What is the first thing a nurse should assess to determine the presence of neurologic

changes? - Level of consciousness

Expressive aphasia – Mr. Jones is able to follow all commands during your physical
examination. However, when you ask him about his medical history, his speech is hesitant,
his word choice is inappropriate, and he appears extremely frustrated.

Agnosia – While at Ms. Smith’s bedside, you observe a conversation between Ms. Smith and
her husband. Mr. Smith asks her to pass him a pen (which is on the bedside table directly in
front of her). Ms. Smith stares at the table, but seems unable to recognize which object her
husband is requesting.

Apraxia – When asked if he is thirsty, Mr. Mark shakes his head yes. When you hand Mr.
Mark a cup filled with juice, he holds the cup and turns it around in his hands, but never
brings the cup to his mouth to drink from it.

Receptive Aphasia – Ms. Gray is awake and alert and seems aware of her surroundings.
When you begin your physical assessment, Ms. Gray stares blankly at you and is unable to
follow any commands.

Cheyne-Stokes Respirations – respirations of increasing and decreasing depth, altering with

periods of apnea. May be caused by structural cerebral dysfunction or by metabolic
problems such as diabetic coma.

Central neurogenic hyperventilation – rapid respiration (>25/minute). Usually attributed to

brain stem dysfunction.

Apneustic breathing – prolonged inspiratory phase followed by a 2-3 second pause. Usually
attributed to dysfunction in the respiratory center of the pons.

Cluster breathing – cluster of irregular breaths with periods of apnea at irregular intervals.
Caused by lesions in the upper medulla and lower pons.

Biot’s (ataxic) breathing – completely irregular breathing pattern. Indicates damage to the
respiratory centers of the medulla.

The facial nerve is cranial nerve VII.

The facial nerve controls facial movement and anterior taste.

Guillan-Barre syndrome – possibly an autoimmune disorder characterized by progressive

ascending paralysis that most often ceases in approximately 4 weeks, with complete
recovery taking 3-6 months. The disease causes motor weakness symmetrically and in an
ascending fashion. The client’s airway is compromised when the diseases reached the
diaphragm.

Lou Gehrig’s disease – a progressive, fatal, motor neuron disease causing progressive
muscular atrophy.
Huntington’s chorea – an inherited disorder causing progressive atrophy of the basal ganglia
and portions of the cerebral cortex. Cardinal symptoms include extreme emotional liability,
dementia, and uncontrolled limb movements.

S3 – heard during rapid ventricular filling and can be a normal finding in young children;
often associated with congestive heart failure and failure of ventricles to eject blood.

S1 – heard over mitral area; created by the closure of the tricuspid

S4 – heard over mitral area; created by the closure of the mitral and tricuspid valves

S2 – heard at the base of the heart; created by the closure of the aortic and pulmonary
valves

Murmurs – created by the flow of blood through narrow valves or incomplete closure of
valves, resulting in prolonged sounds.

Gallops – transient sounds heard during systole and diastole, associated with an impedance
to blood flow.

Friction rubs – caused by the abrasion of pericardial surfaces secondary to inflammation.

S wave – second to negative deflection after the P wave

Q wave – first negative deflection after the P wave

R wave – first positive deflection after the P wave

PR interval – represents the impulse traveling from the atria through the conduction

S-T segment – represents early ventricular repolarization

T wave - represents ventricular muscle repolarization

P wave – represents atrial depolarization

QRS wave – represents ventricular depolarization

Cheyne-Strokes – noted for apneic periods; often associated with severe left ventricular
failure.

Hemoptysis – indicative of pulmonary edema characterized by pink or blood-tinged frothy

sputum.

Tachypnea – rapid, shallow breathing often associated with congestive heart failure, pain, or
anxiety.

Rales – often noted at the base of the lungs; progressive upward; often associated with
congestive heart failure and atelectasis

Wheezes – compression of small airways associated with pulmonary edema or clients taking
b-blockers (e.g. Propanolol HCL, Inderal)
Atelectasis – collapse of alveoli or lobule; can be caused by pressure on lung tissue; often
associated with pericardial effusion, pleural effusion, or pneumothorax.

The client must be NPO at least 8 hours prior to the procedure

Prepare the client for sensation such as heat or palpitations when contrast medium is
injected into the heart

Teach the client of possible catheterization sites such as the femoral artery or brachial
artery.

