NURSES" TAKE NOTE OF THESE!

Categories of Client Needs
The health care needs of the client are grouped under four broad categories with several subcategories.

1. Safe, Effective Care Environment
1. Management of care includes 7-13% of test items. This includes but is not limited to the following:
1. advanced directives
2. advocacy
3. case management
4. client rights
5. concepts of management
6. confidentiality
7. continuity of care
8. continuous quality improvement
9. delegation
10. ethical practice
11. incident/irregular occurrence reports
12. informed consent
13. legal responsibilities
14. organ donation
15. consultation and referrals
16. resource management
17. supervision
2. Safety and infection control comprises 5-11% of test items. This includes but is not limited to the following:
1. accident prevention
2. disaster planning
3. standard (universal) and other precautions
4. medical and surgical asepsis
5. error prevention
6. handling hazardous and infectious materials
2. Health Promotion and Maintenance
1. Growth and development through the life span comprises 7-13% of test questions and includes but is not limited to the following:
1. aging process
2. ante/intra/postpartum and newborn
3. expected body image changes
4. developmental stages and transitions
5. family planning
6. family systems
2. Prevention and Early Detection of Disease comprises 5-11% of test questions and includes but is not limited to the following:
1. disease prevention
2. health and wellness
3. health promotion programs
4. health screening
5. lifestyle changes
6. immunizations
7. techniques of physical assessment
3. Psychosocial Integrity
1. Coping and Adaptation comprises 5-11% of test questions and includes but is not limited to:
1. coping mechanisms
2. sensory/perceptual alterations
3. counseling techniques
4. situational role changes
5. grief and loss
6. stress management
7. mental health concepts
8. support systems
9. unexpected body image changes
10. religious and spiritual influences on health
2. Psychosocial Adaptation comprises 5-11% of test questions and includes but is not limited to:
1. behavioral intervention
2. elder abuse/neglect
3. chemical dependency
4. psychopathology
5. child abuse/neglect
6. sexual abuse
7. crisis intervention
8. therapeutic milieu
9. domestic violence
4. Physiological Integrity
1. Basic care and comfort comprises 7-13% of test questions and includes but is not limited to:
1. assistive devices
2. nutrition and oral hydration
3. elimination
4. mobility/immobility
5. personal hygiene
6. rest and sleep
7. non-pharmacological comfort interventions
2. Pharmacological and parenteral therapies comprise 5-11% of test questions and includes but is not limited to:
1. central venous access devices
2. total parenteral nutrition
3. parenteral fluids
4. intravenous therapy
5. medication administration
6. chemotherapy

Adult Nursing Concepts-Questions

1.A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?

