MEDICAL SURGICAL NURSING BULLETS In a patient with a fractured, dislocated femur, treatment

(NLE & NCLEX) begins with reduction and immobilization of the

affected leg.

In a patient with hypoglycemia (serum potassium level

below 3.5 mEq/L), presenting signs and symptoms Herniated nucleus pulposus (intervertebral disk) most
Include muscle weakness and cardiac arrhythmias. commonly occurs in the lumbar and lumbo -sacral
regions.
During cardiac arrest, if an I.V. route is unavailable,
epinephrine can be administered endotracheally Laminectomy is surgical removal of the herniated
portion of an intervertebral disk
Pernicious anemia results from the to absorb Vitamin
B12 in the GI tract and causes primarily GI Surgical treatment of a gastric ulcer includes severing
and neurologic signs and symptoms. the vagus nerve (vagotomy) to reduce the amount
of gastric acid secreted by the gastric cells.
A patient who has a pressure ulcer should consume a
high-protein, diet, unless Valsalva's maneuver is forced exhalation against a
contraindicated closed glottis, as when taking a deep breath, blowing
air out, or bearing down.
The CK-MB isoenzyme level is used to assess tissue
damage in myocardial infarction. When mean arterial pressure falls below 60 mm Hg and
systolic blood pressure falls below 80 mm Hg,
After a 12-hour fast, the normal blood glucose level is vital organ perfusion is seriously compromised.
80 to 120 mg/dl.
Lidocaine (Xylocaine) is the drug of choice for reducing
A patient who is experiencing disown toxicity may premature ventricular contractions.
report nausea, vomiting, diplopia, blurred vision, light
flashes, and yellow-green halos around images. A patent is at greatest risk of dying during the first 24 to
48 hours after a myocardial infarction.
Anuria is daily urine output of less than 100 ml.
During a myocardial infarction, the left ventricle
In remittent fever, the body temperature varies over a usually sustains the greatest damage.
24-hour period, but remains elevated.
The pain of a myocardial infarction results from
Risk of a fat embolism is greatest in thefirst48 hours myocardial ischemia caused by anoxia.
after the fracture of a long bone. It's manifested by
respiratory distress. For a patient in cardiac arrest, the first priority is to
To help venous blood return in a patient who is in shock establish an airway.
the nurse should elevate the patents legs no more than
45 degrees. This procedure IS contraindicated in a The universal sign for choking is clutching the hand to
patient with a head injury the throat.

The pulse deficit is the difference between the apical For a patient who has heart failure or cardiogenic
and radial pulse rates, when simultaneously by two pulmonary edema, nursing interventions focus on
nurses. decreasing venous return to the heart and increasing left
ventricular output. These interventions include
To reduce the patient's risk of vomiting and aspiration, placing the patient in high Fowler’s position and
the nurse should schedule postural drainage before administering oxygen, diuretics, and positive inotropic
meals or 2 to 4 hours after meals. drugs as prescribed.

Blood pressure can be measured directly by Intra- A positive tuberculin skin test is an induration of 10 mm
arterial insertion of a catheter connected to a pressure- or greater at the injection site.
monitoring device.
The signs and symptoms of histoplasmosis, a chronic
A positive Kemig's sign, seen in meningitis, occurs systemic fungal infection, resemble those of
when an attempt to flex the hip of a recumbent patent tuberculosis.
causes painful spasms of the hamstring muscle and
resistance to further extension of the leg at the knee. In burn victims, the leading cause of death is respiratory
compromise. The second leading cause is
infection. Wrist drop is caused by paralysis of the extensor
muscles in the forearm and hand.
The exocrine function of the pancreas is the secretion of
enzymes used to digest carbohydrates, fats, and Foot drop results from excessive plantar flexion and is
proteins. usually a complication of prolonged bed rest.

A patient who has hepatitis A (infectious hepatitis) A patent who has gonorrhea may be treated with
should consume a diet that's moderately high in fat penicillin and probenecid (Benemid). Probenecid
and high in carbohydrate and protein, and should eat the delays the excretion of penicillin and keeps this
largest meal in the morning. antibiotic in the body longer.

Esophageal balloon tamp made shouldn't be inflated In patients who have glucose-6-phosphate
greater than20 mm Hg. dehydrogenase (G6PD) deficiency, the red blood cells
can't metabolize adequate amounts of glucose, and
Overproduction of prolactin by the pituitary gland can hemolysis occurs.
cause galactorrhea (excessive or abnormal
lactation) and amenorrhea (absence of menstruation). On-call medication is medication that should be ready
for immediate administration when the call to
Intermittent claudicaton (pain during ambulation or administer it's received.
other movement that's relieved with rest) is a
classic symptom of arterial insufficiency in the leg. If gagging, nausea, or vomiting occurs when an airway
is removed, the nurse should place the patient in
In bladder carcinoma, the most common finding is a lateral position with the upper arm supported on a
gross, painless hematuria. pillow.

Parenteral administration of heparin sodium is When a postoperative patient arrives in the recovery
contraindicated in patients with renal or liver disease, room, the nurse should posit-ion the patient on his
Gl side or with his head turned to the side and the chin
bleeding, or recent surgery or trauma; in pregnant extended.
patients; and in women older than age 60.
In the immediate postoperative period, the nurse should
Drugs that potentate the effects of anticoagulants report a respiratory rate greater than 30,
include aspirin, chloral hydrate, glucagon, anabolic temperature greater than 1000 F (37.80 C) or below 970
steroids, and chloramphenicol. F (36.10 C), or a significant drop in blood pressure
or rise in pulse rate from the baseline.
For a burn patent, care priorities include maintaining a
patent airway, preventing or correcting fluid and Irreversible brain damage may occur if the central
electrolyte imbalances, controlling pain, and preventing nervous system is deprived of oxygen for more than 4
infection. minutes.

Elastic stockings should be worn on both legs. Treatment for polycythemia vera includes
administering oxygen, radioisotope therapy, or
Active immunization is the formation of antibodies chemotherapy agents, such as chlorambucil and
within the body in response to vaccination or nitrogen mustard, to suppress bone marrow growth.
exposure to disease.

Passive immunization is administration of antibodies

that were preformed outside the body.
pH PaC02 HC03- = respiratory acidosis compensated
A patent who is receiving digoxin (Lanoxin) shouldn't pH PaC02 HC03-= respiratory alkalosis compensated
receive a calcium preparation because of the increased pH PaC02 HC03-= metabolic acidosis compensated
risk of digoxin toxicity. Concomitant use may affct pH PaC02 HC03-= metabolic alkalosis compensated.
cardiac contractility and lead to arrhythmias.
Polyuria is urine output of 2,500 ml or more within 24
Intermittent positive-pressure breathing is inflation of hours.
the lung during inspiration with compressed air or
oxygen. The goal of this inflation is to keep the lung The presenting sign of pleuritis is chest pain that is
open. usually unilateral and related to respiratory
movement.
 After angiography, the puncture site is covered with a
If a patent has a gastric drainage tube in place, the nurse pressure dressing and the affected part is
should expect the physician to order potassium chloride. immobilized for 8 hours to decrease the risk of bleeding.

An increased pulse rate is one of the first indications of If a water-based medium was used during myelography,
respiratory difficulty. It occurs because the heart the patient remains on bed rest for 6 to 8 hours,
attempts to compensate for a decreased oxygen supply with the head of the bed elevated 30 to 45 degrees. If an
to the tissues by pumping more blood. oil-based medium was used, the patient remains
flat in bed for 6 to 24 hours.
In an adult, a hemoglobin level below 11 mg/dl suggests
iron deficiency anemia and the need for further The level of amputation is determined by estimating the
evaluation. maximum viable tissue (tissue with adequate
circulation) needed to develop a functional stump.
The normal partial pressure of oxygen in arterial blood
is 95 mm Hg (plus or minus 5 mm Hg). Heparin sodium is included in the dialysate used for
renal dialysis.
Vitamin C deficiency is characterized by brittle bones,
pinpoint peripheral hemorrhages, and friable Paroxysmal nocturnal dyspnea may indicate heart
gums with loosened teeth. failure.

Clinical manifestations of pulmonary embolism are A patent who takes a cardiac glycoside, such as digoxin,
variable, but increased respiratory rate, tachycardia, should a diet that includes high-
and hemoptysis are common. potassium foods.

Normally, intraocular pressure is 12 to 20 mm Hg. It can The nurse should limit tracheobronchial suctioning to
be measured with a Schiøtz tonometer. 10 to 15 seconds and should make only two
passes.
In early hemorrhagic shock, blood pressure may be
normal, but respiratory and pulse rates are rapid. Before performing tracheobronchial suctioning, the
The patent may report thirst and may have clammy skin nurse should ventilate and oxygenate the patient five to
and piloerection (goose bumps). Cool, moist, Pak skin, six minutes with a resuscitation bag and 100% oxygen.
as occurs in shock, results from diversion of blood from This procedure is called bagging.
the skin to the major organs.
Signs and symptoms of pneumothorax include
To assess capillary refill, the nurse applies pressure over tachypnea, restlessness, hypotension, and tracheal
the nail bed until blanching occurs, quickly deviation.
releases the pressure, and notes the rate at which
blanching fades. Capillary refill indicates perfusion, The cardinal sign of toxic shock syndrome is rapid onset
which decreases in shock, thereby lengthening refill of a high fever.
time. Normal capillary refill is less than 3 seconds.
A key sign of peptic ulcer is hematemesis, which can be
Except for patients with renal failure, urine output of bright red or dark red, with the consistency of coffee
less than 30 ml/hour signifies dehydration and the grounds.
potential for shock. 103b Signs and symptoms of a perforated peptic ulcer
In elderly patents, the most common fracture is hip include sudden, severe upper abdominal pain;
fracture. Osteoporosis weakens the bones, vomiting; and an extremely tender, rigid (boardlike)
predisposing these patients to fracture, which usually abdomen.
results from a fall. 104B Constipation is a common adverse reaction to
aluminum hydroxide.
Before angiography, the nurse should ask the patient 105B For the first 24 hours after a myocardial
whether he's allergic to the dye, shellfish, or iodine infarction, the patent should use a bedside commode
and advise him to take nothing by mouth for 8 hours and then
before the procedure. progress to walking to the toilet, bathing, and taking
short walks.
106 After a myocardial infarction, the patient should
During myelography, approximately 10 to 15 ml of avoid overexertion and add a new activity daily, as
cerebrospinal fluid is removed for laboratory studies tolerated without dyspnea.
and an equal amount of contrast media is injected.
In a patient with a recent myocardial infarction, frothy, Signs and symptoms of colon cancer include rectal
blood-tinged sputum suggests pulmonary edema. bleeding, change in bowel habits, intestinal
obstruction, abdominal pain, weight loss, anorexia,
In a patient who has acquired immunodeficiency nausea, and vomiting.
syndrome, the primary purpose of drugs is to prevent
secondary infections. Symptoms of prostatitis include frequent urination and
dysuria.
In a patient with acquired immunodeficiency
syndrome, suppression of the immune system increases A chancre is a painless, ulcerative lesion that develops
the risk of opportunistic infections, such as during the primary stage of syphilis.
cytomegalovirus, Pneumocystis carinii pneumonia, and
thrush. During the tertiary stage of syphilis, spirochetes invade
the internal organs and cause permanent
Because of the risk of paralytic ileus, a patient who has damage.
received a general anesthetic can't take anything
by mouth until active bowel sounds are heard in all In total parenteral nutrition, weight gain is the most
abdominal quadrants. reliable indicator of a positive response to therapy.

The level of alpha-fetoprotein, a tumor marker, is The nurse may administer an I.V. fat emulsion through
elevated in patients who have testicular germ cell a central or peripheral catheter, but shouldn't use an in-
cancer. line filter because the fat particles are too large to pass
through the pores.
Clinical manifestations of orchitis caused by bacteria or
mumps include high temperature, chills, and If a patient who has a prostatectomy is using a
sudden pain in the involved testis. Cunningham clamp, instruct him to wash and dry his
penis before applying the clamp. He should apply the
The level of prostate-specific antigen is elevated in clamp horizontally and remove it at least every 4
patents with benign prostatic hyperplasia or prostate hours to empty his bladder to prevent infection.
cancer. me

The level of prostatic acid phosphatase is elevated in

patents with advanced stages of prostate cancer. If a woman has signs of urinary tract infect-ion during
menopause, she should be instructed to drink six to
Phenylephrine (Neo-Synephrine), a mydriatic, is eight glasses of water per day, urinate before and after
instilled in a patient's eye to dilate the eye. intercourse, and perform Kegel exercises.

To promote fluid drainage and relieve edema in a If a menopausal patient experiences a "hot flash," she
patient with epididymitis, the nurse should elevate the should be instructed to seek a cool, breezy
scrotum on a scrotal bridge. location and sip a cool drink.

Fluorescein staining is commonly used to assess corneal Cheilosis causes fissures at the angles of the mouth and
abrasions because it outlines superficial indicates a vitamin 82, riboflavin, or iron
epithelial defects. deficiency.

Presbyopia is loss of near vision as a result of the loss Tetany may result from hypocalcemia caused by
of elasticity of the crystalline lens. hypoparathyroidism.

Transient ischemic attacks are considered precursors to A patient who has cervical cancer may experience
strokes. vaginal bleeding for 1 to 3 months after intracavitary
radiation.
A sign of acute appendicitis, Mc Burnev's sign is
tenderness at Mc Burney's point (about 2" [5 cm] from Ascites is the accumulation of fluid, containing large
the right anterior superior iliac spine on a line between amounts of protein and electrolytes, in the
the spine and the umbilicus). abdominal cavity. It's commonly caused by cirrhosis.

When caring for a patient with Guillain-8arré Normal pulmonary artery pressure is 10 to 25 mm Hg.
syndrome, the nurse should focus on respiratory Normal pulmonary artery wedge pressure is 5 to 12 mm
interventions as the disease process advances. Hg.
 After cardiac catheterization, the site is monitored for Excessive intake of vitamin K may significantly
bleeding and hematoma format-ion, pulses distal antagonize the anticoagulant effects of warfarin
to the site are palpated every 15 minutes for 1 hour, and (Coumadin). The patient should be cautioned to avoid
the patient is maintained on bed rest with the eating an excessive amount of leafy green
extremity extended for 8 hours. vegetables.

Hemophilia is a bleeding disorder that's transmitted A lymph node biopsy that shows Reed-Sternberg cells
generically in a sex-linked (X chromosome) recessive provides a definitive diagnosis of Hodgkin's
pattern. Although girls and women may carry the disease.
defective gene, hemophilia usually occurs only in boys
and men. Bell's palsy is unilateral facial weakness or paralysis
caused by a disturbance of the seventh cranial
Von Willebrand's disease is an autosomal dominant (facial) nerve.
bleeding disorder that's caused by platelet
dysfunction and factor Vlll deficiency. During an initial tuberculin skin test, lack of a wheal
after injection of tuberculin purified protein
Sickle cell anemia is a congenital hemolytic anemia derivative indicates that the test dose was injected too
that's caused by defect-ive hemoglobin S molecules. It deeply. The nurse should inject another dose at
primarily affects blacks. least 2" (5 cm) from the initial site.

Sickle cell anemia has a homozygous inheritance A tuberculin skin test should be read 48 to 72 hours
pattern. Sickle cell trait has a heterozygous inheritance after administration.
pattern.
In reading a tuberculin skin test, erythema without
Ebstein fever is a characteristic sign of Hodgkin's induration is usually not significant.
disease. Fever recurs every few days or weeks and
alternates with afebrile periods. Death caused by botulism usually results from delayed
diagnosis and respiratory complications.
Glucose-6-phosphate dehydrogenase (G6PD)
deficiency is an inherited metabolic disorder that's In a patient who has rabies, saliva contains the virus and
characterized by red blood cells that are deficient in is a hazard for nurses who provide care.
G6PD, a critical enzyme in aerobic glycolysis.
A febrile nonhemolytic reaction is the most common
Preferred sites for bone marrow aspiration are the transfusion reaction.
posterior superior iliac crest, anterior iliac crest, and
sternum. Hypokalemia (abnormally low concentration of
potassium in the blood) may cause muscle weakness or
During bone marrow harvesting, the donor receives paralysis, electrocardiographic abnormalities, and Gl
general anesthesia and 400 to 800 ml of marrow is disturbances.
aspirated.
Beriberi, a serious vitamin Bl (thiamine) deficiency,
A butterfly rash across the bridge of the nose is a affects alcoholics who have poor dietary habits. It's
characteristic sign of systemic lupus erythematosus. epidemic in Asian countries where people subsist on
me unenriched rice. It's characterized by the phrase "l
can't," indicating that the patent is too ill to do anything.

Rheumatoid arthritis is a chronic, destructive collagen Excessive sedation may cause respiratory depression.
disease characterized by symmetric inflammation
of the synovium that leads to joint swelling. The primary postoperative concern is maintenance of a
patent airway.
Screening for human immunodeficiency virus
antibodies begins with the enzyme-linked If cyanosis occurs circumorally, sublingually, or in the
immunosorbent nail bed, the oxygen saturation level (Sao 2) is less
assay. Results are confirmed by the Western blot test. than 80%.

The CK-MB isoenzyme level increases 4 to 8 hours A rapid pulse rate in a postoperative patient may
after a myocardial infarction, peaks at 12 to 24 hours, indicate pain, bleeding, dehydration, or shock.
and returns to normal in 3 days.
 Lidocaine (Xylocaine) exerts anti- arrhythmic action Pacemakers can be powered by lithium batteries for up
by suppressing automaticity in the Purkinje fibers and to 10 years.
elevating the electrical stimulation threshold in the
ventricles. The patient shouldn't void for 1 hour before
percutaneous suprapubic bladder aspiration to ensure
Cullen's sign (a bluish discoloration around the that
umbilicus) is seen in patients who have a perforated sufficient urine remains in the bladder to make the
pancreas. procedure successful.

During the postoperative period, the patient should Left-sided heart failure causes pulmonary congestion,
cough and breathe deeply every 2 hours unless pink-tinged sputum, and dyspnea. (Remember L
otherwise contraindicated (for example, after for left and lung.)
craniotomy, cataract surgery, or throat surgery).

Before surgery, a pat-fiefs respiratory volume may be The current recommended blood cholesterol level is less
measured by incentive spirometry. This than 200 mg/dl.
measurement becomes the patients postoperative goal
for respiratory volume. When caring for a patient who is having a seizure, the
nurse should follow these guidelines: (1) Avoid
The postoperative patient should use incentive restraining the patient, but help a standing patient to a
spirometry 10 to 12 times per hour and breathe deeply. lying posit-ion. (2) Loosen restrictive clothing. (3)

Before ambulating, a postoperative patient should Place a pillow or another soft object under the patient's
dangle his legs over the side of the bed and perform head. (4) Clear the area of hard objects. (5) Don't force
deep-breathing exercises. anything into the patent's mouth, but maintain a patent
airway. (6) Reassure and reorient the patient after the
During the patient’s first postoperative ambulation, the seizure subsides.
nurse should monitor the patient closely and
assist him as needed while he walks a few feet from the Gingival hyperplasia, or overgrowth of gum tissue, is an
bed to a steady chair. adverse reaction to phenytoin (Dilantin).

Hypovolemia occurs when 15% to 25% of the body's With aging, most marrow in long bones becomes
total blood volume is lost. yellow, but it retains the capacity to convert back to red.

Signs and symptoms of hypovolemia include rapid, Clinical manifestations of lymphedema include
weak pulse; low blood pressure; cool, clammy skin; accumulation of fluid in the legs.
shallow respirations; oliguria or anuria; and lethargy.
Afterload is ventricular wall tension during systolic
Acute pericarditis causes sudden severe, constant pain ejection. It's increased in patients who have septal
over the anterior chest. The pain is aggravated by hypertrophy, increased blood viscosity, and conditions
inspiration. that cause blockage of aortic or pulmonary outflow.

Signs and symptoms of septicemia include fever, chills, Red blood cells can be stored frozen for up to 2 years;
rash, abdominal distention, prostration, pain, however, they must be used within 24 hours of thawing.
headache, nausea, and diarrhea.
For the first 24 hours after amputation, the nurse should
Rocky Mountain spotted fever causes a persistent high elevate the stump to prevent edema.
fever, non-pitting edema, and rash. 208B After hysterectomy, a woman should avoid sexual
intercourse for 3 weeks if a vaginal approach was used
Patents who have undergone coronary artery bypass and 6 weeks if the abdominal approach was used.
graft should sleep 6 to 10 hours per day, take their
temperature twice daily, and avoid lifting more than 10 Parkinson's disease characteristically causes
1b (4.5 kg) for at least 6 weeks. progressive muscle rigidity, akinesia, and involuntary
tremor.
Claudication pain (pain on ambulation) is caused by
arterial insufficiency as a result of atheromatous Tonic-clonic seizures are characterized by a loss of
plaque that obstructs arterial blood flow to the consciousness and alternating periods of muscle
extremities. contraction and relaxation.
 Edema is treated by limiting fluid intake and
Status epilepticus, a life-threatening emergency, is a eliminating excess fluid.
series of rapidly repeating seizures that occur
without intervening periods of consciousness. A patient who has had spinal anesthesia should remain
flat for 12 to 24 hours. Vital signs and
The ideal donor for kidney transplantation is an neuromuscular function should be monitored.
identical twin. If an identical twin isn't available, a
biological sibling is the next best choice. A patient who has maple syrup urine disease should
avoid food containing the amino acids leucine,
Breast cancer is the leading cancer among women; isoleucine, and lysine.
however, lung cancer accounts for more deaths.
A severe complication of a femur fracture is excessive
The stages of cervical cancer are as follows: stage O, blood loss that results in shock.
carcinoma in situ; stage l, cancer confined to the cervix;
stage Il, cancer extending beyond the cervix, but not to To prepare a patient for peritoneal dialysis, the nurse
the pelvic wall; stage Ill, cancer extending should ask the patent to void, measure his vital signs,
to the pelvic wall; and stage IV, cancer extending place him in a supine position, and using aseptic
beyond the pelvis or within the bladder or rectum. technique, insert a catheter through the abdominal wall
and into the peritoneal space.
One method used to estimate blood loss after a
hysterectomy is counting perinea' pads. Saturating more If more than 3 L of dialysate solution return during
than one pad in 1 hour or eight pads in 24 hours is peritoneal dialysis, the nurse should notify the
considered hemorrhaging. physician.

Transurethral resection of the prostate is the most Hemodialysis is the removal of certain elements from
common procedure for treating benign prostatic the blood by passing heparinized blood through a
hyperplasia. semipermeable membrane to the dialysate bath, which
contains all of the important electrolytes in their
In a chest drainage system, the water in the water-seal ideal concentrations.
chamber normally rises when a patient breathes
in and falls when he breathes out. Gangrene usually affects the digits first, and begins with
skin color changes that progress from gray-blue
Spinal fusion provides spinal stability through a bone to dark brown or black.
graft, usually from the iliac crest, that fuses two or
more vertebrae.
Kidney function is assessed by evaluating blood urea
A patient who receives any type of transplant must take nitrogen (normal range is 8 to 20 mg/dl) and serum
an immunosuppressant drug for the rest of his creatinine (normal range is 0.6 to 1.3 mg/dl) levels.

Incentive spirometry should be used 5 to 10 times an A weight-bearing transfer is appropriate only for a
hour while the patient is awake. patent who has at least one leg that's strong enough
to bear weight, such as a patent with hemiplegia or a
In women, pelvic inflammatory disease is a common single-leg amputation.
complication of gonorrhea.
Overflow incontinence (voiding of 30 to 60 ml of urine
Scoliosis is lateral S-shaped curvature of the spine. every 15 to 30 minutes) is a sign of bladder
Signs and symptoms of the secondary stage of syphilis distention.
include a rash on the palms and soles, erosion of
the oral mucosa, alopecia, and enlarged lymph nodes. The first sign of a pressure ulcer is reddened skin that
blanches when pressure is applied.
In a patient who is receiving total parenteral nutrition,
the nurse should monitor glucose and electrolyte Late signs and symptoms of sickle cell anemia include
levels. tachycardia, cardiomegaly, systolic and diastolic
murmurs, chronic fatigue, hepatomegaly, and
Unless contraindicated, on admission to the post- splenomegaly.
anesthesia care unit, a patient should be turned on his
side and his vital signs should be taken. A mechanical ventilator, which can maintain ventilation
automatically for an extended period, is
indicated when a patent can't maintain a safe Pa02 or more general such as "Some people live 3 to 6 months,
PaC02 level. but others live longer."

Two types of mechanical ventilators exist: negative- After eye surgery, a patent should avoid using makeup
pressure ventilators, which apply negative pressure until otherwise instructed.
around the chest wall, and positive-pressure ventilators,
which deliver air under pressure to the patient. After a corneal transplant, the patient should wear an
eye shield when engaging in activities such as
Angina pectoris is characterized by substernal pain that playing with children or pets.
lasts for 2 to 3 minutes. The pain, which is
caused by myocardial ischemia, may radiate to the neck, After a corneal transplant, the patient shouldn't lie on
shoulders, or jaw; is described as viselike, or the affected site, bend at the waist, or have sexual
constricting; and may be accompanied by severe intercourse for 1 week. The patient must avoid getting
apprehension or a feeling of impending doom. soapsuds in the eye.

The diagnosis of an acute myocardial infarction is based A Milwaukee brace is used for patients who have
on the patient’ s signs and symptoms, structural scoliosis. The brace helps to halt the
electrocardiogram tracings, troponin level, and cardiac progression of spinal curvature by providing
enzyme studies. longitudinal traction and lateral pressure. It should be
worn
The goal of treatment for a patient with angina pectoris 23 hours a day.
is to reduce the heart's workload, thereby
reducing the myocardial demand for oxygen and Short-term measures used to treat stomal retraction
preventing myocardial infarction. include stool softeners, irrigation, and stomal
dilatation.
Nitroglycerin decreases the amount of blood that returns
to the heart by increasing the capacity of the venous bed. A patient who has a colostomy should be advised to eat
a low-residue diet for 4 to 6 weeks and then to
The patient should take no more than three nitroglycerin add one food at a time to evaluate its effect.
tablets in a 15-minute period.
To relieve postoperative hiccups, the patient should
Hemodialysis is usually performed 24 hours before breathe into a paper bag.
kidney transplantation.
If a patient with an ileostomy has a blocked lumen as a
result of undigested high-fiber food, the patent
Signs and symptoms of acute kidney transplant should be placed in the knee-chest posit-ion and the area
rejection are progressive enlargement and tenderness at below the stoma should be massaged.
the transplant site, increased blood pressure, decreased
urine output, elevated serum creatinine level, and fever. During the initial interview and treatment of a patient
with syphilis, the patient's sexual contacts should
After a radical mastectomy, the patient’ s arm should be identified.
be elevated (with the hand above the elbow) on a
pillow to enhance circulation and prevent edema. The nurse shouldn't administer morphine to a patient
whose respiratory rate is less than 12
Postoperative mastectomy care includes teaching the breaths/minute.
patient arm exercises to facilitate lymph drainage
and prevent shortening of the muscle and contracture of To prevent drying of the mucous membranes, oxygen
the shoulder joint (frozen shoulder). should be administered with hydration.

After radical mastectomy, the patient should help Flavoxate (Urispas) is classified as a urinary tract
prevent infection by making sure that no blood spasmolytic.
pressure readings, inject-ions, or venipunctures are Hypotension is a sign of cardiogenic shock in a patient
performed on the affected arm. with a myocardial infarction.

After a mastectomy, lymphedema may cause a feeling The predominant signs of mechanical ileus are
of heaviness in the affected arm. cramping pain, vomiting, distention, and inability to
pass
A dying patient shouldn't be told exactly how long he's feces or flatus.
expected to live, but should be told something
 For a patient with a myocardial infarct-ion, the nurse The nurse should teach a patient with heart failure to
should monitor fluid intake and output take digoxin and other drugs as prescribed, to
meticulously. Too little intake causes dehydration, and restrict sodium intake, to restrict fluids as prescribed, to
too much may cause pulmonary edema. get adequate rest, to increase walking and other
activities gradually, to avoid extremes of temperature,
Nitroglycerin relaxes smooth muscle, causing to report signs of
vasodilaton and relieving the chest pain associated with
myocardial infarction and angina. The nurse should check and maintain the patency of all
connections for a chest tube. If an air leak is
detected, the nurse should place one Kelly clamp near
The diagnosis of an acute myocardial infarction is based the insert-ion site. If the bubbling stops, the leak is
on the patenfs signs and symptoms, in the thoracic cavity and the physician should be
electrocardiogram tracings, and serum enzyme studies. notified immediately. If the leak continues, the nurse
should take a second clamp, work down the tube until
Arrhythmias are the predominant problem during the the leak is located, and stop the leak.
first 48 hours after a myocardial infarction.
In two-person cardiopulmonary resuscitation, the
Clinical manifestations of malabsorprion include rescuers administer 60 chest compressions per minute
weight oss, muscle wasting, bloating, and steatorrhea. and 1 breath for every 5 compressions.
Asparaginase, an enzyme that inhibits the synthesis of Mitral valve stenosis can result from rheumatic fever.
deoxyribonucleic acid and protein, is used to treat
acute lymphocytic leukemia. Atelectasis is incomplete expansion of lung segments or
lobules (clusters of alveoli). It may cause the
To relieve a patient's sore throat that's caused by lung or lobe to collapse.
nasogastric tube irritation, the nurse should provide
anesthetic lozenges, as prescribed.

For the first 12 to 24 hours after gastric surgery, the The nurse should instruct a patient who has an ilea'
stomach contents (obtained by suctioning) are conduit to empty the collection device frequently
brown. because the weight of the urine may cause the device to
slip from the skin.
After gastric suctioning is discontinued, a patient who
is recovering from a subtotal gastrectomy should A patient who is receiving cardiopulmonary
receive a clear liquid diet. resuscitation should be placed on a solid, flat surface.

The descending colon is the preferred site for a Brain damage occurs 4 to 6 minutes after
permanent colostomy. cardiopulmonary function ceases.

Valvular insufficiency in the veins commonly causes Climacteric is the transition period during which a
varicosity. woman's reproductive function diminishes and
gradually disappears.
A patient with a colostomy should restrict fat and
fibrous foods and should avoid foods that can obstruct After infratentorial surgery, the patient should remain
the stoma, such as corn, nuts, and cabbage. on his side, flat in bed.

A patient who is receiving chemotherapy is placed in In a patient who has an ulcer, milk is contraindicated
reverse isolation because the white blood cell because its high calcium content stimulates
count may be depressed. secretion of gastric acid.

Symptoms of mitral valve stenosis are caused by A patient who has a positive test result for human
improper emptying of the left atrium. immunodeficiency virus has been exposed to the virus
associated with acquired immunodeficiency syndrome
Persistent bleeding after open heart surgery may require (AIDS), but doesn't necessarily have AIDS.
the administration of protamine sulfate to
reverse the effects of heparin sodium used during A common complication after prostatectomy is
surgery. circulatory failure caused by bleeding.
 In right-sided heart failure, a major focus of nursing virus, thereby slowing the development of acquired
care is decreasing the workload of the heart. immunodeficiency syndrome.

Signs and symptoms of digoxin toxicity include nausea, Severe rheumatoid arthritis causes marked edema and
vomiting, confusion, and arrhythmias. congestion, spindle-shaped joints, and severe
flexion deformities.
An asthma attack typically begins with wheezing,
coughing, and increasing respiratory distress. A patent with acquired immunodeficiency syndrome
should advise his sexual partners of his human
In a patient who is recovering from a tonsillectomy, immunodeficiency virus status and observe sexual
frequent swallowing suggests hemorrhage. precautions, such as abstinence or condom use.

Ileostomies and Hartmann's colostomies are permanent If a radioactive implant becomes dislodged, the nurse
stomas. Loop colostomies and double-barre should retrieve it with tongs, place it in a lead
colostomies are temporary ones. shielded container, and notify the radiology department.

A patient who has an ileostomy should eat foods, such A patient who is undergoing radiation therapy should
as spinach and pars ey, because they act as pat his skin dry to avoid abrasions that could easily
intestinal tract deodorizers. become infected.

An adrenalectomy can decrease steroid production, During radiation therapy, a patent should have frequent
which can cause extensive loss of sodium and water. blood tests, especially white blood cell and platelet
counts.
Before administering morphine (Duramorph) to a
patient who is suspected of having a myocardial The nurse should administer an aluminum hydroxide
infarct-ion, the nurse should check the patent's antacid at least 1 hour after an enteric-coated drug
respiratory rate. If it's less than 12 breaths/minute, because it can cause premature release of the enteric-
emergency equipment should be readily available for coated drug in the stomach.
intubation if respiratory depression occurs.
Acid-base balance is the body's hydrogen ion
A patient who is recovering from supratentorial surgery concentration, a measure of the ratio of carbonic acid to
is normally allowed out of bed 14 to 48 hours bicarbonate ions (1 part carbonic acid to 20 parts
after surgery. A patient who is recovering from bicarbonate is normal).
infratentorial surgery normally remains on bed rest for
3 to 5 days. Amyotrophic lateral sclerosis causes progressive
atrophy and wasting of muscle groups that eventually
After a patient undergoes a femoral-popliteal bypass affects the respiratory muscles.
graft, the nurse must closely monitor the
peripheral pulses distal to the operative site and Metabolic acidosis is caused by abnormal loss of
circulation. bicarbonate ions or excessive product-ion or retention
of acid ions.
After a femoral-popliteal bypass graft, the patent
should initially be maintained in a semi-Fowler Hemianopsia is defective vision or blindness in one-
position to avoid flexion of the graft site. Before half of the visual field of one or both eyes.
discharge, the nurse should instruct the patent to avoid
positions that put pressure on the graft site until the next Systemic lupus erythematosus causes early-morning
follow-up visit. joint stiffness and facial erythema in a butterfly
pattern.
Of the five senses, hearing is the last to be lost in a
patent who is entering a coma. After total knee replacement, the patient should remain
in the semi-Fowler position, with the affected leg
Cholelithiasis causes an enlarged, edematous elevated.
gallbladder with multiple stones and an elevated
bilirubin
level.

The antiviral agent zidovudine (Retrovir) successfully In a patient who is receiving transpyloric feedings, the
slows replication of the human immunodeficiency nurse should watch for dumping syndrome and
hypovolemic shock because the stomach is being The Schick test detects diphtheria antigens and
bypassed. immunity or susceptibility to diphtheria. A positive
result
If a total parenteral nutrition infusion must be indicates no immunity; a negative result indicates
interrupted, the nurse should administer dextrose 5% in immunity.
water at a similar rate. Abrupt cessation can cause
hypoglycemia. The recommended adult dosage of sucralfate (Carafate)
for duodenal ulcer is 1 g (1 tablet) four times
Status epilepticus is treated with I.V. diazepam daily 1 hour before meals and at bedtime.
(Valium) and phenytoin (Dilantin).
A patient with facial burns or smoke or heat inhalation
Disequilibrium syndrome causes nausea, vomiting, should be admitted to the hospital for 24-hour
restlessness, and twitching in patients who are observation for delayed tracheal edema.
undergoing dialysis. It's caused by a rapid fluid shift.
In addition to patient teaching, preparation for a
An indication that spinal shock is resolving is the return colostomy includes withholding oral intake overnight,
of reflex activity in the arms and legs below the performing bowel preparation, and administering a
level of injury. cleansing enema.

Hypovolemia is the most common and fatal The physiologic changes caused by burn injuries can be
complication of severe acute pancreatitis. divided into two stages: the hypovolemic stage,
during which intravascular fluid shifts into the
In a patient with stomatitis, oral care includes rinsing interstitial space, and the diuretic stage, during which
the mouth with a mixture of equal parts of capillary integrity and intravascular volume are
hydrogen peroxide and water three times daily. restored, usually 48 to 72 hours after the injury.

In Ott-is media, the tympanic membrane is bright red The nurse should change total parenteral nutrition
and lacks its characteristic light reflex (cone of tubing every 24 hours and the peripheral I.V. access
light). site dressing every 72 hours.

In patents who have pericardiocentesis, fluid is A patient whose carbon monoxide level is 20% to 30%
aspirated from the pericardial sac for analysis or to should be treated with 100% humidified oxygen.
relieve cardiac tamponade.
When in the room of a patient who is in isolation for
Urticaria is an early sign of hemolytic transfusion tuberculosis, staff and visitors should wear
reaction. ultrafilter masks.

During peritoneal dialysis, a return of brown dialysate When providing skin care immediately after pin
suggests bowel perforation. The physician should insertion, the nurse's primary concern is prevent-ion of
be notified immediately. bone infection.

An early sign of ketoacidosis is polyuria, which is After an amputation, moist skin may indicate venous
caused by osmotic diuresis. stasis; dry skin may indicate arterial obstruction.

Patients who have multiple sclerosis should visually In a patient who is receiving dialysis, an internal shunt
inspect their extremities to ensure proper alignment is working if the nurse feels a thrill on palpation or hears
and freedom from injury. a bruit on auscultation.

Aspirated red bone marrow usually appears rust-red, In a patient with viral heparins, the parenchyma', or
with visible fatty material and white bone Kupffer's, cells of the liver become severely
fragments. inflamed, enlarged, and necrotic.

The Dick test detects scarlet fever antigens and Early signs of acquired immunodeficiency syndrome
immunity or susceptibility to scarlet fever. A positive include fatigue, night sweats, enlarged lymph
result indicates no immunity; a negative result indicates nodes, anorexia, weight loss, pallor, and fever.
immunity.
When caring for a patient who has a radioactive
implant, health care workers should stay as far away
from the radiation source as possible. They should Symptoms of hiatal hernia include a feeling of fullness
remember the axiom, "If you double the distance, you in the upper abdomen or chest, heartburn, and
quarter the dose." pain similar to that of angina pectoris.

A patient who has Parkinson's disease should be The incidence of cholelithiasis is higher in women who
instructed to walk with a broad-based gait. have had children than in any other group.

The cardinal signs of Parkinson's disease are muscle Acetaminophen (Tylenol) overdose can severely
rigidity, a tremor that begins in the fingers, and damage the liver.
akinesia.
The prominent clinical signs of advanced cirrhosis are
In a patient with Parkinson's disease, levodopa (Dopar) ascites and jaundice.
is prescribed to compensate for the dopamine
deficiency. The first symptom of pancreatitis is steady epigastric
pain or left upper quadrant pain that radiates from
A patient who has multiple sclerosis is at increased risk the umbilical area or the back.
for pressure ulcers.
Somnambulism is the medical term for sleepwalking.
Pill-rolling tremor is a classic sign of Parkinson’ S
disease. Epinephrine (Adrenalin) is a vasoconstrictor.

For a patient with Parkinson's disease, nursing An untreated liver laceration or rupture can progress
interventions are palliative. rapidly to hypovolemic shock.

Obstipation is extreme, intractable constipation caused

Fat embolism, a serious complication of a long-bone by an intestinal obstruction.
fracture, causes fever, tachycardia, tachypnea, and
anxiety. The definitive test for diagnosing cancer is biopsy with
cytologic examination of the specimen.
Metrorrhagia (bleeding between menstrual periods)
may be the first sign of cervical cancer. Arthrography requires injection of a contrast medium
and can identify joint abnormalities.
Mannitol is a hypertonic solution and an osmotic
diuretic that's used in the treatment of increased
intracranial pressure.
A patient who has had a cataract removed can begin
The classic sign of an absence seizure is a vacant facial most normal activities in 3 or 4 days; however, the
expression. patent shouldn't bend and lift until a physician approves
these activities.
Migraine headaches cause persistent, severe pain that
usually occurs in the temporal region. Symptoms of corneal transplant rejection include eye
irritation and decreasing visual field.
A patient who is in a bladder retraining program should
be given an opportunity to void every 2 hours Graves' disease (hyperthyroidism) is manifested by
during the day and twice at night. weight loss, nervousness, dyspnea, palpitations, heat
intolerance, increased thirst, exophthalmos (bulging
In a patient with a head injury, a decrease in level of eyes), and goiter.
consciousness is a cardinal sign of increased
intracranial pressure. The four types of lipoprotein are chylomicrons (the
lowest-density lipoproteins), very- NJ-density
Ergotamine (Ergomar) is most effective when taken lipoproteins, low-density lipoproteins, and high-density
during the prodromal phase of a migraine or vascular lipoproteins. Health care professionals use
headache. cholesterol level fractionation to assess a patent's risk of
coronary artery disease.
Treatment of acute pancreatitis includes nasogastric
suctioning to decompress the stomach and If a patient who is taking amphotericin B (Fungizone)
meperidine (Demerol) for pain. bladder irrigations for a fungal infection has
systemic candidiasis and must receive I.V. fluconazole
(Diflucan), the irrigations can be discontinued
because fluconazole treats the bladder infection as well. Neurogenic bladder dysfunction is caused by disruption
of nerve transmission to th e bladder. It may be
Pat-tents with adult respiratory distress syndrome can
have high peak inspiratory pressures. Therefore, caused by certain spinal cord injuries, diabetes, or
the nurse should monitor these patients closely for signs multiple sclerosis.
of spontaneous pneumothorax, such as acute
deterioration in oxygenation, absence of breath sounds Oxygen and carbon dioxide move between the lungs
on the affected side, and crepitus beginning on and the bloodstream by diffusion.
the affected side.
To grade the severity of dyspnea, the following system
Adverse reactions to cyclosporine (Sandimmune) is used: grade 1, shortness of breath on mild
include renal and hepatic toxicity, central nervous
system changes (confusion and delirium), Gl bleeding, exert-ion, such as walking up steps; grade 2, shortness
and hypertension. of breath when walking a short distance at a normal

Osteoporosis is a metabolic bone disorder in which the pace on level ground; grade 3, shortness of breath with
rate of bone resorption exceeds the rate of bone mild daily activity, such as shaving; grade 4,
formation.
shortness of breath when supine (orthopnea).
The hallmark of ulcerative colitis is recurrent bloody
diarrhea, which commonly contains pus and mucus A patient with Crohn's disease should consume a diet
and alternates with asymptomatic remissions. low in residue, fiber, and fat, and high in calories,

Safer sexual practices include massaging, hugging, proteins, and carbohydrates. The patent also should take
body rubbing, friendly kissing (dry), masturbating, vitamin supplements, especially vitamin K.
hand-to-genital touching, wearing a condom, and
limiting the number of sexual partners. In the three-bottle urine collection method, the patient
cleans the meatus and urinates 10 to 15 ml in the first
Immunosuppressed patients who contract bottle and 15 to 30 ml (midstream) in the second bottle.
cytomegalovirus (CMV) are at risk for CMV Then the physician performs prostatic massage, and the
pneumonia and patient voids into the third bottle.
septicemia, which can be fatal.
Findings in the three-bottle urine collection method are
Urinary tract infections can cause urinary urgency and interpreted as follows: pus in the urine (pyuria)
frequency, dysuria, abdominal cramps or bladder
spasms, and urethral itching. in the first bottle indicates anterior urethritis; bacteria in
the urine in the second bottle indicate bladder
Mammography is a radiographic technique that's used
to detect breast cysts or tumors, especially those infection; bacteria in the third bottle indicate prostitis.
that aren't palpable on physical examination.
Signs and symptoms of aortic stenosis include a loud,
To promote early detection of testicular cancer, the much systolic murmur over the aortic area; exertional
nurse should palpate the testes during routine dyspnea; fatigue; angina pectoris; arrhythmias; low
physical examinations and encourage the patient to blood pressure; and emboli.
perform monthly self-examinations during a warm
shower.
Elective surgery is primarily a matter of choice. It isn't
essential to the patient’s survival, but it may
Patients who have thalassemia minor require no
treatment. Those with thalassemia major require improve the patient's health, comfort, or self -esteem.

frequenttransfusions of red b ood cells.

Required surgery is recommended by the physician. It
A high level of hepatitis B serum marker that persists may be delayed, but is inevitable.
for 3 months or more after the onset of acute

hepatitis B infect-ion suggests chronic hepatitis or Urgent surgery must be performed within 24 to 48
carrier status. hours.
Emergency surgery must be performed immediately. The nurse shouldn't give analgesics to a patient who has
abdominal pain caused by appendicitis because
these drugs may mask the pain that accompanies a
About 85% of arterial emboli originate in the heart ruptured appendix.
chambers.
The nurse shouldn't give analgesics to a patient who has
abdominal pain caused by appendicitis because
Pulmonary embolism usually results from thrombi these drugs may mask the pain that accompanies a
dislodged from the leg veins. ruptured appendix.

As a last-ditch effort, a barbiturate coma may be

The conscious interpretation of pain occurs in the induced to reverse unrelenting increased intracranial
cerebral cortex. pressure (ICP), which is defined as acute ICP of greater
than 40 mm Hg, persistent elevation of ICP above
20 mm Hg, or rapidly deteriorating neurologic status.
To avoid interfering with new cell growth, the dressing
on a donor skin graft site shouldn't be disturbed. The primary signs and symptoms of epiglottiditis are
stridor and progressive difficulty in swallowing

A sequela is any abnormal condition that follows and is Salivation is the first step in the digestion of starch.
the result of a disease, a treatment, or an injury.
A patient who has a demand pacemaker should measure
During sickle cell crisis, patient care includes bed rest, the pulse rate before rising in the morning,
oxygen therapy, analgesics as prescribed, I.V. fluid notify the physician if the pulse rate drops by 5
monitoring, and thorough documentation of fluid intake beats/minute, obtain a medical identification card and
and output. bracelet, and resume normal activities, including sexual
activity.
A patient who has an ileal conduit should maintain a
daily fluid intake of 2,000 m . Transverse, or loop, colostomy is a temporary
procedure that's performed to divert the fecal stream in
In a closed chest drainage system, continuous bubbling a
in the water seal chamber or bottle indicates a patient who has acute intestinal obstruction.
leak. me

Palpitation is a sensation of heart pounding or racing Normal values for erythrocyte sedimentation rate are O
associated with normal emotional responses and to 15 mm/hour for men younger than age 50
certain heart disorders. and O to 20 mm/hour for women younger than age 50.

Fat embolism is likely to occur within the first 24 hours A CK-M8 level that's more than 5% of total CK or
after a long-bone fracture. more than 10 IJ/L suggests a myocardial infarction.

Foot drop can occur in a patient with a pelvic fracture Propranolol (Inderal) blocks sympathetic nerve stimuli
as a result of peroneal nerve compression against that increase cardiac work during exercise or
the head of the fibula. stress, which reduces heart rate, blood pressure, and
myocardial oxygen consumption.
To promote venous return after an amputation, the nurse
should wrap an elastic bandage around the After a myocardial infarction, electrocardiogram
distal end of the stump. changes (ST-segment elevation, T-wave inversion, and
Q-wave enlargement) usually appear in the first 24
Water that accumulates in the tubing of a ventilator hours, but may not appear until the 5th or 6th day.
should be removed.
Cardiogenic shock is manifested by systolic blood
The most common route for the administration of pressure of less than 80 mm Hg, gray skin, diaphoresis,
epinephrine to a patient who is having a severe cyanosis, weak pulse rate, tachycardia or bradycardia,
allergic reaction is the subcutaneous route. and oliguria (less than 30 ml of urine per hour).

The nurse should use Fowler's posit-ion for a patient A patient who is receiving a low-sodium diet shouldn't
who has abdominal pain caused by appendicitis. eat cottage cheese, fish, canned beans, chuck
steak, chocolate pudding, Italian salad dressing, dill display a systolic blood pressure of 50 to 60 mm Hg,
pickles, and beef broth. and appear confused and lethargic.

High-potassium foods include dried prunes, Arterial blood is bright ed, flows rapidly, and (because
watermelon (15.3 mEq/ port-ion), dried lima beans it's pumped directly from the heart) spurts with
(14.5 each heartbeat.
mEq/porton), soybeans, bananas, and oranges.
Venous blood is dark red and tends to ooze from a
Kussmaul's respirations are faster and deeper than wound.
normal respirations and occur without pauses, as in
diabetic ketoacidosis. Orthostatic blood pressure is taken with the patent in
the supine, sitting, and standing positions, with 1
Cheyne-Stokes respirations are characterized by minute between each reading. A I0-mm Hg decrease in
alternating periods of apnea and deep, rapid breathing. blood pressure or an increase in pulse rate of 10
They occur in patients with central nervous system beats/ minute suggests volume depletion.
disorders.
A pneumatic anti-shock garment should be used
Hyperventilation can result from an increased cautiously in pregnant women and patients with head
frequency of breathing, an increased tidal volume, or injuries.
both.
After a patient's circulating volume is restored, the nurse
Apnea is the absence of spontaneous respirations. should remove the pneumatic anti-shock
garment gradually, starting with the abdominal chamber
Before a thyroidectomy, a patient may receive and followed by each leg. The garment should be
potassium iodide, antithyroid drugs, and propranolol removed under a physician's supervision.
(Inderal) to prevent thyroid storm during surgery.
Most hemolytic transfusion react-ions associated with
The normal life span of red blood cells (erythrocytes) mismatching of ABO blood types stem from
is 110 to 120 days. identification number errors.

Visual acuity of 20/100 means that the patient sees at Warming of blood to more than 1070 F (41.70 C) can
20' (6 m) what a person with normal vision sees at 100' cause hemolysis.
(30 m).
Cardiac output is the amount of blood ejected from the
Urinary tract infections are more common in girls and heart each minute. It's expressed in liters per
women than in boys and men because the shorter minute.
urethra in the female urinary tract makes the bladder
more accessible to bacteria, especially Escherichia Stroke volume is the volume of blood ejected from the
coli. heart during systole.

Total parenteral nutrition solution contains dextrose,

Penicillin is administered orally 1 to 2 hours before amino acids, and additives, such as electrolytes,
meals or 2 to 3 hours after meals because food may minerals, and vitamins.
interfere with the drug's absorption.
The most common type of neurogenic shock is spinal
Mild reactions to local anesthetics may include shock. It usually occurs 30 to 60 minutes after a
palpitations, tinnitus, vertigo, apprehension, confusion, spinal cord injury.
and a metallic taste in the mouth.
After a spinal cord injury, peristalsis stops within 24
hours and usually returns within 3 to 4 days.
About 22% of cardiac output goes to the kidneys.
Toxic shock syndrome is manifested by a temperature
To ensure accurate central venous pressure readings, of at least 1020 F (38.80 C), an erythematous rash, and
the nurse should place the manometer or systolic blood pressure of less than 90 mm Hg. From 1
transducer level with the phlebostatic axis. to 2 weeks after the onset of these signs, desquamation
(especially on the palms and soles) occurs.
A patient who has lost 2,000 to 2,500 ml of blood will
have a pulse rate of 140 beats/minute (or higher), The signs and symptoms of anaphylaxis are commonly
caused by histamine release.
signs and symptoms of anaphylaxis are commonly Most patents with Chlamydia trachomatris infection
caused by histamine release. are asymptomatic, but some have an inflamed urethral
meatus, dysuria, and urinary urgency and frequency.

