Professional Documents
Culture Documents
Nclex Notes 1
Nclex Notes 1
The nurse cares for a client receiving IV antibiotics every 8 hours for the
past 4 days. The antibiotic is mixed in D5W. The nurse determines that a
post-infusion phlebitis has occurred if which of the following is observed?
1. Tenderness at the IV site.
2. Increased swelling at the insertion site.
3. Area around the IV site is reddened with red streaks.
4. Fluid is leaking around the IV catheter.
a. Tenderness occurs with phlebitis but is not specific to it.
b. May indicate either infiltration or phlebitis
c. CORRECT—reddened, warm area noted around insertion site or on
path of vein; discontinue IV, apply warm, moist compresses,
restart IV at new site
d. Not indicative of phlebitis
1 grain = 60mg
Full-thickness burn; all skin is destroyed and muscle and bone may be
involved; substance that remains is called eschar, dry to touch, doesn’t heal
spontaneously, requires grafting. I.E., Charred, waxy, white appearance of
skin on left leg.
Insulin—NPH Onset: 1.5 hours Peak: 4-12 hours Regular Onset: 0.5
hours Peak: 2.5-5 hours
When directing a UAP, the nurse must communicate clearly about each
delegated task with specific instructions on what must be reported. Because
the RN is responsible for all care-related decisions, only implementation
tasks should be assigned because they do not require independent
judgment.
4
When applying the nursing process, assessment is the first step in providing
care. The 5 "Ps" of vascular impairment can be used as a guide (pain,
pulselessness, pallor, paresthesia, paralysis)
Rash and blood dyscrasias are side effects of anti-psychotic drugs. A history
of severe depression is a contraindication to the use of neuroleptics.
Children with celiac disease should eat a gluten free diet. Gluten is found
mainly in grains of wheat and rye and in smaller quantities in barley and
oats. Corn, rice, soybeans and potatoes are digestible in persons with celiac
disease.
The protest phase of separation anxiety is a normal response for a child this
age (2 year-old hospitalized child). In toddlers, ages 1 to 3, separation
anxiety is at its peak
Signs of tardive dyskinesia include smacking lips, grinding of teeth and "fly
catching" tongue movements.
The UAP can be assigned to care for a client with a chronic condition after
an initial assessment by the nurse. This client has no risk of instability of
condition.
Never leave your patient. For example, Ask the LPN/LVN to stay with the
child and his parents while the nurse obtains phone orders from the
physician.
Restraint: frame of bed, quick release ties, document need for restraint Q4
hours
Gag Reflex: don’t assess gag reflex to a client that has an absent swallow
reflex
An RN that is not assigned to a patient does not have the authority to tell a
nurse what to do. Refer it to nursing supervisor.
6
Postoperative care after Supratentorial surgery: maintain airway, elevate
head 30-45
Orange juice does not help acidify urine it makes it more alkaline.
Myelogram
Water-soluble dye—elevate head of bed 30 degrees (not removed)
Oil based dye—flat in bed (removed)
Fractures:
Immobilize joint above and below fracture
Cover open fracture with cleanest material available
Check temperature, color, sensation, capillary refill distal to
fracture
Close reduction—manually manipulate bone or use traction
Buck’s Traction
Use to relieve muscle spasm of leg and back
If used for muscles spasms only, they can turn to either side.
If used for fracture treatment, only can turn to unaffected side.
Use 8-20 lbs of weight, if used for scoliosis will use 40 lbs of weight.
Elevate head of bed for countertraction or foot bed
Place pillow below leg not under heel or behind knee.
