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The water seal chamber of the chest tube drainage system is filled with sterile water and acts as

a one-way valve preventing air from entering the client's chest cavity. The water level in the
water seal chamber rises and falls with inspiration and expiration, a process known
as tidaling. This movement occurs in section B of the water seal chamber and indicates that the
system is functioning properly and maintaining appropriate negative pressure.
(Section A) This is the suction control chamber, which is usually set at -20 cm H2O to
maintain negative pressure in the system. Bubbling will occur when suction is applied.
(Section C) The air leak gauge (part of the water seal chamber) allows for assessment of air
leaks. Continuous bubbling indicates an air leak in the system.
(Section D) This is the drainage collection chamber in which fluid from the client's pleural
cavity will collect; the nurse will assess the color and amount and record the output.
Educational objective:
Tidaling is the fluctuation that occurs in the water seal chamber in relation to the client's
respiratory movements. The level of sterile water will rise with inspiration and fall with
expiration, indicating proper function of the chest tube drainage system.
A chest tube is removed when drainage is minimal (<200 mL/24 hr) or absent, an air leak (if
present) is resolved, and the lung has reexpanded. The general steps for chest tube removal

1. Premedicate the client with analgesic (eg, IV opioid, nonsteroidal anti-inflammatory

drug [ketorolac]) 30-60 minutes before the procedure to promote comfort as evidence
indicates that most clients report significant pain during removal (Option 1).
2. Provide the health care provider (HCP) with sterile suture removal equipment (Option
3. Instruct the client to breathe in, hold it, and bear down (Valsalva maneuver) while the
tube is removed to decrease the risk for a pneumothorax. Most HCPs use this technique
to increase intrathoracic pressure and prevent air from entering the pleural space (Option
4. Apply a sterile airtight occlusive dressing to the chest tube site immediately; this will
prevent air from entering the pleural space (Option 4).
5. Perform a chest x-ray within 2-24 hours after chest tube removal as a post-procedure
pneumothorax or fluid accumulation usually develops within this time frame.

(Option 3) The client should be placed in semi-Fowler's position or on the unaffected side to
promote comfort and facilitate access for tube removal.
The nurse is to administer an albuterol nebulizer treatment to a client with acute
bronchospasm. The prescribed dosage is 5 mg every 4 hours. The available solution is albuterol
inhaled, 2.5 mg/3 mL (0.083%). How many mL does the nurse administer with each
dose? Record your answer as a whole number.
There are 2 ways to calculate this medication dosage.

1. Using the following formula:

Desired x Vehicle
5 mg x 3 mL = 6 mL
2.5 mg
2. Using basic ratio and proportion calculations:

5 mg = 2.5 mg
X mL 3 mL
2.5 X = 15
X = 6 mL

Weight in lb = 8 + 9 oz = 8 + 0.5625 = 8.5625 lb

16 oz

Weight in kg = Weight (lb) = 8.5625 lb = 3.8920 kg

2.2 lb 2.2 lb

Desired dose = Prescribed amount (mg/kg) x weight (kg) = 0.01 mg/kg x 3.8920 kg = 0.03892

Amount to administer = Desired x quantity = 0.038920 mg x 1 mL = 0.973 mL

Available 0.04 mg

The nurse must convert the weight of the infant from pounds and ounces to kilograms
(equivalents: 1 lb = 16 oz and 1 kg = 2.2 lb) and then determine the desired dose. After the
desired dose is obtained, the nurse will then determine the number of milliliters to administer.
Educational objective:
Naloxone is given to the client to reverse respiratory depression resulting from maternal opioid
use during the 1-4 hours prior to birth. The nurse calculates the amount of naloxone to be
administered in mL after converting pounds and ounces to kilograms and determining the desired
dose in mg.
When performing the suctioning procedure, the nurse follows institution policy and observes
principles of infection control and client safety. Strict aseptic technique is maintained because
suctioning can introduce bacteria into the lower airway and lungs.

1. Place the client in semi-Fowler's position, if not contraindicated, to promote lung

expansion and oxygenation.
2. Preoxygenate with 100% oxygen (hyper-oxygenate) to prevent hypoxemia and
microatelectasis. Alternately, if the client is breathing room air independently, ask the
client to take 3-4 deep breaths.
3. Insert the catheter gently the length of the airway without applying suction to prevent
mucosal tissue damage. The distance can be premeasured (0.4-0.8 in [1-2 cm] past the
distal end of the tube).
4. Withdraw the catheter slightly (0.4-0.8 in [1-2 cm]) if resistance is felt at the carina
(bifurcation of the left and right mainstem) to prevent mucosal tissue damage.
5. Apply intermittent suction while rotating the suction catheter during withdrawal to
prevent mucosal tissue damage. Limit suction time to 5-10 seconds with each suction
pass to prevent mucosal tissue damage and limit hypoxia.

The steps for administering an intermittent enteral feeding include:

 Identify the client using 2 identifiers (eg, first and last name, medical record number, date
of birth) (Option 4), and explain the procedure to the client. Perform hand hygiene and
apply clean gloves.
 Elevate head of bed 30-45 degrees and keep elevated for at least 30 minutes after feeding
to minimize risk of aspiration (Option 2).
 Validate tube placement by assessing external tube length and comparing with the initial
measurement at time of insertion. Tube should be marked at the nostril with permanent
marker during the initial x-ray validation (Option 5).
 Flush the tube with 30 mL of water before and after intermittent feedings and medication
administration to prevent clogging (Option 3).
 Administer the prescribed enteral feeding solution using aseptic technique (Option 1).

Distension of jugular neck veins should be performed with the client sitting with the head of the
bed at a 30- to 45-degree angle. The nurse will observe for distension and
prominent pulsation of the neck veins. The presence of JVD in the client with heart failure may
indicate an exacerbation and possible fluid overload.

Muffled heart tones in a client with pericardial effusion can indicate the development of cardiac
tamponade. This results in the build-up of fluid in the pericardial sac, which leads to
compression of the heart. Cardiac output begins to fall as cardiac compression increases,
resulting in hypotension. Additional signs and symptoms of tamponade include tachypnea,
tachycardia, jugular venous distension, narrowed pulse pressure, and the presence of a pulsus
paradoxus. Pulsus paradoxus is defined as an exaggerated fall in systemic BP >10 mm Hg
during inspiration.
The procedure for measurement of pulsus paradoxus is as follows:

1. Place client in semirecumbent position

2. Have client breathe normally
3. Determine the SBP using a manual BP cuff
4. Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP
5. Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the
6. Continue to slowly deflate the cuff until you hear sounds throughout inspiration and
expiration; also note the pressure
7. Determine the difference between the 2 measurements in steps 5 and 6; this equals the
amount of paradox
8. The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the
presence of cardiac tamponade.
Extravasation is the infiltration of a drug into the tissue surrounding the vein. The
vasoconstrictor norepinephrine (Levophed) is a vesicant that can cause skin breakdown
and/or necrosis if absorbed into the tissue. Pain, blanching along the vein pathway, swelling,
and redness are signs of extravasation. Norepinephrine should be infused through a central line
whenever possible. However, it may be infused at lower concentrations via a large peripheral
vein for up to 12 hours until central venous access is established.
The nurse should implement the following interventions to manage norepinephrine

 Stop the infusion immediately and disconnect IV tubing.

 Use a syringe to aspirate the drug from the IV catheter; remove the IV catheter while
 Elevate the extremity above the heart to reduce edema.
 Notify the health care provider. Obtain a prescription for the
antidote phentolamine (Regitine), a vasodilator that is injected subcutaneously to
counteract the effects of norepinephrine.

Inhalation devices include metered-dose inhalers (MDIs), dry powder inhalers, and
nebulizers. The devices deliver a measured dose of medication with each actuation. They are
primarily used to treat respiratory disorders but may also be used for some nonrespiratory
conditions (eg, diabetes, analgesia). The inhaled route is preferred for beta agonist,
anticholinergic, and steroid medications as it causes fewer side effects than the PO route
Correct use of the MDI is necessary to receive the full benefit from inhaled medication. The
steps are as follows:

1. Shake canister well for about 3-5 seconds.

2. Tilt head back slightly and exhale slowly for 3-5 seconds.
3. Hold canister mouthpiece about 1½ inches in front of open mouth; as an alternative, place
the mouthpiece in the mouth with lips sealed around it. Holding it in front of the open
mouth prevents impaction of the particles into the tongue and sides of mouth.
4. Compress canister while inhaling slowly for about 3-5 seconds.
5. Hold breath for 10 seconds, if possible, before exhaling.
6. Wait at least 1-2 minutes before taking a second puff of a bronchodilator, if
prescribed. The first puff of medication dilates the bronchioles and allows easy passage
of the second puff.

To prevent air embolism when discontinuing a central venous catheter, the nurse should
perform the following interventions:

 Instruct the client to lie in a supine position. This will increase the central venous
pressure and decrease the possibility of air getting into the vessel (Option 3).
 Instruct the client to bear down or exhale. The client should never inhale during
removal of the line; inhalation will suck more air into the blood vessel via negative
suction pressure (Options 2 and 5).
 Apply an air-occlusive dressing (usually gauze with a Tegaderm dressing) to help
prevent a delayed air embolism. If possible, the nurse should attempt to cover the site
with the occlusive dressing while pulling out the line (Option 1).
 Pull the line cautiously and never pull harder if there is resistance. Doing so could cause
the catheter to break or become dislodged in the client's vessel (Option 4).
To provide full support when climbing stairs, clients should hold the cane on the stronger
side and move the cane before moving the weaker leg, regardless of the direction of the
stairs (Option 2). They should also keep 2 points of support on the floor at all times (eg, both
feet, cane and foot) and face forward when going up or down the stairs, especially if there is no
handrail (Option 1). The nurse should instruct the client on the following:
When ascending stairs:

1. Step up with the stronger leg first (in this client, the right leg)
2. Move the cane next while bearing weight on the stronger leg
3. Finally, move the weaker leg (in this client, the left leg)

When descending stairs:

1. Lead with the cane

2. Bring the weaker leg down next
3. Finally, step down with the stronger leg

Steps for inserting a nasogastric tube for gastric decompression include the following:

1. Perform hand hygiene and apply clean gloves (no need for sterile gloves)
2. Place client in high Fowler's position
3. Assess nares and oral cavity and select naris
4. Measure and mark the tube
5. Curve 4-6" tube around index finger and release
6. Lubricate end of tube with water-soluble jelly
7. Instruct client to extend neck back slightly
8. Gently insert tube just past nasopharynx, aiming tip downward
9. Rotate tube slightly if resistance is met, allowing rest periods for client
10. Continue insertion until just above oropharynx
11. Ask client to flex head forward and swallow small sips of water (or dry if NPO)
12. Advance tube to marked point
13. Verify tube placement and anchor - use agency policy and procedure to verify
placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating
gastric contents and testing the pH may also give an indication of placement (pH should
be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube
placement initially, but is not definitive as it is not an evidence-based method. Nothing
may be administered through the tube until x-ray confirmation is obtained, or this may
cause aspiration.

Steps for inserting a nasogastric tube for gastric decompression include the following:

1. Perform hand hygiene and apply clean gloves (no need for sterile gloves)
2. Place client in high Fowler's position
3. Assess nares and oral cavity and select naris
4. Measure and mark the tube
5. Curve 4-6" tube around index finger and release
6. Lubricate end of tube with water-soluble jelly
7. Instruct client to extend neck back slightly
8. Gently insert tube just past nasopharynx, aiming tip downward
9. Rotate tube slightly if resistance is met, allowing rest periods for client
10. Continue insertion until just above oropharynx
11. Ask client to flex head forward and swallow small sips of water (or dry if NPO)
12. Advance tube to marked point
13. Verify tube placement and anchor - use agency policy and procedure to verify
placement by anchoring tube in place and obtaining an abdominal x-ray. Aspirating
gastric contents and testing the pH may also give an indication of placement (pH should
be 5.5 or below). Auscultation of inserted air is acceptable for confirming tube
placement initially, but is not definitive as it is not an evidence-based method. Nothing
may be administered through the tube until x-ray confirmation is obtained, or this may
cause aspiration.

A lumbar puncture (spinal tap) is a sterile procedure used to gather a specimen of cerebrospinal
fluid (CSF) for diagnostic purposes (eg, meningitis). A needle is inserted into the vertebral
spaces between L3 and L4 or L4 and L5, and a sample of CSF is drawn. The nurse's role when
assisting with a lumbar puncture includes the following:

1. Verify informed consent

2. Gather the lumbar puncture tray and needed supplies
3. Explain the procedure to older child and adult
4. Have client empty the bladder
5. Place client in the appropriate position (eg, side-lying with knees drawn up and head
flexed or sitting up and bent forward over a bedside table)
6. Assist the client in maintaining the proper position (hold the client if necessary)
7. Provide a distraction and reassure the client throughout the procedure
8. Label specimen containers as they are collected
9. Apply a bandage to the insertion site
10. Deliver specimens to the laboratory
The general procedure for the administration of ophthalmic medications includes the following
steps in sequence:
1. Remove dried secretions with moistened (warm water or normal saline) sterile gauze
pads by wiping from the inner to outer canthus to keep eyelid and eyelash debris from
entering the eye and to prevent transfer of debris into the lacrimal (tear) duct(Option 3)
2. Place client in the supine or sitting position with head tilted back toward side of the
affected eye to prevent excess medication from flowing into the lacrimal duct and
minimize systemic absorption through the nasal mucosa
3. Rest hand on client's forehead and hold dropper 1-2 cm (1/2-3/4 in) above the
conjunctival sac, which keeps the dropper away from the eye globe and avoids
contamination (Option 4)
4. Pull lower eyelid down gently with thumb or forefinger against bony orbit to expose the
conjunctival sac (Option 2)
5. Instruct client to look upward and then instill drops of medication into the conjunctival
sac. This minimizes the blink reflex and retracts the cornea up and away from the
conjunctival sac to avoid instillation onto the cornea
6. Instruct client to close the eyelid and move the eye around (if able). Then apply pressure
to the lacrimal duct for 30-60 secondsif medication has systemic effects (eg, beta blocker,
timolol maleate [Timoptic]). This will distribute the medication, prevent overflow into
the lacrimal duct, and reduce possible systemic absorption (Option 1)
7. Remove excess medication from each eye with a new tissue or gauze pad to prevent
8. Wait 5 minutes before instilling a different medication into the same eye

Large amounts of vitamin K-rich foods can decrease the anticoagulant effects of
warfarin therapy. Clients are not instructed to remove those foods from their diet but are
encouraged to be consistent in the intake of foods high in vitamin K, including leafy green
vegetables, asparagus, broccoli, kale, Brussels sprout, and spinach.
Several beverages also affect warfarin therapy. Green tea, grapefruit juice, and cranberry
juice may alter its anticoagulant effects.

