REVIEW NOTES Things to Remember

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REVIEW NOTES: Things to remember
Tonometry: normal (10-21 mm Hg) PR Interval: normal (0.12-0.20 seconds) Serum Amylase: normal (25-151 units/dL) Serum Ammonia: normal (35 to 65 mcg/dL) Calcium: adult (8.6-10 mg/dL) child (8 to 10.5 mg/dL) term<1week hg =" inadequate">11 mm Hg = too much fluid Potassium: 3.5-5.0 mEq/L Sodium: 135-145 mEq/L Calcium: 4.5-5.2 mEq/L or 8.6-10 mg/dL Magnesium: 1.5-2.5 mEq/L Chloride: 96-107 mEq/L Phosphorus: 2.7 to 4.5 mg/dL PR measurements: normal (0.12 to 0.20 second) QRS measurements: normal (0.04 to 0.10 second) Ammonia: 35 to 65 ug/dL Amylase:25 to 151 IV/L Lipase: 10 to 140 U/L Cholesterol: 140 to 199 mg/dL LDL: <130>0.1 to 0.2 ng/mL = MI Erythrocyte studies: 0-30 mm/hour Serum iron: Male 65-175 ug/dL Female 50-170 ug/dL RBC: Male 4.5 to 6.2 M/uL Female 4.0 to 5.5 M/uL Theophylline levels normal (10 to 20 mcg/dl) MOTOR DEVELOPMENT Chin up: 1 month Chest up: 2 month Knee push and “swim”: 6 month Sits alone/stands with help: 7 month Crawls on stomach:8 month Stands holding on furniture: 10 month Walks when led: 11 month Stands alone: 14 month Walks alone: 15 month

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AT THE PLAY GROUND * Stranger anxiety: 0 -1 year * Separation anxiety: 1 - 3 years * Solitary play: 0 – 1 year * Parallel play: 2 – 3 years * Group play: 3 – 4 years LABORATORY VALUES ELECTROLYTES Sodium (Na+): 135 – 145 meq/L (increase-dehydration; decrease overhydration) Potassium (K+): 3.5 - 5.0 meq/L Magnesium (Mg++): 1.5 – 2.5 meq/L Calcium (Ca++): 4.5 – 5.8 meq/L Neonate : 7.0 to 12 mg/dL Child: 8.0 to 10.5 mg/dL Phosphorus (PO4): 1.7 – 2.6 meq/L Chloride (Cl-): 96 – 106 meq/L COAGULATION STUDIES Activated partial thromboplastin time(APTT): 20 – 36 seconds depending on the type of activator used Prothrombin time(PT): male: 9.6 – 11.8 seconds Female: 9.5 – 11.3 seconds International Normalized Ratio(INR): 2.0 - 3.0 for standard Coumadin therapy 3.0 – 4.5 for high-dose Coumadin therapy Clotting time: 8 – 15 minutes Platelet count: 150,000 to 400,000 cells/Ul Bleeding time: 2.5 to 8 minutes SERUM GASTROINTESTINAL STUDIES Albumin: 3.4 to 5 g/dL Alkaline phosphatase: 4.5 to 13 King-Armstrong units/dL Ammonia: 15 to 45 ug/dL Amylase: 50 – 180 Somogyi U/dL in adult 20 – 160 Somogyi U/dL in the older adult Bilirubin: direct: 0 - 0.3 mg/dL Indirect: 0.1 – 1.0 mg/dL Total: less than 1.5 mg/dL Cholesterol: 120 – 200mg/dL Lipase: 31 -186 U/L 2

Lipids: 400 – 800 mg/dL Triclycerides: Normal range: 10 – 190 mg/dL Borderline high: 200 – 400 mg/dL High: 400 – 1000mg/dL Very high: greater than 1000mg.dL Protien: 6.0 – 8.0 g/L Uric acid: male: 4.5 – 8 ng/dL Female: 2.5 – 6.2 ng/dL GLUCOSE STUDIES Fasting blood sugar: 70 – 105 mg/dL Glucose monitoring (capillary Blood): 60 – 110 mg/dL RENAL FUNCTION TEST Creatinine: 0.6 – 1.3 mg/dL Blood urea nitrogen (BUN): 5 – 20 mg/dL ERYTROCYTES STUDIES Erytrocyte sedimentation rate(ESR): 0 – 30 mm/hr depending on age Hemoglobin: male: 14 – 16.5 g/dL Female: 12 – 15 g/dL Hematocrit: male: 42% - 52% (increased in hemoconcentration, fluid loss and dehydration) Female: 35% - 47% ( decreased in fluid retention) Red blood cell (RBC): male: 4.5 to 6.2 million/uL Female: 4 to 5.5 million/uL White blood cell (WBC): 4500 to 11,000/uL Erytrocyte Protoporthyrin (EP) : <9ug/dl>25 mg/dL CRANIAL NERVES MAJOR FUNCTIONS I. Olfactory (S): smell II. Optic (S): vision III. Oculomotor (M) IV. Trochlear (M): Eye movement V. Trigeminal (S-M) Facial sensation: Jaw movement VI. Abducent (M): Eye movement VII. Facial (S-M) Taste, Facial expression VIII. Acoustic (S): Hearing and balance IX. Glossopharyngeal (S-M) Taste: Throat sensation Gag and swallow X. Vagus (S-M) Gag and swallow, Parasympathetic activity 3

XI. Spinal Accessory (M) Neck and back muscles XII. Hypoglossal (M): Tongue movement On Old Olympus’ Towering Tops, A Finn And German Viewed Some Hops Some Says Marry Money, But My Brother Says Bad Business Marry Money ARTERIAL BLOOD GAS (ABG) pH: 7.35 – 7.45 PCO2: 35 - 45 mmHg PO2: 80 - 100 mmHg HCO3: 22 - 27 mEq/L O2 saturation: 96% - 100% Acid-base “RAMS”(Respiratory Alternate, Metabolic Same) GLASGOW COMA SCALE Eye opening response Motor response Verbal response

FLOW OF BLOOD THROUGH THE HEART Inferior vena cava and superior vena cava – right atrium – tricuspid valve – right ventricle – pulmonic valve – pulmonary artery – lungs – pulmonary veins – left atrium – bicuspid valve (mitral) – left ventricle – aortic valve aorta – systemic circulation CARDIAC IMPULSES Sinoatrial (SA) node – right and left atria (atria contract) – atrioventricular (AV) node – bundle his – bundle brabches – purjinje’s fibers – ventricles contract. Blood volume: 5000mL Central venous pressure: 4 to 10 cmH2O (increased in cardiac overload; decreased in dehydration) Pressure within the right atrium: 2 to 7 mmHg Capillary refill time: <3 gr =" 60" gr =" 300" gr =" 1000mg" gr ="0.4" oz =" 30" dr =" 4" t =" 15" min =" 1" min =" 1mL" min =" 1" dr =" 1" qt =" 1000mL" qt =" 2" pt =" 16" oz =" 1" 2lb =" 1" 8 =" C" 32 =" F" q =" X" factor =" gtt" infuse =" Infusion">25 mg/dL Urine specific gravity: 1.016 - 1.022 increase in SIADH; decrease in diabetes insipidus 4

Normal CSF protein: 15 – 45 mg/dL increase in Guillain-Barre syndrome Normal CSF pressure: 5 – 15 mmHg Normal serum osmolality: 285 – 295 mOsmlkgH2O increase in dehydration; Decrease in over hydration Normal scalp pH: 7.26 and above Borderline acidosis: 7.20 to 7.25

NCLEX/CGFNS REVIEW BULLETS
• • The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20 mcg/mL. Dilantin are given to clients with history of seizure disorder. The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client may be noncompliant with the medication regimen. If the level is within the therapeutic range, the client is most likely compliant with medication therapy. Drug is given to COPD patients. The normal therapeutic range for digoxin is 0.5 to 2.0 ng/ mL. A value of 1.0 is within therapeutic range, and the nurse would administer the next dose as scheduled. An International normalize ratio (INR) of 2.0 to 3.0 is appropriate for most clients. An INR of 3.0 to 4.5 is recommended for clients with mechanical heart valves. If the INR is below the recommended range, the warfarin sodium dose would be increased. If the INR is above the recommended range, the warfarin sodium dose would be decreased. Since the value identified in this question is within the therapeutic range, the nurse would administer the next dose of warfarin. An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one’s body. Negligence involves actions below the standards of care. Invasion of privacy occurs when the individual’s private affairs are unreasonably intruded. In this situation, the nurse can be charged with battery because the nurse administers a medication that the client has refused. Defamation takes place when something untrue is said (slander) or written (libel) about a person, resulting in injury to that person’s good name and reputation. An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the 5

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standard of care for a specific professional group. Although the physician may be aware of the biopsy results, the physician decides when it is best to share such a diagnosis with the client. • If the physician writes an order that requires clarification, it is the nurse’s responsibility to contact the physician for clarification. If there is no resolution regarding the order because the order remains as it was written, after the physician has been contacted or because the physician cannot be located, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until clarification is obtained. Nurses need their own liability insurance for protection against malpractice law suits. Nurses erroneously assume that they are protected by an agency’s professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurse’s actions or inactions. Even though this is the norm, nurses are encouraged to have their own malpractice insurance. A Good Samaritan Law is passed by a state legislature to encourage nurses and other health care providers to give care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called “immunity from suit,” this protection usually applies only if all of the conditions of the law are met, such as the heath care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent. In a fire emergency, the steps to follow use the acronym RACE. The first step is to remove the victim. The other steps are: activate the alarm, contain the fire, then evacuate as needed. This is a universal standard that can be applied to any type of fire emergency. The nurse first removes the victim from the area. Pulling the nearest fire alarm would be the next step. The nurse next contains the fire and then extinguishes the fire. Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. The client with hyperphosphatemia should avoid foods that are naturally high in phosphates. These include fish, eggs, milk products, vegetables, whole grains, and carbonated beverages. Coffee, tea, and cocoa are not high in phosphates.