Russell’s Traction
Sling is used
Check for popliteal pulse
Place pillow below lower leg and heel off the bed
Don’t turn from waist down
Lift patient, not the leg
Cervical Tongs
Never lift the weights
No pillow under head during feedings
Casts
Don’t rest on hard surface
Don’t cover until dry 48+ hours
Handle with palms of hands not with fingers
Keep above level of heart
Check for CSM
Fractured Hip
Assessments
Leg shortened
Adducted
Externally rotated
Implementation
Care after a total hip replacement
Abduction pillows
Crutch walking with 3-point gait
Don’t sleep on operated side
Don’t flex hip more than 45-60 degrees
Don’t elevate head of the bed more than 45 degrees
Amputations
Guillotine (open)
Flap (closed)
Delayed prosthesis fitting
Residual limb covered with dressing and elastic bandage
(figure eight)
Figure-8 doesn’t restrict blood flow, shaped to reduce
edema
Check for bleeding
Elevated 24 hours (AKA-pillow, BKA-foot of bed elevated)
Position prone daily
Exercises, crutch walking
Phantom Pain: acknowledge feelings, that pain is real for
them.
8
Pyridoxine (Vit. B6)—amino acid metabolism; deficiency will cause anemia,
seizures
Enteral feeding held if: 150 or > cc’s aspirated or 50% given in the hour is
aspirated
If cramping, vomiting occurs decrease rate of enteral feeding or keep it
warm.
Guillain-Barre Syndrome
- GBS often preceded by a viral infection as well as
immunizations/vaccinations
- Intervention is symptomatic
- Acute phase: Steroids, plasmapheresis, aggressive respiratory care;
prevent hazards of immobility, maintain adequate nutrition; physical
therapy; pain-reducing measures; eye care, prevention of
complications (UTI, aspiration); psychosocial support
Parkinson’s disease
- Activities should be scheduled for late morning when energy level is
highest and patient won’t be rushed
- Symptoms: tremors, akinesia, rigidity, weakness, “motorized
propulsive gait, slurred monotonous speech, dysphagia, drooling,
mask-like expression.
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- Nursing care: encourage finger exercises. Administer Artane,
Congentin, L-Dopa, Parlodel, Sinemet, Symmetrel.
- Teach: ambulation modification
- Promote family understanding of disease intellect/sight/hearing not
impaired, disease progressive but slow, doesn’t lead to paralysis
Labs
HbA1c (4.5-7.6%)
- indicates overall glucose control for the previous 120 days
Hematocrit (Hct)
- Men (40-45) u/mL
- Women (37-45) u/mL
- Relative volume of plasma to RBC
- Increased with dehydration
- Decreased with volume excess
Serum Glucose
- 60-110 mg/dL
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Sodium (Na+)
- 135-145 mEq/L
- Hypernatremia
o Dehydration and insufficient water intake
Chloride (Cl-)
- 95-105 mEq/L
Potassium (K+)
- 3.5-5.0 mEq/L
Bicarbonate (HCO3)
- 22-26 mEq/L
- Decreased levels seen with starvation, renal failure, diarrhea.
Lithium
- targeted blood level: (1-1.5 mEq/L)
12
Assess before implementation.
Manic patient: decrease stimuli and increase rest period and no competition.
Thiamine sources: organ meats, liver, whole grain, nuts, legume, egg, and
milk.
Sick day rules: take insulin as ordered, check blood glucose q3-4 hours,
soft foods, liquids
Dumping syndrome prevention: restrict fluid with meals, lie down after
eating, small, frequent meals, low-carbohydrate, low-fiber diet
Newborn
Pulse 120-140 bpm, increases with crying
Respirations 30-50/min, diaphgramatic (abdomen moves),
can be irregular
BP 60/40 – 80/50 mmHg
Adult
Pulse: 60-100
Resp: 12-20
BP: 90/60-140/90
15
Aortic Valve: Right of Sternum at the 2nd intercostal space
CPR: Shake, shout, summon help, open airway, look, listen, feel for signs of
breathing, pinch nose, give 2 full breaths (if no rise, reposition)
MI Implementation for MI
Chest pain radiating to
arms, jaw, neck (which Thrombolytic therapy-
is unrelieved by rest or streptokinase, t-PA
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nitroglycerin) Bedrest
Dyspnea Beta-blockers, morphine
Indigestion sulfate, dysrhythmics,
Apprehension anticoagulants
Low grade fever Do not force fluids (will
Elevated WBC (5-10, give heart more to work
ESR, CK-MB, LDH) with)
Defibrillation
Start CPR first
1st attempt – 200 joules
2nd attempt – 200 to 300 joules