Infliximab, adalimumab, and etanercept are tumor necrosis factor (TNF) inhibitors that
suppress the inflammatory response in autoimmune diseases such as rheumatoid arthritis, Crohn
disease, and psoriasis. Due to the immunosuppressive action of TNF inhibitors, clients taking
these drugs are at increased risk for infection. A client with current, recent, or chronic infection
should not take a TNF inhibitor (Option 1).

Clients with infection should not take tumor necrosis factor (TNF) inhibitors (eg, infliximab,
adalimumab, etanercept) as these suppress the immune response. Before starting drug therapy,
clients should be tested for tuberculosis and receive the inactivated (injectable) influenza
vaccine. Clients taking TNF inhibitors should avoid live vaccines.

Thiazolidinediones (rosiglitazone [Avandia] and pioglitazone [Actos]) are used to treat type 2
diabetes mellitus. These agents improve insulin sensitivity but do not release excess insulin,
leading to a low risk for hypoglycemia (similar to metformin). These drugs can worsen heart
failure by causing fluid retention and increase the risk of bladder cancer. Heart failure or
volume overload is a contraindication to thiazolidinedione use. These medications also increase
the risk of cardiovascular events such as myocardial infarction.

A therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve
disease. However, it is never between 4 and 5 (Option 3).
Intestinal bacteria produce vitamin K; most antibiotics kill these bacteria, leading to vitamin K
deficiency. Warfarin is a vitamin K antagonist; therefore, INR would overshoot in the setting of
vitamin K deficiency, placing the client at risk for bleeding (Option 1).
Leafy-green vegetables contain a high amount of vitamin K, which may lower a client's INR and
make it difficult to maintain a therapeutic INR. Clients do not have to avoid consumption of
leafy-green vegetables, but they should eat a consistent quantity and have their INR checked
periodically (Option 2).
Warfarin must be taken at the same time daily to reach a therapeutic INR of 2-3. A diet high in
vitamin K may decrease warfarin's anticoagulant effect. Most antibiotics will increase INR by
causing a vitamin K deficiency.

Hepatic encephalopathy in cirrhosis results from higher serum ammonia levels that cause
neurotoxic effects, including mental confusion. Oral lactulose is given to reduce the ammonia
by trapping it in the gut and then expelling it with a laxative effect. Improved mental status
implies reduction of ammonia levels. Lactulose is a laxative used to trap and expel ammonia in
clients with cirrhosis who have hepatic encephalopathy. Elevated ammonia levels cause mental

Topical capsaicin cream (Zostrix) is an over-the-counter analgesic that effectively relieves

minor pain (eg, osteoarthritis, neuralgia). The nurse should instruct the client to wait at least 30
minutes after massaging the cream into the hands before washing to ensure adequate
absorption (Option 2). The client should avoid contact with mucous membranes (eg, nose,
mouth, eyes) or skin that is not intact, as capsaicin is a component of hot peppers and can cause
burning. When applying cream to other areas of the body (eg, knee), the client should wear
gloves or wash hands immediately after application.

Delirium has a sudden onset and involves fluctuating mental status and inattention with
disorganized thinking and/or altered level of consciousness. Dementia has a slow onset, usually
with normal attention. Depression involves loss of interest in previously pleasurable activities.
The priority nursing action is to explore the content of the hallucinations. This client may be
experiencing command auditory hallucinations that could lead to self-directed or other-directed injury
and harm. After the content of the hallucinations has been explored, implementing an intervention may
be necessary to reduce the potential for violence.

Hallucinations are false sensory perceptions that have no external stimuli. They can occur in any
of the 5 senses. Auditory hallucinations are the most common, followed by visual, tactile
(touch), olfactory (smell), and gustatory (taste).
Additional ways to deal with hallucinations include the following:

 Telling the client that you know they are real to the client but that you do not hear the
voices (or see the vision, feel the sensation)
 Not arguing with or challenging the client about the hallucinations
 Directing the client to a reality-oriented topic of conversation or activity
 The mnemonic SAD PERSONS uses known risk factors and the concept of their
accumulation to help predict who is at a higher risk of committing suicide.
S Sex (men kill themselves more often than women; women make more attempts)

A Age (teenagers/young adults, age >45)

D Depression (and hopelessness)

P Prior history of suicide attempt

E Ethanol and/or drug abuse

R Rational thinking loss (hearing voices to harm self)

S Support system loss (living alone)

O Organized plan; having a method in mind (with lethality and availability)

N No significant other

S Sickness (terminal illness)

Defense mechanisms are strategies or responses, usually unconscious, used by individuals to
distance themselves from a full awareness of unpleasant thoughts, internal conflicts, and external
stresses. Defense mechanisms protect the ego from threatening thoughts and anxiety.
Denial is the refusal to accept the reality of threatening situations, or painful thoughts, feelings,
or events. It is the most frequent defense mechanism used by clients with alcoholism; the client
may deny that drinking is a significant problem and that any issues or problems can be handled
This client is also using projection by saying that the spouse should be hospitalized; projection
involves placing one's own thoughts, feelings, or impulses onto someone else.
(Options 2, 3, and 4) Rationalization, regression, displacement, sublimation, and reaction
formation are not the primary defense mechanisms used by the client. This client displays no
symptoms of depression.
Educational objective:
The most common defense mechanism used by persons with alcoholism is denial, the refusal to
accept the reality of threatening situations, or painful thoughts, feelings, or events. Projection
involves placing one's own thoughts, feelings, or impulses onto someone else.

Cognitive behavioral therapy (CBT) can be effective in treating anxiety disorders, eating
disorders, depressive disorders, and medical conditions such as insomnia and smoking. These
types of disorders are characterized by maladaptive reactions to stress, anxiety, and
conflict. CBT requires that the client learn the skill of self-observation and to apply more
adaptive coping interventions.
CBT involves 5 basic components:

 Education about the client's specific disorder

 Self-observation and monitoring - the client learns how to monitor anxiety, identify
triggers, and assess the severity
 Physical control strategies – deep breathing and muscle relaxation exercises
 Cognitive restructuring – learning new ways to reframe thinking patterns, challenging
negative thoughts
 Behavioral strategies – focusing on situations that cause anxiety and practicing new
coping behaviors, desensitization to anxiety-provoking situations or events

Delusional disorder is a type of psychosis characterized by isolated delusions that last for at least
a month in a client who is otherwise highly functional. The symptoms of other psychotic
disorders, such as those associated with schizophrenia (eg, hallucinations, bizarre behavior,
disorganized thought processes), are not present. The delusions can be bizarre (out of the realm
of possibility) or non-bizarre (possibly true but not).
Typical characteristics of perpetrators of child abuse include:

1. Unrealistic expectations of the child's performance, behavior, and/or accomplishments;

overly critical of the child
2. Confusion between punishment and discipline; having a stern, authoritative approach to
3. Having to cope with ongoing stress and crises such as poverty, violence, illness, lack of
social support, and isolation (Option 2)
4. Low self-esteem – a sense of incompetence or unworthiness as a parent
5. A history of substance abuse, use of alcohol or drugs at the time the abuse
occurs (Option 1)
6. Punitive treatment and/or abuse as a child
7. Lack of parenting skills, inexperience, minimal knowledge about child care and child
development, and young parental age (Option 6)
8. Resentment or rejection of the child
9. Low tolerance for frustration and poor impulse control
10. Attempts to conceal the child's injury or being evasive about an injury; shows little
concern about the child's injury
Clients with schizophrenia often become anxious when around other individuals and will seek to
be alone to relieve anxiety. Impaired social and interpersonal functioning (eg, social withdrawal,
poor social interaction skills) are common negative symptoms of schizophrenia. These are more
difficult to treat than the positive symptoms (eg, hallucinations, delusions) and contribute to a
poor quality of life.
Nursing interventions directed at improving the social interaction skills of a client with
schizophrenia include the following:

 Making brief, frequent contacts

 Accepting the client unconditionally by minimizing expectations and demands
 Assessing the client's readiness for longer contacts with the nurse and/or other staff and
 Being with or close by the client during group activities
 Offering positive reinforcement when the client interacts with others

Social isolation and impaired social interaction are common negative symptoms of
schizophrenia. The client will seek to be alone to relieve anxiety associated with being around
others. The nurse needs to be accepting of the client's behavior and continue attempts at brief
contact until the client is comfortable.

Psychomotor retardation is a clinical symptom of major depressive disorder. Manifestations of

psychomotor retardation include slowed speech, decreased movement, and impaired cognitive
function. The individual may not have the energy or ability to perform activities of daily living
or to interact with others. Psychomotor retardation may range from severe (total immobility and
speechlessness -catatonia) or mild (slowing of speech and behavior).
Specific clinical findings of psychomotor retardation include the following:

 Movement impairment - body immobility, slumping posture, slowed movement, delay in

motor activity, slow gait
 Lack of facial expression
 Downcast gaze
 Speech impairment – reduced voice volume, slurring of speech, delayed verbal responses,
short responses
 Social interaction – reduced or non-interaction

Clients with major depressive disorder may also show symptoms of psychomotor agitation,
characterized by increased body movement, pacing, hand wringing, muscle tension, and erratic
eye movement.

Individuals with borderline personality disorder (BPD) live in fear of rejection and
abandonment. To avoid abandonment, they use manipulation and control, often unconsciously,
to prevent a person from leaving. The manipulative behavior may be of a positive nature, such
as the use of flattery, or a negative nature, such as distancing from the other person. An
individual with BPD may also engage in self harm or suicidal behaviors in an attempt to gain
attention from the other person and keep that person from leaving.
For this client, the nursing care plan must include the assignment of different staff
members. This will help diminish the client's dependence on a particular individual and help the
client learn to relate to more than one person.
Clients with borderline personality disorder, in an attempt to prevent abandonment and control
their environment, may flatter and cling to one staff member while making derogatory remarks
about others. The best nursing action is to rotate staff members assigned to care for the client.

Many clients with advanced Alzheimer disease reside in long-term care centers; therefore, most
routine care activities can be delegated to the licensed practical nurse (LPN) and unlicensed
assistive personnel (UAP).
The role of the LPN includes:

 Administration of enteral feedings (if prescribed)

 Administration of medications
 Monitoring for safety hazards
 Monitoring for behavioral changes

The role of UAP includes:

 Assisting with activities of daily living (eg, toileting, bathing, skin care, oral care,
personal hygiene) (Option 1)
 Assisting with feeding
 Reporting changes in ability to eat or difficulty swallowing (Option 5)
 Reporting changes in behavior
 Placing bed alarms to reduce risk of falls (Option 4)
Disturbance in logical form of thought is characteristic and one of the positive symptoms of
schizophrenia. The client will often have trouble concentrating and maintaining a train of
thought. Thought disturbances are often accompanied by a high level of functional impairment,
and the client may also be agitated and behave aggressively.
Types of impaired thought processes seen in individuals with schizophrenia include the

 Neologisms – made-up words or phrases usually of a bizarre nature; the words have
meaning to the client only. Example: "I would like to have a phjinox."
 Concrete thinking – literal interpretation of an idea; the client has difficulty with
abstract thinking. Example: The phrase, "The grass is always greener on the other side,"
would be interpreted to mean that the grass somewhere else is literally greener (Option
 Loose associations – rapid shifting from one idea to another, with little or no connection
to logic or rationality (Option 2)
 Echolalia – repetition of words, usually uttered by someone else
 Tangentiality – going from one topic to the next without getting to the point of the
original idea or topic (Option 3)
 Word salad – a mix of words and/or phrases having no meaning except to the
client. Example: "Here what comes table, sky, apple." (Option 4)
 Clang associations – rhyming words in a meaningless, illogical manner. Example: "The
pike likes to hike and Mike fed the bike near the tyke."
 Perseveration – repeating the same words or phrases in response to different questions

Educational objective:
Disturbance in thought process (form of thought) is one of the positive symptoms of
schizophrenia. The nurse needs to be able to recognize and identify the various types of thought
disturbances experienced by clients with schizophrenia. These include loose associations,
neologisms, word salad, echolalia, tangentiality, clang association, and perseveration.
A key feature of attention-deficit hyperactivity disorder (ADHD) is hyperactivity; however,
some children with ADHD behave aggressively and have difficulty controlling anger,
especially when frustrated or if unable to meet demands and challenges.
An immediate intervention to help settle an out-of-control child is deep breathing. Taking slow,
deep breaths relaxes the body, slows the heart rate, and distracts the child from inappropriate
behaviors. Asking the child to blow up a balloon provides an easy mode of distraction and
engages the child in a deep breathing exercise. After the child is calm, the nurse and the child
can further discuss the disruptive behavior.
Nursing interventions include the following:

 Stay calm and remove the child from the source of frustration/anger
 Assist the child in calming down with deep breathing exercises
 Discuss what precipitated the behavior and why the behavior is wrong
 Discuss acceptable ways of expressing anger and frustration
 Acknowledge that controlling anger is difficult
 Provide rewards for appropriate behavior
 Discuss the consequences of inappropriate behavior

Hypomagnesemia, a low blood magnesium level (normal 1.5-2.5 mEq/L [0.75-1.25 mmol/L]),
is associated with alcohol abuse due to poor absorption, inadequate nutritional intake, and
increased losses via the gastrointestinal and renal systems. It is associated with 2 major issues:

1. Ventricular arrhythmias (torsades de pointes): This is the most serious concern

2. Neuromuscular excitability: Manifestations of low magnesium, similar to those found
in hypocalcemia and demonstrated by neuromuscular excitability, include tremors,
hyperactive reflexes, positive Trousseau and Chvostek signs, and seizures.