The most common cause of septic shock is gram-

negative bacteria, such as Escherichia coli, Klebsiella, The hypothalamus regulates the autonomic nervous
and Pseudomonas organisms. system and endocrine functions.

Bruits are vascular sounds that resemble heart A patient whose chest excursion is less than normal
murmurs and result from turbulent blood flow through (3" to 6" [7.5 to 15 cm)) must use accessory muscles to
a diseased or partially obstructed artery. breathe.

Signs and symptoms of toxicity from thyroid

Urine pH is normally 4.5 to 8.0. replacement therapy include rapid pulse rate,
diaphoresis, irritability, weight loss, dysuria, and sleep
disturbance.
Urine pH of greater than 8.0 can result from a urinary
tract infection, a high-alkali diet, or systemic alkalosis. An early sign of aspirin toxicity is deep, rapid
respirations.

Urine pH of less than 4.5 may be caused by a high- The most serious and irreversible consequence of lead
protein diet, fever, or metabolic acidosis. poisoning is mental retardation, which resuIts
from neurologic damage.
Before a percutaneous renal biopsy, the patient should
be placed on a firm surface and positioned on the To assess dehydration in the adult, the nurse should
abdomen. A sandbag is placed under the abdomen to check skin turgor on the sternum.
stabilize the kidneys.
For a patient with a peptic ulcer, the type of diet is less
Nephrotic syndrome is characterized by marked important than including foods in the diet that
proteinuria, hypoalbuminemia, mild to severe the patient can tolerate.
dependent edema, ascites, and weight gain.
A patient with a colostomy must establish an irrigation
Underwater exercise is a form of therapy performed in schedule so that regular emptying of the bowel
a Hubbard tank. occurs without stoma' discharge between irrigations.

When using rotating tourniquets, the nurse shouldn't

Most women with trichomoniasis have a malodorous, restrict the blood supply to an arm or leg for more
frothy, greenish gray vaginal discharge. Other women than 45 minutes at a time.
may have no signs or symptoms.
A patient with diabetes should eat high-fiber foods
because they blunt the rise in glucose level that
Voiding cystourethrography may be performed to normally follows a meal.
detect bladder and urethral abnormalities. Contrast
medium is instilled by gentle syringe pressure through Jugular vein distention occurs in patients with heart
a urethral catheter, and overhead X-ray films are failure because the left ventricle can't empty the
taken to visualize bladder filling and excretion. heart of blood as fast as blood enters from the right
ventricle, resulting in congest-ion in the entre venous
Cystourethrography may be performed to identify the system.
cause of urinary tract infections, congenital anomalies,
and incontinence. It also is used to assess for prostate The leading causes of blindness in the United States are
lobe hypertrophy in men. diabetes mellitus and glaucoma.

After a thyroidectomy, the patient should remain in the

Herpes simplex is characterized by recurrent episodes semi-Fowler position, with his head neither
of blisters on the skin and mucous membranes. It has hyperextended nor hyperflexed, to avoid pressure on the
two variations. In type 1, the blisters appear in the suture line. This position can be achieved with
nasolabial region; in type 2, they appear on the the use of a cervical pillow.
genitals, anus, buttocks, and thighs.
Premenstrual syndrome may cause abdominal dyspnea, crackles, persistent cough, frothy sputum, and
distention, engorged and painful breasts, backache, cyanosis. A urinary output of 45 mL/hour is an
headache, nervousness, irritability, restlessness, and appropriate output. The nurse would become concerned
tremors. if the output were below 30 mL/hour. Between 100 and
300 mL of drainage may accumulate during the first 2
Treatment of dehiscence (pathologic opening of a hours after thoracic surgery. Normal arterial blood pH
wound) consists of covering the wound with a moist is 7.35 to 7.45. An arterial blood pH of 7.35 is not
sterile dressing and notifying the physician. indicative of a complication.

When a patent has a radical mastectomy, the ovaries • The client with Raynaud’s disease suffers from body -
also may be removed because they are a source of image disturbance when physical changes begin to occur.
estrogen, which stimulates tumor growth. Therapeutic nursing interventions are implemented to
encourage verbalization about the body changes and to
develop appropriate problemsolving techniques for
Atropine blocks the effects of acetylcholine, thereby
coping with the changes.
obstructing its vagal effects on the sinoatrial node
and increasing heart rate.
• Specific gravity is a measure of the concentration of
particles in the urine. A normal range of urine specific
Salicylates, particularly aspirin, are the treatment of gravity is approximately 1.005 to 1.030. Early in
choice in rheumatoid arthritis because they polycystic kidney disease, the ability of the kidneys to
decrease inflammation and relieve joint pain. concentrate urine decreases. A urine specific gravity of
1.000 is lower than normal, indicating dilute urine.
Deep, intense pain that usually worsens at night and is
unrelated to movement suggests bone pain. • Giving the client with chronic emphysema a high liter
flow of oxygen could stop the hypoxic drive and cause
Pain that follows prolonged or excessive exercise and apnea.
subsides with rest suggests muscle pai
Assays of catecholamines are performed on single
voided urine specimens, 2- to 4-hour specimens, and
NLE TIPS
24-hour urine specimens. The normal range of urinary
Pls Read
catecholamines is up to 14 mcg/100 mL of urine, with
• Breath sounds are the best way to assess the onset of higher levels occurring in pheochromocytoma.
heart failure. The presence of crackles or rales or an
increase in crackles is an indicator of fluid in the lungs
caused by heart. failure.
• After a cerebrovascular accident, clients are often
emotionally labile, confused, forgetful, and frustrated.
Clients may use profanity, which is often termed
• A positive reaction to a tuberculin skin test indicates
exposure to tuberculosis infection. Because the response “automatic language.”
to tuberculin skin testing may be decreased in the
immunosuppressed client, induration reactions more • The complications associated with severe scoliosis
than 5 mm are considered positive. A reading of 6-mm interfere with respiration. The lungs may not fully
induration is a positive result in a client who is HIV expand as a result of the severe curvature of the spine.
positive. A positive result indicates exposure to Atelectasis and dyspnea are complications that can occur
tuberculosis and possibly the development of tuberculin as a result of a decrease in lung expansion.
infection. Further diagnostic tests should be performed
to confirm infection with tuberculosis. • The purpose of a venogram is to assess the severity of
venous obstruction. The test will locate obstructions
• The TNM classification system for staging tumors is and/or thrombi by x-ray films after a radiopaque dye is
widely used. T refers to the tumor size, with T0 injected into a vein that has been previously emptied by
indicating no primary tumor found and T1 to T4 referring gravity. This test is a diagnostic procedure and will not
to progressively larger tumors. TIS is used to indicate a eliminate leg problems or determine whether the support
carcinoma in situ. N refers to regional lymph node stockings can be discontinued. Injections can cause
involvement. N0 indicates regional nodes were normal, discomfort.
and N1 to N4 indicates increasingly a bnormal regional
lymph nodes. M1 indicates that distant metastasis is • The complications associated with pheochromocytoma
present. include hypertensive retinopathy and nephropathy,
myocarditis, congestive heart failure (CHF), increased
∙The complications associated with thoracic surgery platelet aggregation, and cerebrovascular accident
include pulmonary edema, cardiac dysrhythmias, (CVA). Death can occur from shock, CVA, renal failure,
hemorrhage, hemothorax, hypovolemic shock, and dysrhythmias, and dissecting aortic aneurysm. Rales
thrombophlebitis. Signs of pulmonary edema include heard on auscultation are indicative of CHF.
• In myxedema, the TSH level is elevated, and the T3 and • Boiling the vegetables and discarding the water can
T4 levels are decreased. Secretion of T3 and T4 is decrease the potassium content of vegetables. Bananas
regulated by a hypothalamic-pituitary-thyroid gland and oranges are high in potassium and should be avoided.
feedback mechanism. TSH regulates the secretion of Meats contain some potassium and are high in protein
thyroid hormone from the thyroid gland. The circulating and should be limited to 6 oz/day. Salt substitutes are
levels of thyroid hormone are the major factor regulating often high in potassium and are to be avoided.
the release of TSH. If the thyroid levels are low, TSH
release is increased, and if the thyroid levels are high, • Plasmapheresis is a process that separates the plasma
TSH is inhibited. In hyperthyroidism, T3 and T4 from the blood elements, so that plasma proteins that
secretions are elevated because the normal regulatory contain antibodies can be removed. It is used as an
controls of thyroid hormone are lost. adjunct therapy in myasthenia gravis and may give
Hypoparathyroidism is associated with a decrease in temporary relief to clients with actual or impending
serum calcium and an increase in serum phosphate. respiratory failure. Usually three to five treatments are
required. Improvement in vital (respiratory) capacity is
• Cutting the blood glucose monitoring strips in half may an intended effect of this treatment.
affect the accuracy in reading the results.
• The client with CAL should use energy-conservation
• Hydrocortisone is the topical treatment of choice for techniques to conserve oxygen. These include sitting to
cutaneous inflammation and pruritus associated with perform many household chores or activities, and
contact dermatitis. If a rash does not respond to this over- alternating activity with rest periods. The client should
the-counter medication, it should be evaluated by a avoid raising the arms above the head, because use of the
health care provider. arms could increase dyspnea. The client should never
hold the breath during an activity.
• The client should be taught to take the pulse in the wrist
or neck every day at the same time, preferably in the When a client is placed in pelvic traction, the foot end
morning, and to rest a full 5 minutes before taking the of the bed is raised to prevent the client from being
pulse. The pulse is counted for 1 full minute by using a pulled down in bed by the traction. The head of the bed
watch or clock that has an accurate second hand. The is usually kept flat, and the client is maintained in good
pulse is recorded every day in a log that indicates a body alignment. The girdle or belt should be applied
description of the rate, rhythm, and date and time of day. snugly so it does not slip off of the client, and therefore
If a change in rate or rhythm is noted, the physician the skin should be checked for pressure sores.
should be notified.
• Traditional treatment of a UTI involves 7 to 10 days
• Crutch tips should remain dry. Water could cause administration of oral antim icrobial therapy. It is
slipping by decreasing the surface friction of the rubber important to take antibiotics, even if the client is feeling
tip on the floor. If crutch tips get wet, the client should better. While taking these medications, the client should
dry them with a cloth or paper towel. The client should drink at least eight glasses of fluid per day to keep urine
use only crutches measured for the client. The tips should dilute. Voiding regularly will flush bacteria out of the
be inspected for wear, and spare crutches and tips should bladder and urethra. Teaching the client to cleanse the
be available if needed. perineal area from front to back helps to prevent urinary
tract infection.
• The normal random blood glucose level is 70 to 115
mg/dL but may vary depending on the time of the last • The cane is held on the stronger side to minimize stress
meal. on the affected extremity and provide a wide base of
support. The cane is held 6 inches lateral to the fifth toe.
• On removal of a chest tube, an occlusive dressing The cane is moved forward with the affected leg. The
consisting of petrolatum gauze covered by a dry sterile client leans on the cane for added support while the
dressing is usually placed over the chest tube site stronger side swings through.
dressing. This is maintained in place until the physician • Older and immunocompromised clients may not have a
states it may be removed. Monitoring and reporting positive reaction to the initial tuberculin skin test, even if
respiratory difficulty and increased temperature are they had prior exposure to the tubercle bacillus. If the test
appropriate client activities on discharge. The client is negative (no reaction), the client may have a delayed
should avoid heavy lifting for the first 4 to 6 weeks after reaction and should have a repeated tuberculin skin test
discharge to facilitate continued wound healing. in 1 to 2 weeks. The second test should reveal positive
results if the client had prior exposure. The tuberculin
• Postoperative care after a parathyroidectomy includes skin test is read in 48 to 72 hours. Erythema or redness
instructing the client that the weight of the client’s head alone is not considered significant. The size of
must be supported when the client flexes the neck or induration, if any, is what determines the significance of
moves the head. This decreases the stress on the suture the test. A positive test does not indicate active disease.
line, which prevents bleeding.
 Persons with a positive reaction are followed up with a
chest radiograph ▪ For blood transfusion in an adult, the appropriate needle
size is 16 to 20G.
• After restoring circulation to the affected limb, the nurse
reinforces teaching that was done after the origina l ▪ Intractable pain is pain that incapacitates a patient and
surgery. This includes exercise and dietary can’ t be relieved by drugs.
recommendations, as well as instructions on foot care
and prevention of injury to the limb. The client should ▪ In an emergency, consent for treatment can be obtained by
check the condition of the leg and foot every day. Taking fax, telephone, or other telegraphic means.
a baby aspirin every day does not ensure that further
▪ Decibel is the unit of measurement of sound.
complications will not occur. Walking will be a
component of the treatment plan.
▪ Informed consent is required for any invasive procedure.

• Instructions to a client after a aorto-iliac bypass grafting ▪ A patient who can’ t write his name to give consent for
about measures to improve circulation while in the treatment must make an X in the presence of two
hospital includes clot formation in the graft can result witnesses, such as a nurse, priest, or physician.
from any form of pressure that impairs blood flow
through the graft, including bending at the hip or knee, ▪ The Z-track I.M. injection technique seals the drug deep
crossing the knees or ankles, or use of the knee gatch or into the muscle, thereby minimizing skin irritation and
pillows. All of these actions are avoided in the staining. It requires a needle that’ s 1" (2.5 cm) or longer.
postoperative period.
▪ In the event of fire, the acronym most often used is RACE.
• The presence of multiple organisms in a urine culture (R) Remove the patient. (A) Activate the alarm. (C)
usually indicates that contamination has occurred. The Attempt to contain the fire by closing the door. (E)
urinary tract is normally sterile, and infection, if it Extinguish the fire if it can be done safely.
occurs, is usually with one organism. A repeat of the
urine culture is indicated. ▪ A registered nurse should assign a licensed vocational
nurse or licensed practical nurse to perform bedside care,
such as suctioning and drug administration.

▪ If a patient can’ t void, the first nursing action should be

▪ A blood pressure cuff that’ s too narrow can cause a
bladder palpation to assess for bladder distention.
▪ When preparing a single injection for a patient who takes
regular and neutral protein Hagedorn insulin, the nurse
▪ The patient who uses a cane should carry it on the
should draw the regular insulin into the syringe first so
unaffected side and advance it at the same time as the
that it does not contaminate the regular insulin.
affected extremity.
▪ Rhonchi are the rumbling sounds heard on lung
▪ To fit a supine patient for crutches, the nurse should
auscultation. They are more pronounced during expiration
measure from the axilla to the sole and add 2" (5 cm) to
than during inspiration.
that measurement.
▪ Gavage is forced feeding, usually through a gastric tube (a
▪ Assessment begins with the nurse’ s first encounter with
tube passed into the stomach through the mouth).
the patient and continues throughout the patient’ s stay.
The nurse obtains assessment data through the health
▪ According to Maslow’ s hierarchy of needs, physiologic
history, physical examination, and review of diagnostic
needs (air, water, food, shelter, sex, activity, and comfort)
studies.
have the highest priority.
▪ The appropriate needle size for insulin injection is 25G
▪ The safest and surest way to verify a patient’ s identity is
and 5/8" long.
to check the identification band on his wrist.
▪ Residual urine is urine that remains in the bladder after
▪ In the therapeutic environment, the patient’ s safety is the
voiding. The amount of residual urine is normally 50 to
primary concern.
100 ml.
▪ Fluid oscillation in the tubing of a chest drainage system
▪ The five stages of the nursing process are assessment,
indicates that the system is working properly.
nursing diagnosis, planning, implementation, and
evaluation.
▪ The nurse should place a patient who has a Sengstaken -
Blakemore tube in semi-Fowler position.
▪ Assessment is the stage of the nursing process in which
the nurse continuously collects data to identify a patient’ s
▪ The nurse can elicit Trousseau’ s sign by occluding the
actual and potential health needs.
brachial or radial artery. Hand and finger spasms that
occur during occlusion indicate Trousseau’ s sign and
suggest hypocalcemia.
▪ Nursing diagnosis is the stage of the nursing process in the patient is awake and resting, hasn’ t eaten for 14 to 18
which the nurse makes a clinical judgment about hours, and is in a comfortable, warm environment.
individual, family, or community responses to actual or
potential health problems or life processes. ▪ The basal metabolic rate is expressed in calories
consumed per hour per kilogram of body weight.
▪ Planning is the stage of the nursing process in which the
nurse assigns priorities to nursing diagnoses, defines ▪ Dietary fiber (roughage), which is derived from cellulose,
short-term and long-term goals and expected outcomes, supplies bulk, maintains intestinal motility, and helps to
and establishes the nursing care plan. establish regular bowel habits.

▪ Implementation is the stage of the nursing process in ▪ Alcohol is metabolized primarily in the liver. Smaller
which the nurse puts the nursing care plan into action, amounts are metabolized by the kidneys and lungs.
delegates specific nursing interventions to members of the
nursing team, and charts patient responses to nursing ▪ Petechiae are tiny, round, purplish red spots that appear
interventions. on the skin and mucous membranes as a result of
intradermal or submucosal hemorrhage.
▪ Evaluation is the stage of the nursing process in which the
nurse compares objective and subjective data with the ▪ Purpura is a purple discoloration of the skin that’ s caused
outcome criteria and, if needed, modifies the nursing care by blood extravasation.
plan.
▪ According to the standard precautions recommended by
▪ Before administering any “ as needed” pain medication, the Centers for Disease Control and Prevention, the nurse
the nurse should ask the patient to indicate the location of shouldn’ t recap needles after use. Most needle sticks
the pain. result from missed needle recapping.

▪ Jehovah’ s Witnesses believe that they shouldn’ t receive ▪ The nurse administers a drug by I.V. push by using a
blood components donated by other people. needle and syringe to deliver the dose directly into a vein,
I.V. tubing, or a catheter.
▪ To test visual acuity, the nurse should ask the patient to
cover each eye separately and to read the eye chart with ▪ When changing the ties on a tracheostomy tube, the nurse
glasses and without, as appropriate. should leave the old ties in place until the new ones are
applied.
▪ When providing oral care for an unconscious patient, to
minimize the risk of aspiration, the nurse should position ▪ A nurse should have assistance when changing the ties on
the patient on the side. a tracheostomy tube.

▪ During assessment of distance vision, the patient should ▪ A filter is always used for blood transfusions.
stand 20' (6.1 m) from the chart.
▪ A four-point (quad) cane is indicated when a patient needs
▪ For a geriatric patient or one who is extremely ill, the ideal more stability than a regular cane can provide.
room temperature is 66° to 76° F (18.8° to 24.4° C).
▪ A good way to begin a patient interview is to ask, “ What
▪ Normal room humidity is 30% to 60%. made you seek medical help?”

▪ Hand washing is the single best method of limiting the ▪ When caring for any patient, the nurse should follow
spread of microorganisms. Once gloves are removed after standard precautions for handling blood and body fluids.
routine contact with a patient, hands should be washed for ▪ Potassium (K+) is the most abundant cation in
10 to 15 seconds. intracellular fluid.

▪ To perform catheterization, the nurse should place a ▪ In the four-point, or alternating, gait, the patient first
woman in the dorsal recumbent position. moves the right crutch followed by the left foot and then
the left crutch followed by the right foot.
▪ A positive Homan’ s sign may indicate thrombophlebitis.
▪ In the three-point gait, the patient moves two crutches and
▪ Electrolytes in a solution are measured in milliequivalents the affected leg simultaneously and then moves the
per liter (mEq/L). A milliequivalent is the number of unaffected leg.
milligrams per 100 milliliters of a solution.
▪ In the two-point gait, the patient moves the right leg and
▪ Metabolism occurs in two phases: anabolism (the the left crutch simultaneously and then moves the left leg
constructive phase) and catabolism (the destructive and the right crutch simultaneously.
phase).
▪ The vitamin B complex, the water-soluble vitamins that
▪ The basal metabolic rate is the amount of energy needed are essential for metabolism, include thiamine (B1),
to maintain essential body functions. It’ s measured when
 riboflavin (B2), niacin (B3), pyridoxine (B6), and ▪ To turn a patient by logrolling, the nurse folds the
cyanocobalamin (B12). patient’ s arms across the chest; extends the patient’ s
legs and inserts a pillow between them, if needed; places
▪ When being weighed, an adult patient should be lightly a draw sheet under the patient; and turns the patient by
dressed and shoeless. slowly and gently pulling on the draw sheet.

▪ Before taking an adult’ s temperature orally, the nurse ▪ The diaphragm of the stethoscope is used to hear high -
should ensure that the patient hasn’ t smoked or pitched sounds, such as breath sounds.
consumed hot or cold substances in the previous 15
minutes. ▪ A slight difference in blood pressure (5 to 10 mm Hg)
between the right and the left arms is normal.
▪ The nurse shouldn’ t take an adult’ s temperature rectally
if the patient has a cardiac disorder, anal lesions, or ▪ The nurse should place the blood pressure cuff 1" (2.5 cm)
bleeding hemorrhoids or has recently undergone rectal above the antecubital fossa.
surgery.
▪ When instilling ophthalmic ointments, the nurse should
▪ In a patient who has a cardiac disorder, measuring waste the first bead of ointment and then apply the
temperature rectally may stimulate a vagal response and ointment from the inner canthus to the outer canthus.
lead to vasodilation and decreased cardiac output.
▪ The nurse should use a leg cuff to measure blood pressure
▪ When recording pulse amplitude and rhythm, the nurse in an obese patient.
should use these descriptive measures: +3, bounding pulse
(readily palpable and forceful); +2, normal pulse (easily ▪ If a blood pressure cuff is applied too loosely, the reading
palpable); +1, thready or weak pulse (difficult to detect); will be falsely elevated.
and 0, absent pulse (not detectable).
▪ Ptosis is drooping of the eyelid.
▪ The intraoperative period begins when a patient is
transferred to the operating room bed and ends when the ▪ A tilt table is useful for a patient with a spinal cord injury,
patient is admitted to the postanesthesia care unit. orthostatic hypotension, or brain damage because it can
move the patient gradually from a horizontal to a vertical
▪ On the morning of surgery, the nurse should ensure that (upright) position.
the informed consent form has been signed; that the
patient hasn’ t taken anything by mouth since midnight, ▪ To perform venipuncture with the least injury to the
has taken a shower with antimicrobial soap, has had vessel, the nurse should turn the bevel upward when the
mouth care (without swallowing the water), has removed vessel’ s lumen is larger than the needle and turn it
common jewelry, and has received preoperative downward when the lumen is only slightly larger than the
medication as prescribed; and that vital signs have been needle.
taken and recorded. Artificial limbs and other prostheses
are usually removed. ▪ To move a patient to the edge of the bed for transfer, the
nurse should follow these steps: Move the patient’ s head
▪ Comfort measures, such as positioning the patient, and shoulders toward the edge of the bed. Move the
rubbing the patient’ s back, and providing a restful patient’ s feet and legs to the edge of the bed (crescent
environment, may decrease the patient’ s need for position). Place both arms well under the patient’ s hips,
analgesics or may enhance their effectiveness. and straighten the back while moving the patient toward
the edge of the bed.
▪ A drug has three names: generic name, which is used in
official publications; trade, or brand, name (such as ▪ When being measured for crutches, a patient should wear
Tylenol), which is selected by the drug company; and shoes.
chemical name, which describes the drug’ s chemical
composition. ▪ The nurse should attach a restraint to the part of the bed
frame that moves with the head, not to the mattress or side
▪ To avoid staining the teeth, the patient should take a liquid rails.
iron preparation through a straw.
▪ The mist in a mist tent should never become so dense that
▪ The nurse should use the Z-track method to administer an it obscures clea r visualization of the patient’ s respiratory
I.M. injection of iron dextran (Imferon). pattern.

▪ An organism may enter the body through the nose, mouth, ▪ To administer heparin subcutaneously, the nurse should
rectum, urinary or reproductive tract, or skin. follow these steps: Clean, but don’ t rub, the site with
alcohol. Stretch the skin taut or pick up a well-defined skin
▪ In descending order, the levels of consciousness are fold. Hold the shaft of the needle in a dart position. Insert
alertness, lethargy, stupor, light coma, and deep coma. the needle into the skin at a right (90-degree) angle. Firmly
depress the plunger, but don’ t aspirate. Leave the needle
in place for 10 seconds. Withdraw the needle gently at the
 angle of insertion. Apply pressure to the injection site with ▪ If a patient is menstruating when a urine sample is
an alcohol pad. collected, the nurse should note this on the laboratory
request.
▪ For a sigmoidoscopy, the nurse should place the patient in
the knee-chest position or Sims’ position, depending on ▪ During lumbar puncture, the nurse must note the initial
the physician’ s preference. intracranial pressure and the color of the cerebrospinal
fluid.
▪ Maslow’ s hierarchy of needs must be met in the
following order: physiologic (oxygen, food, water, sex, ▪ If a patient can’ t cough to provide a sputum sample for
rest, and comfort), safety and security, love and culture, a heated aerosol treatment can be used to help to
belonging, self-esteem and recognition, and self- obtain a sample.
actualization.
▪ If eye ointment and eyedrops must be instilled in the same
▪ When caring for a patient who has a nasogastric tube, the eye, the eyedrops should be instilled first.
nurse should apply a water-soluble lubricant to the nostril
to prevent soreness. ▪ When leaving an isolation room, the nurse should remove
her gloves before her mask because fewer pathogens are
▪ During gastric lavage, a nasogastric tube is inserted, the on the mask.
stomach is flushed, and ingested substances are removed
through the tube. ▪ Skeletal traction, which is applied to a bone with wire pins
or tongs, is the most effective means of traction.
▪ In documenting drainage on a surgical dressing, the nurse
should include the size, color, and consistency of the ▪ The total parenteral nutrition solution should be stored in
drainage (for example, “ 10 mm of brown mucoid a refrigerator and removed 30 to 60 minutes before use.
drainage noted on dressing” ). Delivery of a chilled solution can cause pain,
hypothermia, venous spasm, and venous constriction.
▪ To elicit Babinski’ s reflex, the nurse strokes the sole of
the patient’ s foot with a moderately sharp object, such as ▪ Drugs aren’ t routinely injected intramuscularly into
a thumbnail. edematous tissue because they may not be absorbed.

▪ A positive Babinski’ s reflex is shown by dorsiflexion of ▪ When caring for a comatose patient, the nurse should
the great toe and fanning out of the other toes. explain each action to the patient in a normal voice.

▪ When assessing a patient for bladder distention, the nurse ▪ Dentures should be cleaned in a sink that’ s lined with a
should check the contour of the lower abdomen for a washcloth.
rounded mass above the symphysis pubis.
▪ A patient should void within 8 hours after surgery.
▪ The best way to prevent pressure ulcers is to reposition the
bedridden patient at least every 2 hours. ▪ An EEG identifies normal and abnormal brain waves.

▪ Antiembolism stockings decompress the superficial blood ▪ Samples of feces for ova and parasite tests should be
vessels, reducing the risk of thrombus formation. delivered to the laboratory without delay and without
refrigeration.
▪ In adults, the most convenient veins for venipuncture are
the basilic and median cubital veins in the antecubital ▪ The autonomic nervous system regulates the
space. cardiovascular and respiratory systems.

▪ Two to three hours before beginning a tube feeding, the ▪ When providing tracheostomy care, the nurse should
nurse should aspirate the patient’ s stomach contents to insert the catheter gently into the tracheostomy tube.
verify that gastric emptying is adequate. When withdrawing the catheter, the nurse should apply
intermittent suction for no more than 15 seconds and use
▪ People with type O blood are considered universal donors. a slight twisting motion.

▪ People with type AB blood are considered universal ▪ A low-residue diet includes such foods as roasted chicken,
recipients. rice, and pasta.

▪ Hertz (Hz) is the unit of measurement of sound frequency. ▪ A rectal tube shouldn’ t be inserted for longer than 20
minutes because it can irritate the rectal mucosa and cause
▪ Hearing protection is required when the sound intensity loss of sphincter control.
exceeds 84 dB. Double hearing protection is required if it
exceeds 104 dB. ▪ A patient’ s bed bath should proceed in this order: face,
neck, arms, hands, chest, abdomen, back, legs, perineum.
▪ Prothrombin, a clotting factor, is produced in the liver.
▪ To prevent injury when lifting and moving a patient, the ▪ A living will is a witnessed document that states a
nurse should primarily use the upper leg muscles. patient’ s desire for certain types of care and treatment.
These decisions are based on the patient’ s wishes and
▪ Patient preparation for cholecystography includes views on quality of life.
ingestion of a contrast medium and a low-fat evening
meal. ▪ The nurse should flush a peripheral heparin lock every 8
hours (if it wasn’ t used during the previous 8 hours) and
▪ While an occupied bed is being changed, the patient as needed with normal saline solution to maintain patency.
should be covered with a bath blanket to promote warmth
and prevent exposure. ▪ Quality assurance is a method of determining whether
nursing actions and practices meet established standards.
▪ Anticipatory grief is mourning that occurs for an extended
time when the patient realizes that death is inevitable. ▪ The five rights of medication administration are the right
▪ The following foods can alter the color of the feces: beets patient, right drug, right dose, right route of
(red), cocoa (dark red or brown), licorice (black), spinach administration, and right time.
(green), and meat protein (dark brown).
▪ The evaluation phase of the nursing process is to
▪ When preparing for a skull X-ray, the patient should determine whether nursing interventions have enabled the
remove all jewelry and dentures. patient to meet the desired goals.

▪ The fight-or-flight response is a sympathetic nervous ▪ Outside of the hospital setting, only the sublingual and
system response. translingual forms of nitroglycerin should be used to
relieve acute anginal attacks.
▪ Bronchovesicular breath sounds in peripheral lung fields
are abnormal and suggest pneumonia. ▪ The implementation phase of the nursing process involves
recording the patient’ s response to the nursing plan,
▪ Wheezing is an abnormal, high-pitched breath sound putting the nursing plan into action, delegating specific
that’ s accentuated on expiration. nursing interventions, and coordinating the patient’ s
activities.
▪ Wax or a foreign body in the ear should be flushed out
gently by irrigation with warm saline solution. ▪ The Patient’ s Bill of Rights offers patients guidance and
protection by stating the responsibilities of the hospital
▪ If a patient complains that his hearing aid is “ not and its staff toward patients and their families during
working,” the nurse should check the switch first to see hospitalization.
if it’ s turned on and then check the batteries.
▪ To minimize omission and distortion of facts, the nurse
▪ The nurse should grade hyperactive biceps and triceps should record information as soon as it’ s gathered.
reflexes as +4.
▪ When assessing a patient’ s health history, the nurse
▪ If two eye medications are prescribed for twice-daily should record the current illness chronologically,
instillation, they should be administered 5 minutes apart. beginning with the onset of the problem and continuing to
the present.
▪ In a postoperative patient, forcing fluids helps prevent
constipation. ▪ When assessing a patient’ s health history, the nurse
should record the current illness chronologically,
▪ A nurse must provide care in accordance with standards beginning with the onset of the problem and continuing to
of care established by the American Nurses Association, the present.
state regulations, and facility policy.
▪ A nurse shouldn’ t give false assurance to a patient.
▪ The kilocalorie (kcal) is a unit of energy measurement that
represents the amount of heat needed to raise the ▪ After receiving preoperative medication, a patient isn’ t
temperature of 1 kilogram of water 1° C. competent to sign an informed consent form.

▪ As nutrients move through the body, they undergo ▪ When lifting a patient, a nurse uses the weight of her body
ingestion, digestion, absorption, transport, cell instead of the strength in her arms.
metabolism, and excretion.
▪ A nurse may clarify a physician’ s explanation about an
▪ The body metabolizes alcohol at a fixed rate, regardless of operation or a procedure to a patient, but must refer
serum concentration. questions about informed consent to the physician.

▪ In an alcoholic beverage, proof reflects the percentage of ▪ When obtaining a health history from an acutely ill or
alcohol multiplied by 2. For example, a 100 -proof agitated patient, the nurse should limit questions to those
beverage contains 50% alcohol. that provide necessary information.
▪ If a chest drainage system line is broken or interrupted, the 15 minutes to prevent reflex dilation (rebound
nurse should clamp the tube immediately. phenomenon) and frostbite injury.
▪ The pons is located above the medulla and consists of
▪ The nurse shouldn’ t use her thumb to take a patient’ s white matter (sensory and motor tracts) and gray matter
pulse rate because the thumb has a pulse that may be (reflex centers).
confused with the patient’ s pulse.
▪ The autonomic nervous system controls the smooth
▪ An inspiration and an expiration count as one respiration. muscles.

▪ Eupnea is normal respiration. ▪ A correctly written patient goal expresses the desired
patient behavior, criteria for measurement, time frame for
▪ During blood pressure measurement, the patient should achievement, and conditions under which the behavior
rest the arm against a surface. Using muscle strength to will occur. It’ s developed in collaboration with the
hold up the arm may raise the blood pressure. patient.

▪ Major, unalterable risk factors for coronary artery disease ▪ Percussion causes five basic notes: tympany (loud
include heredity, sex, race, and age. intensity, as heard over a gastric air bubble or puffed out
cheek), hyperresonance (very loud, as heard over an
▪ Inspection is the most frequently used assessment emphysematous lung), resonance (loud, as heard over a
technique. normal lung), dullness (medium intensity, as heard over
the liver or other solid organ), and flatness (soft, as heard
▪ Family members of an elderly person in a long-term care over the thigh).
facility should transfer some personal items (such as
photographs, a favorite chair, and knickknacks) to the ▪ The optic disk is yellowish pink and circular, with a
person’ s room to provide a comfortable atmosphere. distinct border.

▪ Pulsus alternans is a regular pulse rhythm with alternating ▪ A primary disability is caused by a pathologic process. A
weak and strong beats. It occurs in ventricular secondary disability is caused by ina ctivity.
enlargement because the stroke volume varies with each
heartbeat. ▪ Nurses are commonly held liable for failing to keep an
accurate count of sponges and other devices during
▪ The upper respiratory tract warms and humidifies inspired surgery.
air and plays a role in taste, smell, and mastication.
▪ The best dietary sources of vitamin B6 are liver, kidney,
▪ Signs of accessory muscle use include shoulder elevation, pork, soybeans, corn, and whole-grain cereals.
intercostal muscle retraction, and scalene and
sternocleidomastoid muscle use during respiration. ▪ Iron-rich foods, such as organ meats, nuts, legumes, dried
fruit, green leafy vegetables, eggs, and whole grains,
▪ When patients use axillary crutches, their palms should commonly have a low water content.
bear the brunt of the weight.
▪ Collaboration is joint communication and decision
▪ Activities of daily living include eating, bathing, dressing, making between nurses and physicians. It’ s designed to
grooming, toileting, and interacting socially. meet patients’ needs by integrating the care regimens of
both professions into one comprehensive approach.
▪ Normal gait has two phases: the stance phase, in which the
patient’ s foot rests on the ground, and the swing phase, ▪ Bradycardia is a heart rate of fewer than 60 beats/minute.
in which the patient’ s foot moves forward.
▪ A nursing diagnosis is a statement of a patient’ s actual or
▪ The phases of mitosis are prophase, metaphase, anaphase, potential health problem that can be resolved, diminished,
and telophase. or otherwise changed by nursing interventions.

▪ The nurse should follow standard precautions in the ▪ During the assessment phase of the nursing process, the
routine care of all patients. nurse collects and analyzes three types of data: health
history, physical examination, and laboratory and
▪ The nurse should use the bell of the stethoscope to listen diagnostic test data.
for venous hums and cardiac murmurs.
▪ The patient’ s health history consists primarily of
▪ The nurse can assess a patient’ s general knowledge by subjective data, information that’ s supplied by the
asking questions such as “ Who is the president of the patient.
United States?”
▪ The physical examination includes objective data
▪ Cold packs are applied for the first 20 to 48 hours after an obtained by inspection, palpation, percussion, and
injury; then heat is applied. During cold application, the auscultation.
pack is applied for 20 minutes and then removed for 10 to
▪ When documenting patient care, the nurse should write ▪ To remove a patient’ s artificial eye, the nurse depresses
legibly, use only standard abbreviations, and sign each the lower lid.
entry. The nurse should never destroy or attempt to
obliterate documentation or leave vacant lines. ▪ The nurse should use a warm saline solution to clean an
artificial eye.
▪ Factors that affect body temperature include time of day,
age, physical activity, phase of menstrual cycle, and ▪ A thready pulse is very fine and scarcely perceptible.
pregnancy.
▪ Axillary temperature is usually 1° F lower than oral
▪ The most accessible and commonly used artery for temperature.
measuring a patient’ s pulse rate is the radial artery. To
take the pulse rate, the artery is compressed against the ▪ After suctioning a tracheostomy tube, the nurse must
radius. document the color, amount, consistency, and odor of
secretions.
▪ In a resting adult, the normal pulse rate is 60 to 100
beats/minute. The rate is slightly faster in women than in ▪ On a drug prescription, the abbreviation p.c. means that
men and much faster in children than in adults. the drug should be administered after meals.

▪ Laboratory test results are an objective form of assessment ▪ After bladder irrigation, the nurse should document the
data. amount, color, and clarity of the urine and the presence of
clots or sediment.
▪ The measurement systems most commonly used in
clinical practice are the metric system, apothecaries’ ▪ After bladder irrigation, the nurse should document the
system, and household system. amount, color, and clarity of the urine and the presence of
clots or sediment.
▪ Before signing an informed consent form, the patient
should know whether other treatment options are ▪ Laws regarding patient self-determination vary from state
available and should understand what will occur during to state. Therefore, the nurse must be familiar with the
the preoperative, intraoperative, and postoperative phases; laws of the state in which she works.
the risks involved; and the possible complications. The
patient should also have a general idea of the time required ▪ Gauge is the inside diameter of a needle: the smaller the
from surgery to recovery. In addition, he should have an gauge, the larger the diameter.
opportunity to ask questions.
▪ An adult normally has 32 permanent teeth.
▪ A patient must sign a separate informed consent form for
each procedure. ▪ After turning a patient, the nurse should document the
position used, the time that the patient was turned, and the
▪ During percussion, the nurse uses quick, sharp tapping of findings of skin assessment.
the fingers or hands against body surfaces to produce
sounds. This procedure is done to determine the size, ▪ PERRLA is an abbreviation for normal pupil assessment
shape, position, and density of underlying organs and findings: pupils equal, round, and reactive to light with
tissues; elicit tenderness; or assess reflexes. accommodation.

▪ Ballottement is a form of light palpation involving gentle, ▪ When percussing a patient’ s chest for postural drainage,
repetitive bouncing of tissues against the hand and feeling the nurse’ s hands should be cupped.
their rebound.
▪ When measuring a patient’ s pulse, the nurse should
▪ A foot cradle keeps bed linen off the patient’ s feet to assess its rate, rhythm, quality, and strength.
prevent skin irritation and breakdown, especially in a
patient who has peripheral vascular disease or neuropathy. ▪ Before transferring a patient from a bed to a wheelchair,
the nurse should push the wheelchair’ s footrests to the
▪ Gastric lavage is flushing of the stomach and removal of sides and lock its wheels.
ingested substances through a nasogastric tube. It’ s used
to treat poisoning or drug overdose. ▪ When assessing respirations, the nurse should document
their rate, rhythm, depth, and quality.
▪ During the evaluation step of the nursing process, the
nurse assesses the patient’ s response to therapy. ▪ For a subcutaneous injection, the nurse should use a 5/8"
25G needle.
▪ Bruits commonly indicate life- or limb-threatening
vascular disease. ▪ The notation “ AA & O × 3” indicates that the patient is
awake, alert, and oriented to person (knows who he is),
▪ O.U. means each eye. O.D. is the right eye, and O.S. is the place (knows where he is), and time (knows the date and
left eye. time).
▪ Fluid intake includes all fluids taken by mouth, including ▪ A competent adult has the right to refuse lifesaving
foods that are liquid at room temperature, such as gelatin, medical treatment; however, the individual should be fully
custard, and ice cream; I.V. fluids; and fluids administered informed of the consequences of his refusal.
in feeding tubes. Fluid output includes urine, vomitus, and
drainage (such as from a nasogastric tube or from a ▪ Although a patient’ s health record, or chart, is the health
wound) as well as blood loss, diarrhea or feces, and care facility’ s physical property, its contents belong to
perspiration. the patient.

▪ After administering an intradermal injection, the nurse ▪ Before a patient’ s health record can be released to a third
shouldn’ t massage the area because massage can irritate party, the patient or the patient’ s legal guardian must give
the site and interfere with results. written consent.

▪ When administering an intradermal injection, the nurse ▪ Under the Controlled Substances Act, every dose of a
should hold the syringe almost flat against the patient’ s controlled drug that’ s dispensed by the pharmacy must
skin (at about a 15-degree angle), with the bevel up. be accounted for, whether the dose was administered to a
patient or discarded accidentally.
▪ To obtain an accurate blood pressure, the nurse should
inflate the manometer to 20 to 30 mm Hg above the ▪ A nurse can’ t perform duties that violate a rule or
disappearance of the radial pulse before releasing the cuff regulation established by a state licensing board, even if
pressure. they are authorized by a health care facility or physician.

▪ The nurse should count an irregular pulse for 1 full ▪ To minimize interruptions during a patient interview, the
minute. nurse should select a private room, preferably one with a
door that can be closed.
▪ A patient who is vomiting while lying down should be
placed in a lateral position to prevent aspiration of ▪ In categorizing nursing diagnoses, the nurse addresses
vomitus. life-threatening problems first, followed by potentially
life-threatening concerns.
▪ Prophylaxis is disease prevention.
▪ The major components of a nursing care plan are outcome
▪ Body alignment is achieved when body parts are in proper criteria (patient goals) and nursing interventions.
relation to their natural position.
▪ Standing orders, or protocols, establish guidelines for
▪ Trust is the foundation of a nurse-patient relationship. treating a specific disease or set of symptoms.

▪ Blood pressure is the force exerted by the circulating ▪ In assessing a patient’ s heart, the nurse normally finds
volume of blood on the arterial walls. the point of maximal impulse at the fifth intercostal space,
near the apex.
▪ Malpractice is a professional’ s wrongful conduct,
improper discharge of duties, or failure to meet standards ▪ The S1 heard on auscultation is caused by closure of the
of care that causes harm to another. mitral and tricuspid valves.

▪ As a general rule, nurses can’ t refuse a patient care ▪ To maintain package sterility, the nurse should open a
assignment; however, in most states, they may refuse to wrapper’ s top flap away from the body, open each side
participate in abortions. flap by touching only the outer part of the wrapper, and
open the final flap by grasping the turned-down corner and
▪ A nurse can be found negligent if a patient is injured pulling it toward the body.
because the nurse failed to perform a duty that a
reasonable and prudent person would perform or because ▪ The nurse shouldn’ t dry a patient’ s ear canal or remove
the nurse performed an act that a reasonable and prudent wax with a cotton-tipped applica tor because it may force
person wouldn’ t perform. cerumen against the tympanic membrane.

▪ States have enacted Good Samaritan laws to encourage ▪ A patient’ s identification bracelet should remain in place
professionals to provide medical assistance at the scene of until the patient has been discharged from the health care
an accident without fear of a lawsuit arising from the facility and has left the premises.
assistance. These laws don’ t apply to care provided in a
health care facility. ▪ The Controlled Substances Act designated five categories,
or schedules, that classify controlled drugs according to
▪ A physician should sign verbal and telephone orders their abuse potential.
within the time established by facility policy, usually 24 ▪ Schedule I drugs, such as heroin, have a high abuse
hours. potential and have no currently accepted medical use in
the United States.
▪ Schedule II drugs, such a s morphine, opium, and
meperidine (Demerol), have a high abuse potential, but ▪ The area around a stoma is cleaned with mild soap and
currently have accepted medical uses. Their use may lead water.
to physical or psychological dependence.
▪ Vegetables have a high fiber content.
▪ Schedule III drugs, such as paregoric and butabarbital
(Butisol), have a lower abuse potential than Schedule I or ▪ The nurse should use a tuberculin syringe to administer a
II drugs. Abuse of Schedule III drugs may lead to subcutaneous injection of less than 1 ml.
moderate or low physical or psychological dependence, or
both. ▪ For adults, subcutaneous injections require a 25G 1"
needle; for infants, children, elderly, or very thin patients,
▪ Schedule IV drugs, such as chloral hydrate, have a low they require a 25G to 27G ½" needle.
abuse potential compared with Schedule III drugs.
▪ Before administering a drug, the nurse should identify the
▪ Schedule V drugs, such as cough syrups that contain patient by checking the identification band and asking the
codeine, have the lowest abuse potential of the controlled patient to state his name.
substances.
▪ To clean the skin before an injection, the nurse uses a
▪ Activities of daily living are actions that the patient must sterile alcohol swab to wipe from the center of the site
perform every day to provide self-care and to interact with outward in a circular motion.
society.
▪ The nurse should inject heparin deep into subcutaneous
▪ Testing of the six cardinal fields of gaze evaluates the tissue at a 90-degree angle (perpendicular to the skin) to
function of all extraocular muscles and cranial nerves III, prevent skin irritation.
IV, and VI.
▪ If blood is aspirated into the syringe before an I.M.
▪ The six types of heart murmurs are graded from 1 to 6. A injection, the nurse should withdraw the needle, prepare
grade 6 heart murmur can be heard with the stethoscope another syringe, and repeat the procedure.
slightly raised from the chest.
▪ The nurse shouldn’ t cut the patient’ s hair without
▪ The most important goal to include in a care plan is the written consent from the patient or an appropriate relative.
patient’ s goal.
▪ If bleeding occurs after an injection, the nurse should
▪ Fruits are high in fiber and low in protein, and should be apply pressure until the bleeding stops. If bruising occurs,
omitted from a low-residue diet. the nurse should monitor the site for an enlarging
hematoma.
▪ The nurse should use an objective scale to assess and
quantify pain. Postoperative pain varies greatly among ▪ When providing hair and scalp care, the nurse should
individuals. begin combing at the end of the hair and work toward the
head.
▪ Postmortem care includes cleaning and preparing the
deceased patient for family viewing, arranging ▪ The frequency of patient hair care depends on the length
transportation to the morgue or funeral home, and and texture of the hair, the duration of hospitalization, and
determining the disposition of belongings. the patient’ s condition.

▪ The nurse should provide honest answers to the patient’ s ▪ Proper function of a hearing aid requires careful handling
questions. during insertion and removal, regular cleaning of the ear
piece to prevent wax buildup, and prompt replacement of
▪ Milk shouldn’ t be included in a clear liquid diet. dead batteries.

▪ When caring for an infant, a child, or a confused patient, ▪ The hearing aid that’ s marked with a blue dot is for the
consistency in nursing personnel is paramount. left ear; the one with a red dot is for the right ear.

▪ The hypothalamus secretes vasopressin and oxytocin, ▪ A hearing aid shouldn’ t be exposed to heat or humidity
which are stored in the pituitary gland. and shouldn’ t be immersed in water.

▪ The three membranes that enclose the brain and spinal ▪ The nurse should instruct the patient to avoid using hair
cord are the dura mater, pia mater, and arachnoid. spray while wearing a hearing aid.

▪ A nasogastric tube is used to remove fluid and gas from ▪ The five branches of pharmacology are pharmacokinetics,
the small intestine preoperatively or postoperatively. pharmacodynamics, pharmacotherapeutics, toxicology,
and pharmacognosy.
▪ Psychologists, physical therapists, and chiropractors ▪ The nurse should remove heel protectors every 8 hours to
aren’ t authorized to write prescriptions for drugs. inspect the foot for signs of skin breakdown.
 goal, there are interventions designed to make the goal a
▪ Heat is applied to promote vasodilation, which reduces reality. The keys to answering examination questions
pain caused by inflammation. correctly are identifying the problem presented,
formulating a goal for the problem, a nd selecting the
▪ A sutured surgical incision is an example of healing by intervention from the choices provided that will enable the
first intention (healing directly, without granulation). patient to reach that goal.

▪ Healing by secondary intention (healing by granulation) ▪ Fidelity means loyalty and can be shown as a commitment
is closure of the wound when granulation tissue fills the to the profession of nursing and to the patient.
defect and allows reepithelialization to occur, beginning
at the wound edges and continuing to the center, until the ▪ Administering an I.M. injection against the patient’ s will
entire wound is covered. and without legal authority is battery.
▪ Keloid formation is an abnormality in healing that’ s
characterized by overgrowth of scar tissue at the wound ▪ An example of a third-party payer is an insurance
site. company.

▪ The nurse should administer procaine penicillin by deep ▪ The formula for calculating the drops per minute for an
I.M. injection in the upper outer portion of the buttocks in I.V. infusion is as follows: (volume to be infused × drip
the adult or in the midlateral thigh in the child. The nurse factor) ÷ time in minutes = drops/minute
shouldn’ t massage the injection site.
▪ On-call medication should be given within 5 minutes of
▪ An ascending colostomy drains fluid feces. A descending the call.
colostomy drains solid fecal matter.
▪ Usually, the best method to determine a patient’ s cultural
▪ A folded towel (scrotal bridge) can provide scrotal support or spiritual needs is to ask him.
for the patient with scrotal edema caused by vasectomy,
epididymitis, or orchitis. ▪ An incident report or unusual occurrence report isn’ t part
of a patient’ s record, but is an in-house document that’ s
▪ When giving an injection to a patient who has a bleeding used for the purpose of correcting the problem.
disorder, the nurse should use a small-gauge needle and
apply pressure to the site for 5 minutes after the injection. ▪ Critical pathways are a multidisciplinary guideline for
patient care.
▪ Platelets are the smallest and most fragile formed element
of the blood and are essential for coagulation. ▪ When prioritizing nursing diagnoses, the followin g
hierarchy should be used: Problems associated with the
▪ To insert a nasogastric tube, the nurse instructs the patient airway, those concerning breathing, and those related to
to tilt the head back slightly and then inserts the tube. circulation.
When the nurse feels the tube curving at the pharynx, the
nurse should tell the patient to tilt the head forward to ▪ The two nursing diagnoses that have the highest priority
close the trachea and open the esophagus by swallowin g. that the nurse can assign are Ineffective airway clearance
(Sips of water can facilitate this action.) and Ineffective breathing pattern.