3rd attempt – 360 joules
Check monitor between shocks for rhythm
Cardioversion
Elective procedure, Informed Consent
Valium IV
Synchronizer on
25-360 joules
Check monitor between rhythm
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inspiratio respiration Restricted Thoracentesis
n and up Pain movement on (aspiration of
during Decreased affected side fluid from
expiration breath Decreased/absent pleural space)
sounds breath sounds Chest Tubes
Anxiety Cough
Hypotension
Seizures:
do not restrain
do not insert anything in mouth
Electrolytes
Potassium: 3.5-5.0 mEq/L
Sodium: 135-145 mEq/L
Calcium: 4.5-5.2 mEq/L
Magnesium: 1.5-2.5 mEq/L
Burns Assessments
Superficial partial thickness—pink to red, painful
Deep partial thickness—red to white, blisters, painful
Full thickness—charred, waxy, white, painless
Pheochromocytoma Pheochromocytoma
Assessments—hypersecretions Implementations
of the catecholamines Histamine Test, Regitine Test,
(epinephrine/norepinephrine) 24- hour urine VMA test
Persistent hypertension Avoid emotional and physical
Hyperglycemia stress
Pounding headache Encourage rest
Palpitations Avoid coffee and stimulating
Visual disturbances foods
Postop care after
adrenalectomy and
medullectomy
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Acyanotic Congenital Heart Cyanotic Congenital Heart
Anomalies Assessments Anomalies Assessments
Normal Color Cyanosis
Possible exercise intolerance Clubbing of fingers
Small stature Seizures
Failure to thrive Marked exercise intolerance
Heart murmur Difficulty eating
Frequent respiratory Squat to decrease respiratory
Infections distress
Small stature
Failure to thrive
Characteristic murmur
Frequent respiratory infection
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Pulomonic Stenosis—narrowing at entrance to pulmonary artery;
causes resistance to blood flow and right ventricular hypertrophy;
surgery
CHF Implementations
Administer digoxin, diuretics
Low-sodium, low-calorie, low-residue diet
Oxygen therapy
Daily weight
Teach about medications and diet
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Diet restrictions
Oliguric phase:
limit fluids, TPN
maybe
After Diuretic
phase: high
protein, high
calorie diet
36
Inability to test agitation (don’t ask to tell more
reality, regression Paranoid—late about voices)
Hallucinations— onset in life, With delusions—do not
false sensory suspiciousness, argue, point out feeling
perceptions ideas of tone, provide diversional
Delusions— persecution and activities
persistent false delusions Meet physical needs
beliefs; grandeur Establish therapeutic
(feel higher rank); relationship
persecutory Institute measures to
(beliefs to be a promote trust
victim); ideas of Engage in individual,
reference (see group, or family therapy
people talking Encourage client’s affect
think talking about Accept nonverbal
them) behavior
Loose associations Accept regression
Short attention Provide simple activities
span or tasks
Inability to meet
basic needs:
nutrition, hygiene
Regression
Obssessive-compulsive Obssessive-compulsive
Assessments Implementations
High personal standards Explore feelings
for self and others Help with decision-
Preoccupied with rules, making
lists, organized Confront procrastination
Perfectionists Teach that mistakes are
Intellectualize acceptable
CAT Scan—dye gives flushed, warm face and metallic taste during injection
(if contrast dye is used)
Myelogram: Post-test
Supine 8-24 hours (Pantopaque oil-based dye used)
Head raised 30-45degrees 8-16 hours(metrizamide water-soluble dye
used)
CVP: measures blood volume and efficiency of cardiac work; tells us right
side of heart able to manage fluid
“0” on mamometer at level of right atrium at midaxilliary line
Measure with patient flat in bed
Open stopcock and fill manometer to 18-20 cm
Turn stopcock, fluid goes to patient
Level of fluid fluctuates with respirations
Measure at highest level of fluctuation
After insertion
o Dry, sterile dressing
o Change dressing, IV fluids, manometer, tubing q24 hours
o Instruct patient to hold breath when inserted, withdrawn, tubing
changed
o Check and secure all connections
Normal reading—3-11 cm water
Elevated>11, indicates hypervolemia or poor cardiac contractility
(slow down IV, notify physician)