1. Blood pressure. 2. Breath sounds. 3. Capillary refill. 4. Skin integrity.

Answer 1 Rationale: 1. Withdrawal from glucocorticoid therapy can precipitate addisonian crisis, which is characterized by circulatory collapse and shock. Hypotension is a major manifestation of addisonian crisis and must be treated vigorously. 2.An adult is readmitted to the medical/surgical care unit in addisonian crisis. He is exhibiting signs of tachycardia, dehydration, hyponatremia, hyperkalemia, and hypoglycemia. The nurse should expect that the initial orders for this client will include 1. starting an IV solution of saline and dextrose. 2. administration of oxygen via 100% nonrebreathing mask. 3. administering potassium chloride. 4. preparing for an emergency tracheostomy. Answer: 1 Rationale: Needs immediate replacement of glucocorticoids. Why not 0xygen? Not otmally given at 100%. 3. Excess Mineralocorticoid causes mood disturbances, hypertension, acne.Excess glucocorticoids causes increase adipose tissue esp. in the trunk. Can see this on Cushing's syndrome. If patient constantly lashes at family: there is an increase in ______________? 4.In Cushing syndrome, patient exhibits central obesity with large trunk with thin extremeties, buffalo hump, and fatty cheeks( moon face) 5. In conn's disease, you will see hypertension and hyperkalemia due to increase in glucocoroid. 6.In pheochromocytoma, there is life- threatening hypertension due to increase in catecholamines which stimualtes the SNS.other s/s: palpitation, sweating. 7. post adrenalectomy, theer is a need for life-long corticosteroid replacement and should not alter the dosage. 8. Client with grave's: "why do i need to take inderal( propanolol)" To relieve symptoms of GD: tachucardia, paplpiattion, heat intolerance 9. The nurse is caring for a client who is status postthyroidectomy. The client is exhibiting hyperreflexia, muscle twitching, and spasms. The first action the nurse should perform is to 1. prepare to send a blood sample to the laboratory for a calcium level. 2. assess for additional signs of tetany. 3. place the client in semi-Fowler's position. 4. administer post-op pain medication. Answer Rationale: 1. During a thyroidectomy it is possible for the parathyroid glands to be removed or damaged. If the parathyroid glands are disturbed, hypocalcemia may result. 2. Muscle twitching and spasms are already indicative of tetany after a thyroidectomy; therefore, a calcium level should be drawn and calcium given to correct a life-threatening emergency. 10. An adult who has Grave's disease just received a dose of sodium 131I. Which of the following statements made to the nurse best demonstrates an understanding of immediate care needs? 1. "I should be able to go home after about two hours if I don't have any vomiting." 2. "I have my belongings with me to stay in the isolation room for the next 24 hours." 3. "My daughter is pregnant, so I told her I will not be able to see her for the next month." 4. "I brought my antithyroid drug with me so I will not miss a dose." Answer 1 Rationale: 1. The client remains in the outpatient department for about two hours to be monitored for vomiting. 2. Only very high-dose therapy necessitates hospitalization for isolation. Normally the client has to remain in the outpatient department for about two hours. 3. The client should avoid close body contact with infants, young children, or pregnant women during the first 24 hours, although the radiation risk is minimal. 4. Antithyroid drugs need to be discontinued at least five days before treatment.