Assess the client for numbness, sensation, pulses, and bleeding in the affected extremity
every 15 minutes for 1 to 2 hours following the procedure.

Report to the provider immediately complaints of chest pain or numbness/tingling of

extremity.

Clinical manifestation of pulmonary edema include :

: occurs at night after a few hours lying down
: restlessness or anxiety
: coughing with mucoid sputum; sometimes hemoptysis
: cyanotic nail beds, ashen skin color
: cold, moist extremities
: shortness of breath, tachyapnea
: rales upon auscultation

Oxygenation is used to relieve hypoxia and dyspnea. If hypoxia continues, mechanical

ventilation may be required.

Diuretics cause vasodilation, leading to decreased venous return and decreased pulmonary
congestion. Increase in urine output is seen.

Cardiac glycosides or digoxin is used to improve the contraction of the heart and increase
the output of the left ventricle. This enhances diuresis and reduces diastolic pressure,
subsequently reducing capillary pressure.

Clinical manifestations of left-sided heart failure include :

: coughing
: dyspnea
: hemoptysis
: orthopnea
: pulmonary congestion
: S3 heart sound
: tachycardia

Clinical manifestation of right-sided heart failure include:

: ascites
: dependent edema
: distended neck veins
: hepatomegaly
: nocturia
: visceral/peripheral congestion
Spironolactone (aldactone) is a potassium sparing diuretic

Furosemide (lasix) is a loop diuretic

Hydrochlorothiazide (esidrix) is a thiazide diuretic

Ethacrynic acid (edecrin) is a loop diuretic

Triamterene (dyrenium) is a potassium sparing diuretic

Sign and symptoms of hyponatremia include:

: decreased muscle tone
: headache and lethargy
: low blood pressure
: stomach cramps

Hypokalemia can lead to :

: decreased contractility
: dangerous dysrrhytmias
: precipitate digoxin toxicity
: depress the myocardium, weakening contractions
: cause ventricular irritability

Foods high in potassium include:

: apricots
: bananas
: figs
: orange juice
: potatoes
: prunes
: raisins
: spinach
: tomatoes

Sign and symptoms of digoxin toxicity include:

: anorexia
: bradycardia
: halo effect on vision
: nausea and vomiting
: paroxysmal atrial tachycardia
: premature ventricular contractions
: ventricular bigeminy

In order to prevent toxicity in digoxin therapy the nurse must assess for 3 important things:
: check client’s heart rate
: check digoxin level
: check potassium level

Digoxin: Vasodilator therapy:

: increases cardiac output : Reduces resistance to left ejection
: decrease venous pressure : increases venous capacity
: decreases venous pressure : reduces left ventricular filling pressure
: increases myocardial contractility : reduces pulmonary congestion
Infective endocarditis – an infection of the valves and endothelial surface of the heart; a
direct invasion of bacteria or other organism leading to deformity of the leaflet valves.

Rheumatic endocarditis – heart damage not infectious in origin; response to a streptococcal

infection seen with polyarthritis; results in formation of nodules that eventually lead to
scarring.

Aortic insufficiency – caused by inflammatory lesions deformities flaps of the valve resulting
in incomplete closure; allowing back flow from the aorta into the left ventricle.

Mitral stenosis – causes high pulmonary arterial pressures resulting from incomplete
emptying of left atrium; progressive thickening of valve cusps results, causing obstruction.

Cardiomyopathy – disease of the muscle either from unknown etiology or from a systemic
disorder, leads to severe heart failure and often death.

Pericarditis – pain most common characteristic, often accompanied by friction rub; refers to
the inflammation of the membranous sac protecting the heart.

Coughing and deep breathing prevents atelectasis and pneumonia

Aspiration pneumonia may occur if the client is vomiting and aspirates vomitus.

Elevating the head of the client in at least 45 degrees angle or in a sitting position reduces
the risk of regurgitation and pulmonary aspiration.

Providing pulmonary toilet after feeding may promote vomiting and aspiration of gastric
contents.

Mouth care should be performed with the client in a lateral position, not is a supine position,
in order to prevent aspiration.

Frequent auscultation of breath sounds is essential and is an independent nursing action

which does not require an order from the physician.

Sputum cultures for acid fast bacillus are the definitive diagnosis for tuberculosis

Tachycardia occurs as the heart compensates by increasing oxygen flow through the body,
and restlessness results from decreased oxygen flow to the brain.

Cyanosis is a late sign of hypoxemia.

