SOURCE: http://www.nursereview.

org

REVIEW NOTES: Things to remember

Tonometry: normal (10-21 mm Hg)
PR Interval: normal (0.12-0.20 seconds)
Serum Amylase: normal (25-151 units/dL)
Serum Ammonia: normal (35 to 65 mcg/dL)
Calcium:
adult (8.6-10 mg/dL)
child (8 to 10.5 mg/dL)
term<1week hg =" inadequate">11 mm Hg = too much fluid
Potassium: 3.5-5.0 mEq/L
Sodium: 135-145 mEq/L
Calcium: 4.5-5.2 mEq/L or 8.6-10 mg/dL
Magnesium: 1.5-2.5 mEq/L
Chloride: 96-107 mEq/L
Phosphorus: 2.7 to 4.5 mg/dL
PR measurements: normal (0.12 to 0.20 second)
QRS measurements: normal (0.04 to 0.10 second)
Ammonia: 35 to 65 ug/dL
Amylase:25 to 151 IV/L
Lipase: 10 to 140 U/L
Cholesterol: 140 to 199 mg/dL
LDL: <130>0.1 to 0.2 ng/mL = MI
Erythrocyte studies: 0-30 mm/hour
Serum iron: Male 65-175 ug/dL
Female 50-170 ug/dL
RBC: Male 4.5 to 6.2 M/uL
Female 4.0 to 5.5 M/uL
Theophylline levels normal (10 to 20 mcg/dl)
MOTOR DEVELOPMENT
Chin up: 1 month
Chest up: 2 month
Knee push and swim: 6 month
Sits alone/stands with help: 7 month
Crawls on stomach:8 month
Stands holding on furniture: 10 month
Walks when led: 11 month
Stands alone: 14 month
Walks alone: 15 month

AT THE PLAY GROUND

* Stranger anxiety: 0 -1 year
* Separation anxiety: 1 - 3 years
* Solitary play: 0 1 year
* Parallel play: 2 3 years
* Group play: 3 4 years
LABORATORY VALUES
ELECTROLYTES
Sodium (Na+): 135 145 meq/L
(increase-dehydration; decrease overhydration)
Potassium (K+): 3.5 - 5.0 meq/L
Magnesium (Mg++): 1.5 2.5 meq/L
Calcium (Ca++): 4.5 5.8 meq/L
Neonate : 7.0 to 12 mg/dL
Child: 8.0 to 10.5 mg/dL
Phosphorus (PO4): 1.7 2.6 meq/L
Chloride (Cl-): 96 106 meq/L
COAGULATION STUDIES
Activated partial thromboplastin time(APTT): 20 36 seconds depending on the
type of activator used
Prothrombin time(PT): male: 9.6 11.8 seconds
Female: 9.5 11.3 seconds
International Normalized Ratio(INR): 2.0 - 3.0 for standard Coumadin therapy
3.0 4.5 for high-dose Coumadin therapy
Clotting time: 8 15 minutes
Platelet count: 150,000 to 400,000 cells/Ul
Bleeding time: 2.5 to 8 minutes
SERUM GASTROINTESTINAL STUDIES
Albumin: 3.4 to 5 g/dL
Alkaline phosphatase: 4.5 to 13 King-Armstrong units/dL
Ammonia: 15 to 45 ug/dL
Amylase: 50 180 Somogyi U/dL in adult
20 160 Somogyi U/dL in the older adult
Bilirubin: direct: 0 - 0.3 mg/dL
Indirect: 0.1 1.0 mg/dL
Total: less than 1.5 mg/dL
Cholesterol: 120 200mg/dL
Lipase: 31 -186 U/L
2

Lipids: 400 800 mg/dL

Triclycerides: Normal range: 10 190 mg/dL
Borderline high: 200 400 mg/dL
High: 400 1000mg/dL
Very high: greater than 1000mg.dL
Protien: 6.0 8.0 g/L
Uric acid: male: 4.5 8 ng/dL
Female: 2.5 6.2 ng/dL
GLUCOSE STUDIES
Fasting blood sugar: 70 105 mg/dL
Glucose monitoring (capillary Blood): 60 110 mg/dL
RENAL FUNCTION TEST
Creatinine: 0.6 1.3 mg/dL
Blood urea nitrogen (BUN): 5 20 mg/dL
ERYTROCYTES STUDIES
Erytrocyte sedimentation rate(ESR): 0 30 mm/hr depending on age
Hemoglobin: male: 14 16.5 g/dL
Female: 12 15 g/dL
Hematocrit: male: 42% - 52% (increased in hemoconcentration, fluid loss and
dehydration)
Female: 35% - 47% ( decreased in fluid retention)
Red blood cell (RBC): male: 4.5 to 6.2 million/uL
Female: 4 to 5.5 million/uL
White blood cell (WBC): 4500 to 11,000/uL
Erytrocyte Protoporthyrin (EP) : <9ug/dl>25 mg/dL
CRANIAL NERVES
MAJOR FUNCTIONS
I. Olfactory (S): smell
II. Optic (S): vision
III. Oculomotor (M)
IV. Trochlear (M): Eye movement
V. Trigeminal (S-M) Facial sensation: Jaw movement
VI. Abducent (M): Eye movement
VII. Facial (S-M) Taste, Facial expression
VIII. Acoustic (S): Hearing and balance
IX. Glossopharyngeal (S-M) Taste: Throat sensation
Gag and swallow
X. Vagus (S-M) Gag and swallow, Parasympathetic activity
3

XI. Spinal Accessory (M) Neck and back muscles

XII. Hypoglossal (M): Tongue movement
On Old Olympus Towering Tops, A Finn And German Viewed Some Hops
Some Says Marry Money, But My Brother Says Bad Business Marry Money
ARTERIAL BLOOD GAS (ABG)
pH: 7.35 7.45
PCO2: 35 - 45 mmHg
PO2: 80 - 100 mmHg
HCO3: 22 - 27 mEq/L
O2 saturation: 96% - 100%
Acid-base RAMS(Respiratory Alternate, Metabolic Same)
GLASGOW COMA SCALE
Eye opening response
Motor response
Verbal response

FLOW OF BLOOD THROUGH THE HEART

Inferior vena cava and superior vena cava right atrium tricuspid valve right
ventricle pulmonic valve pulmonary artery lungs pulmonary veins left
atrium bicuspid valve (mitral) left ventricle aortic valve aorta systemic
circulation
CARDIAC IMPULSES
Sinoatrial (SA) node right and left atria (atria contract) atrioventricular (AV) node
bundle his bundle brabches purjinjes fibers ventricles contract.
Blood volume: 5000mL
Central venous pressure: 4 to 10 cmH2O (increased in cardiac overload; decreased
in dehydration)
Pressure within the right atrium: 2 to 7 mmHg
Capillary refill time: <3 gr =" 60" gr =" 300" gr =" 1000mg" gr ="0.4" oz =" 30" dr
=" 4" t =" 15" min =" 1" min =" 1mL" min =" 1" dr =" 1" qt =" 1000mL" qt =" 2" pt
=" 16" oz =" 1" 2lb =" 1" 8 =" C" 32 =" F" q =" X" factor =" gtt" infuse ="
Infusion">25 mg/dL
Urine specific gravity: 1.016 - 1.022 increase in SIADH; decrease in diabetes
insipidus
4

Normal CSF protein: 15 45 mg/dL increase in Guillain-Barre syndrome

Normal CSF pressure: 5 15 mmHg
Normal serum osmolality: 285 295 mOsmlkgH2O increase in dehydration;
Decrease in over hydration
Normal scalp pH: 7.26 and above
Borderline acidosis: 7.20 to 7.25

NCLEX/CGFNS REVIEW BULLETS

The therapeutic range for serum phenytoin (Dilantin) level is 10 to 20

mcg/mL. Dilantin are given to clients with history of seizure disorder.

The therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. If

the level is below the therapeutic range, the client may be noncompliant with
the medication regimen. If the level is within the therapeutic range, the client
is most likely compliant with medication therapy. Drug is given to COPD
patients.

The normal therapeutic range for digoxin is 0.5 to 2.0 ng/ mL. A value of 1.0
is within therapeutic range, and the nurse would administer the next dose as
scheduled.

An International normalize ratio (INR) of 2.0 to 3.0 is appropriate for most

clients. An INR of 3.0 to 4.5 is recommended for clients with mechanical heart
valves. If the INR is below the recommended range, the warfarin sodium dose
would be increased. If the INR is above the recommended range, the warfarin
sodium dose would be decreased. Since the value identified in this question is
within the therapeutic range, the nurse would administer the next dose of
warfarin.

An assault occurs when a person puts another person in fear of a harmful or

offensive contact. For this intentional tort to be actionable, the victim must
be aware of the threat of harmful or offensive contact. Battery is the actual
contact with ones body. Negligence involves actions below the standards of
care. Invasion of privacy occurs when the individuals private affairs are
unreasonably intruded. In this situation, the nurse can be charged with
battery because the nurse administers a medication that the client has
refused.

Defamation takes place when something untrue is said (slander) or

written (libel) about a person, resulting in injury to that persons
good name and reputation. An assault occurs when a person puts
another person in fear of a harmful or an offensive contact.
Negligence involves the actions of professionals that fall below the
5

standard of care for a specific professional group. Although the

physician may be aware of the biopsy results, the physician decides
when it is best to share such a diagnosis with the client.

If the physician writes an order that requires clarification, it is the nurses

responsibility to contact the physician for clarification. If there is no resolution
regarding the order because the order remains as it was written, after the
physician has been contacted or because the physician cannot be located,
the nurse should then contact the nurse manager or supervisor for further
clarification as to what the next step should be. Under no circumstances
should the nurse proceed to carry out the order until clarification is obtained.

Nurses need their own liability insurance for protection against malpractice
law suits. Nurses erroneously assume that they are protected by an agencys
professional liability policies. Usually when a nurse is sued, the employer is
also sued for the nurses actions or inactions. Even though this is the norm,
nurses are encouraged to have their own malpractice insurance.

A Good Samaritan Law is passed by a state legislature to encourage nurses

and other health care providers to give care to a person when an accident,
emergency, or injury occurs, without fear of being sued for the care provided.
Called immunity from suit, this protection usually applies only if all of the
conditions of the law are met, such as the heath care provider receives no
compensation for the care provided, and the care given is not willfully and
wantonly negligent.

In a fire emergency, the steps to follow use the acronym RACE. The
first step is to remove the victim. The other steps are: activate the
alarm, contain the fire, then evacuate as needed. This is a universal
standard that can be applied to any type of fire emergency. The
nurse first removes the victim from the area. Pulling the nearest fire
alarm would be the next step. The nurse next contains the fire and
then extinguishes the fire.