Adult Nursing Concepts

Specific Disorders of the Pituitary Gland Hypopituitarism General information Hypofunction of the anterior pituitary gland resulting in deficiencies of both the hormones secreted by the anterior pituitary gland and those secreted by the target glands May be caused by tumor, trauma, surgical removal, or irradiation of the gland; or may be congenital (See Pituitary Dwarfism, in Unit 5) Medical management: specific treatment depends on cause Tumor: surgical removal or irradiation of the gland Regardless of cause, treatment will include replacement of deficient hormones: e.g., cortico-steroids, thyroid hormone, sex hormones, gonadotropins (may be used to restore fertility). Assessment findings Tumor: bitemporal hemianopia, headache Varying signs of hormonal disturbances depending on which hormones are being undersecreted (e.g., menstrual dysfunction, hypothyroidism, adrenal insufficiency) Retardation of growth if condition occurs before epiphyseal closure Diagnostic tests Skull x-ray, CT scan may reveal pituitary tumor Plasma hormone levels may be decreased depending on specific hormones undersecreted Nursing interventions Provide care for the client undergoing hypophysectomy or radiation therapy if indicated. Provide client teaching and discharge planning concerning Hormone replacement therapy Importance of follow-up care Hyperpituitarism General information Hyperfunction of the anterior pituitary gland resulting in oversecretion of one or more of the anterior pituitary hormones Overproduction of the growth hormone produces acromegaly in adults and gigantism in children (if hypersecretion occurs before epiphyseal closure); see Hyperpituitarim (Gigantism), in Unit 5. Usually caused by a benign pituitary adenoma Medical management: surgical removal or irradiation of the gland Assessment findings Tumor: bitemporal hemianopia; headache Hormonal disturbances depending on which hormones are being excreted in excess Acromegaly caused by oversecretion of growth hormones: transverse enlargement of bones, especially noticeable in skull and in bones of hands and feet; features become coarse and heavy; lips become heavier; tongue enlarged Diagnostic tests Skull x-ray, CT scan reveal pituitary tumor Plasma hormone levels reveal increased growth hormone, oversecretion of other hormones Nursing interventions Monitor for hyperglycemia and cardiovascular problems (hypertension, angina, CHF) and modify care accordingly. Provide psychologic support and acceptance for alterations in body image. Provide care for the client undergoing hypophysectomy or radiation therapy if indicated. Hypophysectomy General information Partial or complete removal of the pituitary gland Indications: pituitary tumors, diabetic retinopathy, metastatic cancer of the breast or prostate, which may be endocrine dependent Surgical approaches Craniotomy: usually transfrontal Transphenoidal: incision made in inner aspect of upper lip and gingiva; sella turcica is entered through the floor of the nose and sphenoid sinuses Nursing care In addition to pre-op care of the craniotomy client, explain post-op expectations. In addition to post-op care of the craniotomy client, observe for signs of target gland deficiencies (diabetes insipidus, adrenal insufficiency, hypothyroidism) due to total removal of the gland or to post-op edema. Perform hourly urine outputs and specific gravities; alert physician if urine output is greater than 800-900 ml/2 hours or if specific gravity is less than 1.004. Administer cortisone replacement as ordered. If transphenoidal approach used Elevate the head of the bed to 30° to decrease headache and pressure on the sella turcica. Administer mild analgesics for headache as ordered. Perform frequent oral hygiene with soft swabs to cleanse the teeth and mouth rinses; no toothbrushing. Observe for and prevent CSF leak from surgical site. warn the client not to cough, sneeze, or blow nose. observe for clear drainage from nose or postnasal drip (constant swallowing); check drainage for glucose; positive results indicate that drainage is CSF. if leakage does occur elevate head of bed and call the physician. most leaks will resolve in 72 hours with bed rest and elevation. may do daily spinal taps to decrease CSF pressure. administer antibiotics as ordered to prevent meningitis. Provide client teaching and discharge planning concerning Hormone therapy if gland is completely removed, client will have permanent diabetes insipidus (see below) cortisone and thyroid hormone replacement replacement of sex hormones testosterone: may be given for impotence in men estrogen: may be given for atropy of the vaginal mucosa in women human pituitary gonadotropins: may restore fertility in some women Need for lifelong follow-up and hormone replacement Need to wear Medic-Alert bracelet If transphenoidal approach was used avoid bending and straining at stool for 2 months post-op no toothbrushing until sutures are removed and incision heals (about 10 days) Diabetes Insipidus General information Hypofunction of the posterior pituitary gland resulting in deficiency of ADH Characterized by excessive thirst and urination Caused by tumor, trauma, inflammation, pituitary surgery Assessment findings Polydipsia (excessive thirst) and severe polyuria with low specific gravity Fatigue, muscle weakness, irritability, weight loss, signs of dehydration Tachycardia, eventual shock if fluids not replaced Diagnostic tests Urine specific gravity less than 1.004 Water deprivation test reveals inability to concentrate urine Nursing interventions Maintain fluid and electrolyte balance. Keep accurate I&O. Weigh daily. Administer IV/oral fluids as ordered to replace fluid losses. Monitor vital signs and observe for signs of dehydration and hypovolemia. Administer hormone replacement as ordered. Vasopressin (Pitressin) and vasopressin tannate (Pitressin tannate in oil); given by IM injection warm to body temperature before giving. shake tannate suspension to ensure uniform dispersion. Lypressin (Diapid): nasal spray Provide client teaching and discharge planning concerning Lifelong hormone replacement; lypressin as needed to control polyuria and polydipsia Need to wear Medic-Alert bracelet 1. Which assessment is most important for the nurse to make when monitoring a client with a pituitary tumor that secretes ACTH?

1. Blood pressure. 2. Height. 3. Pulse rate. 4. Output.

Answer :1 Rationale: 1. ACTH-secreting tumors can cause Cushing's syndrome, which can elevate the blood pressure to dangerously high levels. 2. Growth hormone-secreting tumors can stimulate the growth of long bones and increase height, but ACTH-secreting tumors do not affect height. 3. TSH-secreting tumors can cause hyperthyroidism, with resulting tachycardia. ACTH-secreting tumors do not increase the pulse rate. 4. The syndrome of inappropriate ADH (SIADH) can diminish urinary output, but ACTH-secreting tumors do not alter output substantially.

2. The nurse is caring for a client who underwent surgical hypophysectomy. Which of the following assessments is most essential for the nurse to make immediately post-op?