Clients who abuse alcohol often have low magnesium levels that manifest as ventricular
arrhythmias and/or neuromuscular excitability (similar to hypocalcemia), which includes
tremors, positive Chvostek and Trousseau signs, hyperactive reflexes, and seizures.

Constipation and polyuria indicate hypercalcemia. Calcium has a diuretic effect.

Increased thirst with dry mucous membranes indicates hypernatremia.
Hypokalemia results in muscle weakness/paralysis and soft, flabby muscles. Paralytic ileus
(abdominal distension, decreased bowel sounds) is also common with hypokalemia. However,
the most serious complication is cardiac arrhythmias.
Bulimia nervosa is characterized by episodes of uncontrollable binge eating (consuming very
large amounts of food) followed by inappropriate behaviors to prevent weight gain. Self-induced
vomiting within 1-2 hours of binge eating is the more typical behavior; use of enemas and
laxatives, and frequent, intense exercise are also characteristic behaviors of the client with
bulimia nervosa.
Signs that a parent or friend of someone with this disorder might notice include the following:

 Trips to the bathroom after meals

 Disappearance of large amounts of food
 Finding hidden wrappers and empty containers of food, especially foods that are sweet
and easily consumed
 Smells of vomit; finding packages of laxatives or enemas
 Getting up in the middle of the night followed by a trip to the bathroom some time later
 Engaging in intense physical exercise despite fatigue or pain
 Swelling of the cheeks due to parotid gland damage and enlargement; staining of the
 Periods of starvation
 Preoccupation with weight, food, and dieting

This client is experiencing the symptoms of a panic attack and should not be left alone. The
priority nursing action is to stay with the client to offer support and reassurance that the client is
safe and secure.
Additional nursing actions while the client is experiencing panic symptoms include:

 Maintaining a calm, matter-of-fact approach

 Speaking calmly and using simple, clear words and phrases when providing information
on emergency department procedures
 Placing the client in a room with as little stimuli as possible
 Administering an anti-anxiety medication such as a benzodiazepine (per health care
provider prescription)
 Having the client breathe into a paper bag if hyperventilation is a problem

The priority nursing action for the client experiencing symptoms of a panic attack is for the
nurse to stay with the client in a calm environment and offer support and reassurance that the
client is safe and secure.

In developing a care plan for a client experiencing acute mania, the nurse is aware that an acute
manic episode is characterized by the following:

 Excessive psychomotor activity

 Euphoric mood
 Poor impulse control
 Flight of ideas, non-stop talking
 Poor attention span, distractibility
 Hallucinations and delusions
 Insomnia
 Wearing bizarre or inappropriate clothing, jewelry, and makeup
 Neglected hygiene and inadequate nutritional intake
The care plan for a client experiencing an acute manic episode includes the following:

 Reduction of environmental stimuli

o Providing a quiet, calm environment
o Limiting the number of people who come in contact with the client
o One-on-one interactions rather than group activities
o Low lighting
 A structured schedule of activities to help the client stay focused
 Physical activities to help relieve excess energy
 Providing high-protein, high-calorie meals and snacks that are easy to eat
 Setting limits on behavior
The neonate should be placed on the back with the neck slightly extended. This is a neutral or
"sniffing" position. A blanket or towel roll can be placed under the shoulders, elevating them
0.75-1.0 in (19-25.4 mm) off the mattress. This is particularly useful if the infant has a large
occiput from molding or edema. The nurse must watch that the infant's head does not shift to an
improper position during caregiving activities.

Infant formula is readily available in 3 forms: ready-to-feed, concentrated, and powder. Parents
who feed their infants commercial formula should closely follow the manufacturer's
recommendations for preparation, particularly if the product requires dilution or
reconstitution. Parents should also adhere to basic guidelines for safe storage and handling. Key
teaching points include:

 Keep bottles, nipples, caps, and other parts as clean as possible, either by boiling or
washing in the dishwasher
 Wash the tops of formula cans prior to opening to prevent contamination (Option 2)
 Prepared formula or opened cans of ready-to-feed or concentrated formula should be kept
in the refrigerator and discarded after 48 hours if unused (Option 5). There is a risk of
bacterial growth after this time.
 Prepared bottles can be warmed by placing in a pan of hot water for several minutes
 Test temperature on the inner wrist before serving to the infant; formula should feel
lukewarm, but never hot
 Never microwave formula as it can cause mouth burns (Option 3)

Circumcision is performed relatively close to the time of discharge due to the lack of clotting
factors at birth and to reduce cold stress.
Circumcision care at home includes:

 Wash hands before providing care

 Avoid using alcohol-based prepackaged wipes as alcohol prevents healing and causes
discomfort. Instead, clean with warm water (without soap) every 4 hours to remove
urine and feces.
 Apply petroleum jelly at diaper changes (unless PlastiBell used); the diaper should be
loose over the penis. The diaper should be changed at least every 4 hours to prevent
adhesion to the penis.
 Yellow exudate forms as part of the normal healing process after the first 24 hours. It is
not a sign of infection and should not be removed forcefully. The exudate will disappear
in 2-3 days as healing progresses. Redness, odor, or discharge indicates infection.

 The neural tube develops into the brain and spinal cord. Spina bifida is a defect in which
the spinal cord contents can protrude through the vertebrae that did not close. The
mildest form is spina bifida occulta, most often at the fifth lumbar or first sacral
vertebrae. A tuft of hair or a hemangioma may be seen over the site. This is
distinguished from lanugo, which is fine downy hair on the back that gradually falls out;
a term infant will have minimal lanugo.
 There has been less incidence of spina bifida as there is awareness of the role of folic
acid during pregnancy. The defect needs surgical repair. Depending on the location of
the defect, the child can have bowel and bladder incontinence, hydrocephalus, and
sensory loss.
The nurse should report to the HCP for further investigation if any of the following assessment
abnormalities occur in a newborn:

 Head circumference <32 cm or >37 cm - a normal head circumference is 32-37 cm. The
HCP should assess a neonate with a smaller or larger head circumference (Option 3).
 Jaundice - this is not a normal finding in a neonate, especially during the first 24 hours
and should be investigated further to determine the cause (Option 4).
 Not voiding in 24 hours - neonates should void and pass meconium within 24 hours after
delivery. If they do not, this could indicate a structural anomaly (Option 5).
 Nasal flaring, chest wall retractions, and grunting with respirations are a sign of
respiratory distress (Option 1).
Trisomy 18 (Edwards syndrome) is a chromosome anomaly characterized by severe cardiac
defects and multiple musculoskeletal deformities. Life expectancy for trisomy 18 is a few weeks
after birth, neonates rarely survive to their first birthday. End-of-life issues should be discussed
early after the diagnosis is confirmed. Trisomy 13 (Patau syndrome) also results in early death.

Nursing interventions for a newborn immediately after delivery include:

 Standard precautions - The unbathed newborn is covered in maternal blood and bodily
fluid. Standard precautions (eg, gloves) are implemented when contact with blood or
bodily fluid is anticipated.
 Maintain a clear airway - Suction the pharynx first followed by the nasal passages to
prevent aspiration if the newborn gasps with nasal suctioning.
 Thermoregulation (97.5-99 F [36.4-37.2 C]) reduces oxygen and stored calorie
consumption. Hypothermia predisposes the newborn to metabolic acidosis, hypoxia, and
shock. A radiant warmer is used while performing assessments and interventions. Use
pre-warmed linens, an infant stocking cap, and a thermal skin sensor for
monitoring. Skin-to-skin contact aids in thermoregulation.
 Vitamin K is administered intramuscularly in the vastus lateralis (midanterior lateral
thigh) within 6 hours of birth to prevent bleeding due to absence of vitamin K-producing
intestinal bacteria.
 Ophthalmic ointment - Prophylactic antibiotic eye ointment for Neisseria
gonorrhoeae is legally required; application may be delayed up to 1 hour after delivery.
 Initial bathing of the newborn is limited to removing blood, bodily fluids, or
meconium. Vernix caseosa, a waxy, white coating, protects the skin and should not be
vigorously removed (Option 3).
A key indicator of true labor is the progressive effacement and dilation of the cervix (Option
5). Contractions in true labor are regular, and increase in frequency, duration, and intensity
(Option 1). The pain may initially start in the lower back and radiate to the abdomen (Option
More than 5 contractions in 10 minutes or a resting tone of more than 20 mm Hg
indicates uterine hyperstimulation by the oxytocin (Pitocin). If the fetal heart rate (FHR)
tracings are reassuring, the client is placed/maintained in a side-lying position and a bolus of IV
fluid is given. If these measures do not reduce uterine activity, the oxytocin dose is
reduced. However, if the FHR tracing shows a non-reassuring pattern (late decelerations, fetal
bradycardia, tachycardia, and decreased variability), interventions are performed in the following

1. Stop oxytocin immediately – this will stop uterine stimulation and should be the
nurse's first action
2. Reposition or maintain the side-lying position – this is a simple and effective measure to
decrease aortocaval compression and increase placental blood flow
3. Apply oxygen at 10 L/min via face mask – only if steps 1 and 2 do not reduce
abnormalities. Administering oxygen will be more helpful if there is adequate placental
perfusion of the oxygenated blood. Maternal repositioning should therefore be performed
before oxygen administration.
4. Give IV fluid bolus
5. Consider giving terbutaline subcutaneously per unit protocol or standing prescriptions
6. Notify the health care provider
7. Document the findings

Uterine contractions decrease circulation through the spiral arterioles and the intervillous space,
which can stress the fetus. Uterine contraction duration should not exceed 90 seconds. During
the first stage of labor, duration should be 45-80 seconds. A duration exceeding 90 seconds can
result in reduction of blood flow to the placenta due to uterine hypertonicity.

When a delivery is imminent and possible neonatal resuscitation is anticipated, the focus needs
to be on a brief history that may reveal key information that can assist in preparation for and
performance of resuscitation. Key areas of assessment include the following:

 Multiple gestation – to prepare for the potential of multiple infant resuscitation (Option
 Narcotic use (within the last 4 hours or an illicit drug user) – to anticipate assisted
ventilation (Option 3)
 Preterm labor/birth – to anticipate neonatal ventilation (Option 4)
 Meconium-stained amniotic fluid – to prepare for potential intubation and tracheal
Systemic analgesia may be administered to the laboring client who is in the active phase of
stage 1 labor. Systemic analgesia crosses the blood-brain barrier to provide a central analgesic
effect. These medications also cross the placental barrier, with a resulting effect on the fetus
depending on dose and time of administration prior to delivery. Parameters for safer
administration include the following:

 Stable maternal vital signs

 Fetus with heart rate of 110-160 beats/min
 Well-established labor contractions
 Cervix dilated to at least 4-5 cm in primipara and 4 cm in multipara

Opioid agonist-antagonist medications commonly used in labor are butorphanol tartrate (Stadol)
and nalbuphine hydrochloride (Nubain). IV push is the preferred route and is given over the
peak of 2 contractions to decrease the bolus of medication to the fetus. During contractions, the
uterine muscle is very tense and blood flow to the fetus is slowed. Therefore, medication reaches
the fetus at a slower rate.
This class of medications has a ceiling effect—after a certain dosage, subsequent or higher doses
will not be effective or produce pain relief. Therefore, usually no more than 3 doses will be
prescribed. The medications can precipitate withdrawal in opioid-dependent clients and should
not be used.
This gravida 2 client meets the criteria for medication administration. The client is in the active
phase of stage 1 labor and contractions are well established.
Oxytocin is a high-alert medication commonly used for induction or augmentation of
labor. Oxytocin should be administered via an electronic infusion pump (Option 5). This
decreases medication errors, provides for accurate dosing, and prevents
maternal hypotension associated with rapid oxytocin bolus.
The nurse should evaluate and document the fetal heart rate (FHR) and uterine contraction
pattern every 15 minutes during the first stage of labor and every 5 minutes during the second
stage (Option 2). Oxytocin is administered at the lowest possible dose to achieve an adequate
contraction pattern and is titrated based on fetal tolerance of labor and uterine activity. Infusion
may be decreased or discontinued once active labor is achieved. Excessive oxytocin
administration can lead to uterine tachysystole, decreased placental perfusion, and fetal distress.
A significant potential adverse reaction of oxytocin administration is water intoxication, which
can lead to dilutional hyponatremia, convulsions, and death. The nurse should monitor intake
and output to identify fluid retention, which precedes water intoxication

The Bishop score is a system for rating the inducibility of the cervix. The cervix is scored (0,
1, 2, or 3) on consistency, position, dilation, effacement, and station of the fetal presenting
part. Usually, a score ≥8 indicates that labor induction will be successful (ie, result in vaginal
Fetal occiput posterior (OP) position is a common fetal malposition that occurs when the fetal
occiput rotates and faces the mother's posterior or sacrum. OP fetal position can cause increased
back pain or "back labor." Many fetuses in OP position during early labor spontaneously rotate
to occiput anterior position (occiput facing the mother's anterior or pubis).
The nurse or labor support person can apply counterpressure to the client's sacrum during
contractions to help alleviate back pain associated with OP fetal positioning. Firm, continuous
pressure is applied with a closed fist, heel of the hand, or other firm object (eg, tennis ball, back
massager) (Option 1).
Uterine atony causes 80% of cases of early postpartum hemorrhage (PPH), which occurs
within the first 24 hours after birth. A soft, "boggy," and poorly contracted uterus is
characteristic of uterine atony. A risk factor for PPH includes giving birth to a macrosomic
infant (usually defined as ≥8 lb, 13 oz [4000 g]) (Option 2). A macrosomic infant causes uterine
overdistension (ie, stretching of the uterine muscle), which may also be due to multiple gestation
or polyhydramnios (ie, excessive amniotic fluid). Other risk factors include the following:

 Uterine fatigue (prolonged labor)

 Grand multiparity (a woman with a history of ≥5 births at 20 wk 0 d or beyond) (Option
 Use of uterine relaxants or anesthesia

All of these factors inhibit the ability of the uterine muscles to contract and occlude the open
sinuses that bring blood to the site of placental detachment.
PPH may also be due to retained placental fragments; a long third stage of labor (time from birth
of baby to expulsion of placenta) raises suspicion for this etiology. The third stage of labor
usually lasts <30 minutes (Option 4).
In placenta previa, the placenta is implanted over or very near the cervix. As a result,
placental blood vessels may be disrupted during dilation and effacement. Because of the
increased risk of hemorrhage, the client should have a type and screen on file at the
selected hospital. A nonstress test or biophysical profile should be performed once or
twice a week to ensure fetal well-being. With asymptomatic clients, a cesarean birth is
planned after 36 weeks gestation and prior to the onset of labor to prevent blood loss of
mother and fetus. However, if the client is bleeding profusely or constantly or goes into
active labor, then a cesarean birth is typically performed immediately.