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Lowered<3, hypovolemia
Chest tray at bedside
Nasogastric Tubes:
Levin-single—single-lumen, used for decompression or tube feeding
Salem sump—double-lumen, used for decompression or tube feeding
Sengstaken-Blakemore—triple-lumen, used for bleeding esophageal
varices
Linton-Nachlas—4-lumen, used for bleeding esophageal varices
Keofeed/Dobhoff—soft silicone, used for long-term feedings
Cantor—single lumen with mercury-filled balloon and suction port
Miller-Abbott—double-lumen with mercury-filled balloon and suction
port
Harris—single lumen with mercury-filled balloon and suction port
NG tube placement:
“BEST WAY” to check is to aspirate for gastric contents and check for pH of
aspirate <4
Implementation of feeding:
Check residual before intermittent feeding, reinstall residual
Check residual Q4 hours with continuous feeding, reinstall residual
Hold feeding if >50% residual from previous hour (adults) or >25%
(children)
Flush tube with water before and after feeding
Use pump to control rate of tube feeding
Administer fluid at room temperature
Change bag Q8 hours for continuous feeding
Elevate head of bed while feeding is running
Check patency Q4 hours
Good mouth care
NG Irrigation Tubing:
Verify placement of tube
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Insert 30-50 cc of normal saline into tube
If feel resistance, change patient position, check for kinks
Withdraw solution or record amount as input
NG removal:
Clamp tube
Remove tape
Instruct patient to exhale
Remove tube with smooth, continuous pull
Enema Implementation
Position on left side
Use tepid solution
Hold irrigation set no more than 18” above rectum
Insert tube no more than 4”
Do not use if abdominal pain, nausea, vomiting, suspected appendicitis
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Catheter Urine Drainage bag: do not remove more than 700 cc at one time,
clamp prior to removal
Ileostomy: post-op has loose, dark green, liquid drainage from stoma
Object in eye: never remove visible glass; apply loose cover and remain
quiet.
Retina detached: sleep prone with affected side down; avoid jarring
movements; avoid pin point movement with eye (sewing); high fluid and
roughage (prevents constipation=no straining); make light sufficient for
needs (75watt+); no hairwashing
Only patient we use distractions on the NCLEX are manic patients and
toddlers not for pain.
1 cup= 240cc
Pregnancy is a contraindication to an MRI.
48
Raynaud’s disease have decreased vascularity in the extremities.
Autologous Transfusion:
Collected 4-6 weeks before surgery
Contraindicated—infection, chronic disease, cerebrovascular or
cardiovascular
disease
IV Clotting
Assessment—decreased flow rate, back flow of blood into tubing
Implementation—discontinue, do not irrigate, do not milk, do not
increase rate of flow or hang solution higher, do not aspirate cannula,
inject Urokinase, D/C and start on other site.
UTIs
Medication:
o Furadantin
Action:
o Anti-infective
Side effects:
o Asthma attacks
o Diarrhea
Nursing Considerations:
o Give with food or milk
o Monitor pulmonary status
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UTIs
Medication
o Mandelamine
Action:
o Anti-infective
Side effects:
o Elevated liver enzymes
Nursing Considerations:
o Give with cranberry juice to acidify urine
o Limit alkaline foods: vegetables, milk, almonds, coconut
UTIs
Medication
o Pyridium
Side effects:
o Headache
o Vertigo
Action
o Urinary tract analgesic
Nursing Consideration
o Tell patient urine will be orange
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Antihypertensives Antihypertensives Antihypertensives
Type: Peripheral-acting alpha- Medications: Side Effects:
adrenergic blockers Reserpine Depression
Action: Orthostatic
Depletes stores of Hypotension
norepinephrine in Brachycardia
sympathetic nerve Nursing
endings Considerations:
Used for: Give with
Hypertension meals or milk
Change
position slowly
66
Thyroid Thyroid Thyroid
Replacement Replacement Replacement
Agents Medications Side Effects:
Action: Synthroid Nervousness
Increases Cytomel Tachycardia
metabolic rate Weight loss
Used for: Nursing
Hypothyroidism Considerations:
Monitor pulse
and BP
Monitor weight
Take in a.m.