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The nurse manager needs to attend to the client assignments first. Client care is the priority. In addition, the nursing staff needs assignments so that they can begin client assessments and begin delivering client care. The nurse manager should next check the crash cart (which is normally done every shift) to ensure that needed equipment is available in the event of an emergency. The nurse manager could also delegate this task to another registered nurse while client assignments are being planned. The nurse manager would next begin the problem-solving process related to finding a charge nurse for the next shift. Since this activity directly affects client care, this would be done before reading the stack of mail. Arriving late to work is an unacceptable behavior. Although the nurse’s behavior has caused unrest with other staff members, the primary concern is that this behavior affects client care. The nurse manager needs to confront the nurse, discuss the lateness, and initiate problem-solving measures that ensure that the behavior does not continue. The nurse needs to stay with the client and consult with the nurse manager about the situation. It may be necessary for the nurse manager to contact the supervisor to obtain an additional staff member to care for the client. Since the client has a head injury, a major concern is the development of increased intracranial pressure (ICP). The application of restraints may agitate the client, causing further restlessness and thus increasing ICP. A nursing assistant is not trained to monitor for increased ICP. It is inappropriate to ask a family member to sit with the client. If a conflict arises, it is most appropriate to try to resolve the conflict directly. In this situation, the nurse has attempted to explain the reasons for being uncomfortable with the surgeon but was unable to resolve the conflict. The nurse would then most appropriately use the organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the surgeon or seek assistance from the nursing supervisor. External disasters occur in the community, and many victims may be brought to the emergency room for care. In this situation, the nurse manager would initially contact the nursing supervisor about the need for additional staffing and to discuss activation of the disaster plan. The nurse manager should ask, not demand that nurses from the night shift stay until all of the victims are treated. The nurse manager would not ask emergency medical services to take the victims to another hospital or close the emergency room temporarily to incoming clients. These decisions are made by administration.

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If a nurse feels that an assignment is more difficult than the assignment delegated to other nurses on the unit, the nurse would most appropriately discuss the assignment with the nurse manager of the neurological unit. The nurse may or may not have a more difficult assignment than the other nursing staff. However, this action will assist in either identifying the rationale for the assignment or determining if the assignment is actually more difficult. A nurse would not refuse an assignment. Specific situations may be present in which a nurse should not take care of a specific client, for example, if a pregnant nurse is assigned to care for a client with rubella or a client with an internal radiation implant. In these situations, the nurse would also discuss the assignment with the nurse manager. The nurse would not return to the cardiac unit; this would be client abandonment, and this action does not address the conflict directly. The signs of hypoglycemia and hyperglycemia can be difficult to distinguish. Weakness, headache, and blurred vision can occur in either blood glucose alteration. A blood glucose reading will assist in confirming the diagnosis so that the appropriate action can be taken. Hypoglycemia is immediately treated with 10 to 15 grams of carbohydrate. Glucose tablets or glucose gel may be administered. Other items used to treat hypoglycemia include 1/2 cup of fruit juice, 1/2 cup of regular (nondiet) soft drink, 8 oz of skim milk, 6 to 10 hard candies, 4 cubes or 4 teaspoons of sugar, 6 saltines, 3 graham crackers, or 1 tablespoon of honey or syrup. Most minor burns can be handled at home by the parents. For minor burns, exposure to cool running water is the best treatment. This stops the burning process and helps to alleviate pain. Ice is contraindicated, because it may add more damage to already injured skin. When a bee sting occurs and is painful, it is best to treat the site locally rather than systemically. Pain can be alleviated by applying an ice pack and elevating the site. When a Salem sump tube is connected to suction, the air vent permits a free, continuous flow of secretions. The air vent should never be clamped or tied off, connected to suction, or used for irrigation. The nurse manager should handle this problem directly with the nurse who is performing this action and should initially review the skills checklist of the nurse who is tying the knots to assess if this skill has ever been performed and validated. When cord compression is suspected, the woman is immediately repositioned. The client’s hips can be elevated to shift the fetal presenting part toward her diaphragm, thus relieving cord compression. A hands-and8

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knees position can reduce compression on the cord that is entrapped behind the fetus. Several position changes may be required before the fetal pattern improves or resolves. • If a nonreassuring fetal heart pattern occurs (tachycardia, bradycardia, decreased variability, and late decelerations), the nurse would intervene to increase fetal oxygenation. The oxytocin infusion is stopped immediately. The infusion rate of the nonadditive IV solution is increased. The client is positioned in a side-lying position, and oxygen via a snug facemask is administered at 8 to 10 liters per minute. The physician is notified of the adverse reactions, the nursing interventions that have been implemented, and the client’s response to the interventions. The maternal blood pressure is monitored closely. If physical abuse or neglect is suspected, the priority nursing action is to assess the client, treat any physical injuries, and ensure that the client is safe. The nurse also notifies the physician and the social worker to investigate the situation. All states in the United States and other Western countries have laws requiring health care professionals to report suspected elder abuse. Calling the police is a premature action. Telling the son that he cannot visit with his mother could initiate aggressive behavior in the son. Although the nurse may be involved in obtaining psychiatric assistance for the son, this is not the priority action. Severe leg pain, once traction has been established, indicates a problem. A client who complains of severe pain may need realignment or may have traction weights ordered that are too heavy. The nurse realigns the client, and if that is ineffective, then calls the physician. The nurse never removes traction weights unless specifically prescribed by the physician. The client should be medicated only after an attempt has been made to determine and treat the cause. With a trachea–innominate artery fistula, a malpositioned tube causes its distal tip to push against the lateral wall of the tracheostomy. Continued pressure from the tracheostomy tube causes necrosis and erosion of the innominate artery. This situation is a life-threatening complication. The tracheostomy tube is immediately removed. Direct pressure is then applied to the innominate artery at the stoma site. The client is then prepared for immediate surgical repair. An IV line will need to be initiated, but this is not the immediate action. The nurse should monitor the client’s heart rate and pulse oximetry during suctioning to assess the client’s tolerance of the procedure. Oxygen desaturation below 90% indicates hypoxemia. If hypoxia occurs during 9

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suctioning, the nurse terminates the suctioning procedure. Using the 100% oxygen delivery system, the client is reoxygenated until baseline parameters are achieved. The size of the catheter should not exceed half the size of the tracheal lumen. In adults, the standard catheter size is 12 to 14 French. Adequate catheter size facilitates efficient removal of secretions without causing hypoxemia. • In most situations, clamping of chest tubes is contraindicated, and agency policy and procedure must be followed with regard to clamping a chest tube. When the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax because the air has no escape route. If the tube becomes disconnected, it is best to immediately reattach it to the drainage system or to submerge the end in a bottle of sterile water or saline to reestablish a water seal. If sterile water or saline is not readily available, it is preferable to leave the tube open because the risk of tension pneumothorax outweighs the consequences of an open tube. The physician may need to be notified, but this is not the immediate action. The client would not be instructed to inhale. Surface foreign bodies are often removed simply by irrigating the eye with sterile normal saline. The nurse would not use clamps because this action will risk causing further injury to the eye. Applying an eye patch would not provide relief for the problem. Visual acuity tests are not the priority at this time, and might not be feasible because the client most likely has excessive blinking and tearing as well at this time. Keratoplasty is done by removing damaged corneal tissue and replacing it with corneal tissue from a human donor (live or cadaver). Preoperative preparation of the recipient’s eye can include obtaining a culture and sensitivity with conjunctival swabs, instilling antibiotic ophthalmic medication, and cutting the eyelashes. Some ophthalmologists order a medication such as 2% pilocarpine to constrict the pupil before surgery. Discharge instructions to a client after a keratoplasty includes telling the client that sutures are usually left in place for as long as 6 months. After the sutures are removed and complete healing has occurred, prescription glasses or contact lenses will be prescribed. Enucleation is removal of the eye, leaving the eye muscles and remaining orbital contents intact. Topical glucocorticoids can be absorbed in sufficient amounts to produce systemic toxicity. Primary concerns are growth retardation (in children), and adrenal suppression in all age groups. Systemic 10

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toxicity is more likely under extreme conditions, such as with prolonged therapy in which extensive surfaces are treated with high doses of high potency agents in conjunction with occlusive dressings. • Isotretinoin (Accutane) is prescribed for a clietn to treat severe cystic acne. It is usually administered two times daily for a period of 15 to 20 weeks. The usual adult dosage is 0.5 to 1 mg/kg/day. If needed, a second course may be administered, but not until 2 months have elapsed after completing the first course. Saquinavir (Invirase) is an antiviral medication. It is administered within 2 hours after a full meal. If the medication is taken without food in the stomach, it may result in no antiviral activity. Anastrozole (Arimidex) is prescribed for a postmenopausal client with breast cancer. The most dangerous adverse reaction to anastrozole is thromboembolism. Common reactions include nausea, chest pain, edema, and shortness of breath. A variety of gastrointestinal tract or nervous system effects may also occur. Cytarabine (Cytosar-U) is being prescribed to a nonlymphocytic anemia patient. The major toxic effect of cytarabine is bone marrow depression, resulting in hematologic toxicity. Signs of hematologic toxicity include fever, sore throat, signs of local infection, easy bruising, or unusual bleeding from any site. If these signs occur, the physician is notified. Anorexia, nausea, and a transient headache can occur as side effects of the medication but do not necessarily warrant physician notification, unless they are persistent in nature. Docetaxel (Taxotere) is an antineoplastic medication. Frequent side effects include alopecia, hypersensitivity reaction, fluid retention, nausea, vomiting, diarrhea, fever, myalgia, and nail changes. Before receiving docetaxel, the client is premedicated with an oral corticosteroid (dexamethasone (Decadron) 16 mg per day for 5 days, beginning day 1 before docetaxel therapy) to reduce the severity of fluid retention or prevent a hypersensitivity reaction. Paclitxel is being prescribed to a client with ovarian cancer. Side effects of paclitaxel (Taxol) include alopecia, pain in the joints and muscles, diarrhea, nausea, vomiting, peripheral neuropathy, hypotension, mucositis, pain and redness at the injection site, cardiac disturbances (bradycardia), and an abnormal electrocardiogram. Fatigue is an occasional side effect.