Placenta previa is suspected in any client with painless vaginal bleeding after 20 weeks
gestation. In placenta previa, the placenta is implanted over or very near the cervix. This
placement, confirmed through ultrasound, may result in damage to placental blood
vessels during dilation and effacement, leading to massive blood loss. Because of the
risk of hemorrhage, the client should have a pelvic ultrasound using the abdominal (not
vaginal) approach and blood drawn on admission for baseline hemoglobin or hematocrit
levels and for a type and screen. The client should be monitored frequently for signs of
hypovolemic shock. Fetal well-being should also be assessed constantly
through electronic fetal monitoring. In the presence of profuse or constant bleeding, the
client should be prepared for an emergency cesarean delivery.

Folic acid, or folate, is a water-soluble, B-complex vitamin necessary for red blood cell
production. Pregnant women and those attempting pregnancy need a minimum of 400 mcg of
folic acid per day to decrease the chance of fetal neural tube defects (eg, spina bifida,
anencephaly). Most prenatal vitamins contain 400-800 mcg of folic acid; additional folic acid
can come from the diet. Leafy green vegetables are the best dietary sources of folic
acid. However, other appropriate food choices include cooked beans, rice, fortified cereals, and
peanut butter, which provide at least 40 mcg folic acid per serving (Options 1, 2, and 4).
Weight gain during pregnancy should be determined by prepregnancy BMI. Underweight clients
need to gain more weight (1 lb [0.5 kg]/wk) during the second and third trimesters of pregnancy
than do obese clients (0.5 lb [0.2 kg]/wk). However, weight gain in the first trimester should be
1.1-4.4 lb (0.5-2.0 kg) regardless of BMI.
Preeclampsia is a systemic disease characterized by hypertension and proteinuria after the 20th
gestational week with unknown etiology. Eclampsia is the onset of convulsions or seizures that
cannot be attributed to other causes in a woman with preeclampsia. Delivery is the only cure for
preeclampsia-eclampsia syndrome.
Magnesium sulfate is a central nervous system depressant used to prevent/control seizure
activity in preeclampsia/eclampsia clients. During administration, the nurse should assess vital
signs, intake and output, and monitor for signs of magnesium toxicity (eg, decreased deep-tendon
reflexes, respiratory depression, decreased urine output). A therapeutic magnesium level of 4-
7 mEq/L (2.0-3.5 mmol/L) is necessary to prevent seizures in a preeclamptic client.
The nurse applies the uterine activity transducer to the woman's upper abdomen, in the fundal
area. Before applying an external fetal heart monitor, Leopold's maneuvers are performed to
assess the position and presentation of the fetus. The Doppler transducer for sensing the fetal
heart rate is usually placed on the lower abdomen when the fetus is in the cephalic
presentation. The Doppler transducer should be placed at the approximate location of the fetal
back. This fetus is in the left occiput anterior position; therefore, the fetal back is located
halfway between the midline and anterior superior iliac spine on the mother's lower left anterior
abdomen (versus lower lateral left abdomen for the left occiput posterior position).
Educational objective:
Leopold's maneuvers are performed to determine the position and presentation of the
fetus. After determining the position and presentation, the nurse should place the Doppler
transducer over the fetal back.

Hyperemesis gravidarum is a disorder that causes pregnant clients to have severe nausea and
vomiting. This leads to fluid and electrolyte imbalances, nutritional deficiencies, ketonuria,
and weight loss. On assessment, the nurse should expect signs and symptoms of dehydration,
which include dry mucous membranes, poor skin turgor, decreased urine output, tachycardia, and
low blood pressure. Ketonuria indicates that the body is breaking down fat to use for energy due
to the client's starvation state.
(Options 1 and 5) The client with hyperemesis gravidarum is dehydrated. Blood pressure is
expected to be low due to lack of blood volume. The urine specific gravity will be increased
(>1.030) as the urine is in a concentrated state. Blood urea nitrogen is also elevated (>20 mg/dL
[7.1 mmol/L]).

Placental abruption occurs when the placenta separates prematurely from the uterine wall,
causing hemorrhage beneath the placenta. Abruptions are classified as partial, complete, or
marginal and may be overt (visible vaginal bleeding) or concealed (bleeding behind
placenta). Risk factors include abdominal trauma, hypertension, cocaine use, history of previous
abruption, and preterm premature rupture of membranes.
Symptoms and their severity depend on extent of abruption and include abdominal and/or back
pain, uterine contractions, uterine rigidity, and dark red vaginal bleeding. Tachysystole (ie,
excessive uterine contractions), with or without fetal distress, is often present, and continuous
fetal monitoring is necessary (Option 2). A type and crossmatch should be drawn as treatment
may include blood transfusion (Option 4). In severe cases, emergent cesarean birth is
indicated (Option 1). Although blood loss is maternal, the loss of functional placental surface
area can result in decreased placental perfusion, impaired fetal oxygenation, and fetal death.
Pyrosis, also known as heartburn, occurs during pregnancy from an increase in the hormone
progesterone. Progesterone causes the esophageal sphincter to relax, leading to
pyrosis. Interventions to reduce heartburn include:

1. Upright position after meals to reduce gastroesophageal reflux

2. Small, frequent meals rather than 3 large meals a day (Option 4)
3. Keeping the head of the bed elevated using pillows
4. Drinking smaller amounts of fluid while eating
5. Eliminating dietary triggers, including fried and fatty foods, caffeine/chocolate, spicy
foods, carbonated drinks, and peppermint (Option 2)

The nurse should ascertain potential risks to the client and her baby due to teenage
pregnancy. Lack of family/social support or fear of social discrimination may prevent the
client from obtaining prenatal care (Option 2). Poverty, dangerous living conditions, and
exposure to teratogens (eg, tobacco, alcohol, illicit drugs) may place the client at risk for
complications. Adolescents are at risk for poor nutritional status and poor pregnancy weight
gain, which can have deleterious effects on the baby (eg, small for gestational age, low birth
weight) (Option 4). They are also less likely to take prenatal vitamins with folic
acid. Adolescents who are pregnant should be evaluated for sexual abuse; girls age 11-14 do
not usually seek sexual relationships, and the pregnancy may be evidence of abuse (Option 5).

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, indomethacin, or naproxen

inhibit prostaglandin synthesis and can be taken to decrease pain and inflammation or reduce a
fever. Ibuprofen is assigned the pregnancy category C through 29 weeks gestation and
pregnancy category D starting at 30 weeks gestation. It must be avoided starting at 30 weeks
gestation due to the risk of causing premature closure of the ductus arteriosus in the fetus
and prolonged labor for the client. Prior to 30 weeks gestation, ibuprofen should be taken only
if the benefits outweigh the risks and under supervision of a health care provider (HCP).
Interventions to treat back and sciatic pain during pregnancy include:

1. Acetaminophen – may be taken during pregnancy for discomfort and to reduce

fever. Oral and rectal acetaminophen is assigned the pregnancy category B (Option 2).
2. Heat – a warm bath or a warm compress may help relieve discomforts during pregnancy
3. Reposition – lying on the unaffected side or changing positions may help relieve pain
Fetal heart tones can be detected by 7 weeks gestation. Fetal sex may be determined on
ultrasound as early as the end of 12 weeks gestation. Fetal movements are typically felt at
around 16-20 weeks gestation.
Women who are planning to become pregnant should consume 400-800 mcg of folic acid daily
to prevent neural tube defects (eg, spina bifida, anencephaly). Food options that are rich in folic
acid include fortified grain products (eg, cereals, bread, pasta) and green, leafy vegetables.

Pregnant women experience a 40%-45% increase in total blood volume during pregnancy to
meet the increased oxygen demand and nutritional needs of the growing fetus and maternal
tissues. Because the increase in plasma volume is greater than the increase in red blood cells,
a hemodiluted state called physiologic anemia of pregnancy occurs, and is reflected in lower
hemoglobin and hematocrit values. It is also normal for the white blood cell count to increase
during pregnancy; counts can be as high as 15,000/mm3 (15.0 x 109/L).
Amniotic fluid is produced by the fetal kidney and serves 2 major purposes - to prevent cord
compression and promote lung development. Oligohydramnios is a condition characterized
by low amniotic fluid volume. This can occur due to fetal kidney anomalies (eg, renal agenesis
or urine flow obstruction) or fluid leaking through the vagina (eg, undiagnosed ruptured
membranes). Fluid volume also declines gradually after 41 weeks. Small uterine size for
gestational age or a fetal outline that is easily palpated through the maternal abdomen should
raise suspicion for oligohydramnios. Ultrasound confirms the diagnosis.
Major complications of oligohydramnios are:

1. Pulmonary hypoplasia - due to the lack of normal alveolar distension by aspirated

amniotic fluid. Therefore, additional neonatal personnel should attend the birth in
anticipation of possible resuscitation (Option 1).
2. Umbilical cord compression - continuous (not intermittent) fetal monitoring should be
applied to monitor for variable decelerations (Option 2).
In a pregnant client, a serum sample is collected at the first prenatal visit to determine
immunity to the rubella virus. A positive immune response indicates immunity to the
rubella virus, attributed to either past infection or vaccination. A negative,
or nonimmune, response indicates that the client is susceptible to rubella disease and
requires vaccination. An equivocal response indicates partial immunity to rubella and is
treated clinically the same as nonimmune status.
3. Measles-mumps-rubella (MMR) is a live attenuated vaccine. Live
vaccines are contraindicated in pregnancy due to the theoretical risk of contracting the
disease from the vaccine. Maternal rubella infection can be teratogenic for the
fetus. The fetal effects of congenital rubella syndrome include congenital cataracts,
deafness, heart defects (patent ductus arteriosus), and cerebral palsy. The best time to
administer an MMR vaccine to a nonimmune client is in the postpartum period just
prior to discharge (Option 2). The MMR vaccine can safely be administered to
breastfeeding clients.

Subjective (presumptive) signs of pregnancy are those that are self-reported by a pregnant
client. These signs may have pathologic medical causes and therefore cannot be considered
diagnostic for pregnancy.
Subjective signs include:

 Breast fullness and tenderness (may occur just prior to menstrual periods or with use of
birth control hormones)
 Amenorrhea (may be seen with early menopause, endocrine dysfunction, acute or chronic
diseases, or psychological stress)
 Nausea and vomiting that begin around the sixth week after the last menstrual period
(may be result of many other conditions, such as gastroenteritis)

Right upper quadrant (RUQ) or epigastric pain can be an indicator of HELLP syndrome,
a severe form of preeclampsia. HELLP syndrome (Hemolysis, Elevated Liver enzymes,
and Low Platelet count) is often mistaken for viral gastroenteritis due to its variable and
nonspecific presentation. Misdiagnosis may lead to severe complications (eg, placental
abruption, liver failure, stroke) and/or maternal/fetal death. Clients may have RUQ pain,
nausea, vomiting, and malaise. Headache, visual changes, proteinuria, and hypertension
may or may not be present.