Enhance
action of
anticoagulants
,
antidepressant
s, decrease
action of
insulin and
digitalis
67
combination
Antivirals Antivirals Antivirals
Action: Medications: Side Effects:
Inhibits DNA Zovirax Headache
and RNA AZT Dizziness
replication Videx GI symptoms
Used for: Famvir Nursing
Recurrent HSV Cytovene Considerations:
HIV infection Encourage
fluids
Not a cure,
but relieves
symptoms
71
hy Monitor I&O
and kidney
function
Administered
with local
anesthetic
Seizure
precautions
74
Thrombolytics Thrombolytics Thrombolytics
Action: Medications: Side Effects:
Dissolves or lyses Streptokinase Bleeding
blood clots Urokinase Bradycardia
Used for: Tissue Dysrhythmias
Acute Pulmonary Plasminogen Nursing
Emboli Activator Considerations:
Thrombosis Monitor for
MI bleeding
Contraindicated in: Have Amino
hemophilia, CVA, Caproic Acid
Trauma, not used in Available
patients over 75 years Check pulse,
old, not used in color, sensation
patients taking of extremities
anticoagulants Monitor EKG
Anaphylaxis
Symptoms
o Hives
o Rash
o Difficulty breathing (first sign)
o Diaphoresis
Nursing care
o Epinephrine 0.3 ml of 1:1000 solution SQ
o Massage site
o May repeat in 15-20 min.
Anticholinergic Effects
Symptoms:
o Dry mouth, Dysphagia, Nasal Congestion
o Urinary retention, Impotence
Nursing Care:
o Sugarless lozenges
o Good mouth care
o Void before taking medication
Parkinson’s-like effects
Symptoms:
o Akinesia (temporarily paralysis of muscles)
o Tremors
o Drooling
o Changes in gait
o Rigidity
o Akathisia (Extreme restlessness)
o Dyskinesia (Spasms)
Nursing Care:
o Anticholinergic and Antiparkinsonian medications
o Safety measures for gait
Universal Donor Blood: Packed red blood cells (help oxygen deliver to
tissue, if you use whole blood there will be a risk for fluid overload), type O,
Rh-negative
Older adults are asymptomatic when they have an infection and can lead to
confusion.
98
WBC after pregnancy?
Tracheostomy care: no powder, suction trachea first then mouth, use pre-cut
gauze.
Chest Tubes
Fill water-seal chamber with sterile water to 2 cm
(middle chamber)
Fill suction control chamber with sterile water to 20 cm
(chamber all the way to the right)
Air-leak if bubbling in water-seal chamber (middle
chamber)
Obstruction: “milk” tube in direction of drainage
Removal o chest tube: pt. does valsalva maneuver,
clamp chest tube, remove quickly, apply occlusive
dressing
Dislodged: apply tented dressing
Tube becomes disconnected from drainage system, cut
off contaminated tip, insert sterile connector and
reinsert
Tube becomes disconnected from drainage system,
immerse in 2cm of water
NCLEX-RN exam is a “here and now” test; take care of problem now to
prevent harm to client.
Do not ask “why” on the licensure exam
Morphine Sulfate for pancreatitis causes spasms of the sphincter of
Oddi; Meperidine is drug of choice.
Normal Intraocular Pressure is 10-21 mm Hg
Ecchymosis (faint discoloration) around the umbilicus or in either flank
indicates retroperitoneal bleeding
Chamomile
Echinacea
Uses: Largely because white blood cells in the laboratory can be stimulated
to eat particles, Echinacea has been touted to be able to boost the body's
ability to fight off infection.
100
Reactions: The most common side effect is an unpleasant taste. Echinacea
can cause liver toxicity. It should be avoided in combination with other
medications that can affect the liver (such as ketaconazole, leflunomide
(Arava), methotrexate (Rheumatrex), isoniazide (Nizoral).