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Stavudine (Zerit) is prescribed for a client with advanced human immunodeficiency virus. Peripheral neuropathy, characterized by numbness, tingling, or pain in the hands or feet can occur frequently with this medication and is an adverse reaction. Ritonavir (Norvir) oral solution is prescribed to a client with HIV virus. The drug is preferably administered with food. It may be mixed with chocolate milk or a dietary supplement to improve the taste. The client is also instructed to consume the dose within 1 hour of mixing. Propofol (Diprivan) is an anesthetic agent that is used to provide continuous sedation for a client receiving mechanical ventilation. An adverse effect of the medication is hypotension. It can also cause respiratory depression and bradycardia. Facial flushing can occur as an occasional side effect. An adverse reaction of gemcitabine hydrochloride, an antineoplastic medication, is severe bone marrow depression, evidenced by anemia, thrombocytopenia, and leukopenia. The medication may be discontinued or the dosage may be modified if bone marrow depression occurs. The normal platelet count is 150,000 to 450,000/mm3. The nurse would contact the physician if a platelet count of 90,000/mm3 were noted. The normal range for the total bilirubin is 8.4 to 10.2 mg/dL. The normal BUN is 7 to 25 mg/dL. The normal range for the alkaline phosphatase is 42 to 128 units/L. IGIV is an immune serum that increases antibody titer and antigen-antibody reaction, providing passive immunity against infection. Anaphylactic reactions, although rare, can occur, and so the nurse ensures that epinephrine is readily available when administering this medication. Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for oral anticoagulants. Acetylcysteine is used to treat acetaminophen overdose. Lepirudin (Refludan) is an anticoagulant used for clients with heparin-induced thrombocytopenia and associated thromboembolitic disease to prevent additional thromboembolitic complications. For the postoperative client, the initial dose is administered as soon as possible after surgery but not more than 24 hours after surgery. Letrozole (Femara) is an aromatase inhibitor that is used to treat advanced breast cancer in postmenopausal women whose disease has progressed after antiestrogen therapy. The most frequent side effects include skeletal pain, and back, arm, and leg pain. Less frequent side effects include nausea, headache, fatigue, constipation, vomiting, and dyspnea. Amprenavir (Agenerase) is an antiretroviral agent, classified as a protease inhibitor, used to treat HIV infection. 12

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Indinavir (Crisxivan) is an antiretroviral agent. This medication can cause kidney stones; therefore, the client is instructed to increase fluid intake to at least 1.5 liters per day. The client is also instructed to report sharp back pain or the presence of blood in the urine. The client is instructed to take the medication 1 hour before or 2 hours after a large meal. If the medication needs to be taken with food, the client should consume a light meal, such as dry toast, juice, or a bowl of cereal with milk. Unexplained weight loss needs to be reported to the physician. Lamivudine is an antiretroviral agent that is administered in combination with zidovudine to delay the appearance of zidovudine resistance. Lamivudine is well absorbed orally either with or without food. Peripheral neuropathy can occur with its use, and the client is instructed to notify the physician if burning, numbness, or tingling of the hands, arms, feet, or legs occurs. Pancreatitis, evidenced by nausea, vomiting, and abdominal pain is also an adverse reaction to the medication, requiring physician notification. Levalbuterol (Xopenex) is a bronchodilator. This medication stimulates the beta receptors in the lungs, relaxes bronchial smooth muscle, increases vital capacity, and decreases airway resistance. Central nervous system (CNS) stimulation can occur with the use of this medication. The client is instructed to avoid caffeine-containing products such as coffee, tea, colas, and chocolate, because these products can cause further CNS stimulation. Moxifloxacin (Avelox) is a fluoroquinolone. Increased sensitivity of the skin to sunlight can occur, and the client is instructed to avoid excessive sunlight and artificial ultraviolet light. The client should wear sunscreen and protective clothing when outdoors. The client should also drink fluids liberally and avoid the use of antacids, because antacids will decrease absorption of the medication. The medication can cause inflamed and ruptured tendons, so that the client is instructed to notify the physician if inflammation or tendon pain occurs. Nelfinavir (Viracept) is an antiviral medication used in the treatment of HIV infection when antiretroviral therapy is warranted. It is available in both tablet and powder form. The powder form is prepared by mixing the dose with a small amount of water, milk, formula, soy milk, or dietary supplements. The powder is not mixed with acidic foods or juices such as apple juice or applesauce, orange juice, or grapefruit juice.

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Antacids are generally not administered with other medications because of their interactive effects. Additionally, antacids delay the absorption of other medications The client with hyperparathyroidism is likely to have elevated calcium levels. This client should reduce the intake of dairy products such as milk, cheese, ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are considered to be low-calcium foods. Sodium should not be limited for the client with hypercalcemia unless contraindicated for another reason, such as cardiac disease. When sodium is retained, then calcium is lost through the kidneys. The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse’s primary responsibility to follow up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse would document that the task was completed but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift. The client with a thoracic burn and smoke inhalation requires aggressive pulmonary measures to prevent atelectasis and pneumonia. These include turning and repositioning, using humidified oxygen, providing incentive spirometry, and suctioning on an as-needed basis. The client should not be left lying in a single position and should not have the head of bed flat. These could promote the development of complications by limiting chest expansion. Wound dehiscence is the disruption of the surgical incision or wound. When dehiscence occurs, the nurse immediately places the client in low-Fowler’s position and instructs the client to lie quietly. These actions will minimize protrusion of the underlying body tissues. The nurse then covers the abdominal wound with a sterile dressing moistened with sterile saline. The physician is then notified and the nurse documents the occurrence and the nursing actions implemented. Adult diabetes mellitus can be diagnosed either by symptoms (polydipsia, polyuria, polyphagia), or by laboratory values. Diabetes mellitus is diagnosed by an abnormal glucose tolerance test, or when random plasma glucose levels are greater than 200 mg/dL, or fasting plasma glucose levels are greater than 140 mg/dL on two separate occasions.

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Hemorrhage is a potential complication following tonsillectomy and adenoidectomy. If the client vomits large amounts of altered blood or bright red blood, or if the pulse rate or temperature rises and the client is restless, the nurse must notify the surgeon immediately. The nurse should obtain a light, mirror, gauze, curved hemostats, and a waste basin for examination of the surgical site. The nurse would also gather additional assessment data, but the immediate nursing action would be to contact the surgeon. The client with hypertension is at risk for cardiovascular complications, such as angina pectoris, myocardial infarction, and heart failure. Thyroid preparations increase metabolic rate, oxygen demands, and demands on the heart. The client should know to report the onset of chest pain immediately. Lethargy, constipation, and weight gain are symptoms of hypothyroidism, which should improve with medication therapy such as levothyroxine sodium. Pulmonary embolism is a life-threatening emergency. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. IV infusion lines are needed to administer medications or fluids. A perfusion scan, among other tests, may be performed. The ECG is monitored for the presence of dysrhythmias. Additionally, a urinary catheter may be inserted and arterial blood gases may be drawn. However, the immediate nursing action is to administer oxygen. Fludrocortisone acetate (Florinef) is a long-acting oral medication with mineralocorticoid and moderate glucocorticoid activity. It is prescribed for the long-term management of Addison’s disease. Mineralocorticoids cause renal resorption of sodium and chloride ions, and the excretion of potassium and hydrogen ions. These actions help restore electrolyte balance in the body. The client with diabetic neuropathy of the lower extremities has diminished ability to feel sensations in the legs and feet. This client is at risk for tissue injury and for falls as a result of this nervous system impairment. A traumatic open pneumothorax is an emergency. Stopping the flow of air through the opening in the chest wall is a life saving measure. In such an emergency, anything may be used that is large enough to fill the chest wound including a towel, a handkerchief, or the heel of the hand. If conscious, the victim is instructed to inhale and strain against a closed glottis. This action assists in reexpanding the lung and ejecting the air from the thorax. In the hospitalized client who experiences an open pneumothorax, the opening is plugged by sealing it with gauze impregnated with petrolatum. The client with severe osteoporosis as a result of hyperparathyroidism is at great risk for injury as a result of pathological fractures from bone 15

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demineralization. The client may or may not have a risk for impaired urinary elimination, depending on other elements in the client history, and whether or not the client is at risk for stone formation from high serum calcium levels. The client may also have a risk for constipation from the disease process, but this would be a lesser priority than client safety. A risk for ineffective health maintenance may be a concern but is not the priority. • Clients with myxedema or hypothyroidism have decreased metabolic demands from reduced metabolic rate. For this reason they often experience weight gain. The diet should be low in calories overall and yet be representative of all food groups. Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this disorder then is one that is high in calcium but low in phosphorus, because these two electrolytes have inverse proportions in the body. Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If no external air leak is present, the physician is notified immediately because an air leak may be present in the pleural space. Leaking and trapping of air in the pleural space can result in a tension pneumothorax. The client taking NPH insulin obtains peak medication effects 6 to 12 hours after administration. At the time that the medication peaks, the client is at risk of hypoglycemia if food intake is insufficient. The nurse would teach the client to watch for signs and symptoms of hypoglycemia, including anxiety, confusion, difficulty concentrating, blurred vision, cold sweating, headache, increased pulse, shakiness, and hunger. Before doing a fingerstick for blood glucose measurement, the client should first wash the hands. Warm water should be used to stimulate the circulation to the area. The finger is punctured near the side, not the center, since there are fewer nerve endings along the side of the finger. The puncture is only deep enough to obtain an adequately sized drop of blood; excessively deep punctures can lead to pain and bruising. The arm should be allowed to hang dependently, and the finger can be milked to promote obtaining a good size blood drop. Diabetic clients should take in approximately 15 grams of carbohydrate every 1 to 2 hours when unable to tolerate food due to illness. The client with DKA initially becomes hyperkalemic as potassium leaves the cells in response to a lowered pH. Once fluid replacement and insulin therapy 16