Placental abruption is a possible complication of preeclampsia that can be life-

threatening to mother and baby. It occurs when the placenta tears away from the wall of
the uterus due to stress, causing significant bleeding to the mother and depriving the baby
of oxygen. Bleeding can be concealed inside the uterus. This may require immediate
delivery of the baby. Preeclampsia in pregnancy manifests with high blood pressure and
protein in the urine. Edema is expected, although it is not part of the
criteria. Complications of preeclampsia include eclampsia, placental abruption, and
HELLP (Hemolysis, Elevated Liver enzymes, Low Platelets) syndrome.
The GTPAL system is a shorthand system of documenting a client's obstetric history. Under this
system, twins, triplets, or other multiple births count as one in the term (T) or preterm (P)
category but are counted separately (as 2, 3, or more) in the living child (L) category. A current
pregnancy (not yet delivered), as in this client, counts in the gravida (G) category as this
category includes all pregnancies, past and present.
In this scenario, the client is a G4 T1 P1 A1 L3. She is gravida (G) 4 as she has a history of 4
pregnancies (which includes the present pregnancy) (Option 3).
The client delivered a child at 40 weeks gestation (counts 1 in the term [T] category).
She delivered twins at 34 weeks gestation, reflected as a single birth (1 pregnancy) in the
preterm (P) category and as 2 living children in the living child (L) category.
She had an elective abortion, reflected as 1 in the abortion (A) category.
She has a total of 3 living children (1 term and 2 preterm children), reflected in the living child
(L) category.
Health promotion during pregnancy includes the administration or avoidance of certain vaccines
to decrease risks to mother and fetus. Pregnant women have suppressed immune systems and
are at increased risk for illness and subsequent complications. Some viruses (eg, rubella,
varicella) can cause severe birth defects if contracted during pregnancy.
Inactivated vaccines contain a "killed" version of the virus and pose no risk of causing illness
from the vaccine. Some vaccines contain weakened (ie, attenuated) live virus and pose a slight
theoretical risk of contracting the illness from the vaccine. For this reason, women should not
receive live virus vaccines during pregnancy or become pregnant within 4 weeks of receiving
such a vaccine.
The tetanus, diphtheria, and pertussis (Tdap) vaccine is recommended for all pregnant women
between the beginning of the 27th and the end of the 36th week of gestation as it provides the
newborn with passive immunity against pertussis (whooping cough) (Option 4).
During influenza season (October-March), it is safe and recommended for pregnant women to
receive the injectable inactivated influenza vaccine regardless of trimester (Option 1).
(Options 2, 3, and 5) The influenza nasal spray; measles, mumps, and rubella (MMR) vaccine;
and varicella vaccine contain live viruses and are contraindicated in pregnancy.
Educational objective:
Inactivated vaccines (eg, inactivated influenza; tetanus, diphtheria, and pertussis) may be given
during pregnancy to protect pregnant clients from illness and provide the fetus with passive
immunity. Live virus vaccines are contraindicated in pregnancy.
When seeking to apply research findings in practice, the nurse should consider the similarities
between the research study population and the client population.
Members of the health care team providing direct care for clients in physical restraints are
required to complete an educational training program and demonstrate competency in caring for
a client in restraints. Therefore, the RN can safely delegate the following tasks to the UAP:
ROM exercises, reapplication of restraints, repositioning a restrained client in bed, and
immediately reporting changes observed in the skin or any other problems.

Systemic inflammatory response syndrome (SIRS) occurs due to trauma, ischemia, infection
(ie, sepsis), or other distributive shock processes that trigger systemic inflammation remote from
the primary source. This overwhelming inflammatory response can
rapidly progress to hemodynamic instability, respiratory failure, and end-organ dysfunction.
This client has fever and decreased arterial pCO2. Due to the high morbidity and mortality of
clients with SIRS, early therapy with aggressive fluid resuscitation and other indicated
treatments (eg, antibiotics) based on cause is crucial, so this client is the highest priority (Option
Glyburide is used to treat diabetes mellitus, and it can cause significantly low blood sugar if
ingested by a client who does not have diabetes, especially a child. Based on the symptoms the
child is exhibiting (irritability, confusion), hypoglycemia is likely. This client requires
immediate intervention as severe hypoglycemia can result in coma and/or death.

A serious complication of infectious mononucleosis is a ruptured spleen, which would cause

sudden onset of severe abdominal pain in the left upper quadrant.

A pedal pulse decreased from baseline or an absent pedal pulse and a cool or mottled extremity
in a client who is postoperative abdominal aortic aneurysm repair can indicate the presence of an
arterial or graft occlusion and poses the greatest threat to survival.

There are several circumstances in which the nurse is legally required to report to appropriate
civil authorities:

 Suspected elder abuse must be reported to the appropriate authorities for

investigation. The nurse has a legal obligation to report signs of abuse regardless of
clients' ability or willingness to advocate for themselves (Option 2).
 The nurse should report deaths that meet medical examiner reporting guidelines (eg,
suspected to be the result of a crime, trauma, or suicide) to the authorities for
investigation. The local medical examiner has the legal authority and obligation to
perform an autopsy independent of the family's wishes (Option 3).
 For the sake of client safety, nurses should immediately report impaired or intoxicated
health care workers, regardless of their position (Option 5).
 Under the Health Insurance Portability and Accountability Act, a client's reason for an
emergency department visit cannot be communicated to employers without the client's
permission (Option 1).
 Health authorities must be notified of a reportable sexually transmitted disease regardless
of client wishes. Depending on the condition, authorities may report findings to sexual
contacts, but it is a violation of client privacy for the nurse to share this information with
the client's family or spouse (Option 4).

A power of attorney (POA) designates a representative to act on a person's behalf in

the event that the individual becomes incapacitated. There are different types of POAs,
including medical and financial.
 An advance directive or living will describes the client's health care decisions (eg, do
not resuscitate). As part of an advance directive, the client may designate a
representative to make health care decisions for the client - a durable POA for health care
or POA for health care (Canada). This client's statement requires further clarification
regarding what type of POA is in place (Option 4).
The American Society for Parenteral and Enteral Support (ASPEN) recommends 140-180 mg/dL
(7.8-10.0 mmol/L) as the target range for glucose control in clients receiving nutritional
support. Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate
of the infusion. Although it occurs less frequently in clients receiving total parenteral nutrition
(TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can
lead to life-threatening complications (eg, seizures, nervous system dysfunction). Therefore,
the serum glucose of 68 mg/dL (3.8 mmol/L) is the laboratory finding of highest priority for the
nurse to report to the health care provider (HCP).
Hyperthyroidism results from excessive secretion of thyroid hormones. Affected clients are at
risk for developing thyroid storm, a life-threatening form of hyperthyroidism. Symptoms of
thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea,
vomiting, diarrhea, and altered mental status. Client management includes reducing fever,
maintaining hydration, and preventing cardiac compromise (eg, heart failure).
Anti-embolism stockings are part of venous thromboembolism (VTE) prophylaxis in
hospitalized clients. Anti-embolism stockings improve blood circulation in the leg veins by
applying graduated compression. When fitted properly and worn consistently, the stockings
decrease VTE risk. The stockings should not be rolled down, folded down, cut, or altered in
any way. If stockings are not fitted and worn correctly, venous return can actually be impeded.
(Option 1) Anti-embolism stockings should be applied before ambulating while the client is in
bed; this maximizes the compression effects of the stockings and promotes venous return. The
UAP has performed this correctly.
(Option 2) Wrinkles should be smoothed out to avoid impeding venous return. The UAP has
performed this correctly.
(Option 3) The toe opening should be located on the plantar side of the foot/under the toes. The
UAP has performed this correctly.
SBAR (Situation, Background, Assessment, and Recommendation/Request)

Assault is a deliberate threat with the power to carry out the threat.

Battery is the intentional touching of a person that is legally defined as unacceptable or

occurs without the person's consent.
The National Council of State Boards of Nursing advises any individual who has knowledge of a
potential violation of a nursing law or rule to file a complaint with the appropriate state board of
nursing. A nurse should be knowledgeable concerning the presiding board's stance on
mandatory reporting and which actions are considered reportable. In general, reportable actions
may include any behavior by a licensed nurse that
is unsafe, unethical, incompetent, impaired (eg, by substances or a mental or physical
condition), or in violation of nursing law.

 Practicing outside of the scope of the license is reportable even if the practice meets
quality standards (Option 1).
 Documenting an intervention that was not performed is considered falsification of
records regarding client care and is a reportable action (Option 3).
 Stealing narcotics is a criminal offense (a violation punishable by the state that can
result in prison or a fine) and is reportable in all states. Many states offer an alternate
rehabilitation program to nurses who diverted or abused drugs (Option 4).
 Abandonment (eg, leaving without proper replacement of personnel and transfer of
responsibility for client care) is reportable in all states (Option 5).

Violence in the workplace should not be tolerated or ignored by either staff or

management. Actions that staff members can take if they become victims of lateral violence

 Documenting and keeping a file of all incidents (Option 1)

 Reporting the incidents to the immediate supervisor
 Letting the bully know that the behavior will not be tolerated (Option 5)
 Observing interactions between the bully and other colleagues (may validate the victim's
experiences and serve as a source of support) (Option 3)
 Seek support from within the facility or from an external source

Ventricular bigeminy is a rhythm in which every other heartbeat is a premature ventricular

contraction (PVC). PVCs in the presence of a myocardial infarction (MI) indicate ventricular
irritability and increase the risk for a more serious dysrhythmia (eg, ventricular tachycardia,
ventricular fibrillation). Possible causes of ventricular bigeminy include electrolyte imbalances
and ischemia. After assessing the client's vital signs, the nurse should
assess potassium and magnesium levels and apical-radial pulse, administer the scheduled
amiodarone, and notify the health care provider (HCP).
Post-procedure care of a client who has undergone heart catheterization should focus on
evaluating hemodynamics - blood pressure, heart rate, strength of the distal pulses, color, and
temperature of extremities. The client should be also assessed several times per hour for active
bleeding, hematoma, or pseudoaneurysm formation at the incision.
The first hour after cardiac catheterization requires assessment every 15 minutes. Any report of
back or flank pain should be assessed for possible retroperitoneal bleeding as back pain,
tachycardia, and hypotension may be the only indication of internal bleeding. More than a liter
of blood can pool behind the peritoneum in the pelvis undetected, and it may take up to 12 hours
before a significant drop in hematocrit can be measured. Internal bleeding after cardiac
catheterization is particularly dangerous due to frequent use of anticoagulant prescriptions in
these clients.

The best indication of moving air in a client with asthma is peak flow. The results are
categorized as green (≥80% of personal best and good control), yellow (50%-79% of personal
best and caution), and red (<50% of personal best - a medical alert). This client is currently in
good control. Other findings to note include effortless breathing, no cough or wheeze, and
sleeping well all night (Option 3).

Sinus tachycardia is typically stable, especially if the underlying cause (eg, pain, fever, anemia,
anxiety) can be identified and treated. Clients with cardiac stents are often discharged from the
hospital 1-2 days after the procedure.

At least one hour should be allowed between completion of a blood transfusion and
administration of amphotericin B. The adverse effects of a transfusion-related reaction and an
adverse reaction from amphotericin B are similar, and the observation time allows the nurse to
distinguish the triggering event if symptoms develop.

BLLs (≥5 mcg/dL) Proper intake of iron and vitamin C decreases lead absorption.

Improvements in oxygen saturation and peak expiratory flow are the best indicators of treatment
effectiveness during an acute asthma attack. Primero que los sibilantes( wheezes)

Scabies is spread easily via direct skin-to-skin contact. Due to the lengthy incubation period of
scabies(30-90 days), all who have been in contact with the infested child must be treated. This
involves a one-time application of a scabicide (typically 1% topical permethrin). The child's
bedding and clothing should be placed in plastic bags (for a minimum of 3 days) or washed in
hot water and dried on the hottest dryer cycle.

Trisomy 21 (Down syndrome) is often associated with the cardiac anomaly AV canal
defect. Assessment typically includes a loud murmur that requires no immediate action when
vital signs are stable. Surgery will correct the anomaly when the neonate grows in size and can
tolerate the invasive procedure better.

Distance visual acuity of children age 6 or older is best assessed by asking the child to read
letters from the Snellen letter chart using one eye at a time. The child should be able to identify
4 out of 6 letters on the 10/15 line (equivalent to 20/30 vision) with both eyes. In infancy, visual
fixation should be present by age 3-4 months and is assessed by following a target.

Involuntary bed-wetting at night in a child beyond the age of expected bladder control is known
as nocturnal enuresis. Primary enuresis is bed-wetting in children who have never had
bladder control. Secondary enuresis occurs in a child who has had a previous period of bladder
control. Pharmacologic and nonpharmacologic interventions can be used in the treatment of
enuresis. Parents should be educated on the following therapeutic techniques for nocturnal

1. Encourage fluids during the day but restrict after the evening meal
2. Have the child void before going to bed
3. Use bed alarms that waken the child when voiding begins
4. Use positive reinforcement and motivation (eg, a calendar showing wet and dry
nights) (Option 3)
5. Avoid punishing, scolding, or ridiculing the child
6. Avoid the use of Pull-Ups and diapers at bedtime
7. Have the child assist with wet linen changes but reassure that this is not a
punishment (Option 2)
8. Awaken the child at a specified time each night to void (Option 5)

Intussusception (the intestine telescoping into itself) causes intermittent cramping and
progressive abdominal pain, inconsolable crying, and currant jelly stool (from blood or
mucus). It is often treated successfully with an air enema.

To measure the urinary output of an infant in diapers, subtract the weight of the diaper when dry
from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of
fluid. Adequate urinary output for an infant is 2 mL/kg/hr.
Urine output in diapers:
Diaper 1: 50 − 30 = 20 g
Diaper 2: 52 − 30 = 22 g
Diaper 3: 46 − 30 = 16 g
Total mg of urine:
58 g = 58 mL
Total output:
(Emesis) + (Urine) = 120 mL + 58 mL = 178 mL
Educational objective:
Urinary output for a child in diapers is calculated by subtracting the dry weight of the diaper
from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid.
Fetal alcohol syndrome (FAS) is a leading cause of intellectual disability and developmental
delay in the United States. Diagnosis includes history of prenatal exposure to any amount of
alcohol, growth deficiency, neurological symptoms (eg, microcephaly), or specific facial
characteristics (indistinct philtrum, thin upper lip, epicanthal folds, flat midface, and short
palpebral fissures). Asking about alcohol use during pregnancy can identify newborns and
infants who are at risk for FAS. Family support, early intervention, and prevention for
subsequent pregnancies are important for families with an infant with this diagnosis.

Cigarette smoking is linked to perinatal loss, sudden infant death syndrome, low birth weight,
and prematurity. Specific facial characteristics or syndromes are not typically caused by tobacco
exposure in utero.
Foreign body aspiration can be life-threatening. Alkaline battery ingestion can cause corrosive
(caustic) damage to the esophagus and intestine and result in perforation. Therefore, batteries
must be removed emergently by endoscopy.

Celiac disease is an autoimmune disorder in which an individual cannot tolerate gluten, a

protein found in barley, rye, oats, and wheat (BROW). Rice, corn, and potatoes are allowed
in the diet and can be used as grain substitutes. Affected individuals must adhere to a gluten-free
diet for life.

Pediatric asthma can present as night coughing until the child vomits.