Teaching the client to balance mild exercise, such as walking, with rest helps conserve
energy.

Strenuous exercise in the COPD client must be avoided. If oxygen needs (which are
increased with exercise) exceed supply (which is reduced in this disease) it causes hypoxia.

Use of medications may help tolerate exercise, but the medications must be given before
exercise.

Some exercise is beneficial. In the COPD client, the exercise depends on the client’s general
condition.
The four parts of the abdominal assessment, in order:
: inspection
: auscultation
: percussion
: palpation

Fiber-optic colonoscopy – a flexible fiber-optic scope is used to visualize the entire colon.

Oral cholecystogram – x-ray exam after oral ingestion of radiopaque dye to determine the
patency of the biliary duct.

Liver biopsy – percutaneous or intraoperative microscopic exam to confirm diagnosis of

hepatocellular diseases.

Ultrasound – non-invasive exam using sound waves to determine organ size and shape.

CAT scan – non-invasive radiological exam using tomography to present organ structure at
different depths and views; can be used with or without contrast.

Upper GI series (barium swallow) – observation of contrast medium movement through the
esophagus and into the stomach by means of fluoroscopy and x-ray. The contrast dye can
cause impaction of stool so keep the client well hydrated; stool may be white for up to 2
days after the test.

Lower GI series (barium enema) – radiological observation of contrast medium filling the
colon.

Endoscopic retrograde cholangiopancreatography (E.R.C.P.) – flexible fiber-optic scope

inserted into the mouth and via the common bile duct and pancreatic ducts to visualize
these structures. After the test, observe for hemorrhage.

Upper GI endoscopy – flexible fiber-optic endoscope that directly visualize the structures of
the upper GI tract. After the test, assess the client’s gag reflex before allowing PO intake.

Percutaneous transhepatic cholangiogram (P.T.C.) – using fluoroscopy, the bile duct is

entered percutaneously and injected with dye to observe filling of hepatic and biliary ducts.
After the test, observe for hemorrhage.

IV cholangiogram – radiographic exam used to visualize the biliary duct system after
intravenous injection of radiopaque dye.

Much of the chewing process is innervated by the fifth (trigeminal) cranial nerve.

Salivary glands secretions begins basic starch digestion.

Salivary amylase begins the chemical breakdown of starches to maltose.

Parotitis is usually caused by prolonged NPO status, Staphylococcus aureu, or poor oral
hygiene.

In caring for the client with an esophageal (hiatal) hernia, provide small, frequent, meals
and maintain the client in an upright position during and after meals to avoid regurgitation.
Gastrostomy – creating an opening directly into the stomach into which a feeding tube is
inserted to bypass the stomach.

Esophagectomy – removal of part or all of the esophagus, which is replaced by a graft

Esophagogastrectomy – resection of part of the esophagus and stomach, the stomach is

reconnected to the proximal end of the esophagus.

Gastroesophageal reflux disease (G.E.R.D.) is the reflux of stomach contents into the
esophagus, causing regurgitation and heartburn.

Instruct clients to have small, frequent meals, a lot of liquids, and to avoid caffeine, alcohol,
coffee, citrus juices, spicy foods, carbonation, peppermint, and chocolate in their diets.

Gastritis may be caused by the following:

: cigarette smoking
: contaminated foods
: alcohol
: caffeine
: radiation therapy
: chemotherapy
: C.N.S. lesions
: steroids
: infection

In the acute phase of gastritis the client should be NPO and then advanced to a bland diet

Vagotomy – severance of the vagus nerve, which eliminates neural stimulation of acid
secretion

Pyloroplasty – surgical enlargement of the pyloric sphincter, allowing easy passage of

contents from the stomach.

Subtotal gastrectomy – removal of most of the body and all the antrum of the stomach.

Gastroduodenostomy (Billroth I) – partial gastrectomy with removal of the distal 2/3 of the
stomach and anastomosis of the gastric stump to the duodenum.

Gastrojejunostomy (Billroth II) – partial gastrectomy of the distal 2/3 of the stomach with
anastomosis of the gastric stump to the jejunum.

The client may have a cholecystectomy, which is surgical removal of the gallbladder.

Kock pouch – Colectomy with creation of an internal pouch from the ileum that has a nipple
valve to control stool and flatus, thereby maintaining continence; also known as a continent
ileostomy.