Generally there are only two instances in which the informed consent of an
adult client is not needed. One instance is when an emergency is present and
delaying treatment for the purpose of obtaining informed consent would
result in injury or death to the client. The second instance is when the client
waives the right to give informed consent.

The client with hyperphosphatemia should avoid foods that are naturally high
in phosphates. These include fish, eggs, milk products, vegetables, whole
grains, and carbonated beverages. Coffee, tea, and cocoa are not high in
phosphates.

The nurse manager needs to attend to the client assignments first. Client
care is the priority. In addition, the nursing staff needs assignments so that
they can begin client assessments and begin delivering client care. The nurse
manager should next check the crash cart (which is normally done every
shift) to ensure that needed equipment is available in the event of an
emergency. The nurse manager could also delegate this task to another
registered nurse while client assignments are being planned. The nurse
manager would next begin the problem-solving process related to finding a
charge nurse for the next shift. Since this activity directly affects client care,
this would be done before reading the stack of mail.

Arriving late to work is an unacceptable behavior. Although the nurses

behavior has caused unrest with other staff members, the primary concern is
that this behavior affects client care. The nurse manager needs to confront
the nurse, discuss the lateness, and initiate problem-solving measures that
ensure that the behavior does not continue.

The nurse needs to stay with the client and consult with the nurse manager
about the situation. It may be necessary for the nurse manager to contact the
supervisor to obtain an additional staff member to care for the client. Since
the client has a head injury, a major concern is the development of increased
intracranial pressure (ICP). The application of restraints may agitate the
client, causing further restlessness and thus increasing ICP. A nursing
assistant is not trained to monitor for increased ICP. It is inappropriate to ask
a family member to sit with the client.

If a conflict arises, it is most appropriate to try to resolve the conflict directly.

In this situation, the nurse has attempted to explain the reasons for being
uncomfortable with the surgeon but was unable to resolve the conflict. The
nurse would then most appropriately use the organizational channels of
communication and discuss the issue with the nurse manager, who would
then proceed to resolve the conflict. The nurse manager may attempt to
discuss the situation with the surgeon or seek assistance from the nursing
supervisor.

External disasters occur in the community, and many victims may be brought
to the emergency room for care. In this situation, the nurse manager would
initially contact the nursing supervisor about the need for additional staffing
and to discuss activation of the disaster plan. The nurse manager should ask,
not demand that nurses from the night shift stay until all of the victims are
treated. The nurse manager would not ask emergency medical services to
take the victims to another hospital or close the emergency room temporarily
to incoming clients. These decisions are made by administration.

If a nurse feels that an assignment is more difficult than the assignment

delegated to other nurses on the unit, the nurse would most appropriately
discuss the assignment with the nurse manager of the neurological unit. The
nurse may or may not have a more difficult assignment than the other
nursing staff. However, this action will assist in either identifying the rationale
for the assignment or determining if the assignment is actually more difficult.
A nurse would not refuse an assignment. Specific situations may be present
in which a nurse should not take care of a specific client, for example, if a
pregnant nurse is assigned to care for a client with rubella or a client with an
internal radiation implant. In these situations, the nurse would also discuss
the assignment with the nurse manager. The nurse would not return to the
cardiac unit; this would be client abandonment, and this action does not
address the conflict directly.

The signs of hypoglycemia and hyperglycemia can be difficult to

distinguish. Weakness, headache, and blurred vision can occur in
either blood glucose alteration. A blood glucose reading will assist in
confirming the diagnosis so that the appropriate action can be
taken.

Hypoglycemia is immediately treated with 10 to 15 grams of carbohydrate.

Glucose tablets or glucose gel may be administered. Other items used to
treat hypoglycemia include 1/2 cup of fruit juice, 1/2 cup of regular (nondiet)
soft drink, 8 oz of skim milk, 6 to 10 hard candies, 4 cubes or 4 teaspoons of
sugar, 6 saltines, 3 graham crackers, or 1 tablespoon of honey or syrup.

Most minor burns can be handled at home by the parents. For minor burns,
exposure to cool running water is the best treatment. This stops the burning
process and helps to alleviate pain. Ice is contraindicated, because it may
add more damage to already injured skin.

When a bee sting occurs and is painful, it is best to treat the site locally
rather than systemically. Pain can be alleviated by applying an ice pack and
elevating the site.

When a Salem sump tube is connected to suction, the air vent permits a free,
continuous flow of secretions. The air vent should never be clamped or tied
off, connected to suction, or used for irrigation. The nurse manager should
handle this problem directly with the nurse who is performing this action and
should initially review the skills checklist of the nurse who is tying the knots
to assess if this skill has ever been performed and validated.

When cord compression is suspected, the woman is immediately

repositioned. The clients hips can be elevated to shift the fetal presenting
part toward her diaphragm, thus relieving cord compression. A hands-and8

knees position can reduce compression on the cord that is entrapped behind
the fetus. Several position changes may be required before the fetal pattern
improves or resolves.

If a nonreassuring fetal heart pattern occurs (tachycardia, bradycardia,

decreased variability, and late decelerations), the nurse would intervene to
increase fetal oxygenation. The oxytocin infusion is stopped immediately. The
infusion rate of the nonadditive IV solution is increased. The client is
positioned in a side-lying position, and oxygen via a snug facemask is
administered at 8 to 10 liters per minute. The physician is notified of the
adverse reactions, the nursing interventions that have been implemented,
and the clients response to the interventions. The maternal blood pressure is
monitored closely.

If physical abuse or neglect is suspected, the priority nursing action is to

assess the client, treat any physical injuries, and ensure that the client is
safe. The nurse also notifies the physician and the social worker to
investigate the situation. All states in the United States and other Western
countries have laws requiring health care professionals to report suspected
elder abuse. Calling the police is a premature action. Telling the son that he
cannot visit with his mother could initiate aggressive behavior in the son.
Although the nurse may be involved in obtaining psychiatric assistance for
the son, this is not the priority action.

Severe leg pain, once traction has been established, indicates a problem. A
client who complains of severe pain may need realignment or may have
traction weights ordered that are too heavy. The nurse realigns the client,
and if that is ineffective, then calls the physician. The nurse never removes
traction weights unless specifically prescribed by the physician. The client
should be medicated only after an attempt has been made to determine and
treat the cause.

With a tracheainnominate artery fistula, a malpositioned tube

causes its distal tip to push against the lateral wall of the
tracheostomy. Continued pressure from the tracheostomy tube
causes necrosis and erosion of the innominate artery. This situation
is a life-threatening complication. The tracheostomy tube is
immediately removed. Direct pressure is then applied to the
innominate artery at the stoma site. The client is then prepared for
immediate surgical repair. An IV line will need to be initiated, but
this is not the immediate action.

The nurse should monitor the clients heart rate and pulse oximetry during
suctioning to assess the clients tolerance of the procedure. Oxygen
desaturation below 90% indicates hypoxemia. If hypoxia occurs during
9

suctioning, the nurse terminates the suctioning procedure. Using the 100%
oxygen delivery system, the client is reoxygenated until baseline parameters
are achieved. The size of the catheter should not exceed half the size of the
tracheal lumen. In adults, the standard catheter size is 12 to 14 French.
Adequate catheter size facilitates efficient removal of secretions without
causing hypoxemia.

In most situations, clamping of chest tubes is contraindicated, and

agency policy and procedure must be followed with regard to
clamping a chest tube. When the client has a residual air leak or
pneumothorax, clamping the chest tube may precipitate a tension
pneumothorax because the air has no escape route. If the tube
becomes disconnected, it is best to immediately reattach it to the
drainage system or to submerge the end in a bottle of sterile water
or saline to reestablish a water seal. If sterile water or saline is not
readily available, it is preferable to leave the tube open because the
risk of tension pneumothorax outweighs the consequences of an
open tube. The physician may need to be notified, but this is not the
immediate action. The client would not be instructed to inhale.

Surface foreign bodies are often removed simply by irrigating the eye with
sterile normal saline. The nurse would not use clamps because this action will
risk causing further injury to the eye. Applying an eye patch would not
provide relief for the problem. Visual acuity tests are not the priority at this
time, and might not be feasible because the client most likely has excessive
blinking and tearing as well at this time.

Keratoplasty is done by removing damaged corneal tissue and replacing it

with corneal tissue from a human donor (live or cadaver). Preoperative
preparation of the recipients eye can include obtaining a culture and
sensitivity with conjunctival swabs, instilling antibiotic ophthalmic
medication, and cutting the eyelashes. Some ophthalmologists order a
medication such as 2% pilocarpine to constrict the pupil before surgery.

Discharge instructions to a client after a keratoplasty includes telling the

client that sutures are usually left in place for as long as 6 months. After the
sutures are removed and complete healing has occurred, prescription glasses
or contact lenses will be prescribed.

Enucleation is removal of the eye, leaving the eye muscles and

remaining orbital contents intact.

Topical glucocorticoids can be absorbed in sufficient amounts to

produce systemic toxicity. Primary concerns are growth retardation
(in children), and adrenal suppression in all age groups. Systemic
10

toxicity is more likely under extreme conditions, such as with

prolonged therapy in which extensive surfaces are treated with high
doses of high potency agents in conjunction with occlusive
dressings.

Isotretinoin (Accutane) is prescribed for a clietn to treat severe

cystic acne. It is usually administered two times daily for a period of
15 to 20 weeks. The usual adult dosage is 0.5 to 1 mg/kg/day. If
needed, a second course may be administered, but not until 2
months have elapsed after completing the first course.

Saquinavir (Invirase) is an antiviral medication. It is administered

within 2 hours after a full meal. If the medication is taken without
food in the stomach, it may result in no antiviral activity.

Anastrozole (Arimidex) is prescribed for a postmenopausal client with breast

cancer. The most dangerous adverse reaction to anastrozole is
thromboembolism. Common reactions include nausea, chest pain, edema,
and shortness of breath. A variety of gastrointestinal tract or nervous system
effects may also occur.

Cytarabine (Cytosar-U) is being prescribed to a nonlymphocytic

anemia patient. The major toxic effect of cytarabine is bone marrow
depression, resulting in hematologic toxicity. Signs of hematologic
toxicity include fever, sore throat, signs of local infection, easy
bruising, or unusual bleeding from any site. If these signs occur, the
physician is notified. Anorexia, nausea, and a transient headache
can occur as side effects of the medication but do not necessarily
warrant physician notification, unless they are persistent in nature.

Docetaxel (Taxotere) is an antineoplastic medication. Frequent side

effects include alopecia, hypersensitivity reaction, fluid retention,
nausea, vomiting, diarrhea, fever, myalgia, and nail changes. Before
receiving docetaxel, the client is premedicated with an oral
corticosteroid (dexamethasone (Decadron) 16 mg per day for 5 days,
beginning day 1 before docetaxel therapy) to reduce the severity of
fluid retention or prevent a hypersensitivity reaction.