▪ Families with loved ones in intensive care units report that ▪ A subjective sign that a sitz bath has been effective is the
their four most important needs are to have their questions patient’ s expression of decreased pain or discomfort.
answered honestly, to be assured that the best possible
care is being provided, to know the patient’ s prognosis, ▪ For the nursing diagnosis Deficient diversional activity to
and to feel that there is hope of recovery. be valid, the patient must state that he’ s “ bored,” that
he has “ nothing to do,” or words to that effect.
▪ Double-bind communication occurs when the verbal
message contradicts the nonverbal message and the ▪ The most appropriate nursing diagnosis for an individual
receiver is unsure of which message to respond to. who doesn’ t speak English is Impaired verbal
communication related to inability to speak dominant
▪ A nonjudgmental attitude displayed by a nurse shows that language (English).
she neither approves nor disapproves of the patient.
▪ The family of a patient who has been diagnosed as hearing
▪ Target symptoms are those that the patient finds most impaired should be instructed to face the individual when
distressing. they speak to him.

▪ A patient should be advised to take aspirin on an empty ▪ Before instilling medication into the ear of a patient who
stomach, with a full glass of water, and should avoid is up to age 3, the nurse should pull the pinna down and
acidic foods such as coffee, citrus fruits, and cola. back to straighten the eustachian tube.

▪ For every patient problem, there is a nursing diagnosis; f or

every nursing diagnosis, there is a goal; and for every
▪ To prevent injury to the cornea when administering ▪ Long-handled forceps and a lead-lined container should
eyedrops, the nurse should waste the first drop and instill be available in the room of a patient who has a radiation
the drug in the lower conjunctival sac. implant.

▪ After administering eye ointment, the nurse should twist ▪ Usually, patients who have the same infection and are in
the medication tube to detach the ointment. strict isolation can share a room.

▪ When the nurse removes gloves and a mask, she should ▪ Diseases that require strict isolation include chickenpox,
remove the gloves first. They are soiled and are likely to diphtheria, and viral hemorrhagic fevers such as Marburg
contain pathogens. disease.

▪ Crutches should be placed 6" (15.2 cm) in front of the ▪ For the patient who abides by Jewish custom, milk and
patient and 6" to the side to form a tripod arrangement. meat shouldn’ t be served at the same meal.

▪ Listening is the most effective communication techniqu e. ▪ Whether the patient can perform a procedure
(psychomotor domain of learning) is a better indicator of
▪ Before teaching any procedure to a patient, the nurse must the effectiveness of patient teaching than whether the
assess the patient’ s current knowledge and willingness to patient can simply state the steps involved in the
learn. procedure (cognitive domain of learning).

▪ Process recording is a method of evaluating one’ s ▪ According to Erik Erikson, developmental stages are trust
communication effectiveness. versus mistrust (birth to 18 months), autonomy versus
shame and doubt (18 months to age 3), initiative versus
▪ When feeding an elderly patient, the nurse should limit guilt (ages 3 to 5), industry versus inferiority (ages 5 to
high-carbohydrate foods because of the risk of glucose 12), identity versus identity diffusion (ages 12 to 18),
intolerance. intimacy versus isolation (a ges 18 to 25), generativity
versus stagnation (ages 25 to 60), and ego integrity versus
▪ When feeding an elderly patient, essential foods should be despair (older than age 60).
given first.
▪ When communicating with a hearing impaired patient, the
▪ Passive range of motion maintains joint mobility. nurse should face him.
Resistive exercises increase muscle mass.
▪ An appropriate nursing intervention for the spouse of a
▪ Isometric exercises are performed on an extremity that’ s patient who has a serious incapacitating disease is to help
in a cast. him to mobilize a support system.

▪ A back rub is an example of the gate-control theory of ▪ Hyperpyrexia is extreme elevation in temperature above
pain. 106° F (41.1° C).

▪ Anything that’ s located below the waist is considered ▪ Milk is high in sodium and low in iron.
unsterile; a sterile field becomes unsterile when it comes
in contact with any unsterile item; a sterile field must be ▪ When a patient expresses concern about a health-related
monitored continuously; and a border of 1" (2.5 cm) issue, before addressing the concern, the nurse should
around a sterile field is considered unsterile. assess the patient’ s level of knowledge.

▪ A “ shift to the left” is evident when the number of ▪ The most effective way to reduce a fever is to administer
immature cells (bands) in the blood increases to fight an an antipyretic, which lowers the temperature set point.
infection.
▪ When a patient is ill, it’ s essential for the members of his
▪ A “ shift to the right” is evident when the number of family to maintain communication about his health needs.
mature cells in the blood increases, as seen in advanced
liver disease and pernicious anemia. ▪ Ethnocentrism is the universal belief that one’ s way of
life is superior to others.
▪ Before administering preoperative medication, the nurse
should ensure that an informed consent form has been ▪ When a nurse is communicating with a patient through an
signed and attached to the patient’ s record. interpreter, the nurse should speak to the patient and the
interpreter.
▪ A nurse should spend no more than 30 minutes per 8-hour
shift providing care to a patient who has a radiation ▪ In accordance with the “ hot-cold” system used by some
implant. Mexicans, Puerto Ricans, and other Hispanic and Latino
groups, most foods, beverages, herbs, and drugs are
▪ A nurse shouldn’ t be assigned to care for more than one described as “ cold.”
patient who has a radiation implant.
▪ Prejudice is a hostile a ttitude toward individuals of a from an upper respiratory infection, and edema from
particular group. trauma or an allergic reaction.

▪ Discrimination is preferential treatment of individuals of ▪ B = Breathing. This category includes everything that
a particular group. It’ s usually discussed in a negative affects the breathing pattern, including hyperventilation or
sense. hypoventilation and abnormal breathing patterns, such as
Korsakoff’ s, Biot’ s, or Cheyne-Stokes respiration.
▪ Increased gastric motility interferes with the absorption of
oral drugs. ▪ C = Circulation. This category includes everything that
affects the circulation, including fluid and electrolyte
▪ The three phases of the therapeutic relationship are disturbances and disease processes that affect cardiac
orientation, working, and termination. output.

▪ Patients often exhibit resistive and challenging behaviors ▪ D = Disease processes. If the patient has no problem with
in the orientation phase of the therapeutic relationship. the airway, breathing, or circulation, then the nurse should
evaluate the disease processes, giving priority to the
▪ Abdominal assessment is performed in the followin g disease process that poses the greatest immediate risk. For
order: inspection, auscultation, palpation, and percussion. example, if a patient has terminal cancer and
hypoglycemia, hypoglycemia is a more immediate
▪ When measuring blood pressure in a neonate, the nurse concern.
should select a cuff that’ s no less than one-half and no
more than two-thirds the length of the extremity that’ s ▪ E = Everything else. This category includes such issues as
used. writing an incident report and com pleting the patient
chart. When evaluating needs, this category is never the
▪ When administering a drug by Z-track, the nurse highest priority.
shouldn’ t use the same needle that was used to draw the
drug into the syringe because doing so could stain the skin. ▪ When answering a question on an NCLEX examination,
the basic rule is “ assess before action.” The student
▪ Sites for intradermal injection include the inner arm, the should evaluate each possible answer carefully. Usually ,
upper chest, and on the back, under the scapula. several answers reflect the implementation phase of
nursing and one or two reflect the assessment phase. In
▪ When evaluating whether an answer on an examination is this case, the best choice is an assessment response unless
correct, the nurse should consider whether the action a specific course of action is clearly indicated.
that’ s described promotes autonomy (independence),
safety, self-esteem, and a sense of belonging. ▪ Rule utilitarianism is known as the “ greatest good for the
greatest number of people” theory.
▪ When answering a question on the NCLEX examination,
the student should consider the cue (the stimulus for a ▪ Egalitarian theory emphasizes that equal access to goods
thought) and the inference (the thought) to determine and services must be provided to the less fortunate by an
whether the inference is correct. When in doubt, the nurse affluent society.
should select an answer that indicates the need for further
information to eliminate ambiguity. For example, the ▪ Active euthanasia is actively helping a person to die.
patient complains of chest pain (the stimulus for the
thought) and the nurse infers that the patient is having ▪ Brain death is irreversible cessation of all brain function.
cardiac pain (the thought). In this case, the nurse hasn’ t
confirmed whether the pain is cardiac. It would be more ▪ Passive euthanasia is stopping the therapy that’ s
appropriate to make further assessments. sustaining life.

▪ Veracity is truth and is an essential component of a ▪ A third-party payer is an insurance company.

therapeutic relationship between a health care provider
and his patient. ▪ Utilization review is performed to determine whether the
care provided to a patient wa s appropriate and cost-
▪ Beneficence is the duty to do no harm and the duty to do effective.
good. There’ s an obligation in patient care to do no harm ▪ A value cohort is a group of people who experienced an
and an equal obligation to assist the patient. out-of-the-ordinary event that shaped their values.

▪ Nonmaleficence is the duty to do no harm. ▪ Voluntary euthanasia is actively helping a patient to die at
the patient’ s request.
▪ Frye’ s ABCDE cascade provides a framework for
prioritizing care by identifying the most important ▪ Bananas, citrus fruits, and potatoes are good sources of
treatment concerns. potassium.

▪ A = Airway. This category includes everything that ▪ Good sources of magnesium include fish, nuts, and grains.
affects a patent airway, including a foreign object, fluid
▪ Beef, oysters, shrimp, scallops, spinach, beets, and greens ▪ Secondary prevention is early detection. Examples
are good sources of iron. include purified protein derivative (PPD), breast self -
examination, testicular self-examination, and chest X-ray.
▪ Intrathecal injection is administering a drug through the
spine. ▪ Tertiary prevention is treatment to prevent long-term
complications.
▪ When a patient asks a question or makes a statement
that’ s emotionally charged, the nurse should respond to ▪ A patient indicates that he’ s coming to terms with having
the emotion behind the statement or question rather than a chronic disease when he says, “ I’ m never going to get
to what’ s being said or asked. any better.”

▪ The steps of the trajectory-nursing model are as follows: ▪ On noticing religious artifacts and literature on a
– Step 1: Identifying the trajectory phase patient’ s night stand, a culturally aware nurse would ask
– Step 2: Identifying the problems and establishing goals the patient the meaning of the items.
– Step 3: Establishing a plan to meet the goals
– Step 4: Identifying factors that facilitate or hinder ▪ A Mexican patient may request the intervention of a
attainment of the goals curandero, or faith healer, who involves the family in
– Step 5: Implementing interventions healing the patient.
– Step 6: Evaluating the effectiveness of the interventions
▪ In an infant, the normal hemoglobin value is 12 g/dl.
▪ A Hindu patient is likely to request a vegetarian diet.
▪ The nitrogen balance estimates the difference between the
▪ Pain threshold, or pain sensation, is the initial point at intake and use of protein.
which a patient feels pain.
▪ Most of the absorption of water occurs in the large
▪ The difference between acute pain and chronic pain is its intestine.
duration.
▪ Most nutrients are absorbed in the small intestine.
▪ Referred pain is pain that’ s felt at a site other than its
origin. ▪ When assessing a patient’ s eating habits, the nurse
should ask, “ What have you eaten in the last 24 hours?”
▪ Alleviating pain by performing a back massage is
consistent with the gate control theory. ▪ A vegan diet should include an abundant supply of fiber.

▪ Romberg’ s test is a test for balance or gait. ▪ A hypotonic enema softens the feces, distends the colon,
and stimulates peristalsis.
▪ Pain seems more intense at night because the patient isn’ t
distracted by daily activities. ▪ First-morning urine provides the best sample to measure
glucose, ketone, pH, and specific gravity values.
▪ Older patients commonly don’ t report pain because of
fear of treatment, lifestyle changes, or dependency. ▪ To induce sleep, the first step is to minimize
environmental stimuli.
▪ No pork or pork products are allowed in a Muslim diet.
▪ Before moving a patient, the nurse should assess the
▪ Two goals of Healthy People 2010 are: patient’ s physical abilities and ability to understand
– Help individuals of all ages to increase the quality of life instructions as well as the amount of strength required to
and the number of years of optimal health move the patient.
– Eliminate health disparities among different segments of
the population. ▪ To lose 1 lb (0.5 kg) in 1 week, the patient must decrease
his weekly intake by 3,500 calories (approximately 500
▪ A community nurse is serving as a patient’ s advocate if calories daily). To lose 2 lb (1 kg) in 1 week, the patient
she tells a malnourished patient to go to a meal program must decrease his weekly caloric intake by 7,000 calories
at a local park. (approximately 1,000 calories daily).

▪ If a patient isn’ t following his treatment plan, the nurse ▪ To avoid shearing force injury, a patient who is
should first ask why. completely immobile is lifted on a sheet.

▪ Falls are the leading cause of injury in elderly people. ▪ To insert a catheter from the nose through the trachea for
suction, the nurse should ask the patient to swallow.
▪ Primary prevention is true prevention. Examples are
immunizations, weight control, and smoking cessation. ▪ Vitamin C is needed for collagen production.

▪ Only the patient can describe his pain accurately.

▪ Cutaneous stimulation creates the release of endorphins
that block the transmission of pain stimuli. ▪ The three elements that are necessary for a fire are heat,
oxygen, and combustible material.
▪ Patient-controlled analgesia is a safe method to relieve
acute pain caused by surgical incision, traumatic injury, ▪ Sebaceous glands lubricate the skin.
labor and delivery, or cancer.
▪ To check for petechiae in a dark-skinned patient, the nurse
▪ An Asian American or European American typically should assess the oral mucosa.
places distance between himself and others when
communicating. ▪ To put on a sterile glove, the nurse should pick up the first
glove at the folded border and adjust the fingers when both
▪ The patient who believes in a scientific, or biomedical, gloves are on.
approach to health is likely to expect a drug, treatment, or
surgery to cure illness. ▪ To increase patient comfort, the nurse should let the
alcohol dry before giving an intramuscular injection.
▪ Chronic illnesses occur in very young as well as middle-
aged and very old people. ▪ Treatment for a stage 1 ulcer on the heels includes heel
protectors.
▪ The trajectory framework for chronic illness states that
preferences about daily life activities affect treatment ▪ Seventh-Day Adventists are usually vegetarians.
decisions.
▪ Endorphins are morphine-like substances that produce a
▪ Exacerbations of chronic disease usually cause the patient feeling of well-being.
to seek treatment and may lead to hospitalization.
▪ Pain tolerance is the maximum amount and duration of
▪ School health programs provide cost-effective health care pain that an individual is willing to endure.
for low-income families and those who have no health
insurance.

▪ Collegiality is the promotion of collaboration,

development, and interdependence among members of a
profession.

▪ A change agent is an individual who recognizes a need for

change or is selected to make a change within an
established entity, such as a hospital.

▪ The patients’ bill of rights was introduced by the

American Hospital Association.

▪ Abandonment is premature termination of treatment

without the patient’ s permission and without appropriate
relief of symptoms.

▪ Values clarification is a process that individuals use to

prioritize their personal values.

▪ Distributive justice is a principle that promotes equal

treatment for all.

▪ Milk and milk products, poultry, grains, and fish are good
sources of phosphate.

▪ The best way to prevent falls at night in an oriented, but

restless, elderly patient is to raise the side rails.

▪ By the end of the orientation phase, the patient should

begin to trust the nurse.

▪ Falls in the elderly are likely to be caused by poor vision.

▪ Barriers to communication include language deficits,

sensory deficits, cognitive impairments, structural
deficits, and paralysis.
 ▪ An Apgar score of 7 to 10 indicates no immediate distress,
4 to 6 indicates moderate distress, and 0 to 3 indicates
severe distress.

MATERNAL & CHILD HEALTH NURSING ▪ To elicit Moro’ s reflex, the nurse holds the neonate in
both hands and suddenly, but gently, drops the neonate’ s
▪ Unlike false labor, true labor produces regular rhythmic head backward. Normally, the neonate abducts and
contractions, abdominal discomfort, progressive descent extends all extremities bilaterally and symmetrically,
of the fetus, bloody show, and progressive effacement and forms a C shape with the thumb and forefinger, and first
dilation of the cervix. adducts and then flexes the extremities.

▪ To help a mother break the suction of her breast-feeding ▪ Pregnancy-induced hypertension (preeclampsia) is an
infant, the nurse should teach her to insert a finger at the increase in blood pressure of 30/15 mm Hg over baseline
corner of the infant’ s mouth. or blood pressure of 140/95 mm Hg on two occasions at
least 6 hours apart accompanied by edema and
▪ Administering high levels of oxygen to a premature albuminuria after 20 weeks’ gestation.
neonate can cause blindness as a result of retrolental
fibroplasia. ▪ Positive signs of pregnancy include ultrasound evidence,
fetal heart tones, and fetal movement felt by the examiner
▪ Amniotomy is artificial rupture of the amniotic (not usually present until 4 months’ gestation
membranes.
▪ Goodell’ s sign is softening of the cervix.
▪ During pregnancy, weight gain averages 25 to 30 lb (11 to
13.5 kg). ▪ Quickening, a presumptive sign of pregnancy, occurs
between 16 and 19 weeks’ gestation.
▪ Rubella has a teratogenic effect on the fetus during the
first trimester. It produces abnormalities in up to 40% of ▪ Ovulation ceases during pregnancy.
cases without interrupting the pregnancy.
▪ Any vaginal bleeding during pregnancy should be
▪ Immunity to rubella can be m easured by a considered a complication until proven otherwise.
hemagglutination inhibition test (rubella titer). This test ▪ To estimate the date of delivery using Nägele’ s rule, the
identifies exposure to rubella infection and determines nurse counts backward 3 months from the first day of the
susceptibility in pregnant women. In a woman, a titer last menstrual period and then adds 7 days to this date.
greater than 1:8 indicates immunity.
▪ At 12 weeks’ gestation, the fundus should be at the top
▪ When used to describe the degree of fetal descent during of the symphysis pubis.
labor, floating means the presenting part isn’ t engaged in
the pelvic inlet, but is freely movable (ballotable) above ▪ Cow’ s milk shouldn’ t be given to infants younger than
the pelvic inlet. age 1 because it has a low linoleic acid content and its
protein is difficult for infants to digest.
▪ When used to describe the degree of fetal descent,
engagement means when the largest diameter of the ▪ If jaundice is suspected in a neonate, the nurse should
presenting part has passed through the pelvic inlet. examine the infant under natural window light. If natural
light is unavailable, the nurse should examine the infant
▪ Fetal station indicates the location of the presenting part under a white light.
in relation to the ischial spine. It’ s described as – 1, – 2,
– 3, – 4, or – 5 to indicate the number of centimeters ▪ The three phases of a uterine contraction are increment,
above the level of the ischial spine; station – 5 is at the acme, and decrement.
pelvic inlet.
▪ The intensity of a labor contraction can be assessed by the
indentability of the uterine wall at the contraction’ s peak.
▪ Fetal station also is described as +1, +2, +3, +4, or +5 to Intensity is graded as mild (uterine muscle is somewhat
indicate the number of centimeters it is below the level of tense), moderate (uterine muscle is moderately tense), or
the ischial spine; station 0 is at the level of the ischial strong (uterine muscle is boardlike).
spine.
▪ Chloasma, the mask of pregnancy, is pigmentation of a
▪ During the first stage of labor, the side-lying position circumscribed area of skin (usually over the bridge of the
usually provides the greatest degree of comfort, although nose and cheeks) that occurs in some pregnant women.
the patient may assume any comfortable position.
▪ The gynecoid pelvis is most ideal for delivery. Other types
▪ During delivery, if the umbilical cord can’ t be loosened include platypelloid (flat), anthropoid (apelike), and
and slipped from around the neonate’ s neck, it should be android (malelike).
clamped with two clamps and cut between the clamps.
▪ Pregnant women should be advised that there is no safe
level of alcohol intake. ▪ To perform nasotracheal suctioning in an infant, the nurse
positions the infant with his neck slightly hyperextended
▪ The frequency of uterine contractions, which is measured in a “ sniffing” position, with his chin up and his head
in minutes, is the time from the beginning of one tilted back slightly.
contraction to the beginning of the next.
▪ Organogenesis occurs during the first trimester of
▪ Vitamin K is administered to neonates to prevent pregnancy, specifically, days 14 to 56 of gestation.
hemorrhagic disorders because a neonate’ s intestine
can’ t synthesize vitamin K. ▪ After birth, the neonate’ s umbilical cord is tied 1" (2.5
▪ Before internal fetal monitoring can be performed, a cm) from the abdominal wall with a cotton cord, plastic
pregnant patient’ s cervix must be dilated at least 2 cm, clamp, or rubber band.
the amniotic membranes must be ruptured, and the
fetus’ s presenting part (scalp or buttocks) must be at ▪ Gravida is the number of pregnancies a woman has had,
station – 1 or lower, so that a small electrode can be regardless of outcome.
attached.
▪ Para is the number of pregnancies that reached viability,
▪ Fetal alcohol syndrome presents in the first 24 hours after regardless of whether the fetus was delivered alive or
birth and produces lethargy, seizures, poor sucking reflex, stillborn. A fetus is considered viable at 20 weeks’
abdominal distention, and respiratory difficulty. gestation.
▪ An ectopic pregnancy is one that implants abnormally,
▪ Variability is any change in the fetal heart rate (FHR) f rom outside the uterus.
its normal rate of 120 to 160 beats/minute. Acceleration is
increased FHR; deceleration is decreased FHR. ▪ The first stage of labor begins with the onset of labor and
ends with full cervical dilation at 10 cm.
▪ In a neonate, the symptoms of heroin withdrawal may
begin several hours to 4 days after birth. ▪ The second stage of labor begins with full cervical dilation
and ends with the neonate’ s birth.
▪ In a neonate, the symptoms of methadone withdrawal may
begin 7 days to several weeks after birth. ▪ The third stage of labor begins after the neonate’ s birth
and ends with expulsion of the placenta.
▪ In a neonate, the cardinal signs of narcotic withdrawal ▪ In a full-term neonate, skin creases appear over two-thirds
include coarse, flapping tremors; sleepiness; restlessness; of the neonate’ s feet. Preterm neonates have heel creases
prolonged, persistent, high-pitched cry; and irritability. that cover less than two-thirds of the feet.

▪ The nurse should count a neonate’ s respirations for 1 full ▪ The fourth stage of labor (postpartum stabilization) lasts
minute. up to 4 hours after the placenta is delivered. This time is
needed to stabilize the mother’ s physical and emotional
▪ Chlorpromazine (Thorazine) is used to treat neonates who state after the stress of childbirth.
are addicted to narcotics.
▪ At 20 weeks’ gestation, the fundus is at the level of the
▪ The nurse should provide a dark, quiet environment for a umbilicus.
neonate who is experiencing narcotic withdrawal.
▪ At 36 weeks’ gestation, the fundus is at the lower border
▪ In a premature neonate, signs of respiratory distress of the rib cage.
include nostril flaring, substernal retractions, and
inspiratory grunting. ▪ A premature neonate is one born before the end of the 37th
week of gestation.
▪ Respiratory distress syndrome (hyaline membrane
disease) develops in premature infants because their ▪ Pregnancy-induced hypertension is a leading cause of
pulmonary alveoli lack surfactant. maternal death in the United States.
▪ Whenever an infant is being put down to sleep, the parent
or caregiver should position the infant on the back. ▪ A habitual aborter is a woman who has had three or more
(Remember back to sleep.) consecutive spontaneous abortions.

▪ The male sperm contributes an X or a Y chromosome; the ▪ Threatened abortion occurs when bleeding is present
female ovum contributes an X chromosome. without cervical dilation.

▪ Fertilization produces a total of 46 chromosomes, ▪ A complete abortion occurs when all products of
including an XY combination (male) or an XX conception are expelled.
combination (female).
▪ Hydramnios (polyhydramnios) is excessive amniotic fluid
▪ The percentage of water in a neonate’ s body is about (more than 2,000 ml in the third trimester).
78% to 80%.
▪ Stress, dehydration, and fatigue may reduce a breast- ▪ Cutis marmorata is mottling or purple discoloration of the
feeding mother’ s milk supply. skin. It’ s a transient vasomotor response that occurs
primarily in the arms and legs of infants who are exposed
▪ During the transition phase of the first stage of labor, the to cold.
cervix is dilated 8 to 10 cm and contractions usually occur
2 to 3 minutes apart and last for 60 seconds. ▪ The classic triad of symptoms of preeclampsia are
hypertension, edema, and proteinuria. Additional
▪ A nonstress test is considered nonreactive (positive) if symptoms of severe preeclampsia include hyperreflexia,
fewer than two fetal heart rate accelerations of at least 15 cerebral and vision disturbances, and epigastric pain.
beats/minute occur in 20 minutes.
▪ Ortolani’ s sign (an audible click or palpable jerk that
▪ A nonstress test is considered reactive (negative) if two or occurs with thigh abduction) confirms congenital hip
more fetal heart rate accelerations of 15 beats/minute dislocation in a neonate.
above baseline occur in 20 minutes.
▪ The first immunization for a neonate is the hepatitis B
▪ A nonstress test is usually performed to assess fetal well- vaccine, which is administered in the nursery shortly after
being in a pregnant patient with a prolonged pregnancy birth.
(42 weeks or more), diabetes, a history of poor pregnancy
outcomes, or pregnancy-induced hypertension. ▪ If a patient misses a menstrual period while taking an oral
contraceptive exactly as prescribed, she should continue
▪ A pregnant woman should drink at least eight 8-oz glasses taking the contraceptive.
(about 2,000 ml) of water daily.
▪ If a patient misses two consecutive menstrual periods
▪ When both breasts are used for breast-feeding, the infant while taking an oral contraceptive, she should discontinue
usually doesn’ t empty the second breast. Therefore, the the contraceptive and take a pregnancy test.
second breast should be used first at the next feeding.
▪ If a patient who is taking an oral contraceptive misses a
▪ A low-birth-weight neonate weighs 2,500 g (5 lb 8 oz) or dose, she should take the pill as soon as she remembers or
less at birth. take two at the next scheduled interval and continue with
the normal schedule.
▪ A very-low-birth-weight neonate weighs 1,500 g (3 lb 5
oz) or less at birth. ▪ If a patient who is taking an oral contraceptive misses two
consecutive doses, she should double the dose for 2 days
▪ When teaching parents to provide umbilical cord care, the and then resume her normal schedule. She also should use
nurse should teach them to clean the umbilical area with a an additional birth control method for 1 week.
cotton ball saturated with alcohol after every diaper
change to prevent infection and promote drying. ▪ Eclampsia is the occurrence of seizures that aren’ t caused
by a cerebral disorder in a patient who has pregnancy -
▪ Teenage mothers are more likely to have low-birth-weigh t induced hypertension.
neonates because they seek prenatal care late in pregnancy
(as a result of denial) and are more likely than older ▪ In placenta previa, bleeding is painless and seldom fatal
mothers to have nutritional deficiencies. on the first occasion, but it becomes heavier with each
subsequent episode.
▪ Linea nigra, a dark line that extends from the umbilicus to
the mons pubis, commonly appears during pregnancy and ▪ Treatment for abruptio placentae is usually immediate
disappears after pregnancy. cesarean delivery.

▪ Implantation in the uterus occurs 6 to 10 days after ovum ▪ Drugs used to treat withdrawal symptoms in neonates
fertilization. include phenobarbital (Luminal), camphorated opium
tincture (paregoric), and diazepam (Valium).
▪ Placenta previa is abnormally low implantation of the
placenta so that it encroaches on or covers the cervical os. ▪ Infants with Down syndrome typically have marked
hypotonia, floppiness, slanted eyes, excess skin on the
▪ In complete (total) placenta previa, the placenta back of the neck, flattened bridge of the nose, f lat facial
completely covers the cervical os. features, spadelike hands, short and broad feet, small male
genitalia, absence of Moro’ s reflex, and a simian crease
▪ In partial (incomplete or marginal) placenta previa, the on the hands.
placenta covers only a portion of the cervical os.
▪ The failure rate of a contraceptive is determined by the
▪ Abruptio placentae is premature separation of a normally experience of 100 women for 1 year. It’ s expressed as
implanted placenta. It may be partial or complete, and pregnancies per 100 woman-years.
usually causes abdominal pain, vaginal bleeding, and a
boardlike abdomen. ▪ The narrowest diameter of the pelvic inlet is the
anteroposterior (diagonal conjugate).
 ▪ Preterm neonates or neonates who can’ t maintain a skin
▪ The chorion is the outermost extraembryonic membrane temperature of at least 97.6° F (36.4° C) should receive
that gives rise to the placenta. care in an incubator (Isolette) or a radiant warmer. In a
radiant warmer, a heat-sensitive probe taped to the
▪ The corpus luteum secretes large quantities of neonate’ s skin activates the heater unit automatically to
progesterone. maintain the desired temperature.

▪ From the 8th week of gestation through delivery, the ▪ During labor, the resting phase between contractions is at
developing cells are known as a fetus. least 30 seconds.

▪ In an incomplete abortion, the fetus is expelled, but parts ▪ Lochia rubra is the vaginal discharge of almost pure blood
of the placenta and membrane remain in the uterus. that occurs during the first few days after childbirth.

▪ The circumference of a neonate’ s head is normally 2 to 3 ▪ Lochia serosa is the serous vaginal discharge that occurs
cm greater than the circumference of the chest. 4 to 7 days after childbirth.

▪ After administering magnesium sulfate to a pregnant ▪ Lochia alba is the vaginal discharge of decreased blood
patient for hypertension or preterm labor, the nurse should and increased leukocytes that’ s the final stage of lochia.
monitor the respiratory rate and deep tendon reflexes. It occurs 7 to 10 days after childbirth.

▪ During the first hour after birth (the period of reactivity), ▪ Colostrum, the precursor of milk, is the first secretion
the neonate is alert and awake. from the breasts after delivery.

▪ When a pregnant patient has undiagnosed vaginal ▪ The length of the uterus increases from 2½" (6.3 cm)
bleeding, vaginal examination should be avoided until before pregnancy to 12½" (32 cm) at term.
ultrasonography rules out placenta previa.
▪ To estimate the true conjugate (the smallest inlet
▪ After delivery, the first nursing action is to establish the measurement of the pelvis), deduct 1.5 cm from the
neonate’ s airway. diagonal conjugate (usually 12 cm). A true conjugate of
10.5 cm enables the fetal head (usually 10 cm) to pass.
▪ Nursing interventions for a patient with placenta previa
include positioning the patient on her left side for ▪ The smallest outlet measurement of the pelvis is the
maximum fetal perfusion, monitoring fetal heart tones, intertuberous diameter, which is the transverse diameter
and administering I.V. fluids and oxygen, as ordered. between the ischial tuberosities.

▪ The specific gravity of a neonate’ s urine is 1.003 to ▪ Electronic fetal monitoring is used to assess fetal well-
1.030. A lower specific gravity suggests overhydration; a being during labor. If compromised fetal status is
higher one suggests dehydration. suspected, fetal blood pH may be evaluated by obtaining
a scalp sample.
▪ The neonatal period extends from birth to day 28. It’ s
also called the first 4 weeks or first month of life. ▪ In an emergency delivery, enough pressure should be
applied to the emerging fetus’ s head to guide the descent
▪ A woman who is breast-feeding should rub a mild and prevent a rapid change in pressure within the molded
emollient cream or a few drops of breast milk (or fetal skull.
colostrum) on the nipples after each feeding. She should
let the breasts air-dry to prevent them from cracking. ▪ After delivery, a multiparous woman is more susceptible
to bleeding than a primiparous woman because her uterine
▪ Breast-feeding mothers should increase their fluid intake muscles may be overstretched and may not contract
to 2½ to 3 qt (2,500 to 3,000 ml) daily. efficiently.

▪ After feeding an infant with a cleft lip or palate, the nurse ▪ Neonates who are delivered by cesarean birth have a
should rinse the infant’ s mouth with sterile water. higher incidence of respiratory distress syndrome.

▪ The nurse instills erythromycin in a neonate’ s eyes ▪ The nurse should suggest ambulation to a postpartum
primarily to prevent blindness caused by gonorrhea or patient who has gas pain and flatulence.
chlamydia.
▪ Massaging the uterus helps to stimulate contractions after
▪ Human immunodeficiency virus (HIV) has been cultured the placenta is delivered.
in breast milk and can be transmitted by an HIV-positive
mother who breast-feeds her infant. ▪ When providing phototherapy to a neonate, the nurse
should cover the neonate’ s eyes and genital area.
▪ A fever in the first 24 hours postpartum is most likely
caused by dehydration rather than infection.
▪ The narcotic a ntagonist naloxone (Narcan) may be given contractions are felt in the front of the abdomen and back
to a neonate to correct respiratory depression caused by and lead to progressive cervical dilation and effacement.
narcotic administration to the mother during labor.
▪ The average birth weight of neonates born to mothers who
▪ In a neonate, symptoms of respiratory distress syndrome smoke is 6 oz (170 g) less than that of neonates born to
include expiratory grunting or whining, sandpaper breath nonsmoking mothers.
sounds, and seesaw retractions.
▪ Culdoscopy is visualization of the pelvic organs through
▪ Cerebral palsy presents as asymmetrical movement, the posterior vaginal fornix.
irritability, and excessive, feeble crying in a long, thin
infant. ▪ The nurse should teach a pregnant vegetarian to obtain
protein from alternative sources, such as nuts, soybeans,
▪ The nurse should assess a breech-birth neonate for and legumes.
hydrocephalus, hematomas, fractures, and other
anomalies caused by birth trauma. ▪ The nurse should instruct a pregnant patient to take only
prescribed prenatal vitamins because over-the-counter
▪ When a patient is admitted to the unit in active labor, the high-potency vitamins may harm the fetus.
nurse’ s first action is to listen for fetal heart tones.
▪ High-sodium foods can cause fluid retention, especially in
▪ In a neonate, long, brittle fingernails are a sign of pregnant patients.
postmaturity.
▪ A pregnant patient can avoid constipation and
▪ Desquamation (skin peeling) is common in postmature hemorrhoids by adding fiber to her diet.
neonates.
▪ If a fetus has late decelerations (a sign of fetal hypoxia),
▪ A mother should allow her infant to breast-feed until the the nurse should instruct the mother to lie on her left side
infant is satisfied. The time may vary from 5 to 20 and then administer 8 to 10 L of oxygen per minute by
minutes. mask or cannula. The nurse should notify the physician.
The side-lying position removes pressure on the inferior
▪ Nitrazine paper is used to test the pH of vaginal discharge vena cava.
to determine the presence of amniotic fluid.
▪ Oxytocin (Pitocin) promotes lactation and uterine
▪ A pregnant patient normally gains 2 to 5 lb (1 to 2.5 kg) contractions.
during the first trimester and slightly less than 1 lb (0.5
kg) per week during the last two trimesters. ▪ Lanugo covers the fetus’ s body until about 20 weeks’
gestation. Then it begins to disappear from the face, trunk,
▪ Neonatal jaundice in the first 24 hours after birth is known arms, and legs, in that order.
as pathological jaundice and is a sign of erythroblastosis
fetalis. ▪ In a neonate, hypoglycemia causes temperature
instability, hypotonia, jitteriness, and seizures. Premature,
▪ A classic difference between abruptio placentae and postmature, small-for-gestational-age, and large-for-
placenta previa is the degree of pain. Abruptio placentae gestational-age neonates are susceptible to this disorder.
causes pain, whereas placenta previa causes painless
bleeding. ▪ Neonates typically need to consume 50 to 55 cal per
pound of body weight daily.
▪ Because a major role of the placenta is to function as a
fetal lung, any condition that interrupts normal blood flow ▪ Because oxytocin (Pitocin) stimulates powerful uterine
to or from the placenta increases fetal partial pressure of contractions during labor, it must be administered under
arterial carbon dioxide and decreases fetal pH. close observation to help prevent maternal and fetal
distress.
▪ Precipitate labor lasts for approximately 3 hours and ends
with delivery of the neonate. ▪ During fetal heart rate monitoring, variable decelerations
indicate compression or prolapse of the umbilical cord.
▪ Methylergonovine (Methergine) is an oxytocic agent used
to prevent and treat postpartum hemorrhage caused by ▪ Cytomegalovirus is the leading cause of congenital viral
uterine atony or subinvolution. infection.

▪ As emergency treatment for excessive uterine bleeding, ▪ Tocolytic therapy is indicated in premature labor, but
0.2 mg of methylergonovine (Methergine) is injected I.V. contraindicated in fetal death, fetal distress, or severe
over 1 minute while the patient’ s blood pressure and hemorrhage.
uterine contractions are monitored.
▪ Through ultrasonography, the biophysical profile assesses
▪ Braxton Hicks contractions are usually felt in the fetal well-being by measuring fetal breathing movements,
abdomen and don’ t cause cervical change. True labor
 gross body movements, fetal tone, reactive fetal heart rate outweigh its risks; and X, fetal anomalies noted, and the
(nonstress test), and qualitative amniotic fluid volume. risks clearly outweigh the potential benefits.

▪ A neona te whose mother has diabetes should be assessed ▪ A patient with a ruptured ectopic pregnancy commonly
for hyperinsulinism. has sharp pain in the lower abdomen, with spotting and
cramping. She may have abdominal rigidity; rapid,
▪ In a patient with preeclampsia, epigastric pain is a late shallow respirations; tachycardia; and shock.
symptom and requires immediate medical intervention.
▪ A patient with a ruptured ectopic pregnancy commonly
▪ After a stillbirth, the mother should be allowed to hold the has sharp pain in the lower abdomen, with spotting and
neonate to help her come to terms with the death. cramping. She may have abdominal rigidity; rapid,
shallow respirations; tachycardia; and shock.
▪ Molding is the process by which the fetal head changes
shape to facilitate movement through the birth canal. ▪ The mechanics of delivery are engagement, descent and
flexion, internal rotation, extension, external rotation,
▪ If a woman receives a spinal block before delivery, the restitution, and expulsion.
nurse should monitor the patient’ s blood pressure
closely. ▪ A probable sign of pregnancy, McDonald’ s sign is
characterized by an ease in flexing the body of the uterus
▪ If a woman suddenly becomes hypotensive during labor, against the cervix.
the nurse should increase the infusion rate of I.V. fluids as
prescribed. ▪ Amenorrhea is a probable sign of pregnancy.

▪ The best technique for assessing jaundice in a neonate is ▪ A pregnant woman’ s partner should avoid introducing
to blanch the tip of the nose or the area just abo ve the air into the vagina during oral sex because of the
umbilicus. possibility of air embolism.

▪ During fetal heart monitoring, early deceleration is caused ▪ The presence of human chorionic gonadotropin in the
by compression of the head during labor. blood or urine is a probable sign of pregnancy.
▪ Radiography isn’ t usually used in a pregnant woman
▪ After the placenta is delivered, the nurse may add because it may harm the developing fetus. If radiography
oxytocin (Pitocin) to the patient’ s I.V. solution, as is essential, it should be performed only after 36 weeks’
prescribed, to promote postpartum involution of the uterus gestation.
and stimulate lactation.
▪ A pregnant patient who has had rupture of the membranes
▪ Pica is a craving to eat nonfood items, such as dirt, or who is experiencing vagina l bleeding shouldn’ t
crayons, chalk, glue, starch, or hair. It may occur during engage in sexual intercourse.
pregnancy and can endanger the fetus.
▪ Milia may occur as pinpoint spots over a neonate’ s nose.
▪ A pregnant patient should take folic acid because this
nutrient is required for rapid cell division. ▪ The duration of a contraction is timed from the moment
that the uterine muscle begins to tense to the moment that
▪ A woman who is taking clomiphene (Clomid) to induce it reaches full relaxation. It’ s measured in seconds.
ovulation should be informed of the possibility of multiple
births with this drug. ▪ The union of a male and a female gamete produces a
zygote, which divides into the fertilized ovum.
▪ If needed, cervical suturing is usually done between 14
and 18 weeks’ gestation to reinforce an incompetent ▪ The first menstrual flow is called menarche and may be
cervix and maintain pregnancy. The suturing is typically anovulatory (infertile).
removed by 35 weeks’ gestation.
▪ During the first trimester, a pregnant woman should avoid ▪ Spermatozoa (or their fragments) remain in the vagina for
all drugs unless doing so would adversely affect her 72 hours after sexual intercourse.
health.
▪ Prolactin stimulates and sustains milk production.
▪ Most drugs that a breast-feeding mother takes appear in
breast milk. ▪ Strabismus is a normal finding in a neonate.

▪ The Food and Drug Administration has established the ▪ A postpartum patient may resume sexual intercourse after
following five categories of drugs based on their potential the perineal or uterine wounds heal (usually within 4
for causing birth defects: A, no evidence of risk; B, no risk weeks after delivery).
found in animals, but no studies have been done in
women; C, animal studies have shown an adverse effect, ▪ A pregnant staff member shouldn’ t be assigned to work
but the drug may be beneficial to women despite the with a patient who has cytomegalovirus infection because
potential risk; D, evidence of risk, but its benefits may the virus can be transmitted to the fetus.
 ▪ The duration of pregnancy averages 280 days, 40 weeks,
▪ Fetal demise is death of the fetus after viability. 9 calendar months, or 10 lunar months.

▪ Respiratory distress syndrome develops in premature ▪ The initia l weight loss for a healthy neonate is 5% to 10%
neonates because their alveoli lack surfactant. of birth weight.

▪ The most common method of inducing labor after ▪ The normal hemoglobin value in neonates is 17 to 20 g/dl.
artificial rupture of the membranes is oxytocin (Pitocin )
infusion. ▪ Crowning is the appearance of the fetus’ s head when its
largest diameter is encircled by the vulvovaginal ring.
▪ After the amniotic membranes rupture, the initial nursing
action is to assess the fetal heart rate. ▪ A multipara is a woman who has had two or more
pregnancies that progressed to viability, regardless of
▪ The most common reasons for cesarean birth are whether the offspring were alive at birth.
malpresentation, fetal distress, cephalopelvic
disproportion, pregnancy-induced hypertension, previous ▪ In a pregnant patient, preeclampsia may progress to
cesarean birth, and inadequate progress in labor. eclampsia, which is characterized by seizures and may
lead to coma.
▪ Amniocentesis increases the risk of spontaneous abortion,
trauma to the fetus or placenta, premature labor, infection, ▪ The Apgar score is used to assess the neonate’ s vital
and Rh sensitization of the fetus. functions. It’ s obtained at 1 minute and 5 minutes after
delivery. The score is based on respiratory effort, heart
▪ After amniocentesis, abdominal cramping or spontaneous rate, muscle tone, reflex irritability, and color.
vaginal bleeding may indicate complications.
▪ Because of the anti-insulin effects of placental hormones,
▪ To prevent her from developing Rh antibodies, an Rh- insulin requirements increase during the third trimester.
negative primigravida should receive Rho(D) immune
globulin (RhoGAM) after delivering an Rh-positive ▪ Gestational age can be estimated by ultrasound
neonate. measurement of maternal abdominal circumference, fetal
femur length, and fetal head size. These measurements are
▪ If a pregnant patient’ s test results are negative for glucose most accurate between 12 and 18 weeks’ gestation.
but positive for acetone, the nurse should assess the
patient’ s diet for inadequate caloric intake. ▪ Skeletal system abnormalities and ventricular septal
defects are the most common disorders of infants who are
▪ If a pregnant patient’ s test results are negative for glucose born to diabetic women. The incidence of congenital
but positive for acetone, the nurse should assess the malformation is three times higher in these infants than in
patient’ s diet for inadequate caloric intake. those born to nondiabetic women.

▪ Rubella infection in a pregnant patient, especially during ▪ Skeletal system abnormalities and ventricular septal
the first trimester, can lead to spontaneous abortion or defects are the most common disorders of infants who are
stillbirth as well as fetal cardiac and other birth defects. born to diabetic women. The incidence of congenital
malformation is three times higher in these infants than in
▪ A pregnant patient should take an iron supplement to help those born to nondiabetic women.
prevent anemia.
▪ The patient with preeclampsia usually has puffiness
▪ Direct antiglobulin (direct Coombs’ ) test is used to detect around the eyes or edema in the hands (for example, “ I
maternal antibodies attached to red blood cells in the can’ t put my wedding ring on.” ).
neonate.
▪ Kegel exercises require contraction and relaxation of the
▪ Nausea and vomiting during the first trimester of perineal muscles. These exercises help strengthen pelvic
pregnancy are caused by rising levels of the hormone muscles and improve urine control in postpartum patients.
human chorionic gonadotropin.
▪ Symptoms of postpartum depression range from mild
▪ Before discharging a patient who has had an abortion, the postpartum blues to intense, suicidal, depressive
nurse should instruct her to report bright red clots, psychosis.
bleeding that lasts longer than 7 days, or signs of infection,
such as a temperature of greater than 100° F (37.8° C), ▪ The preterm neonate may require gavage feedings
foul-smelling vaginal discharge, severe uterine cramping, because of a weak sucking reflex, uncoordinated sucking,
nausea, or vomiting. or respiratory distress.

▪ When informed that a patient’ s amniotic membrane has ▪ Acrocyanosis (blueness and coolness of the arms and legs)
broken, the nurse should check fetal heart tones and then is normal in neonates because of their immature peripheral
maternal vital signs. circulatory system.
▪ To prevent ophthalmia neonatorum (a severe eye infection ▪ The presence of meconium in the amniotic fluid during
caused by maternal gonorrhea), the nurse may administer labor indicates possible fetal distress and the need to
one of three drugs, as prescribed, in the neonate’ s eyes: evaluate the neonate for meconium aspiration.
tetracycline, silver nitrate, or erythromycin.
▪ Neonatal testing for phenylketonuria is mandatory in most ▪ To assess a neonate’ s rooting reflex, the nurse touches a
states. finger to the cheek or the corner of the mouth. Normally,
the neonate turns his head toward the stim ulus, opens his
▪ The nurse should place the neonate in a 30 -degree mouth, and searches for the stimulus.
Trendelenburg position to facilitate mucus drainage.
▪ Harlequin sign is present when a neonate who is lying on
▪ The nurse may suction the neonate’ s nose and mouth as his side appears red on the dependent side and pale on the
needed with a bulb syringe or suction trap. upper side.

▪ To prevent heat loss, the nurse should place the neonate ▪ Mongolian spots can range from brown to blue. Their
under a radiant warmer during suctioning and initial color depends on how close melanocytes are to the surface
delivery-room care, and then wrap the neonate in a of the skin. They most commonly appear as patches across
warmed blanket for transport to the nursery. the sacrum, buttocks, and legs.

▪ The umbilical cord normally has two arteries and one ▪ Mongolian spots are common in non-white infants and
vein. usually disappear by age 2 to 3 years.

▪ When providing care, the nurse should expose only one ▪ Vernix caseosa is a cheeselike substance that covers and
part of an infant’ s body at a time. protects the fetus’ s skin in utero. It may be rubbed into
the neonate’ s skin or washed away in one or two baths.
▪ Lightening is settling of the fetal head into the brim of the
pelvis. ▪ Caput succedaneum is edema that develops in and under
the fetal scalp during labor and delivery. It resolves
▪ If the neonate is stable, the mother should be allowed to spontaneously and presents no danger to the neonate. The
breast-feed within the neonate’ s first hour of life. edema doesn’ t cross the suture line.

▪ The nurse should check the neonate’ s temperature every ▪ Nevus flammeus, or port-wine stain, is a diffuse pink to
1 to 2 hours until it’ s maintained within normal limits. dark bluish red lesion on a neonate’ s face or neck.
▪ At birth, a neonate normally weighs 5 to 9 lb (2 to 4 kg),
measures 18" to 22" (45.5 to 56 cm) in length, has a head ▪ The Guthrie test (a screening test for phenylketonuria) is
circumference of 13½" to 14" (34 to 35.5 cm), and has a most reliable if it’ s done between the second and sixth
chest circumference that’ s 1" (2.5 cm) less than the head days after birth and is performed after the neonate has
circumference. ingested protein.

▪ In the neonate, temperature normally ranges from 98° to ▪ To assess coordination of sucking and swallowing, the
99° F (36.7° to 37.2° C), apical pulse rate averages 120 to nurse should observe the neonate’ s first breast-feeding or
160 beats/minute, and respirations are 40 to 60 sterile water bottle-feeding.
breaths/minute.
▪ To establish a milk supply pattern, the mother should
▪ The diamond-shaped anterior fontanel usually closes breast-feed her infant at least every 4 hours. During the
between ages 12 and 18 months. The triangular posterior first month, she should breast-feed 8 to 12 times daily
fontanel usually closes by age 2 months. (demand feeding).

▪ In the neonate, a straight spine is normal. A tuft of hair ▪ To avoid contact with blood and other body fluids, the
over the spine is an abnormal finding. nurse should wear gloves when handling the neonate until
after the first bath is given.
▪ Prostaglandin gel may be applied to the vagina or cervix
to ripen an unfavorable cervix before labor induction with ▪ If a breast-fed infant is content, has good skin turgor, an
oxytocin (Pitocin). adequate number of wet diapers, and normal weight gain,
the mother’ s milk supply is assumed to be adequate.
▪ Supernumerary nipples are occasionally seen on neonates.
They usually appear along a line that runs from each ▪ In the supine position, a pregnant patient’ s enlarged
axilla, through the normal nipple area, and to the groin. uterus impairs venous return from the lower half of the
body to the heart, resulting in supine hypotensive
▪ Meconium is a material that collects in the fetus’ s syndrome, or inferior vena cava syndrome.
intestines and forms the neonate’ s first feces, which are
black and tarry. ▪ Tocolytic agents used to treat preterm labor include
terbutaline (Brethine), ritodrine (Yutopar), and
magnesium sulfate.
▪ A pregnant woman who has hyperemesis gravidarum may ▪ F/T: Full-term delivery at 38 weeks or longer
require hospitalization to treat dehydration and starvation. ▪ P: Preterm delivery between 20 and 37 weeks
▪ A: Abortion or loss of fetus before 20 weeks
▪ Diaphragmatic hernia is one of the most urgent neonatal ▪ L: Number of children living (if a child has died, further
surgical emergencies. By compressing and displacing the explanation is needed to clarify the discrepancy in
lungs and heart, this disorder can cause respiratory numbers).
distress shortly after birth.
▪ Parity doesn’ t refer to the number of infants delivered,
▪ Common complications of early pregnancy (up to 20 only the number of deliveries.
weeks’ gestation) include fetal loss and serious threats to
maternal health. ▪ Women who are carrying more than one fetus should be
encouraged to gain 35 to 45 lb (15.5 to 20.5 kg) during
▪ Fetal embodiment is a maternal developmental task that pregnancy.
occurs in the second trimester. During this stage, the
mother may complain that she never gets to sleep because ▪ The recommended amount of iron supplement for the
the fetus always gives her a thump when she tries. pregnant patient is 30 to 60 mg daily.