1. Blood pressure. 2. Serum calcium levels. 3. Breath sounds. 4. Bowel sounds.

Answer 1 Rationale: 1. Hypophysectomy (removal of the pituitary gland) interferes with the secretion of both glucocorticoids and antidiuretic hormone, both of which are essential to maintain fluid balance and blood pressure. Careful monitoring of blood pressure is essential to ensure that hormone replacement therapy is adequate. 2. Removal of the pituitary gland does not substantially affect serum calcium levels. The pituitary gland does not stimulate the parathyroid glands, which regulate serum calcium. 3. Although assessment of breath sounds is routinely carried out in the immediate post-op period, this is not the most essential assessment for the nurse to make. 4. Although assessment of bowel sounds is routinely carried out post-op, this is not the most essential assessment for the nurse to make.

Mr. P. has had a hypophysectomy with a complete removal of the pituitary gland. Which of the following statements represents to the nurse the most complete understanding of follow-up care?

1. I will need to have lifelong follow-up, to take hormone replacement therapy for the rest of my life, and to wear a Medic-Alert bracelet. 2. I will need to wear a Medic-Alert bracelet. 3. I will need to take hormone replacements for the next two months. 4. I will need to wear a Medic-Alert bracelet and take hormone replacements for the next year.

Answer Rationale: 1. Hormone replacement and follow-up care are needed for the rest of his life because the pituitary gland has been removed. This is the master gland that secretes trophic hormones that stimulate target glands to produce their hormones. A Medic-Alert bracelet is needed to alert others of his condition.

A 62-year-old female is admitted with a posterior pituitary tumor and is experiencing diabetes insipidus, a complication of that tumor. The nursing diagnosis most appropriate for this client is

1. fluid volume deficit. 2. fluid volume excess. 3. incontinence, bowel. 4. diarrhea.

Answer 1 Rationale: 1. Diabetes insipidus is characterized by polydipsia and polyuria. It occurs with lesions of the hypothalamus and pituitary. Because antidiuretic hormone synthesis is affected, the client is at high risk for dehydration, which is life-threatening. 2. Fluid volume excess is an appropriate diagnosis for a client experiencing the syndrome of inappropriate antidiuretic hormone (SIADH).

MCN CONCEPTS

Pregnancy can be complicated by situations unique to childbearing (e.g., placental bleeding), or by long-standing conditions predating pregnancy and continuing into the childbearing process (e.g., age socioeconomic status, cardiac problems); for common discomforts of pregnancy, see Table 6.5.

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TABLE 6.5 Common Discomforts During Pregnancy

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Discomfort	Trimester	Intervention
Morning sickness	First	Eat dry carbohydrate in am; avoid fried, odorous, and greasy foods; small meals rather than large.
Fatigue	First	Rest frequently, as needed.
Urinary frequency	First, end of third	Kegel exercises, perineal pad for leakage.
Heartburn	Second, third	Small meals, bland foods, antacids if ordered.
Constipation	Second, third	Sufficient fluids, foods high in roughage, regular bowel habits. No laxatives unless ordered, including mineral oil.
Hemorrhoids	Third	Avoid constipation; promote regular bowel habits.
Varicosities	Third	Avoid crossing legs and long periods of sitting or standing; rest with feet and hips elevated; avoid elastic garters and other constrictive clothing.
Backache	Third	Use good posture and body mechanics; low-heeled shoes; exercises to strengthen back muscles.
Insomnia	Third	Conscious relaxation; supportive pillows as needed; warm shower before retiring.
Leg cramps	Third	Flex toes toward knees for relief; ensure adequate calcium in diet.
Supine hypotensive syndrome	Third	Left side-lying position.
Vaginal discharge	Second	Correct personal hygiene, refer to physician. Do not douche.
Skin changes, dryness, itching	All	Interventions are symptomatic; cool baths, lotions, oils as indicated.

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General Nursing Responsibilities

1. Teach danger signals of pregnancy early in prenatal period so that client is aware of what needs to be reported to health care provider on an immediate basis (see Table 6.6).
2. Be aware that early teaching allows the client to participate in the identification and reporting of symptoms that can indicate a problem in her pregnancy.
3. Early recognition and reporting of danger signals usually results in diminishing the risk and controlling the severity of maternal/fetal complications.
4. Interventions are specific for the individual risks.
5. Evaluation centers around whether or not the risk was controlled or eliminated, and how the maternal/fetal reaction was controlled.