Paclitxel is being prescribed to a client with ovarian cancer. Side effects of

paclitaxel (Taxol) include alopecia, pain in the joints and muscles, diarrhea,
nausea, vomiting, peripheral neuropathy, hypotension, mucositis, pain and
redness at the injection site, cardiac disturbances (bradycardia), and an
abnormal electrocardiogram. Fatigue is an occasional side effect.

11

Stavudine (Zerit) is prescribed for a client with advanced human

immunodeficiency virus. Peripheral neuropathy, characterized by
numbness, tingling, or pain in the hands or feet can occur frequently
with this medication and is an adverse reaction.

Ritonavir (Norvir) oral solution is prescribed to a client with HIV virus. The
drug is preferably administered with food. It may be mixed with chocolate
milk or a dietary supplement to improve the taste. The client is also
instructed to consume the dose within 1 hour of mixing.

Propofol (Diprivan) is an anesthetic agent that is used to provide continuous

sedation for a client receiving mechanical ventilation. An adverse effect of
the medication is hypotension. It can also cause respiratory depression and
bradycardia. Facial flushing can occur as an occasional side effect.

An adverse reaction of gemcitabine hydrochloride, an antineoplastic

medication, is severe bone marrow depression, evidenced by anemia,
thrombocytopenia, and leukopenia. The medication may be discontinued or
the dosage may be modified if bone marrow depression occurs. The normal
platelet count is 150,000 to 450,000/mm3. The nurse would contact the
physician if a platelet count of 90,000/mm3 were noted. The normal range for
the total bilirubin is 8.4 to 10.2 mg/dL. The normal BUN is 7 to 25 mg/dL. The
normal range for the alkaline phosphatase is 42 to 128 units/L.

IGIV is an immune serum that increases antibody titer and antigen-antibody

reaction, providing passive immunity against infection. Anaphylactic
reactions, although rare, can occur, and so the nurse ensures that
epinephrine is readily available when administering this medication.
Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for oral
anticoagulants. Acetylcysteine is used to treat acetaminophen overdose.

Lepirudin (Refludan) is an anticoagulant used for clients with

heparin-induced thrombocytopenia and associated thromboembolitic
disease to prevent additional thromboembolitic complications. For
the postoperative client, the initial dose is administered as soon as
possible after surgery but not more than 24 hours after surgery.

Letrozole (Femara) is an aromatase inhibitor that is used to treat advanced

breast cancer in postmenopausal women whose disease has progressed after
antiestrogen therapy. The most frequent side effects include skeletal pain,
and back, arm, and leg pain. Less frequent side effects include nausea,
headache, fatigue, constipation, vomiting, and dyspnea.

Amprenavir (Agenerase) is an antiretroviral agent, classified as a protease

inhibitor, used to treat HIV infection.
12

Indinavir (Crisxivan) is an antiretroviral agent. This medication can

cause kidney stones; therefore, the client is instructed to increase
fluid intake to at least 1.5 liters per day. The client is also instructed
to report sharp back pain or the presence of blood in the urine. The
client is instructed to take the medication 1 hour before or 2 hours
after a large meal. If the medication needs to be taken with food,
the client should consume a light meal, such as dry toast, juice, or a
bowl of cereal with milk. Unexplained weight loss needs to be
reported to the physician.

Lamivudine is an antiretroviral agent that is administered in

combination with zidovudine to delay the appearance of zidovudine
resistance. Lamivudine is well absorbed orally either with or without
food. Peripheral neuropathy can occur with its use, and the client is
instructed to notify the physician if burning, numbness, or tingling
of the hands, arms, feet, or legs occurs. Pancreatitis, evidenced by
nausea, vomiting, and abdominal pain is also an adverse reaction to
the medication, requiring physician notification.

Levalbuterol (Xopenex) is a bronchodilator. This medication stimulates the

beta receptors in the lungs, relaxes bronchial smooth muscle, increases vital
capacity, and decreases airway resistance. Central nervous system (CNS)
stimulation can occur with the use of this medication. The client is instructed
to avoid caffeine-containing products such as coffee, tea, colas, and
chocolate, because these products can cause further CNS stimulation.

Moxifloxacin (Avelox) is a fluoroquinolone. Increased sensitivity of

the skin to sunlight can occur, and the client is instructed to avoid
excessive sunlight and artificial ultraviolet light. The client should
wear sunscreen and protective clothing when outdoors. The client
should also drink fluids liberally and avoid the use of antacids,
because antacids will decrease absorption of the medication. The
medication can cause inflamed and ruptured tendons, so that the
client is instructed to notify the physician if inflammation or tendon
pain occurs.

Nelfinavir (Viracept) is an antiviral medication used in the treatment of HIV

infection when antiretroviral therapy is warranted. It is available in both
tablet and powder form. The powder form is prepared by mixing the dose
with a small amount of water, milk, formula, soy milk, or dietary
supplements. The powder is not mixed with acidic foods or juices such as
apple juice or applesauce, orange juice, or grapefruit juice.

13

Antacids are generally not administered with other medications because of

their interactive effects. Additionally, antacids delay the absorption of other
medications

The client with hyperparathyroidism is likely to have elevated calcium levels.

This client should reduce the intake of dairy products such as milk, cheese,
ice cream, or yogurt. Apples, bananas, chicken, oatmeal, and pasta are
considered to be low-calcium foods.

Sodium should not be limited for the client with hypercalcemia unless
contraindicated for another reason, such as cardiac disease. When sodium is
retained, then calcium is lost through the kidneys.

The ultimate responsibility for a task lies with the person who delegated it.
Therefore, it is the nurses primary responsibility to follow up with each staff
member regarding the performance of the task and the outcomes related to
implementing the task. Not all staff members have the education, knowledge,
and ability to make judgments about tasks being performed. The nurse would
document that the task was completed but this would not be done until
follow-up was implemented and outcomes were identified. It is not
appropriate to assign the tasks that were not completed to the next nursing
shift.

The client with a thoracic burn and smoke inhalation requires aggressive
pulmonary measures to prevent atelectasis and pneumonia. These include
turning and repositioning, using humidified oxygen, providing incentive
spirometry, and suctioning on an as-needed basis. The client should not be
left lying in a single position and should not have the head of bed flat. These
could promote the development of complications by limiting chest expansion.

Wound dehiscence is the disruption of the surgical incision or wound. When

dehiscence occurs, the nurse immediately places the client in low-Fowlers
position and instructs the client to lie quietly. These actions will minimize
protrusion of the underlying body tissues. The nurse then covers the
abdominal wound with a sterile dressing moistened with sterile saline. The
physician is then notified and the nurse documents the occurrence and the
nursing actions implemented.

Adult diabetes mellitus can be diagnosed either by symptoms (polydipsia,

polyuria, polyphagia), or by laboratory values. Diabetes mellitus is diagnosed
by an abnormal glucose tolerance test, or when random plasma glucose
levels are greater than 200 mg/dL, or fasting plasma glucose levels are
greater than 140 mg/dL on two separate occasions.

14

Hemorrhage is a potential complication following tonsillectomy and

adenoidectomy. If the client vomits large amounts of altered blood or bright
red blood, or if the pulse rate or temperature rises and the client is restless,
the nurse must notify the surgeon immediately. The nurse should obtain a
light, mirror, gauze, curved hemostats, and a waste basin for examination of
the surgical site. The nurse would also gather additional assessment data,
but the immediate nursing action would be to contact the surgeon.

The client with hypertension is at risk for cardiovascular complications, such

as angina pectoris, myocardial infarction, and heart failure. Thyroid
preparations increase metabolic rate, oxygen demands, and demands on the
heart. The client should know to report the onset of chest pain immediately.
Lethargy, constipation, and weight gain are symptoms of hypothyroidism,
which should improve with medication therapy such as levothyroxine sodium.

Pulmonary embolism is a life-threatening emergency. Nasal oxygen is

administered immediately to relieve hypoxemia, respiratory distress, and
central cyanosis. IV infusion lines are needed to administer medications or
fluids. A perfusion scan, among other tests, may be performed. The ECG is
monitored for the presence of dysrhythmias. Additionally, a urinary catheter
may be inserted and arterial blood gases may be drawn. However, the
immediate nursing action is to administer oxygen.

Fludrocortisone acetate (Florinef) is a long-acting oral medication with

mineralocorticoid and moderate glucocorticoid activity. It is prescribed for the
long-term management of Addisons disease. Mineralocorticoids cause renal
resorption of sodium and chloride ions, and the excretion of potassium and
hydrogen ions. These actions help restore electrolyte balance in the body.

The client with diabetic neuropathy of the lower extremities has diminished
ability to feel sensations in the legs and feet. This client is at risk for tissue
injury and for falls as a result of this nervous system impairment.

A traumatic open pneumothorax is an emergency. Stopping the flow of air

through the opening in the chest wall is a life saving measure. In such an
emergency, anything may be used that is large enough to fill the chest
wound including a towel, a handkerchief, or the heel of the hand. If
conscious, the victim is instructed to inhale and strain against a closed
glottis. This action assists in reexpanding the lung and ejecting the air from
the thorax. In the hospitalized client who experiences an open
pneumothorax, the opening is plugged by sealing it with gauze impregnated
with petrolatum.

The client with severe osteoporosis as a result of hyperparathyroidism is at

great risk for injury as a result of pathological fractures from bone
15

demineralization. The client may or may not have a risk for impaired urinary
elimination, depending on other elements in the client history, and whether
or not the client is at risk for stone formation from high serum calcium levels.
The client may also have a risk for constipation from the disease process, but
this would be a lesser priority than client safety. A risk for ineffective health
maintenance may be a concern but is not the priority.

Clients with myxedema or hypothyroidism have decreased metabolic

demands from reduced metabolic rate. For this reason they often experience
weight gain. The diet should be low in calories overall and yet be
representative of all food groups.

Hypoparathyroidism results in hypocalcemia. A therapeutic diet for this

disorder then is one that is high in calcium but low in phosphorus, because
these two electrolytes have inverse proportions in the body.

Constant bubbling in the water seal chamber of a closed chest tube drainage
system may indicate the presence of an air leak. The nurse would assess the
chest tube system for the presence of an external air leak if constant
bubbling were noted in this chamber. If no external air leak is present, the
physician is notified immediately because an air leak may be present in the
pleural space. Leaking and trapping of air in the pleural space can result in a
tension pneumothorax.