Infants with bacterial meningitis can develop hydrocephalus. Bulging/tense fontanels and
increasing head circumference are important early indicators of increased ICP in children and
should be monitored to prevent long-term complications.
Kawasaki disease (KD) is a systemic vasculitis of childhood that presents with ≥5 days of
fever, nonexudative conjunctivitis, lymphadenopathy, mucositis, hand and foot swelling, and a
rash. First-line treatment consists of IV immunoglobulin and aspirin to prevent coronary
artery aneurysms.
When children with KD are discharged home, parents are instructed to monitor them
for fever by checking the temperature (orally or rectally) every 6 hours for the first 48 hours
following the last fever. Temperature should also be checked daily until the follow-up
appointment. If the child develops a fever, the health care provider should be notified as this
may indicate the acute phase of KD recurrence. The child may require additional treatment with
IV immunoglobulin to prevent development of coronary artery aneurysms and occlusions.
Separation anxiety starts around age 6 months, peaks at age 10-18 months, and can last until age
3 years. It produces more stress than any other factor (eg, pain, injury, change in surroundings)
for children in this age range. However, separation anxiety is normal and resolves by age 3

Laboratory results that support a vaso-occlusive crisis (pain crisis) in a client with sickle cell
disease include elevated reticulocytes, elevated bilirubin, and anemia.

Valproate (Depakote), a medication used to control seizures, is an FDA pregnancy category D

drug that can cause neural tube defects such as spina bifida, but not the distinct facial features of

Adolescence in psychosocial development is marked by risk-taking behaviors, a sense of

invincibility, the need for independence, and a strong connection to peers.
Developmental dysplasia of the hip (DDH)
Shaken baby syndrome is a form of child physical abuse resulting from violent shaking of an
infant by the extremities or shoulder that causes bleeding within the brain and/or eyes. The
clinical findings of shaken baby syndrome are nonspecific and include lethargy, vomiting,
seizures, irritability, inability to eat, and inconsolable crying. Multiple and severe shaking
episodes can result in breathing difficulty and lifelessness. Caregivers typically do not report a
history of trauma.
Hemophilia is a hereditary bleeding disorder caused by a deficiency in coagulation
proteins. Treatment consists of replacing the missing clotting factor and teaching the client
about injury prevention, including:

 Avoid medications such as ibuprofen and aspirin that have platelet inhibition
properties (Option 4).
 Avoid intramuscular injections; subcutaneous injections are preferred.
 Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging,
tennis) and use of protective equipment (eg, helmets, padding) are encouraged (Option
 Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be
 MedicAlert bracelets should be worn at all times (Option 3).
 Clients with hemophilia are at risk for permanent joint destruction due to frequent
bleeds into the joint spaces. Assisting clients with decreasing the incidence of bleeding
episodes and prompt treatment when bleeding occurs can help minimize joint destruction.

 (Option 1) Fantasy play with puppets is more appropriate for a preschool-age child as
imaginary play and magical thinking peak during this stage of development.
 (Option 2) Although school-age children enjoy spending time with friends, peer
relationships are significantly more important during the adolescent period.
 (Option 4) Watching television is a good diversion for all hospitalized children, but it
does not promote age-specific growth and development.
 Educational objective:
According to Erikson's stages of psychosocial development, school-age children deal
with the conflict of industry versus inferiority. During this stage, unlike other
developmental stages, learning is a priority and completing school work provides a sense
of accomplishment and satisfaction. It is therefore important that parents provide
hospitalized school-age children with missed school work on a regular basis.

A child who demonstrates a slow growth pattern will undergo diagnostic evaluation to determine
the cause. If the cause is found to be growth hormone deficiency, the child may undergo growth
hormone replacement therapy. The biosynthetic hormone is administered via subcutaneous
injection on a daily basis. Despite replacement therapy, the child may still have a final height
less than "normal." Treatment is most successful when diagnosis and replacement
therapy begin early in the child's life. When to stop therapy is decided by the client, family,
and provider. However, growth less than 1 inch (2.5 cm) per year and bone age of 14 years in
girls and 16 years in boys are the criteria often used to stop therapy.

Although more than one of these parent comments are concerning, the most concerning is
feeding honey to a child under age 1 year. Honey (especially raw or wild) is not recommended
for children under age 1 due to the risk for infant botulism. An infant under age 1 has an
immature gut system that can allow Clostridium botulinum spores contaminated in honey to
colonize the gastrointestinal tract and release toxin that causes botulism.
Botulinum toxin produces muscle paralysis by inhibiting the release of acetylcholine at the
neuromuscular junction. Infants often present with constipation, diminished deep tendon
reflexes, and generalized weakness. Additional symptoms are lack of head control, difficulty in
feeding, and decreased gag reflex, which can progress to respiratory failure. Isolation of the
organism from the child's stool can take several days; therefore, diagnosis is usually made by
history, and treatment with botulism immune globulin is started before laboratory results are

This child has chicken pox (varicella), given the vesicular lesions. Chicken pox is transmitted
primarily by airborne spread of secretions from the nasopharyngeal secretions of an infected
individual and through direct contact of open lesions. It is most contagious 1–2 days before the
rash until shortly after onset of rash (until all lesions are crusted over). Supportive care is
usually adequate, and most children recover fully. Children who are immunocompromised are at
risk for complications. Contact and airborne precautions are used. A mask will help prevent the
spread of infection until the child is placed in an isolation negative airflow room.

Tetralogy of Fallot is a congenital cardiac defect that typically has 4 characteristics: pulmonary
stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect.
This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of
tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child
should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea
as this angle improves oxygenation by reducing the volume of blood that is shunted through the
overriding aorta and the ventricular septal defect.

Vaccines should be administered at specific ages and intervals as passive placental immunity
decreases and the child's immune system is developed enough to produce antibodies in response
to the vaccine.
The nurse should always assess for allergies to vaccine components (eg, neomycin, gelatin,
yeast) and screen for an allergy to latex (eg, lips swell with bananas, kiwis, or latex balloons).
Common misperceptions of contraindications to immunization:

 Mild illness (with or without an elevated temperature) (Option 2)

 Currently taking antibiotics
 Mild site reactions (eg, swelling, erythema, soreness) (Option 1)
 Recent infection exposure (Option 3)
 Penicillin allergy (Option 4)

The concerns presented by this child's parent are suggestive of a developmental delay and
very possibly autism spectrum disorder (ASD).
ASD is a complex neurodevelopmental disorder characterized by the onset of abnormal
functioning before age 3. The 2 core symptoms of ASD are abnormalities in social
interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or
activities that can be restricted and repetitive. Social skills, especially communication, are
delayed more significantly than other developmental functioning and are the focus during client
The vast majority of children diagnosed with ASD lack the acquisition of communication skills
during the first 2 years of life. A healthy 2-year-old should have a vocabulary of about 300
words and should be able to string 2 or more words together in a meaningful phrase. Assessing
this child's language abilities would be the priority.
Fifth disease ("slapped face," or erythema infectiosum) is a viral illness caused by the human
parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions,
and the period of communicability occurs before onset of symptoms. The child will have a
distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash
spreads to the extremities and a maculopapular rash develops, which then progresses from the
proximal to distal surfaces. The child may have general malaise and joint pain that are typically
well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children
typically recover quickly, within 7-10 days.
Once these children develop symptoms (eg, rash, joint pains), they are no longer
infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis
or immunocompromising condition.
A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon,
which can lead to sepsis and death. Enterocolitis will present with fever; lethargy; explosive,
foul-smelling diarrhea; and rapidly worsening abdominal distension.
Weight gain slows during the toddler years with an average yearly weight gain of 4-6 lb (1.8-2.7
kg). By age 30 months, current weight should be approximately 4 times greater than birth
weight. A toddler weighing 6 times the initial birth weight requires further evaluation. Family
nutrition and meal habits should be discussed.

Weak lower and strong upper extremity pulses are present in coarctation of the aorta.
In a child with atrial septal defect, the nurse would expect to hear a heart murmur on
auscultation of heart sounds.
Bronchiolitis is a common viral illness of childhood that is usually caused by RSV. The focus
of home care is on monitoring respiratory status and periodic nasal suctioning using saline nose
drops to ease breathing. Additional fluids should be offered.
Marfan syndrome is an autosomal dominant disorder affecting the connective tissues of the
body. Abnormalities are mainly seen in the cardiovascular, musculoskeletal, and ocular
systems. Clients with Marfan syndrome are very tall and thin, with disproportionately long
arms, legs, and fingers.
Cardiovascular manifestations of Marfan syndrome include abnormalities of the aorta and
cardiac valves, including aneurysms, tears (dissection), and leaky heart valves that may require
replacement or repair. Therefore, competitive or contact sports are discouraged due to the risk
of cardiac injury and sudden death (Option 1).
Initial newborn assessments performed by the nurse are helpful in identifying anomalies that
require further investigation by the HCP.
Hypotonia, or decreased muscle tone, may be related to hypoxia, Down syndrome, or a
muscular/neurologic disorder (Option 2).
A sacra l dimple may be a sign of spina bifida occulta, a defect where the bones that protect
the meninges and spinal cord fail to close during gestation (Option 4). Although many clients
with spina bifida occulta have no other disturbances or impairment, the HCP must assess for the
extent of any neurologic involvement.
A normal umbilical cord contains 2 arteries and 1 vein. The presence of a single umbilical
artery is sometimes associated with congenital defects, particularly of the kidneys and
heart (Option 5).
Microcephaly is an effect of fetal alcohol syndrome or cytomegalovirus infection.

Craniofacial defects, including cleft lip and palate (eg, congenital anomalies), can be caused
by maternal anticonvulsant use (eg, valproic acid).

Meconium ileus is classic for cystic fibrosis, a genetic disorder.

Floppy muscle tone is typical for Down's syndrome, a genetic disorder.

The normal range for hemoglobin in a 1-month-old is 12.5-20.5 g/dL (125-205

g/L). Hemoglobin of 24.9 g/dL (249 g/L) is diagnostic of polycythemia (elevated hemoglobin
levels). Infants with cyanotic cardiac defects can develop polycythemia as a compensatory
mechanism due to prolonged tissue hypoxia. Polycythemia will increase blood viscosity,
placing an infant at risk for stroke or thromboembolism (Option 1). Clubbing is another
manifestation of prolonged hypoxia.

Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Treatment

consists of replacing the missing clotting factor and teaching the client about injury
prevention. Clients with hemophilia who are injured should be monitored closely for bleeding
(eg, intracranial bleeds, bleeding into joints). Signs of an intracranial bleed include lethargy,
headache, irritability, and vomiting. An intracranial bleed is lethal if unchecked, so
administration of factor VIII to a client with hemophilia A is the first order of action, followed
by a CT scan.

The ductus arteriosus of a newborn should close spontaneously when fetal circulation changes to
pulmonary circulation. If the ductus arteriosus remains open, blood will shunt from the aorta to
the pulmonary arteries. The child will be acyanotic but will have a machine-like murmur heard
on both systole and diastole.

Established family patterns that can play a role in recurrent OM should be assessed and include:

 Recurring exposure to tobacco smoke

 Regular pacifier use, particularly after age 6 months
 Drinking from a bottle while lying down
 Lack of immunizations, particularly the pneumococcal vaccine series
Developmental dysplasia of the hip (DDH) is a range of various hip abnormalities that may be
present at birth or develop during the first few years of life. There are many risk factors,
including breech birth, large infant size, and family history. Although all cases cannot be
prevented, several interventions have been shown to help reduce the risk of DDH development.
Key measures include:
 Proper swaddling technique - infants should be swaddled with their hips bent up
(flexion) and out (abduction), allowing room for hip movement (Option 3)
 Choosing infant carriers or car seats with wide bases - infant seats should allow for
proper hip positioning in an abducted manner
 Avoiding any positioning device, seat, or carrier that causes hip extension with the knees
straight and together
In pyloric stenosis, a hypertrophied pyloric muscle causes postprandial projectile vomiting
secondary to an obstruction at the gastric outlet. An olive-shaped mass may be palpated in the
epigastric area just to the right of the umbilicus. Emesis is nonbilious (formula in/formula out)
and leads to progressive dehydration. Infants will be hungry constantly despite regular
feedings. A hematocrit of 57% (0.57) is elevated and indicative of hemoconcentration caused
by dehydration (Option 2). Elevated blood urea nitrogen is also a sign of dehydration.

Retinoblastoma, a unilateral or bilateral retinal tumor, is the most common childhood

intraocular malignancy. It is typically diagnosed in children under age 2 and is usually first
recognized when parents report a white "glow" of the pupil (leukocoria). Light reflecting off
the tumor will cause the pupil to appear white instead of displaying the usual red reflex (Option
1). Parents may even accidentally visualize leukocoria when taking a photograph of the child
using a flash. Strabismus (misalignment of the eyes) is the second most common sign; visual
impairment is a late sign indicative of advanced disease.
Treatment depends on severity and may include radiation therapy or enucleation (removal of the
eye) and fitting for prosthesis. Siblings should undergo regular ocular screening, as some forms
of retinoblastoma are hereditary.
FTT is generally defined as weight less than 80% of ideal for age and/or depressed weight for
length, correcting for gestational age, sex, and special medical conditions. The underlying cause
of FTT is inadequate dietary intake; contributing factors include a disturbance in feeding
behavior and psychosocial factors.
Observing the child feeding or when hungry will provide the nurse the opportunity to identify
potential factors contributing to insufficient intake. The nurse can observe the type of food being
offered, the quantity of food consumed, how the child is held or positioned while being fed, the
amount of time for feeding, the parent's response to the child's cues, the tone of the feeding, and
the interaction between the child and the parent.

Clinical manifestations of acyanotic defects may include:

 Tachypnea
 Tachycardia, even at rest
 Diaphoresis during feeding or exertion (Option 3)
 Heart murmur or extra heart sounds (Option 4)
 Signs of congestive heart failure
 Increased metabolic rate with poor weight gain (Option 5)

A gluten-free diet is required for clients with celiac disease who cannot tolerate barley, rye, oats,
or wheat (mnemonic: BROW). Low-phosphate diets are indicated for clients with certain
kidney disorders. Low-sodium diets are indicated for volume overload states (eg, heart failure,
ascites) and hypertension.