1. Anne T. is hospitalized for the treatment of severe preeclampsia. Which of the following represents an unusual finding for this condition?

1. Proteinuria 3+. 2. Blood pressure 160/100. 3. Convulsions. 4. Generalized edema.

Answer Rationale:3 Convulsions are associated with an eclamptic condition. The other findings are usual for severe preeclampsia.

2.

A woman is admitted with severe preeclampsia. What type of room should the nurse select for this woman?

1. The room farthest from the nursing station. 2. The quietest room on the floor. 3. The labor suite. 4. A room next to the elevator.

Answer Rationale:2 A quiet room, in which stimuli are minimized and controlled, is essential to the nursing care of the severely preeclamptic client. Because she will need continuous monitoring, the room farthest from the nursing station is inappropriate. Additionally, this client may not need to be in the labor suite; the first goal of care is to prevent the condition from worsening.

3.

The action of hormones during pregnancy affects the body by

1. blocking the release of insulin from the pancreas. 2. preventing the liver from metabolizing glycogen. 3. raising resistance to insulin. 4. enhancing the conversion of food to glucose.

Answer Rationale:3 Hormonal influences during pregnancy cause a resistance to insulin utilization at the cellular level. It allows sufficient glucose for placental transport to the fetus, and also prevents the blood sugar in the nondiabetic client from falling to dangerous levels. In the diabetic client, it requires increases in her insulin doses. It does not affect the release of insulin. Gluconeogenesis is not altered. The conversion of food to glucose is not the problem in pregnancy; the problem is, rather, the utilization of the glucose.

Pediatric Oncology

Pediatric Oncology
STAGES OF CANCER TREATMENT

Induction Goal: to remove bulk of tumor Methods: surgery, radiation/chemotherapy, bone marrow transplant Effects: often the most intensive phase; side effects of treatment are potentially life threatening Consolidation Goal: to eliminate any remaining malignant cells Methods: often chemotherapy/radiation therapy Effects: side effects will still be evident Maintenance Goal: to keep child disease free Method: chemotherapy (this phase may last for several years) Observation Goal: to monitor the child at intervals for evidence of recurrent disease and complications of treatment Method: treatment is complete; child may continue in this stage indefinitely Late effects of treatment Impaired growth and development, usually related to radiation of growth centers CNS damage resulting in intellectual, psychologic, or neurologic sequelae Impaired pubertal development including hormonal or reproductive problems Development of secondary malignancy Psychologic problems (poor self-esteem, depression, anxiety) related to living with a life-threatening disease and complex treatment regimen Side Effects From combined effects of treatment: nausea, vomiting, diarrhea, alopecia, anemia (low RBCs), increased susceptibility to infection (low WBCs), bleeding (low platelets), stomatitis, mucositis, pain, learning problems From radiation (findings differ according to site radiated): sleepiness, reddened skin From chemotherapy: drug toxicity specific to agents used Developmental: behavior problems, avoidance of school and friends, low self-esteem or self-image Nursing Interventions Help child cope with intrusive procedures. Provide information geared to developmental level and emotional readiness. Explain what is going to happen, why it is necessary, and how it will feel. Allow child to handle and manipulate equipment. Use needle play as indicated. Allow child some control in situations (e.g., positioning, selecting injection site). Support child and parents. Maintain frequent clinical conferences to keep all informed. Always tell the truth. Acknowledge feelings and encourage child/family to express them, assure them that feelings are normal. Provide contact with another parent or an organized support group such as Candlelighters. Try to keep daily life as normal as possible. Minimize side effects of treatment. Skin breakdown Keep clean and dry; wash with warm water, no soaps or creams. Do not wash off radiation markings. Avoid exposure to sunlight. Avoid all topical agents with alcohol (perfumes and powders). Do not use electric heating pads or hot water bottles. Bone marrow suppression Decreased RBCs allow child to determine activities. provide frequent rest periods. Decreased WBCs avoid crowds, isolate from children with known communicable disease. evaluate any potential site of infection. monitor temperature elevations. Decreased platelets make environment safe. select activities that are physically safe. avoid use of salicylates. Administer transfusions as ordered. Interpret peripheral blood counts to guide specific interventions and precautions. Nausea and vomiting Administer antiemetic at least half an hour before chemotherapy; repeat as necessary. Encourage relaxation techniques. Eat light meal prior to administration of therapy. Ensure adequate oral intake or administer IV fluids as necessary. Alopecia Reduce trauma of hair loss (especially in children over age 5 years). Buy wig before hair falls out. Discuss various head coverings with boys and girls. Avoid exposing head to sunlight. Discuss feelings. Stomatitis, mucositis (see Pediatric Oncology - Bone Marrow Transplant in Unit 5). Nutrition deficits Establish baseline prior to start of treatment. Measure height and weight regularly. Provide small, frequent meals. Consult dietitian as needed. Provide high-calorie, high-protein supplements. Developmental delays Discuss limit setting, discipline. Some behavior problems might be side effects of drug therapy. Facilitate return to school as soon as able. Realize changing needs of child.