The client taking NPH insulin obtains peak medication effects 6 to 12 hours
after administration. At the time that the medication peaks, the client is at
risk of hypoglycemia if food intake is insufficient. The nurse would teach the
client to watch for signs and symptoms of hypoglycemia, including anxiety,
confusion, difficulty concentrating, blurred vision, cold sweating, headache,
increased pulse, shakiness, and hunger.

Before doing a fingerstick for blood glucose measurement, the client should
first wash the hands. Warm water should be used to stimulate the circulation
to the area. The finger is punctured near the side, not the center, since there
are fewer nerve endings along the side of the finger. The puncture is only
deep enough to obtain an adequately sized drop of blood; excessively deep
punctures can lead to pain and bruising. The arm should be allowed to hang
dependently, and the finger can be milked to promote obtaining a good size
blood drop.

Diabetic clients should take in approximately 15 grams of carbohydrate every

1 to 2 hours when unable to tolerate food due to illness.

The client with DKA initially becomes hyperkalemic as potassium leaves the
cells in response to a lowered pH. Once fluid replacement and insulin therapy
16

are started, the potassium level drops quickly. This occurs because
potassium is carried into the cells along with glucose and insulin, and also
because potassium is excreted in the urine once rehydration has occurred.
Thus, the nurse must plan to monitor the results of serum potassium levels
carefully, and report hypokalemia

In the immediate postoperative period following a radical neck dissection, the

nurse assesses for stridor (a coarse, high-pitched sound on inspiration when
auscultating over the trachea). This finding is reported immediately, because
it indicates airway obstruction.

Variances are actual deviations or detours from the critical paths. Variances
can be positive or negative, avoidable or unavoidable, and can be caused by
a variety of things. Positive variance occurs when the client achieves
maximum benefit and is discharged earlier than anticipated. Negative
variance occurs when untoward events prevent a timely discharge. Variance
analysis occurs continually in order to anticipate and recognize negative
variance early, so that appropriate action can be taken

In functional nursing, a task approach method is used to provide care to

clients.

The client in diabetic ketoacidosis exhibits Kussmaul's respirations, which are

deep and nonlabored. They occur as the body tries to eliminate carbon
dioxide to compensate for lactic acidosis. As ketoacidosis improves, this
pattern of respiration resolves. The nurse monitors the clients respiratory
status as part of the clients overall status.

The client is likely to have tachycardia due to efforts by the body to

compensate for the effects of anemia. The client with anemia is likely to
complain of fatigue, because of decreased ability of the body to carry oxygen
to tissues to meet metabolic demands. Increased respiratory rate is not an
associated finding, although some clients may have shortness of breath.

Spinal cord compression should be suspected in a client with metastatic

disease, particularly when a new and sudden onset of back pain occurs.
Spinal cord compression causes back pain before neurological changes occur.
Spinal cord compression is an oncological emergency, and the physician
should be notified.

The client with iron deficiency anemia should increase intake of foods that
are naturally high in iron. The best sources of dietary iron are red meat, liver
and other organ meats, blackstrap molasses, and oysters.

Iron preparations can be very irritating to the stomach and are best taken
after a meal. The tablet is swallowed whole, not chewed. Because the client
17

might experience constipation, the client should increase fluids and fiber in
the diet to counteract this side effect of therapy.

For most hematological laboratory studies, including CBC, no special care is

needed either before or after the test. There is no reason to fast after
midnight, drink extra liquids, or avoid red meat prior to the laboratory test
being drawn.

Before bone marrow aspiration, the site is cleansed with an antiseptic

solution such as povidone-iodine. This helps reduce the number of bacteria
on the skin, and decreases the risk of infection from the procedure.

When delegating nursing assignments, the nurse needs to consider the skills
and educational levels of the nursing staff. The nursing assistant can most
appropriately give a shower, a bed bath, ambulate a client with a walker,
take an oral temperature. The LPN can administer the rectal suppository to
the client requiring the enema. The LPN is skilled in wound irrigations and
dressing changes, and this client would most appropriately be assigned to
this staff member.

After ear surgery, clients need to avoid straining when having a bowel
movement. Clients need to be instructed to avoid drinking with a straw for 2
to 3 weeks, traveling by air, and coughing excessively. Clients need to avoid
getting their head wet, washing their hair, and showering for 1 week.
Swimming is also avoided. Clients need to avoid moving the head rapidly,
bouncing, and bending over for 3 weeks.

Exacerbation of Mnires disease is characterized by severe vertigo. The

nurse instructs the client to make slow head movements to prevent
worsening of the vertigo. Dietary changes such as salt and fluid restrictions
that reduce the amount of endolymphatic fluid are sometimes prescribed.
Activities such as reading and watching TV will worsen the vertigo. Clients are
advised to stop smoking because of its vasoconstrictive effects.

The client who is thrombocytopenic is at risk for bleeding. The family should
observe the puncture site for bleeding for several days after the procedure,
since the client is at high risk. Acetaminophen may be given for discomfort,
and aspirin should be avoided because it could aggravate bleeding

The client who has had surgical resection of the stomach or small intestine
may develop pernicious anemia as a complication. This results from
decreased production of intrinsic factor (gastrectomy) or decreased surface
area for vitamin B12 absorption (intestinal resection). The client then requires
vitamin B12 injections for life. Decreased iron intake leads to iron deficiency
anemia, which is often easily treated with iron supplements.
18

Otoscopic examination in a client with mastoiditis reveals a red, dull, thick,

and immobile tympanic membrane with or without perforation. Postauricular
lymph nodes are tender and enlarged. Clients also have a low-grade fever,
malaise, anorexia, swelling behind the ear, and pain with minimal movement
of the head.

The RN would plan to care for the client who is scheduled for surgery at 1:00
p.m. first. There are several items that need to be addressed preoperatively,
including client preparation (physically and emotionally) and physician orders
that need to be carried out. This preparation takes time. Additionally, many
times the operating room makes late changes in the schedule, depending on
room and physician availability, and requests an earlier surgical time.
Therefore, it is best to ensure that this client is prepared.

Clozapine is an antipsychotic medication with no demonstrated

extrapyramidal side effects. The risk of extrapyramidal effects with the other
medications listed is moderate (chlorpromazine) to high (haloperidol,
loxapine).

Denial is a response by the rape victim. It is described as an adaptive and

protective reaction. Projection is blaming or scapegoating. Rationalization is
justifying the unacceptable attributes about himself or herself.
Intellectualization is the excessive use of abstract thinking or generalizations
to decrease painful thinking.

Agoraphobia is a fear of open spaces and the fear of being trapped in a

situation in which there may not be an escape. Agoraphobia includes the
possibility of experiencing a sense of helplessness or embarrassment if a
phobic attack occurs. Avoidance of such situations usually results in reduction
of social and professional interactions. Social phobia focuses more on a
specific situation, such as the fear of speaking, performing, or eating in
public. Claustrophobia is a fear of closed in spaces. Clients with
hypochondriacal symptoms focus their anxiety on physical complaints and
are preoccupied with their health.

Appropriate nursing diagnosis for a client scheduled to have

electroconvulsive theraphy (ECT) is Risk for aspiration. Aspiration is
safeguarded against by keeping the client NPO for 6 to 8 hours before the
procedure, removing dentures, and administering glycopyrrolate (Robinul) or
atropine sulfate as prescribed.

When analyzing data obtained from a client suspected of family violence, the
physiological well-being of the client is always considered first.

19

During the acute phase of the rape crisis, the client can display a wide range
of emotional and somatic responses. All of the symptoms noted in the
question indicate a normal reaction to a very intensely difficult crisis event.
Although the clients initial reactions may be predictive of later problems,
they do not indicate an abnormal initial response.

Finding the right drug at the right dose that provides the least side effects for
the client, providing clients with the injectable, long-acting form of the
medication, and including the family in the medication planning process are
measures that will promote compliance. Not all medications can be given on
a once-per-day dosing regimen due to a short half-life of some medications.
Lithium carbonate is an example of one such medication that must be taken
throughout the day to maintain steady serum drug levels.

Obsessions are defined as persistent thoughts that are intrusive and that the
person tries to ignore or suppress. This client wants to snap out of this daily
review, but the thoughts continue for hours. Compulsions are defined as
repetitive behaviors that the client feels driven to perform, such as changing
clothes frequently until he gets it just right.

Al-Anon support groups provide a supportive opportunity for spouses and

significant others to learn what to expect about successful behavioral
changes.

Any clear threats by psychiatric clients to harm specific people must be

reported to the authorities (law enforcement) and the intended victims by
mental health care providers and psychotherapists.

Major depression occurs twice as frequently in females as in males. Reacting

to loss by experiencing altered sleep for 1 week is a normal grief response.
While depression is often associated with substance abuse, it would not, in
and of itself, constitute a major depression.

A conversion disorder is an alteration or loss of a physical function that

cannot be explained by any known pathophysiological mechanism. It is
thought to be an expression of a psychological need or conflict. In this
scenario, the client witnessed an accident that was so psychologically painful
that the client became blind. Psychosis is a state in which a persons mental
capacity to recognize reality, communicate, and relate to others is impaired,
thus interfering with the persons capacity to deal with life demands. A
dissociative disorder is a disturbance or alteration in the normally integrative
functions of identity, memory, or consciousness. Repression is a coping
mechanism in which unacceptable feelings are kept out of awareness.

20

Ego defense mechanisms are operations outside of a persons awareness that

the ego calls into play to protect against anxiety. Displacement is the
discharging of pent-up feelings on persons less dangerous than those who
initially aroused the emotion. In this scenario, the nurse manager reprimands
the unit secretary for overusing clerical supplies. The secretary lashes out at
the temporary secretary and student nurses for wasting supplies. These are
much safer targets to become angry with than the nurse manager. Denial
is the blocking out of painful or anxiety-inducing events or feelings.
Suppression is consciously keeping unacceptable feelings and thoughts out of
awareness. Repression is unconsciously keeping unacceptable feelings out of
awareness.

Taking time to discuss the clients concerns is as important a nursing action

in many instances as any intervention for physical care. Therapeutic
communication should focus on the clients nonverbal cues and encourage
the client to express feelings or concerns about surgery.

When a client harms himself, immediate 1:1 nursing supervision is instituted.

This meets the safety needs of the client. After doing this, the psychiatrist is
notified of the incident. The client should not be restrained or placed in
seclusion.

Tardive dyskinesia, the involuntary movements of the tongue, jaw,

lips, and facial muscles, is a manifestation of EPS. Flaccid muscles
are not a characteristic of EPS. Agraphia, the inability to read or
write, is not a characteristic of EPS. Dystonia is characterized by
acute spasms of the tongue, neck, face, and back, laryngospasms,
torticollis, and eyes locked upwards.