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are started, the potassium level drops quickly. This occurs because potassium is carried into the cells along with glucose and insulin, and also because potassium is excreted in the urine once rehydration has occurred. Thus, the nurse must plan to monitor the results of serum potassium levels carefully, and report hypokalemia • In the immediate postoperative period following a radical neck dissection, the nurse assesses for stridor (a coarse, high-pitched sound on inspiration when auscultating over the trachea). This finding is reported immediately, because it indicates airway obstruction. Variances are actual deviations or detours from the critical paths. Variances can be positive or negative, avoidable or unavoidable, and can be caused by a variety of things. Positive variance occurs when the client achieves maximum benefit and is discharged earlier than anticipated. Negative variance occurs when untoward events prevent a timely discharge. Variance analysis occurs continually in order to anticipate and recognize negative variance early, so that appropriate action can be taken In functional nursing, a task approach method is used to provide care to clients. The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are deep and nonlabored. They occur as the body tries to eliminate carbon dioxide to compensate for lactic acidosis. As ketoacidosis improves, this pattern of respiration resolves. The nurse monitors the client’s respiratory status as part of the client’s overall status. The client is likely to have tachycardia due to efforts by the body to compensate for the effects of anemia. The client with anemia is likely to complain of fatigue, because of decreased ability of the body to carry oxygen to tissues to meet metabolic demands. Increased respiratory rate is not an associated finding, although some clients may have shortness of breath. Spinal cord compression should be suspected in a client with metastatic disease, particularly when a new and sudden onset of back pain occurs. Spinal cord compression causes back pain before neurological changes occur. Spinal cord compression is an oncological emergency, and the physician should be notified. The client with iron deficiency anemia should increase intake of foods that are naturally high in iron. The best sources of dietary iron are red meat, liver and other organ meats, blackstrap molasses, and oysters. Iron preparations can be very irritating to the stomach and are best taken after a meal. The tablet is swallowed whole, not chewed. Because the client 17

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might experience constipation, the client should increase fluids and fiber in the diet to counteract this side effect of therapy. • For most hematological laboratory studies, including CBC, no special care is needed either before or after the test. There is no reason to fast after midnight, drink extra liquids, or avoid red meat prior to the laboratory test being drawn. Before bone marrow aspiration, the site is cleansed with an antiseptic solution such as povidone-iodine. This helps reduce the number of bacteria on the skin, and decreases the risk of infection from the procedure. When delegating nursing assignments, the nurse needs to consider the skills and educational levels of the nursing staff. The nursing assistant can most appropriately give a shower, a bed bath, ambulate a client with a walker, take an oral temperature. The LPN can administer the rectal suppository to the client requiring the enema. The LPN is skilled in wound irrigations and dressing changes, and this client would most appropriately be assigned to this staff member. After ear surgery, clients need to avoid straining when having a bowel movement. Clients need to be instructed to avoid drinking with a straw for 2 to 3 weeks, traveling by air, and coughing excessively. Clients need to avoid getting their head wet, washing their hair, and showering for 1 week. Swimming is also avoided. Clients need to avoid moving the head rapidly, bouncing, and bending over for 3 weeks. Exacerbation of Ménière’s disease is characterized by severe vertigo. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Activities such as reading and watching TV will worsen the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects. The client who is thrombocytopenic is at risk for bleeding. The family should observe the puncture site for bleeding for several days after the procedure, since the client is at high risk. Acetaminophen may be given for discomfort, and aspirin should be avoided because it could aggravate bleeding The client who has had surgical resection of the stomach or small intestine may develop pernicious anemia as a complication. This results from decreased production of intrinsic factor (gastrectomy) or decreased surface area for vitamin B12 absorption (intestinal resection). The client then requires vitamin B12 injections for life. Decreased iron intake leads to iron deficiency anemia, which is often easily treated with iron supplements. 18

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Otoscopic examination in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise, anorexia, swelling behind the ear, and pain with minimal movement of the head. The RN would plan to care for the client who is scheduled for surgery at 1:00 p.m. first. There are several items that need to be addressed preoperatively, including client preparation (physically and emotionally) and physician orders that need to be carried out. This preparation takes time. Additionally, many times the operating room makes late changes in the schedule, depending on room and physician availability, and requests an earlier surgical time. Therefore, it is best to ensure that this client is prepared. Clozapine is an antipsychotic medication with no demonstrated extrapyramidal side effects. The risk of extrapyramidal effects with the other medications listed is moderate (chlorpromazine) to high (haloperidol, loxapine). Denial is a response by the rape victim. It is described as an adaptive and protective reaction. Projection is blaming or “scapegoating.” Rationalization is justifying the unacceptable attributes about himself or herself. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation in which there may not be an escape. Agoraphobia includes the possibility of experiencing a sense of helplessness or embarrassment if a phobic attack occurs. Avoidance of such situations usually results in reduction of social and professional interactions. Social phobia focuses more on a specific situation, such as the fear of speaking, performing, or eating in public. Claustrophobia is a fear of closed in spaces. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health. Appropriate nursing diagnosis for a client scheduled to have electroconvulsive theraphy (ECT) is Risk for aspiration. Aspiration is safeguarded against by keeping the client NPO for 6 to 8 hours before the procedure, removing dentures, and administering glycopyrrolate (Robinul) or atropine sulfate as prescribed. When analyzing data obtained from a client suspected of family violence, the physiological well-being of the client is always considered first.

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During the acute phase of the rape crisis, the client can display a wide range of emotional and somatic responses. All of the symptoms noted in the question indicate a normal reaction to a very intensely difficult crisis event. Although the client’s initial reactions may be predictive of later problems, they do not indicate an abnormal initial response. Finding the right drug at the right dose that provides the least side effects for the client, providing clients with the injectable, long-acting form of the medication, and including the family in the medication planning process are measures that will promote compliance. Not all medications can be given on a once-per-day dosing regimen due to a short half-life of some medications. Lithium carbonate is an example of one such medication that must be taken throughout the day to maintain steady serum drug levels. Obsessions are defined as persistent thoughts that are intrusive and that the person tries to ignore or suppress. This client wants to “snap out of” this daily review, but the thoughts continue for hours. Compulsions are defined as repetitive behaviors that the client feels driven to perform, such as changing clothes frequently until he gets it “just right.” Al-Anon support groups provide a supportive opportunity for spouses and significant others to learn what to expect about successful behavioral changes. Any clear threats by psychiatric clients to harm specific people must be reported to the authorities (law enforcement) and the intended victims by mental health care providers and psychotherapists. Major depression occurs twice as frequently in females as in males. Reacting to loss by experiencing altered sleep for 1 week is a normal grief response. While depression is often associated with substance abuse, it would not, in and of itself, constitute a major depression. A conversion disorder is an alteration or loss of a physical function that cannot be explained by any known pathophysiological mechanism. It is thought to be an expression of a psychological need or conflict. In this scenario, the client witnessed an accident that was so psychologically painful that the client became blind. Psychosis is a state in which a person’s mental capacity to recognize reality, communicate, and relate to others is impaired, thus interfering with the person’s capacity to deal with life demands. A dissociative disorder is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. Repression is a coping mechanism in which unacceptable feelings are kept out of awareness.

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Ego defense mechanisms are operations outside of a person’s awareness that the ego calls into play to protect against anxiety. Displacement is the discharging of pent-up feelings on persons less dangerous than those who initially aroused the emotion. In this scenario, the nurse manager reprimands the unit secretary for overusing clerical supplies. The secretary lashes out at the temporary secretary and student nurses for wasting supplies. These are much “safer targets” to become angry with than the nurse manager. Denial is the blocking out of painful or anxiety-inducing events or feelings. Suppression is consciously keeping unacceptable feelings and thoughts out of awareness. Repression is unconsciously keeping unacceptable feelings out of awareness. Taking time to discuss the client’s concerns is as important a nursing action in many instances as any intervention for physical care. Therapeutic communication should focus on the client’s nonverbal cues and encourage the client to express feelings or concerns about surgery. When a client harms himself, immediate 1:1 nursing supervision is instituted. This meets the safety needs of the client. After doing this, the psychiatrist is notified of the incident. The client should not be restrained or placed in seclusion. Tardive dyskinesia, the involuntary movements of the tongue, jaw, lips, and facial muscles, is a manifestation of EPS. Flaccid muscles are not a characteristic of EPS. Agraphia, the inability to read or write, is not a characteristic of EPS. Dystonia is characterized by acute spasms of the tongue, neck, face, and back, laryngospasms, torticollis, and eyes locked upwards. The dosage of lithium carbonate needs to remain constant to maintain blood levels between 0.6 mEq/L and 1.2 mEq/L. There is a narrow margin between therapeutic and toxic levels. Blood levels are necessary to assess this narrow range. Adequate salt and fluids are necessary to prevent toxicity. Vomiting and diarrhea could be signs of toxicity and need to be reported. Dosages should never be adjusted. Amitriptyline (Elavil) has a sedative effect, and a single maintenance dose should be taken at bedtime. This also precludes the need for insomnia medication. Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI). Clients taking MAOIs should report any headache to the physician, because it may signal an impending hypertensive crisis. A low tyramine diet needs to be consumed. Dry crackers can be eaten if the client gets nauseated. Chewing sugarless gum is appropriate. 21