Garlic
Uses: Garlic has been used to lower blood pressure and cholesterol (Dr.
Lucinda Miller notes that there is "...still insufficient evidence to recommend
its routine use in clinical practice.")
Reactions: Allergic reactions, skin inflammation, and stomach upset have
been reported. Bad breath is a notorious accompaniment. Studies in rats
have shown decreases in male rats' ability to make sperm cells. Garlic may
decrease normal blood clotting and should be used with caution in patients
taking medications to prevent blood clotting (anticoagulants) such as
warfarin /Coumadin.
Feverfew
Ginko Biloba
Ginseng
Uses: Ginseng has been used to stimulate the adrenal gland, and thereby
increase energy. It also may have some beneficial effect on reducing blood
sugar .in patients with diabetes mellitus. (Dr. Miller emphasized that there is
substantial variation in the chemical components of substances branded as
"Ginseng.")
Reactions: Ginseng can cause elevation in blood pressure, headache,
vomiting, insomnia, and nose bleeding. Ginseng can also cause falsely
abnormal blood tests for digoxin level. It is unclear whether ginseng may
affect female hormones. Its use in pregnancy is not recommended. Ginseng
may affect the action of the normal blood clotting element (platelets). It
should be avoided in patients taking aspirin, nonsteroidal antiinflammatory
drugs (such as ibuprofen (Advil), naproxen (Aleve) or Motrin), or medications
to prevent blood clotting (anticoagulants) such as warfarin (Coumadin).
Ginseng may also cause headaches, tremors, nervousness, and
sleeplessness. It should be avoided in persons with manic disorder and
psychosis.
Ginger
102
Uses: Ginger has been used as a treatment for nausea and bowel spasms.
Reactions: Ginger may lead to blood thinning. It is not recommended to be
taken with medications that prevent blood clotting (anticoagulants) such as
warfarin (Coumadin).
Saw Palmetto
Uses: Saw palmetto has been most commonly used for enlargement of the
prostate gland. (Dr. Miller emphasized that studies verifying this assertion
are necessary.) Saw palmetto has also been touted as a diuretic and urinary
antiseptic to prevent bladder infections.
Reactions: This herb may affect the action of the sex hormone testosterone,
thereby reducing sexual drive or performance. Dr. Miller states that "While
no drug-herb interactions have been documented to date, it would be
prudent to avoid concomitant use with other hormonal therapies (e.g.,
estrogen replacement therapy and oral contraceptives...")
Black Cohosh
A child with celiac disease mustn’t consume foods containing gluten and
therefore should avoid prepared puddings, commercially prepared ice
cream, malted milk, and all food and beverages containing wheat, rye, oats,
or barley.
Stump elevation for the first 24 hours after surgery helps reduce edema
and pain by increasing venous return and decreasing venous pooling at the
distal portion of the extremity.
103
A platypelloid pelvis has a flat shape. A gynecoid pelvis is a normal female
pelvis. An anthropoid pelvis has an oval shape, and an android pelvis has a
heart shape.
Chronic Pain: normal blood pressure, heart rate, and respiratory rate.
Normal pupils and dry skin.
The tip of the endotracheal tube lies 1 cm above the carina. This is
positioned above the bifurcation of the right and left mainstem bronchi.
MB band reflects CPK from CARDIAC MUSCLE (This is the level that
elevates with an MI.)
MM band reflects CPK from SKELETAL MUSCLE
VINCA ALKALOIDS: are cell cycle phase-specific and act on the M PHASE
104
MMR: administered SQ in the outer aspect of the upper arm.
AIR EMBOLISM POSITIONING: Place the client on the left side in the
trendelenburg position. Lying on the left side may prevent air from flowing
into the pulmonary veins. The trendelenburg position increases
intrathoracic pressure, which decreases the amount of blood pulled into the
vena cava during inspiration.