Hypospadias, a condition in which the urethral opening is on the underside of the penis, is
surgically corrected by rerouting the urethra and inserting a temporary stent to aid
healing. Urinary output is closely monitored postoperatively to ensure patency.

A marked decrease in respiratory rate or increased work of breathing may indicate respiratory
fatigue, and immediate intervention is needed (Option 3). Impending respiratory failure is the
immediate priority.

FTT in a child is characterized by a low weight/height ratio and/or falling below the 5th
percentile on the growth curve due to inadequate caloric intake, inadequate absorption of
calories, or excess caloric expenditure. Most children with a diagnosis of FTT have inadequate
caloric intake caused by multiple behavioral or psychosocial factors, including disturbances in
child-parent interaction. Risk factors for FTT include:

 Young parent age

 Unplanned or unwanted pregnancy
 Lower levels of parental education
 Single-parent home
 Social isolation
 Chronic life stresses/anxiety in the home
 Disordered feeding techniques
o Prolonged breast or bottle feeding
o Unstructured meal times
o Negative or difficult interactions at meal time
o Poor parental feeding skills
o Negative attitudes toward food – fear of obesity or an overweight child
 Substance abuse
 Domestic violence and/or parental history of child abuse
 Poverty, food insecurity
 Parents who have a negative perception of the child

 Epiglottitis should be considered first in a 3-7-year-old child with acute respiratory
distress, toxic appearance (eg, sitting up, leaning forward, drooling), stridor, and high-
grade fever. Tachycardia and tachypnea are also present. This is a
pediatric emergency and should be managed with endotracheal intubation; however,
intubation of such clients is difficult, and preparation for possible tracheostomy is also
standard. The complications of epiglottitis are serious and include sudden airway
Premature infants require iron supplementation by age 2-3 months, which is when maternal
iron stores are depleted. Appropriate sources include oral iron drops if breastfeeding or iron-
fortified formula.

The priority nursing action when providing oxygen therapy and monitoring oxygen saturation is
to verify the accuracy of the saturation reading. Additional actions may then be taken, which
may involve auscultating the child's lungs. Interventions to improve oxygenation include
increasing the rate of oxygen flow and having the child sit in full Fowler's position and take
slow, deep breaths.
Hearing impairment in infants delays development of intelligible speech. As these infants
become toddlers, they often have a loud voice and monotone speech that is difficult to
understand. They appear shy, timid, and inattentive.

Prevention of symptoms plays an important role in the management of chronic allergic

rhinitis. Preventive measures to reduce exposure include using hypoallergenic pillow and
mattress covers, eliminating carpet in the home, keeping windows closed, installing high-
efficiency air filters, regularly mopping hard floors, and frequently damp-dusting furniture.

Pertussis (whooping cough) is a very contagious communicable disease caused by

the Bordetella pertussis bacteria. These organisms attach to the small hairs in the airway and
release a toxin that causes swelling and irritation. Pertussis is spread from person to person by
coughing, sneezing, and close contact. As a result, an affected client should be placed in
standard (universal) and droplet isolation precautions when hospitalized.
At first, symptoms similar to the common cold and a mild fever occur, but eventually these
clients develop a characteristic violent, spasmodic cough. Coughing is so severe that the person
is forced to inhale afterward, resulting in a distinctive, high-pitched "whooping"
sound. Coughing episodes may continue until a thick mucus plug is expectorated and are
sometimes followed by vomiting (posttussive emesis).
Treatment consists of antibiotics and supportive measures. Humidified oxygen and adequate
fluids will help loosen the thick mucus. Suction as needed is important in infants. Respiratory
status should be monitored for obstruction. The client should be positioned on the left side to
prevent aspiration if vomiting occurs. Vaccination against whooping cough is available, but
some individuals will still develop the disease, although in a milder form.
Epiglottitis, a sudden-onset medical emergency due to Haemophilus influenzae, causes severe
inflammatory obstruction above and around the glottis. The affected child will typically progress
from having no symptoms to having a completely occluded airway within hours. Sitting in
a tripod position (upright and leaning forward with the chin and tongue sticking out) is a classic
presentation. The child will likely drool and be very restless and anxious secondary to airway
obstruction and hypoxia. Throat inspection should not be done until emergency intubation is
readily available (if necessary).

Symptoms of infant botulism include constipation, generalized weakness, difficulty feeding, and
diminished deep-tendon reflexes. This condition is a high priority due to the risk of respiratory

Before initiating a treatment program that requires a client and family to make major lifestyle
and behavior changes, the nurse needs to assess readiness for change. Motivation and a desire
for change are the keys to successful weight loss.

At age 15, clients should have their permanent teeth. If tooth avulsion occurs, there is limited
time (≤1 hour, longer if placed in cold milk) until death of the tooth. This is a time-sensitive
condition and the client should be seen first to avoid loss of a permanent tooth.

Epiglottitis (supraglottitis). It is an inflammation by bacteria of the tissues surrounding the

epiglottis, a long, narrow structure that closes off the glottis during swallowing. Edema can
develop rapidly (as quickly as a few minutes) and obstruct the airway by occluding the
trachea. The majority of cases of epiglottitis are caused by Haemophilus influenza type B (HiB),
which is covered under the standard vaccinations given during the 2- and 4-month
visits. Epiglottitis is rarely seen in vaccinated children.

The classic symptoms include a high-grade fever with toxic appearance, severe sore throat, and
the 4 Ds - dysphonia (muffled voice), dysphagia (difficulty swallowing), drooling, and
distressed respiratory effort. The tripod position opens the airway and helps air flow. The child
should be allowed to assume a position of comfort (usually sitting rather than lying down). The
priority nursing response is to protect the airway.
Screening for developmental dysplasia of the hip is a standard part of infant
assessment. Manifestations in infants age <2-3 months include the presence of extra inguinal
or thigh folds and laxity of the hip joint on the affected side. After age 3 months, limited hip
abduction and limb shortening on the affected side are evident. A pelvic tilt is noted once the
child learns to walk.
The introduction of solid foods generally occurs at 4-6 months. The process usually starts with
a form of iron-fortified infant cereal, such as rice or oatmeal. Cereal can be mixed with
breast milk, formula, or water. When introducing new foods, it is important to allow 5-7 days
between foods to observe for any allergies to a particular food. Allergic responses often worsen
with subsequent exposure, so it is a priority to identify food triggers as soon as possible (Option
Screening for developmental dysplasia of the hip is a standard part of infant
assessment. Manifestations in infants age <2-3 months include the presence of extra inguinal
or thigh folds and laxity of the hip joint on the affected side. After age 3 months, limited hip
abduction and limb shortening on the affected side are evident. A pelvic tilt is noted once the
child learns to walk.

This client is in status epilepticus, a serious and life-threatening emergency in which a client has
been seizing for 5 minutes or longer. Grunting and a dazed appearance are 2 common
signs. A client with hydrocephalus (abnormal collection of cerebrospinal fluid in the head) and
a ventriculoperitoneal (VP) shunt is at a higher risk for seizures. Stopping seizure activity is
the first nursing priority. IV benzodiazepines (diazepam or lorazepam) are used acutely to
control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable
or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer
a dose before bringing a child to the emergency department.

IVIG along with aspirin is the recommended initial treatment for Kawasaki disease, with the
primary goal of coronary disease prevention.
Parvovirus B-19 is a common childhood infection also known as "fifth disease." Infected
clients display a characteristic "slapped cheek" rash on the face. Symptoms range in severity;
however, most children do not require intervention. Transmission of the infection is usually
through person-to-person contact, especially with respiratory secretions.
Although rare, infection with parvovirus B-19 during pregnancy can cause fetal anomalies (eg,
hydrops fetalis, stillbirth). It is recognized as a TORCH infection (Toxoplasmosis, Other
[parvo-B19/varicella zoster], Rubella, Cytomegalovirus, Herpes simplex virus), a group of
infections that cause fetal abnormalities. Delegation of this client to a pregnant nurse is
inappropriate due to potential harm to the fetus.
Absence seizures occur in children age 4-12 and usually disappear at puberty. Clinical
manifestations include a brief loss of consciousness and an appearance
of inattention or daydreaming (the absence attack) without loss of postural body
tone. However, slight loss of tone may lead to dropping objects held in hands. Most absence
seizures last less than 10 seconds and often go unrecognized. Following an attack, behavior and
awareness return immediately to normal. The child does not experience a postictal period but
usually has no recollection that a seizure has occurred. A child may have multiple absence
seizures each day. Treatment includes the use of anticonvulsant medication(s). SEE STARE

Toddlers engage in parallel play, which involves playing alongside, not with, other
children. Activities such as playing with dolls or toy cars, pushing and pulling large toys,
smearing paint, and digging in a sandbox encourage parallel play.

During bouts of acute diarrhea and dehydration, treatment focuses on maintaining adequate
fluid and electrolyte balance. The first-line treatment is oral rehydration therapy, using oral
rehydration solutions (ORSs) to increase reabsorption of water and sodium. Even if the diarrhea
is accompanied by vomiting, ORS should still be offered in small amounts at frequent
intervals. Continuing the child's normal diet (solid foods) is encouraged as it shortens the
duration and severity of the diarrhea. The BRAT (bananas, rice, applesauce, and toast) diet is
not recommended as it does not provide sufficient protein or energy.

Hemolytic uremic syndrome (HUS) is a life-threatening complication of Escherichia

coli diarrhea and results in red cell hemolysis, low platelets, and acute kidney
injury. Hemolysis results in anemia, and low platelets manifest as petechiae or
purpura. Therefore, the presence of petechiae in this client could indicate underlying HUS and
needs further assessment.

Peritonsillar or retropharyngeal abscess is a serious complication that can result from

tonsillitis or pharyngitis. A "hot potato" or muffled voice, trismus (inability to open the
mouth), pooling of saliva, and deviation of the uvula to one side are the presenting
features. Maintaining an adequate airway is essential.

Management of sickle cell crisis focuses on the following:

1. Pain control with narcotics - analgesics are provided around the clock or with patient-
controlled analgesia, rather than as needed, to prevent breakthrough pain. Clients with
SCD often need large doses of narcotics.
2. Hydration - aggressive intravenous and oral hydration is recommended (to reduce the
viscosity of the blood)
3. Oxygenation - to prevent pulmonary complications and provide comfort
4. Infection prevention – age-appropriate vaccination plus pneumococcal, influenza, and
meningococcal vaccination
5. Diet - the client is encouraged to have a high-protein, high-calorie diet with folic acid
and a multivitamin without iron
6. Folic acid - given to help in the creation of the new red blood cells needed due to the
Positive orthostatic vital signs (eg, rise in pulse of ≥20/min) indicate increased risk of syncope
and falls

Clients experiencing a manic episode are often undernourished and dehydrated on hospital
admission. They need more calories, protein, and fluids due to their excessive energy and
psychomotor activity. Most clients with mania are unable to sit still long enough to consume a
meal and they would not be able, on their own, to choose foods that would meet their caloric
Clients will need frequent reminders to eat, and their intake should be monitored. Foods that are
readily available and easy to consume should be provided. Foods that can be eaten "on the run"
increase the probability that the client will consume them. Items such as sandwiches, smoothies,
milkshakes, ice cream bars, fresh fruit, chips, pizza slices, burritos, fruit juices, and granola bars
have high nutritional density and are easily consumed.

Acceptable abbreviations include ac, pc, QID, and cm. Unacceptable abbreviations include qd,
qod, and q1d; SSRI for insulin; and u for units. There must be a zero before a decimal dose and
no trailing zero after a decimal point.
When there is new, sudden onset of restlessness/agitation, the nurse should first think about
oxygenation (or blood glucose). The desired level of sedation is level 3 on the Ramsay Sedation
Scale, during which the client is drowsy but responds to a voice command. Primero Saturation de
Oxygen y Glicemia.

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive diagnostic test used

to visualize the biliary and hepatic ducts via MRI. MRCP uses oral or
IV gadolinium (noniodine contrast material) and is a safer, less invasive alternative to
endoscopic retrograde cholangiopancreatography (ERCP) to determine the cause of cholecystitis,
cholelithiasis, or biliary obstruction.
The nurse must assess for contraindications prior to the procedure, including presence of
certain metal implants (eg, pacemaker, aneurysm clip, cochlear implant), pregnancy, or any
previous allergy or reaction to gadolinium (Options 3 and 4). Most orthopedic implants (eg,
rods, pins, artificial joints) are considered safe for MRI imaging.

Net intake and output is calculated by subtracting total output from total intake. The nurse
should record all occurrences of intake and output. Clients with a significant discrepancy in fluid
intake and output are at risk for a fluid volume imbalance; however, daily weights are always the
best indicator of fluid balance. Net intake and output can be calculated by performing these steps

In addition to standard precautions, the client infected with multidrug-resistant organisms (eg,
vancomycin-resistant enterococci [VRE] or methicillin-resistant Staphylococcus
aureus [MRSA]), Clostridium difficile, and scabies will require contact precautions that include
the following:

 Place client in a private room (preferred) or semi-private room with another client with
the same infection
 Dedicate equipment for client (must be kept in the client's room and disinfected when
removed from room) (Option 1)
 Wear gloves when entering the room
 Perform excellent hand hygiene before exiting the room (use soap and water or alcohol-
based hand rubs for MRSA and VRE, but only soap and water for C difficile and
scabies) (Option 2)
 Wear gown with client contact and remove it before leaving the room (Option 5)
 Place door notice for visitors
 Ensure client leaves the room only for essential clinical reasons (ie, tests, procedures)

Culturally competent nursing care involves recognizing certain cultural and religious beliefs. A
health-related belief of Jehovah's Witnesses is that transfusions containing blood in any form
are not acceptable. Witnesses do not accept transfusions of whole blood or any of its 4 major
components (ie, red cells, white cells, platelets, and plasma. Shock prevention is a major
concern in the setting of blood loss and can be accomplished with the use of non-blood volume
expanders such as saline, lactated Ringer's, dextran, and hetastarch. These can be administered
safely to clients who refuse blood products.
Recombinant human erythropoietin (eg, epoetin alfa) and IV iron are accepted by most Jehovah's
Witnesses. These medications stimulate the bone marrow to produce more red blood cells,
resulting in increased hematocrit and hemoglobin levels

Recommended bed-to-chair transfer method

Transfer method

 Independent; no assistance required

 1-person standby assistance or observation for
Full clients who are uncooperative or at high risk
for falls

 1-person assist stand & pivot transfer with gait

belt or motorized assist device if cooperative
Partial  2-person assist with full body sling if client is

 Motorized assist device if client is cooperative

& has upper body strength
 2-person assist with full body sling if client is
uncooperative &/or has no upper body

 Client should use as much of his or her own strength as possible.