▪ Visualization in pregnancy is a process in which the ▪ Drinking six alcoholic beverages a day or a single episode
mother imagines what the child she’ s carrying is like and of binge drinking in the first trimester can cause fetal
becomes acquainted with it. alcohol syndrome.
▪ Chorionic villus sampling is performed at 8 to 12 weeks
▪ Hemodilution of pregnancy is the increase in blood of pregnancy for early identification of genetic defects.
volume that occurs during pregnancy. The increased
volume consists of plasma and causes an imbalance ▪ In percutaneous umbilical blood sampling, a blood sample
between the ratio of red blood cells to plasma and a is obtained from the umbilical cord to detect anemia,
resultant decrease in hematocrit. genetic defects, and blood incompatibility as well as to
assess the need for blood transfusions.
▪ Mean arterial pressure of greater than 100 mm Hg after 20
weeks of pregnancy is considered hypertension. ▪ The period between contractions is referred to as the
interval, or resting phase. During this phase, the uterus and
▪ The treatment for supine hypotension syndrome (a placenta fill with blood and allow for the exchange of
condition that sometimes occurs in pregnancy) is to have oxygen, carbon dioxide, and nutrients.
the patient lie on her left side.
▪ In a patient who has hypertonic contractions, the uterus
▪ A contributing factor in dependent edema in the pregnant doesn’ t have an opportunity to relax and there is no
patient is the increase of femoral venous pressure from 10 interval between contractions. As a result, the fetus may
mm Hg (normal) to 18 mm Hg (high). experience hypoxia or rapid delivery may occur.

▪ Hyperpigmentation of the pregnant patient’ s face, ▪ Two qualities of the myometrium are elasticity, which
formerly called chloasma and now referred to as melasma, allows it to stretch yet maintain its tone, and contractility,
fades after delivery. which allows it to shorten and lengthen in a synchronized
pattern.
▪ The hormone relaxin, which is secreted first by the corpus
luteum and later by the placenta, relaxes the connective ▪ During crowning, the presenting part of the fetus remains
tissue and cartilage of the symphysis pubis and the visible during the interval between contractions.
sacroiliac joint to facilitate passage of the fetus during
delivery. ▪ Uterine atony is failure of the uterus to remain firmly
contracted.
▪ Progesterone maintains the integrity of the pregnancy by
inhibiting uterine motility. ▪ The major cause of uterine atony is a full bladder.

▪ Ladin’ s sign, an early indication of pregnancy, causes ▪ If the mother wishes to breast-feed, the neonate should be
softening of a spot on the anterior portion of the uterus, nursed as soon as possible after delivery.
just above the uterocervical juncture.
▪ A smacking sound, milk dripping from the side of the
▪ During pregnancy, the abdominal line from the symphysis mouth, and sucking noises all indicate improper
pubis to the umbilicus changes from linea alba to linea placement of the infant’ s mouth over the nipple.
nigra.
▪ Before feeding is initiated, an infant should be burped to
▪ In neonates, cold stress affects the circulatory, regulatory, expel air from the stomach.
and respiratory systems.
▪ Most authorities strongly encourage the continuation of
▪ Obstetric data can be described by using the F/TPAL breast-feeding on both the affected and the unaffected
system: breast of patients with mastitis.
 ▪ Infants of diabetic mothers are susceptible to macrosomia
▪ Neonates are nearsighted and focus on items that are held as a result of increased insulin production in the fetus.
10" to 12" (25 to 30.5 cm) away.
▪ To prevent heat loss in the neonate, the nurse should bathe
▪ In a neonate, low-set ears are associated with one part of his body at a time and keep the rest of the body
chromosomal abnormalities such as Down syndrome. covered.

▪ Meconium is usually passed in the first 24 hours; ▪ A patient who has a cesarean delivery is at greater risk for
however, passage may take up to 72 hours. infection than the patient who gives birth vaginally.

▪ Boys who are born with hypospadias shouldn ’ t be ▪ The occurrence of thrush in the neonate is probably caused
circumcised at birth because the foreskin may be needed by contact with the organism during delivery through the
for constructive surgery. birth canal.

▪ In the neonate, the normal blood glucose level is 45 to 90 ▪ The nurse should keep the sac of meningomyelocele moist
mg/dl. with normal saline solution.

▪ Hepatitis B vaccine is usually given within 48 hours of ▪ If fundal height is at least 2 cm less than expected, the
birth. cause may be growth retardation, missed abortion,
transverse lie, or false pregnancy.
▪ Hepatitis B immune globulin is usually given within 12
hours of birth. ▪ Fundal height that exceeds expectations by more than 2
cm may be caused by multiple gestation, polyhydramnios,
▪ HELLP (hemolysis, elevated liver enzymes, and low uterine myomata, or a large baby.
platelets) syndrome is an unusual variation of pregnancy -
induced hypertension. ▪ A major developmental task for a woman during the first
trimester of pregnancy is accepting the pregnancy.
▪ Maternal serum alpha -fetoprotein is detectable at 7 weeks
of gestation and peaks in the third trimester. High levels ▪ Unlike formula, breast milk offers the benefit of maternal
detected between the 16th and 18th weeks are associated antibodies.
with neural tube defects. Low levels are associated with
Down syndrome. ▪ Spontaneous rupture of the membranes increases the risk
of a prolapsed umbilical cord.
▪ An arrest of descent occurs when the fetus doesn ’ t
descend through the pelvic cavity during labor. It’ s ▪ A clinical manifestation of a prolapsed umbilical cord is
commonly associated with cephalopelvic disproportion, variable decelerations.
and cesarean delivery may be required.
▪ During labor, to relieve supine hypotension manifested by
▪ A late sign of preeclampsia is epigastric pain as a result of nausea and vomiting and paleness, turn the patient on her
severe liver edema. left side.

▪ In the patient with preeclampsia, blood pressure returns to ▪ If the ovum is fertilized by a spermatozoon carrying a Y
normal during the puerperal period. chromosome, a male zygote is formed.

▪ To obtain an estriol level, urine is collected for 24 hours. ▪ Implantation occurs when the cellular walls of the
blastocyte implants itself in the endometrium, usually 7 to
▪ An estriol level is used to assess fetal well-being and 9 days after fertilization.
maternal renal functioning as well as to monitor a
pregnancy that’ s complicated by diabetes. ▪ Implantation occurs when the cellular walls of the
blastocyte implants itself in the endometrium, usually 7 to
▪ A pregnant patient with vaginal bleeding shouldn’ t have 9 days after fertilization.
a pelvic examination.
▪ Heart development in the embryo begins at 2 to 4 weeks
▪ In the early stages of pregnancy, the finding of glucose in and is complete by the end of the embryonic stage.
the urine may be related to the increased shunting of
glucose to the developing placenta, without a ▪ Methergine stimulates uterine contractions.
corresponding increase in the reabsorption capability of
the kidneys. ▪ The administration of folic acid during the early stages of
gestation may prevent neural tube defects.
▪ A patient who has premature rupture of the membranes is
at significant risk for infection if labor doesn’ t begin ▪ With advanced maternal age, a common genetic problem
within 24 hours. is Down syndrome.
▪ With early maternal age, cephalopelvic disproportion ▪ Breast-feeding of a premature neonate born at 32 weeks’
commonly occurs. gestation can be accomplished if the mother expresses
milk and feeds the neonate by gavage.
▪ In the early postpartum period, the fundus should be
midline at the umbilicus. ▪ If a pregnant patient’ s rubella titer is less than 1:8, she
should be immunized after delivery.
▪ A rubella vaccine shouldn’ t be given to a pregnant
woman. The vaccine can be administered after delivery, ▪ The administration of oxytocin (Pitocin) is stopped if the
but the patient should be instructed to avoid becoming contractions are 90 seconds or longer.
pregnant for 3 months.
▪ For an extramural delivery (one that takes place outside of
▪ A 16-year-old girl who is pregnant is at risk for having a a normal delivery center), the priorities for care of the
low-birth-weight neonate. neonate include maintaining a patent airway, supporting
efforts to breathe, monitoring vital signs, and maintaining
▪ The mother’ s Rh factor should be determined before an adequate body temperature.
amniocentesis is performed.
▪ Subinvolution may occur if the bladder is distended after
▪ Maternal hypotension is a complication of spinal block. delivery.

▪ After delivery, if the fundus is boggy and deviated to the ▪ The nurse must place identification bands on both the
right side, the patient should empty her bladder. mother and the neonate before they leave the delivery
room.
▪ Before providing a specimen for a sperm count, the patient
should avoid ejaculation for 48 to 72 hours. ▪ Erythromycin is given at birth to prevent ophthalmia
neonatorum.
▪ The hormone human chorionic gonadotropin is a marker
for pregnancy. ▪ Pelvic-tilt exercises can help to prevent or relieve
backache during pregnancy.
▪ Painless vaginal bleeding during the last trimester of
pregnancy may indicate placenta previa. ▪ Before performing a Leopold maneuver, the nurse should
ask the patient to empty her bladder.
▪ During the transition phase of labor, the woman usually is
irritable and restless.

▪ Because women with diabetes have a higher incidence of MEDICAL SURGICAL NURSING
birth anomalies than women without diabetes, an alpha-
fetoprotein level may be ordered at 15 to 17 weeks’ In a patient with hypokalemia (serum potassium level below
gestation. 3.5 mEq/L), presenting signs and symptoms include muscle
weakness and cardiac arrhythmias.
▪ To avoid puncturing the placenta, a vaginal examination
shouldn’ t be performed on a pregnant patient who is During cardiac arrest, if an I.V. route is unavailable,
bleeding. epinephrine can be administered endotracheally.

▪ A patient who has postpartum hemorrhage caused by Pernicious anemia results from the failure to absorb vitamin
uterine atony should be given oxytocin as prescribed. B12 in the GI tract and causes primarily GI and neurologic
signs and symptoms.
▪ Laceration of the vagina, cervix, or perineum produces
bright red bleeding that often comes in spurts. The A patient who has a pressure ulcer should consume a high -
bleeding is continuous, even when the fundus is firm. protein, high-calorie diet, unless contraindicated.

▪ Hot compresses can help to relieve breast tenderness after The CK-MB isoenzyme level is used to assess tissue
breast-feeding. damage in myocardial infarction.

▪ The fundus of a postpartum patient is massaged to After a 12-hour fast, the normal fasting blood glucose level
stimulate contraction of the uterus and prevent is 80 to 120 mg/dl.
hemorrhage.
A patient who is experiencing digoxin toxicity may report
▪ A mother who has a positive human immunodeficiency nausea, vomiting, diplopia, blurred vision, light flashes, and
virus test result shouldn’ t breast-feed her infant. yellow-green halos around images.

▪ Dinoprostone (Cervidil) is used to ripen the cervix. Anuria is daily urine output of less than 100 ml.

In remittent fever, the body temperature varies over a 24-

hour period, but remains elevated.
 Risk of a fat embolism is greatest in the first 48 hours after
the fracture of a long bone. It’ s manifested by respiratory For a patient who has heart failure or cardiogenic
distress. pulmonary edema, nursing interventions focus on decreasing
venous return to the heart and increasing left ventricular
To help venous blood return in a patient who is in shock, output. These interventions include placing the patient in
the nurse should elevate the patient’ s legs no more than 45 high Fowler’ s position and administering oxygen, diuretics,
degrees. This procedure is contraindicated in a patient with a and positive inotropic drugs as prescribed.
head injury.
A positive tuberculin skin test is an induration of 10 mm or
The pulse deficit is the difference between the apical and greater at the injection site.
radial pulse rates, when taken simultaneously by two nurses.
The signs and symptoms of histoplasmosis, a chronic
systemic fungal infection, resemble those of tuberculosis.
To reduce the patient’ s risk of vomiting and aspiration, the
nurse should schedule postural drainage before meals or 2 to In burn victims, the leading cause of death is respiratory
4 hours after meals. compromise. The second leading cause is infection.

Blood pressure can be measured directly by intra -arterial The exocrine function of the pancreas is the secretion of
insertion of a catheter connected to a pressure-monitoring enzymes used to digest carbohydrates, fats, and proteins.
device.
A patient who has hepatitis A (infectious hepatitis) should
A positive Kernig’ s sign, seen in meningitis, occurs when consume a diet that’ s moderately high in fat and high in
an attempt to flex the hip of a recumbent patient causes carbohydrate and protein, and should eat the largest meal in
painful spasms of the hamstring muscle and resistance to the morning.
further extension of the leg at the knee.
Esophageal balloon tamponade shouldn’ t be inflated
In a patient with a fractured, dislocated femur, treatment greater than 20 mm Hg.
begins with reduction and immobilization of the affected
leg. Overproduction of prolactin by the pituitary gland can
cause galactorrhea (excessive or abnormal lactation) and
Herniated nucleus pulposus (intervertebral disk) most amenorrhea (absence of menstruation).
commonly occurs in the lumbar and lumbosacral regions.
Intermittent claudication (pain during ambulation or other
Laminectomy is surgical removal of the herniated portion movement that’ s relieved with rest) is a classic symptom of
of an intervertebral disk. arterial insufficiency in the leg.
In bladder carcinoma, the most common finding is gross,
Surgical treatment of a gastric ulcer includes severing the painless hematuria.
vagus nerve (vagotomy) to reduce the amount of gastric acid
secreted by the gastric cells. Parenteral administration of heparin sodium is
contraindicated in patients with renal or liver disease, GI
Valsalva ’ s maneuver is forced exhalation a gainst a closed bleeding, or recent surgery or trauma; in pregnant patients;
glottis, as when taking a deep breath, blowing air out, or and in women older than age 60.
bearing down.
Drugs that potentiate the effects of anticoagulants include
When mean arterial pressure falls below 60 mm Hg and aspirin, chloral hydrate, glucagon, anabolic steroids, and
systolic blood pressure falls below 80 mm Hg, vital organ chloramphenicol.
perfusion is seriously compromised.
For a burn patient, care priorities include maintaining a
Lidocaine (Xylocaine) is the drug of choice for reducing patent airway, preventing or correcting fluid and electrolyte
premature ventricular contractions. imbalances, controlling pain, and preventing infection.

A patient is at greatest risk of dying during the first 24 to 48 Elastic stockings should be worn on both legs.
hours after a myocardial infarction.
Active immunization is the formation of antibodies with in
During a myocardial infarction, the left ventricle usually the body in response to vaccination or exposure to disease.
sustains the greatest damage.
The pain of a myocardial infarction results from myocardial Passive immunization is administration of antibodies that
ischemia caused by anoxia. were preformed outside the body.

For a patient in cardiac arrest, the first priority is to A patient who is receiving digoxin (Lanoxin) shouldn’ t
establish an airway. receive a calcium preparation because of the increased risk
of digoxin toxicity. Concomitant use may affect cardiac
The universal sign for choking is clutching the hand to the contractility and lead to arrhythmias.
throat.
 Intermittent positive-pressure breathing is inflation of the monitor the partial thromboplastin time.
lung during inspiration with compressed air or oxygen. The
goal of this inflation is to keep the lung open. Urinary frequency, incontinence, or both can occur after
catheter removal. Incontinence may be manifested as
Wristdrop is caused by paralysis of the extensor muscles in dribbling.
the forearm and hand.
When teaching a patient about colostomy care, the nurse
Footdrop results from excessive plantar flexion and is should instruct the patient to hang the irrigation reservoir
usually a complication of prolonged bed rest. 18" to 22" (45 to 55 cm) above the stoma, insert the catheter
2" to 4" (5 to 10 cm) into the stoma, irrigate the stoma with
A patient who has gonorrhea may be treated with penicillin 17 to 34 oz (503 to 1,005 ml) of water at a temperature of
and probenecid (Benemid). Probenecid delays the excretion 105° to 110° F (40° to 43° C) once a day, clean the area
of penicillin and keeps this antibiotic in the body longer. around the stoma with soap and water before applying a new
In patients who have glucose-6-phosphate dehydrogenase bag, and use a protective skin covering, such as a
(G6PD) deficiency, the red blood cells can’ t metabolize Stomahesive wafer, karaya paste, or karaya ring, around the
adequate amounts of glucose, and hemolysis occurs. stoma.

On-call medication is medication that should be ready for The first sign of Hodgkin’ s disease is painless, superficial
immediate administration when the call to administer it’ s lymphadenopathy, typically found under one arm or on one
received. side of the neck in the cervical chain.

If gagging, nausea, or vomiting occurs when an airway is To differentiate true cyanosis from deposition of certain
removed, the nurse should place the patient in a lateral pigments, the nurse should press the skin over the discolored
position with the upper arm supported on a pillow. area. Cyanotic skin blanches, but pigmented skin doesn ’ t.

When a postoperative patient arrives in the recovery room, A patient who has a gastric ulcer is most likely to report
the nurse should position the patient on his side or with his pain during or shortly after eating.
head turned to the side and the chin extended.
Widening pulse pressure is a sign of increasing intracranial
In the immediate postoperative period, the nurse should pressure. For example, the blood pressure may rise from
report a respiratory rate greater than 30, temperature greater 120/80 to 160/60 mm Hg.
than 100° F (37.8° C) or below 97° F (36.1° C), or a In a burn victim, a primary goal of wound care is to prevent
significant drop in blood pressure or rise in pulse rate from contamination by microorganisms.
the baseline.
To prevent external rotation in a patient who has had hip
Irreversible brain damage may occur if the central nervous nailing, the nurse places trochanter rolls from the knee to the
system is deprived of oxygen for more than 4 minutes. ankle of the affected leg.

Treatment for polycythemia vera includes administering Severe hip pain after the insertion of a hip prosthesis
oxygen, radioisotope therapy, or chemotherapy agents, such indicates dislodgment. If this occurs, before calling the
as chlorambucil and nitrogen musta rd, to suppress bone physician, the nurse should assess the patient for shortening
marrow growth. of the leg, external rotation, and absence of reflexes.

A patient with acute renal failure should receive a high- As much as 75% of renal function is lost before blood urea
calorie diet that’ s low in protein as well as potassium and nitrogen and serum creatinine levels rise above normal.
sodium.
When compensatory efforts are present in acid-base
Addison’ s disease is caused by hypofunction of the balance, partial pressure of arterial carbon dioxide (PaCO2)
adrenal gland and is characterized by fa tigue, anemia, and bicarbonate (HCO3– ) always point in the same
weight loss, and bronze skin pigmentation. Without cortisol direction:
replacement therapy, it’ s usually fatal. pH PaCO2 HCO3– = respiratory acidosis compensated
pH PaCO2 HCO3– = respiratory alkalosis compensated
Glaucoma is managed conservatively with beta -adrenergic pH PaCO2 HCO3– = metabolic acidosis compensated
blockers such as timolol (Timoptic), which decrease pH PaCO2 HCO3– = metabolic alkalosis compensated.
sympathetic impulses to the eye, and with miotic eyedrops
such as pilocarpine (Isopto Carpine), which constrict the Polyuria is urine output of 2,500 ml or more within 24
pupils. hours.

Miotics effectively treat glaucoma by reducing intraocular The presenting sign of pleuritis is chest pain that is usually
pressure. They do this by constricting the pupil, contracting unilateral and related to respiratory movement.
the ciliary muscles, opening the anterior chamber angle, and
increasing the outflow of aqueous humor. If a pa tient has a gastric drainage tube in place, the nurse
should expect the physician to order potassium chloride.
While a patient is receiving heparin, the nurse should
 An increased pulse rate is one of the first indications of The level of amputation is determined by estimating the
respiratory difficulty. It occurs because the heart attempts to maximum viable tissue (tissue with adequate circulation)
compensate for a decreased oxygen supply to the tissues by needed to develop a functional stump.
pumping more blood.
Heparin sodium is included in the dialysate used for renal
dialysis.
In an adult, a hemoglobin level below 11 mg/dl suggests
iron deficiency anemia and the need for further evaluation. Paroxysmal nocturnal dyspnea may indicate heart failure.

The normal partial pressure of oxygen in arterial blood is 95 A patient who takes a cardiac glycoside, such as digoxin,
mm Hg (plus or minus 5 mm Hg). should consume a diet that includes high-potassium foods.

Vitamin C deficiency is characterized by brittle bones, The nurse should limit tracheobronchial suctioning to 10 to
pinpoint peripheral hemorrhages, and friable gums with 15 seconds and should make only two passes.
loosened teeth.
Before performing tracheobronchial suctioning, the nurse
Clinical manifestations of pulmonary embolism are should ventilate and oxygenate the patient five to six times
variable, but increased respiratory rate, tachycardia, and with a resuscitation bag and 100% oxygen. This procedure
hemoptysis are common. is called bagging.

Normally, intraocular pressure is 12 to 20 mm Hg. It can be Signs and symptoms of pneumothorax include tachypnea,
measured with a Schiøtz tonometer. restlessness, hypotension, and tracheal deviation.

In early hemorrhagic shock, blood pressure may be normal, The cardinal sign of toxic shock syndrome is rapid onset of
but respiratory and pulse rates are rapid. The patient may a high fever.
report thirst and may have clammy skin and piloerection A key sign of peptic ulcer is hematemesis, which can be
(goose bumps). bright red or dark red, with the consistency of coffee
grounds.
Cool, moist, pale skin, as occurs in shock, results from
diversion of blood from the skin to the major organs. Signs and symptoms of a perforated peptic ulcer include
sudden, severe upper abdominal pain; vomiting; and an
To assess capillary refill, the nurse applies pressure over the extremely tender, rigid (boardlike) abdomen.
nail bed until blanching occurs, quickly releases the
pressure, and notes the rate at which blanching fades. Constipation is a common adverse reaction to aluminum
Capillary refill indicates perfusion, which decreases in hydroxide.
shock, thereby lengthening refill time. Normal capillary
refill is less than 3 seconds. For the first 24 hours after a myocardial infarction, the
patient should use a bedside commode and then progress to
Except for patients with renal failure, urine output of less walking to the toilet, bathing, and taking short walks.
than 30 ml/hour signifies dehydration and the potential for
shock. After a myocardial infarction, the patient should avoid
overexertion and add a new activity daily, as tolerated
In elderly patients, the most common fracture is hip without dyspnea.
fracture. Osteoporosis weakens the bones, predisposing
these patients to fracture, which usually results from a fall. In a patient with a recent myocardial infarction, frothy,
blood-tinged sputum suggests pulmonary edema.
Before angiography, the nurse should ask the patient
whether he’ s allergic to the dye, shellfish, or iodine and In a patient who has acquired immunodeficiency syndrome,
advise him to take nothing by mouth for 8 hours before the the primary purpose of drugs is to prevent secondary
procedure. infections.

During myelography, approximately 10 to 15 ml of In a patient with acquired imm unodeficiency syndrome,

cerebrospinal fluid is removed for laboratory studies and an suppression of the immune system increases the risk of
equal amount of contrast media is injected. opportunistic infections, such as cytomegalovirus,
Pneumocystis carinii pneumonia, and thrush.
After angiography, the puncture site is covered with a
pressure dressing and the affected part is immobilized for 8 A patient with acquired immunodeficiency syndrome may
hours to decrease the risk of bleeding. have rapid weight loss, a sign of wasting syndrome.

If a water-based medium was used during myelography, the If the body doesn’ t use glucose for energy, it metabolizes
patient remains on bed rest for 6 to 8 hours, with the head of fat and produces ketones.
the bed elevated 30 to 45 degrees. If an oil-based medium
was used, the patient remains flat in bed for 6 to 24 hours. Approximately 20% of patients with Guillain-Barré
syndrome have residual deficits, such as mild motor
weakness or diminished lower extremity reflexes.
Clinical manifestations of orchitis caused by bacteria or
Hypertension and hypokalemia are the most significant mumps include high temperature, chills, and sudden pain in
clinical manifestations of primary hyperaldosteronism. the involved testis.
After percutaneous aspiration of the bladder, the patient’ s
first void is usually pink; however, urine with frank blood The level of prostate-specific antigen is elevated in patients
should be reported to the physician. with benign prostatic hyperplasia or prostate cancer.

A urine culture that grows more than 100,000 colonies of The level of prostatic acid phosphatase is elevated in
bacteria per milliliter of urine indicates infection. patients with advanced stages of prostate cancer.

A patient who is undergoing dialysis should take a vitamin Phenylephrine (Neo-Synephrine), a mydriatic, is instilled in
supplement and eat foods that are high in calories, but low a patient’ s eye to dilate the eye.
in protein, sodium, and potassium.
To promote fluid drainage and relieve edema in a patient
In a patient who has chronic obstructive pulmonary disease, with epididymitis, the nurse should elevate the scrotum on a
the most effective ways to reduce thick secretions are to scrotal bridge.
increase fluid intake to 2,500 ml/day and encourage
ambulation. Fluorescein staining is commonly used to assess corneal
abrasions because it outlines superficial epithelial defects.
The nurse should teach a patient with emphysema how to
perform pursed-lip breathing because this slows expiration, Presbyopia is loss of near vision as a result of the loss of
prevents alveolar collapse, and helps to control the elasticity of the crystalline lens.
respiratory rate.
Transient ischemic attacks are considered precursors to
Clubbing of the digits and a barrel chest may develop in a strokes.
patient who has chronic obstructive pulmona ry disease. A sign of acute appendicitis, McBurney’ s sign is
tenderness at McBurney’ s point (about 2" [5 cm] from the
A stroke (“ brain attack” ) disrupts the brain’ s blood right anterior superior iliac spine on a line between the spine
supply and may be caused by hypertension. and the umbilicus).

In a patient who is undergoing dialysis, desired outcomes When caring for a patient with Guillain-Barré syndrome,
are normal weight, normal serum albumin level (3.5 to 5.5 the nurse should focus on respiratory interventions as the
g/dl), and adequate protein intake (1.2 to 1.5 g/kg of body disease process advances.
weight daily).
Signs and symptoms of colon cancer include rectal
Intermittent peritoneal dialysis involves performing three to bleeding, change in bowel habits, intestinal obstruction,
seven treatments that total 40 hours per week. abdominal pain, weight loss, anorexia, nausea, and
vomiting.
In a patient with chronic obstructive pulmonary disease, the
best way to administer oxygen is by nasal cannula. The Symptoms of prostatitis include frequent urination and
normal flow rate is 2 to 3 L/ minute. dysuria.

Isoetharine (Bronkosol) can be administered with a A chancre is a painless, ulcerative lesion that develops
handheld nebulizer or by intermittent positive-pressure during the primary stage of syphilis.
breathing.
During the tertiary stage of syphilis, spirochetes invade the
internal organs and cause permanent damage.
Brain death is irreversible cessation of brain function.
In total parenteral nutrition, weight gain is the most reliable
Continuous ambula tory peritoneal dialysis requires four indicator of a positive response to therapy.
exchanges per day, 7 days per week, for a total of 168 hours
per week. The nurse may administer an I.V. fat emulsion through a
central or peripheral catheter, but shouldn’ t use an in-line
The classic adverse reactions to antihistamines are dry filter because the fat particles are too large to pass through
mouth, drowsiness, and blurred vision. the pores.

Because of the risk of paralytic ileus, a patient who has If a patient who has a prostatectomy is using a Cunningham
received a general anesthetic can’ t take anything by mouth clamp, instruct him to wash and dry his penis before
until active bowel sounds are heard in all abdominal applying the clamp. He should apply the clamp horizontally
quadrants. and remove it at least every 4 hours to empty his bladder to
prevent infection.
The level of alpha -fetoprotein, a tumor marker, is elevated
in patients who have testicular germ cell cancer. If a woman has signs of urinary tract infection during
menopause, she should be instructed to drink six to eight
glasses of water per day, urinate before and after Rheumatoid arthritis is a chronic, destructive collagen
intercourse, and perform Kegel exercises. disease characterized by symmetric inflammation of the
synovium that leads to joint swelling.
If a menopausal patient experiences a “ hot flash,” she
should be instructed to seek a cool, breezy location and sip a Screening for human immunodeficiency virus antibodies
cool drink. begins with the enzyme-linked immunosorbent assay.
Results are confirmed by the Western blot test.
Cheilosis causes fissures at the angles of the mouth and
indicates a vitamin B2, riboflavin, or iron deficiency. The CK-MB isoenzyme level increases 4 to 8 hours after a
myocardial infarction, peaks at 12 to 24 hours, and returns
Tetany may result from hypocalcemia caused by to normal in 3 days.
hypoparathyroidism.
Excessive intake of vitamin K may significantly antagonize
A patient who has cervical cancer may experience vaginal the anticoagulant effects of warfarin (Coumadin). The
bleeding for 1 to 3 months after intracavitary radiation. patient should be cautioned to avoid eating an excessive
amount of leafy green vegetables.
Ascites is the accumulation of fluid, containing large
amounts of protein and electrolytes, in the abdominal cavity. A lymph node biopsy that shows Reed-Sternberg cells
It’ s commonly caused by cirrhosis. provides a definitive diagnosis of Hodgkin’ s disease.

Normal pulmonary artery pressure is 10 to 25 mm Hg. Bell’ s palsy is unilateral facial weakness or paralysis
Normal pulmonary artery wedge pressure is 5 to 12 mm Hg. caused by a disturbance of the seventh cranial (facial) nerve.

After cardiac catheterization, the site is monitored for

bleeding and hematoma formation, pulses distal to the site During an initial tuberculin skin test, lack of a wheal after
are palpated every 15 minutes for 1 hour, and the patient is injection of tuberculin purified protein derivative indicates
maintained on bed rest with the extremity extended for 8 that the test dose was injected too deeply. The nurse should
hours. inject another dose at least 2" (5 cm) from the initial site.

Hemophilia is a bleeding disorder that’ s transmitted A tuberculin skin test should be read 48 to 72 hours after
genetically in a sex-linked (X chromosome) recessive administration.
pattern. Although girls and women may carry the defective
gene, hemophilia usually occurs only in boys and men. In reading a tuberculin skin test, erythema without
induration is usually not significant.
Von Willebrand’ s disease is an autosomal dominant
bleeding disorder that’ s caused by platelet dysfunction and Death caused by botulism usually results from delayed
factor VIII deficiency. diagnosis and respiratory complications.

Sickle cell anemia is a congenital hemolytic anemia that’ s In a patient who has rabies, saliva contains the virus and is
caused by defective hemoglobin S molecules. It primarily a hazard for nurses who provide care.
affects blacks.
A febrile nonhemolytic reaction is the most common
Sickle cell anemia has a homozygous inheritance pattern. transfusion reaction.
Sickle cell trait has a heterozygous inheritance pattern.
Hypokalemia (abnormally low concentration of potassium
in the blood) may cause muscle weakness or paralysis,
Pel-Ebstein fever is a characteristic sign of Hodgkin’ s electrocardiographic abnormalities, and GI disturbances.
disease. Fever recurs every few days or weeks and alternates
with afebrile periods. Beriberi, a serious vitamin B1 (thiamine) deficiency, affects
alcoholics who have poor dietary habits. It’ s epidemic in
Glucose-6-phosphate dehydrogenase (G6PD) deficiency is Asian countries where people subsist on unenriched rice.
an inherited metabolic disorder that’ s characterized by red It’ s characterized by the phrase “ I can’ t,” indicating that
blood cells that are deficient in G6PD, a critical enzyme in the patient is too ill to do anything.
aerobic glycolysis.
Excessive sedation may cause respiratory depression.
Preferred sites for bone marrow aspiration are the posterior
superior iliac crest, anterior iliac crest, and sternum. The primary postoperative concern is maintenance of a
patent airway.
During bone marrow harvesting, the donor receives general
anesthesia and 400 to 800 ml of marrow is aspirated. If cyanosis occurs circumorally, sublingually, or in the nail
bed, the oxygen saturation level (Sao 2) is less than 80%.
A butterfly rash across the bridge of the nose is a
characteristic sign of systemic lupus erythematosus. A rapid pulse rate in a postoperative patient may indicate
pain, bleeding, dehydration, or shock. Pacemakers can be powered by lithium batteries for up to
10 years.

Increased pulse rate and blood pressure may indicate that a The patient shouldn’ t void for 1 hour before percutaneous
patient is experiencing “ silent pain” (pain that can’ t be suprapubic bladder aspiration to ensure that sufficient urine
expressed verbally, such as when a patient is recovering remains in the bladder to make the procedure successful.
from anesthesia).
Left-sided heart failure causes pulmonary congestion, pink-
Lidocaine (Xylocaine) exerts antiarrhythmic action by tinged sputum, and dyspnea. (Remember L for left and
suppressing automaticity in the Purkinje fibers and elevating lung.)
the electrical stimulation threshold in the ventricles.
The current recommended blood cholesterol level is less
Cullen’ s sign (a bluish discoloration around the umbilicus) than 200 mg/dl.
is seen in patients who have a perforated pancreas.
When caring for a patient who is having a seizure, the nurse
During the postoperative period, the patient should cough should follow these guidelines: (1) Avoid restraining the
and breathe deeply every 2 hours unless otherwise patient, but help a standing patient to a lying position. (2)
contraindicated (for example, after craniotomy, cataract Loosen restrictive clothing. (3) Place a pillow or another
surgery, or throat surgery). soft object under the patient’ s head. (4) Clear the area of
hard objects. (5) Don’ t force anything into the patient’ s
Before surgery, a patient’ s respiratory volume may be mouth, but maintain a patent airway. (6) Reassure and
measured by incentive spirometry. This measurement reorient the patient after the seizure subsides.
becomes the patient’ s postoperative goal for respiratory
volume.
Gingival hyperplasia, or overgrowth of gum tissue, is an
The postoperative patient should use incentive spirometry adverse reaction to phenytoin (Dilantin).
10 to 12 times per hour and breathe deeply.
With aging, most marrow in long bones becomes yellow,
Before ambulating, a postoperative patient should dangle but it retains the capacity to convert back to red.
his legs over the side of the bed and perform deep-breathing
exercises. Clinical manifestations of lymphedema include
accumulation of fluid in the legs.
During the patient’ s first postoperative ambulation, the
nurse should monitor the patient closely and assist him as Afterload is ventricular wall tension during systolic
needed while he walks a few feet from the bed to a steady ejection. It’ s increased in patients who have septal
chair. hypertrophy, increased blood viscosity, and conditions that
cause blockage of aortic or pulmonary outflow.
Hypovolemia occurs when 15% to 25% of the body ’ s total
blood volume is lost. Red blood cells can be stored frozen for up to 2 years;
however, they must be used within 24 hours of thawing.
Signs and symptoms of hypovolemia include rapid, weak
pulse; low blood pressure; cool, clammy skin; shallow For the first 24 hours after amputation, the nurse should
respirations; oliguria or anuria; and lethargy. elevate the stump to prevent edema.

After hysterectomy, a woman should avoid sexual

Acute pericarditis causes sudden severe, constant pain over intercourse for 3 weeks if a vaginal approach was used and 6
the anterior chest. The pain is aggravated by inspiration. weeks if the abdominal approach was used.

Signs and symptoms of septicemia include fever, chills, Parkinson’ s disease characteristically causes progressive
rash, abdominal distention, prostration, pain, headache, muscle rigidity, akinesia, and involuntary tremor.
nausea, and diarrhea.
Tonic-clonic seizures are characterized by a loss of
Rocky Mountain spotted fever causes a persistent high consciousness and alternating periods of muscle contraction
fever, nonpitting edema, and rash. and relaxation.

Patients who have undergone coronary artery bypass graft Status epilepticus, a life-threatening emergency, is a series
should sleep 6 to 10 hours per day, take their temperature of rapidly repeating seizures that occur without intervening
twice daily, and avoid lifting more than 10 lb (4.5 kg) for at periods of consciousness.
least 6 weeks.
The ideal donor for kidney transplantation is an identical
Claudication pain (pain on ambulation) is caused by arterial twin. If an identical twin isn’ t available, a biological sibling
insufficiency as a result of atheromatous plaque that is the next best choice.
obstructs arterial blood flow to the extremities.
Breast cancer is the leading cancer among women;
however, lung cancer accounts for more deaths. a supine position, and using aseptic technique, insert a
catheter through the abdominal wall and into the peritoneal
space.
The stages of cervical cancer are as follows: stage 0,
carcinoma in situ; stage I, cancer confined to the cervix; If more than 3 L of dialysate solution return during
stage II, cancer extending beyond the cervix, but not to the peritoneal dialysis, the nurse should notify the physician.
pelvic wall; stage III, cancer extending to the pelvic wall;
and stage IV, cancer extending beyond the pelvis or within Hemodialysis is the removal of certain elements from the
the bladder or rectum. blood by passing heparinized blood through a
semipermeable membrane to the dialysate bath, which
One method used to estimate blood loss after a contains all of the important electrolytes in their ideal
hysterectomy is counting perineal pads. Saturating more concentrations.
than one pad in 1 hour or eight pads in 24 hours is
considered hemorrhaging. Gangrene usually affects the digits first, and begins with
skin color changes that progress from gray-blue to dark
Transurethral resection of the prostate is the most common brown or black.
procedure for treating benign prostatic hyperplasia.
Kidney function is assessed by evaluating blood urea
In a chest dra inage system, the water in the water-seal nitrogen (normal range is 8 to 20 mg/dl) and serum
chamber normally rises when a patient breathes in and falls creatinine (normal range is 0.6 to 1.3 mg/dl) levels.
when he breathes out.
A weight-bearing transfer is appropriate only for a patient
Spinal fusion provides spinal stability through a bone graft, who has at least one leg that’ s strong enough to bear
usually from the iliac crest, that fuses two or more vertebrae. weight, such as a patient with hemiplegia or a single-leg
amputation.
A patient who receives any type of transplant must take an
immunosuppressant drug for the rest of his life. Overflow incontinence (voiding of 30 to 60 ml of urine
every 15 to 30 minutes) is a sign of bladder distention.
Incentive spirometry should be used 5 to 10 times an hour
while the patient is awake. The first sign of a pressure ulcer is reddened skin that
blanches when pressure is applied.
In women, pelvic inflammatory disease is a common
complication of gonorrhea. Late signs and symptoms of sickle cell anemia include
tachycardia, cardiomegaly, systolic and diastolic murmurs,
Scoliosis is lateral S-shaped curvature of the spine. chronic fatigue, hepatomegaly, and splenomegaly.

Signs and symptoms of the secondary stage of syphilis A mechanical ventilator, which can maintain ventilation
include a rash on the palms and soles, erosion of the oral automatically for an extended period, is indicated when a
mucosa, alopecia, and enlarged lymph nodes. patient can’ t maintain a safe PaO2 or PaCO2 level.

In a patient who is receiving total parenteral nutrition, the Two types of mechanical ventilators exist: negative-
nurse should monitor glucose and electrolyte levels. pressure ventilators, which apply negative pressure around
the chest wall, and positive-pressure ventilators, which
deliver air under pressure to the patient.
Unless contraindicated, on admission to the postanesthesia
care unit, a patient should be turned on his side and his vital Angina pectoris is characterized by substernal pain that
signs should be taken. lasts for 2 to 3 minutes. The pain, which is caused by
myocardial ischemia, may radiate to the neck, shoulders, or
Edema is treated by limiting fluid intake and eliminating jaw; is described as viselike, or constricting; and may be
excess fluid. accompanied by severe apprehension or a feeling of
impending doom.
A patient who has had spinal anesthesia should remain flat
for 12 to 24 hours. Vital signs and neuromuscular function The diagnosis of an acute myocardial infarction is based on
should be monitored. the patient’ s signs and symptoms, electrocardiogram
tracings, troponin level, and cardiac enzyme studies.
A patient who has maple syrup urine disease should avoid
food containing the amino acids leucine, isoleucine, and The goal of treatment for a patient with angina pectoris is to
lysine. reduce the heart’ s workload, thereby reducing the
myocardial demand for oxygen and preventing myocardial
A severe complication of a femur fracture is excessive infarction.
blood loss that results in shock.
Nitroglycerin decreases the amount of blood that returns to
To prepare a patient for peritoneal dialysis, the nurse should the heart by increasing the capacity of the venous bed.
ask the patient to void, measure his vital signs, place him in
 Anticoagulant therapy is contraindicated in a patient who
The patient should take no more than three nitroglycerin has liver or kidney disease or GI ulcers or who isn’ t likely
tablets in a 15-minute period. to return for follow-up visits.

Hemodialysis is usually performed 24 hours before kidney The nurse can assess a patient for thrombophlebitis by
transplantation. measuring the affected and unaffected legs and comparing
their sizes. The nurse should mark the measurement
Signs and symptoms of acute kidney transplant rejection are locations with a pen so that the legs can be measured at the
progressive enlargement and tenderness at the transplant same place each day.
site, increased blood pressure, decreased urine output,
elevated serum creatinine level, and fever. Drainage of more than 3,000 ml of fluid daily from a
nasogastric tube may suggest intestinal obstruction. Yellow
After a radical mastectomy, the patient’ s arm should be drainage that has a foul odor may indicate small-bowel
elevated (with the hand above the elbow) on a pillow to obstruction.
enhance circulation and prevent edema.
Preparation for sigmoidoscopy includes administering an
Postoperative mastectomy care includes teaching the patient enema 1 hour before the examination, warming the scope in
arm exercises to facilitate lymph drainage and prevent warm water or a sterilizer (if using a metal sigmoidoscope),
shortening of the muscle and contracture of the shoulder and draping the patient to expose the perineum.
joint (frozen shoulder).

After radical mastectomy, the patient should help prevent

infection by making sure that no blood pressure readings, Treatment for a patient with bleeding esophageal varices
injections, or venipunctures are performed on the affected includes administering vasopressin (Pitressin), giving an ice
arm. water lavage, aspirating blood from the stomach, using
esophageal balloon tamponade, providing parenteral
For a patient who has undergone mastectomy and is nutrition, and administering blood transfusions, as needed.
susceptible to lymphedema, a program of hand exercises can
begin shortly after surgery, if prescribed. The program A trauma victim shouldn’ t be moved until a patent airway
consists of opening and closing the hand tightly six to eight is established and the cervical spine is immobilized.
times per hour and performing such tasks as washing the
face and combing the hair. After a mastectomy, lymphedema may cause a feeling of
heaviness in the affected arm.
Signs and symptoms of theophylline toxicity include
vomiting, restlessness, and an apical pulse rate of more than A dying patient shouldn’ t be told exactly how long he’ s
200 beats/minute. expected to live, but should be told something more general
such as “ Some people live 3 to 6 months, but others live
The nurse shouldn’ t induce vomiting in a person who has longer.”
ingested poison and is having seizures or is semiconscious
or comatose. After eye surgery, a patient should avoid using makeup
until otherwise instructed.

After a corneal transplant, the patient should wear an eye

shield when engaging in activities such as playing with
Central venous pressure (CVP), which is the pressure in the children or pets.
right atrium and the great veins of the thorax, is normally 2
to 8 mm Hg (or 5 to 12 cm H2O). CVP is used to assess After a corneal transplant, the patient shouldn’ t lie on the
right-sided cardiac function. affected site, bend at the waist, or have sexual intercourse
for 1 week. The patient must avoid getting soapsuds in the
CVP is monitored to assess the need for fluid replacement eye.
in seriously ill patients, to estimate blood volume deficits,
and to evaluate circula tory pressure in the right atrium. A Milwaukee brace is used for patients who have structural
scoliosis. The brace helps to halt the progression of spinal
To prevent deep vein thrombosis after surgery, the nurse curvature by providing longitudinal traction and lateral
should administer 5,000 units of heparin subcutaneously pressure. It should be worn 23 hours a day.
every 8 to 12 hours, as prescribed.
Short-term measures used to treat stomal retraction include
Oral anticoagulants, such as warfarin (Coumadin) and stool softeners, irrigation, and stomal dilatation.
dicumarol, disrupt natural blood clotting mechanisms,
prevent thrombus formation, and limit the extension of a A patient who has a colostomy should be advised to eat a
formed thrombus. low-residue diet for 4 to 6 weeks and then to add one food at
a time to evaluate its effect.
Anticoagulants can’ t dissolve a formed thrombus.
 To relieve postoperative hiccups, the patient should breathe Valvular insufficiency in the veins commonly causes
into a paper bag. varicosity.

If a patient with an ileostomy has a blocked lumen as a A patient with a colostomy should restrict fat and fibrous
result of undigested high-fiber food, the patient should be foods and should avoid foods that can obstruct the stoma,
placed in the knee-chest position and the area below the such as corn, nuts, and cabbage.
stoma should be massaged.
A patient who is receiving chemotherapy is placed in
During the initial interview and treatment of a patient with reverse isolation because the white blood cell count may be
syphilis, the patient’ s sexual contacts should be identified. depressed.

The nurse shouldn’ t administer morphine to a patient Symptoms of mitral valve stenosis are caused by improper
whose respiratory rate is less than 12 breaths/minute. emptying of the left atrium.

To prevent drying of the mucous membranes, oxygen Persistent bleeding after open heart surgery may require the
should be administered with hydration. administration of protamine sulfate to reverse the effects of
heparin sodium used during surgery.
Flavoxate (Urispas) is classified as a urinary tract
spasmolytic. The nurse should teach a patient with heart failure to take
digoxin and other drugs as prescribed, to restrict sodium
Hypotension is a sign of cardiogenic shock in a patient with intake, to restrict fluids as prescribed, to get adequate rest, to
a myocardial infarction. increase walking and other activities gradually, to avoid
extremes of temperature, to report signs of
The predominant signs of mechanical ileus are cramping The nurse should check and maintain the patency of all
pain, vomiting, distention, and inability to pass feces or connections for a chest tube. If an air leak is detected, the
flatus. nurse should place one Kelly clamp near the insertion site. If
the bubbling stops, the leak is in the thoracic cavity and the
For a patient with a myocardial infarction, the nurse should physician should be notified immediately. If the leak
monitor fluid intake and output meticulously. Too little continues, the nurse should take a second clamp, work down
intake causes dehydration, and too much may cause the tube until the leak is located, and stop the leak.
pulmonary edema.
In two-person cardiopulmonary resuscitation, the rescuers
Nitroglycerin relaxes smooth muscle, causing vasodilation administer 60 chest compressions per minute and 1 breath
and relieving the chest pain associated with myocardial for every 5 compressions.
infarction and angina.
Mitral valve stenosis can result from rheumatic fever.
The diagnosis of an acute myocardial infarction is based on
the patient’ s signs a nd symptoms, electrocardiogram Atelectasis is incomplete expansion of lung segments or
tracings, and serum enzyme studies. lobules (clusters of alveoli). It may cause the lung or lobe to
collapse.
Arrhythmias are the predominant problem during the first
48 hours after a myocardial infarction. The nurse should instruct a patient who has an ileal condu it
to empty the collection device frequently because the weight
Clinical manifestations of malabsorption include weight of the urine may cause the device to slip from the skin.
loss, muscle wasting, bloating, and steatorrhea.
A patient who is receiving cardiopulmonary resuscitation
Asparaginase, an enzyme that inhibits the synthesis of should be placed on a solid, flat surface.
deoxyribonucleic acid and protein, is used to treat acute
lymphocytic leukemia. Brain damage occurs 4 to 6 minutes after cardiopulmonary
function ceases.
To relieve a patient’ s sore throat that’ s caused by
nasogastric tube irritation, the nurse should provide Climacteric is the transition period during which a
anesthetic lozenges, as prescribed. woman’ s reproductive function diminishes and gradually
disappears.
For the first 12 to 24 hours after gastric surgery, the
stomach contents (obtained by suctioning) are brown. After infratentorial surgery, the patient should remain on
his side, flat in bed.
After gastric suctioning is discontinued, a patient who is
recovering from a subtotal gastrectomy should receive a In a patient who has an ulcer, milk is contraindicated
clear liquid diet. because its high calcium content stimulates secretion of
gastric acid.
The descending colon is the preferred site for a permanent
colostomy. A patient who has a positive test result for human
immunodeficiency virus has been exposed to the virus
associated with acquired immunodeficiency syndrome deformities.
(AIDS), but doesn’ t necessarily have AIDS.
A patient with acquired immunodeficiency syndrome
A common complication after prostatectomy is circulatory should advise his sexual partners of his human
failure caused by bleeding. immunodeficiency virus status and observe sexual
precautions, such as abstinence or condom use.
In right-sided heart failure, a major focus of nursing care is
decreasing the workload of the heart. If a radioactive implant becomes dislodged, the nurse
should retrieve it with tongs, place it in a lead-shielded
Signs and symptoms of digoxin toxicity include nausea, container, and notify the radiology department.
vomiting, confusion, and arrhythmias.
A patient who is undergoing radiation therapy should pat
An asthma attack typically begins with wheezing, his skin dry to avoid abrasions that could easily become
coughing, and increasing respiratory distress. infected.
During radiation therapy, a patient should have frequent
In a patient who is recovering from a tonsillectomy, blood tests, especially white blood cell and platelet counts.
frequent swallowing suggests hemorrhage.
The nurse should administer an aluminum hydroxide
Ileostomies and Hartmann’ s colostomies are permanent antacid at least 1 hour after an enteric-coated drug because it
stomas. Loop colostomies and double-barrel colostomies are can cause premature release of the enteric-coated drug in the
temporary ones. stomach.

A patient who has an ileostomy should eat foods, such as Acid-base balance is the body’ s hydrogen ion
spinach and parsley, because they act as intestinal tract concentration, a measure of the ratio of carbonic acid to
deodorizers. bicarbonate ions (1 part carbonic acid to 20 parts
bicarbonate is normal).
An adrenalectomy can decrease steroid production, which
can cause extensive loss of sodium and water. Amyotrophic lateral sclerosis causes progressive atrophy
and wasting of muscle groups that eventually affects the
Before administering morphine (Duramorph) to a patient respiratory muscles.
who is suspected of having a myocardial infarction, the
nurse should check the patient’ s respiratory rate. If it’ s Metabolic acidosis is caused by abnormal loss of
less than 12 breaths/minute, emergency equipment should bicarbonate ions or excessive production or retention of acid
be readily available for intubation if respiratory depression ions.
occurs.
Hemianopsia is defective vision or blindness in one-half of
A patient who is recovering from supratentorial surgery is the visual field of one or both eyes.
normally allowed out of bed 14 to 48 hours after surgery. A
patient who is recovering from infratentorial surgery Systemic lupus erythematosus causes early-morning joint
normally remains on bed rest for 3 to 5 days. stiffness and facial erythema in a butterfly pattern.