NCLEX PEDIA 3

Nephrosis (Nephrotic Syndrome)
General information

Autoimmune process leading to structural alteration of glomerular membrane that results in increased permeability to plasma proteins, particularly albumin
Course of the disease consists of exacerbations and remissions over a period of months to years
Commonly affects preschoolers, boys more often than girls

Pathophysiology
Plasma proteins enter the renal tubule and are excreted in the urine, causing proteinuria.
Protein shift causes altered oncotic pressure and lowered plasma volume.
Hypovolemia triggers release of renin and angiotensin, which stimulates increased secretion of aldosterone; aldosterone increases reabsorption of water and sodium in distal tubule.
Lowered blood pressure also stimulates release of ADH, further increasing reabsorption of water; together with a general shift of plasma into interstitial spaces, results in edema.
Prognosis is good unless edema does not respond to steroids.

Medical management

Drug therapy
Corticosteroids to resolve edema
Antibiotics for bacterial infections
Thiazide diuretics in edematous stage
Bed rest
Diet modification: high protein, low sodium

Assessment findings
Proteinuria, hypoproteinemia, hyperlipidemia
Dependent body edema
Puffiness around eyes in morning- due to circulatory congestion
Ascites
Scrotal edema
Ankle edema
Anorexia, vomiting, and diarrhea, malnutrition
Pallor, lethargy
Hepatomegaly

Nursing interventions
Provide bed rest.
Conserve energy.
Find activities for quiet play.
Provide high-protein, low-sodium diet during edema phase only.
Maintain skin integrity. Do not use Band-Aids.
Avoid IM injections (medication is not absorbed into edematous tissue).
Turn frequently.
Obtain morning urine for protein studies.
Provide scrotal support.
Monitor I&O, vital signs and weigh daily.
Administer steroids to suppress autoimmune response as ordered.
Protect from known sources of infection.

1. 2 Y.O OLD WITH NRPHROTIC SYNDROME ON REMISSION, WHAT IS THE PRESCRIBED DIET:
A.LOW SALT, LOW FAT
B.REG DIET WITH NO ADDED SALT

ANSWER: B. LOW SALT DIET IS INDICATED DURING EXACERBATIONS.

NCLEX 3 CV DEFECTS

Congenital heart defects

Classification:

1.Acyanotic heart defects
Oxygenated blood is shunted from the systemic to pulmonary circulation (left-to-right shunt) and blood leaving the aorta is completely oxygenated.
Increased blood volume on right side of heart results in hypertrophy of right ventricle.
Eventually, most acyanotic heart defects will result in CHF.

2.Cyanotic heart defects
Unoxygenated blood is shunted from the right to the left side of the heart where it mixes with oxygenated blood.
The blood pumped to the peripheral tissues has a much lower oxygen content than normal, causing the bluish color called cyanosis.

1. Infant in CHF- highest priority is maintaining adequate fluid balance.

2. Difference of cyanotic and acyanotic defects: pulse oximeter does not read over 93% ( n =95 and above)

3. Tetralogy of fallot- cyanotic-tet spell- most important set up on bed side= oxygen set-up.

4. infants BP is very hight- initial action of nurse?= measure the cuff , should be 2/3 of the humerus.

5. 10 yr old with VSD for cardiac cath= highest priority for assessment is : pedal pulses. Breath sounds are

priority but pedal pulses is more a priority since the procedure is invasive(circulation).