The dosage of lithium carbonate needs to remain constant to maintain blood

levels between 0.6 mEq/L and 1.2 mEq/L. There is a narrow margin between
therapeutic and toxic levels. Blood levels are necessary to assess this narrow
range. Adequate salt and fluids are necessary to prevent toxicity. Vomiting
and diarrhea could be signs of toxicity and need to be reported. Dosages
should never be adjusted.

Amitriptyline (Elavil) has a sedative effect, and a single maintenance dose

should be taken at bedtime. This also precludes the need for insomnia
medication.

Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI). Clients

taking MAOIs should report any headache to the physician, because it may
signal an impending hypertensive crisis. A low tyramine diet needs to be
consumed. Dry crackers can be eaten if the client gets nauseated. Chewing
sugarless gum is appropriate.
21

The client needs to be able to put the trauma into a new context. The client
needs to realize that the trauma did not occur because he or she did
something wrong, used poor judgment, or somehow deserved it. The client
will often express feelings of guilt, but the goal will be to assist to put it in
perspective and eventually to be able to work through the feelings of guilt.

A situational crisis arises from external rather than internal sources. External
situations that could precipitate crisis include loss of or change of a job, the
death of a loved one, abortion, a change in financial status, divorce, the
addition of new family members, pregnancy, and severe illness.

An adventitious crisis is not a part of every day life, is unplanned, and

accidental.

As with all loss experienced by individuals and families, opening up the

communication channels is a key factor in successful grieving and surviving.
Often, estrangement occurs in families because well-meaning relatives and
friends do not know how to respond. This uncertainty and fear causes
relatives and friends to isolate when communication and an opportunity to
grieve with support are crucial. Joining a survivor-victim group is a positive
outcome, but if the client is not talking with his or her family members, it is
likely that maximum benefit from the group will not be achieved.

Recognizing situations that produce anxiety allows the client to prepare to

cope with anxiety or avoid specific stimulus. Counselors will not be available
for all anxiety-producing situations.

Sertraline hydrochloride (zoloft), a selective serotonin reuptake inhibitor, can

cause a dry mouth that is alleviated by sucking on sugarless hard candy and
chewing gum. Foods such as cheese, wine, and chocolate contain an amino
acid, tyramine that reacts with monoamine oxidase inhibitors. Monthly blood
levels are usually required for clients who are receiving lithium carbonate
(Eskalith) therapy. Sertraline is usually taken with meals.

Central nervous system depressants such as alcohol will produce an addictive

effect if taken with diazepam, which can be lethal. Diazepam can cause initial
drowsiness. It should not be discontinued abruptly, because the client may
develop withdrawal symptoms. Many of the over-the-counter medications
used to treat the flu contain medication that should not be taken when a
client is taking diazepam.

Clients who are taking monoamine oxidase inhibitors (MAOIs) must maintain
a low tyramine diet and receive health teaching regarding the foods,
beverages, and medications that must be avoided. Foods with aged cheese
can cause a hypertensive crisis if taken with MAOIs.
22

Fluoxetine hydrochloride (Prozac) tends to improve the energy level,

and if it is taken late in the day, insomnia may occur. Many clients
suffer from sexual dysfunction throughout treatment, such as
decreased libido. Side effects can be expected to some degree with
any medication. The lag time from the time the medication is started
until therapeutic effects are achieved is anywhere from 2 to 4 weeks
or longer. This is true with any antidepressant.

Sodium depletion will decrease renal excretion of lithium, thereby causing

the medication to accumulate and potentiating toxicity. Clients need to be
instructed to maintain a normal sodium intake. Diuretics promote sodium
loss, and these medications need to be used with caution in the client taking
lithium. Sodium loss secondary to diarrhea can cause lithium accumulation,
and the client should be forewarned of this possibility.

Chlorpromazine blocks dopamine neurotransmission at postsynaptic

dopamine receptor sites, reversing psychotic symptoms.

Lithium is an antimanic medication and is used to treat the manic phase of a

manic-depressive disorder.

Neuroleptic malignant syndrome is a serious and potentially fatal reaction to

antipsychotics. The classic symptoms include hyperthermia; severe
extrapyramidal symptoms, such as muscular rigidity; and autonomic
dysfunction, such as hypertension and tachycardia.

The first priority in planning care for a client with dysfunctional grieving is to
assess the risk for violence toward self and others. The plan will include
efforts to work toward resolving the grief through emotional, cognitive, and
behavioral means.

Ensuring safety is a major aspect in the plan of care for the abused elder. The
nurse may need to contact the social worker to plan care for the client, but
this is not the priority action.

In all child abuse cases, the primary concern is the health and safety of the
child.

Adventitious crises are the unpredictable tragedies that occur

without warning. A maturational crisis involves the normal life
transition that creates changes with individuals and how they
perceive themselves, their role, and their status. A situational crisis
occurs when a specific, external event disturbs an individuals
psychological equilibrium. An individual may experience a crisis;
however, there is no formal type of crisis known as individual crisis.
23

In the ECT suite, blood pressure, cardiac, and electroencephalographic

monitors are placed on the client to assess vital functions. Whenever ECT is
administered, emergency equipment, including oxygen, suction, and a
cardiac arrest cart, must also be available.

In the norming stage, members express intimate personal opinions

and feelings around personal tasks. In the forming or initial stage,
the members are identifying tasks and boundaries. Storming
involves responding emotionally to tasks. In the performing stage,
members direct group energy toward the completion of tasks.

Feelings of low self-esteem and worthlessness are common symptoms of the

depressed client. Reminders of the clients recent accomplishments or
personal successes are ways to interrupt the clients negative self-talk and
distorted cognitive view of self.

In a client with a diagnosis of delirium. It is important to provide a

consistent daily routine and a low stimulating environment when the
client is disorientated. Noise, including radio and television, can add
to the confusion and disorientation. A well-lit room will increase
stimulation.

In the immediate post-disaster period, it is important that a nurse go to

places where victims are likely to gather, such as morgues, hospitals, and
shelters. Rather than waiting for people to publicly identify themselves as
being unable to cope with stress, it is suggested that nurses work with the
American Red Cross. The nurse should talk to people waiting to receive
assistance, go door to door, or go to a relocation site. The nurse should ask
people how they are managing their affairs and explore their reactions to
stress.

If a client is in the act of preparing to commit suicide, the most appropriate

nursing activity is to communicate with the client and attempt to develop a
therapeutic relationship. The nurse should communicate hope, and hope is
most often the most therapeutic element in any nursing intervention with a
suicidal patient.

Identification is the process by which a person tries to become like someone

he or she admires by taking on thoughts, mannerisms, or tastes of that
person. Intellectualization is excessive reasoning or logic used to avoid
experiencing disturbed feelings. Projection is attributing ones thoughts or
impulses to another person. Regression is retreating to a behavior
characteristic of an earlier level of development.

24

Direct expressions of self-hate or low self-esteem can include the clients

expression of self-criticism. The client will exhibit negative thinking and
believe that he is doomed to failure. The underlying goal of the client is to
demoralize himself or herself. The client may describe himself as stupid, no
good, or a born loser. The client will view the normal stressors of life as
impossible barriers and become preoccupied with self-pity.

It is the nurses responsibility to tell a client that secrets cannot be kept and
also that any disclosures that reveal behavior that may be harmful to the
client will need to be communicated to the appropriate professionals in the
health care team.

To de-escalate aggressive behavior, the nurse should manage the

environment by persuading the client to move to another area. This will help
prevent anxiety contagion and protect others. The nurse should also give the
client clear instructions that are brief and assertive and should also negotiate
options with the client. This shows the nurses confidence and leadership and
also avoids misunderstandings in regard to not knowing what to do.
Negotiating options allows the client to feel that he or she has some room in
exercising the options. The nurse must allow the client body space and
should not stand closer than about 8 feet to the client. Standing close to the
client will convey a threat.

Recreational therapy helps clients with personality disorders explore

ways to enjoy themselves without the use of self-destructive
behaviors, such as abusing alcohol or drugs. This modality is helpful
to clients who have difficulty socializing, because recreation
strengthens social skills. Movement therapy may be helpful for
clients who become numb when experiencing intense feelings. Art
therapy may be helpful for the client who is angry. The client who is
exhibiting violent behavior may require medication therapy.

Concentration and memory are poor in severe depression. When a client has
a diagnosis of severe depression, the nurse needs to provide activities that
require little concentration. Activities that have no right or wrong choices or
activities that require minimal decision making minimize opportunities for
clients to put themselves down.

When the client demonstrates calm behavior and communicates that he or

she is no longer a threat to self or others, the nurse would gather additional
assessment data to determine if the client is safe to come out of seclusion.

Social phobia focuses on a specific situation, such as the fear of speaking,

performing, or eating in public. Agoraphobia is a fear of open spaces and the
fear of being trapped in a situation from which there may not be an escape.
25

Claustrophobia is a fear of closed places. Clients with hypochondriacal

symptoms focus their anxiety on physical complaints and are preoccupied
with their health.

It is most therapeutic for the nurse to empathize with the clients experience.
Disagreeing with delusions may make the client more defensive and the
client may cling to the delusions even more. Encouraging discussion
regarding the delusion is inappropriate.

If a client with severe anxiety is left alone, he or she may feel abandoned and
become overwhelmed. Placing the client in a quiet room is also important,
but the nurse must stay with the client. It is not possible to teach the client
deep breathing exercises until the anxiety decreases. Encouraging the client
to discuss the accident would not take place until the anxiety has decreased.

Systematic desensitization is a form of therapy used when the client is

introduced to short periods of exposure to the phobic object while in a
relaxed state. Gradually, exposure is increased, until the anxiety about or
fear of the object or situation has ceased.

If a client is monopolizing the group, it is important that the nurse be direct

and decisive. The best action is to suggest that the client stop talking and try
listening to others.

Using therapeutic communication techniques, the nurse acknowledges the

husbands concerns and conveys that the clients symptoms are common
with myxedema. With thyroid hormone therapy, these symptoms should
decrease, and cognitive function often returns to normal within 2 weeks.

When a nurse delegates aspects of a clients care to another staff member,

the nurse assigning the tasks is responsible for ensuring that each task is
appropriately assigned on the basis of the educational level and competency
of the staff member. Noninvasive interventions can be assigned to a nursing
assistant.

A drop in blood pressure and rise in pulse rate could indicate postoperative
bleeding, which is a complication of a parathyroidectomy. Because bleeding
might not be observed on the front of the dressing due to the effects of
gravity, the nurse must check underneath it as well.

Democratic leadership is a people-centered approach that is

primarily concerned with human relations and teamwork. This
leadership style facilitates goal accomplishment and contributes to
the growth and development of the staff. In autocratic leadership,
the leader retains all authority and is primarily concerned with task
accomplishment. Situational leadership is a comprehensive approach
26

that incorporates the leaders style, the maturity of the work group,
and the situation at hand. Laissez faire is a permissive style of
leadership in which the leader gives up control and delegates all
decision making to the work group.