Hemovac self-suctioning device – a collapsible device attached to a drain with multiple

openings; exerts negative pressure to withdraw accumulated fluids

Salem sump – a nasogastric tube that has a second lumen for air entry that keeps the
gastric lining from occluding the drainage holes; often attached to intermittent or low
continuous suction. Requires frequent irrigation to maintain patency.
Penrose – the most common abdominal drain; its flat, single lumen withdraws drainage by
capillary action.

Jackson-Pratt drain – oval, clear, pliable reservoir connected to drainage tubing; reservoir or
bulb can be compressed to form negative pressure, often referred to an “self-suction”

Levine tube – single lumen nasogastric tube used to evacuate air and fluid from the
stomach; requires frequent irrigation to maintain patency

Jejunostomy tube – tube that bypasses the stomach and allows for feedings to maintain or
restore a client’s nutrition.

t-tube – thin drainage catheter inserted into the common bile duct during surgery to protect
the suture line.

The five rights of medication administration :

: client
: dose
: drug
: route
: time

List three ways that the HIV virus can be transmitted : blood (transfusions prior to mid-
1985, sharing IV drug equipment, needle sticks with a contaminated needle), body
fluids/sexual contact (homosexual and heterosexual), and mother to infant (prenatal and
through breast milk).

A normal CD4 count is usually over 800mm3.

A normal CD4 count falls below 200mm3, the client is considered to have AIDS.

The basic screening test for HIV antibodies if the ELISA (enzyme linked immunosorbent
assay). A positive test is confirmed using the more specific Western blot test.

If a person has two or more opportunistic infections, she is considered to have AIDS,
regardless of HIV testing status or CD4 count.

List of the four components of personal protective gear:

: Gloves
: Gown
: Mask
: Face shield

To protect clients from respiratory infections, nurses and visitors who are symptomatic
should wear a mask.

Antiretrovirals are usually started when the CD4 count falls to 500 or below. List three
antiretrovirals used to treat HIV/AIDS:
: retrovir, zidovudine
: DDC (dideoxycytidien
: DDI (dedeoxyinosine
The newer nucleoside analog reverse transcriptase inhibitors that are used to treat
HIV/AIDS in combination with zidovudine include d4T and 3TC (Zerit).

A medication class that inhibits replication of HIV in chronically infected cells, thereby
decreasing the HIV viral load, is protease inhibitors

List of the common side effects of zidovudine:

: anemia
: granulocytopenia
: headache
: nausea

The leading cause of death in AIDS clients is infection

The best way for nurses to decrease the incidence of Nosocomial infections is through
diligent hand-washing.

An opportunistic infection is one that a person with an intact immune system would
normally not get.

Early signs and symptoms of infection in an HIV/AIDS client include:

: bowel changes
: fever
: restlessness
: increased pulse rate
: productive cough
: change in wound drainage
: lethargy

Opportunistic infections that could be considered AIDS defining in most clients include:
: candidiasis infection of esophagus, trachea, bronchi, or lungs
: Cryptococcus meningitis
: cytomegalovirus (CMV) retinitis
: herpes simplex outbreaks lasting longer than 30 days
: HIV wasting syndrome
: Invasive cervical cancer
: Kaposi’s sarcoma in clients over age 60
: Lymphoma
: Myobacterium tuberculosis (TB)
: PCP (Pneumocystis carinii pneumonia)
: toxoplasmic encephalitis
: toxoplasmosis

To decrease a client’s chance of developing an upper respiratory infection, what four things
can the client be encouraged to do?
: ambulate
: breathe deeply
: Cough
: turn from side to side frequently

Because of the increased risk of invasive cervical carcinoma, female clients who are HIV
positive should have a Pap smear once every 6 months.
When placing a PPD (purified protein derivative) to test to tuberculosis (TB), it is important
to read the test between 48 and 72 hours.

Anergy testing is done to determine a client’s ability to respond to TB testing. A control unit
measles or mumps antigen is commonly used.

HIV-positive clients should be tested for syphilis using a VDRL or RPR blood test.

Glomeruli – clumps of capillaries surrounded by Bowman’s capsule.

Nephrons – functional units of the kidneys that use three processes: filtration, reabsorption,
and secretion.

Blood enters the glomerulus under high pressure via the afferent arteriole.

The rate of filtration, or the glomerular filtration rate, is normally 125cc/minute and is
dependent upon capillary wall permeability, blood pressure, and effective filtration
pressures.