After a patient undergoes a femoral-popliteal bypass graft, After total knee replacement, the patient should remain in
the nurse must closely monitor the peripheral pulses distal to the semi-Fowler position, with the affected leg elevated.
the operative site and circulation.
In a patient who is receiving transpyloric feedings, the
After a femoral-popliteal bypass graft, the patient should nurse should watch for dumping syndrome and hypovolemic
initially be maintained in a semi-Fowler position to avoid shock because the stomach is being bypa ssed.
flexion of the graft site. Before discharge, the nurse should
instruct the patient to avoid positions that put pressure on If a total parenteral nutrition infusion must be interrupted,
the graft site until the next follow-up visit. the nurse should administer dextrose 5% in water at a
similar rate. Abrupt cessation can cause hypoglycemia.
Of the five senses, hearing is the last to be lost in a patient
who is entering a coma. Status epilepticus is treated with I.V. diazepam (Valium)
and phenytoin (Dilantin).
Cholelithiasis causes an enlarged, edematous gallbladder
with multiple stones a nd an elevated bilirubin level.
Disequilibrium syndrome causes nausea, vomiting,
The antiviral agent zidovudine (Retrovir) successfully restlessness, and twitching in patients who are undergoing
slows replication of the human immunodeficiency virus, dialysis. It’ s caused by a rapid fluid shift.
thereby slowing the development of acquired
immunodeficiency syndrome. An indication that spinal shock is resolving is the return of
reflex activity in the arms and legs below the level of injury.
Severe rheumatoid arthritis causes marked edema and
congestion, spindle-shaped joints, and severe flexion Hypovolemia is the most common and fatal complication of
severe acute pancreatitis. When in the room of a patient who is in isolation for
tuberculosis, staff and visitors should wear ultrafilter masks.
In a patient with stomatitis, oral care includes rinsing the
mouth with a mixture of equal parts of hydrogen peroxide When providing skin care immediately after pin insertion,
and water three times daily. the nurse’ s primary concern is prevention of bone
infection.
In otitis media, the tympanic membrane is bright red and
lacks its characteristic light reflex (cone of light). After an amputation, moist skin may indicate venous stasis;
dry skin may indicate arterial obstruction.
In patients who have pericardiocentesis, fluid is aspirated
from the pericardial sac for analysis or to relieve cardiac In a patient who is receiving dialysis, an internal shunt is
tamponade. working if the nurse feels a thrill on palpation or hears a
bruit on auscultation.
Urticaria is an early sign of hemolytic transfusion reaction.
In a patient with viral hepatitis, the parenchymal, or
During peritoneal dialysis, a return of brown dialysate Kupffer’ s, cells of the liver become severely inflamed,
suggests bowel perforation. The physician should be enlarged, and necrotic.
notified immediately.
Early signs of acquired immunodeficiency syndrome
An early sign of ketoacidosis is polyuria, which is caused include fatigue, night sweats, enlarged lymph nodes,
by osmotic diuresis. anorexia, weight loss, pallor, and fever.

Patients who have multiple sclerosis should visually inspect When caring for a patient who has a radioactive implant,
their extremities to ensure proper alignment and freedom health care workers should stay as far away from the
from injury. radiation source as possible. They should remember the
axiom, “ If you double the distance, you quarter the dose.”
Aspirated red bone marrow usually appears rust-red, with
visible fatty material and white bone fragments. A patient who has Parkinson’ s disease should be instructed
to walk with a broad-based gait.
The Dick test detects scarlet fever antigens and immunity or
susceptibility to scarlet fever. A positive result indicates no The cardinal signs of Parkinson’ s disease are muscle
immunity; a negative result indicates immunity. rigidity, a tremor that begins in the fingers, and akinesia.

In a patient with Parkinson’ s disease, levodopa (Dopar) is

The Schick test detects diphtheria antigens and immunity or prescribed to compensate for the dopamine deficiency.
susceptibility to diphtheria. A positive result indicates no
immunity; a negative result indicates immunity. A patient who has multiple sclerosis is at increased risk for
pressure ulcers.
The recommended adult dosage of sucralfate (Carafate) for
duodenal ulcer is 1 g (1 tablet) four times daily 1 hour Pill-rolling tremor is a classic sign of Parkinson’ s disease.
before meals and at bedtime.
For a patient with Parkinson’ s disease, nursing
A patient with facial burns or smoke or heat inhalation interventions are palliative.
should be admitted to the hospital for 24-hour observation
for delayed tracheal edema. Fat embolism, a serious complication of a long-bone
fracture, causes fever, tachycardia, tachypnea, and anxiety.
In addition to patient teaching, preparation for a colostomy
includes withholding oral intake overnight, performing Metrorrhagia (bleeding between menstrual periods) may be
bowel preparation, and administering a cleansing enema. the first sign of cervical cancer.

The physiologic changes caused by burn injuries can be Mannitol is a hypertonic solution and an osmotic diuretic
divided into two stages: the hypovolemic stage, during that’ s used in the treatment of increased intracranial
which intravascular fluid shifts into the interstitial space, pressure.
and the diuretic stage, during which capillary integrity and
intravascular volume are restored, usually 48 to 72 hours The classic sign of an absence seizure is a vacant facial
after the injury. expression.

The nurse should change total parenteral nutrition tubing Migraine headaches cause persistent, severe pain that
every 24 hours and the peripheral I.V. access site dressing usually occurs in the temporal region.
every 72 hours.
A patient who is in a bladder retraining program should be
A patient whose carbon monoxide level is 20% to 30% given an opportunity to void every 2 hours during the day
should be treated with 100% humidified oxygen. and twice at night.
 In a patient with a head injury, a decrease in level of
consciousness is a cardinal sign of increased intracranial Hepatitis A is usually mild and won’ t advance to a carrier
pressure. state.

Ergotamine (Ergomar) is most effective when taken during In the preicteric phase of all forms of hepatitis, the patient is
the prodromal phase of a migraine or vascular headache. highly contagious.

Treatment of acute pancreatitis includes nasogastric Enteric precautions are required for a patient who has
suctioning to decompress the stomach and meperidine hepatitis A.
(Demerol) for pain.
Cholecystography is ineffective in a patient who has
Symptoms of hiatal hernia include a feeling of fullness in jaundice as a result of gallbladder disease. The liver cells
the upper abdomen or chest, heartburn, and pain similar to can’ t transport the contrast medium to the biliary tract.
that of angina pectoris.
In a patient who has diabetes insipidus, dehydration is a
The incidence of cholelithiasis is higher in women who concern because diabetes causes polyuria.
have had children than in any other group.
In a patient who has a reducible hernia, the protruding mass
Acetaminophen (Tylenol) overdose can severely damage spontaneously retracts into the abdomen.
the liver.
To prevent purple glove syndrome, a nurse shouldn’ t
The prominent clinical signs of advanced cirrhosis are administer I.V. phenytoin (Dilantin) through a vein in the
ascites and jaundice. back of the hand, but should use a larger vessel.

The first symptom of pa ncreatitis is steady epigastric pain During stage III of surgical anesthesia, unconsciousness
or left upper quadrant pain that radiates from the umbilical occurs and surgery is permitted.
area or the back.
Types of regional anesthesia include spinal, caudal,
Somnambulism is the medical term for sleepwalking. intercostal, epidural, and brachial plexus.

Epinephrine (Adrenalin) is a vasoconstrictor. The first step in managing drug overdose or drug toxicity is
to establish and maintain an airway.
An untreated liver laceration or rupture can progress rapidly
to hypovolemic shock. Respiratory paralysis occurs in stage IV of anesthesia (toxic
stage).
Obstipation is extreme, intractable constipation caused by
an intestinal obstruction. In stage I of anesthesia, the patient is conscious and
tranquil.
The definitive test for diagnosing cancer is biopsy with
cytologic examination of the specimen. Dyspnea and sharp, stabbing pain that increases with
respiration are symptoms of pleurisy, which can be a
Arthrography requires injection of a contrast medium and complication of pneumonia or tuberculosis.
can identify joint abnormalities.
Vertigo is the major symptom of inner ear infection or
Brompton’ s cocktail is prescribed to help relieve pain in disease.
patients who have terminal cancer.
Loud talking is a sign of hearing impairment.
A sarcoma is a malignant tumor in connective tissue.
A patient who has an upper respiratory tract infection
Aluminum hydroxide (Amphojel) neutralizes gastric acid. should blow his nose with both nostrils open.

Subluxation is partial dislocation or separation, with A patient who has had a cataract removed can begin most
spontaneous reduction of a joint. normal activities in 3 or 4 days; however, the patient
shouldn’ t bend and lift until a physician approves these
Barbiturates can cause confusion and delirium in an elderly activities.
patient who has an organic brain disorder.
Symptoms of corneal transplant rejection include eye
In a patient with arthritis, physica l therapy is indicated to irritation and decreasing visual field.
promote optimal functioning.
Graves’ disease (hyperthyroidism) is manifested by weight
Some patients who have hepatitis A may be anicteric loss, nervousness, dyspnea, palpitations, heat intolerance,
(without jaundice) and lack symptoms, but some have increased thirst, exophthalmos (bulging eyes), and goiter.
headaches, jaundice, anorexia, fatigue, fever, and respiratory
tract infection. The four types of lipoprotein are chylomicrons (the lowest-
density lipoproteins), very-low-density lipoproteins, low- the bloodstream by diffusion.
density lipoproteins, and high-density lipoproteins. Health
care professionals use cholesterol level fractionation to To grade the severity of dyspnea, the following system is
assess a patient’ s risk of coronary artery disease. used: grade 1, shortness of breath on mild exertion, such as
walking up steps; grade 2, shortness of breath when walking
If a patient who is taking amphotericin B (Fungizone) a short distance at a normal pace on level ground; grade 3,
bladder irrigations for a fungal infection has systemic shortness of breath with mild daily activity, such as shaving;
candidiasis and must receive I.V. fluconazole (Diflucan), the grade 4, shortness of breath when supine (orthopnea).
irrigations can be discontinued because fluconazole treats
the bladder infection as well. A patient with Crohn’ s disease should consume a diet low
in residue, fiber, and fat, and high in calories, proteins, and
Patients with adult respiratory distress syndrome can have carbohydrates. The patient also should take vitamin
high peak inspiratory pressures. Therefore, the nurse should supplements, especially vitamin K.
monitor these patients closely for signs of spontaneous
pneumothorax, such as acute deterioration in oxygenation, In the three-bottle urine collection method, the patient
absence of breath sounds on the affected side, and crepitus cleans the meatus and urinates 10 to 15 ml in the first bottle
beginning on the affected side. and 15 to 30 ml (midstream) in the second bottle. Then the
physician performs prostatic massage, and the patient voids
Adverse reactions to cyclosporine (Sandimmune) include into the third bottle.
renal and hepatic toxicity, central nervous system changes
(confusion and delirium), GI bleeding, and hypertension. Findings in the three-bottle urine collection method are
interpreted as follows: pus in the urine (pyuria) in the first
Osteoporosis is a metabolic bone disorder in which the rate bottle indicates anterior urethritis; bacteria in the urine in the
of bone resorption exceeds the rate of bone formation. second bottle indicate bladder infection; bacteria in the third
bottle indicate prostatitis.
The hallmark of ulcerative colitis is recurrent bloody
diarrhea, which commonly contains pus and mucus and Signs and symptoms of aortic stenosis include a loud, rough
alternates with asymptomatic remissions. systolic murmur over the aortic area; exertional dyspnea;
fatigue; angina pectoris; arrhythmias; low blood pressure;
Safer sexual practices include massaging, hugging, body and emboli.
rubbing, friendly kissing (dry), masturbating, hand-to-
genital touching, wearing a condom, and limiting the Elective surgery is primarily a matter of choice. It isn’ t
number of sexual partners. essential to the patient’ s survival, but it may improve the
patient’ s health, comfort, or self-esteem.
Immunosuppressed patients who contract cytomegalovirus
(CMV) are at risk for CMV pneumonia and septicemia, Required surgery is recommended by the physician. It may
which can be fatal. be delayed, but is inevitable.

Urinary tract infections can cause urinary urgency and Urgent surgery must be performed within 24 to 48 hours.
frequency, dysuria, abdominal cramps or bladder spasms,
and urethral itching. Emergency surgery must be performed immediately.

Mammography is a radiographic technique that’ s used to About 85% of arterial emboli originate in the heart
detect breast cysts or tumors, especially those that aren’ t chambers.
palpable on physical examination.
Pulmonary embolism usually results from thrombi
To promote early detection of testicular cancer, the nurse dislodged from the leg veins.
should palpate the testes during routine physical
examinations and encourage the patient to perform monthly The conscious interpretation of pain occurs in the cerebral
self-examinations during a warm shower. cortex.

Patients who have thalassemia minor require no treatment. To avoid interfering with new cell growth, the dressing on a
Those with thalassemia major require frequent transfusions donor skin graft site shouldn’ t be disturbed.
of red blood cells.
A sequela is any abnormal condition that follows and is the
A high level of hepatitis B serum marker that persists for 3 result of a disease, a treatment, or an injury.
months or more after the onset of acute hepatitis B infection
suggests chronic hepatitis or carrier status. During sickle cell crisis, patient care includes bed rest,
oxygen therapy, analgesics as prescribed, I.V. fluid
Neurogenic bladder dysfunction is caused by disruption of monitoring, and thorough documentation of fluid intake and
nerve transmission to the bladder. It may be caused by output.
certain spinal cord injuries, diabetes, or multiple sclerosis.
A patient who has an ileal conduit should maintain a daily
Oxygen and carbon dioxide move between the lungs and fluid intake of 2,000 ml.
 In a closed chest drainage system, continuous bubbling in Propranolol (Inderal) blocks sympathetic nerve stimuli that
the water seal chamber or bottle indicates a leak. increase cardiac work during exercise or stress, which
reduces heart rate, blood pressure, and myocardial oxygen
Palpitation is a sensation of heart pounding or racing consumption.
associated with normal emotional responses and certain
heart disorders. After a myocardial infarction, electrocardiogram changes
(ST-segment elevation, T-wave inversion, and Q-wave
Fat embolism is likely to occur within the first 24 hours enlargement) usually appear in the first 24 hours, but may
after a long-bone fracture. not appear until the 5th or 6th day.

Footdrop can occur in a patient with a pelvic fracture as a Cardiogenic shock is manifested by systolic blood pressure
result of peroneal nerve compression against the head of the of less than 80 mm Hg, gray skin, diaphoresis, cyanosis,
fibula. weak pulse rate, tachycardia or bradycardia, and oliguria
(less than 30 ml of urine per hour).
To promote venous return after an amputation, the nurse
should wrap an elastic bandage around the distal end of the A patient who is receiving a low-sodium diet shouldn’ t eat
stump. cottage cheese, fish, canned beans, chuck steak, chocolate
pudding, Italian salad dressing, dill pickles, and beef broth.
Water that accumulates in the tubing of a ventilator should
be removed. High-potassium foods include dried prunes, watermelon
(15.3 mEq/ portion), dried lima beans (14.5 mEq/portion),
The most common route for the administration of soybeans, bananas, and oranges.
epinephrine to a patient who is having a severe allergic
reaction is the subcutaneous route. Kussmaul’ s respirations are faster and deeper than normal
respirations and occur without pauses, as in diabetic
The nurse should use Fowler’ s position for a patient who ketoacidosis.
has abdominal pain caused by appendicitis.
Cheyne-Stokes respirations are characterized by alternating
The nurse shouldn’ t give analgesics to a patient who has periods of apnea and deep, rapid breathing. They occur in
abdominal pain caused by appendicitis because these drugs patients with central nervous system disorders.
may mask the pain that accompanies a ruptured appendix.
Hyperventilation can result from an increased frequency of
The nurse shouldn’ t give analgesics to a patient who has breathing, an increased tidal volume, or both.
abdominal pain caused by appendicitis because these drugs
may mask the pain that accompanies a ruptured appendix. Apnea is the absence of spontaneous respirations.

As a last-ditch effort, a barbiturate coma may be induced to

reverse unrelenting increased intracranial pressure (ICP),
which is defined as acute ICP of greater than 40 mm Hg, Before a thyroidectomy, a patient may receive potassium
persistent elevation of ICP above 20 mm Hg, or rapidly iodide, antithyroid drugs, and propranolol (Inderal) to
deteriorating neurologic status. prevent thyroid storm during surgery.

The primary signs and symptoms of epiglottiditis are stridor The normal life span of red blood cells (erythrocytes) is 110
and progressive difficulty in swallowing. to 120 days.

Salivation is the first step in the digestion of starch. Visual acuity of 20/100 means that the patient sees at 20' (6
m) what a person with normal vision sees at 100' (30 m).
A patient who has a demand pacemaker should measure the
pulse rate before rising in the morning, notify the physician Urinary tract infections are more common in girls and
if the pulse rate drops by 5 beats/minute, obtain a medical women than in boys and men because the shorter urethra in
identification card and bracelet, and resume normal the female urinary tract makes the bladder more accessible
activities, including sexual activity. to bacteria, especially Escherichia coli.

Transverse, or loop, colostomy is a temporary procedure Penicillin is administered orally 1 to 2 hours before meals
that’ s performed to divert the fecal stream in a patient who or 2 to 3 hours after meals because food may interfere with
has acute intestinal obstruction. the drug’ s absorption.

Normal values for erythrocyte sedimentation rate are 0 to Mild reactions to local anesthetics may include palpitations,
15 mm/hour for men younger than age 50 and 0 to 20 tinnitus, vertigo, apprehension, confusion, and a metallic
mm/hour for women younger than age 50. taste in the mouth.

A CK-MB level that’ s more than 5% of total CK or more About 22% of cardiac output goes to the kidneys.
than 10 U/L suggests a myocardial infarction.
 To ensure accurate central venous pressure readings, the Pseudomonas organisms.
nurse should place the manometer or transducer level with
the phlebostatic axis. Bruits are vascular sounds that resemble heart murmurs and
result from turbulent blood flow through a diseased or
A patient who has lost 2,000 to 2,500 ml of blood will have partially obstructed artery.
a pulse rate of 140 beats/minute (or higher), display a
systolic blood pressure of 50 to 60 mm Hg, and appear Urine pH is normally 4.5 to 8.0.
confused and lethargic.
Urine pH of greater than 8.0 can result from a urinary tract
Arterial blood is bright red, flows rapidly, and (because infection, a high-alkali diet, or systemic alkalosis.
it’ s pumped directly from the heart) spurts with each
heartbeat. Urine pH of less than 4.5 may be caused by a high-protein
diet, fever, or metabolic acidosis.
Venous blood is dark red and tends to ooze from a wound.
Before a percutaneous renal biopsy, the patient should be
Orthostatic blood pressure is taken with the patient in the placed on a firm surface and positioned on the abdomen. A
supine, sitting, and standing positions, with 1 minute sandbag is placed under the abdomen to stabilize the
between each reading. A 10-mm Hg decrease in blood kidneys.
pressure or an increase in pulse rate of 10 beats/ minute
suggests volume depletion. Nephrotic syndrome is characterized by marked proteinuria,
hypoalbuminemia, mild to severe dependent edema, ascites,
A pneumatic antishock garment should be used cautiously and weight gain.
in pregnant women and patients with head injuries.
Underwater exercise is a form of therapy perform ed in a
After a patient’ s circulating volume is restored, the nurse Hubbard tank.
should remove the pneumatic antishock garment gradually,
starting with the abdominal chamber and followed by each Most women with trichomoniasis have a malodorous,
leg. The garment should be removed under a physician’ s frothy, greenish gray vaginal discharge. Other women may
supervision. have no signs or symptoms.

Most hemolytic transfusion reactions associated with Voiding cystourethrography may be performed to detect
mismatching of ABO blood types stem from identification bladder and urethral abnormalities. Contra st medium is
number errors. instilled by gentle syringe pressure through a urethral
catheter, and overhead X-ray films are taken to visualize
Warming of blood to more than 107° F (41.7° C) can cause bladder filling and excretion.
hemolysis.
Cystourethrography may be performed to identify the cause
Cardiac output is the amount of blood ejected from the of urinary tract infections, congenita l anomalies, and
heart each minute. It’ s expressed in liters per minute. incontinence. It also is used to assess for prostate lobe
hypertrophy in men.
Stroke volume is the volume of blood ejected from the heart
during systole. Herpes simplex is characterized by recurrent episodes of
blisters on the skin and mucous membranes. It has two
Total parenteral nutrition solution contains dextrose, a mino variations. In type 1, the blisters appear in the nasolabial
acids, and additives, such as electrolytes, minerals, and region; in type 2, they appear on the genitals, anus, buttocks,
vitamins. and thighs.

The most common type of neurogenic shock is spinal Most patients with Chlamydia trachomatis infection are
shock. It usually occurs 30 to 60 minutes after a spinal cord asymptomatic, but some have an inflamed urethral meatus,
injury. dysuria, and urinary urgency and frequency.

After a spinal cord injury, peristalsis stops within 24 hours The hypothalamus regulates the autonomic nervous system
and usually returns within 3 to 4 days. and endocrine functions.

Toxic shock syndrome is manifested by a temperature of at A patient whose chest excursion is less than normal (3" to
least 102° F (38.8° C), an erythematous rash, and systolic 6" [7.5 to 15 cm]) must use accessory muscles to breathe.
blood pressure of less than 90 mm Hg. From 1 to 2 weeks
after the onset of these signs, desquamation (especially on Signs and symptoms of toxicity from thyroid replacement
the palms and soles) occurs. therapy include rapid pulse rate, diaphoresis, irritability,
The signs and symptoms of anaphylaxis are commonly weight loss, dysuria, and sleep disturbance.
caused by histamine release.
The most common allergic reaction to penicillin is a rash.
The most common cause of septic shock is gram -negative
bacteria, such as Escherichia coli, Klebsiella, and An early sign of aspirin toxicity is deep, rapid respirations.
 cardiogenic shock are decreased left ventricular function and
The most serious and irreversible consequence of lead decreased cardiac output.
poisoning is mental retardation, which results from
neurologic damage. Before thyroidectomy, the patient should be advised that he
may experience hoarseness or loss of his voice for several
To assess dehydration in the adult, the nurse should check days after surgery.
skin turgor on the sternum.
Acceptable adverse effects of long-term steroid use include
For a patient with a peptic ulcer, the type of diet is less weight gain, acne, headaches, fatigue, and increased urine
importa nt than including foods in the diet that the patient retention.
can tolerate.
Unacceptable adverse effects of long-term steroid use are
A patient with a colostomy must establish an irrigation dizziness on rising, nausea, vomiting, thirst, and pain.
schedule so that regular emptying of the bowel occurs
without stomal discharge between irrigations. After a craniotomy, nursing care includes maintaining
normal intracranial pressure, maintaining cerebral perfusion
When using rotating tourniquets, the nurse shouldn’ t pressure, and preventing injury related to cerebral and
restrict the blood supply to an arm or leg for more than 45 cellular ischemia.
minutes at a time.
Folic acid and vitamin B12 are essential for nucleoprotein
A patient with diabetes should eat high-fiber foods because synthesis and red blood cell maturation.
they blunt the rise in glucose level that normally follows a
meal. Immediately after intracranial surgery, nursing care
includes not giving the patient anything by mouth until the
Jugular vein distention occurs in patients with heart failure gag and cough reflexes return, monitoring vital signs and
because the left ventricle can’ t empty the heart of blood as assessing the level of consciousness (LOC) for signs of
fast as blood enters from the right ventricle, resulting in increasing intracranial pressure, and administering
congestion in the entire venous system. analgesics that don’ t mask the LOC.

The leading causes of blindness in the United States are Chest physiotherapy includes postural drainage, chest
diabetes mellitus and glaucoma. percussion and vibration, and coughing and deep-breathing
exercises.
After a thyroidectomy, the patient should remain in the
semi-Fowler position, with his head neither hyperextended Cushing’ s syndrome results from excessive levels of
nor hyperflexed, to avoid pressure on the suture line. This adrenocortical hormones and is manifested by fat pads on
position can be achieved with the use of a cervical pillow. the face (moon face) and over the upper back (buffalo
hump), acne, mood swings, hirsutism, amenorrhea, and
Premenstrual syndrome may cause abdominal distention, decreased libido.
engorged and painful breasts, backache, headache,
nervousness, irritability, restlessness, and tremors. To prevent an addisonian crisis when discontinuing long-
term prednisone (Deltasone) therapy, the nurse should taper
Treatment of dehiscence (pathologic opening of a wound) the dose slowly to allow for monitoring of disease flare-ups
consists of covering the wound with a moist sterile dressing and for the return of hypothalamic-pituitary-adrenal
and notifying the physician. function.

When a patient has a radical mastectomy, the ovaries also Pulsus paradoxus is a pulse that becomes weak during
may be removed because they are a source of estrogen, inspiration and strong during expiration. It may be a sign of
which stimulates tumor growth. cardiac tamponade.

Atropine blocks the effects of acetylcholine, thereby Substances that are expelled through portals of exit include
obstructing its vagal effects on the sinoatrial node and saliva, mucus, feces, urine, vomitus, blood, and vaginal and
increasing heart rate. penile discharges.

Salicylates, particularly aspirin, are the treatment of choice A microorganism may be transmitted directly, by contact
in rheumatoid arthritis because they decrease inflammation with an infected body or droplets, or indirectly, by contact
and relieve joint pain. with contaminated air, soil, water, or fluids.

Deep, intense pain that usually worsens at night and is A postmenopausal woman who receives estrogen therapy is
unrelated to movement suggests bone pain. at an increased risk for gallbladder disease and breast
cancer.
Pain that follows prolonged or excessive exercise and
subsides with rest suggests muscle pain. The approximate oxygen concentrations delivered by a
nasal cannula are as follows: 1 L = 24%, 2 L = 28%, 3 L =
The major hemodynamic changes associated with 32%, 4 L= 36%, and 5 L = 40%.
 Cardinal features of diabetes insipidus include polydipsia Flurazepam (Dalmane) toxicity is manifested by confusion,
(excessive thirst) and polyuria (increased urination to 5 L/24 hallucinations, and ataxia.
hours).
A silent myocardial infarction is one that has no symptoms.
A patient with low specific gravity (1.001 to 1.005) may
have an increased desire for cold water. Adverse reactions to verapamil (Isoptin) include dizziness,
headache, constipation, hypotension, and atrioventricular
Diabetic coma can occur when the blood glucose level conduction disturbances. The drug also may increase the
drops below 60 mg/dl. serum digoxin level.

For a patient with heart failure, the nurse should elevate the When a rectal tube is used to relieve flatulence or enhance
head of the bed 8" to 12" (20 to 30 cm), provide a bedside peristalsis, it should be inserted for no longer than 20
commode, and administer cardiac glycosides and diuretics minutes.
as prescribed.
Yellowish green discharge on a wound dressing indicates
The primary reason to treat streptococcal sore throat with infection and should be cultured.
antibiotics is to protect the heart valves and prevent
rheumatic fever. Sickle cell crisis can cause severe abdominal, thoracic,
muscular, and bone pain along with painful swelling of soft
A patient with a nasal fracture may lose consciousness tissue in the hands and feet.
during reduction.
Oral candidiasis (thrush) is characterized by cream -colored
Hoarseness and change in the voice are commonly the first or bluish white patches on the oral mucous membrane.
signs of laryngeal cancer.
Treatment for a patient with cystic fibrosis may include
The lungs, colon, and rectum are among the most common drug therapy, exercises to improve breathing and posture,
cancer sites. exercises to facilitate mobilization of pulmonary secretions,
a high-salt diet, and pancreatic enzyme supplements with
The most common preoperative problem in elderly patients snacks and meals.
is lower-than-normal total blood volume.
Pancreatic cancer may cause weight loss, jaundice, and
Mannitol (Osmitrol), an osmotic diuretic, is administered to intermittent dull-to-severe epigastric pain.
reduce intraocular or intracranial pressure.
Metastasis is the spread of cancer from one organ or body
When a stroke is suspected, the nurse should place the part to another through the lymphatic system, circulation
patient on the affected side to promote lung expansion on system, or cerebrospinal fluid.
the unaffected side.
The management of pulmonary edema focuses on opening
For a patient who has had chest surgery, the nurse should the airways, supporting ventilation and perfusion, improving
recommend sitting upright and performing coughing and cardiac functioning, reducing preload, and reducing patient
deep-breathing exercises. These actions promote expansion anxiety.
of the lungs, removal of secretions, and optimal pulmonary
functioning. Factors that contribute to the death of patients with
Alzheimer’ s disease include infection, malnutrition, and
During every sleep cycle, the sleeper passes through four dehydration.
stages of nonrapid-eye-movement sleep and one stage of
rapid-eye-movement sleep. Hodgkin’ s disease is characterized by painless,
progressive enlargement of cervical lymph nodes and other
A patient who is taking calcifediol (Calderol) should avoid lymphoid tissue as a result of proliferation of Reed-
concomitant use of preparations that contain vitamin D. Sternberg cells, histiocytes, and eosinophils.

A patient should begin and end a 24-hour urine collection Huntington’ s disease (chorea) is a hereditary disease
period with an empty bladder. For example, if the physician characterized by degeneration in the cerebral cortex and
orders urine to be collected from 0800 Thursday to 0800 basal ganglia.
Friday, the urine voided at 0800 Thursday should be
discarded and the urine voided at 0800 Friday should be A patient with Huntington’ s disease may exhibit suicidal
retained. ideation.

In a patient who is receiving digoxin (Lanoxin), a low At discharge, an amputee should be able to demonstrate
potassium level increases the risk of digoxin toxicity. proper stump care and perform stump-toughening exercises.

Blood urea nitrogen values normally range from 10 to 20 Acute tubular necrosis is the most common cause of acute
mg/dl. renal failure.
 the prescriber should ask for the date of her last menstrual
Common complications of ice water lavage are vomiting period and ask if she may be pregnant.
and aspiration.
Acidosis may cause insulin resistance.
Foods high in vitamin D include fortified milk, fish, liver,
liver oil, herring, and egg yolk. A patient with glucose-6-phosphate dehydrogenase
deficiency may have acute hemolytic anemia when given a
For a pelvic examination, the patient should be in the sulfonamide.
lithotomy position, with the buttocks extending 2½" (6.4
cm) past the end of the examination table. The five basic activities of the digestive system are
ingestion, movement of food, digestion, absorption, and
If a patient can’ t assume the lithotomy position for a pelvic defecation.
examination, she may lie on her left side.
Signs and symptoms of acute pancreatitis include epigastric
A male examiner should have a female assistant present pain, vomiting, bluish discoloration of the left flank (Grey
during a vaginal examination for the patient’ s emotional Turner’ s sign), bluish discoloration of the periumbilical
comfort and the examiner’ s legal protection. area (Cullen’ s sign), low-grade fever, tachycardia, and
hypotension.
Cervical secretions are clear and stretchy before ovulation
and white and opaque after ovulation. They’ re normally A patient with a gastric ulcer may have gnawing or burning
odorless and don’ t irritate the mucosa. epigastric pain.

A patient with an ileostomy shouldn’ t eat corn because it To test the first cranial nerve (olfactory nerve), the nurse
may obstruct the opening of the pouch. should ask the patient to close his eyes, occlude one nostril,
and identify a nonirritating substance (such as peppermint or
Liver dysfunction affects the metabolism of certain drugs. cinnamon) by smell. Then the nurse should repeat the test
with the patient’ s other nostril occluded.
Edema that accompanies burns and malnutrition is caused
by decreased osmotic pressure in the capillaries. Salk and Sabin introduced the oral polio vaccine.

Hyponatremia is most likely to occur as a complication of A patient with a disease of the cerebellum or posterior
nasogastric suctioning. column has an ataxic gait that’ s characterized by staggering
and inability to remain steady when standing with the feet
In a man who has complete spinal cord separation at S4, together.
erection and ejaculation aren’ t possible.
In trauma patients, improved outcome is directly related to
The early signs of pulmonary edema (dyspnea on exertion early resuscitation, aggressive management of shock, and
and coughing) reflect interstitial fluid accumulation and appropriate definitive care.
decreased ventilation and alveolar perfusion.
To check for leakage of cerebrospinal fluid, the nurse
Methylprednisolone (Solu-Medrol) is a first-line drug used should inspect the patient’ s nose and ears. If the patient can
to control edema after spinal cord trauma. sit up, the nurse should observe him for leakage as the
patient leans forward.
For the patient who is recovering from an intracranial bleed,
the nurse should maintain a quiet, restful environment for Locked-in syndrome is complete paralysis as a result of
the first few days. brain stem damage. Only the eyes can be moved voluntarily.

Neurosyphilis is associated with widespread damage to the Neck dissection, or surgical removal of the cervical lymph
central nervous system, including general paresis, nodes, is performed to prevent the spread of malignant
personality changes, slapping gait, and blindness. tumors of the head and neck.

A woman who has had a spinal cord injury can still become A patient with cholecystitis typically has right epigastric
pregnant. pain that may radiate to the right scapula or shoulder;
nausea; and vomiting, especially after eating a heavy meal.
In a patient who has had a stroke, the most serious
complication is increasing intracranial pressure. Atropine is used preoperatively to reduce secretions.

A patient with an intracranial hemorrhage should undergo Serum calcium levels are normally 4.5 to 5.5 mEq/L.
arteriography to identify the site of the bleeding.
Suppressor T cells regulate overall immune response.
Factors that affect the action of drugs include absorption,
distribution, metabolism, and excretion. Serum levels of aspartate aminotransferase and alanine
aminotransferase show whether the liver is adequately
Before prescribing a drug for a woman of childbearing age, detoxifying drugs.
Serum sodium levels are normally 135 to 145 mEq/L. In elderly patients, the incidence of noncompliance with
prescribed drug therapy is high. Many elderly patients have
Serum potassium levels are normally 3.5 to 5.0 mEq/L. diminished visual acuity, hearing loss, or forgetfulness, or
need to take multiple drugs.
A patient who is taking prednisone (Deltasone) should
consume a salt-restricted diet that’ s rich in potassium and Tuberculosis is a reportable communicable disease that’ s
protein. caused by infection with Mycobacterium tuberculosis (an
acid-fast bacillus).
When performing continuous ambulatory peritoneal
dialysis, the nurse must use sterile technique when handling For right-sided cardiac catheterization, the physician passes
the catheter, send a peritoneal fluid sample for culture and a multilumen catheter through the superior or inferior vena
sensitivity testing every 24 hours, and report signs of cava.
infection and fluid imbalance.
After a fracture, bone healing occurs in these stages:
When working with patients who have acquired hematoma formation, cellular proliferation and callus
immunodeficiency syndrome, the nurse should wear goggles formation, and ossification and remodeling.
and a mask only if blood or another body fluid could splash
onto the nurse’ s face. A patient who is scheduled for positron emission
tomography should avoid alcohol, tobacco, and caffeine for
Blood spills that are infected with human 24 hours before the test.
immunodeficiency virus should be cleaned up with a 1:10
solution of sodium hypochlorite 5.25% (household bleach). In a stroke, decreased oxygen destroys brain cells.

Raynaud’ s phenomenon is intermittent ischemic attacks in A patient with glaucoma shouldn’ t receive atropine sulfate
the fingers or toes. It causes severe pallor and sometimes because it increases intraocular pressure.
paresthesia and pain.
The nurse should instruct a patient who is hyperventilating
Intussusception (prolapse of one bowel segment into the to breathe into a paper bag.
lumen of another) causes sudden epigastric pain, sausage-
shaped abdominal swelling, passage of mucus and blood During intermittent positive-pressure breathing, the patient
through the rectum, shock, and hypotension. should bite down on the mouthpiece, breathe normally, and
let the machine do the work. After inspiration, the patient
Bence Jones protein occurs almost exclusively in the urine should hold his breath for 3 or 4 seconds and exhale
of patients who have multiple myeloma. completely through the mouthpiece.

Gaucher’ s disease is an autosomal disorder that’ s Flexion contractures of the hips may occur in a patient who
characterized by abnormal accumulation of sits in a wheelchair for a long time.
glucocerebrosides (lipid substances that contain glucose) in
monocytes and macrocytes. It has three forms: Type 1 is the Nystagmus is rapid horizontal or rotating eye movement.
adult form, type 2 is the infantile form, and type 3 is the
juvenile form. After myelography, the patient should remain recumbent
for 24 hours.
A patient with colon obstruction may have lower abdominal
pain, constipation, increasing distention, and vomiting. The treatment of sprains and strains consists of applying ice
immediately and elevating the arm or leg above heart level.
Colchicine (Colsalide) relieves inflammation and is used to
treat gout. An anticholinesterase agent shouldn’ t be prescribed for a
patient who is taking morphine because it can potentiate the
Some people have gout as a result of hyperuricemia effect of morphine and cause respiratory depression.
because they can’ t metabolize and excrete purines
normally. Myopia is nearsightedness. Hyperopia and presbyopia are
two types of farsightedness.
A normal sperm count is 20 to 150 million/ml.
The most effective contraceptive method is one that the
A first-degree burn involves the stratum corneum layer of woman selects for herself and uses consistently.
the epidermis and causes pain and redness.
To perform Weber’ s test for bone conduction, a vibrating
Sheehan’ s syndrome is hypopituitarism caused by a tuning fork is placed on top of the patient’ s head at
pituitary infarct after postpartum shock and hemorrhage. midline. The patient should perceive the sound equally in
both ears. In a patient who has conductive hearing loss, the
When caring for a patient who has had an asthma attack, the sound is heard in (lateralizes to) the ear that has conductive
nurse should place the patient in Fowler’ s or semi- loss.
Fowler’ s position.
 In the Rinne test, bone conduction is tested by placing a facilities on a nursing unit are ina dequate for storing blood
vibrating tuning fork on the mastoid process of the temporal products.
bone and air conduction is tested by holding the vibrating
tuning fork ½" (1.3 cm) from the external auditory meatus. Blood that’ s discolored and contains gas bubbles is
These tests are alternated, at different frequencies, until the contaminated with bacteria and shouldn’ t be transfused.
tuning fork is no longer heard at one position. Fifty percent of patients who receive contaminated blood
die.
After an amputation, the stump may shrink because of
muscle atrophy and decreased subcutaneous fat. For massive, rapid blood transfusions and for exchange
transfusions in neonates, blood should be warmed to 98.7° F
A patient who has deep vein thrombosis is given heparin for (37° C).
7 to 10 days, followed by 12 weeks of warfarin (Coumadin)
therapy. A chest tube permits air and fluid to drain from the pleural
space.
After pneumonectomy, the patient should be positioned on
the operative side or on his back, with his head slightly A handheld resuscitation bag is an inflatable device that
elevated. can be attached to a face mask or an endotracheal or
tracheostomy tube. It allows manual delivery of oxygen to
To reduce the possibility of formation of new emboli or the lungs of a patient who can’ t breathe independently.
expansion of existing emboli, a patient with deep vein Mechanical ventilation artificially controls or assists
thrombosis should receive heparin. respiration.

Atherosclerosis is the most common cause of coronary The nurse should encourage a patient who has a closed
artery disease. It usually involves the aorta a nd the femoral, chest drainage system to cough frequently and breathe
coronary, and cerebral arteries. deeply to help drain the pleural space and expand the lungs.

Pulmonary embolism is a potentially fatal complication of Tracheal suction removes secretions from the trachea and
deep vein thrombosis. bronchi with a suction catheter.

Chest pain is the most common symptom of pulmonary During colostomy irrigation, the irrigation bag should be
embolism. hung 18" (45.7 cm) above the stoma.

The nurse should inform a patient who is taking The water used for colostomy irrigation should be 100° to
phenazopyridine (Pyridium) that this drug colors urine 105° F (37.8° to 40.6° C).
orange or red.
Pneumothorax is a serious complication of central venous An arterial embolism may cause pain, loss of sensory
line placement; it’ s caused by inadvertent lung puncture. nerves, pallor, coolness, paralysis, pulselessness, or
paresthesia in the affected arm or leg.
Pneumocystis carinii pneumonia isn’ t considered
contagious because it only affects patients who have a Respiratory alkalosis results from conditions that cause
suppressed immune system. hyperventilation and reduce the carbon dioxide level in the
arterial blood.
To enhance drug absorption, the patient should take regular
erythromycin tablets with a full glass of water 1 hour before Mineral oil is contraindicated in a patient with
or 2 hours after a meal or should take enteric-coated tablets appendicitis, acute surgical abdomen, fecal impaction, or
with food. The patient should avoid taking either type of intestinal obstruction.
tablet with fruit juice.
When using a Y-type administration set to transfuse
Trismus, a sign of tetanus (lockjaw), causes painful spasms packed red blood cells (RBCs), the nurse can add normal
of the masticatory muscles, difficulty opening the mouth, saline solution to the bag to dilute the RBCs and make
neck rigidity and stiffness, and dysphagia. them less viscous.

The nurse should place the patient in an upright position for Autotransfusion is collection, filtration, and reinfusion of
thoracentesis. If this isn’ t possible, the nurse should the patient’ s own blood.
position the patient on the unaffected side.
Prepared I.V. solutions fall into three general categories:
If gravity flow is used, the nurse should hang a blood bag 3' isotonic, hypotonic, and hypertonic. Isotonic solutions have
(1 m) above the level of the planned venipuncture site. a solute concentration that’ s similar to body fluids; adding
them to plasma doesn’ t change its osmolarity. Hypotonic
The nurse should place a patient who has a closed chest solutions have a lower osmotic pressure than body fluids;
drainage system in the semi-Fowler position. adding them to plasma decreases its osmolarity. Hypertonic
solutions have a higher osmotic pressure than body fluids;
If blood isn’ t transfused within 30 minutes, the nurse adding them to plasma increases its osmolarity.
should return it to the blood bank because the refrigeration
 Stress incontinence is involuntary leakage of urine
triggered by a sudden physical strain, such as a cough, When irrigating the eye, the nurse should direct the
sneeze, or quick movement. solution toward the lower conjunctival sac.

Decreased renal function makes an elderly patient more Emergency care for a corneal injury caused by a caustic
susceptible to the development of renal calculi. substance is flushing the eye with copious amounts of
water for 20 to 30 minutes.
The nurse should consider using shorter needles to inject
drugs in elderly patients because these patients experience Debridement is mechanical, chemical, or surgical removal
subcutaneous tissue redistribution and loss in areas, such as of necrotic tissue from a wound.
the buttocks and deltoid muscles.
Severe pain after cataract surgery indicates bleeding in the
Urge incontinence is the inability to suppress a sudden eye.
urge to urinate.
A bivalve cast is cut into anterior and posterior portions to
Total incontinence is continuous, uncontrollable leakage of allow skin inspection.
urine as a result of the bladder’ s inability to retain urine.
After ear irrigation, the nurse should place the patient on
Protein, vitamin, and mineral needs usually remain the affected side to permit gravity to drain fluid that
constant as a person ages, but caloric requirements remains in the ear.
decrease.
If a patient with an indwelling catheter has abdominal
Four valves keep blood flowing in one direction in the discomfort, the nurse should assess for bladder distention,
heart: two atrioventricular valves (tricuspid and mitral) and which may be caused by catheter blockage.
two semilunar valves (pulmonic and aortic).
Continuous bladder irrigation helps prevent urinary tract
An elderly patient’ s height may decrease because of obstruction by flushing out small blood clots that form after
narrowing of the intervertebral spaces and exaggerated prostate or bladder surgery.
spinal curvature.
The nurse should remove an indwelling catheter when
bladder decompression is no longer needed, when the
catheter is obstructed, or when the patient can resume
Constipation most commonly occurs when the urge to voiding. The longer a catheter remains in place, the greater
defecate is suppressed and the muscles associated with the risk of urinary tract infection.
bowel movements remain contracted.
In an adult, the extent of a burn injury is determined by
Gout develops in four stages: asymptomatic, acute, using the Rule of Nines: the head and neck are counted as
intercritical, and chronic. 9%; each arm, as 9%; each leg, as 18%; the back of the
trunk, as 18%; the front of the trunk, as 18%; and the
Common postoperative complications include hemorrhage, perineum, as 1%.
infection, hypovolemia, septicemia, septic shock,
atelectasis, pneumonia, thrombophlebitis, and pulmonary A deep partial-thickness burn affects the epidermis and
embolism. dermis.

An insulin pump delivers a continuous infusion of insulin In a patient who is having an asthma attack, nursing
into a selected subcutaneous site, commonly in the interventions include administering oxygen and
abdomen. bronchodilators as prescribed, placing the patient in the
semi-Fowler position, encouraging diaphragmatic
A common symptom of salicylate (aspirin) toxicity is breathing, and helping the patient to relax.
tinnitus (ringing in the ears).

A frostbitten extremity must be thawed rapidly, even if

definitive treatment must be delayed. Prostate cancer is usually fatal if bone metastasis occurs.

A patient with Raynaud’ s disease shouldn’ t smoke A strict vegetarian needs vitamin B12 supplements
cigarettes or other tobacco products. because animals and animal products are the only source of
this vitamin.
Raynaud’ s disease is a primary arteriospastic disorder
that has no known cause. Raynaud’ s phenomenon, Regular insulin is the only type of insulin that can be
however, is caused by another disorder such as mixed with other types of insulin and can be given I.V.
scleroderma.
If a patient pulls out the outer tracheostomy tube, the nurse
To remove a foreign body from the eye, the nurse should should hold the tracheostomy open with a surgical dilator
irrigate the eye with sterile normal saline solution. until the physician provides appropriate ca re.
 of rupturing the enlarged spleen.
The medulla oblongata is the part of the brain that controls
the respiratory center. Daily application of a long-acting, transdermal
nitroglycerin patch is a convenient, effective way to
For an unconscious patient, the nurse should perform prevent chronic angina.
passive range-of-motion exercises every 2 to 4 hours.
The nurse must wear a cap, gloves, a gown, and a mask
A timed-release drug isn’ t recommended for use in a when providing wound care to a patient with third-degree
patient who has an ileostomy because it releases the drug at burns.
different rates along the GI tract.
The nurse should expect to administer an analgesic before
The nurse isn’ t required to wear gloves when applying bathing a burn patient.
nitroglycerin paste; however, she should wash her hands
after applying this drug. The passage of black, tarry feces (melena) is a common
sign of lower GI bleeding, but also may occur in patients
Before excretory urography, a patient’ s fluid intake is who have upper GI bleeding.
usually restricted after midnight.
A patient who has a gastric ulcer should avoid taking
A sodium polystyrene sulfonate (Kayexalate) enema, aspirin and aspirin-containing products beca use they can
which exchanges sodium ions for potassium ions, is used to irritate the gastric mucosa.
decrease the potassium level in a patient who has
hyperkalemia. While administering chemotherapy agents with an I.V.
line, the nurse should discontinue the infusion at the first
If the color of a stoma is much lighter than when sign of extravasation.
previously assessed, decreased circulation to the stoma
should be suspected. A low-fiber diet may contribute to the development of
hemorrhoids.
Massage is contraindicated in a leg with a blood clot
because it may dislodge the clot. A pa tient who has abdominal pain shouldn’ t receive an
analgesic until the cause of the pain is determined.
The first place a nurse can detect jaundice in an adult is in
the sclera. If surgery requires hair removal, the recommendation of
the Centers for Disease Control and Prevention is that a
Jaundice is caused by excessive levels of conjugated or depilatory be used to avoid skin abrasions and cuts.
unconjugated bilirubin in the blood.
For nasotracheal suctioning, the nurse should set wall
Mydriatic drugs are used primarily to dilate the pupils for suction at 50 to 95 mm Hg for an infant, 95 to 115 mm Hg
intraocular examinations. for a child, or 80 to 120 mm Hg for an adult.

After eye surgery, the patient should be placed on the After a myocardial infarction, a change in pulse rate and
unaffected side. rhythm may signal the onset of fatal arrhythmias.

When assigning tasks to a licensed practical nurse, the Treatment of epistaxis includes nasal packing, ice packs,
registered nurse should delegate tasks that are considered cautery with silver nitrate, and pressure on the nares.
bedside nursing care, such as taking vital signs, changing
simple dressings, and giving baths. Palliative treatment relieves or reduces the intensity of
uncomfortable symptoms, but doesn’ t cure the causative
Deep calf pa in on dorsiflexion of the foot is a positive disorder.
Homans’ sign, which suggests venous thrombosis or
thrombophlebitis. Placing a postoperative patient in an upright position too
quickly may cause hypotension.
Ultra-short-acting barbiturates, such as thiopental
(Pentothal), are used as injection anesthetics when a short Verapamil (Calan) and diltiazem (Cardizem) slow the
duration of anesthesia is needed such as outpatient surgery. inflow of calcium to the heart, thereby decreasing the risk
of supraventricular tachycardia.
Atropine sulfate may be used as a preanesthetic drug to
reduce secretions and minimize vagal reflexes. After cardiopulmonary bypass graft, the patient will
perform turning, coughing, deep breathing, and wound
For a patient with infectious mononucleosis, the nursing splinting, and will use assistive breathing devices.
care plan should emphasize strict bed rest during the acute
febrile stage to ensure adequate rest. A patient who is exposed to hepatitis B should receive
0.06 ml/kg I.M. of immune globulin within 72 hours after
During the acute phase of infectious mononucleosis, the exposure and a repeat dose at 28 days after exposure.
patient should curtail activities to minimize the possibility
 The nurse should advise a patient who is undergoing overnight fast and abstinence from alcohol for 24 hours
radiation therapy not to remove the markings on the skin before the test.
made by the radiation therapist because they are landmarks
for treatment. The fasting plasma glucose test measures glucose levels
after a 12- to 14-hour fast.
The most common symptom of osteoarthritis is joint pain
that’ s relieved by rest, especially if the pain occurs after Normal blood pH ranges from 7.35 to 7.45. A blood pH
exercise or weight bearing. higher than 7.45 indicates alkalemia; one lower than 7.35
indicates acidemia.
In adults, urine volume normally ranges from 800 to 2,000
ml/day and averages between 1,200 and 1,500 ml/day .
During an acid perfusion test, a small amount of weak
Directly applied moist heat softens crusts and exudates, hydrochloric acid solution is infused with a nasoesophageal
penetrates deeper than dry heat, doesn’ t dry the skin, and tube. A positive test result (pain after infusion) suggests
is usually more comfortable for the patient. reflux esophagitis.

Tetracyclines are seldom considered drugs of choice for Normally, the partial pressure of arterial carbon dioxide
most common bacterial infections because their overuse (PaCO2) ranges from 35 to 45 mm Hg. A PaCO2 greater
has led to the emergence of tetracycline-resistant bacteria. than 45 mm Hg indicates acidemia as a result of
hypoventilation; one less than 35 mm Hg indicates
Because light degrades nitroprusside (Nitropress), the drug alkalemia as a result of hyperventilation.
must be shielded from light. For example, an I.V. bag that
contains nitroprusside sodium should be wrapped in f oil. Red cell indices aid in the diagnosis and classification of
anemia.

Normally, the partial pressure of arterial oxygen (Pao 2)

Cephalosporins should be used cautiously in patients who ranges from 80 to 100 mm Hg. A Pao 2 of 50 to 80 mm Hg
are allergic to penicillin. These patients are more indicates respiratory insufficiency. A Pao 2 of less than 50
susceptible to hypersensitivity reactions. mm Hg indicates respiratory failure.

If chloramphenicol and penicillin must be administered The white blood cell (WBC) differential evaluates WBC
concomitantly, the nurse should give the penicillin 1 or distribution and morphology and provides more specific
more hours before the chloramphenicol to avoid a information about a patient’ s immune system than the
reduction in penicillin’ s bactericidal activity. WBC count.