To promote adequate healing and to meet continued high metabolic needs,

the client with a major burn should eat a diet that is high in calories, protein,
and carbohydrate. This type of diet also keeps the client in positive nitrogen
balance.

Autocratic leadership is an approach in which the leader retains all authority

and is primarily concerned with task accomplishment. It is an effective
leadership style to implement in an emergency or crisis situation. The leader
assigns clearly defined tasks and establishes one-way communication with
the work group, making all of the decisions alone. Situational leadership is a
comprehensive approach that incorporates the leaders style, the maturity of
the work group, and the situation at hand. Laissez faire is a permissive style
of leadership in which the leader gives up control and delegates all decision
making to the work group. Democratic leadership is a people-centered
approach that is primarily concerned with human relations and teamwork.
This leadership style facilitates goal accomplishment and contributes to the
growth and development of the staff.

The clinical manifestations of a disulfiram-alcohol reaction include flushing,

throbbing in the head and neck, difficulty breathing, nausea, vomiting,
sweating, dizziness, and weakness. This type of reaction can occur in a client
taking disulfiram (Antabuse). The reaction can occur even if only one-half
ounce of alcohol is absorbed into the body (whether ingested by mouth or
applied to the skin).

Clients who are depressed often suffer insomnia, and relaxation measures
are recommended to induce sleeping. The nurse might also give the client a
back rub and use soft, dim lighting.

Responsible assertiveness provides clients with the skill to stand up for their
personal and professional rights and to express their thoughts and beliefs
directly, honestly, and appropriately in a manner that will not violate the
rights of other.

Benztropine mesylate is an anticholinergic agent that is used in the

treatment of Parkinsons disease and the extrapyramidal symptoms
(except tardive dyskinesia) that result from the use of neuroleptic or
antipsychotic medication. The medication increases and prolongs
the dopamine activity in the CNS, thereby correcting

27

neurotransmitter imbalances and minimizing involuntary

movements.

Buspirone hydrochloride (Buspar) is used in the management of

anxiety disorders. It is contraindicated in clients with severe renal or
hepatic impairment and in clients taking monoamine oxidase
inhibitors. The nurse would notify the physician if the client had a
history of renal impairment.

A therapeutic serum level for the use of carbamazepine is a level between 3

mcg/mL to 12 mcg/mL.

Neuroleptic malignant syndrome is a rare, life-threatening syndrome

that is an adverse reaction of the use of chlorpromazine. Its signs
include severe rigidity, fever, increased white blood cell count,
unstable blood pressure, tachycardia, tachypnea, and renal failure.
Signs of acute dystonias include painful neck spasms, torticollis,
oculogyric crisis, and convulsions. Tardive dyskinesia includes
choreiform movements of the tongue, face, mouth, jaw, and possibly
the extremities.

Common side effects experienced during the first 2 weeks of therapy with
disulfiram include mild drowsiness, fatigue, headaches, metallic or garlic
aftertaste, allergic dermatitis, and acne eruptions. Symptoms disappear
spontaneously with continued therapy or reduced dosage.

Donepezil hydrochloride is a cholinergic medication and is to be taken in the

evening before bedtime. The medication should be taken with food;
therefore, a snack should be provided to the client when the medication is
administered.

Fluoxetine hydrochloride (Prozac) takes 2 to 5 weeks to produce an elevation

of mood. Advantages of the medication are few anticholinergic side effects
and a low incidence of cardiovascular effects. It may, however, impair
judgment, thinking, and motor skills. The client should be instructed that it
will take more time for the medication to produce the desired effect.

Lithium should be administered with meals. The client should be instructed to

maintain a regular diet and an average salt intake to keep the serum lithium
level in the therapeutic range. The client is instructed to avoid alcohol and to
drink 2 to 3 liters of liquids per day during initial therapy, and 1 to 1.5 liters
per day during the remainder of therapy.

Phenelzine sulfate is a monoamine oxidase inhibitor (MAOI) antidepressant.

The client needs to be instructed to avoid foods that require bacteria or mold
for their preparation or preservation or those that contain tyramine. These
28

food items include cheese, sour cream, beer, wine, pickles herring, liver, figs,
raisins, bananas, avocados, soy sauce, yeast extracts, yogurt, papaya, broad
beans, meat tenderizers, or excessive amounts of caffeine such as in coffee,
tea, or chocolate. The client is also instructed to avoid over-the-counter
preparations used for hay fever, colds, or for weight reduction. The client
should also avoid alcohol.

When a client is experiencing an auditory hallucination, it is important initially

to understand what the voices are saying or telling the client to do. Suicidal
or homicidal messages, if heard by the client, necessitate implementing
priority measures.

The therapeutic maintenance range of lithium is 0.6 to 1.2 mEq/L.

Early signs of lithium toxicity include nausea and vomiting, slurred
speech, muscle weakness, thirst, and polyuria. Advanced signs of
toxicity (1.5 to 2.0 mEq/L) would include hand tremors and muscle
incoordination (option 4). Severe toxicity (greater than 2.0 mEq/L) is
present if the client exhibits ataxia, hypotension, oliguria, and
confusion (options 2 and 3). Seizures, coma, and death can also
result.

Levels of mania may be labeled as hypomania, acute mania, and

delirious mania. The client in the acute state experiences relative
sleeplessness, which over time decreases cognitive functioning,
concentration, and judgment. The client is continuously active and
does not take time to eat. The clients mood may alternate rapidly
between periods of good humor and irritability. In hypomania, the
client experiences feelings of euphoria and sociability. Judgment is
often poor in this level. In delirious mania, the client is out of touch
with reality.

Blood levels are drawn weekly in many cases when a client is beginning
lithium therapy. The literature varies somewhat and states that blood levels
may be drawn initially from 3 times a week to biweekly during this phase.
After therapeutic levels are achieved, blood level draws may be reduced to
monthly. If levels are stable after 6 to 12 months, the frequency may be
further reduced to every 3 months.

Amitriptyline is a tricyclic antidepressant used to treat the client experiencing

a mood disorder. It takes an average of 10 to 14 days for the client to begin
feeling medication effects. The nurse should give the client information about
the medication, and should encourage the client to continue the medication
as prescribed.

29

Memory loss is an expected temporary effect of ECT. The client should be

told that this might occur, and that memory usually returns within a few
weeks. Occasionally clients have memory loss that lasts up to 6 months. The
nurse uses therapeutic communication techniques that will focus on the
clients concerns and do not block further communication.

Fluoxetine (Prozac) is a selective serotonin uptake inhibitor used in the

treatment of depression. The medication is effective if the client experiences
relief of symptoms of depression.

The client taking a MAOI medication should be advised to avoid eating foods
that are high in tyramine. The tyramine in foods reacts with the medication,
causing a hypertensive crisis, which could prove to be fatal. Most fruits and
vegetables are naturally low in tyramine, with the exception of figs, bananas
(in large amounts), avocados, soybeans, and sauerkraut.

Clients with a histrionic personality disorder are overly concerned with

impressing others, and they are often preoccupied with their appearance.
Their emotional responses are often shallow and changeable, although they
are also intense. Clients who have a borderline personality tend to have
intense needs that they seek to fulfill in relationships. Clients with a
narcissistic personality disorder have a great need for admiration, exploit
others to meet their own needs and desires, and have a lack of empathy for
others. The client with an avoidant personality disorder is often preoccupied
with a fear of rejection and criticism.

Clients with cluster A personality disorders often behave in a

manner that is odd or eccentric. Suspicion of others is particularly
typical in paranoid personality disorder, a cluster A disorder.
Manipulative and dramatic behaviors are typical of some of the
cluster B disorders. Anger, anxiety, and fearfulness are typical of
clients with cluster C disorders.

The nurse should avoid getting into power struggles with the manipulative
client, such as arguing with the client or making accusations.

The client with a dependent personality disorder exhibits an unusually strong

need to be cared for, and has difficulty making personal choices and making
everyday decisions. An appropriate goal would be for the client to use the
problem-solving process effectively in everyday situations.

The nurse who is preparing a treatment plan for a client in prison must
employ a framework that integrates the built-in realities and limitations of the
correctional setting and the compulsory regimen that has been created for
the offender. The incidence of suicide in correctional settings is higher among
30

inmates than it is in the general population. The prison nurses ability to

assess for self-violence and suicide is critical.

One of the criteria that the Parole Board will investigate is the clients ability
to engage in strategic planning. The fact that the client has plans for
employment and regaining custody of the children will be viewed in a positive
way as an example of changed behavior.

Codependence involves overly responsible behavior, that is, doing for

another person what that person could be doing for himself or herself.

The least helpful strategy by the nurse is to demand that the client stop
taking drugs. This blocks further communication, and does not affect
behavior change on the part of the client. If client health maintenance is the
goal, it is helpful for the nurse to instruct the client about aseptic conditions
for drug use to reduce the risk of human immunodeficiency virus and
hepatitis. It is also useful to educate the client about the short- and long-term
effects of the substance being abused. Since many clients who use drugs are
malnourished, it is also helpful to teach the client the elements of basic
nutrition.

In larger organizations such as hospitals, there are often employee assistance

programs that offer services such as information, counseling, and referral for
employees who experience a wide variety of problems, including substance
abuse.

Bradykinesia is described as decreased speed and spontaneity of movement.

The client appears to slow down.

Hypertensive crisis, a potentially fatal problem that occurs when the

norepinephrine levels are excessively elevated, produces severe
occipital headache, stiff or sore neck, palpitations, increase or
decrease in heart rate, nausea, vomiting, hypertension, and an
increase in temperature.

Tricyclic antidepressant agents produce an enhanced mood, an increase in

activity level, and an improvement in appetite. In addition, sleep patterns
become more like that of the clients baseline normal sleeping pattern

Employing a hopeful attitude that is not excessively cheery will combat the
negative and gloomy affect that is intrinsic to depression. The client can
interpret an excessively cheerful approach as belittling. A matter-of-fact
approach will be more reassuring to the client and avoid any regressive
struggles that might emerge.

31

In addition to the 4 weeks required to establish maximum therapeutic effects,

tricyclic antidepressants have significant adverse effects. Most notable are
their effects on the heart

The use of TCAs in individuals with second-degree and third-degree heart

block can be fatal. Therefore, the nurse is responsible to ensure that the
psychiatrist orders a baseline ECG before treating the client with TCAs. This
will enable the psychiatrist to determine if there are any preexisting cardiac
abnormalities, which would necessitate eliminating this group of medications
from the treatment protocol.

Establishment of a trusting nurse-client relationship is the foundation for

giving effective nursing care to the client with a mental health disorder.