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The client needs to be able to put the trauma into a new context. The client needs to realize that the trauma did not occur because he or she did something wrong, used poor judgment, or somehow deserved it. The client will often express feelings of guilt, but the goal will be to assist to put it in perspective and eventually to be able to work through the feelings of guilt. A situational crisis arises from external rather than internal sources. External situations that could precipitate crisis include loss of or change of a job, the death of a loved one, abortion, a change in financial status, divorce, the addition of new family members, pregnancy, and severe illness. An adventitious crisis is not a part of every day life, is unplanned, and accidental. As with all loss experienced by individuals and families, opening up the communication channels is a key factor in successful grieving and surviving. Often, estrangement occurs in families because well-meaning relatives and friends do not know how to respond. This uncertainty and fear causes relatives and friends to isolate when communication and an opportunity to grieve with support are crucial. Joining a survivor-victim group is a positive outcome, but if the client is not talking with his or her family members, it is likely that maximum benefit from the group will not be achieved. Recognizing situations that produce anxiety allows the client to prepare to cope with anxiety or avoid specific stimulus. Counselors will not be available for all anxiety-producing situations. Sertraline hydrochloride (zoloft), a selective serotonin reuptake inhibitor, can cause a dry mouth that is alleviated by sucking on sugarless hard candy and chewing gum. Foods such as cheese, wine, and chocolate contain an amino acid, tyramine that reacts with monoamine oxidase inhibitors. Monthly blood levels are usually required for clients who are receiving lithium carbonate (Eskalith) therapy. Sertraline is usually taken with meals. Central nervous system depressants such as alcohol will produce an addictive effect if taken with diazepam, which can be lethal. Diazepam can cause initial drowsiness. It should not be discontinued abruptly, because the client may develop withdrawal symptoms. Many of the over-the-counter medications used to treat the flu contain medication that should not be taken when a client is taking diazepam. Clients who are taking monoamine oxidase inhibitors (MAOIs) must maintain a low tyramine diet and receive health teaching regarding the foods, beverages, and medications that must be avoided. Foods with aged cheese can cause a hypertensive crisis if taken with MAOIs. 22

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Fluoxetine hydrochloride (Prozac) tends to improve the energy level, and if it is taken late in the day, insomnia may occur. Many clients suffer from sexual dysfunction throughout treatment, such as decreased libido. Side effects can be expected to some degree with any medication. The lag time from the time the medication is started until therapeutic effects are achieved is anywhere from 2 to 4 weeks or longer. This is true with any antidepressant. Sodium depletion will decrease renal excretion of lithium, thereby causing the medication to accumulate and potentiating toxicity. Clients need to be instructed to maintain a normal sodium intake. Diuretics promote sodium loss, and these medications need to be used with caution in the client taking lithium. Sodium loss secondary to diarrhea can cause lithium accumulation, and the client should be forewarned of this possibility. Chlorpromazine blocks dopamine neurotransmission at postsynaptic dopamine receptor sites, reversing psychotic symptoms. Lithium is an antimanic medication and is used to treat the manic phase of a manic-depressive disorder. Neuroleptic malignant syndrome is a serious and potentially fatal reaction to antipsychotics. The classic symptoms include hyperthermia; severe extrapyramidal symptoms, such as muscular rigidity; and autonomic dysfunction, such as hypertension and tachycardia. The first priority in planning care for a client with dysfunctional grieving is to assess the risk for violence toward self and others. The plan will include efforts to work toward resolving the grief through emotional, cognitive, and behavioral means. Ensuring safety is a major aspect in the plan of care for the abused elder. The nurse may need to contact the social worker to plan care for the client, but this is not the priority action. In all child abuse cases, the primary concern is the health and safety of the child. Adventitious crises are the unpredictable tragedies that occur without warning. A maturational crisis involves the normal life transition that creates changes with individuals and how they perceive themselves, their role, and their status. A situational crisis occurs when a specific, external event disturbs an individual’s psychological equilibrium. An individual may experience a crisis; however, there is no formal type of crisis known as individual crisis. 23

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In the ECT suite, blood pressure, cardiac, and electroencephalographic monitors are placed on the client to assess vital functions. Whenever ECT is administered, emergency equipment, including oxygen, suction, and a cardiac arrest cart, must also be available. In the norming stage, members express intimate personal opinions and feelings around personal tasks. In the forming or initial stage, the members are identifying tasks and boundaries. Storming involves responding emotionally to tasks. In the performing stage, members direct group energy toward the completion of tasks. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. Reminders of the client’s recent accomplishments or personal successes are ways to interrupt the client’s negative self-talk and distorted cognitive view of self. In a client with a diagnosis of delirium. It is important to provide a consistent daily routine and a low stimulating environment when the client is disorientated. Noise, including radio and television, can add to the confusion and disorientation. A well-lit room will increase stimulation. In the immediate post-disaster period, it is important that a nurse go to places where victims are likely to gather, such as morgues, hospitals, and shelters. Rather than waiting for people to publicly identify themselves as being unable to cope with stress, it is suggested that nurses work with the American Red Cross. The nurse should talk to people waiting to receive assistance, go door to door, or go to a relocation site. The nurse should ask people how they are managing their affairs and explore their reactions to stress. If a client is in the act of preparing to commit suicide, the most appropriate nursing activity is to communicate with the client and attempt to develop a therapeutic relationship. The nurse should communicate hope, and hope is most often the most therapeutic element in any nursing intervention with a suicidal patient. Identification is the process by which a person tries to become like someone he or she admires by taking on thoughts, mannerisms, or tastes of that person. Intellectualization is excessive reasoning or logic used to avoid experiencing disturbed feelings. Projection is attributing one’s thoughts or impulses to another person. Regression is retreating to a behavior characteristic of an earlier level of development.

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Direct expressions of self-hate or low self-esteem can include the client’s expression of self-criticism. The client will exhibit negative thinking and believe that he is doomed to failure. The underlying goal of the client is to demoralize himself or herself. The client may describe himself as stupid, no good, or a born loser. The client will view the normal stressors of life as impossible barriers and become preoccupied with self-pity. It is the nurse’s responsibility to tell a client that secrets cannot be kept and also that any disclosures that reveal behavior that may be harmful to the client will need to be communicated to the appropriate professionals in the health care team. To de-escalate aggressive behavior, the nurse should manage the environment by persuading the client to move to another area. This will help prevent anxiety contagion and protect others. The nurse should also give the client clear instructions that are brief and assertive and should also negotiate options with the client. This shows the nurse’s confidence and leadership and also avoids misunderstandings in regard to not knowing what to do. Negotiating options allows the client to feel that he or she has some room in exercising the options. The nurse must allow the client body space and should not stand closer than about 8 feet to the client. Standing close to the client will convey a threat. Recreational therapy helps clients with personality disorders explore ways to enjoy themselves without the use of self-destructive behaviors, such as abusing alcohol or drugs. This modality is helpful to clients who have difficulty socializing, because recreation strengthens social skills. Movement therapy may be helpful for clients who become “numb” when experiencing intense feelings. Art therapy may be helpful for the client who is angry. The client who is exhibiting violent behavior may require medication therapy. Concentration and memory are poor in severe depression. When a client has a diagnosis of severe depression, the nurse needs to provide activities that require little concentration. Activities that have no right or wrong choices or activities that require minimal decision making minimize opportunities for clients to put themselves down. When the client demonstrates calm behavior and communicates that he or she is no longer a threat to self or others, the nurse would gather additional assessment data to determine if the client is safe to come out of seclusion. Social phobia focuses on a specific situation, such as the fear of speaking, performing, or eating in public. Agoraphobia is a fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. 25

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Claustrophobia is a fear of closed places. Clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health. • It is most therapeutic for the nurse to empathize with the client’s experience. Disagreeing with delusions may make the client more defensive and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate. If a client with severe anxiety is left alone, he or she may feel abandoned and become overwhelmed. Placing the client in a quiet room is also important, but the nurse must stay with the client. It is not possible to teach the client deep breathing exercises until the anxiety decreases. Encouraging the client to discuss the accident would not take place until the anxiety has decreased. Systematic desensitization is a form of therapy used when the client is introduced to short periods of exposure to the phobic object while in a relaxed state. Gradually, exposure is increased, until the anxiety about or fear of the object or situation has ceased. If a client is monopolizing the group, it is important that the nurse be direct and decisive. The best action is to suggest that the client stop talking and try listening to others. Using therapeutic communication techniques, the nurse acknowledges the husband’s concerns and conveys that the client’s symptoms are common with myxedema. With thyroid hormone therapy, these symptoms should decrease, and cognitive function often returns to normal within 2 weeks. When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the tasks is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. Noninvasive interventions can be assigned to a nursing assistant. A drop in blood pressure and rise in pulse rate could indicate postoperative bleeding, which is a complication of a parathyroidectomy. Because bleeding might not be observed on the front of the dressing due to the effects of gravity, the nurse must check underneath it as well. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. In autocratic leadership, the leader retains all authority and is primarily concerned with task accomplishment. Situational leadership is a comprehensive approach 26

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that incorporates the leader’s style, the maturity of the work group, and the situation at hand. Laissez faire is a permissive style of leadership in which the leader gives up control and delegates all decision making to the work group. • To promote adequate healing and to meet continued high metabolic needs, the client with a major burn should eat a diet that is high in calories, protein, and carbohydrate. This type of diet also keeps the client in positive nitrogen balance. Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, making all of the decisions alone. Situational leadership is a comprehensive approach that incorporates the leader’s style, the maturity of the work group, and the situation at hand. Laissez faire is a permissive style of leadership in which the leader gives up control and delegates all decision making to the work group. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. The clinical manifestations of a disulfiram-alcohol reaction include flushing, throbbing in the head and neck, difficulty breathing, nausea, vomiting, sweating, dizziness, and weakness. This type of reaction can occur in a client taking disulfiram (Antabuse). The reaction can occur even if only one-half ounce of alcohol is absorbed into the body (whether ingested by mouth or applied to the skin). Clients who are depressed often suffer insomnia, and relaxation measures are recommended to induce sleeping. The nurse might also give the client a back rub and use soft, dim lighting. Responsible assertiveness provides clients with the skill to stand up for their personal and professional rights and to express their thoughts and beliefs directly, honestly, and appropriately in a manner that will not violate the rights of other. Benztropine mesylate is an anticholinergic agent that is used in the treatment of Parkinson’s disease and the extrapyramidal symptoms (except tardive dyskinesia) that result from the use of neuroleptic or antipsychotic medication. The medication increases and prolongs the dopamine activity in the CNS, thereby correcting