The erythrocyte sedimentation rate measures the distance An exercise stress test (treadmill test, exercise
and speed at which erythrocytes in whole blood fall in a electrocardiogram) continues until the patient reaches a
vertical tube in 1 hour. The rate at which they fall to the predetermined target heart rate or experiences chest pain,
bottom of the tube corresponds to the degree of fatigue, or other signs of exercise intolerance.
inflammation.
Alterable risk factors for coronary artery disease include
When teaching a patient with myasthenia gravis about cigarette smoking, hypertension, high cholesterol or
pyridostigmine (Mestinon) therapy, the nurse should stress triglyceride levels, and diabetes.
the importance of taking the drug exactly a s prescribed, on
time, and in evenly spaced doses to prevent a relapse and The mediastinum is the space between the lungs that
maximize the effect of the drug. contains the heart, esophagus, trachea, and other structures.

If an antibiotic must be administered into a peripheral Major complications of acute myocardial infarction
heparin lock, the nurse should flush the site with normal include arrhythmias, acute heart failure, cardiogenic shock,
saline solution after the infusion to maintain I.V. patency. thromboembolism, and left ventricular rupture.

The nurse should instruct a patient with angina to take a The sinoatrial node is a cluster of hundreds of cells located
nitroglycerin tablet before anticipated stress or exercise or, in the right atrial wall, near the opening of the superior
if the angina is nocturnal, at bedtime. vena cava.

Arterial blood gas analysis evaluates gas exchange in the For one-person cardiopulmonary resuscitation, the ratio of
lungs (alveolar ventilation) by measuring the partial compressions to ventilations is 15:2.
pressures of oxygen and carbon dioxide and the pH of an
arterial sample. For two-person cardiopulmonary resuscitation, the ratio of
compressions to ventilations is 5:1.
The normal serum magnesium level ranges from 1.5 to 2.5
mEq/L. A patient who has pulseless ventricular tachycardia is a
candidate for cardioversion.
Patient preparation for a total cholesterol test includes an
 Echocardiography, a noninvasive test that directs ultra - by Staphylococcus aureus.
high-frequency sound waves through the chest wall and
into the heart, evaluates cardiac structure and function and A patient who is undergoing external radiation therapy
can show valve deformities, tumors, septal defects, shouldn’ t apply cream or lotion to the treatment site.
pericardial effusion, and hypertrophic cardiomyopathy.
The most common vascular complication of diabetes
Ataxia is impaired a bility to coordinate movements. It’ s mellitus is atherosclerosis.
caused by a cerebellar or spinal cord lesion.
Insulin deficiency may cause hyperglycemia.
On an electrocardiogram strip, each small block on the
horizontal axis represents 0.04 second. Each large block Signs of Parkinson’ s disease include drooling, a masklike
(composed of five small blocks) represents 0.2 second. expression, and a propulsive gait.

Starling’ s law states that the force of contraction of each I.V. cholangiography is contraindicated in a patient with
heartbeat depends on the length of the muscle fibers of the hyperthyroidism, severe renal or hepatic damage,
heart wall. tuberculosis, or iodine hypersensitivity.

The therapeutic blood level for digoxin is 0.5 to 2.5 ng/ml. Mirrors should be removed from the room of a patient who
has disfiguring wounds such as facial burns.
Pancrelipase (Pancrease) is used to treat cystic fibrosis and
chronic pancreatitis. A patient who has gouty arthritis should increase fluid
intake to prevent calculi formation.
Treatment for mild to moderate varicose veins includes
antiembolism stockings and an exercise program that Anxiety is the most common cause of chest pain.
includes walking to minimize venous pooling.
A patient who is following a low-salt diet should avoid
An intoxicated patient isn’ t considered competent to canned vegetables.
refuse required medical treatment and shouldn’ t be
allowed to check out of a hospital against medical advice. Bananas are a good source of potassium and should be
included in a low-salt diet for patients who are taking a
The primary difference between the pain of angina and loop diuretic such as furosemide (Lasix).
that of a myocardial infarction is its duration.
The nurse should encourage a patient who is at risk for
Gynecomastia is excessive mammary gland development pneumonia to turn frequently, cough, and breathe deeply.
and increased breast size in boys and men. These actions mobilize pulmonary secretions, promote
alveolar gas exchange, and help prevent atelectasis.
Classic symptoms of Graves’ disease are an enlarged
thyroid, nervousness, heat intolerance, weight loss despite The nurse should notify the physician whenever a
increased appetite, sweating, diarrhea, tremor, and patient’ s blood pressure reaches 180/100 mm Hg.
palpitations.
Buck’ s traction is used to immobilize and reduce spasms
Generalized malaise is a common symptom of viral and in a fractured hip.
bacterial infections and depressive disorders.
For a patient with a fractured hip, the nurse should assess
Vitamin C and protein are the most important nutrients for neurocirculatory status every 2 hours.
wound healing.
When caring for a patient with a fractured hip, the nurse
A patient who has portal hypertension should receive should use pillows or a trochanter roll to maintain
vitamin K to promote active thrombin formation by the abduction.
liver. Thrombin reduces the risk of bleeding.
Orthopnea is a symptom of left-sided heart failure.
The nurse should administer a sedative cautiously to a
patient with cirrhosis because the damaged liver can’ t Although a fiberglass cast is more durable and dries more
metabolize drugs effectively. quickly than a plaster cast, it typically causes skin
irritation.
Beta-hemolytic streptococcal infections should be treated
aggressively to prevent glomerulonephritis, rheumatic In an immobilized patient, the major circulatory
fever, and other complications. complication is pulmonary embolism.

The most common nosocomial infection is a urinary tract To relieve edema in a fractured limb, the patient should
infection. keep the limb elevated.

The nurse should implement strict isolation precautions to I.V. antibiotics are the treatment of choice for a patient
protect a patient with a third-degree burn that’ s infected with osteomyelitis.
 is the laxative of choice for patients who are recovering
Blue dye in cimetidine (Tagamet) can cause a false- from a myocardial infarction, rectal or cardiac surgery, or
positive result on a fecal occult blood test such as a postpartum constipation.
Hemoccult test.
After prostate surgery, a patient’ s primary sources of pain
The nurse should suspect elder abuse if wounds are are bladder spasms and irritation in the area around the
inconsistent with the patient’ s history, multiple wounds catheter.
are present, or wounds are in different stages of healing.
Toxoplasmosis is more likely to affect a pregnant cat
Immediately after amputation, patient care includes owner than other pregnant women because cat feces in the
monitoring drainage from the stump, positioning the litter box harbor the infecting organism.
affected limb, assisting with exercises prescribed by a
physical therapist, and wrapping and conditioning the Good food sources of folic acid include green leafy
stump. vegetables, liver, and legumes.

A patient who is prone to constipation should increase his The Glasgow Coma Scale evaluates verbal, eye, and motor
bulk intake by eating whole-grain cereals and fresh fruits responses to determine the patient’ s level of
and vegetables. consciousness.

In the pelvic examination of a sexual assault victim, the The nurse should place an unconscious patient in low
speculum should be lubricated with water. Commercial Fowler’ s position for intermittent nasogastric tube
lubricants retard sperm motility and interfere with feedings.
specimen collection and analysis.
Laënnec’ s (alcoholic) cirrhosis is the most common type
For a terminally ill patient, physical comfort is the top of cirrhosis.
priority in nursing care.
In decorticate posturing, the patient’ s arms are adducted
Dorsiflexion of the foot provides immediate relief of leg and flexed, with the wrists and fingers flexed on the chest.
cramps. The legs are extended stiffly and rotated internally, with
plantar flexion of the feet.
After cardiac surgery, the patient should limit daily sodium
intake to 2 g and daily cholesterol intake to 300 mg. Candidates for surgery should receive nothing by mouth
from midnight of the day before surgery unless cleared by a
Bleeding after intercourse is an early sign of cervical physician.
cancer.
Meperidine (Demerol) is an effective analgesic to relieve
Oral antidiabetic agents, such as chlorpropamide the pain of nephrolithiasis (urinary calculi).
(Diabinese) and tolbutamide (Orinase), stimula te insulin
release from beta cells in the islets of Langerhans of the An injured patient with thrombocytopenia is at risk for
pancreas. life-threatening internal and external hemorrhage.

When visiting a patient who has a radiation implant, The Trendelenburg test is used to check for unilateral hip
family members and friends must limit their stay to 10 dislocation.
minutes. Visitors and nurses who are pregnant are
restricted from entering the room.
As soon as possible after death, the patient should be
Common causes of vaginal infection include using an placed in the supine position, with the arms at the sides and
antibiotic, an oral contraceptive, or a corticosteroid; the head on a pillow.
wearing tight-fitting panty hose; and having sexual
intercourse with an infected partner. Vascular resistance depends on blood viscosity, vessel
length and, most important, inside vessel diameter.
A patient with a radiation implant should remain in
isolation until the implant is removed. To minimize A below-the-knee amputation leaves the knee intact for
radiation exposure, which increases with time, the nurse prosthesis application and allows a more normal gait than
should carefully plan the time spent with the patient. above-the-knee amputation.

Among cultural groups, Native Americans have the lowest Cerebrospinal fluid flows through and protects the four
incidence of cancer. ventricles of the brain, the subarachnoid space, and the
spinal canal.
The kidneys filter blood, selectively reabsorb substances
that are needed to maintain the constancy of body fluid, Sodium regulates extracellular osmolality.
and excrete metabolic wastes.
The heart and brain can maintain blood circulation in the
To prevent straining during defecation, docusate (Colace) early stages of shock.
 The best times to test a diabetic patient’ s glucose level
After limb amputation, narcotic analgesics may not relieve are before each meal and at bedtime.
“ phantom limb” pain.
Intermediate-acting insulins begin to act in 1 to 2 hours,
A patient who receives multiple blood transfusions is at reach a peak concentration in 4 to 15 hours, and have a
risk for hypocalcemia. duration of action of 22 to 28 hours.

Syphilis initially causes painless chancres (small, fluid- Long-acting insulins begin to act in 4 to 8 hours, reach a
filled lesions) on the genitals and sometimes on other parts peak concentration in 10 to 30 hours, and have a duration
of the body. of action of 36 hours or more.

Exposure to a radioactive source is controlled by time If the results of a nonfasting glucose test show above-
(limiting time spent with the patient), distance (from the normal glucose levels after glucose administration, but the
patient), and shield (a lead apron). patient has normal plasma glucose levels otherwise, the
patient has impaired glucose tolerance.
Jaundice is a sign of dysfunction, not a disease.
Insulin requirements are increased by growth, pregnancy,
Severe jaundice can cause brain stem dysfunction if the increased food intake, stress, surgery, infection, illness,
unconjugated bilirubin level in blood is elevated to 20 to 25 increased insulin antibodies, and some drugs.
mg/dl.
Insulin requirements are decreased by hypothyroidism,
The patient should take cimetidine (Tagamet) with meals decreased food intake, exercise, and some drugs.
to help ensure a consistent therapeutic effect.
Hypoglycemia occurs when the blood glucose level is less
When caring for a patient with jaundice, the nurse should than 50 mg/dl.
relieve pruritus by providing a soothing lotion or a baking
soda bath and should prevent injury by keeping the An insulin-resistant patient is one who requires more than
patient’ s fingernails short. 200 units of insulin daily.
Type B hepatitis, which is usually transmitted parenterally,
also can be spread through contact with human secretions Hypoglycemia may occur 1 to 3 hours after the
and feces. administration of a rapid-acting insulin, 4 to 18 hours after
the administration of an intermediate-acting insulin, and 18
Insulin is a naturally occurring hormone that’ s secreted to 30 hours after the administration of a long-acting insulin.
by the beta cells of the islets of Langerhans in the pancreas
in response to a rise in the blood glucose level. When the blood glucose level decreases rapidly, the
patient may experience sweating, tremors, pallor,
Diabetes mellitus is a chronic endocrine disorder that’ s tachycardia, and palpitations.
characterized by insulin deficiency or resistance to insulin
by body tissues. Objective signs of hypoglycemia include slurred speech,
lack of coordination, staggered gait, seizures, and possibly,
A diagnosis of diabetes mellitus is based on the classic coma.
symptoms (polyuria, polyphagia, weight loss, and
polydipsia) and a random blood glucose level of m ore than A conscious patient who has hypoglycemia should receive
200 mg/dl or a fasting plasma glucose level of more than sugar in an easily digested form, such as orange juice,
140 mg/dl when tested on two separate occasions. candy, or lump sugar.

A patient with non– insulin-dependent (type 2) diabetes An unconscious patient who has hypoglycemia should
mellitus produces some insulin and normally doesn’ t need receive an S.C. or I.M. injection of glucagon as prescribed
exogenous insulin supplementation. Most patients with this by a physician or 50% dextrose by I.V. injection.
type of diabetes respond well to oral antidiabetic agents,
which stimulate the pancreas to increase the synthesis and A patient with diabetes mellitus should inspect his feet
release of insulin. daily for calluses, corns, and blisters. He should also use
warm water to wa sh his feet and trim his toenails straight
A patient with insulin-dependent (type 1) diabetes mellitus across to prevent ingrown toenails.
can’ t produce endogenous insulin and requires exogenous
insulin administration to meet the body’ s needs. The early stage of ketoacidosis causes polyuria,
polydipsia, anorexia, muscle cramps, and vomiting. The
Rapid-acting insulins are clear; intermediate- and long- late stage causes Kussmaul’ s respirations, sweet breath
acting insulins are turbid (cloudy). odor, and stupor or coma.

Rapid-acting insulins begin to act in 30 to 60 minutes, An allergen is a substance that can cause a hypersensitivity
reach a peak concentra tion in 2 to 10 hours, and have a reaction.
duration of action of 5 to 16 hours.
A corrective lens for nearsightedness is concave.
 in place over the affected area and observing the area for
Chronic untreated hypothyroidism or abrupt withdrawal of drainage; maintaining the patient in the position specified
thyroid medication may lead to myxedema coma. by the ophthalmologist (usually, lying on his abdomen,
with his head parallel to the floor and turned to the side);
Signs and symptoms of myxedema coma are lethargy, avoiding bumping the patient’ s head or bed; and
stupor, decreased level of consciousness, dry skin and hair, encouraging deep breathing, but not coughing.
delayed deep tendon reflexes, progressive respiratory
center depression and cerebral hypoxia, weight gain, A patient with a cataract may have vision disturbances,
hypothermia, and hypoglycemia. such as image distortion, light glaring, and gradual loss of
vision.
Nearsightedness occurs when the focal point of a ray of
light from an object that’ s 20' (6 m) away falls in front of When talking to a hearing-impaired patient who can lip-
the retina. read, the nurse should face the patient, speak slowly and
enunciate clearly, point to objects as needed, and avoid
Farsightedness occurs when the focal point of a ray of chewing gum.
light from an object that’ s 20' away falls behind the retina.
Clinical manifestations of venous stasis ulcer include
A corrective lens for fa rsightedness is convex. hemosiderin deposits (visible in fair-skinned individuals);
dry, cracked skin; and infection.
Refraction is clinical measurement of the error in eye
focusing. The fluorescent treponemal antibody absorption test is a
specific serologic test for syphilis.
Adhesions are bands of granulation and scar tissue that
develop in some patients after a surgical incision. To reduce fever, the nurse may give the patient a sponge
bath with tepid water (80° to 93° F [26.7° to 33.9° C]).
The nurse should moisten an eye patch for an unconscious
patient because a dry patch may irritate the cornea. When communicating with a patient who has had a stroke,
the nurse should allow ample time for the patient to speak
A patient who has had eye surgery shouldn’ t bend over, and respond, face the patient’ s unaffected side, avoid
comb his hair vigorously, or engage in activity that talking quickly, give visual clues, supplement speech with
increases intraocular pressure. gestures, and give instructions consistently.

When caring for a patient who has a penetrating eye The major complication of Bell’ s palsy is keratitis
injury, the nurse should patch both eyes loosely with sterile (corneal inflammation), which results from incomplete eye
gauze, administer an oral antibiotic (in high doses) and closure on the affected side.
tetanus injection as prescribed, and refer the patient to an
ophthalmologist for follow-up. Immunosuppressants are used to combat tissue rejection
and help control autoimmune disorders.
Signs and symptoms of colorectal cancer include changes
in bowel habits, rectal bleeding, abdominal pain, anorexia, After a unilateral stroke, a patient may be able to propel a
weight loss, malaise, anemia, and constipation or diarrhea. wheelchair by using a heel-to-toe movement with the
unaffected leg and turning the wheel with the unaffected
When climbing stairs with crutches, the patient should lead hand.
with the uninvolved leg and follow with the crutches and
involved leg. First-morning urine is the most concentrated and most
likely to show abnormalities. It should be refrigerated to
When descending stairs with crutches, the patient should retard bacterial growth or, for microscopic examination,
lead with the crutches and the involved leg and follow with should be sent to the laboratory immediately.
the uninvolved leg.
A patient who is recovering from a stroke should align his
When surgery requires eyelash trimming, the nurse should arms and legs correctly, wear high-top sneakers to prevent
apply petroleum jelly to the scissor blades so that the footdrop and contracture, and use an egg crate, flotation, or
eyelashes will adhere to them. pulsating mattress to help prevent pressure ulcers.

Pain after a corneal transplant may indicate that the After a fracture of the arm or leg, the bone may show
dressing has been applied too tightly, the graft has slipped, complete union (normal healing), delayed union (healing
or the eye is hemorrhaging. that takes longer than expected), or nonunion (failure to
heal).
A patient with retinal detachment may report floating
spots, flashes of light, and a sensation of a veil or curtain The most common complication of a hip fracture is
coming down. thromboembolism, which may occlude an artery and cause
the area it supplies to become cold and cyanotic.
Immediate postoperative care for a patient with retinal
detachment includes maintaining the eye patch and shield Chloral hydrate suppositories should be refrigerated.
Cast application usually requires two persons; it shouldn ’ t If a patient feels faint during a bath or shower, the nurse
be attempted alone. should turn off the water, cover the patient, lower the
patient’ s head, and summon help.
A plaster cast reaches maximum strength in 48 hours; a
synthetic cast, within 30 minutes because it doesn’ t A patient who is taking oral contraceptives shouldn’ t
require drying. smoke because smoking can intensify the drug’ s adverse
cardiovascular effect.
Severe pain indicates the development of a pressure ulcer
within a cast; the pain decreases significantly after the ulcer The use of soft restraints requires a physician’ s order and
develops. assessment and documentation of the patient and affected
limbs, according to facility policy.
Indications of circulatory interference are abnormal skin
coolness, cyanosis, and rubor or pallor. A vest restraint should be used cautiously in a patient with
heart failure or a respiratory disorder. The restraint can
During the postoperative phase, increasing pulse rate and tighten with movement, further limiting respiratory
decreasing blood pressure may indicate hemorrhage and function. To ensure patient safety, the least amount of
impending shock. restraint should be used.

Orthopedic surgical wounds bleed more than other surgical

wounds. The nurse can expect 200 to 500 ml of drainage If a piggyback system becomes dislodged, the nurse
during the first 24 hours and less than 30 ml each 8 hours should replace the entire piggyback system with the
for the next 48 hours. appropriate solution and drug, as prescribed.

A patient who has had hip surgery shouldn’ t adduct or The nurse shouldn’ t secure a restraint to a bed’ s side
flex the affected hip because flexion greater than 90 rails because they might be lowered inadvertently and
degrees may cause dislocation. cause patient injury or discomfort.

The Hoyer lift, a hydraulic device, allows two persons to The nurse should assess a patient who has limb restraints
lift and move a nonambulatory patient safely. every 30 minutes to detect signs of impaired circulation.

A patient with carpal tunnel syndrome, a complex of The Centers for Disease Control and Prevention
symptoms caused by compression of the median nerve in recommends using a needleless system for piggybacking an
the carpal tunnel, usually has weakness, pain, burning, I.V. drug into the main I.V. line.
numbness, or tingling in one or both hands.
If a gown is required, the nurse should put it on when she
The nurse should instruct a patient who has had heatstroke enters the patient’ s room and discard it when she leaves.
to wear light-colored, loose-fitting clothing when exposed
to the sun; rest frequently; and drink plenty of fluids. When changing the dressing of a patient who is in
isolation, the nurse should wear two pairs of gloves.
A conscious patient with heat exhaustion or heatstroke
should receive a solution of ½ teaspoon of salt in 120 ml of A disposable bedpan and urinal should remain in the room
water every 15 minutes for 1 hour. of a patient who is in isolation and be discarded on
discharge or at the end of the isolation period.
An I.V. line inserted during an emergency or outside the
hospital setting should be changed within 24 hours. Mycoses (fungal infections) may be systemic or deep
(affecting the internal organs), subcutaneous (involving the
After a tepid bath, the nurse should dry the patient skin), or superficial (growing on the outer layer of skin and
thoroughly to prevent chills. hair).

The nurse should take the patient’ s temperature 30 The night before a sputum specimen is to be collected by
minutes after completing a tepid bath. expectoration, the patient should increase fluid intake to
promote sputum production.
Shower or bath water shouldn’ t exceed 105° F (40.6° C).
A sample of feces for an ova and parasite study should be
Dilatation and curettage is widening of the cervical canal collected directly into a waterproof container, covered with
with a dilator and scraping of the uterus with a curette. a lid, and sent to the laboratory immediately. If the patient
is bedridden, the sample can be collected into a clean, dry
When not in use, all central venous catheters must be bedpan and then transferred with a tongue depressor into a
capped with adaptors after flushing. container.

Care after dilatation and curettage consists of bed rest for 1 When obtaining a sputum specimen for testing, the nurse
day, mild analgesics for pain, and use of a sterile pad for as should instruct the patient to rinse his mouth with clean
long as bleeding persists. water, cough deeply from his chest, and expectorate into a
sterile container.
Oxygen therapy is used in severe asthma attacks to prevent
Tonometry allows indirect measurement of intraocular or treat hypoxemia.
pressure and aids in early detection of glaucoma.
During an asthma attack, the patient may prefer nasal
Pulmonary function tests (a series of measurements that prongs to a Venturi mask because of the mask’ s
evaluate ventilatory function through spirometric smothering effect.
measurements) help to diagnose pulmonary dysfunction.
Chronic obstructive pulmonary disease usually develops
After a liver biopsy, the patient should lie on the right side over a period of years. In 95% of patients, it results from
to compress the biopsy site and decrease the possibility of smoking.
bleeding.
An early sign of chronic obstructive pulmonary disease
A patient who has cirrhosis should follow a diet that (COPD) is slowing of forced expiration. A healthy person
restricts sodium, but provides protein and vitamins can empty the lungs in less than 4 seconds; a patient with
(especially B, C, and K, and folate). COPD may take 6 to 10 seconds.

If 12 hours of gastric suction don’ t relieve bowel Chronic obstructive pulmonary disease eventually leads to
obstruction, surgery is indicated. structural changes in the lungs, including overdistended
alveoli and hyperinflated lungs.
The nurse can puncture a nifedipine (Procardia) capsule
with a needle, withdraw its liquid, and instill it into the Cellulitis causes localized heat, redness, swelling and,
buccal pouch. occasionally, fever, chills, and malaise.

When administering whole blood or packed red blood cells Venous stasis may precipitate thrombophlebitis.
(RBCs), the nurse should use a 16 to 20G needle or cannula
to avoid RBC hemolysis. Treatment of thrombophlebitis includes leg elevation, heat
application, and possibly, anticoagulant therapy.
Hirsutism is excessive body hair in a masculine
distribution. A suctioning machine should remain at the bedside of a
patient who has had maxillofacial surgery.
One unit of whole blood or packed red blood cells is
administered over 2 to 4 hours. For a bedridden patient with heart failure, the nurse should
check for edema in the sacral area.
Scurvy is associated with vitamin C deficiency.
In passive range-of-motion exercises, the therapist moves
A vitamin is an organic compound that usually can ’ t be the patient’ s joints through as full a range of motion as
synthesized by the body and is needed in metabolic possible to improve or maintain joint mobility and help
processes. prevent contractures.

Pulmonary embolism can be caused when In resistance exercises, which allow muscle length to
thromboembolism of fat, blood, bone marrow, or amniotic change, the patient performs exercises against resistance
fluid obstructs the pulmonary artery. applied by the therapist.

After maxillofacial surgery, a patient whose mandible and In isometric exercises, the patient contracts muscles
maxilla have been wired together should keep a pair of against stable resistance, but without joint movement.
scissors or wire cutters readily available so that he can cut Muscle length remains the same, but strength and tone may
the wires and prevent aspiration if vomiting occurs. increase.

Rapid instillation of fluid during colonic irrigation can Impetigo is a contagious, superficial, vesicopustular skin
cause abdominal cramping. infection. Predisposing factors include poor hygiene,
anemia, malnutrition, and a warm climate.
A collaborative relationship between health care workers
helps shorten the hospital stay and increases patient After cardiopulmonary resuscitation (CPR) begins, it
satisfaction. shouldn’ t be interrupted, except when the administrator is
alone and must summon help. In this case, the
For elderly patients in a health care facility, predictable administrator should perform CPR for 1 minute before
hazards include nighttime confusion (sundowning), calling for help.
fractures from falling, immobility-induced pressure ulcers,
prolonged convalescence, and loss of home and support The tongue is the most common airway obstruction in an
systems. unconscious patient.

Respiratory tract infections, especially viral infections, can For adult cardiopulmonary resuscitation, the chest
trigger asthma attacks. compression rate is 80 to 100 times per minute.
 Phimosis is tightness of the prepuce of the penis that
A patient with ulcers should avoid bedtime snacks because prevents retraction of the foreskin over the glans.
food may stimulate nocturnal secretions.
Aminoglycosides are natural antibiotics that are effective
In angioplasty, a blood vessel is dilated with a balloon against gram-negative bacteria. They must be used with
catheter that’ s inserted through the skin and the vessel’ s caution because they can cause nephrotoxicity and
lumen to the narrowed area. Once in place, the balloon is ototoxicity.
inflated to flatten plaque against the vessel wall.
On scrotal examination, varicoceles and tumors don’ t
A full liquid diet supplies nutrients, fluids, and calories in transilluminate, but spermatoceles and hydroceles do.
simple, easily digested foods, such as apple juice, cream of
wheat, milk, coffee, strained cream soup, high-protein A hordeolum (eyelid stye) is an infection of one or more
gelatin, cranberry juice, custard, and ice cream. It’ s sebaceous glands of the eyelid.
prescribed for patients who can’ t tolerate a regular diet.
A chalazion is an eyelid mass that’ s caused by chronic
A pureed diet meets the patient’ s nutritional needs inflammation of the meibomian gland.
without including foods that are difficult to chew or
swallow. Food is blended to a semisolid consistency. During ophthalmoscopic examination, the absence of the
red reflex indicates a lens opacity (cataract) or a detached
A soft, or light, diet is specifically designed for patients retina.
who have difficulty chewing or tolerating a regular diet.
It’ s nutritionally adequate and consists of foods such as Respiratory acidosis is associated with conditions such as
orange juice, cream of wheat, scrambled eggs, enriched drug overdose, Guillain-Barré syndrome, myasthenia
toast, cream of chicken soup, wheat bread, fruit cocktail, gravis, chronic obstructive pulmonary disease, pickwickian
and mushroom soup. syndrome, and kyphoscoliosis. Bullets

A regular diet is provided for patients who don’ t require Respiratory alkalosis is associated with conditions such as
dietary modification. high fever, severe hypoxia, asthma, and pulmonary
embolism.
A bland diet restricts foods that cause gastric irritation or
produce acid secretion without providing a neutralizing Metabolic acidosis is associated with such conditions as
effect. renal failure, diarrhea, diabetic ketosis, and lactic ketosis,
and with high doses of acetazolamide (Diamox).
A clear liquid diet provides fluid and a gradual return to a
regular diet. This type of diet is deficient in all nutrients Gastrectomy is surgical excision of all or part of the
and should be followed for only a short period. stomach to remove a chronic peptic ulcer, stop hemorrhage
in a perforated ulcer, or remove a malignant tumor.
Patients with a gastric ulcer should avoid alcohol,
caffeinated beverages, aspirin, and spicy foods. Metabolic alkalosis is associated with nasogastric
suctioning, excessive use of diuretics, and steroid therapy.
In active assistance exercises, the patient performs
exercises with the therapist’ s help. Vitiligo (a benign, acquired skin disease) is marked by
stark white skin patches that are caused by the destruction
Penicillinase is an enzyme produced by certain bacteria. It and loss of pigment cells.
converts penicillin into an inactive product, increasing the
bacteria ’ s resistance to the antibiotic. Overdose or accidental overingestion of disulfiram
(Antabuse) should be treated with gastric aspiration or
Battle’ s sign is a bluish discoloration behind the ear in lavage and supportive therapy.
some patients who sustain a basilar skull fracture.
The causes of abdominal distention are represented by the
Crackles are nonmusical clicking or rattling noises that are six F’ s: flatus, feces, fetus, fluid, fat, and fatal (malignant)
heard during auscultation of abnormal breath sounds. They neoplasm.
are caused by air passing through fluid-filled airways.
A positive Murphy’ s sign indicates cholecystitis.
Antibiotics aren’ t effective against viruses, protozoa, or
parasites. Signs of appendicitis include right abdominal pain,
abdominal rigidity and rebound tenderness, nausea, and
Most penicillins and cephalosporins produce their anorexia.
antibiotic effects by cell wall inhibition.
Ascites can be detected when more than 500 ml of fluid
When assessing a patient with an inguinal hernia, the nurse has collected in the intraperitoneal space.
should suspect strangulation if the patient reports severe
pain, nausea, and vomiting. For a patient with organic brain syndrome or a senile
disease, the ideal environment is stable and limits
confusion. For the patient with suspected renal or urethral calculi, the
nurse should strain the urine to determine whether calculi
In a patient with organic brain syndrome, memory loss have been passed.
usually affects all spheres, but begins with recent memory
loss. The nurse should place the patient with ascites in the semi-
Fowler position because it permits maximum lung
During cardiac catheterization, the patient may experience expansion.
a thudding sensation in the chest, a strong desire to cough,
and a transient feeling of heat, usually in the face, as a For the patient who has ingested poison, the nurse should
result of injection of the contrast medium. save the vomitus for analysis.

Slight bubbling in the suction column of a thoracic The earliest signs of respiratory distress are increased
drainage system, such as a Pleur-evac unit, indicates that respiratory rate and increased pulse rate.
the system is working properly. A lack of bubbling in the
suction chamber indicates inadequate suction. In adults, gastroenteritis is commonly self-limiting and
causes diarrhea, abdominal discomfort, nausea, and
Nutritional deficiency is a common finding in people who vomiting.
have a long history of alcohol abuse.
Cardiac output equals stroke volume multiplied by the
In the patient with varicose veins, graduated compression heart rate per minute.
elastic stockings (30 to 40 mm Hg) may be prescribed to
promote venous return. In patients with acute meningitis, the cerebrospinal fluid
protein level is elevated.
Nonviral hepatitis usually results from exposure to certain
chemicals or drugs. When a patient is suspected of having food poisoning, the
nurse should notify public health authorities so that they
Substantial elevation of the serum transaminase level is a can interview patients and food handlers and take samples
symptom of acute hepatitis. of the suspected contaminated food.

Normal cardiac output is 4 to 6 L/minute, with a stroke The patient who is receiving a potassium -wasting diuretic
volume of 60 to 70 ml. should eat potassium-rich foods.

Excessive vomiting or removal of the stomach conten ts A patient with chronic obstructive pulmonary disease
through suction can decrease the potassium level and lead should receive low-level oxygen administration by nasal
to hypokalemia. cannula (2 to 3 L/minute) to avoid interfering with the
hypoxic drive.
As a heparin antagonist, protamine is an antidote for
heparin overdose. In metabolic acidosis, the patient may have Kussmaul’ s
respirations because the rate and depth of respira tions
If a patient has a positive reaction to a tuberculin skin test, increase to “ blow off” excess carbonic acids.
such as the purified protein derivative test, the nurse should
suspect current or past exposure. The nurse should ask the In women, gonorrhea affects the vagina and fallopian
patient about a history of tuberculosis (TB) and the tubes.
presence of early signs and symptoms of TB, such as low-
grade fever, weight loss, night sweats, fatigue, and After traumatic amputation, the greatest threats to the
anorexia. patient are blood loss and hypovolemic shock. Initial
Signs and symptoms of acute rheumatic fever include interventions should control bleeding and replace fluid and
chorea, fever, carditis, migratory polyarthritis, erythema blood as needed.
marginatum (rash), and subcutaneous nodules.
Epinephrine is a sympathomimetic drug that acts primarily
Before undergoing any invasive dental procedure, the on alpha, beta1, and beta2 receptors, causing
patient who has a history of rheumatic fever should receive vasoconstriction.
prophylactic penicillin therapy. This therapy helps to
prevent contamination of the blood with oral bacteria, Epinephrine’ s adverse effects include dyspnea,
which could migrate to the heart valves. tachycardia, palpitations, headaches, and hypertension.

After a myocardial infarction, most patients can resume A cardinal sign of pancreatitis is an elevated serum
sexual activity when they can climb two flights of stairs amylase level.
without fatigue or dyspnea.
High colonic irrigation is used to stimulate peristalsis and
Elderly patients are susceptible to orthostatic hypotension reduce flatulence.
because the baroreceptors become less sensitive to position
changes as people age. Bleeding is the most common postoperative problem.
 The patient can control some colostomy odors by avoiding consume a high-calorie, high-protein diet.
such foods as fish, eggs, onions, beans, and cabbage and
related vegetables. Adverse effects of chemotherapy include bone marrow
depression, which causes anemia, leukopenia, and
thrombocytopenia; GI epithelial cell irritation, which
When paralysis or coma impairs or erases the corneal causes GI ulceration, bleeding, and vomiting; and
reflex, frequent eye care is performed to keep the exposed destruction of hair follicles and skin, which causes alopecia
cornea moist, preventing ulceration and inflammation. and dermatitis.

Interventions for the patient with acquired The hemoglobin electrophoresis test differentiates between
immunodeficiency syndrome include treating existing sickle cell trait and sickle cell anemia.
infections and cancers, reducing the risk of opportunistic
infections, maintaining adequate nutrition and hydration, The antibiotics erythromycin, clindamycin, and
and providing emotional support to the patient and family. tetracycline act by inhibiting protein synthesis in
susceptible organisms.
Signs and symptoms of chlamydial infection are urinary
frequency; thin, white vaginal or urethral discharge; and The nurse administers oxygen as prescribed to the patient
cervical inflammation. with heart failure to help overcome hypoxia and dyspnea.

Chlamydial infection is the most prevalent sexually Signs and symptoms of small-bowel obstruction include
transmitted disease in the United States. decreased or absent bowel sounds, abdominal distention,
decreased flatus, and projectile vomiting.
The pituitary gland is located in the sella turcica of the
sphenoid bone in the cranial cavity.
The nurse should use both hands when ventilating a patient
Myasthenia gravis is a neuromuscular disorder that’ s with a manual resuscitation bag. One hand can deliver only
characterized by impulse disturbances at the myoneural 400 cc of air; two hands can deliver 1,000 cc of air.
junction.
Dosages of methylxanthine agents, such as theophylline
Myasthenia gravis, which usually affects young women, (Theo-Dur) and aminophylline (Aminophyllin), should be
causes extreme muscle weakness and fatigability, difficulty individualized based on serum drug level, patient response,
chewing and talking, strabismus, and ptosis. and adverse reactions.

Hypothermia is a life-threatening disorder in which the The patient should a pply a transdermal scopolamine patch
body’ s core temperature drops below 95° F (35° C). (Transderm-Scop) at least 4 hours before its antiemetic
action is needed.
Signs and symptoms of hypopituitarism in adults may
include gonadal failure, diabetes insipidus, hypothyroidism, Early indications of gangrene are edema, pain, redness,
and adrenocortical insufficiency. darkening of the tissue, and coldness in the affected body
part.
Reiter’ s syndrome causes a triad of symptoms: arthritis,
conjunctivitis, and urethritis. Ipecac syrup is the emetic of choice because of its
effectiveness in evacuating the stomach and relatively low
For patients who have ha d a partial gastrectomy, a incidence of adverse reactions.
carbohydrate-restricted diet includes foods that are high in
protein and fats and restricts foods that are high in Oral iron (ferrous sulfate) may cause green to black feces.
carbohydrates. High-carbohydrate foods are digested
quickly and are readily emptied from the stomach into the Polycythemia vera causes pruritus, painful fingers and
duodenum, causing diarrhea and dumping syndrome. toes, hyperuricemia, plethora (reddish purple skin and
mucosa), weakness, and easy fatigability.
A woman of childbearing age who is undergoing
chemotherapy should be encouraged to use a contraceptive Rheumatic fever is usually preceded by a group A beta -
because of the risk of fetal damage if she becomes hemolytic streptococcal infection, such as scarlet fever,
pregnant. otitis media, streptococcal throat infection, impetigo, or
tonsillitis.
Pernicious anemia is vitamin B12 deficiency that’ s
caused by a lack of intrinsic factor, which is produced by A thyroid storm, or crisis, is an extreme form of
the gastric mucosal parietal cells. hyperthyroidism. It’ s characterized by hyperpyrexia with
a temperature of up to 106° F (41.1° C), diarrhea,
To perform pursed-lip breathing, the patient inhales dehydration, tachycardia of up to 200 beats/minute,
through the nose and exhales slowly and evenly against arrhythmias, extreme irritability, hypotension, and
pursed lips while contracting the abdominal muscles. delirium. It may lead to coma, shock, and death.

A patient who is undergoing chemotherapy should Tardive dyskinesia, an adverse reaction to long-term use of
antipsychotic drugs, causes involuntary repetitive
movements of the tongue, lips, extremities, and trunk. Essential hypertensive renal disease is commonly
characterized by progressive renal impairment.
Asthma is bronchoconstriction in response to allergens,
such as food, pollen, and drugs; irritants, such as smoke Mean arterial pressure (MAP) is calculated using the
and paint fumes; infections; weather changes; exercise; or following formula, where S = systolic pressure and D =
gastroesophageal reflux. In the United States, about 5% of diastolic pressure: MAP = [(D × 2) + S] ÷ 3
children have chronic asthma.
Symptoms of supine hypotension syndrome are dizziness,
Blood cultures help identify the cause of endocarditis. An light-headedness, nausea, and vomiting.
increased white blood cell count suggests bacterial
infection. An immunocompromised patient is at risk for Kaposi’ s
sarcoma.
In a patient who has acute aortic dissection, the nursing
priority is to maintain the mean arterial pressure between Doll’ s eye movement is the normal lag between head
60 and 65 mm Hg. A vasodilator such as nitroprusside movement and eye movement.
(Nitropress) may be needed to achieve this goal.
Third spacing of fluid occurs when fluid shifts from the
For a patient with heart failure, one of the most important intravascular space to the interstitial space and remains
nursing diagnoses is decreased cardiac output related to there.
altered myocardial contractility, increased preload and
afterload, and altered rate, rhythm, or electrical conduction. Chronic pain is any pain that lasts longer than 6 months.
Acute pain lasts less than 6 months.
For a patient receiving peritoneal dialysis, the nurse must The mechanism of action of a phenothiazine derivative is
monitor body weight and blood urea nitrogen, creatinine, to block dopamine receptors in the brain.
and electrolyte levels.
Patients shouldn’ t take bisacodyl, antacids, and dairy
Angiotensin-converting enzyme inhibitors, such as products all at the same time.
captopril (Capoten) and enalapril (Vasotec), decrease blood
pressure by interfering with the renin-angiotensin- Advise the patient who is taking digoxin to avoid foods
aldosterone system. that are high in fiber, such as bran cereal and prunes.

A patient who has stable ventricular tachycardia has a A patient who is taking diuretics should avoid foods that
blood pressure and is conscious; therefore, the patient’ s contain monosodium glutamate because it can cause
cardiac output is being maintained, and the nurse must tightening of the chest and flushing of the face.
monitor the patient’ s vital signs continuously.
Furosemide (Lasix) should be taken 1 hour before meals.
Angiotensin-converting enzyme inhibitors inhibit the
enzyme that converts angiotensin I into angiotensin II, A patient who is taking griseofulvin (Grisovin FP) should
which is a potent vasoconstrictor. Through this action, they maintain a high-fat diet, which enhances the secretion of
reduce peripheral arterial resistance and blood pressure. bile.

Patients should take oral iron products with citrus drinks to

enhance absorption.
In a patient who is receiving a diuretic, the nurse should
monitor serum electrolyte levels, check vital signs, and Isoniazid should be taken on an empty stomach, with a full
observe for orthostatic hypotension. glass of water.

Breast self-examination is one of the most important Foods that are high in protein decrease the absorption of
health habits to teach a woman. It should be performed 1 levodopa.
week after the menstrual period because that’ s when
hormonal effects, which can cause breast lumps and A patient who is taking tetracycline shouldn’ t take iron
tenderness, are reduced. supplements or antacids.

Postmenopausal women should choose a regular time each A patient who is taking warfarin (Coumadin) should avoid
month to perform breast self-examination (for example, on foods that are high in vitamin K, such as liver and green
the same day of the month as the woman’ s birthday). leafy vegetables.

The difference between acute and chronic arterial disease The normal value for cholesterol is less than 200 mg/dl.
is that the acute disease process is life-threatening. The normal value for low-density lipoproteins is 60 to 180
mg/dl; for high-density lipoproteins, it’ s 30 to 80 mg/dl.
When preparing the patient for chest tube removal, the
nurse should explain that removal may cause pain or a The normal cardiac output for an adult who weighs 155 lb
burning or pulling sensation. (70.3 kg) is 5 to 6 L/minute.
 left ventricular pressure.

A pulmonary artery pressure catheter (Swan-Ganz) Pulmonary artery wedge pressure greater than 18 to 20
measures the pressure in the cardiac chambers. mm Hg indicates increased left ventricular pressure, as
seen in left-sided heart failure.
Severe chest pain that’ s aggravated by breathing and is
described as “ sharp,” “ stabbing,” or “ knifelike” is When measuring pulmonary artery wedge pressure, the
consistent with pericarditis. nurse should place the patient in a supine position, with the
head of the bed elevated no more than 25 degrees.
Water-hammer pulse is a pulse that’ s loud and bounding
and rises and falls rapidly. It can be caused by emotional Pulmonary artery pressure, which indicates right and left
excitement or aortic insufficiency. ventricular pressure, is taken with the balloon deflated.

Pathologic splitting of S2 is normally heard between Pulmonary artery systolic pressure is the peak pressure
inspiration and expiration. It occurs in right bundle-branch generated by the right ventricle. Pulmonary artery diastolic
block. pressure is the lowest pressure in the pulmonary artery.

Pink, frothy sputum is associated with pulmonary edema. Normal adult pulmonary artery systolic pressure is 15 to
Frank hemoptysis may be associated with pulmonary 25 mm Hg.
embolism.
Normal adult pulmonary artery diastolic pressure is 8 to 12
An aortic aneurysm can be heard just over the umbilical mm Hg.
area and can be detected as an abdominal pulsation (bruit).
The normal oxygen saturation of venous blood is 75%.
Heart murmurs are graded according to the following
system: grade 1 is faint and is heard after the examiner Central venous pressure is the amount of pressure in the
“ tunes in” ; grade 2 is heard immediately; grade 3 is superior vena cava and the right atrium.
moderately loud; grade 4 is loud; grade 5 is very loud, but
is heard only with a stethoscope; and grade 6 is very loud Normal adult central venous pressure is 2 to 8 mm Hg, or
and is heard without a stethoscope. 3 to 10 cm H2O.

Clot formation during cardiac catheterization is minimized A decrease in central venous pressure indicates a fall in
by the administration of 4,000 to 5,000 units of heparin. circulating fluid volume, as seen in shock.

Most complications that arise from cardiac catheterization An increase in central venous pressure is associated with
are associated with the puncture site. an increase in circulating volume, as seen in renal failure.

Allergic symptoms associated with iodine-based contrast In a patient who is on a ventilator, central venous pressure
media used in cardiac catheterization include urticaria, should be taken at the end of the expiratory cycle.
nausea and vomiting, and flushing.
To ensure an accurate baseline central venous pressure
To ensure that blood flow hasn’ t been compromised, the reading, the zero point of the transducer must be at the
nurse should mark the peripheral pulses distal to the level of the right atrium.
cutdown site to aid in locating the pulses after the
procedure. A blood pressure reading obtained through intra -arterial
The extremity used for the cutdown site should remain pressure monitoring may be 10 mm Hg higher than one
straight for 4 to 6 hours. If an antecubital vessel was used, obtained with a blood pressure cuff.
an armboard is needed. If a femoral artery was used, the
patient should remain on bed rest for 6 to 12 hours. In Mönckeberg’ s sclerosis, calcium deposits form in the
medial layer of the arterial walls.
If a patient experiences numbness or tingling in the
extremity after a cutdown, the physician should be notified The symptoms associated with coronary artery disease
immediately. usually don’ t appear until plaque has narrowed the vessels
by at least 75%.
After cardiac catheterization, fluid intake should be
encouraged to aid in flushing the contrast medium through Symptoms of coronary artery disease appear only when
the kidneys. there is an imbalance between the demand for oxygenated
blood and its availability.
In a patient who is undergoing pulmonary artery
catheterization, risks include pulmonary artery infarction, Percutaneous transluminal coronary angioplasty is an
pulmonary embolism, injury to the heart valves, and injury invasive procedure in which a balloon-tipped catheter is
to the myocardium. inserted into a blocked artery. When the balloon is inflated,
it opens the artery by compressing plaque against the
Pulmonary artery wedge pressure is a direct indicator of artery’ s intimal layer.
 medical facility.
Before percutaneous transluminal coronary angioplasty is
performed, an anticoagulant (such as aspirin) is usually Cardiac cells can withstand 20 minutes of ischemia before
administered to the patient. During the procedure, the cell death occurs.
patient is given heparin, a calcium agonist, or nitroglycerin
to reduce the risk of coronary artery spasms. During a myocardial infarction, the most common site of
injury is the anterior wall of the left ventricle, near the
During coronary artery bypass graft surgery, a blocked apex.
coronary artery is bypassed by using the saphenous vein
from the patient’ s thigh or lower leg. After a myocardial infarction, the infarcted tissue causes
significant Q-wave changes on an electrocardiogram.
When a vein is used to bypass an artery, the vein is These changes remain evident even after the myocardium
reversed so that the valves don’ t interfere with blood flow. heals.

During a coronary artery bypass graft procedure, the The level of CK-MB, an isoenzyme specific to the heart,
patient’ s heart is stopped to allow the surgeon to sew the increases 4 to 6 hours after a myocardial infarction and
new vessel in place. Blood flow to the body is maintained peaks at 12 to 18 hours. It returns to normal in 3 to 4 days.
with a cardiopulmonary bypass.
Patients who survive a myocardial infarction and have no
During an anginal attack, the cells of the heart convert to other cardiovascular pathology usually require 6 to 12
anaerobic metabolism, which produces lactic acid as a weeks for a full recovery.
waste product. As the level of la ctic acid increases, pain
develops. After a myocardial infarction, the patient is at greatest risk
for sudden death during the first 24 hours.
Pain that’ s described as “ sharp” or “ knifelike” is not
consistent with angina pectoris. After a myocardial infarction, the first 6 hours is the
crucial period for salvaging the myocardium.
Anginal pain typically lasts for 5 minutes; however,
attacks associated with a heavy meal or extreme emotional After a myocardial infarction, if the patient consistently
distress may last 15 to 20 minutes. has more than three premature ventricular contractions per
minute, the physician should be notified.
A pattern of “ exertion-pain-rest-relief” is consistent with
stable angina. After a myocardial infarction, increasing vascular
resistance through the use of vasopressors, such as
Unlike stable angina, unstable angina can occur without dopamine and levarterenol, can raise blood pressure.
exertion and is considered a precursor to a myocardial
infarction. Clinical manifestations of heart failure include distended
neck veins, weight gain, orthopnea, crackles, and enlarged
A patient who is scheduled for a stress electrocardiogram liver.
should notify the staff if he has taken nitrates. If he has, the
test must be rescheduled. Risk factors associated with embolism are increased blood
viscosity, decreased circulation, prolonged bed rest, and
Exercise equipment, such as a treadmill or an exercise increased blood coagulability.
bike, is used for a stress electrocardiogram. Activity is
increased until the patient reaches 85% of his maximum Antiembolism stockings should be worn around the clock,
heart rate. but should be removed twice a day for 30 minutes so that
skin care can be performed.
In patients who take nitroglycerin for a long time,
tolerance often develops and reduces the effectiveness of Before the nurse puts antiembolism stockings back on the
nitrates. A 12-hour drug-free period is usually maintained patient, the patient should lie with his feet elevated 6" (15.2
at night. cm) for 20 minutes.

Beta-adrenergic blockers, such as propranolol (Inderal), Dressler’ s syndrome is known as late pericarditis because
reduce the workload on the heart, thereby decreasing it occurs approximately 6 weeks to 6 months after a
oxygen demand. They also slow the heart rate. myocardial infarction. It causes pericardial pain and a fever
that lasts longer than 1 week.
Calcium channel blockers include nifedipine (Procardia),
which is used to treat angina; verapamil (Calan, Isoptin), In phase I after a myocardial infarction, for the first 24
which is used primarily as an antiarrhythmic; and diltiazem hours, the patient is kept on a clear liquid diet and bed rest
(Cardizem), which combines the effects of nifedipine and with the use of a bedside commode.
verapamil without the adverse effects.

A patient who has anginal pain that radiates or worsens

and doesn’ t subside should be evaluated at an emergency
 In phase I after a myocardial infarction, on the second day, Signs of urinary tract infection include frequency, urgency,
the patient gets out of bed and spends 15 to 20 minutes in a and dysuria.
chair. The number of times that the patient goes to the chair
and the length of time he spends in the chair are increased In tertiary-intention healing, wound closure is delayed
depending on his endurance. In phase II, the length of time because of infection or edema.
that the patient spends out of bed and the distance to the
chair are increased. A patient who has had supratentorial surgery should have
the head of the bed elevated 30 degrees.
After transfer from the cardiac care unit, the post-
myocardial infarction patient is allowed to walk the halls as An acid-ash diet acidifies urine.
his endurance increases.
Vitamin C and cranberry juice acidify urine.
Sexual intercourse with a known partner usually can be
resumed 4 to 8 weeks after a myocardial infarction. A patient who takes probenecid (Colbenemid) for gout
should be instructed to take the drug with food.
A patient under cardiac care should avoid drinking
alcoholic beverages or eating before engaging in sexual If wound dehiscence is suspected, the nurse should instruct
intercourse. the patient to lie down and should examine the wound and
monitor the vital signs. Abnormal findings should be
The ambulation goal for a post-myocardial infarction reported to the physician.
patient is 2 miles in 60 minutes.
Zoster immune globulin is administered to stimulate
A post-myocardial infarction patient who doesn’ t have a immunity to varicella.
strenuous job may be able to return to work full-time in 8
or 9 weeks.