Alprazolam is an antianxiety agent (benzodiazepine) used in the short-term

management of panic disorder. Central nervous system side effects include
disorientation, drowsiness, and clumsiness, among others.

BuSpar is classified as a nonbenzodiazepine antianxiety agent. It

does not appear to cause either physical or psychological
dependence in clients who use it. Clonazepam, oxazepam, and
lorazepam are benzodiazepines that may cause dependence.

The client with post-traumatic stress disorder is not treated with behavior
therapy. It may be treated with psychotherapy, family or group therapy,
relaxation techniques, and vocational rehabilitation as needed.

Dimenhydrinate (Dramamine) is used to treat and prevent the symptoms of

dizziness, vertigo, and nausea and vomiting that accompany motion sickness.

Zollinger-Ellison syndrome is a hypersecretory condition of the

stomach. The client should avoid taking medications that are
irritating to the stomach lining. Irritants would include aspirin and
nonsteroidal antiinflammatory medications (Naprosyn and
ibuprofen). The client should take acetaminophen for pain relief.
Medication includes lansoprazole (Prevacid).

A client who has a long history of antisocial and acting-out behavior needs to
demonstrate the motivation to change behavior, not just verbalization that
change will occur. The nurse would be therapeutic by assisting the client to
look at the behaviors that indicate the motivation to change.

A client in prison is knowledgeable about the rules for behavior in the

correctional setting. Many clients will test the nurses capacity to be
victimized and will make inappropriate statements. These behaviors need to

32

be verbally confronted directly and then carefully documented in the clients

chart.

Acute toxicity of MAO inhibitors is manifested by restlessness,

anxiety, and insomnia. Dizziness and hypertension may also occur.

The nurse working with chronically mentally ill clients in crisis should focus on
the clients strengths, modify and set realistic goals with the client, take an
active role in assisting the client in the problem-solving process, and provide
direct interventions that the individual might be able to do.

Methylphenidate hydrochloride (Ritalin) is a central nervous system (CNS)

stimulant and can cause insomnia. Its usually prescribed to clients with
ADHD. Taking the medication at breakfast and lunch and avoiding taking the
medication in the evening can prevent insomnia. It is taken orally 30 to 45
minutes before breakfast and lunch.

When depressed, a client sees the negative side of everything. Neutral

comments such as :You are wearing a new dress this morning" will avoid
negative interpretations.

In psychomotor agitation, it is best to provide activities that involve the use

of hands and gross motor movements. These activities include Ping-Pong,
volleyball, finger-painting, drawing, and working with clay. These activities
provide the client a more appropriate way of discharging motor tension than
pacing or ringing the hands.

When a client is manic, solitary activities requiring a short attention

span or mild physical exertion activities are best initially. These
include writing, painting, finger-painting, woodworking, or walks
with the staff. Solitary activities minimize stimuli, and mild physical
activities release tension constructively. When less manic, the client
may join one or two other clients in quiet, nonstimulating activities.
Competitive games should be avoided because they can stimulate
aggression and cause increased psychomotor activity.

An inappropriate affect refers to an emotional response to a situation that is

not congruent with the tone of the situation. A flat affect is an immobile facial
expression or blank look. A blunted affect is a minimal emotional response
and expresses the clients outward affect. It may not coincide with the
clients inner emotions. A bizarre affect such as grimacing, giggling, and
mumbling to ones self is marked when the client is unable to relate logically
to the environment.

Poverty of speech is speech that is restricted in amount and ranges

from brief to monosyllabic one-word answers. Poverty of content of
33

speech is speech that is adequate in amount but conveys little

information because of vagueness, empty repetitions, or use of
stereotypes or obscure phrases. Thought blocking is when the client
stops talking in the middle of a sentence and remains quiet.

When caring for a paranoid client, the nurse must avoid any physical contact
and not touch the client. The nurse should ask the clients permission if touch
is necessary, because touch may be interpreted as a physical or sexual
assault. The nurse should use simple and clear language when speaking to
the client to prevent misinterpretation and to clarify the nurses intent and
actions. A warm approach is avoided because it can be frightening to a
person who needs emotional distance. Anger and hostile verbal attacks are
diffused with a nondefensive stand. The anger a paranoid client expresses is
often displaced, and when a staff member becomes defensive, anger of both
the client and staff member escalates. A nondefensive and nonjudgmental
attitude provides an environment in which feelings can be explored more
easily.

In a paranoid client, The nurse should arrange solitary noncompetitive

activities that take some concentration such as crossword puzzles, picture
puzzles, photography, and typing. When the client feels less threatened,
games such as bridge or chess or playing cards with another client may be
appropriate. When the client is extremely distrustful of others, solitary
activities are best and activities that demand concentration keep the clients
attention on reality and minimize hallucinatory and delusional preoccupation.

Propantheline (Pro-Banthine) is an antimuscarinic anticholinergic

medication that decreases gastrointestinal secretions. It should be
administered 30 minutes prior to meals.

The nurse would most appropriately assess the clients eating patterns and
food preferences and concerns about eating. Assessing previous and current
coping skills is most appropriately related to a nursing diagnosis of Ineffective
Coping. Assessing the clients feelings about self and body weight is most
appropriately related to a Disturbed Body Image. Assessing the clients lack
of control about the treatment plan is most closely related to the nursing
diagnosis of Powerlessness.

Repetition of words or phrases that are similar in sound and in no other way
(rhyming) is one altered thought and language pattern used by clients with
schizophrenia. Clang associations often take the form of rhyming. Echolalia is
the pathological repeating of anothers word by imitation and is often seen in
people with catatonia. Word salad is a phrase used to identify a mixture of
phrases that is meaningless to the listener and perhaps to the speaker as
well. Thought broadcasting is the belief that others can hear ones thoughts.
34

Whenever a client has been identified as a victim of abuse, priority must be

placed on ascertaining whether the person is in any immediate danger. If so,
emergency action must be taken to remove the person from the abusing
situation.

A social phobia is characterized by a fear of appearing inadequate or inept in

the presence of others and of doing something embarrassing. Thus, the client
becomes anxious as the center of attention.

Physical assessment findings such as bruises, along with the other

assessment findings noted in the question, should alert the nurse to the
potential for elder abuse.

Tertiary prevention involves the reduction of the amount and degree

of disability, injury, and damage following a crisis. Primary
prevention means keeping the crisis from ever occurring, and
secondary prevention focuses on reducing the intensity and duration
of the crisis during the crisis itself. A precrisis level of prevention is
similar to primary prevention.

Thioridazine hydrochloride (Mellaril), an antipsychotic medication,

has a higher likelihood of producing impotence than other
neuroleptics

A nurse who is preparing a medication-teaching plan for a client who is

receiving fluphenazine decanoate would be certain to advise the client to
immediately report any clinical manifestations such as a sore throat or fever,
because these signs could signal the onset of agranulocytosis. In addition,
any extrapyramidal symptoms also require the physicians immediate
attention.

Trifluoperazine (Stelazine) can cause the clients urine to turn pink

to reddish-brown. This condition is not harmful; it disappears when
the medication is discontinued. Nevertheless, the nurse will want to
instruct the client to report its occurrence to the nursing staff or the
medical staff.

One of the side effects of antipsychotic agents is that they decrease

moisture around the eyes. This can cause difficulty for clients who
wear contact lenses. Because the client has emphasized the
importance of these lenses, it is a potential problem that may occur
and lead to medication noncompliance by the client.

The most commonly occurring side effects of antipsychotic agents include dry
mouth, blurred vision, nasal stuffiness, and weight gain. Additional side
effects include difficulty in urinating, constipation, risk of infection, decreased
35

sweating and increased sensitivity to heat, increased sensitivity to sunlight,

yellowing of the eyes (especially the whites of the eyes), and decreased
moisture around the eyes. Painful or interrupted menstruation, vaginal
dryness, dizziness, drowsiness, breast enlargement/lactation, skin rash or
itchy skin, and anhedonia can also occur.

Lithium and sodium, similar in chemical structure, compete to

occupy sites within the body. Therefore, sodium levels often
decrease, which causes lithium to be reabsorbed. When this
happens, it increases the amount of lithium in the body, causing side
effects. For this reason, the nurse instructs the client to drink 2 to 3
liters of water each day and eat a diet that is adequate in sodium.
Once the clients lithium level is established (usually within 2
weeks), a blood lithium level will be drawn every 1 to 2 months.

The most therapeutic response for the nurse to make to effectively teach the
client about lithium is the one that emphasizes the necessity that the client
does not discontinue the medication even if feeling an upset stomach. Clients
who are taking this medicine are instructed to take their medication with
meals to minimize the occurrence of an upset stomach.

Depersonalization constitutes a symptom that displays disturbance in the

clients sense of self. A flat affect is a symptom of schizophrenic disturbance
in affect. Magical thinking is a symptom of the content of thought in
schizophrenia. Word salad is a schizophrenic disturbance in the form of
thought.

Fluphenazine decanoate (Prolixin) can decrease the normal bacteria

in the oral cavity and increase sensitivity to infection. This can be
prevented by instructing the client to avoid high-sugar foods;
increase the frequency of mouth care (brushing, including the
tongue, flossing, and gargling with mouthwash); and frequently
inspect the tongue for a thick, white coating, which signals infection.

Lithium is contraindicated in pregnancy and for breastfeeding

mothers. The client will be taught that breastfeeding is not possible
while taking this medication and will be instructed to notify the
physician immediately if pregnancy is even suspected or is being
planned.

Tranylcypromine (Parnate), an antidepressant, can cause serious and

potentially fatal adverse reactions if used with other antidepressants. Its use
is avoided within 2 weeks of another antidepressant.

36

For clients with somatoform disorder, they are told to exercise because it
helps to release endorphins, which enhance the feeling of well-being.

If a client who is taking an antidepressant complains of tiredness,

the nurse instructs the client to report the side effect to the
psychiatrist, take medication at hour of sleep (except fluoxetine
hydrochloride [Prozac], which must be taken in the morning), and
avoid alcohol or alcohol-containing foods (even over-the-counter
medications that contain alcohol). The client should also be
instructed to lie down and rest.

Some of the side effects of benzodiazepines are drowsiness, lethargy and

confusion, dizziness, blurred vision, rash or itchy skin, unusual irritability or
nervousness, headache, and nausea.

The Abnormal Involuntary Movement Scale (AIMS) scale is used to

assist the nurse to recognize tardive dyskinesia. The three areas of
examination are facial and oral movements, extremity movements,
and trunk movement. Tardive dyskinesia can occur from the use of
antipsychotics.

Abdominal pain is the most prominent symptom of acute pancreatitis. The

main focus of nursing care is aimed at reducing discomfort and pain by the
use of measures that decrease gastrointestinal tract activity, thereby
decreasing pancreatic stimulation.