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neurotransmitter imbalances and minimizing involuntary movements. • Buspirone hydrochloride (Buspar) is used in the management of anxiety disorders. It is contraindicated in clients with severe renal or hepatic impairment and in clients taking monoamine oxidase inhibitors. The nurse would notify the physician if the client had a history of renal impairment. A therapeutic serum level for the use of carbamazepine is a level between 3 mcg/mL to 12 mcg/mL. Neuroleptic malignant syndrome is a rare, life-threatening syndrome that is an adverse reaction of the use of chlorpromazine. Its signs include severe rigidity, fever, increased white blood cell count, unstable blood pressure, tachycardia, tachypnea, and renal failure. Signs of acute dystonias include painful neck spasms, torticollis, oculogyric crisis, and convulsions. Tardive dyskinesia includes choreiform movements of the tongue, face, mouth, jaw, and possibly the extremities. Common side effects experienced during the first 2 weeks of therapy with disulfiram include mild drowsiness, fatigue, headaches, metallic or garlic aftertaste, allergic dermatitis, and acne eruptions. Symptoms disappear spontaneously with continued therapy or reduced dosage. Donepezil hydrochloride is a cholinergic medication and is to be taken in the evening before bedtime. The medication should be taken with food; therefore, a snack should be provided to the client when the medication is administered. Fluoxetine hydrochloride (Prozac) takes 2 to 5 weeks to produce an elevation of mood. Advantages of the medication are few anticholinergic side effects and a low incidence of cardiovascular effects. It may, however, impair judgment, thinking, and motor skills. The client should be instructed that it will take more time for the medication to produce the desired effect. Lithium should be administered with meals. The client should be instructed to maintain a regular diet and an average salt intake to keep the serum lithium level in the therapeutic range. The client is instructed to avoid alcohol and to drink 2 to 3 liters of liquids per day during initial therapy, and 1 to 1.5 liters per day during the remainder of therapy. Phenelzine sulfate is a monoamine oxidase inhibitor (MAOI) antidepressant. The client needs to be instructed to avoid foods that require bacteria or mold for their preparation or preservation or those that contain tyramine. These 28

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food items include cheese, sour cream, beer, wine, pickles herring, liver, figs, raisins, bananas, avocados, soy sauce, yeast extracts, yogurt, papaya, broad beans, meat tenderizers, or excessive amounts of caffeine such as in coffee, tea, or chocolate. The client is also instructed to avoid over-the-counter preparations used for hay fever, colds, or for weight reduction. The client should also avoid alcohol. • When a client is experiencing an auditory hallucination, it is important initially to understand what the voices are saying or telling the client to do. Suicidal or homicidal messages, if heard by the client, necessitate implementing priority measures. The therapeutic maintenance range of lithium is 0.6 to 1.2 mEq/L. Early signs of lithium toxicity include nausea and vomiting, slurred speech, muscle weakness, thirst, and polyuria. Advanced signs of toxicity (1.5 to 2.0 mEq/L) would include hand tremors and muscle incoordination (option 4). Severe toxicity (greater than 2.0 mEq/L) is present if the client exhibits ataxia, hypotension, oliguria, and confusion (options 2 and 3). Seizures, coma, and death can also result. Levels of mania may be labeled as hypomania, acute mania, and delirious mania. The client in the acute state experiences relative sleeplessness, which over time decreases cognitive functioning, concentration, and judgment. The client is continuously active and does not take time to eat. The client’s mood may alternate rapidly between periods of good humor and irritability. In hypomania, the client experiences feelings of euphoria and sociability. Judgment is often poor in this level. In delirious mania, the client is out of touch with reality. Blood levels are drawn weekly in many cases when a client is beginning lithium therapy. The literature varies somewhat and states that blood levels may be drawn initially from 3 times a week to biweekly during this phase. After therapeutic levels are achieved, blood level draws may be reduced to monthly. If levels are stable after 6 to 12 months, the frequency may be further reduced to every 3 months. Amitriptyline is a tricyclic antidepressant used to treat the client experiencing a mood disorder. It takes an average of 10 to 14 days for the client to begin feeling medication effects. The nurse should give the client information about the medication, and should encourage the client to continue the medication as prescribed.

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Memory loss is an expected temporary effect of ECT. The client should be told that this might occur, and that memory usually returns within a few weeks. Occasionally clients have memory loss that lasts up to 6 months. The nurse uses therapeutic communication techniques that will focus on the client’s concerns and do not block further communication. Fluoxetine (Prozac) is a selective serotonin uptake inhibitor used in the treatment of depression. The medication is effective if the client experiences relief of symptoms of depression. The client taking a MAOI medication should be advised to avoid eating foods that are high in tyramine. The tyramine in foods reacts with the medication, causing a hypertensive crisis, which could prove to be fatal. Most fruits and vegetables are naturally low in tyramine, with the exception of figs, bananas (in large amounts), avocados, soybeans, and sauerkraut. Clients with a histrionic personality disorder are overly concerned with impressing others, and they are often preoccupied with their appearance. Their emotional responses are often shallow and changeable, although they are also intense. Clients who have a borderline personality tend to have intense needs that they seek to fulfill in relationships. Clients with a narcissistic personality disorder have a great need for admiration, exploit others to meet their own needs and desires, and have a lack of empathy for others. The client with an avoidant personality disorder is often preoccupied with a fear of rejection and criticism. Clients with cluster A personality disorders often behave in a manner that is odd or eccentric. Suspicion of others is particularly typical in paranoid personality disorder, a cluster A disorder. Manipulative and dramatic behaviors are typical of some of the cluster B disorders. Anger, anxiety, and fearfulness are typical of clients with cluster C disorders. The nurse should avoid getting into power struggles with the manipulative client, such as arguing with the client or making accusations. The client with a dependent personality disorder exhibits an unusually strong need to be cared for, and has difficulty making personal choices and making everyday decisions. An appropriate goal would be for the client to use the problem-solving process effectively in everyday situations. The nurse who is preparing a treatment plan for a client in prison must employ a framework that integrates the built-in realities and limitations of the correctional setting and the compulsory regimen that has been created for the offender. The incidence of suicide in correctional settings is higher among 30

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inmates than it is in the general population. The prison nurse’s ability to assess for self-violence and suicide is critical. • One of the criteria that the Parole Board will investigate is the client’s ability to engage in strategic planning. The fact that the client has plans for employment and regaining custody of the children will be viewed in a positive way as an example of changed behavior. Codependence involves overly responsible behavior, that is, doing for another person what that person could be doing for himself or herself. The least helpful strategy by the nurse is to demand that the client stop taking drugs. This blocks further communication, and does not affect behavior change on the part of the client. If client health maintenance is the goal, it is helpful for the nurse to instruct the client about aseptic conditions for drug use to reduce the risk of human immunodeficiency virus and hepatitis. It is also useful to educate the client about the short- and long-term effects of the substance being abused. Since many clients who use drugs are malnourished, it is also helpful to teach the client the elements of basic nutrition. In larger organizations such as hospitals, there are often employee assistance programs that offer services such as information, counseling, and referral for employees who experience a wide variety of problems, including substance abuse. Bradykinesia is described as decreased speed and spontaneity of movement. The client appears to slow down. Hypertensive crisis, a potentially fatal problem that occurs when the norepinephrine levels are excessively elevated, produces severe occipital headache, stiff or sore neck, palpitations, increase or decrease in heart rate, nausea, vomiting, hypertension, and an increase in temperature. Tricyclic antidepressant agents produce an enhanced mood, an increase in activity level, and an improvement in appetite. In addition, sleep patterns become more like that of the client’s baseline normal sleeping pattern Employing a hopeful attitude that is not excessively cheery will combat the negative and gloomy affect that is intrinsic to depression. The client can interpret an excessively cheerful approach as belittling. A matter-of-fact approach will be more reassuring to the client and avoid any regressive struggles that might emerge.

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In addition to the 4 weeks required to establish maximum therapeutic effects, tricyclic antidepressants have significant adverse effects. Most notable are their effects on the heart The use of TCAs in individuals with second-degree and third-degree heart block can be fatal. Therefore, the nurse is responsible to ensure that the psychiatrist orders a baseline ECG before treating the client with TCAs. This will enable the psychiatrist to determine if there are any preexisting cardiac abnormalities, which would necessitate eliminating this group of medications from the treatment protocol. Establishment of a trusting nurse-client relationship is the foundation for giving effective nursing care to the client with a mental health disorder. Alprazolam is an antianxiety agent (benzodiazepine) used in the short-term management of panic disorder. Central nervous system side effects include disorientation, drowsiness, and clumsiness, among others. BuSpar is classified as a nonbenzodiazepine antianxiety agent. It does not appear to cause either physical or psychological dependence in clients who use it. Clonazepam, oxazepam, and lorazepam are benzodiazepines that may cause dependence. The client with post-traumatic stress disorder is not treated with behavior therapy. It may be treated with psychotherapy, family or group therapy, relaxation techniques, and vocational rehabilitation as needed. Dimenhydrinate (Dramamine) is used to treat and prevent the symptoms of dizziness, vertigo, and nausea and vomiting that accompany motion sickness. Zollinger-Ellison syndrome is a hypersecretory condition of the stomach. The client should avoid taking medications that are irritating to the stomach lining. Irritants would include aspirin and nonsteroidal antiinflammatory medications (Naprosyn and ibuprofen). The client should take acetaminophen for pain relief. Medication includes lansoprazole (Prevacid). A client who has a long history of antisocial and acting-out behavior needs to demonstrate the motivation to change behavior, not just verbalization that change will occur. The nurse would be therapeutic by assisting the client to look at the behaviors that indicate the motivation to change. A client in prison is knowledgeable about the rules for behavior in the correctional setting. Many clients will test the nurse’s capacity to be victimized and will make inappropriate statements. These behaviors need to