Stroke volume is the amount of blood ejected from the

heart with each heartbeat. The most common symptoms associated with
compartmental syndrome are pain that’ s not relieved by
Afterload is the force that the ventricle must exert during analgesics, loss of movement, loss of sensation, pain with
systole to eject the stroke volume. passive movement, and lack of pulse.

The three-point position (with the patient upright and To help relieve muscle spasms in a patient who has
leaning forward, with the hands on the knees) is multiple sclerosis, the nurse should administer baclofen
characteristic of orthopnea, as seen in left-sided heart (Lioresal) as ordered; give the patient a warm, soothing
failure. bath; and teach the patient progressive relaxation
techniques.
Paroxysmal nocturnal dyspnea indicates a severe form of
pulmonary congestion in which the patient awakens in the A patient who has a cervical injury and impairment at C5
middle of the night with a feeling of being suffocated. should be able to lift his shoulders and elbows partially, but
has no sensation below the clavicle.
Clinical manifestations of pulmonary edema include
breathlessness, nasal flaring, use of accessory muscles to A patient who has cervical injury and impairment at C6
breath, and frothy sputum. should be able to lift his shoulders, elbows, and wrists
A late sign of heart fa ilure is decreased cardiac output that partially, but has no sensation below the clavicle, except a
causes decreased blood flow to the kidneys and results in small amount in the arms and thumb.
oliguria.
A patient who has cervical injury and impairment at C7
A late sign of heart failure is anasarca (generalized should be able to lift his shoulders, elbows, wrists, and
edema). hands partially, but has no sensation below the midchest.

Dependent edema is an early sign of right-sided heart Injuries to the spinal cord at C3 and above may be fatal as
failure. It’ s seen in the legs, where increased capillary a result of loss of innervation to the diaphragm and
hydrostatic pressure overwhelms plasma protein, causing a intercostal muscles.
shift of fluid from the capillary beds to the interstitial
spaces. Signs of meningeal irritation seen in meningitis include
nuchal rigidity, a positive Brudzinski’ s sign, and a
Dependent edema, which is most noticeable at the end of positive Kernig’ s sign.
the day, usually starts in the feet and ankles and continues
upward. Laboratory values that show pneumomeningitis include an
elevated cerebrospinal fluid (CSF) protein level (more than
For the recumbent patient, edema is usually seen in the 100 mg/dl), a decreased CSF glucose level (40 mg/dl), and
presacral area. an increased white blood cell count.
 at bedtime.
Before undergoing ma gnetic resonance imaging, the
patient should remove all objects containing metal, such as A patient who is having a seizure usually requires
watches, underwire bras, and jewelry. protection from the environment only; however, anyone
who needs airway management should be turned on his
side.
Usually food and medicine aren’ t restricted before
magnetic resonance imaging. Status epilepticus is treated with I.V. diphenylhydantoin.

Patients who are undergoing magnetic resonance imaging A xenograft is a skin graft from an animal.
should know that they can ask questions during the
procedure; however, they may be asked to lie still at certain The antidote for magnesium sulfate is calcium gluconate
times. 10%.

If a contrast medium is used during magnetic resonance Allergic reactions to a blood transfusion are flushing,
imaging, the patient may experience diuresis as the wheezing, urticaria, and rash.
medium is flushed from the body.
A patient who has a history of basal cell carcinoma should
The Tzanck test is used to confirm herpes genitalis. avoid sun exposure.

Hepatitis C is spread primarily through blood (for When potent, nitroglycerin causes a slight stinging
example, during transfusion or in people who work with sensation under the tongue.
blood products), personal contact and, possibly, the fecal-
oral route. A patient who appears to be “ fighting the ventilator” is
holding his breath or breathing out on an inspiratory cycle.
The best method for soaking an open, infected, draining
wound is to use a hot-moist dressing. An antineoplastic drug that’ s used to treat breast cancer is
tamoxifen (Nolvadex).
Sputum culture is the confirmation test for tuberculosis.
Adverse effects of vincristine (Oncovin) are alopecia,
Dexamethasone (Decadron) is a steroidal anti- nausea, and vomiting.
inflammatory that’ s used to treat adrenal insufficiency.
Increased urine output is an indication that a hypertensive
Signs of increased intracranial pressure include alteration crisis is normalizing.
in level of consciousness, restlessness, irritability, and
pupillary changes. If a patient who is receiving I.V. chemotherapy has pain at
the insertion site, the nurse should stop the I.V. infusion
The patient who has a lower limb amputation should be immediately.
instructed to assume a prone position at least twice a day.
Extravasation is leakage of fluid into surrounding tissue
During the first 24 hours after amputation, the residual from a vein that’ s being used for I.V. therapy.
limb is elevated on a pillow. After that time, the limb is
placed flat to reduce the risk of hip flexion contractures. Clinica l signs of prostate cancer are dribbling, hesitancy,
and decreased urinary force.

Cardiac glycosides increase cardiac contractility.

A tourniquet should be in full view at the bedside of the
patient who has a n amputation. Adverse effects of cardiac glycosides include headache,
hypotension, nausea and vomiting, and yellow-green halos
An emergency tracheostomy set should be kept at the around lights.
bedside of a patient who is suspected of having epiglottitis.
A T tube should be clamped during patient meals to aid in
Rocky Mountain spotted fever is spread through the bite of fat digestion.
a tick harboring the Rickettsia organism.
A T tube usually remains in place for 10 days.
A patient who has acquired immunodeficiency syndrome
shouldn’ t share razors or toothbrushes with others, but During a vertigo attack, a patient who has Ménière’ s
there are no special precautions for dinnerware or laundry disease should be instructed to lie down on his side with his
services. eyes closed.

Because antifungal creams may stain clothing, patients When maintaining a Jackson-Pratt drainage system, the
who use them should use sanitary napkins. nurse should squeeze the reservoir and expel the air before
recapping the system.
An antifungal cream should be inserted high in the vagina
 The most common symptom associated with sleep apnea is system depression for 24 hours after the administration of
snoring. nitrous oxide.

Histamine is released during an inflammatory response. In the postanesthesia care unit, the proper position of an
adult is with the head to the side and the chin extended
When dealing with a patient who has a severe speech upward. The Sims’ position also can be used unless
impediment, the nurse should minimize background noise contraindicated.
and avoid interrupting the patient.
After a patient is admitted to the postanesthesia care unit,
Fever and night sweats, hallmark signs of tuberculosis, the first action is to assess the patency of the airway.
may not be present in elderly patients who have the
disease. If a patient is admitted to the postanesthesia care unit
without the pharyngeal reflex, he’ s positioned on his side.
A suitable dressing for wound debridement is wet-to-dry. The nurse stays at the bedside until the gag reflex returns.

Drinking warm milk at bedtime aids sleeping because of In the postanesthesia care unit, the patient’ s vital signs
the natural sedative effect of the amino acid tryptophan. are taken every 15 minutes routinely, or more often if
indicated, until the patient is stable.
The initial step in promoting sleep in a hospitalized patien t
is to minimize environmental stimulation. In the postanesthesia care unit, the T tube should be
unclamped and attached to a drainage system.
Before moving a patient, the nurse should assess how
much exertion the patient is permitted, the patient’ s After the patient receives anesthesia, the nurse must
physical ability, and his ability to understand instruction as observe him for a drop in blood pressure or evidence of
well as her own strength and ability to move the patient. labored breathing.
If a patient begins to go into shock during the
A patient who is in a restraint should be checked every 30 postanesthesia assessment, the nurse should administer
minutes and the restraint loosened every 2 hours to permit oxygen, place the patient in the Trendelenburg position,
range of motion exercises for the extremities. and increase the I.V. fluid rate according to the
physician’ s order or the policy of the postanesthesia care
Antibiotics that are given four times a day should be given unit.
at 6 a.m., 12 p.m., 6 p.m., and 12 a.m. to minimize
disruption of sleep. Types of benign tumors include myxoma, fibroma, lipoma,
osteoma, and chondroma.
Sundowner syndrome is seen in patients who become
more confused toward the evening. To counter this Malignant tumors include sarcoma, basal cell carcinoma,
tendency, the nurse should turn a light on. fibrosarcoma, osteosarcoma, myxosarcoma,
chondrosarcoma, and adenocarcinoma.
For the patient who has somnambulism, the primary goal
is to prevent injury by providing a safe environment. For a cancer patient, palliative surgery is performed to
reduce pain, relieve airway obstruction, relieve GI
For the patient who has somnambulism, the primary goal obstruction, prevent hemorrhage, relieve pressure on the
is to prevent injury by providing a safe environment. brain and spinal cord, drain abscesses, and remove or drain
infected tumors.
Naloxone (Narcan) should be kept at the bedside of the
patient who is receiving patient-controlled analgesia. A patient who is undergoing radiation implant therapy
Hypnotic drugs decrease rapid eye movement sleep, but should be kept in a private room to reduce the risk of
increase the overall amount of sleep. exposure to others, including nursing personnel.

A sudden wave of overwhelming sleepiness is a symptom After total knee replacement surgery, the knee should be
of narcolepsy. kept in maximum extension for 3 days.

A diabetic patient should be instructed to buy shoes in th e Partial weight bearing is allowed approximately 1 week
afternoon because feet are usually largest at that time of after total knee replacement. Weight bearing to the point of
day. pain is allowed at 2 weeks.

If surgery is scheduled late in the afternoon, the surgeon Sjögren’ s syndrome is a chronic inflammatory disorder
may approve a light breakfast. associated with a decrease in salivation and lacrimation.
Clinical manifestations include dryness of the mouth, eyes,
A hearing aid is usually left in place during surgery to and vagina.
permit communication with the patient. The operating
room team should be notified of its presence. Normal values of cerebrospinal fluid include the
following: protein level, 15 to 45 mg/100 ml; fasting
The nurse should monitor the patient for central nervous glucose, 50 to 80 mg/100 ml; red blood cell count, 0; white
blood cell count, 0 to 5/µl: pH, 7.3; potassium ion value, alkaline (greater than 26 mEq/L). Determine which value
2.9 mmol/L; chloride, 120 to 130 mEq/L. the pH matches; it will determine whether the problem is
metabolic acidosis or metabolic alkalosis. If both the
PaCO2 and HCO3– are abnormal, then the body is
The following mnemonic device can be used to identify compensating. If the pH has returned to normal, the body is
whether a cranial nerve is a motor nerve: I Some | II Say | in full compensation.
III Marry | IV Money, | V but | VI My | VII Brother | VII
Says | IX Bad | X Business | XI Marry | XII Money. The Tensilon (edrophonium chloride) test is used to
confirm myasthenia gravis.
To interpret the mnemonic device: If the word begins with
an S, it’ s a sensory nerve; if it starts with an M, it’ s a A masklike facial expression is a sign of myasthenia gravis
motor nerve; and if it starts with a B, it’ s both a sensory and Parkinson’ s disease.
and a motor nerve.
Albumin is a colloid that aids in maintaining fluid within
The Glasgow Coma Scale evaluates level of the vascular system. If albumin were filtered out through
consciousness, pupil reaction, and motor activity. A score the kidneys and into the urine, edema would occur.
between 3 and 15 is possible.
Edema caused by water and trauma doesn’ t cause pitting.
When assessing a patient’ s pupils, the nurse should
remember that anisocoria, unequal pupils of 1 mm or Dehydration is water loss only; fluid volume deficit
larger, occurs in approximately 17% of the population. includes all fluids in the body.

Homonymous hemianopsia is a visual defect in which the The primary action of an oil retention enema is to lubricate
patient sees only one-half of the visual field with each eye. the colon. The secondary action is softening the feces.
Therefore, the patient sees only one-half of a normal visual
field. A patient who uses a walker should be instructed to move
the walker approximately 12" (30.5 cm) to the front and
Passive range-of-motion exercises are commonly started then advance into the walker.
24 hours after a stroke. They’ re performed four times per
day. Bradykinesia is a sign of Parkinson’ s disease.

In treating a patient with a transient ischemic attack, the Lordosis is backward arching curvature of the spine.
goal of medical management is to prevent a stroke. The
patient is administered antihypertensive drugs, antiplatelet Kyphosis is forward curvature of the spine.
drugs or aspirin and, in some cases, warfarin (Coumadin).
In a patient with anorexia nervosa, a positive response to
A patient who has an intraperitoneal shunt should be therapy is sustained weight gain.
observed for increased abdominal girth.
The drug in dialysate is heparin.
Digestion of carbohydrates begins in the mouth.
An autograft is a graft that’ s removed from one area of
Digestion of fats begins in the stomach, but occurs the body for transplantation to another.
predominantly in the small intestine.
Signs of cervical cancer include midmenses bleeding and
Dietary sources of magnesium are fish, grains, and nuts. postcoital bleeding.

A rough estimate of serum osmolarity is twice the serum After prostatectomy, a catheter is inserted to irrigate the
sodium level. bladder and keep urine straw-colored or light pink, to put
direct pressure on the operative side, and to maintain a
In determining acid– base problems, the nurse should first patent urethra.
note the pH. If it’ s above 7.45, it’ s a problem of
alkalosis; if it’ s below 7.35, it’ s a problem of acidosis. If a radiation implant becomes dislodged, but remains in
The nurse should next look at the partial pressure of arterial the patient, the nurse should notify the physician.
carbon dioxide (PaCO2). This is the respiratory indicator.
If the pH indicates acidosis and the PaCO2 indicates The best method to reduce the risk for atelectasis is to
acidosis as well (greater than 45 mm Hg), then there’ s a encourage the patient to walk.
match, and the source of the problem is respiration. It’ s
called respiratory acidosis. If the pH indicates alkalosis and Atelectasis usually occurs 24 to 48 hours after surgery.
the PaCO2 also indicates alkalosis (less than 35 mm Hg),
then there’ s a match, and the source of the problem is Patients who are at the greatest risk for atelectasis are
respiration. This is called respiratory alkalosis. If the those who have had high abdominal surgery, such as
PaCO2 is normal, then the nurse should look at the cholecystectomy.
bicarbonate (HCO3– ), which is the metabolic indicator,
and note whether it’ s acidic (less than 22 mEq/L) or A persistent decrease in oxygen to the kidneys causes
erythropoiesis. lead, and chloramphenicol can cause aplastic anemia.

Rhonchi and crackles indicate ineffective airway After a patient undergoes bone marrow aspiration, the
clearance. nurse should apply direct pressure to the site for 3 to 5
minutes to reduce the risk of bleeding.
Wheezing indicates bronchospasms.
Fresh frozen plasma is thawed to 98.6° F (37° C) before
Clinical signs and symptoms of hypoxemia are restlessness infusion.
(usually the first sign), agitation, dyspnea, and
disorientation. Signs of thrombocytopenia include petechiae, ecchymoses,
hematuria, and gingival bleeding.
Common adverse effects of opioids are constipation and
respiratory depression. A patient who has thrombocytopenia should be taught to
use a soft toothbrush and use an electric razor.
Disuse osteoporosis is caused by demineralization of
calcium as a result of prolonged bed rest. Signs of fluid overload include increased central venous
pressure, increased pulse rate, distended jugular veins, and
The best way to prevent disuse osteoporosis is to bounding pulse.
encourage the patient to walk.
A patient who has leukopenia (or any other patient who is
A cane should be carried on the unaffected side and at an increased risk for infection) should avoid eating raw
advanced with the affected extremity. meat, fresh fruit, and fresh vegetables.

Steroids shouldn’ t be used in patients who have To prevent a severe graft-versus-host reaction, which is
chickenpox or shingles because they may cause adverse most commonly seen in patients older than age 30, the
effects. donor marrow is treated with monoclonal antibodies before
transplantation.
Seroconversion occurs approximately 3 to 6 months after
exposure to human immunodeficiency virus. The four most common signs of hypoglycemia reported by
patients are nervousness, mental disorientation, weakness,
Therapy with the antiviral agent zidovudine is initiated and perspiration.
when the CD4+ T-cell count is 500 cells/µl or less.
Prolonged attacks of hypoglycemia in a diabetic patient
In a light-skinned person, Kaposi’ s sarcoma causes a can result in brain damage.
purplish discoloration of the skin. In a dark-skinned person,
the discoloration is dark brown to black. Activities that increase intracranial pressure include
coughing, sneezing, straining to pass feces, bending over,
After an esophageal balloon tamponade is in place, it and blowing the nose.
should be inflated to 20 mm Hg.
Treatment for bleeding esophageal varices includes
A patient who has Kaposi’ s sarcoma should avoid acidic vasopressin, esophageal tamponade, iced saline lavage, and
or highly seasoned foods. vitamin K.

The treatment for oral candidiasis is amphotericin B Hepatitis C (also known as blood-transfusion hepatitis) is a
(Fungizone) or fluconazole (Diflucan). parenterally transmitted form of hepatitis that has a high
incidence of carrier status.
A sign of respiratory failure is vital capacity of less than
15 ml/kg and respiratory rate of greater than 30 The nurse should be concerned about fluid and electro lyte
breaths/minute or less than 8 breaths/ minute. problems in the patient who has ascites, edema, decreased
urine output, or low blood pressure.
For left-sided cardiac catheterization, the catheter is
threaded through the descending aorta, aortic arch, The nurse should be concerned about GI bleeding, low
ascending aorta, aortic valve, and left ventricle. blood pressure, and increased heart rate in a patient who is
hemorrhaging.
For right-sided cardiac catheterization, the catheter is
threaded through the superior vena cava, right atrium, right The nurse should be concerned about generalized malaise,
ventricle, pulmonary artery, and pulmonary capillaries. cloudy urine, purulent drainage, tachycardia, and increased
temperature in a patient who has an infection.
Anemia can be divided into four groups according to its
cause: blood loss, impaired production of red blood cells In a patient who has edema or ascites, the serum
(RBCs), increased destruction of RBCs, and nutritional electrolyte level should be monitored. The patient also
deficiencies. should be weighed daily; have his abdominal girth
measured with a centimeter tape at the same location, using
Aspirin, ibuprofen, phenobarbital, lithium, colchicine, the umbilicus as a checkpoint; have his intake and output
measured; and have his blood pressure taken at least every
4 hours. Secondary methods to prevent postoperative respiratory
complications include having the patient use an incentive
Endogenous sources of ammonia include azotemia, GI spirometer, turning the patient, advising the patient to
bleeding, catabolism, and constipation. cough and breathe deeply, and providing hydration.

Exogenous sources of ammonia include protein, blood A characteristic of allergic inspiratory and expiratory
transfusion, and amino acids. wheezing is a dry, hacking, nonproductive cough.

The following histologic grading system is used to classify The incubation period for Rocky Mountain spotted fever is
cancers: grade 1, well-differentiated; grade 2, moderately 7 to 14 days.
well-differentiated; grade 3, poorly differentiated; and
grade 4, very poorly differentiated. Miconazole (Monistat) vaginal suppository should be
administered with the patient lying flat.
The following grading system is used to classify tumors:
T0, no evidence of a primary tumor; TIS, tumor in situ; and The nurse should place the patient who is having a seizure
T1, T2, T3, and T4, according to the size and involvement on his side.
of the tumor; the higher the number, the greater the
involvement. Signs of hip dislocation are one leg that’ s shorter than the
other and one leg that’ s externally rotated.
Pheochromocytoma is a catecholamine-secreting neoplasm
of the adrenal medulla. It causes excessive production of Anticholinergic medication is administered before surgery
epinephrine and norepinephrine. to diminish secretion of saliva and gastric juices.

Clinical manifestations of pheochromocytoma include Extrapyramidal syndrome in a patient with Parkinson ’ s

visual disturbances, headaches, hypertension, and elevated disease is usually caused by a deficiency of dopamine in
serum glucose level. the substantia nigra.

The patient shouldn’ t consume any caffeine-containing In a burn patient, the order of concern is airway,
products, such as cola, coffee, or tea, for at least 8 hours circulation, pain, and infection.
before obtaining a 24-hour urine sample for
vanillylmandelic acid. Hyperkalemia normally occurs during the hypovolemic
phase in a patient who has a serious burn injury.
A patient who is taking ColBenemid (probenecid and
colchicine) for gout should increase his fluid intake to Black feces in the burn patient are commonly related to
2,000 ml/day. Curling’ s ulcer.

A miotic such as pilocarpine is administered to a patient In a patient with burn injury, immediate care of a full-
with glaucoma to increase the outflow of aqueous humor, thickness skin graft includes covering the site with a bulky
which decreases intraocular tension. dressing.

The drug that’ s most commonly used to treat The donor site of a skin graft should be left exposed to the
streptococcal pharyngitis and rheumatic fever is penicillin. air.

A patient with gout should avoid purine-containing foods, Leaking around a T tube should be reported immediately
such as liver and other organ meats. to the physician.

A patient who undergoes magnetic resonance imaging lies A patient who has Ménière’ s disease should consume a
on a flat platform that moves through a magnetic field. low-sodium diet.

Laboratory values in patients who have bacterial In any postoperative patient, the priority of concern is
meningitis include increased white blood cell count, airway, breathing, and circulation, followed by self -care
increased protein and lactic acid levels, and decreased deficits.
glucose level.
The symptoms of myasthenia gravis are most likely related
Mannitol is a hypertonic osmotic diuretic that decreases to nerve degeneration.
intracranial pressure.
Symptoms of septic shock include cold, clammy skin;
The best method to debride a wound is to use a wet-to-dry hypotension; and decreased urine output.
dressing and remove the dressing after it dries.
Ninety-five percent of women who have gonorrhea are
The greatest risk for respiratory complications occurs after asymptomatic.
chest wall injury, chest wall surgery, or upper abdominal
surgery.
 An adverse sign in a patient who has a Steinmann’ s pin in A clinical manifestation of a ruptured lumbar disk includes
the femur would be erythema, edema, and pain around the pain that shoots down the leg and terminates in the
pin site. popliteal space.

Signs of chronic glaucoma include halos around lights, The most important nutritional need of the burn patient is
gradual loss of peripheral vision, and cloudy vision. I.V. fluid with electrolytes.

Signs of a detached retina include a sensation of a veil (or The patient who has systemic lupus erythematosus should
curtain) in the line of sight. avoid sunshine, hair spray, hair coloring products, and
dusting powder.
Toxic levels of streptomycin can cause hearing loss.
The best position for a patient who has low back pain is
A long-term effect of rheumatic fever is mitral valve sitting in a straight-backed chair.
damage.
Clinical signs of ulcerative colitis include bloody,
Laboratory values noted in rheumatic fever include an purulent, mucoid, and watery feces.
antistreptolysin-O titer, the presence of C-reactive protein,
leukocytosis, and an increased erythrocyte sedimentation A patient who has a protein systemic shunt must follow a
rate. lifelong protein-restricted diet.

Crampy pain in the right lower quadrant of the abdomen is A patient who has a hiatal hernia should maintain an
a consistent finding in Crohn’ s disease. upright position after eating.
A suction apparatus should be kept at the bedside of a
Crampy pain in the left lower quadrant of the abdomen is a patient who is at risk for status epilepticus.
consistent finding in diverticulitis.
The leading cause of death in the burn patient is
In the icteric phase of hepatitis, urine is amber, feces are respiratory compromise and infection.
clay-colored, and the skin is yellow.
In patients who have herpes zoster, the primary concern is
Signs of osteomyelitis include pathologic fractures, pain management.
shortening or lengthening of the bone, and pain deep in th e
bone. The treatment for Rocky Mountain spotted fever is
tetracycline.
The laboratory test that would best reflect fluid loss
because of a burn would be hematocrit. Strawberry tongue is a sign of sca rlet fever.

A patient who has acute pancreatitis should take nothing If a patient has hemianopsia, the nurse should place the
by mouth and undergo gastric suction to decompress the call light, the meal tray, and other items in his field of
stomach. vision.

A mist tent is used to increase the hydration of secretions. The best position for the patient after a craniotomy is
semi-Fowler.
A patient who is receiving levodopa should avoid foods
that contain pyridoxine (vitamin B6), such as beans, tuna, Signs of renal trauma include flank pain, hem atoma and,
and beef liver, because this vitamin decreases the possibly, blood in the urine and decreased urine output.
effectiveness of levodopa.
Flank pain and hematoma in the back indicate renal
A patient who has a transa ctional injury at C3 requires hemorrhage in the trauma patient.
positive ventilation.
Natural diuretics include coffee, tea, and grapefruit juice.
The action of phenytoin (Dilantin) is potentiated when
given with anticoagulants. Central venous pressure of 18 cm H2O indicates
hypervolemia.
Cerebral palsy is a nonprogressive disorder that persists
throughout life. Salmonellosis can be acquired by eating contaminated
meat such as chicken, or eggs.
A complication of ulcerative colitis is perforation.
Good sources of magnesium include fish, nuts, and grains.
When a patient who has multiple sclerosis experiences
diplopia, one eye should be patched. Patients who have low blood urea nitrogen levels should
be instructed to eat high-protein foods, such as fish and
A danger sign after hip replacement is lack of reflexes in chicken.
the affected extremity.
The nurse should monitor a patient who has Guillain-Barré
syndrome for respiratory compromise. result of osteoporosis.

A heating pad may provide comfort to a patient who has Tricyclic antidepressants such as amitriptyline (Elavil)
pelvic inflammatory disease. shouldn’ t be administered to patients with narrow-angle
glaucoma, benign prostatic hypertrophy, or coronary artery
After supratentorial surgery, the patient should be placed disease.
in the semi-Fowler position.
Pulmonary embolism is characterized by a sudden, sharp,
To prevent deep vein thrombosis, the patient should stabbing pain in the chest; dyspnea; decreased breath
exercise his legs at least every 2 hours, elevate the legs sounds; and crackles or a pleural friction rub on
above the level of the heart while lying down, and auscultation.
ambulate with assistance.
Clinical manifestations of cardiac tamponade are
After bronchoscopy, the patient’ s gag reflex should be hypotension and jugular vein distention.
checked.
To avoid further damage, the nurse shouldn’ t induce
In a patient with mononucleosis, abdominal pain and pain vomiting in a patient who has swallowed a corrosive
that radiates to the left shoulder may indicate a ruptured chemical, such as oven cleaner, drain cleaner, or kerosene.
spleen.
A brilliant red reflex excludes most serious defects of the
For a skin graft to take, it must be autologous. cornea, aqueous chamber, lens, and vitreous chamber.

Untreated retinal detachment leads to blindness. Oral hypoglycemic agents stimulate the islets of
Langerhans to produce insulin.
A patient who has fibrocystic breast disease should To treat wound dehiscence, the nurse should help the
consume a diet that’ s low in caffeine and salt. patient to lie in a supine position; cover the protruding
intestine with moist, sterile, normal saline packs; and
A foul odor at the pin site of a patient who is in skeletal change the packs frequently to keep the area moist.
traction indicates infection.
While a patient is receiving an I.V. nitroglycerin drip, the
A muscle relaxant that’ s administered with oxygen may nurse should monitor his blood pressure every 15 minutes
cause malignant hyperthermia and respiratory depression. to detect hypotension.

Pain that occurs on movement of the cervix, together with Any type of fluid loss can trigger a crisis in a patient with
adnexal tenderness, suggests pelvic inflammatory disease. sickle cell anemia.

The goal of crisis intervention is to restore the person to a The patient should rinse his mouth after using a
precrisis level of functioning and order. corticosteroid inhaler to avoid steroid residue and reduce
oral fungal infections.
Nephrotic syndrome causes proteinuria, hypoalbuminemia,
and edema, and sometimes hematuria, hypertension, and a A patient with low levels of triiodothyronine and thyroxine
decreased glomerular filtration rate. may have fatigue, lethargy, cold intolerance, constipation,
and decreased libido.
Bowel sounds may be heard over a hernia, but not over a
hydrocele. During a sickle cell crisis, treatment includes pain
management, hydration, and bed rest.
S1 is decreased in first-degree heart block. S2 is decreased
in aortic stenosis. A patient who is hyperventilating should rebreathe into a
paper bag to increase the retention of carbon dioxide.
Gas in the colon may cause tympany in the right upper
quadrant, obscure liver dullness, and lead to falsely Chorea is a major clinical manifestation of central nervous
decreased estimates of liver size. system involvement caused by rheumatic fever.

In ataxia caused by loss of position sense, vision Chorea causes constant jerky, uncontrolled movements;
compensates for the sensory loss. The patient stands well fidgeting; twisting; grimacing; and loss of bowel and
with the eyes open, but loses balance when they’ re closed bladder control.
(positive Romberg test result).
Severe diarrhea can cause electrolyte deficiencies and
Inability to recognize numbers when drawn on the hand metabolic acidosis.
with the blunt end of a pen suggests a lesion in the sensory
cortex. To reduce the risk of hypercalcemia in a patient with
metastatic bone cancer, the nurse should help the patient
During the late stage of multiple myeloma, the patient ambulate, promote fluid intake to dilute urine, and limit the
should be protected against pathological fractures as a patient’ s oral intake of calcium.
 (Quinaglute), lidocaine hydrochloride, and procainamide
Pain associated with a myocardial infarction usually is hydrochloride (Pronestyl).
described as “ pressure” or as a “ heavy” or
“ squeezing” sensation in the midsternal area. The patient Angiotensin-converting enzyme inhibitors include
may report that the pain feels as though someone is captopril and enalapril maleate (Vasotec).
standing on his chest or as though an elephant is sitting on
his chest. After a myocardial infarction, the patient should avoid
stressful activities and situations, such as exertion, hot or
Calcium and phosphorus levels are elevated until cold temperatures, and emotional stress.
hyperparathyroidism is stabilized.
Antihypertensive drugs include hydralazine hydrochloride
The pain associated with carpal tunnel syndrome is caused (Apresoline) and methyldopa (Aldomet).
by entrapment of the median nerve at the wrist.
Both parents must have a recessive gene for the of fspring
Pancreatic enzyme replacement enhances the absorption of to inherit the gene.
protein.
A dominant gene is a gene that only needs to be present in
Laminectomy with spinal fusion is performed to relieve one parent to have a 50– 50 chance of affecting each
pressure on the spinal nerves and stabilize the spine. offspring.

A transection injury of the spinal cord at any level causes Bronchodilators dilate the bronchioles and relax
paralysis below the level of the lesion. bronchiolar smooth muscle.
The primary function of aldosterone is sodium
For pulseless ventricular tachycardia, the patient should be reabsorption.
defibrillated immediately, with 200 joules, 300 joules, and
then 360 joules given in rapid succession. The goal of positive end-expiratory pressure is to achieve
adequate arterial oxygenation without using a toxic level of
Pleural friction rub is heard in pleurisy, pneumonia, and inspired oxygen or compromising cardiac output.
plural infarction.
Furosemide (Lasix) is a loop diuretic. Its onset of action is
Wheezes are heard in emphysema, foreign body 30 to 60 minutes, peak is achieved at 1 to 2 hours, and
obstruction, and asthma. duration is 6 to 8 hours for the I.M. or oral route.

Rhonchi are heard in pneumonia, emphysema, bronchitis, Pregnancy, myocardial infarction, GI bleeding, bleeding
and bronchiectasis. disorders, and hemorrhoids are contraindications to manual
removal of fecal impaction.
Crackles are heard in pulmonary edema, pneumonia, and
pulmonary fibrosis. Ambulation is the best method to prevent postoperative
atelectasis. Other measures include incentive spirometry
The electrocardiogram of a patient with heart failure and turning, coughing, and breathing deeply.
shows ventricular hypertrophy.
The blood urea nitrogen test and the creatinine clearance
A decrease in the potassium level decreases the test measure how effectively the kidneys excrete these
effectiveness of cardiac glycosides, increases the respective substances.
possibility of digoxin toxicity, and can cause fatal cardiac
arrhythmias. The first sign of respiratory distress or compromise is
restlessness.
A 12-lead electrocardiogram reading should be obtained
during a myocardial infarction or an anginal attack. The antidote for magnesium sulfate overdose is calcium
gluconate 10%.
The primary difference between a ngina and the symptoms
of a myocardial infarction (MI) is that angina can be The antidote for heparin overdose is protamine sulfate.
relieved by rest or nitroglycerin administration. The
symptoms of an MI aren’ t relieved with rest, and the pain An allergic reaction to a blood transfusion may include
can last 30 minutes or longer. flushing, urticaria, wheezing, and a rash. If the patient has
any of these signs of a reaction, the nurse should stop the
Calcium channel blockers include verapamil (Calan), transfusion immediately, keep the vein open with normal
diltiazem hydrochloride (Cardizem), nifedipine (Procardia), saline, and notify the physician.
and nicardipine hydrochloride (Cardene).
A patient taking digoxin and furosemide (Lasix) should
After a myocardial infarction, electrocardiograph changes call the physician if he experiences muscle weakness.
include elevations of the Q wave and ST segment.
A patient with basal cell carcinoma should avoid exposure
Antiarrhythmic agents include quinidine gluconate to the sun during the hottest time of day (between 10 a.m.
and 3 p.m.). Blacks are particularly susceptible to hypertension.
A clinical manifestation of acute pain is diaphoresis.
Women with the greatest risk for cervical cancer are those
Gardnerella vaginitis is a type of bacterial vaginosis that whose mothers had cervical cancer, followed by those
causes a thin, watery, milklike discharge that has a fishy whose female siblings had cervical cancer.
odor.
A postmenopausal woman should perform breast self-
A patient who is taking Flagyl (metronidazole) shouldn ’ t examination on the same day each month, for example, on
consume alcoholic beverages or use preparations that the same day of the month as her birthday.
contain alcohol because they may cause a disulfiram -like
reaction (flushing, headache, vomiting, and abdominal Middle-ear hearing loss usually results from otosclerosis.
pain).
After testicular surgery, the patient should use an ice pack
During the administration of transcutaneous electrical for comfort.
nerve stimulation, the patient feels a tingling sensation.
A patient with chronic open-angle glaucoma has tunnel
In patients with glaucoma, the head of the bed should be vision. The nurse must be careful to place items directly in
elevated in the semi-Fowler position or as ordered after front of him so that he can see them.
surgery to promote drainage of aqueous humor.
Clinical signs of bacterial pneumonia include shaking,
Postoperative care after peripheral iridectomy includes chills, fever, and a cough tha t produces purulent sputum.
administering drugs (steroids and cycloplegics) as
prescribed to decrease inflammation and dilate the pupils. Clinical manifestations of flail chest include paradoxical
movement of the involved chest wall, dyspnea, pain, and
Retinopathy refers to changes in retinal capillaries that cyanosis.
decrease blood flow to the retina and lead to ischemia,
hemorrhage, and retinal detachment. Right-sided cardiac function is assessed by evaluating
central venous pressure.
Kegel exercises are recommended after surgery to improve
the tone of the sphincter and pelvic muscles. A patient with a pacemaker should immediately report an
increase in the pulse rate or a slowing of the pulse rate of
One of the treatments for trichomoniasis vaginalis is more than 4 to 5 beats/minute.
metronidazole (Flagyl), which must be prescribed for the
patient and the patient’ s sexual partner. Dizziness, fainting, palpitation, hiccups, and chest pain
indicate pacemaker failure.
A common symptom after cataract laser surgery is blurred
vision. Leukemia causes easy fatigability, generalized malaise,
and pallor.
A patient with acute open-angle glaucoma may see halos
around lights. After cardiac catheterization, the puncture, or cutdown,
site should be monitored for hematoma formation.
An Asian patient with diabetes mellitus usually can drink
ginseng tea.
Kussmaul’ s breathing is associated with diabetic
To prevent otitis externa, the patient should keep the ears ketoacidosis.
dry when bathing.
If the nurse notices water in a ventilator tube, she should
Patients who receive prolonged high doses of I.V. remove the water from the tube and reconnect it.
furosemide (Lasix) should be assessed for tinnitus and
hearing loss. Tamoxifen is an antineoplastic drug that’ s used to treat
breast cancer.
The treatment for toxic shock syndrome is I.V. fluid
administration to restore blood volume and pressure a nd The adverse effects of vincristine (Oncovin) include
antibiotic therapy to eliminate infection. alopecia, nausea, and vomiting.

In patients with glaucoma, beta -adrenergic blockers Emphysema is characterized by destruction of the alveoli,
facilitate the outflow of aqueous humor. enlargement of the distal air spaces, and breakdown of the
alveolar walls.
A man who loses one testicle should still be able to father
a child. To keep secretions thin, the patient who has emphysema
should increase his fluid intake to approximately 2.5 L/day.
Native Americans are particularly susceptible to diabetes
mellitus. The clinical manifestations of asthma are wheezing,
dyspnea, hypoxemia, diaphoresis, and increased heart and
respiratory rate. or the airways of the lungs.

Extrinsic asthma is an antigen– antibody reaction to The patient should be instructed not to cough during
allergens, such as pollen, animal, dander, feathers, foods, thoracentesis.
house dust, or mites.
The patient should be instructed not to cough during
After endoscopy is performed, the nurse should assess the thoracentesis.
patient for hemoptysis.
A patient who has thrombophlebitis should be placed in
Increased urine output is an indication that a hypertensive the Trendelenburg position.
crisis has resolved.
Symptoms of Pneumocystis carinii pneumonia include
After radical mastectomy, the patient should be positioned dyspnea and nonproductive cough.
with the affected arm on pillows with the hand elevated and
aligned with the arm. To counteract vitamin B1 deficiency, a patient who has
pernicious anemia should eat meat and animal products.
After pneumonectomy, the patient should perform arm
exercises to prevent frozen shoulder. BulletsBullets A patient who is on a ventilator and becomes restless
should undergo suctioning.
Left-sided heart failure causes crackles, coughing,
tachycardia, and fatigability. (Think of L to remember Left Autologous bone marrow transplantation doesn’ t cause
and Lungs.) Bullets graft-versus-host disease.

Cardiac glycosides increase contractility and cardiac A patient who has mild thrombophlebitis is likely to have
output. mild cramping on exertion.

Right-sided heart failure causes edema, distended neck If the first attempt to perform colostomy irrigation is
veins, nocturia, and weakness. unsuccessful, the procedure is repeated with normal saline
solution.
Adverse effects of cardiac glycosides include cardiac
disturbance, headache, hypotension, GI symptoms, blurred Breast enlargement, or gynecomastia, is an adverse effect
vision, and yellow-green halos around lights. of estrogen therapy.

A patient who is receiving anticoagulant therapy should In a patient who has leukemia, a low platelet count may
take acetaminophen (Tylenol) instead of aspirin for pain lead to hemorrhage.
relief.
After radical neck dissection, the immediate concern is
Adequate humidification is important after laryngectomy. respiratory distress as a result of tracheal edema.
At home, the patient can use pans of water or a cool mist
vaporizer, especially in the bedroom. After radical mastectomy, the patient’ s arm should be
elevated to prevent lymphedema.
Late symptoms of renal cancer include hematuria, flank
pain, and a palpable mass in the flank. Hypoventilation causes respiratory acidosis.

Heparin is given subcutaneously, usually in the lower The high Fowler position is the best position for a patient
abdominal fat pad. who has orthopnea.

In a patient with sickle cell anemia, warm packs should be A transient ischemic attack affects sensory and motor
used over the extremities to relieve pain. Cold packs may function and may cause diplopia, dysphagia, aphasia, and
stimulate vasoconstriction and cause further ischemia. The ataxia.
extremities should be placed on pillows for comfort.
Sickle cell crisis causes sepsis (fever greater than 102° F After mastectomy, the patient should squeeze a ball with
[38.9° C], meningeal irritation, tachypnea, tachycardia, and the hand on the affected side.
hypotension) and vaso-occlusive crisis (severe pain) with
hypoxia (partial pressure of arterial oxygen of less than 70 Cholestyramine (Questran), which is used to reduce the
mm Hg). serum cholesterol level, may cause constipation.

Adverse effects of digoxin include headache, weakness, Glucocorticoid, or steroid, therapy may mask the signs of
vision disturbances, anorexia, and GI upset. infection.

To perform a tuberculosis test, a 26-gauge needle is used Melanoma is most commonly seen in light-skinned people
with a 1-ml syringe. who work or spend time outdoors.

Respiratory failure occurs when mucus blocks the alveoli A patient who has a pacemaker should take his pulse at the
same time every day. Cheilosis is caused by riboflavin deficiency.

A patient who has stomatitis should rinse his mouth with The concentration of oxygen in inspired air is reduced at
mouthwash frequently. high altitudes. As a result, dyspnea may occur on exertion.

An adverse effect of theophylline administration is A patient who is receiving enteric feeding should be
tachycardia. assessed for abdominal distention.

The treatment for laryngotracheobronchitis includes Thiamine deficiency causes neuropathy.

postural drainage before meals.
A patient who has abdominal distention as a result of
After radical neck dissection, a high priority is providing a flatus can be treated with a carminative enema (Harris
means of communication. flush).

A high-fat diet that includes red meat is a contributing Pernicious anemia is caused by a deficiency of vitamin
factor for colorectal cancer. B12, or cobalamin.

After a modified radical mastectomy, the patient should be After a barium enema, the patient is given a laxative.
placed in the semi-Fowler position, with the arm placed on
a pillow. The appropriate I.V. fluid to correct a hypovolemic, or
fluid volume, deficit is normal saline solution.
Knifelike, stabbing pain in the chest may indicate
pulmonary embolism. Serum albumin deficiency commonly occurs after burn
injury.
Esophageal cancer is associated with excessive alcohol
consumption. Before giving a gastrostomy feeding, the nurse should
inspect the patient’ s stoma.
A patient who has pancytopenia and is undergoing
chemotherapy may experience hemorrhage and infection. The most common intestinal bacteria identified in urinary
tract infection is Escherichia coli.
A grade I tumor is encapsulated and grows by expansion.
Hyponatremia may occur in a patient who has a high fever
Cancer of the pancreas causes anorexia, weight loss, and and drinks only water.
jaundice.
Folic acid deficiency causes muscle weakness as a result
Prolonged gastric suctioning can cause metabolic of hypoxemia.
alkalosis.
Dehydration causes increased respiration and heart rate,
To measure the amount of residual urine, the nurse followed by irritability and fussiness.
performs straight catheterization after the patient voids.
Glucocorticoids can cause an electrolyte imbalance.
Dexamethasone (Decadron) is a steroidal anti-
inflammatory agent that’ s used to treat brain tumors. A decrease in potassium level decreases the effectiveness
of cardiac glycosides, increases possible digoxin toxicity,
Long-term reduction in the delivery of oxygen to the and can cause fatal cardiac arrhythmias.
kidneys causes an increase in erythropoiesis.
Diuresis can cause decreased absorption of vitamins A, D,
A patient who subsists on canned foods and canned fish is E, and K.
at risk for sodium imbalance (hypernatremia).
Protein depletion causes a decrease in lymphocyte count.
Clinical signs and symptoms of hypoxia include
confusion, diaphoresis, changes in blood pressure, To prevent paraphimosis after the insertion of a Foley
tachycardia, and tachypnea. catheter, the nurse should replace the prepuce.

Red meat can cause a false-positive result on fecal occult Loop diuretics, such as furosemide (Lasix), decrease
blood test. plasma levels of potassium and sodium.

Carbon monoxide replaces hemoglobin in the red blood After pyelography, the patient should drink plenty of fluids
cells, decreasing the amount of oxygen in the tissue. to promote the excretion of dye.
Alkaline urine can result in urinary tra ct infection.
Potassium should be taken with food and fluids.
Bladder retraining is effective if it lengthens the intervals
between urination. Proper measurement of a nasogastric tube is from the
corner of the mouth to the ear lobe to the tip of the sternum.
Full agonist analgesics include morphine, codeine, Diabetic neuropathy is a long-term complication of
meperidine (Demerol), propoxyphene (Darvon), and diabetes mellitus.
hydromorphone (Dilaudid).
Portal vein hypertension is associated with liver cirrhosis.
Buprenorphine (Buprenex) is a partial agonist analgesic.
After thyroidectomy, the nurse should assess the patient
Poor skin turgor is a clinical manifestation of diabetes for laryngeal damage manifested by hoarseness.
insipidus.
The patient with hypoparathyroidism has hypocalcemia.
A patient who has Addison’ s disease and is receiving
corticosteroid therapy may be at risk for infection. A patient who has chronic pancreatitis should consume a
bland, low-fat diet.
To assess a patient for hemorrhage after a thyroidectomy,
the nurse should roll the patient onto his side to examine A patient with hepatitis A should be on enteric precautions
the sides and ba ck of the neck. to prevent the spread of hepatitis A.

A patient who is receiving hormone therapy for The patient who has liver disease is likely to have
hypothyroidism should take the drug at the same time each jaundice, which is caused by an increased bilirubin level.
day.
An adverse effect of phenytoin (Dilantin) administration is
Hyperproteinemia may contribute to the development of hyperplasia of the gingiva.
hepatic encephalopathy.
Hematemesis is a clinical sign of esophageal varices.
To minimize bleeding in a patient who has liver
dysfunction, small-gauge needles are used for injections. Fat destruction is the chemical process that causes ketones
to appear in urine.
A patient who has cirrhosis of the liver and ascites should
follow a low-sodium diet. The glucose tolerance test is the definitive diagnostic test
for diabetes.
Before an excretory urography, the nurse must ask the
patient whether he’ s allergic to iodine or shellfish. Atelectasis and dehiscence are postoperative conditions
associated with removal of the gallbladder.
A buffalo hump is an abnormal distribution of adipose
tissue that occurs in Cushing’ s syndrome. After liver biopsy, the patient should be positioned on his
right side, with a pillow placed underneath the liver border.
Levothyroxine (Synthroid) is used as replacement therapy Categorized
in hypothyroidism. Bullets

Levothyroxine (Synthroid) treats, but doesn’ t cure, Lugol’ s solution is used to devascularize the gland before
hypothyroidism and must be taken for the patient’ s thyroidectomy.
lifetime. It shouldn’ t be taken with food because food may Cholecystitis causes low-grade fever, nausea and
interfere with its absorption. vomiting, guarding of the right upper quadrant, and biliary
pain that radiates to the right scapula.
Imipramine (Tofranil) with concomitant use of
barbiturates may result in enhanced CNS depression. Early symptoms of liver cirrhosis include fatigue,
anorexia, edema of the ankles in the evening, epistaxis, and
A patient who is receiving levothyroxine (Synthroid) bleeding gums.
therapy should report tachycardia to the physician.
The clinical manifestations of diabetes insipidus include
The signs and symptoms of hyperkalemia include muscle polydipsia, polyuria, specific gravity of 1.001 to 1.005, and
weakness, hypotension, shallow respiration, apathy, and high serum osmolality.
anorexia.
The clinical manifestations of diabetes insipidus include
In a patient with well-controlled diabetes, the 2-hour polydipsia, polyuria, specific gravity of 1.001 to 1.005, and
postprandial blood sugar level may be 139 mg/dl. high serum osmolality.

A patient who has diabetes mellitus should wash his feet Hypertension is a sign of rejection of a transplanted
daily in warm water and dry them carefully, especially kidney.
between the toes.
Lactulose is used to prevent and treat portal-systemic
Acute pancreatitis causes constant epigastric abdominal encephalopathy.
pain that radiates to the back and flank and is more intense
in the supine position. Extracorporeal and intracorporeal shock wave lithotripsy
is the use of shock waves to perform noninvasive The universal blood recipient is AB positive.
destruction of biliary stones. It’ s indicated in the treatment
of symptomatic high-risk patients who have few Mucus in a colostomy bag
noncalcified cholesterol stones.
indicates that the colon is beginning to function.
Decreased consciousness is a clinical sign of an increased
ammonia level in a patient with kidney failure or cirrhosis After a vasectomy, the patient is considered sterile if he has
of the liver. no sperm cells.

The pain medication that’ s given to patients who have Fatigue is an adverse effect of radiation therapy.
acute pancreatitis is meperidine (Demerol).
To prevent dumping syndrome, the patient’ s consumption
Prochlorperazine (Compazine), meclizine, and of high-carbohydrate foods and liquids should be limited.
trimethobenzamide (Tigan) are used to trea t the nausea and
vomiting caused by cholecystitis. Cryoprecipitate contains factors VIII and XIII and
fibrinogen and is used to treat hemophilia.
Obese women are more susceptible to gallstones than any
other group. Insomnia is the most common sleep disorder.

Metabolic acidosis is a common finding in acute renal Bruxism is grinding of the teeth during sleep.
failure.
Elderly patients are at risk for osteoporosis because of age-
For a patient who has acute pancreatitis, the most related bone demineralization.
important nursing intervention is to maintain his fluid and
electrolyte balance. The clinical manifestations of local infection in an
extremity are tenderness, loss of use of the extremity,
After thyroidectomy, the patient is monitored for erythema, edema, and warmth.
hypocalcemia.
Clinical manifestations of systemic infection include fever
In end-stage cirrhosis of the liver, the patient’ s ammonia and swollen lymph nodes.
level is elevated.
An immobile patient is predisposed to thrombus formation
In a patient who has liver cirrhosis, abdom inal girth is because of increased blood stasis.
measured with the superior iliac crest used as a landmark.
Urea is the chief end product of amino acid metabolism.
The symptoms of Alzheimer’ s disease have an insidious
onset. Morphine and other opioids relieve pain by binding to the
nerve cells in the dorsal horn of the spinal cord.
Fracture of the skull in the area of the cerebellum may
cause ataxia and inability to coordinate movement. Trichomonas and Candida infections can be acquired
nonsexually.
Serum creatinine is the laboratory test that provides the
most specific indication of kidney disease. Presbycusis is progressive sensorineural hearing loss that
occurs as part of the aging process.
A patient who has bilateral adrenalectomy must take
cortisone for the rest of his life.

Portal vein hypertension causes esophageal varices.

Signs and symptoms of hypoxia include tachycardia,

shortness of breath, cyanosis, and mottled skin.

The three types of embolism are air, fat, and thrombus.