G T P A L
Abortions/miscarriage
Gravidity, Term Preterm s Live births,
the number births, the births, the the
of number number Included in gravida number of
pregnancie born at born if before 20 weeks’ live births
s. term (40 before 40 gestation or living
weeks). weeks’ children
gestation. Included in parity if
past 20 weeks’
105
gestation
Therefore a woman who is pregnant with twins and has a child has a
gravida of 2. Because the child was delivered at 38 weeks, the number
of preterm births is 1, and the number of term births is 0. The number of
abortions is 0, and the number of live births is 1.
Uterine enlargement
Hegar’s sign (Softening and thinning of the lower uterine segment
that occurs about week 6)
106
Hyperkalemia on Electrocardiogram:
Tall, peaked T waves; prolonged PR interval; widening QRS complex
ANGINA
B1: Found in the heart and cause an increase in heart rate, atrioventricular
node conduction, and contractility.
B2: Arterial and bronchial walls and cause vasodilation and bronchodilation.
Suggested toys
a. birth to six months - mobiles, unbreakable mirrors, music boxes, rattles
b. six to 12 months - blocks, nesting boxes or cups, simple take apart
toys, large ball, large puzzles, jack in the box, floating toys, teething
toys, activity box, push-pull toys
c. Solitary play
Play is parallel
108
Suggested toys: push-pull toys, finger paints, thick crayons, riding toys,
balls, blocks, puzzles, simple tape recorder, housekeeping toys,
puppets, cloth picture books, large beads to string, toy telephone,
water toys, sand box, play dough or clay, chalk and chalkboard
Tympany: Drumlike, loud, high pitch, moderate duration; usually found over
spaces containing air such as the stomach
Flat sound of soft intensity; high pitch; short duration; Usually heard over
muscle
110
adult: 12 to 20 breaths/minute
1. Olfactory (CN I)
3, 4, 6. Oculomotor (CN III), trochlear (CN IV), and abducens (CN VI)
5. Trigeminal (CN V)
111
8. Acoustic (CN VIII)
112
o Example: Woman becomes blind after seeing her husband with
another woman.
3. Denial - treating obvious reality factors as though they do not exist
because they are consciously intolerable
o Example: Mother refuses to believe her child has been diagnosed
with leukemia. "She just has the flu."
4. Displacement - transferring unacceptable feelings aroused by one
object to another, more acceptable substitute
o Example: Adolescent lashes out at parents after not being invited
to party.
5. Dissociation - walling off specific areas of the personality from
consciousness
o Example: Adolescent talks about failing grades as if they belong
to someone else; jokes about them.
6. Fantasy - a conscious distortion of unconscious wishes and need to
obtain satisfaction
o Example: A student nurse fails the critical care exam and
daydreams about her heroic role in a cardiac arrest.
7. Fixation - becoming stagnated in a level of emotional development in
which one is comfortable
o Example: A sixty year old man who dresses and acts as if he were
still in the 1960's.
8. Identification - subconsciously attributing to oneself qualities of
others
o Example: Elvis impersonators.
9. Intellectualization - use of thinking, ideas, or intellect to avoid
emotions
o Example: Parent becomes extremely knowledgeable about child's
diabetes.
10. Introjection - incorporating the traits of others
o Example: Husband's symptoms mimic wife's before she died.
11. Projection - unconsciously projecting one's own unacceptable
qualities or feelings onto others
o Example: Woman who is jealous of another woman's wealth
accuses her of being a gold-digger.
12. Rationalization - justifying behaviors, emotions, motives,
considered intolerable through acceptable excuses
o Example: "I didn't get chosen for the team because the coach
plays favorites."
13. Reaction Formation - expressing unacceptable wishes or
behavior by opposite overt behavior
113
o Example: Recovered smoker preaches about the dangers of
second hand smoke.
14. Regression - retreating to an earlier and more comfortable
emotional level of development
o Example: Four year old insists on climbing into crib with younger
sibling.
15. Repression - unconscious, deliberate forgetting of unacceptable
or painful thoughts, impulses, feelings or acts
o Example: Adolescent "forgets" appointment with counselor to
discuss final grades.
16. Sublimation - diversion of unacceptable instinctual drives into
personally and socially acceptable areas.
o Example: Young woman who hated school becomes a teacher.
115
mucomyst: acetaminophen toxicity
116
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