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be verbally confronted directly and then carefully documented in the client’s chart. • • Acute toxicity of MAO inhibitors is manifested by restlessness, anxiety, and insomnia. Dizziness and hypertension may also occur. The nurse working with chronically mentally ill clients in crisis should focus on the client’s strengths, modify and set realistic goals with the client, take an active role in assisting the client in the problem-solving process, and provide direct interventions that the individual might be able to do. Methylphenidate hydrochloride (Ritalin) is a central nervous system (CNS) stimulant and can cause insomnia. Its usually prescribed to clients with ADHD. Taking the medication at breakfast and lunch and avoiding taking the medication in the evening can prevent insomnia. It is taken orally 30 to 45 minutes before breakfast and lunch. When depressed, a client sees the negative side of everything. Neutral comments such as :You are wearing a new dress this morning" will avoid negative interpretations. In psychomotor agitation, it is best to provide activities that involve the use of hands and gross motor movements. These activities include Ping-Pong, volleyball, finger-painting, drawing, and working with clay. These activities provide the client a more appropriate way of discharging motor tension than pacing or ringing the hands. When a client is manic, solitary activities requiring a short attention span or mild physical exertion activities are best initially. These include writing, painting, finger-painting, woodworking, or walks with the staff. Solitary activities minimize stimuli, and mild physical activities release tension constructively. When less manic, the client may join one or two other clients in quiet, nonstimulating activities. Competitive games should be avoided because they can stimulate aggression and cause increased psychomotor activity. An inappropriate affect refers to an emotional response to a situation that is not congruent with the tone of the situation. A flat affect is an immobile facial expression or blank look. A blunted affect is a minimal emotional response and expresses the client’s outward affect. It may not coincide with the client’s inner emotions. A bizarre affect such as grimacing, giggling, and mumbling to one’s self is marked when the client is unable to relate logically to the environment. Poverty of speech is speech that is restricted in amount and ranges from brief to monosyllabic one-word answers. Poverty of content of 33

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speech is speech that is adequate in amount but conveys little information because of vagueness, empty repetitions, or use of stereotypes or obscure phrases. Thought blocking is when the client stops talking in the middle of a sentence and remains quiet. • When caring for a paranoid client, the nurse must avoid any physical contact and not touch the client. The nurse should ask the client’s permission if touch is necessary, because touch may be interpreted as a physical or sexual assault. The nurse should use simple and clear language when speaking to the client to prevent misinterpretation and to clarify the nurse’s intent and actions. A warm approach is avoided because it can be frightening to a person who needs emotional distance. Anger and hostile verbal attacks are diffused with a nondefensive stand. The anger a paranoid client expresses is often displaced, and when a staff member becomes defensive, anger of both the client and staff member escalates. A nondefensive and nonjudgmental attitude provides an environment in which feelings can be explored more easily. In a paranoid client, The nurse should arrange solitary noncompetitive activities that take some concentration such as crossword puzzles, picture puzzles, photography, and typing. When the client feels less threatened, games such as bridge or chess or playing cards with another client may be appropriate. When the client is extremely distrustful of others, solitary activities are best and activities that demand concentration keep the client’s attention on reality and minimize hallucinatory and delusional preoccupation. Propantheline (Pro-Banthine) is an antimuscarinic anticholinergic medication that decreases gastrointestinal secretions. It should be administered 30 minutes prior to meals. The nurse would most appropriately assess the client’s eating patterns and food preferences and concerns about eating. Assessing previous and current coping skills is most appropriately related to a nursing diagnosis of Ineffective Coping. Assessing the client’s feelings about self and body weight is most appropriately related to a Disturbed Body Image. Assessing the client’s lack of control about the treatment plan is most closely related to the nursing diagnosis of Powerlessness. Repetition of words or phrases that are similar in sound and in no other way (rhyming) is one altered thought and language pattern used by clients with schizophrenia. Clang associations often take the form of rhyming. Echolalia is the pathological repeating of another’s word by imitation and is often seen in people with catatonia. “Word salad” is a phrase used to identify a mixture of phrases that is meaningless to the listener and perhaps to the speaker as well. Thought broadcasting is the belief that others can hear one’s thoughts. 34

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Whenever a client has been identified as a victim of abuse, priority must be placed on ascertaining whether the person is in any immediate danger. If so, emergency action must be taken to remove the person from the abusing situation. A social phobia is characterized by a fear of appearing inadequate or inept in the presence of others and of doing something embarrassing. Thus, the client becomes anxious as the center of attention. Physical assessment findings such as bruises, along with the other assessment findings noted in the question, should alert the nurse to the potential for elder abuse. Tertiary prevention involves the reduction of the amount and degree of disability, injury, and damage following a crisis. Primary prevention means keeping the crisis from ever occurring, and secondary prevention focuses on reducing the intensity and duration of the crisis during the crisis itself. A precrisis level of prevention is similar to primary prevention. Thioridazine hydrochloride (Mellaril), an antipsychotic medication, has a higher likelihood of producing impotence than other neuroleptics A nurse who is preparing a medication-teaching plan for a client who is receiving fluphenazine decanoate would be certain to advise the client to immediately report any clinical manifestations such as a sore throat or fever, because these signs could signal the onset of agranulocytosis. In addition, any extrapyramidal symptoms also require the physician’s immediate attention. Trifluoperazine (Stelazine) can cause the client’s urine to turn pink to reddish-brown. This condition is not harmful; it disappears when the medication is discontinued. Nevertheless, the nurse will want to instruct the client to report its occurrence to the nursing staff or the medical staff. One of the side effects of antipsychotic agents is that they decrease moisture around the eyes. This can cause difficulty for clients who wear contact lenses. Because the client has emphasized the importance of these lenses, it is a potential problem that may occur and lead to medication noncompliance by the client. The most commonly occurring side effects of antipsychotic agents include dry mouth, blurred vision, nasal stuffiness, and weight gain. Additional side effects include difficulty in urinating, constipation, risk of infection, decreased 35

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sweating and increased sensitivity to heat, increased sensitivity to sunlight, yellowing of the eyes (especially the whites of the eyes), and decreased moisture around the eyes. Painful or interrupted menstruation, vaginal dryness, dizziness, drowsiness, breast enlargement/lactation, skin rash or itchy skin, and anhedonia can also occur. • Lithium and sodium, similar in chemical structure, compete to occupy sites within the body. Therefore, sodium levels often decrease, which causes lithium to be reabsorbed. When this happens, it increases the amount of lithium in the body, causing side effects. For this reason, the nurse instructs the client to drink 2 to 3 liters of water each day and eat a diet that is adequate in sodium. Once the client’s lithium level is established (usually within 2 weeks), a blood lithium level will be drawn every 1 to 2 months. The most therapeutic response for the nurse to make to effectively teach the client about lithium is the one that emphasizes the necessity that the client does not discontinue the medication even if feeling an upset stomach. Clients who are taking this medicine are instructed to take their medication with meals to minimize the occurrence of an upset stomach. Depersonalization constitutes a symptom that displays disturbance in the client’s sense of self. A flat affect is a symptom of schizophrenic disturbance in affect. Magical thinking is a symptom of the content of thought in schizophrenia. Word salad is a schizophrenic disturbance in the form of thought. Fluphenazine decanoate (Prolixin) can decrease the normal bacteria in the oral cavity and increase sensitivity to infection. This can be prevented by instructing the client to avoid high-sugar foods; increase the frequency of mouth care (brushing, including the tongue, flossing, and gargling with mouthwash); and frequently inspect the tongue for a thick, white coating, which signals infection. Lithium is contraindicated in pregnancy and for breastfeeding mothers. The client will be taught that breastfeeding is not possible while taking this medication and will be instructed to notify the physician immediately if pregnancy is even suspected or is being planned. Tranylcypromine (Parnate), an antidepressant, can cause serious and potentially fatal adverse reactions if used with other antidepressants. Its use is avoided within 2 weeks of another antidepressant.

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For clients with somatoform disorder, they are told to exercise because it helps to release endorphins, which enhance the feeling of well-being. If a client who is taking an antidepressant complains of tiredness, the nurse instructs the client to report the side effect to the psychiatrist, take medication at hour of sleep (except fluoxetine hydrochloride [Prozac], which must be taken in the morning), and avoid alcohol or alcohol-containing foods (even over-the-counter medications that contain alcohol). The client should also be instructed to lie down and rest. Some of the side effects of benzodiazepines are drowsiness, lethargy and confusion, dizziness, blurred vision, rash or “itchy” skin, unusual irritability or nervousness, headache, and nausea. The Abnormal Involuntary Movement Scale (AIMS) scale is used to assist the nurse to recognize tardive dyskinesia. The three areas of examination are facial and oral movements, extremity movements, and trunk movement. Tardive dyskinesia can occur from the use of antipsychotics. Abdominal pain is the most prominent symptom of acute pancreatitis. The main focus of nursing care is aimed at reducing discomfort and pain by the use of measures that decrease gastrointestinal tract activity, thereby decreasing pancreatic stimulation. A diagnosis of gout is made on the basis of clinical manifestations, hyperuricemia, and the presence of uric acid crystals in the synovial fluid of the inflamed joint. Blood studies show an increased serum uric acid level of more than 7 mg/100 mL. The erythrocyte sedimentation rate and the white blood cell count may be elevated during an acute episode. T Probenecid is a uricosuric medication. The client should be instructed to avoid alcohol, because it increases the urate levels and to avoid medications that contain aspirin. Increased fluid intake is encouraged to maintain an adequate urine output and prevent hematuria, renal colic, and stone development. The client is instructed to administer the medication with milk or meals to prevent gastric distress and is also told to limit high-purine foods. Calcium supplements should not be taken with whole grain cereals, rhubarb, spinach, or bran, because these foods decrease the absorption of the calcium. Most supplements should be taken on an empty stomach (1 hour before meals or at bedtime) to promote absorption, but food might be necessary if gastric irritation develops. The client should be instructed to drink water while taking 37

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the supplements to prevent renal stones. Side effects include constipation, gastric irritation, a chalky taste, nausea, and gastric bleeding. • Blood glucose levels for an adult normally range between 60 and 120 mg/dL. A level of 33 mg/dL indicates hypoglycemia. Metabolic disorders can be an etiological factor of delirium. The Romberg test is an assessment for cerebellar functioning related to balance. The client stands with feet together and arms at the side and then closes the eyes. Slight swaying is normal, but loss of balance indicates a problem and a positive Romberg test. For the first 12 hours following a laparotomy, the NG tube drainage may be dark brown to dark red. The drainage should then change to a light yellowish brown color. The presence of bile may cause a greenish tinge. The physician should be notified at once of the possibility of hemorrhage if the dark red color continues or if bright red blood is observed. Due to the presence of small amounts of blood and the action of gastric secretions, coffee ground granules might be seen in the NG tube drainage. The diagnosis of HIV is difficult to accept. Clients can exhibit a variety of reactions that are not necessarily a direct result of ineffective coping skills. The nurse must also know that persons with HIV are living well beyond 1 year. Ignoring the problem will not eliminate the client’s difficulty in understanding the disease process. The nurse must focus on the knowledge deficit of a disease process and other psychosocial interventions. Sheet grafts are often used to graft burns in visible areas. Sheet grafts are done on cosmetically important areas, such as the face and hands, to avoid the meshed pattern that occurs with meshed grafts. The incidence of invasive cervical cancer in situ peaks around age 45 and occurs twice as often in African American women than in other races. A classic symptom is painless vaginal bleeding; it can be accompanied by watery, blood-tinged vaginal discharge that can become dark and foul smelling as the disease progresses. A Papanicolaou smear is the initial diagnostic test performed. Organisms present in the synovial fluid are characteristic of a septic joint condition. Urate crystals are found in gout. Bloody synovial fluid is seen with trauma. Cloudy synovial fluid is diagnostic of rheumatoid arthritis.