 Use assistive devices when lifting >35 lb (15.9 kg) of client’s body

Children age <10 should automatically be upgraded to 1 level higher than the triaged urgency of
their medical issues. The combination of status asthmaticus and an oxygen saturation ≤92%
qualifies for the highest priority level of triage at any age.
Nonmaleficence is doing no harm, fidelity is loyalty and commitment, justice is equal treatment
for all, beneficence is doing good for the client's best interest, and autonomy is making
decisions for oneself.

The Centers for Disease Control and Prevention (CDC) recommends that the first dose of MMR
vaccine be given to children between age 12-15 months to ensure optimal vaccine
response. However, the vaccine is safe for children age <12 months; it could provide some
protection or modify the clinical course of the disease if administered within 72 hours of the
child's initial measles exposure. Immunoglobulin, if administered within 6 days of exposure, is
also utilized as post-exposure prophylaxis.
A child who receives the MMR vaccine prior to the first birthday will need to be revaccinated at
age 12-15 months and again between age 4-6 years.
Phenylketonuria (PKU) is a genetic inborn error of metabolism. Individuals with PKU lack the
required enzyme (phenylalanine hydroxylase) for converting the amino acid phenylalanine into
the amino acid tyrosine. As unconverted phenylalanine builds up, irreversible neurologic
damage can occur.
A low-phenylalanine diet is the only treatment for PKU (Option 1). Phenylalanine cannot be
totally eliminated from the diet as it is an essential amino acid and necessary for normal
development. The diet must meet nutritional needs while maintaining phenylalanine levels
within a safe range (2-6 mg/dL for clients under age 12). There is no known age at which the
diet can be discontinued safely, and lifetime dietary restrictions are recommended for optimum

Dietary management of the client with PKU includes:

1. Monitoring serum levels of phenylalanine

2. Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the
diet (Option 4)
3. Eliminating high-protein/phenylalanine foods (eg, meats, eggs, milk) from the
diet (Option 2)
4. Encouraging consumption of natural foods low in phenylalanine (most fruits and

Key instructions for safe, effective administration of oral iron supplements include:
 Administer between meals - Concentrations of stomach acid are higher between meals,
breaking down the iron to an easily absorbed state
 Give with citrus juice - Absorption is enhanced when taken with a good source of
vitamin C, such as orange juice or other citrus fruit
 Place medicine at the back of the mouth - Liquid iron can cause temporary staining of
the teeth.
 Avoid giving with milk - Milk and other products with high amounts of calcium reduce
adequate absorption of iron supplements
 Keep no more than a 1-month supply
A reward system is one of the behavioral strategies used in the treatment of functional
incontinence (due to constipation). The reward is given to encourage the child's involvement in
the treatment to restore normal bowel function. Rewards are given for the child's effort and
participation, not for having bowel movements while sitting on the toilet.

FTT, or growth failure, is a state of undernutrition and inadequate growth in infants and young
children. Most cases of FTT are related to an inadequate intake of calories, which can be tied to
many different etiologies. Physiologic risk factors for FTT include preterm birth, breastfeeding
difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include:

 Poverty – most common

 Social or emotional isolation – parents may lack the support system needed to assist them
with the problems of child rearing
 Cognitive disability or mental health disorder
 Lack of nutritional education – parents may not have knowledge of proper feeding
techniques or appropriate calorie intake based on age and size of the child

Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins,

increasing the risk for bleeding. The nurse should avoid procedures that can cause
bleeding (eg, intramuscular injections, rectal temperature measurement). Vaccinations
are administered subcutaneously whenever possible to prevent intramuscular
hematoma (Option 2). The smallest gauge needle is used, and firm, continuous pressure
is applied at the site for 5 minutes

 Auscultate heart and lungs

 Palpate fontanels
 Percuss abdomen
 Assess pupillary response
 Elicit Moro reflex. Es lo ultimo
A neonate born to an opioid-dependent mother (eg, heroin, methadone, hydrocodone) is at high
risk for neonatal abstinence syndrome, in which the newborn experiences opioid withdrawal
typically within 24-48 hours after birth. Clinical manifestations of withdrawal in infants
include irritability, jitteriness, high-pitched cry, sneezing, diarrhea, vomiting, and poor
Hypersensitivity can make feeding difficult; the newborn should be placed in a side-lying
position while swaddled to minimize stimulation and promote nutritive sucking (Option
1). Between feedings, a pacifier may be used to soothe the infant and help establish an organized
sucking pattern.
Excessive movement places the newborn at high risk for skin excoriation; the infant should
be tightly swaddled with arms flexed to minimize irritation and prevent damage to the
skin. Hand mittens and barrier skin protection to the knees, elbows, and heels may also be

The normal MMRV vaccine reactions that occur within 5-12 days after vaccination
include mild fever and rash, irritability and restlessness, and swelling and erythema at the
injection site. Febrile seizure is a rare but more serious reaction to the vaccine.

This client is exhibiting localized (eg, pain, limited range of motion) and systemic infection
symptoms (eg, fever), which may indicate septic arthritis. Possible causes include recent
surgery, injections, trauma, or spread from adjacent infection (eg, cellulitis).
A septic hip is considered a surgical emergency. The hip joint is prone to develop avascular
necrosis (eg, damage to the femoral head) from compromised blood supply due to infection or
injury (eg, fracture). This can result in sequelae that are significant in both the short term (eg,
sepsis, death) and long term (eg, joint destruction). Management includes culturing synovial
fluid and blood, giving antibiotics, and debriding the infected joint.
Macular degeneration is a progressive, incurable disease of the eye in which the central portion
of the retina, the macula, begins to deteriorate with age. This causes distortion (blurred or wavy
disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact.

Manifestations of acute angle-closure glaucoma include sudden onset of severe eye pain,
reduced central vision, blurred vision, ocular redness, and report of seeing halos around
lights. This condition requires immediate medical intervention to reduce IOP and prevent
permanent blindness.
Primary open-angle glaucoma is characterized by an increase in intraocular pressure and
gradual loss of peripheral vision (ie, tunnel vision).
Retinal detachment is separation of the retina from the underlying epithelium that allows fluid
to collect in the space. The signs/symptoms include sudden onset of light flashes, floaters,
cloudy vision, or a curtain appearing in the vision.

Chronic hyperglycemia can cause micro vascular damage in the retina, leading to diabetic
retinopathy, the most common cause of new blindness in adults. A partial retinal detachment
may be painless and cause symptoms such as a curtain blocking part of the visual field, floaters
or lines, and sudden flashes of light.

Classic signs of retinal detachment include a curtain coming across the vision, floaters
or lightning in the vision field, and "gnats/hairnet/cobweb" throughout the vision. Aging can
be a cause and result in retinal tears or holes and spontaneous detachment. However, retinal
detachment can also be caused by forceful head trauma. Retinal detachment requires emergent
consultation and treatment as most untreated, symptomatic detachments result in blindness of the
affected eyes.
Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and
occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated
with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations,
and cyanosis.

Scleroderma is an overproduction of collagen that causes tightening and hardening of the skin
and connective tissue. This is a progressive disease without a cure, and treatment is aimed at
managing complications. Renal crisis is a life-threatening complication that causes malignant
hypertension due to narrowing of the vessels that provide blood to the kidneys. Early
recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with
treatment, this can be fatal.

Rarely, allergy shots may induce an immediate and potentially fatal anaphylactic reaction. The
client must remain at the facility for 30 minutes after an injection so the nurse can monitor for
severe systemic reactions (eg, respiratory failure, tongue and throat swelling)
Botulism is caused by the gastrointestinal absorption of the neurotoxin produced by Clostridium
botulinum. The neurotoxin blocks acetylcholine at the neuromuscular junction, resulting
in muscle paralysis. The organism is found in the soil and can grow in any food contaminated
with the spores. Manifestations include descending flaccid paralysis (starting from the face),
dysphagia, and constipation (smooth muscle paralysis).
The main source is improperly canned or stored food. A metal can's swollen/bulging end can
be caused by the gases from C botulinum and should be discarded. The infant form of botulism
can occur in children under age 1 year if they eat honey, particularly raw (wild) honey. The
immature gut system in these children makes them more susceptible.

Peripherally inserted central venous catheters (PICC) are commonly used for long-term
antibiotic administration, chemotherapy treatments, and nutritional support with total parenteral
nutrition (TPN). Complications related to the PICC are occlusion of the catheter, phlebitis, air
embolism, and infection due to bacterial contamination.

The maximum rate for infusion of IV potassium chloride through a peripheral vein is 10 mEq/hr,
and the maximum rate through a central vein is 40 mEq/hr.

The management of anaphylactic shock includes:

1. Call for help (activate emergency management systems) – first action

2. Maintain airway and breathing – administer high-flow O2 via non-rebreather mask
3. Epinephrine, intramuscular – the drug of choice and should be
given next. Epinephrine stimulates both alpha- and beta-adrenergic receptors, dilates
bronchial smooth muscle (beta 2), and provides vasoconstriction (alpha 1). The IM
route is better than the subcutaneous route. The dose should be repeated every 5-15
minutes if there is no response.
4. Elevate the legs
5. Volume resuscitation with IV fluids
6. Bronchodilator such as albuterol is administered to dilate the small airways and reverse
7. Antihistamine (diphenhydramine) is administered to modify the hypersensitivity
reaction and relieve pruritus
8. Corticosteroids (methylprednisolone [Solu-Medrol]) are administered to decrease
airway inflammation and swelling associated with the allergic reaction
Sjögren's syndrome is a chronic autoimmune disorder in which moisture-producing exocrine
glands of the body are attacked by white blood cells. The most commonly affected glands are
the salivary and lacrimal glands, leading to dry eyes (xerophthalmia) and dry
mouth (xerostomia). Dryness in these areas can lead to corneal ulcerations, dental caries, and
oral thrush. Other areas that can be affected and their symptoms include:

 Skin - dry skin and rashes

 Throat and bronchi - chronic dry cough
 Vagina - vaginal dryness and painful intercourse

Treatment is focused on alleviating symptoms as there is currently no cure for Sjögren's

syndrome. Over-the-counter or prescribed drops are used to relieve itching, burning, dryness,
and gritty sensation in the eyes. Wearing goggles may offer further protection from drying
caused by the wind. Dry mouth is treated with sugarless gum and candy or artificial
saliva. Regular dental appointments to prevent dental caries are recommended. Lubricants (eg,
K-Y Jelly) help to ease vaginal dryness. Use of lukewarm water and mild soap when showering
can prevent dry skin. Avoiding low-humidity environments (eg, centrally heated houses,
airplanes) and using humidifiers to maintain adequate humidity (mainly at night) are also
When caring for a client who is blind, the nurse should create a safe therapeutic environment and
foster client independence by orienting the client to the surroundings, announcing room entry
and exit, guiding the client by offering an elbow and walking slightly in front, using a clock-face
description to orient the client to the location of objects, and asking the client directly about
For medical procedures, the nurse should ensure that the client:

 Has an empty bladder and is in high Fowler's or a sitting position for paracentesis
 Is Trendelenburg on the left side for suspected air embolism
 Has the arm raised above the head on the affected side for chest tube insertion
 Lies on the right side (for 2 hours) and then supine (12-14 hours) after liver biopsy
 Is side-lying with the head, back, and knees flexed for lumbar puncture

In triaging victims from a radiation contamination disaster, nurses should assist clients who are
farthest away from the source and have the least symptoms as most damage is internal and
will not be apparent initially. Nerve agents (eg, sarin) cause excess acetylcholine with copious
secretions. Neurologic symptoms are classic for biological threats such as botulinum toxin.

Ensure proper measurement prior to inserting a large-bore NG tube by measuring from the tip of
the nose, extending the tube to the earlobe, and then down to the xiphoid process. Mark the
distance with a small piece of tape that can be easily removed.
Cauda equina syndrome is a disorder that results from injury to the lumbosacral nerve roots
(L4-L5) causing motor and sensory deficits. The main symptoms are severe lower back pain,
inability to walk, saddle anesthesia (ie, motor weakness/loss of sensation to inner thighs and
buttocks), and bowel and bladder incontinence (late sign). Cauda equina syndrome is
a medical emergency. Treatment requires urgent reduction of pressure on the spinal nerves to
prevent permanent damage. This client displays characteristic late signs of cauda equine
syndrome (ie, incontinence); therefore, the nurse should assess this client first.

The client with atrial fibrillation is at increased risk for the development of atrial thrombi due to
blood stasis, which can embolize and lead to an ischemic brain attack. The INR (normal 0.75-
1.25) is a measurement used to assess and monitor coagulation status in clients receiving
anticoagulation therapy. The therapeutic INR level for a client receiving warfarin (Coumadin)
to treat atrial fibrillation is 2-3. The subtherapeutic INR of 1.3 is the most important result to
report to the health care provider (HCP) as the client is at increased risk for a stroke and dose
adjustment is needed.