Substances filtered out in the glomerulus are useful to the body and would be lost in the
urine if not for selective tubular reabsorption through active transport or passive diffusion.

Active transport requires energy. Most positive ions, glucose, and amino acids are actively
reabsorbed from the tubules into the surrounding capillaries.

Passive transport (diffusion) does not require energy, as it takes advantage of established
concentration gradients. Water, urea and most negative ions are passively reabsorbed.

Proximal tubules – primary location for reabsorption and secretion of glucose, amino acids
and electrolytes.

Distal tubules – secretion of hydrogen ions (H+) to maintain the acid-base balance

Loop of Henle – reabsorption of water and sodium to concentrate the urine and some
electrolytes

Collecting duct – primary location for water reabsorption (increase urine concentration)

Glomeruli – filtration of water, sodium, potassium, calcium, magnesium, chloride,

phosphate, urea, creatinine, glucose, and amino acids occurs here.

Osmolality – an indicator of the body’s water balance; high serum levels indicate
dehydration, low serum levels indicate hypervolemia.

ADH is either stimulated or inhibited according to these serum levels indicate dehydration,
low serum levels indicate hypervolemia.

An elevated sodium level, known as hypernatremia (>146mEq/L), is caused by steroid

therapy, renal disease, aldosterone excess, or gain of total body water. Signs and
symptoms include water retention, edema, weight gain, and hypertension.
An elevated magnesium level, known as (>2.5mEq/L), is caused by renal insufficiency,
diabetic ketoacidosis, and excessive intake (usually via antacids). Signs and symptoms
include central nervous system and neuromuscular depression, hypotension, sedation, and
cardiac arrest.

Creatinine is a specific indicator of renal function, as renal impairment or failure is virtually

the only cause of its elevation. Usually viewed with the BUN serum level to obtain a broad
view of kidney function. Normal value is 0.7-1.6mg/dL.

A decreased potassium level, known as hypokalemia (<3.5mEq/L), is caused by diuretic

therapy, poor nutritional intake, gastrointestinal loss (via nasogastric tube, nausea, or
vomiting), ulcerative colitis, Cushing’s syndrome, and alkalosis. Signs and symptoms
include muscle weakness, decreased reflexes, flaccid paralysis, C.N.S. depression, lethargy,
hypotension, anorexia, and E.C.G. changes.

A decreased calcium level, known as (<8.5mg/dL), is caused by the hypoparathyroidism,

low vitamin D intake, pregnancy, rickets, and renal disease. Signs and symptoms include
tetany, paresthesia of fingers and around the mouth, muscle twitching, cramps,
laryngospasm, and elevated phosphorous levels.

Phosphorous is inversely proportional to serum calcium levels. Altered levels occur in renal
disease, as the kidneys regulate the calcium and phosphorous balance by activating vitamin
D. Normal values: 3.0-4.5mg/dL.

An elevated potassium level, known as Hyperkalemia (>5.5mEq/L), can be caused by

burns, renal failure, acidosis, or excessive intake. Sings and symptoms include skeletal
muscle cramps, weakness, bradycardia, arrhythmias, oliguria, diarrhea, and cardiac arrest.

A decreased magnesium level, known as hypomagnesemia (<1.5mEq/L), is caused by

alcoholism, malnutrition, and decreased oral intake. Signs and symptoms include tremors,
neuromuscular irritability, disorientation, and convulsions.

A decreased sodium level, known as hyponatremia (<135mEq/L), is caused by diuretic

therapy, burns, gastrointestinal loss, or excess body fluid reducing its ratio to water. Signs
and symptoms include decreased blood pressure, poor skin turgor, dehydration, shock,
oliguria and seizures.

Decreased hematocrit levels are seen in clients with renal failure due to low erythropoietin
secretion. Normal values range from 40-47%.

An elevated calcium level, known as hypercalemia (>10.5mg/dL), is due to immobility, bone

metastasis, excess vitamin D intake, osteoporosis, decreased renal excretion, and
parathyroid tumors. Signs and symptoms include skeletal muscle weakness, bone pain,
renal calculi, pathological fractures ,altered level of consciousness, constipation, nausea,
vomiting, anorexia, polyuria, and decreased serum phosphorous levels.

Intravenous pyelogram – a contrast materials is injected intravenously. As the kidneys filter

and excrete the dye, x-rays are taken at specific time intervals over 1 hour. The kidneys,
ureters, and bladder are visualized to evaluate function and identity obstructions present.