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Trigeminal neuralgia affects cranial nerve V, causing sudden bursts of electric current–like pain in the face. In atrial fibrillation with rapid ventricular response, the atrial chambers quiver, do not contract normally, and fill the ventricles with blood during the last part of diastole. This results in the loss of an important atrial contribution to cardiac output, called the “atrial kick.” Loss of the atrial kick and the rapid ventricular rate causes a reduction of cardiac output by as much as 25%. Physical changes in the client's appearance can occur with Cushing's syndrome. Such changes include hirsutism, moon face, buffalo hump, acne, and striae. These changes cause a body image disturbance. A fasciotomy is a treatment for compartment syndrome. The client with unilateral neglect must learn to scan the environment and gradually come to a realization of the affected side Alcohol can precipitate an attack of pancreatitis. Coffee and cola products, which contain caffeine, stimulate the pancreas. Carbohydrates actually should be encouraged, since they are less stimulating to the pancreas. Since smoking can overstimulate the pancreas, teaching is effective when the client will try to stop smoking. Hypercalcemia is a phenomenon associated with multiple myeloma. Due to the hypercalcemia, pathological fractures are possible. Ambulation is important, because immobility increases the likelihood of hypercalcemia. Most clients with multiple myeloma will not tolerate aerobic exercise because of their anemia. Even if testicular cancer is detected in an early stage, the client newly diagnosed with testicular cancer might be afraid he will be sexually handicapped, and feelings of sexual inadequacy may occur. An appropriate nursing diagnosis would be Ineffective Role Performance. Ventilators need to be assessed routinely by the respiratory therapist. Ventilators are machines, and machines can fail. The normal white blood cell count is 5,000 to 10,000/mm3. Chemotherapy agents cause medication-induced leukopenia, and treatment focuses on this side effect. A fractured femur may require up to 20 weeks for healing in an adult. Full weight-bearing is permitted as soon as bony union is present. Ambulation with a cane requires at least partial to full weight-bearing status. Full weight39

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bearing is usually restricted until there is radiographic evidence of bony union of the fracture fragments. Callus formation is too weak, and the fracture site may refracture with full weight-bearing. The stage of fracture healing dictates the amount of weight-bearing, not range of motion, muscle strength, or pain. • Perforation of the gastrointestinal wall is a potential complication of any endoscopic procedure. Signs of perforation include abdominal pain, bleeding, and fever. Temperature elevation does not usually accompany internal hemorrhage. The temperature may be elevated in both severe dehydration and with a nosocomial infection, but the potential complication that can occur with this procedure is perforation of the intestine. Clients who test positive for HIV antibody are at risk for opportunistic infection. The normal CD4+ T cell count is between 500 mcg/L and 1600 mcg/L. As the CD4+ T cell count falls, the client’s risk for infection increases. Clients with HIV infection or acquired immunodeficiency syndrome are commonly afflicted with diarrhea, not constipation. Clients with chronic illness often experience feelings of anger and depression. Manifestations of chronic hepatitis include profound fatigue, resulting in an inability to pursue normal daily activities. Ineffective coping involves inappropriate use of defense mechanisms (alcohol consumption). It can also include the inability to meet role expectations (working). The destructive use of alcohol will contribute to the client’s illness and rehabilitation time, and further prolong fatigue and the inability to work. Nocturnal attacks of reflux from hiatal hernias are common, especially if the person has eaten near bedtime. Large meals, alcohol, and smoking can also precipitate attacks. Therefore, if the client did more entertaining earlier in the day, attacks might be decreased or eliminated. The client with Addison’s disease is experiencing deficits of mineralocorticoids, glucocorticoids, and androgens. Aldosterone deficiency affects the ability of the nephrons to conserve sodium, so the client experiences sodium and fluid volume deficit. The client needs to manage this problem with daily hormone replacement and increased fluid and sodium intake. Clients are instructed to weigh themselves daily as a means of monitoring fluid volume balance. Glucocorticoids and mineralocorticoids are essential components of the stress response. Additional doses of hormone replacement therapy are needed with any type of physical or psychological stressor. This information needs to be conveyed to the client and also requires that the client wear a Medic-Alert bracelet, so that health care

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professionals are aware of this problem if the client were to experience a medical emergency. • The client with ulcerative colitis is most likely anemic due to chronic blood loss in small amounts that occur with exacerbations of the disease. These clients often have bloody stools and are therefore at increased risk for anemia If a transfusion reaction is suspected, the transfusion is stopped and then normal saline is infused, pending further physician orders. This maintains a patent IV access line and aids in maintaining the client’s intravascular volume. The IV line would not be removed, because then there would be no IV access route. Normal saline is the solution of choice over solutions containing dextrose, because saline does not allow red blood cells to clump. A frequent side effect of therapy with any of the angiotensin-converting enzyme (ACE) inhibitors, such as ramipril, is the appearance of a persistent, dry cough. The cough generally does not improve while the client is taking the medication. Clients are advised to notify the physician if the cough becomes very troublesome to them. Nitroglycerin is a coronary vasodilator used in the management of coronary artery disease. The client is generally advised to apply a new patch each morning and leave it in place for 12 to 14 hours as per physician directions. This prevents the client from developing tolerance (as happens with 24-hour use). The client should avoid placing the system in skin folds, hairy areas, or excoriated areas. The client can apply a new patch if it falls off, because the dose is released continuously in small amounts through the skin. Verapamil is a calcium channel–blocking agent that can be used to treat rapid-rate supraventricular tachydysrhythmias, such as atrial flutter or atrial fibrillation. The client must be attached to a cardiac monitor to evaluate the effectiveness of the medication. A noninvasive blood pressure monitor is also helpful, but is not as essential as the cardiac monitor. The client should take in increased fluids (2000 to 3000 mL/day) to make secretions less viscous. This can help the client to expectorate secretions. This is standard advice given to clients receiving any of the adrenergic bronchodilators, such as albuterol, unless the client has another health problem that could be worsened by increased fluid intake. The client taking a potassium-wasting diuretic such as chlorothiazide needs to be monitored for decreased potassium levels. Amiloride is a potassium-sparing diuretic used to treat edema or hypertension. A daily dose should be taken in the morning to avoid 41

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nocturia. The dose should be taken with food to increase bioavailability. Sodium should be restricted if used as an antihypertensive. Increased blood pressure is not a reason to hold the medication, although it may be an indication for its use. • When ranitidine is given as a single daily dose, it should be taken at bedtime. This allows for prolonged effect, and the greatest protection of gastric mucosa around the clock. Urinary retention is a side effect of benztropine mesylate. The nurse needs to observe for dysuria, distended abdomen, infrequent voiding of small amounts, and overflow incontinence. Quinapril hydrochloride is an angiotensin-converting enzyme inhibitor used in the treatment of hypertension. The client should be instructed to rise slowly from a lying to sitting position and to permit the legs to dangle from the bed momentarily before standing to reduce the hypotensive effect. The medication does not need to be taken with meals. It may be given without regards to food. If nausea occurs, the client should be instructed to consume a non-cola carbonated beverage and salted crackers or dry toast. A full therapeutic effect may take place in 1 to 2 weeks. Quinidine gluconate is an antidysrhythmic medication used as prophylactic therapy to maintain normal sinus rhythm after conversion of atrial fibrillation and/or atrial flutter. It is contraindicated in complete AV block, intraventricular conduction defects, abnormal impulses and rhythms due to escape mechanisms, and in myasthenia gravis. It is used with caution in clients with preexisting asthma, muscle weakness, infection with fever, and hepatic or renal insufficiency. Ganciclovir causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client for signs and symptoms of bleeding, and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize the risk of trauma that could result in bleeding. Venipuncture sites should be held for approximately 10 minutes. The medication does not have to be taken on an empty stomach. The medication may cause hypoglycemia, but not hyperglycemia. Diarrhea, nausea, vomiting, loss of appetite, and dizziness are all common side effects of quinidine. If these should occur, the physician should be notified; however, the patient should not discontinue the medication. A rapid

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decrease in medication levels of antidysrhythmics could precipitate dysrhythmia. • Benzonatate (Tessalon) is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough without eliminating the cough reflex. Drowsiness, dizziness, nausea, and vomiting are frequent side effects associated with Carbamazepine (Tegretol). Adverse reactions include blood dyscrasias. If the client developed a fever, sore throat, mouth ulcerations, unusual bleeding or bruising, or joint pain, this might be indicative of a blood dyscrasia and the physician should be notified. Parlodel is an antiparkinson prolactin inhibitor used in the treatment of neuroleptic malignant syndrome. Vitamin K is the antidote for warfarin (Coumadin) overdose. Protamine sulfate is the antidote for heparin overdose. Vasotec is an angiotensin-converting enzyme (ACE) inhibitor and an antihypertensive that is used in the treatment of hypertension. Hematological reactions can occur in the client taking clozapine, and include agranulocytosis and mild leukopenia. The white blood cell count should be assessed before treatment is initiated and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever.

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