Associations for patients who have had laryngeal cancer

include the Lost Cord Club and the New Voice Club. PSYCHIATRIC NURSING

Before discharge, a patient who has had a total ▪ According to Kübler-Ross, the five stages of death and
laryngectomy must be able to perform tracheostomy care dying are denial, anger, bargaining, depression, and
and suctioning and use alternative means of acceptance.
communication.
▪ Flight of ideas is a n alteration in thought processes that’ s
The universal blood donor is O negative. characterized by skipping from one topic to another,
unrelated topic.
 ▪ Denial is the defense mechanism used by a patient who
▪ La belle indifférence is the lack of concern for a profound denies the reality of an event.
disability, such as blindness or paralysis that may occur in
a patient who has a conversion disorder. ▪ In a psychiatric setting, seclusion is used to reduce
overwhelming environmental stimulation, protect the
▪ Moderate anxiety decreases a person’ s ability to perceive patient from self-injury or injury to others, and prevent
and concentrate. The person is selectively inattentive damage to hospital property. It’ s used for patients who
(focuses on immediate concerns), and the perceptual field don’ t respond to less restrictive interventions. Seclusion
narrows. controls external behavior until the patient can assume
self-control and helps the patient to regain self-control.
▪ A patient who has a phobic disorder uses self -protective
avoidance as an ego defense mechanism. ▪ Tyramine-rich food, such as aged cheese, chicken liver,
avocados, bananas, meat tenderizer, salami, bologna,
▪ In a patient who has anorexia nervosa, the highest Chianti wine, and beer may cause severe hypertension in
treatment priority is correction of nutritional and a patient who takes a monoamine oxidase inhibitor.
electrolyte imbalances.
▪ A patient who takes a monoamine oxidase inhibitor
▪ A patient who is taking lithium must undergo regular should be weighed biweekly and monitored for suicidal
(usually once a month) monitoring of the blood lithium tendencies.
level because the margin between therapeutic and toxic
levels is narrow. A normal laboratory value is 0.5 to 1.5 ▪ If the patient who takes a monoamine oxidase inhibito r
mEq/L. has palpitations, headaches, or severe orthostatic
hypotension, the nurse should withhold the drug and
▪ Early signs and symptoms of alcohol withdrawal include notify the physician.
anxiety, anorexia, tremors, and insomnia. They may begin
up to 8 hours after the last alcohol intake. ▪ Common causes of child abuse are poor impulse control
by the parents and the lack of knowledge of growth and
▪ Al-Anon is a support group for families of alcoholics. development.

▪ The nurse shouldn’ t administer chlorpromazine ▪ The diagnosis of Alzheimer’ s disease is based on clinical
(Thorazine) to a patient who has ingested alcohol because findings of two or more cognitive deficits, progressive
it may cause oversedation and respiratory depression. worsening of memory, and the results of a
neuropsychological test.
▪ Lithium toxicity can occur when sodium and fluid intake
are insufficient, causing lithium retention. ▪ Memory disturbance is a classic sign of Alzheimer’ s
disease.
▪ An alcoholic who achieves sobriety is called a recovering
alcoholic because no cure for alcoholism exists. ▪ Thought blocking is loss of the train of thought because of
a defect in mental processing.
▪ According to Erikson, the school-age child (ages 6 to 12)
is in the industry-versus-inferiority stage of psychosocial ▪ A compulsion is an irresistible urge to perform an
development. irrational act, such as walking in a clockwise circle before
leaving a room or washing the hands repeatedly.
▪ When caring for a depressed patient, the nurse’ s first
priority is safety because of the increased risk of suicide. ▪ A patient who has a chosen method and a plan to commit
suicide in the next 48 to 72 hours is at high risk for suicide.
▪ Echolalia is parrotlike repetition of another person’ s
words or phrases. ▪ The therapeutic serum level for lithium is 0.5 to 1.5
mEq/L.
▪ According to psychoanalytic theory, the ego is the part of
the psyche that controls internal demands and interacts ▪ Phobic disorders are treated with desensitization therapy,
with the outside world at the conscious, preconscious, and which gradually exposes a patient to an anxiety-producing
unconscious levels. stimulus.

▪ According to psychoanalytic theory, the superego is the ▪ Dysfunctional grieving is absent or prolonged grief.
part of the psyche that’ s composed of morals, values, and
ethics. It continually evaluates thoughts and actions, ▪ During phase I of the nurse-patient relationship
rewarding the good and punishing the bad. (Think of the (beginning, or orientation, phase), the nurse obtains an
superego as the “ supercop” of the unconscious.) initial history and the nurse and the patient agree to a
contract.
▪ According to psychoanalytic theory, the id is the part of
the psyche that contains instinctual drives. (Remember i ▪ During phase II of the nurse-patient relationship (middle,
for instinctual and d for drive.) or working, phase), the patient discusses his problems,
 behavioral changes occur, and self-defeating behavior is ▪ Suppression is voluntary exclusion of stress-producing
resolved or reduced. thoughts from the consciousness.

▪ During phase III of the nurse-patient relationship ▪ In psychodrama, life situations are approximated in a
(termination, or resolution, phase), the nurse terminates structured environment, allowing the participant to
the therapeutic relationship and gives the patient positive recreate and enact scenes to gain insight and to practice
feedback on his accomplishments. new skills.

▪ According to Freud, a person between ages 12 and 20 is ▪ Psychodrama is a therapeutic technique that’ s used with
in the genital stage, during which he learns independence, groups to help participants gain new perception and self -
has an increased interest in members of the opposite sex, awareness by acting out their own or assigned problems.
and establishes an identity.

▪ According to Erikson, the identity-versus-role confusion ▪ A patient who is taking disulfiram (Antabuse) must avoid
stage occurs between ages 12 and 20. ingesting products that contain a lcohol, such as cough
syrup, fruitcake, and sauces and soups made with cooking
▪ Tolerance is the need for increasing amounts of a wine.
substance to achieve an effect that formerly was achieved
with lesser amounts. ▪ A patient who is admitted to a psychiatric hospital
involuntarily loses the right to sign out against medical
▪ Suicide is the third leading cause of death among white advice.
teenagers.
▪ “ People who live in glass houses shouldn’ t throw
▪ Most teenagers who kill themselves made a previous stones” and “ A rolling stone gathers no moss” are
suicide attempt and left telltale signs of their plans. examples of proverbs used during a psychiatric interview
to determine a patient’ s ability to think abstractly.
▪ In Erikson’ s stage of generativity versus despair, (Schizophrenic patients think in concrete terms and might
generativity (investment of the self in the interest of the interpret the glass house proverb as “ If you throw a stone
larger community) is expressed through procreation, in a glass house, the house will break.” )
work, community service, and creative endeavors.
▪ Signs of lithium toxicity include diarrhea, tremors,
▪ Alcoholics Anonymous recommends a 12-step program to nausea, muscle weakness, ataxia, and confusion.
achieve sobriety.
▪ A labile affect is characterized by rapid shifts of emotions
▪ Signs and symptoms of anorexia nervosa include and mood.
amenorrhea, excessive weight loss, lanugo (fine body
hair), abdominal distention, and electrolyte disturbances. ▪ Amnesia is loss of memory from an organic or inorganic
cause.
▪ A serum lithium level that exceeds 2.0 mEq/L is
considered toxic. ▪ A person who has borderline personality disorder is
demanding and judgmental in interpersonal relationships
▪ Public Law 94-247 (Child Abuse and Neglect Act of and will attempt to split staff by pointing to discrepancies
1973) requires reporting of suspected cases of child abuse in the treatment plan.
to child protection services.
▪ Disulfiram (Antabuse) shouldn’ t be taken concurrently
▪ The nurse should suspect sexual abuse in a young child with metronidazole (Flagyl) because they may interact
who has blood in the feces or urine, penile or vaginal and cause a psychotic reaction.
discharge, genital trauma that isn’ t readily explained, or
a sexually transmitted disease. ▪ In rare cases, electroconvulsive therapy causes
arrhythmias and death.
▪ An alcoholic uses alcohol to cope with the stresses of life.
▪ A patient who is scheduled for electroconvulsive therapy
▪ The human personality operates on three levels: should receive nothing by mouth after midnight to prevent
conscious, preconscious, and unconscious. aspiration while under anesthesia.

▪ Asking a patient an open-ended question is one of the best ▪ Electroconvulsive therapy is normally used for patients
ways to elicit or clarify information. who have severe depression that doesn’ t respond to drug
therapy.
▪ The diagnosis of autism is often made when a child is
between ages 2 and 3.
▪ For electroconvulsive therapy to be effective, the patient
▪ Defense mechanisms protect the personality by reducing usually receives 6 to 12 treatments at a rate of 2 to 3 per
stress and anxiety. week.
▪ During the manic phase of bipolar affective disorder, ▪ Methylphenidate (Ritalin) is the drug of choice for
nursing care is directed at slowing the patient down treating attention deficit hyperactivity disorder in
because the patient may die as a result of self-induced children.
exhaustion or injury.
▪ Setting limits is the most effective way to control
▪ For a patient with Alzheimer’ s disease, the nursing care manipulative behavior.
plan should focus on safety measures.
▪ Violent outbursts are common in a patient who has
▪ After sexual assault, the patient’ s needs are the primary borderline personality disorder.
concern, followed by medicolegal considerations.
▪ When working with a depressed patient, the nurse should
▪ Patients who are in a maintenance program for narcotic explore meaningful losses.
abstinence syndrome receive 10 to 40 mg of methadone
(Dolophine) in a single daily dose and are monitored to ▪ An illusion is a misinterpretation of an actual
ensure that the drug is ingested. environmental stimulus.

▪ Stress management is a short-range goal of ▪ Anxiety is nonspecific; fear is specific.

psychotherapy.
▪ Extrapyramidal adverse effects are common in patients
▪ The mood most often experienced by a patient with who take antipsychotic drugs.
organic brain syndrome is irritability.
▪ The nurse should encourage an angry patient to follow a
▪ Creative intuition is controlled by the right side of the physical exercise program as one of the ways to ventilate
brain. feelings.

▪ Methohexital (Brevital) is the general anesthetic that’ s ▪ Depression is clinically significant if it’ s characterized
administered to patients who are scheduled for by exaggerated feelings of sadness, melancholy,
electroconvulsive therapy. dejection, worthlessness, and hopelessness that are
inappropriate or out of proportion to reality.
▪ The decision to use restraints should be based on the
patient’ s safety needs. ▪ Free-floating anxiety is anxiousness with generalized
apprehension and pessimism for unknown reasons.
▪ Diphenhydramine (Benadryl) relieves the extrapyramidal
adverse effects of psychotropic drugs. ▪ In a patient who is experiencing intense anxiety, the fight-
or-flight reaction (alarm reflex) may take over.
▪ In a patient who is stabilized on lithium (Eskalith) therapy,
blood lithium levels should be checked 8 to 12 hours after ▪ Confabulation is the use of imaginary experiences or
the first dose, then two or three times weekly during the made-up information to fill missing gaps of memory.
first month. Levels should be checked weekly to monthly
during maintenance therapy. ▪ When starting a therapeutic relationship with a patient, the
▪ The primary purpose of psychotropic drugs is to decrease nurse should explain that the purpose of the therapy is to
the patient’ s symptoms, which improves function and produce a positive change.
increases compliance with therapy.
▪ A basic assumption of psychoanalytic theory is that all
▪ Manipulation is a maladaptive method of meeting one’ s behavior has meaning.
needs because it disregards the needs and feelings of
others. ▪ Catharsis is the expression of deep feelings and emotions.

▪ If a patient has symptoms of lithium toxicity, the nurse ▪ According to the pleasure principle, the psyche seeks
should withhold one dose and call the physician. pleasure and avoids unpleasant experiences, regardless of
the consequences.
▪ A patient who is taking lithium (Eskalith) for bipolar
affective disorder must maintain a balanced diet with ▪ A patient who has a conversion disorder resolves a
adequate salt intake. psychological conflict through the loss of a specific
physical function (for example, paralysis, blindness, or
▪ A patient who constantly seeks approval or assistance inability to swallow). This loss of function is involuntary,
from staff members and other patients is demonstrating but diagnostic tests show no organic cause.
dependent behavior.
▪ Chlordiazepoxide (Librium) is the drug of choice for
▪ Alcoholics Anonymous advocates total abstinence from treating alcohol withdrawal symptoms.
alcohol.
▪ For a patient who is at risk for alcohol withdrawal, the
nurse should assess the pulse rate and blood pressure
every 2 hours for the first 12 hours, every 4 hours for the
 next 24 hours, and every 6 hours thereafter (unless the
patient’ s condition becomes unstable). ▪ Ritualism and negativism are typical toddler behaviors.
They occur during the developmental stage identified by
▪ Alcohol detoxification is most successful when carried Erikson as autonomy versus shame and doubt.
out in a structured environment by a supportive,
nonjudgmental staff. ▪ Circumstantiality is a disturbance in associated thought
and speech patterns in which a patient gives unnecessary,
▪ The nurse should follow these guidelines when caring for minute details and digresses into inappropriate thoughts
a patient who is experiencing alcohol withdrawal: that delay communication of central ideas and goal
Maintain a calm environment, keep intrusions to a achievement.
minimum, speak slowly and calmly, adjust lighting to
prevent shadows and glare, call the patient by name, and ▪ Idea of reference is an incorrect belief that the statements
have a friend or family member stay with the patient, if or actions of others are related to oneself.
possible.
▪ Group therapy provides an opportunity for each group
▪ The therapeutic regimen for an alcoholic patient includes member to examine interactions, learn and practice
folic acid, thiamine, and multivitamin supplements as well successful interpersonal communication skills, and
as adequate food and fluids. explore emotional conflicts.

▪ A patient who is addicted to opiates (drugs derived from ▪ Korsakoff’ s syndrome is believed to be a chronic form
poppy seeds, such as heroin and morphine) typically of Wernicke’ s encephalopathy. It’ s marked by
experiences withdrawal symptoms within 12 hours after hallucinations, confabulation, amnesia, and disturbances
the last dose. The most severe symptoms occur within 48 of orientation.
hours and decrease over the next 2 weeks. ▪ A patient with antisocial personality disorder often
engages in confrontations with authority figures, such as
▪ Reactive depression is a response to a specific life event. police, parents, and school officials.

▪ Projection is the unconscious assigning of a thought, ▪ A patient with paranoid personality disorder exhibits
feeling, or action to someone or something else. suspicion, hypervigilance, and hostility toward others.

▪ Sublimation is the channeling of unacceptable impulses ▪ Depression is the most common psychiatric disorder.
into socially acceptable behavior.
▪ Adverse reactions to tricyclic antidepressant drugs include
▪ Repression is an unconscious defense mechanism tachycardia, orthostatic hypotension, hypomania, lowered
whereby unacceptable or painful thoughts, impulses, seizure threshold, tremors, weight gain, problems with
memories, or feelings are pushed from the consciousness erections or orgasms, and anxiety.
or forgotten.
▪ The Minnesota Multiphasic Personality Inventory
▪ Hypochondriasis is morbid anxiety about one’ s health consists of 550 statements for the subject to interpret. It
associated with various symptoms that aren’ t caused by assesses personality and detects disorders, such as
organic disease. depression and schizophrenia, in adolescents and adults.

▪ Denial is a refusal to acknowledge feelings, thoughts, ▪ Organic brain syndrome is the most common form of
desires, impulses, or external facts that are consciously mental illness in elderly patients.
intolerable.
▪ Reaction formation is the avoidance of anxiety through ▪ A person who has an IQ of less than 20 is profoundly
behavior and attitudes that are the opposite of repressed retarded and is considered a total-care patient.
impulses and drives.
▪ Reframing is a therapeutic technique that’ s used to help
▪ Displacement is the transfer of unacceptable feelings to a depressed patients to view a situation in alternative ways.
more acceptable object.
▪ Fluoxetine (Prozac), sertraline (Zoloft), and paroxetine
▪ Regression is a retreat to an earlier developmental stage. (Paxil) are serotonin reuptake inhibitors used to treat
depression.
▪ According to Erikson, an older adult (age 65 or older) is
in the developmental stage of integrity versus despair. ▪ The ea rly stage of Alzheimer’ s disease lasts 2 to 4 years.
Patients have inappropriate affect, transient paranoia,
▪ Family therapy focuses on the family as a whole rather disorientation to time, memory loss, careless dressing, and
than the individual. Its major objective is to reestablish impaired judgment.
rational communication between family members.
▪ The middle stage of Alzheimer’ s disease lasts 4 to 7
▪ When caring for a patient who is hostile or angry, the years and is marked by profound personality changes, loss
nurse should attempt to remain calm, listen impartially, of independence, disorientation, confusion, inability to
use short sentences, and speak in a firm, quiet voice. recognize family members, and nocturnal restlessness.
 ▪ Transsexuals believe that they were born the wrong
▪ The last stage of Alzheimer’ s disease occurs during the gender and may seek hormonal or surgical treatment to
final year of life and is characterized by a blank facial change their gender.
expression, seizures, loss of appetite, emaciation,
irritability, and total dependence. ▪ Fugue is a dissociative state in which a person leaves his
familiar surroundings, assumes a new identity, and has
▪ Threatening a patient with an injection for failing to take amnesia about his previous identity. (It’ s also described
an oral drug is an example of assault. as “ flight from himself.” )

▪ Reexamination of life goals is a major developmental task ▪ In a psychiatric setting, the patient should be able to
during middle adulthood. predict the nurse’ s behavior and expect consistent
positive attitudes and approaches.
▪ Acute alcohol withdrawal causes anorexia, insomnia,
headache, and restlessness and escalates to a syndrome ▪ When establishing a schedule for a one-to-one interaction
that’ s characterized by agitation, disorientation, vivid with a patient, the nurse should state how long the
hallucinations, and tremors of the hands, feet, legs, and conversation will last and then adhere to the time limit.
tongue.
▪ Thought broadcasting is a type of delusion in which the
▪ In a hospitalized alcoholic, alcohol withdrawal delirium person believes that his thoughts are being broadcast for
most commonly occurs 3 to 4 days after admission. the world to hear.

▪ Confrontation is a communication technique in which the ▪ Lithium should be taken with food. A patient who is
nurse points out discrepancies between the patient’ s taking lithium shouldn’ t restrict his sodium intake.
words and his nonverbal behaviors.
▪ A patient who is taking lithium should stop taking the drug
▪ For a patient with substance-induced delirium, the time of and call his physician if he experiences vomiting,
drug ingestion can help to determine whether the drug can drowsiness, or muscle weakness.
be evacuated from the body.
▪ The patient who is taking a monoamine oxidase inhibitor
▪ Treatment for alcohol withdrawal may include for depression can include cottage cheese, cream cheese,
administration of I.V. glucose for hypoglycemia, I.V. yogurt, and sour cream in his diet.
fluid containing thiamine and other B vitamins, and
antianxiety, antidiarrheal, anticonvulsant, and antiemetic ▪ Sensory overload is a state in which sensory stimulation
drugs. exceeds the individual’ s capacity to tolerate or process it.

▪ The alcoholic patient receives thiamine to help prevent ▪ Symptoms of sensory overload include a feeling of
peripheral neuropathy and Korsakoff’ s syndrome. distress and hyperarousal with impaired thinking and
concentration.

▪ Alcohol withdrawal may precipitate seizure activity ▪ In sensory deprivation, overall sensory input is decreased.
because alcohol lowers the seizure threshold in some
people. ▪ A sign of sensory deprivation is a decrease in stimulation
from the environment or from within oneself, such as
▪ Paraphrasing is an active listening technique in which the daydreaming, inactivity, sleeping excessively, and
nurse restates what the patient has just said. reminiscing.

▪ A patient with Korsakoff’ s syndrome may use ▪ The three stages of general adaptation syndrome are
confabulation (made up information) to cover memory alarm, resistance, and exhaustion.
lapses or periods of amnesia.
▪ A maladaptive response to stress is drinking alcohol or
▪ People with obsessive-compulsive disorder realize that smoking excessively.
their behavior is unreasonable, but are powerless to
control it. ▪ Hyperalertness and the startle reflex are characteristics of
posttraumatic stress disorder.
▪ When witnessing psychiatric patients who are engaged in
a threatening confrontation, the nurse should first separate ▪ A treatment for a phobia is desensitization, a process in
the two individuals. which the patient is slowly exposed to the feared stimuli.

▪ Patients with anorexia nervosa or bulimia must be ▪ Symptoms of major depressive disorder include depressed
observed during meals and for some time afterward to mood, inability to experience pleasure, sleep disturbance,
ensure that they don’ t purge what they have eaten. appetite changes, decreased libido, and feelings of
worthlessness.
▪ Clinical signs of lithium toxicity are nausea, vomiting, and ▪ Delusional thought patterns commonly occur during the
lethargy. manic phase of bipolar disorder.

▪ Asking too many “ why” questions yields scant ▪ Apathy is typically observed in patients who have
information and may overwhelm a psychiatric patient and schizophrenia.
lead to stress and withdrawal.
▪ Manipulative behavior is characteristic of a pa tient who
▪ Remote memory may be impaired in the late stages of has passive– aggressive personality disorder.
dementia.
▪ When a patient who has schizophrenia begins to
▪ According to the DSM-IV, bipolar II disorder is hallucinate, the nurse should redirect the patient to
characterized by at least one manic episode that’ s activities that are focused on the here and now.
accompanied by hypomania.
▪ When a patient who is receiving an antipsychotic drug
▪ The nurse can use silence and active listening to promote exhibits muscle rigidity and tremors, the nurse should
interactions with a depressed patient. administer an antiparkinsonian drug (for example,
Cogentin or Artane) as ordered.
▪ A psychiatric patient with a substance abuse problem and
a major psychiatric disorder has a dual diagnosis. ▪ A patient who is receiving lithium (Eskalith) therapy
should report diarrhea, vomiting, drowsiness, muscular
▪ When a patient is readmitted to a mental health unit, the weakness, or lack of coordination to the physician
nurse should assess compliance with medication orders. immediately.

▪ Alcohol potentiates the effects of tricyclic ▪ The therapeutic serum level of lithium (Eskalith) for
antidepressants. maintenance is 0.6 to 1.2 mEq/L.

▪ Flight of ideas is movement from one topic to another ▪ Obsessive-compulsive disorder is an anxiety-related
without any discernible connection. disorder.

▪ Conduct disorder is manifested by extreme behavior, such ▪ Al-Anon is a self-help group for families of alcoholics.
as hurting people and animals.
▪ Desensitization is a treatment for phobia, or irrational fear.
▪ During the “ tension-building” phase of an abusive
relationship, the abused individual feels helpless. ▪ After electroconvulsive therapy, the patient is placed in
the lateral position, with the head turned to one side.
▪ In the emergency treatment of an alcohol-intoxicated
patient, determining the blood-alcohol level is paramount ▪ A delusion is a fixed false belief.
in determining the amount of medication that the patient
needs. ▪ Giving away personal possessions is a sign of suicidal
ideation. Other signs include writing a suicide note or
▪ Side effects of the antidepressant fluoxetine (Prozac) talking about suicide.
include diarrhea, decreased libido, weight loss, and dry
mouth. ▪ Agoraphobia is fear of open spaces.

▪ Before electroconvulsive therapy, the patient is given the ▪ A person who has paranoid personality disorder projects
skeletal muscle relaxant succinylcholine (Anectine) by hostilities onto others.
I.V. administration.
▪ To assess a pa tient’ s judgment, the nurse should ask the
▪ When a psychotic patient is admitted to an inpatient patient what he would do if he found a stamped, addressed
facility, the primary concern is safety, followed by the envelope. An appropriate response is that he would mail
establishment of trust. the envelope.

▪ An effective way to decrease the risk of suicide is to make ▪ After electroconvulsive therapy, the patient should be
a suicide contract with the patient for a specified period of monitored for post-shock amnesia.
time.
▪ A mother who continues to perform cardiopulmonary
▪ A depressed patient should be given sufficient portions of resuscitation after a physician pronounces a child dead is
his favorite foods, but shouldn’ t be overwhelmed with showing denial.
too much food.
▪ Transvestism is a desire to wear clothes usually worn by
▪ The nurse should assess the depressed patient for suicidal members of the opposite sex.
ideation.
▪ Tardive dyskinesia causes excessive blinking and unusual ▪ Adverse effects of haloperidol (Haldol) administration
movement of the tongue, and involuntary sucking and include drowsiness; insomnia; weakness; headache; and
chewing. extrapyramidal symptoms, such as akathisia, tardive
dyskinesia, and dystonia.
▪ Trihexyphenidyl (Artane) and benztropine (Cogentin) are
administered to counteract extrapyramidal adverse ▪ Hypervigilance and déjà vu are signs of posttraumatic
effects. stress disorder (PTSD).

▪ To prevent hypertensive crisis, a patient who is taking a ▪ A child who shows dissociation has probably been
monoamine oxidase inhibitor should avoid consuming abused.
aged cheese, caffeine, beer, yeast, chocolate, liver,
processed foods, and monosodium glutamate. ▪ Confabulation is the use of fantasy to fill in gaps of
memory.
▪ Extrapyramidal symptoms include parkinsonism,
dystonia, akathisia (“ ants in the pants” ), and tardive >Spinal shock that occurs after spinal cord injury lasts 3
dyskinesia. to 6 weeks after the injury and is characterized by a flaccid
neurogenic bladder with urinary retention. Intermittent
▪ One theory that supports the use of electroconvulsive catheterization used to empty the bladder should be carried
therapy suggests that it “ resets” the brain circuits to out in a manner that prevents urinary tract infection (UTI).
allow normal function.
Cloudy or blood-tinged urine may indicate the onset of
infection. Because fluid is lost through the skin, lungs, and
▪ A patient who has obsessive-compulsive disorder usually
recognizes the senselessness of his behavior but is bowel, intake does not normally equal output. Sensations of
powerless to stop it (ego-dystonia). the need to void require an intact cord, which would not be
present in this client. Cholinergic action stimulates bla dder
▪ In helping a patient who has been abused, physical safety emptying, so anticholinergics would produce the undesirable
▪ is the nurse’ s first priority. effect of relaxation of the bladder in this client.

▪ Pemoline (Cylert) is used to treat attention deficit • First-degree heart block indicates a delayed conduction
hyperactivity disorder (ADHD). somewhere between the junctional tissue and the Purkinje
network, causing a prolonged PR interval. Lying still will not
▪ Clozapine (Clozaril) is contraindicated in pregnant relieve the problem. A pacemaker is not necessary for first-
women and in patients who have severe granulocytopenia degree heart block. Medication may be prescribed to treat this
or severe central nervous system depression. condition.

▪ Repression, an unconscious process, is the inability to

recall painful or unpleasant thoughts or feelings.
• The client should use the walker by placing the hands on the
handgrips for stability. The client lifts the walker to advance
it, and leans forward slightly while moving it. The client
▪ Projection is shifting of unwanted characteristics or
shortcomings to others (scapegoat). walks into the walker, supporting the body weight on the
hands while moving the weaker leg. A disadvantage of the
▪ Hypnosis is used to treat psychogenic amnesia. walker is that it does not allow reciprocal walking motion. If
the client were to try to use reciprocal motion with a walker,
▪ Disulfiram (Antabuse) is administered orally as an the walker would advance forward one side at a time as the
aversion therapy to treat alcoholism. client walks; thus the client would not be supporting the
weaker leg with the walker during ambulation.
▪ Ingestion of alcohol by a patient who is taking disulfiram
(Antabuse) can cause severe reactions, including nausea • Within 2 or 3 days of surgery, a lung is generally fully re-
and vomiting, and may endanger the patient’ s life. expanded. The nurse notes an absence of fluctuation or
bubbling in the water seal chamber or drainage from the chest
▪ Improved concentration is a sign that lithium is taking tube. At this time, the client’s status is confirmed by chest x-
effect. ray. If the lung is fully reexpanded, the physician may remove
the chest tube.
▪ Behavior modification, including time-outs, token
economy, or a reward system, is a treatment for attention
• The irreversible stage of cardiogenic shock represents the
deficit hyperactivity disorder.
point along the shock continuum when organ damage is so
severe that the client does not respond to treatment and is
▪ For a patient who has anorexia nervosa, the nurse should
unable to survive. Multiple organ failure has occurred, and
provide support at mealtime and record the amount the
death is imminent. As it becomes obvious that the client is
patient eats.
unlikely to survive, the client’s family needs to be informed
▪ A significant toxic risk associated with clozapine about the prognosis and outcome. Support to the grievin g
(Clozaril) administration is blood dyscrasia. family members becomes an integral part of the nursing care
plan.
• The purpose of ECG monitoring is to record cardiac electrical • Treatment of prostatitis includes medication with antibiotics,
activity during the depolarization and repolarization phases. analgesics, and stool softeners. The client also is taught to rest,
The two types of single-lead monitoring are hardwire and increase fluid intake, and use sitz baths for comfort.
telemetry. With a wireless battery-operated telemetry system, Antimicrobial therapy is always continued until the
the client is afforded more freedom and mobility than with the prescription is completely finished.
hardwire system.
• The client with respiratory disease may have Ineffective
• The most common problems with ECG monitoring are related Coping related to the inability to tolerate activity and social
to client movement, electrical interference from equipment in isolation. The client demonstrates adaptive responses by
the room, poor choice of monitoring leads, and poor contact increasing the activity to the highest level possible before
between the skin and electrode. symptoms are triggered, using relaxation or other learned
Tracheostomy dressings should be changed whenever they get coping skills, or enrolling in a pulmonary rehabilitation
wet or damp. A soiled dressing promotes microorganism program.
growth and enhances tissue irritation and skin breakdown. The
oxygen collar may be cleaned if it becomes soiled between • The primary symptom in placenta previa is painless vaginal
collar and tubing changes, which are done every 24 hours. bleeding in the second or third trimester of pregnancy.
Tracheostomy care should be done at least every 8 hours or Passage of the mucus plug appears pink or as blood-tinged
per agency policy. It would not be beneficial to the client to mucus. A ruptured amniotic sac would include findings such
limit fluids, because thicker secretions pose added problems as a watery vaginal drainage. Findings of abruptio placenta
with airway ma nagement. include dark red vaginal bleeding and abdominal pain.

• Before discharging a ventilator-dependent client to home, the • Magnesium sulfate depresses the respiratory rate. If the
nurse determines that the family is able to perform CPR, respiratory rate is less than 12 breaths per minute, the
including mouth-to-tracheostomy ventilation. The CPR course continuation of the medication should be reassessed.
designed for lay people in the community does not include this • The symptoms of jitteriness and tachypnea (respiratory rate of
element of care. The electrical service to the home must be 62 breaths per minute) in a 42-week-gestation newborn infant
sufficient for the equipment that will be used. The ventilator are indicative of hypoglycemia. Hypoglycemia may develop
should have a built-in converter to battery power if the electrical in a 42-week-gestation newborn infant because of the
power should fail. Otherwise, a generator must be installed. The insufficient stores of glycogen, which may have been depleted
home itself should be free of drafts and provide adequate air during the post-term period. Insufficient amounts of glucose
circulation. in the infant’s brain could possibly cause central nervous
system damage.
• Back pain after AAA repair may indicate a problem with the
repair. It should be reported to the physician immediately. • A normal blood glucose level for newborn infants is 40 mg/dL
and higher.
• Disease processes, such as cirrhosis, damage the blood flow
through the liver, resulting in hypertension in the portal • Rho(D) immune globulin is not administered if a client has
venous system. The increased portal pressure causes experienced a severe reaction to its component, human
esophageal varices, which are swollen and distended veins. globulin. Rho(D) immune globulin is indicated when
Factors such as increased intrathoracic pressure or irritations Rhnegative clients are exposure to Rh-positive fetal blood
can cause these varices to rupture with subsequent cells in any way, including amniocentesis and abortion.
hemorrhage. • A person who lacks hope feels that life is too much to handle.
By seeing no way out of the situation except death, the client
• Cryosurgery entails freezing cervical tissue with nitrous meets the criteria for hopelessness.
oxide. It is performed in an outpatient setting. Cryosurgery
may result in cramping and a vasovagal response that may • Abdominal exercises should not be started after abdominal
cause faintness. A watery discharge is normal for a few weeks surgery until 3 to 4 postoperative weeks to allow healing of
after the procedure. the incision.

• The client who experiences epididymitis from a urinary tract • Coagulation failure, particularly disseminated intravascular
infection should increase the intake of fluids to flush the coagulopathy (DIC), is a common result of an amniotic fluid
urinary system. Because organisms can be forced into the vas embolus. Manifestations are internal and external hemorrhage
deferens and epididymis from strain or pressure during clinically determined by bleeding at the site of any trauma
voiding, the client should limit the force of the urinary stream. (pressure, needle prick, or incision), and petechiae resulting
Condom use can help to prevent epididymitis that can occur from slight to moderate touch. A postpartum woman who
as a result of STDs. Antibiotics is always taken until the full saturates a Peripad in 15 minutes or less is considered to be
course of therapy is completed. hemorrhaging, which in this case is caused by lack of
coagulation at the placental site.
 • Prevention of recurrence of urinary stones is accomplished by
• A pulsating rope-like object seen in the vagina indicates the drinking at least 3 L of fluid per day; voiding every 2 hours;
presence of the umbilical cord. Each contraction will press the following an acid ash diet if the stones are calcium oxalate
presenting part downward against the bony pelvis, applying stones; and notifying the physician promptly if symptoms of
pressure to the prolapsed cord, compressing it between the UTI occur.
presenting part and the bony pelvis. The compression will
shut off the fetal circulation at the point of compression, • The client with polycystic kidney disease should report any
leading to impaired fetal tissue perfusion and hypoxia of the signs and symptoms of urinary tract infection so that
fetus. treatment may begin promptly. The client should also report
increases in blood pressure, because control of hypertension
• Situational Low Self-Esteem represents temporary negative is essential. The client may experience heart failure as a result
feelings about self in response to an event. This is a normal of hypertension, and thus any symptoms of heart failure, such
response to cesarean section. as shortness of breath, also are reported.
Pregnancy taxes the circulating system of every woman
because both the blood volume and cardiac output increase • The goal of therapy in nephrotic syndrome is to heal the
approximately 30%. This is especially important to monitor in leaking glomerular membrane.
the client whose heart may not tolerate this normal increase. This would then control edema by stopping loss of protein in
the urine. Fluid balance and albumin levels are monitored to
• HIV has a strong affinity for surface marker proteins on determine effectiveness of therapy.
lymphocytes. This affinity of HIV for T lymphocytes leads to
significant cell destruction. Angiotensin is produced in the • Stair climbing may be restricted or limited for several weeks
kidney and plays a role in blood pressure control. after spinal fusion with instrumentation. The nurse assures
• that resources are in place before discharge so that the client
• HIV infection in a pregnant woman may cause both maternal may sleep and perform all activities of daily living on a single
and fetal complications. Fetal compromise can occur because living level.
of premature rupture of the membranes, preterm birth, or low
birth weight. Potential maternal effects include an increased • The skin under a casted area may be discolored and crusted
risk of opportunistic infections. Individuals in the later stages of with dead skin layers. The client should gently soak and wash
HIV are further susceptible to other invasive conditions, such the skin for the first few days. The skin should be patted dry,
as tuberculosis and a wide variety of bacterial infections. and a lubricating lotion should be applied. Clients often want
• The anterior fontanel is normally 2.5 to 5 cm in width and to scrub the dead skin away, which irritates the skin. The
diamond-like in shape. It can be described as soft, which is client should avoid overexposing the skin to the sunlight.
normal, or full and bulging, which could be indicative of • Expected outcomes for Impaired Physical Mobility for the
increased intracranial pressure. Conversely, a depressed client in traction include absence of thrombophlebitis
fontanel could mean that the neonate is dehydrated. (measurable by negative Homans' sign), active baseline ROM
to uninvolved joints, clear lung sounds, intact skin, and bowel
• Clients with Cushing’s syndrome experience weight gain with movement every other day.
truncal obesity. The extremities appear thin with the presence • After three unsuccessful defibrillation attempts, CPR should
of muscle wasting and weakness. The skin is often described as be done for 1 minute, followed by three more shocks, each
being thin and translucent. A butterfly rash across the cheeks of delivered at 360 joules.
the face is seen in systemic lupus erythematosus. Polydipsia and • Typical discharge activity instructions for the first 6 weeks
polyphagia are seen in diabetes mellitus. Weight loss and include lifting nothing heavier than 5 pounds, not driving, and
peripheral edema may be seen in a number of conditions. avoiding any activities that cause straining. The client is
taught to use the arms for balance, but not weight support, to
• Situations that precipitate sickle cell crisis include hypoxia, avoid the effects of straining. These limitations are to allow
vascular stasis, low environmental and/or body temperature, sternal healing, which takes approximately 6 weeks.
acidosis, strenuous exercise, anesthesia, dehydration, and
infections. • Clients can resume sexual activity on the advice of a
physician, which generally occurs when the client can walk
• The client undergoing radiation therapy should avoid washing one block and climb two flights of stairs without discomfort.
the site until instructed to do so. The client should then wash Suggestions to minimize potential problems include waiting
with mild soap and warm or cool water, and pat the area dry. for 2 hours after meals or alcohol consumption, making sure
No lotions, creams, alcohol, or deodorants should be placed on one feels well rested, using a comfortable position, and
the skin over the treatment site. Lines or ink marks that are keeping the room at a mild (not chilly) temperature.
placed on the skin to guide the radiation therapy should be left • Expected outcomes for the client with pulmonary edema
in place. The affected skin should be protected from include improved cardiac output as evidenced by stable
temperature extremes, direct sunlight, and chlorinated water (as vital signs, and urine output of at least 30 mL/hour.
from swimming pools).
• The client’s blood gas results indicate respiratory acidosis. laboratory. This gives initial information about the type of
Symptoms of respiratory acidosis include headache, organism when initiation of antibiotic therapy is a high
irritability, muscle twitching, behavioral changes, priority. The specimen is then incubated on a culture
confusion, lethargy, and coma. medium for at least 24 hours more to identify the specific
organism(s). The sensitivity test gives the physician precise
• When the carboxyhemoglobin levels are greater than 25% information about which antibiotics the organism is
(acute toxicity), the respiratory center becomes depressed sensitive to.
because of inadequate oxygenation, and hypoxia occurs.
• In the early weeks of pregnancy, the cervix becomes softer
• A long-range approach to the prevention of pulmonary as a result of pelvic vasoconstriction, which causes
edema is to minimize any pulmonary congestion. During Goodell’s sign. Cervical softening will be noted during
recumbent sleep, fluid (which has seeped into the pelvic examination by the examiner. A soft blowing sound
interstitium by day with the assistance of the effects of that corresponds to the maternal pulse may be auscultated
gravity) is rapidly reabsorbed into the systemic circulation. over the uterus and is due to blood circulation through the
Sleeping with the head of the bed elevated helps prevent placenta. hCG is noted in maternal urine in a urine
circulatory overload. pregnancy test. Goodell’s sign does not indicate the
presence of fetal movement.
• Complications after pleural biopsy include hemothorax,
pneumothorax, and temporary pain from intercostal nerve • Quickening is fetal movement and is not perceived until the
injury. The nurse notes indications of these complications, second trimester. Between 16 and 20 weeks of gestation,
such as dyspnea, excessive pain, pallor, or diaphoresis. the expectant mother first notices subtle fetal movements
Mild pain is expected, because the procedure itself is that gradually increase in intensity. A soft blowing sound
painful. that corresponds to the maternal pulse may be auscultated
over the uterus and this in known as uterine souffle. This
• The nurse teaches the client that the pain of fractured ribs sound is due to the blood circulation to the placenta and
generally lasts for about 5 to 7 days. Full healing takes corresponds to the maternal pulse. Braxton Hicks
about 6 weeks, after which full activity may be resumed. contractions are irregular, painless contractions that occur
throughout pregnancy, although many expectant mothers
do not notice them until the third trimester. A thinning of
• Coughing and deep breathing will effectively promote lung
the lower uterine segment occurs about the sixth week of
expansion and clearance of mucus. Using an incentive
pregnancy and is called Hegar’s sign
spirometer is helpful, but it is most effective if the client
uses it independently without coaching. The nurse may not
need to suction the client if the client is not intubated • Fetal heart sounds can be heard with a fetoscope by 18 to
20 weeks of gestation.
• Prinzmetal’s angina results from spasm of the coronary
vessels. The risk factors are unknown, and it is relatively • To check for the presence of ballottement, near
unresponsive to nitrates. Beta blockers may worsen the midpregnancy, a sudden tap on the cervix during a vaginal
spasm. exam may cause the fetus to rise in the amniotic fluid and
then rebound to its original position. When the cervix is
tapped, the fetus floats upward in the amniotic fluid. The
• Exercise is most effective when done at least 3 times a
examiner feels a rebound when the fetus falls down.
week for a client with angina pectoris. Other positive habits
include limiting salt and fat in the diet, using
stressmanagement techniques, and knowing when and how • Fetal movement, called quickening, is not perceived until
to use medications. the second trimester. Between16 and 20 weeks' gestation,
the expectant mother first notices subtle fetal movements
that gradually increase in intensity.
• Nosebleeds may occur during the winter because of
decreased humidity in the home. The use of a humidifier
helps to alleviate this problem. • A rubella titer is performed to determine immunity to
rubella. If the mother’s titer is less than 1:8, the mother is
not immune. A retest during pregnancy is prescribed, and
• If pulse oximeter values fall below a preset norm, which is
the mother is immunized postpartum if not immune.
usually 90% to 91%, the client should be instructed to take
several deep breaths. This is especially true of a client • A maternal glucose assay is prescribed to screen for
without a respiratory history who is still under the effects gestational diabetes. If it is elevated, a 3-hour glucose
of sedation. If the client did have a respiratory disease tolerance test is recommended to determine the presence of
history, it might be an indication that supplemental oxygen gestational diabetes.
should be put in place or increased if already in place.
• A Gram stain classifies the organism as gram -negative or • A hepatitis B screen is performed to detect the presence of
gram-positive, and may be done immediately by the antigens in maternal blood. If antigens are present, the
 infant should receive a hepatitis immune globulin and a pseudomenstruation, like that of breast engorgement, is the
vaccine soon after birth. withdrawal of maternal hormones.
• A myelomeningocele is a neural tube defect caused by
• During a menstrual period, a woman loses about 40 mL of failure of the posterior neural tube to close. The meninges
blood. Because of the recurrent loss of blood, many women are exposed through the surface of the skin in a herniated
are mildly anemic during their reproductive years, sac that may be either healed or leaking. Skin integrity is
especially if their diets are low in iron. impaired because a thin membrane covers the protruding
sac.
• Montgomery’s tubercles are sebaceous glands in the • Prolactin stimulates the secretion of milk, called
areola. They are inactive and not obvious except during lactogenesis. Testosterone is produced by the adrenal
pregnancy and lactation, when they enlarge and secrete a glands in the female and induces the growth of pubic and
substance that keeps the nipples soft. Within each breast axillary hair at puberty. Oxytocin stimulates contractions
are lobes of glandular tissue that secrete milk. Alveoli are during birth and stimulates postpartum contractions to
small sacs that contain acinar cells to secrete milk. The compress uterine vessels and control bleeding.
alveoli drain into lactiferous ducts that connect to drain Progesterone stimulates the secretions of the endometrial
milk from all areas of the breast. glands, causing endometrial vessels to become highly
dilated and tortuous in preparation for possible embryo
• Before conception, the uterus is a small pear-shaped organ implantation.
entirely contained in the pelvic cavity. Before pregnancy,
the uterus weighs approximately 60 grams (2 oz) and has a
capacity of about 10 mL (one third of an ounce). At the end
of pregnancy, the uterus weighs approximately 1000 grams • The normal duration of the menstrual cycle is about 28
(2.2 pounds) and has a sufficient capacity for the fetus, days, although it may range from 20 to 45 days. Significant
placenta, and amniotic fluid, a total of about 5000 mL. deviations for the 28-day cycle are associated with reduced
fertility. The first day of the menstrual period is counted as
At 12 weeks' gestation, the uterus extends out of the day 1 of the adolescent’s cycle.
maternal pelvis and can be palpated above the symphysis
pubis. At 16 weeks, the fundus reaches midway between • The ovaries are the endocrine glands that produce estrogen
the symphysis pubis and the umbilicus. At 20 weeks, the and progesterone. FSH and LH are produced by the
fundus is located at the umbilicus. By 36 weeks, the anterior pituitary gland. Oxytocin is produced by the
fundus reaches its highest level at the xiphoid process. posterior pituitary gland and stimulates the uterus to
produce contractions during labor and birth.
• The muscular action of the fallopian tube and movement of
the cilia within the tube transport the mature ovum through • Mittelschmerz (middle pain) refers to pelvic pain that
the fallopian tube. Fertilization normally occurs in the occurs midway between menstrual periods or at the tim e of
distal third of the fallopian tube near the ovaries. The ovum, ovulation. The pain is due to growth of the dominant
fertilized or not, enters the uterus about 3 days after its follicle within the ovary, or rupture of the follicle and
release from the ovary. subsequent spillage of follicular fluid and blood into the
peritoneal space. The pain is fairly sharp and is felt on the
• The uterus has three divisions, the corpus, isthmus, and the right or left side of the pelvis. It generally lasts a few hours
cervix. The upper division is the corpus or the body of the to 2 days, and slight vaginal bleeding may accompany the
uterus. The uppermost part of the uterine corpus, above the discomfort.
area where the fallopian tubes enter the uterus, is the fundus
of the uterus. • Endometriosis is defined as the presence of tissue outside
the uterus that resembles the endometrium in both structure
• By week 13, the fetal sex can be determined by the and function. The response of this tissue to the stimulation
appearance of the external genitalia on ultrasound. of estrogen and progesterone during the menstrual cycle is
identical to that of the endometrium. Primary
• Mineral oil should not be used as a stool softener because
it inhibits the absorption of fat-soluble vitamins in the dysmenorrhea refers to menstrual pain without identified
body. Constipation should be treated with increased fluids pathology. Mittelschmerz refers to pelvic pain that occurs
(six to eight glasses per day) and a diet high in fiber. midway between menstrual periods, and amenorrhea is the
Increasing exercise is also an excellent way to improve cessation of menstruation for a period of at least three
gastric motility. cycles or 6 months in a woman who has established a
pattern of menstruation, and can be due to a variety of
• The genitalia of a newborn female a re frequently red and
causes.
swollen. This edema disappears in a few days. A vaginal
discharge of thick white mucus is seen in the first week of
life. The mucus is occasionally blood tinged by about the
third or fourth day, and stains the diaper. The cause of the
 • In early pregnancy, hCG is produced by trophoblastic cells • Effective pain management during labor does not interrupt the
that surround the developing embryo. This hormone is labor process but does provide relaxation and moderate pain
responsible for positive pregnancy tests. relief to the mother. The increased bloody show and intensity
of the contractions are not measures of effective pain
• Progesterone maintains uterine lining for implantation and management.
relaxes all smooth muscle, including the uterus. Relaxin is
the hormone that softens the muscles and joints of the • Accelerations are an indication of fetal well-being and an
pelvis. Thyroxine increases during pregnancy to stimulate oxygenated fetal central nervous system. Bradycardia, late
basal metabolic rates, and prolactin is the primary hormone decelerations, and decreased variability are representative of
of milk production. decreased oxygenation of the fetus.

• Estrogen stimulates uterine development to provide an • Signs of impaired fetal oxygenation include late
environment for the fetus and stimulates the breasts to decelerations, decreased baseline variability, and tachycardia
prepare for lactation. Progesterone maintains the uterine or bradycardia. A normal fetal heart range is 120 to 160 beats
lining for implantation and relaxes all smooth muscle. per minute. Accelerations occur in a fetus with a mature
Human placental lactogen stimulates the metabolism of central nervous system and who is well oxygenated.
glucose and converts the glucose to fat. Human chorionic
gonadotropin (hCG) prevents involution of the corpus • Breastfeeding is contraindicated if the mother is positive for
luteum and maintains the production of progesterone until HIV because the virus may be spread to the infant in the breast
the placenta is formed. milk. HIV is not spread through casual contact, so holding,
hugging, and sleeping with other family members is not
• During pregnancy, the breasts change in both size and prohibited. A newborn may test positive for HIV for up to 2
appearance. The increase in size is due to the effects of years after birth because of placental transfer of maternal
estrogen and progesterone. Estrogen stimulates the growth antibodies. It is vital that the nurse ascertain that the client has
of mammary ductal tissue, and progesterone promotes the correct knowledge regarding the transmission of the disease
growth of lobes, lobules, and alveoli. A delicate network of and precautions necessary to prevent the spread of HIV.
veins is often visible just beneath the surface of the skin.
• In response to the increasing levels of estrogen, the cervix • AIDS decreases the body’s immune response, making the
becomes congested with blood, resulting in the infected person susceptible to infections. AIDS affects helper
characteristic bluish color that extends to include the T lymphocytes, which are vital to the body’s defense system.
vagina and labia. This discoloration, referred to as Opportunistic infections are a primary cause of death in
Chadwick’s sign, is one of the earliest signs of pregnancy. persons affected with AIDS. Therefore preventing infection is
a priority of nursing care.
• Ovulation ceases during pregnancy because the circulating
levels of estrogen and progesterone are high, inhibiting the • In this client, diuresis is a positive sign that indicates that
release of the follicle stimulating hormone (FSH) and the edema and vasoconstriction in the brain and kidneys have
luteinizing hormone (LH), which are necessary for decreased. Diuresis also reflects an increased tissue perfusion
ovulation. to the kidneys. Clients who have severe preeclampsia are not
considered to be out of danger until birth and diuresis occurs.
• The ovarian cycle consists of three phases, the follicular, Diuresis is not an indication of impending seizure. Although
ovulatory, and luteal phases. The proliferative phase is a renal failure is a complication of severe preeclampsia, it is not
phase of the endometrial cycle. of the high-output type of failure. Potassium is lost through
the urine; therefore hyperkalemia is not associated with
• A nutritional supplement commonly needed during diuresis.
pregnancy is iron. Anemia of pregnancy is primarily
caused by iron deficiency. Iron supplements usually cause • In a pregnant woman, the supine position adds gravity
constipation. Meats are an excellent source of iron. Iron for pressure onto the inferior vena cava, which is already
the fetus comes from the maternal serum. displaced and partially compressed by the term gravid
uterus. The increased compression decreases the cardiac
• Signs of congenital neonatal syphilis may be nonspecific at output, leading to beginning tissue hypoxia, which brings
first, including poor feedings, slight hyperthermia, and on the signs and symptoms as described in the question.
“snuffles.” Snuffles refers to copious, clear serosanguineous The signs and symptoms identified in the question are not
mucus discharge from the nose. By the end of the first week, indicative of progression to active first-stage labor.
a copper-colored maculopapular dermal rash is
characteristically observed on the palms of the hands, soles of • Short-term variability averages 6 to 10 beats per minute,
the feet, diaper area, and around the mouth and anus. and long-term variability averages 2 to 6 cycles per minute.
The FHR should accelerate with fetal activity. The baseline
range for the FHR is 120 to 160 beats per minute. Late
decelerations are a result of decreased uteroplacental
perfusion that causes a decrease in fetal oxygenation.
Late decelerations are not a reassuring pattern.