Abdominal x-ray – a flat x-ray plate is placed over the abdomen and an x-ray is taken.
Renal arteriogram – a radioactive isotope is injected via translumbar or femoral catheter
and x-rays are taken. The renal circulation is visualized and perfusion insufficiencies can be
identified.

Cystourethrogram – a catheter is inserted via the urethra and radiopaque dye is injected.
While the client voids, x-rays are taken. The bladder and urethra are visualized.

Uric acid stones – low purine diet with alkaline ash foods such as milk, fruits, rhubarb, and
vegetables.

Calcium stones – reduced dairy products with acid ash foods such as meat, whole grains,
cranberry juice, and prunes.

Pyelolithotomy – removal of a stone form the renal pelvis through a flank incision; urethral
catheter and Penrose drain are inserted.

Percutaneous lithotripsy – an endoscope is passed through a small incision made over the
kidney to remove the calculi or disintegrate it with ultrasonic waves.

Nephrectomy – removal of a kidney is required if extensive damage has occurred to the

parenchyma. A Penrose drain is placed in the renal bed.

Ureterolithotomy – an incision is made into the ureter through an abdominal or flank

excision to extract a stone. A Penrose drain is inserted to act as a splint that should never
be irrigated.

Nephrolithotomy – parenchyma of the kidney is cut through a flank incision to extract a

stone. A nephrostomy tube is placed to divert the urine away from the kidney.

Transcutaneous shock wave lithotripsy – the client is submerged in a large bath of warm
water as ultrasonic waves are delivered to the areas near the stone to crush or disintegrate
it.

The usual heart rate of a neonate is 120-160pbm and regular

A soft cardiac murmur during the first month of life is not normal

The yellowish color an infant develops by the third day of life is due to an immature liver.

A neonate’s breathing pattern is chiefly abdominal and irregular with a rate between 30 and
60 minute.

Periods of apnea up to 15 seconds in duration are normal for a newborn

There is often a brick red stain on the neonate’s diaper during the first week

Phenylketonuria testing is done after the ingestion of protein

A neonate should be placed on a rigid feeding schedule

Parent-infant relationship can be fostered during feeding times.

At 1 minute of life, the nurse assesses the neonate to have an apical heart rate of 90bpm
and an irregular breathing pattern. The neonate is flaccid, cries when the nurse slaps his
foot, and his extremities are cyanotic. This infant would receive an Apgar score of 5.

At 5 minutes of life the nurse assesses the neonate and finds that the apical heart rate is
110bpm and respirations remain irregular and slow. The neonate’s extremities are flexed,
he cries in response to a slap on the foot, and he is pink all over. The infant’s Apgar
score is 8.

Molding – temporary changes in the shape of the head of a neonate as it accommodates to

the birth canal during labor.

Cephalohematoma – due to the pressure of the presenting part against the cervix, blood
from periosteum accumulates in the tissue of the infant’s head, creating a circular swelling
that does not cross suture lines.

Caput succesaneum – swelling or edema of the head of an infant during labor and delivery;
crosses suture lines.

A neonate’s mother strikes his cheek and he turns his head toward that side. This an
example of the rooting reflex.

A neonate’s mother places an object close to the baby’s mouth and he attempts to such.
This is an example of sucking reflex.

A neonate’s father places his finger in the palm of the neonate’s hand. The neonate flexes
his finger around his father’s finger. This is an example of the grasp reflex.

A neonate father runs his thumb up the middle undersurface of the neonate’s foot. His toes
separate and flare out. This is an example of the Babinski reflex.

A neonate’s father runs his thumb up the lateral undersurface of his son’s foot and his toes
curl downward. This is an example of the plantar reflex.

There is a loud noise in the room and the neonate abducts his arms with flexion of elbows.
This is an example of the startle reflex.

A neonate’s brother bumps bassinet causing a jarring motion. The neonate extends and
abducts his extremities and fans hi fingers. This is an example of the Moro reflex.

A neonate is lying prone and he attempts crawling movement. This is a example of the
crawl reflex.

A neonate’s father supports him under both arms and places his feet on a firm surface. The
neonate makes stepping movements. This is an example of the Step reflex.

