notify the health care provider of any signs or symptoms of hepatotoxicity (eg, jaundice, fatigue, weakness, nausea, anorexia), and expect red-orange-colored body secretions.
A client with seizure activity should be assessed as soon as possible after a hand-off report due to
increased risk for recurrent seizures, injury, aspiration, and airway obstruction.
most hemolytic reactions from blood
occur within 15-30 min
an increase in RBCs, is an anticipated compensatory response to chronically low blood oxygen levels in clients with severe COPD.
Neutropenia (low white blood cell count)
is not expected in COPD. Chemotherapy and many medications (clozapine [antipsychotic], methimazole [antithyroid]) can cause neutropenia which increases the risk of infection.
Thrombocytopenia (low platelet count) is not anticipated in COPD.
Alcohol use, HIV infection, and many medications (heparin) can cause thrombocytopenia.
Teaching points to assist a client in appropriate use of a cane include:
-Hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed (20-30 degrees) -Place the cane 6"-10" (15-25 cm) in front of and to the side of the foot to keep the body weight on both legs to provide balance -For maximum stability, move the weaker leg forward to the level of the cane, so that body weight is divided between the cane and the stronger leg If minimal support is needed, the cane and weaker leg are advanced forward at the same time.-Move the stronger leg forward past the cane and the weaker leg, so the weight is divided between the cane and the weaker leg.-Always keep at least 2 points of support on the floor at all times.-cane handle level with greater trochanter right below the waist
.Febrile seizures, although alarming, are generally benign.
Parents should be instructed on appropriate cooling methods (eg, antipyretics, cool compresses), seizure safety precautions, and the avoidance of shivering.
Decontamination is a priority nursing action for clients who have been exposed to a chemical or radioactive agent.
During a mass casualty disaster, the nurse should assist clients with complete decontamination before providing care. Decontamination limits further client injury and prevents exposure to other clients and staff.
The common adverse effects of codeine, an opioid drug, include
constipation, nausea, vomiting, orthostatic hypotension, and dizziness. Interventions to help prevent them include increasing fluid intake and bulk in the diet, laxatives, taking the medication with food, and changing position slowly.
Clients with type 1 diabetes should not discontinue insulin usage during an illness.
Encouraging fluids and monitoring glucose and ketone levels are priorities for this client.
Clients undergoing hypophysectomies are at risk for developing neurogenic diabetes insipidus (DI), a metabolic disorder of low ADH levels. ADH promotes water reabsorption in the kidneys. Therefore, loss of circulating ADH results in massive diuresis of dilute urine. Clinical manifestations associated with DI include
-Decreased urine specific gravity (<1.003) -Elevated serum osmolality (>295 mOsm/kg [295 mmol/kg]) -Hypernatremia (>145 mEq/L [145 mmol/L])-Hypovolemia and potential hypotension-Polydipsia-Polyuria (2-20 L/day)
endoscopic procedure to surgically remove a pituitary tumor through an incision in the sphenoid sinus without disturbing brain tissue
Positional plagiocephaly (flat head syndrome) occurs when an infant is placed in the same position (eg, supine)
for an extended period of time and the pliable skull molds to the surface (flattens). Parents can intervene to avoid or correct plagiocephaly (eg, periodically repositioning the head during sleep, tummy time). Minor skull deformation is not a priority.
Eight wet diapers in 24 hours is within the normal range (6-10 diapers/day or approximately 1 diaper every 4 hours)
indicating that the infant is likely producing >1 mL/kg/hr urine output and is not dehydrated, despite vomiting.
The Babinski reflex (ie, toes fan outward and the big toe dorsiflexes with stimuli)
is expected in infants and is a normal finding up to age 1 year. However, its presence beyond this age can indicate neurologic disease.
The presence of sunset eyes (sclera visible above the iris) is
a late sign of increased intracranial pressure and a priority to report to the health care provider.
Clinical manifestations of Pulmonary Embolism include:
-Pleuritic chest pain (ie, sharp lung pain while inhaling) -Dyspnea and hypoxemia -Tachypnea and cough (eg, dry or productive cough with bloody sputum) -Tachycardia-Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis
sign of tension pneumothorax
A life-threatening collection of air within the pleural space; the volume and pressure have both collasped the involved lung and caused a shift of the mediastinal structures to the opposite side.