A neonate’s head is turned to the right side by his mother. His right arm and leg extend and
his left arm and leg flex. This is an example of Tonic Neck reflex.
Signs of respiratory distress in a newborn include:
: Grunting
: Retractions
: Stridor
: Unequal breath sounds
: Wheezing

Lanugo – soft, fine, downy hair found on both preterm and term newborns

Mongolian spots – dark spots on the lumbar region in the newborn children of non-
Caucasian races.

Acrocyanosis – cyanosis of the hands and feet.

Erythema toxicum – pink, popular rash that may have purulent vesicles

Harlequin sign – outlined color change as an infant lies on one side; the lower half of the
body becomes pink and the upper half pales

Milia – white, evanescent, pinhead-sized papules that occur on the face and less often on
the trunk.

A newborn is labeled “preterm” when it is born before 37 weeks of gestation.

A low birth weight infant is one who weighs less than 2,500 grams (5.5 pounds) at birth.

Preterm infants have lanugo on the face, less subcutaneous fat, and ears that are less
supported by cartilage than term infants.

In the preterm infants, respirations are efficient and the neonate is not at greater risk than
a full-term infant for respiratory distress.

Heat regulation is poorly developed in the neonate due to poor development of the central
nervous system.

The nurse should first assess the neonates hydration status.

The neonate will, most likely, require IV antibiotic treatment.

It is important to assess the neonate’s vital signs

Sepsis (infection) in infants is difficult to determine because there are no definitive signs.

To correct hydrocephalus and decrease intracranial pressure, a ventricular-peritoneal shunt

is often placed. Postoperative care includes monitoring for signs of cerebrospinal fluid
infection and increased intracranial pressure.

Postoperative care for the ventricular-peritoneal shunt includes placing the infant on the
non-operated side with the head of the bed elevated.
Hydrocephalus is often associated with myelomeningocele.

The earliest signs of hydrocephalus include increased head circumference and bulging
fontanels.

Hydrocephalus is characterized by an accumulation of cerebrospinal fluid in the ventricles.

Increased intracranial pressure can be caused by any mater that tries to take up some of
the fixed space of the cranium.

Myelomeningocele is a soft sac containing spinal fluid, meninges, spinal cord, and/or nerve
roots protruding through a bony defect in the spine.

If a client has a lumbar myelomeningocele there is no effect on the lower extremities.

Overflow incontinence with constant dribbling is common in infants with myelomeningocele.

Applying pressure to the suprapubic area is the best way to facilitate emptying of the
bladder.

Cleft lip and palate are facial malformations including a defect in the lip and soft and/or hard
palate.

Infants with cleft palate who are fitted with special prosthetics can use bottles for feeding.

After cleft lip repair, a rubber-tipped syringe should be used for feeding.

Cryptorchidism – undescended testicles

Hydrocele – collection of fluid in the tunica vaginalis of the testicles or along the spermatic
cord.

Hypospadias – urethra opens the ventral surface of the penis or perineum

THERAPEUTIC :
: Using silence
: “My name is …..”
: restating and/or reflecting
: “Go on.”
: Exploring
: “Describe how you feel about being here.”
: Making observation
: “What would you like to do now?”
NON-THERAPEUTIC:
: “Don’t be silly.”
: Reassuring
: Challenging
: Advising
: Giving approval or disapproving
: “Nice weather we’re having.”
: “I agree; that’s right.”
A client hears the wind blowing into a room at night and thinks it’s a voice. This is an
illusion.

Though blocking – suddenly stopping in the steam of thoughts for no apparent reason, with
no recall of the topic.

Loosening of associations – free-flowing thoughts that seem to have little or no connection

to one another.

Word salad – an incoherent, incomprehensible mixture of words and phrases, consisting of

both real and imaginary terms.

Flight of ideas – talking in a continuous but fragmentary way, with extremely rapid speech

Punning – associating thought by double meaning

Neologisms – newly invented words, having no public, consensual meaning

Clang associations - a rhythmic speech pattern in which sounds govern the choice of words.

Nihilistic delusion – false feeling that the self, part of the self, others, or the world does not
exist.

Delusions of persecution – false paranoid thoughts and beliefs

Though insertion – belief that thought can be inserted into one’s head by another

Ideas of influence – beliefs involving another persons or force controlling an aspects of one’s
behavior

Somatic delusion – false belief involving a body’s parts or functions changing.

Ideas of reference – beliefs that a radio or television is speaking to or about oneself.

Delusion of grandeur – exaggerated, unrealistic sense of importance and sense of self

Thought broadcasting – belief that one’s thoughts are being aired to the outside world.