A diagnosis of gout is made on the basis of clinical manifestations,

hyperuricemia, and the presence of uric acid crystals in the synovial fluid of
the inflamed joint. Blood studies show an increased serum uric acid level of
more than 7 mg/100 mL. The erythrocyte sedimentation rate and the white
blood cell count may be elevated during an acute episode. T

Probenecid is a uricosuric medication. The client should be instructed to avoid

alcohol, because it increases the urate levels and to avoid medications that
contain aspirin. Increased fluid intake is encouraged to maintain an adequate
urine output and prevent hematuria, renal colic, and stone development. The
client is instructed to administer the medication with milk or meals to prevent
gastric distress and is also told to limit high-purine foods.

Calcium supplements should not be taken with whole grain cereals,

rhubarb, spinach, or bran, because these foods decrease the
absorption of the calcium. Most supplements should be taken on an
empty stomach (1 hour before meals or at bedtime) to promote
absorption, but food might be necessary if gastric irritation
develops. The client should be instructed to drink water while taking
37

the supplements to prevent renal stones. Side effects include

constipation, gastric irritation, a chalky taste, nausea, and gastric
bleeding.

Blood glucose levels for an adult normally range between 60 and 120 mg/dL.
A level of 33 mg/dL indicates hypoglycemia. Metabolic disorders can be an
etiological factor of delirium.

The Romberg test is an assessment for cerebellar functioning

related to balance. The client stands with feet together and arms at
the side and then closes the eyes. Slight swaying is normal, but loss
of balance indicates a problem and a positive Romberg test.

For the first 12 hours following a laparotomy, the NG tube drainage may be
dark brown to dark red. The drainage should then change to a light yellowish
brown color. The presence of bile may cause a greenish tinge. The physician
should be notified at once of the possibility of hemorrhage if the dark red
color continues or if bright red blood is observed. Due to the presence of
small amounts of blood and the action of gastric secretions, coffee ground
granules might be seen in the NG tube drainage.

The diagnosis of HIV is difficult to accept. Clients can exhibit a variety of

reactions that are not necessarily a direct result of ineffective coping skills.
The nurse must also know that persons with HIV are living well beyond 1
year. Ignoring the problem will not eliminate the clients difficulty in
understanding the disease process. The nurse must focus on the knowledge
deficit of a disease process and other psychosocial interventions.

Sheet grafts are often used to graft burns in visible areas. Sheet
grafts are done on cosmetically important areas, such as the face
and hands, to avoid the meshed pattern that occurs with meshed
grafts.

The incidence of invasive cervical cancer in situ peaks around age 45 and
occurs twice as often in African American women than in other races. A
classic symptom is painless vaginal bleeding; it can be accompanied by
watery, blood-tinged vaginal discharge that can become dark and foul
smelling as the disease progresses. A Papanicolaou smear is the initial
diagnostic test performed.

Organisms present in the synovial fluid are characteristic of a septic

joint condition. Urate crystals are found in gout. Bloody synovial
fluid is seen with trauma. Cloudy synovial fluid is diagnostic of
rheumatoid arthritis.

38

Trigeminal neuralgia affects cranial nerve V, causing sudden bursts of electric

currentlike pain in the face.

In atrial fibrillation with rapid ventricular response, the atrial

chambers quiver, do not contract normally, and fill the ventricles
with blood during the last part of diastole. This results in the loss of
an important atrial contribution to cardiac output, called the atrial
kick. Loss of the atrial kick and the rapid ventricular rate causes a
reduction of cardiac output by as much as 25%.

Physical changes in the client's appearance can occur with Cushing's

syndrome. Such changes include hirsutism, moon face, buffalo hump, acne,
and striae. These changes cause a body image disturbance.

A fasciotomy is a treatment for compartment syndrome.

The client with unilateral neglect must learn to scan the environment and
gradually come to a realization of the affected side

Alcohol can precipitate an attack of pancreatitis. Coffee and cola products,

which contain caffeine, stimulate the pancreas. Carbohydrates actually
should be encouraged, since they are less stimulating to the pancreas. Since
smoking can overstimulate the pancreas, teaching is effective when the
client will try to stop smoking.

Hypercalcemia is a phenomenon associated with multiple myeloma.

Due to the hypercalcemia, pathological fractures are possible.
Ambulation is important, because immobility increases the likelihood
of hypercalcemia. Most clients with multiple myeloma will not
tolerate aerobic exercise because of their anemia.

Even if testicular cancer is detected in an early stage, the client newly

diagnosed with testicular cancer might be afraid he will be sexually
handicapped, and feelings of sexual inadequacy may occur. An appropriate
nursing diagnosis would be Ineffective Role Performance.

Ventilators need to be assessed routinely by the respiratory therapist.

Ventilators are machines, and machines can fail.

The normal white blood cell count is 5,000 to 10,000/mm3. Chemotherapy

agents cause medication-induced leukopenia, and treatment focuses on this
side effect.

A fractured femur may require up to 20 weeks for healing in an adult. Full

weight-bearing is permitted as soon as bony union is present. Ambulation
with a cane requires at least partial to full weight-bearing status. Full weight39

bearing is usually restricted until there is radiographic evidence of bony union

of the fracture fragments. Callus formation is too weak, and the fracture site
may refracture with full weight-bearing. The stage of fracture healing dictates
the amount of weight-bearing, not range of motion, muscle strength, or pain.

Perforation of the gastrointestinal wall is a potential complication of

any endoscopic procedure. Signs of perforation include abdominal
pain, bleeding, and fever. Temperature elevation does not usually
accompany internal hemorrhage. The temperature may be elevated
in both severe dehydration and with a nosocomial infection, but the
potential complication that can occur with this procedure is
perforation of the intestine.

Clients who test positive for HIV antibody are at risk for
opportunistic infection. The normal CD4+ T cell count is between 500
mcg/L and 1600 mcg/L. As the CD4+ T cell count falls, the clients
risk for infection increases. Clients with HIV infection or acquired
immunodeficiency syndrome are commonly afflicted with diarrhea,
not constipation.

Clients with chronic illness often experience feelings of anger and depression.
Manifestations of chronic hepatitis include profound fatigue, resulting in an
inability to pursue normal daily activities. Ineffective coping involves
inappropriate use of defense mechanisms (alcohol consumption). It can also
include the inability to meet role expectations (working). The destructive use
of alcohol will contribute to the clients illness and rehabilitation time, and
further prolong fatigue and the inability to work.

Nocturnal attacks of reflux from hiatal hernias are common, especially if the
person has eaten near bedtime. Large meals, alcohol, and smoking can also
precipitate attacks. Therefore, if the client did more entertaining earlier in the
day, attacks might be decreased or eliminated.

The client with Addisons disease is experiencing deficits of

mineralocorticoids, glucocorticoids, and androgens. Aldosterone deficiency
affects the ability of the nephrons to conserve sodium, so the client
experiences sodium and fluid volume deficit. The client needs to manage this
problem with daily hormone replacement and increased fluid and sodium
intake. Clients are instructed to weigh themselves daily as a means of
monitoring fluid volume balance. Glucocorticoids and mineralocorticoids are
essential components of the stress response. Additional doses of hormone
replacement therapy are needed with any type of physical or psychological
stressor. This information needs to be conveyed to the client and also
requires that the client wear a Medic-Alert bracelet, so that health care

40

professionals are aware of this problem if the client were to experience a

medical emergency.

The client with ulcerative colitis is most likely anemic due to chronic blood
loss in small amounts that occur with exacerbations of the disease. These
clients often have bloody stools and are therefore at increased risk for
anemia

If a transfusion reaction is suspected, the transfusion is stopped and then

normal saline is infused, pending further physician orders. This maintains a
patent IV access line and aids in maintaining the clients intravascular
volume. The IV line would not be removed, because then there would be no
IV access route. Normal saline is the solution of choice over solutions
containing dextrose, because saline does not allow red blood cells to clump.

A frequent side effect of therapy with any of the angiotensin-converting

enzyme (ACE) inhibitors, such as ramipril, is the appearance of a persistent,
dry cough. The cough generally does not improve while the client is taking
the medication. Clients are advised to notify the physician if the cough
becomes very troublesome to them.

Nitroglycerin is a coronary vasodilator used in the management of coronary

artery disease. The client is generally advised to apply a new patch each
morning and leave it in place for 12 to 14 hours as per physician directions.
This prevents the client from developing tolerance (as happens with 24-hour
use). The client should avoid placing the system in skin folds, hairy areas, or
excoriated areas. The client can apply a new patch if it falls off, because the
dose is released continuously in small amounts through the skin.

Verapamil is a calcium channelblocking agent that can be used to treat

rapid-rate supraventricular tachydysrhythmias, such as atrial flutter or atrial
fibrillation. The client must be attached to a cardiac monitor to evaluate the
effectiveness of the medication. A noninvasive blood pressure monitor is also
helpful, but is not as essential as the cardiac monitor.

The client should take in increased fluids (2000 to 3000 mL/day) to make
secretions less viscous. This can help the client to expectorate secretions.
This is standard advice given to clients receiving any of the adrenergic
bronchodilators, such as albuterol, unless the client has another health
problem that could be worsened by increased fluid intake.

The client taking a potassium-wasting diuretic such as chlorothiazide needs

to be monitored for decreased potassium levels.

Amiloride is a potassium-sparing diuretic used to treat edema or

hypertension. A daily dose should be taken in the morning to avoid
41

nocturia. The dose should be taken with food to increase

bioavailability. Sodium should be restricted if used as an
antihypertensive. Increased blood pressure is not a reason to hold
the medication, although it may be an indication for its use.

When ranitidine is given as a single daily dose, it should be taken at

bedtime. This allows for prolonged effect, and the greatest
protection of gastric mucosa around the clock.

Urinary retention is a side effect of benztropine mesylate. The nurse

needs to observe for dysuria, distended abdomen, infrequent
voiding of small amounts, and overflow incontinence.

Quinapril hydrochloride is an angiotensin-converting enzyme

inhibitor used in the treatment of hypertension. The client should be
instructed to rise slowly from a lying to sitting position and to
permit the legs to dangle from the bed momentarily before standing
to reduce the hypotensive effect. The medication does not need to
be taken with meals. It may be given without regards to food. If
nausea occurs, the client should be instructed to consume a non-cola
carbonated beverage and salted crackers or dry toast. A full
therapeutic effect may take place in 1 to 2 weeks.

Quinidine gluconate is an antidysrhythmic medication used as

prophylactic therapy to maintain normal sinus rhythm after
conversion of atrial fibrillation and/or atrial flutter. It is
contraindicated in complete AV block, intraventricular conduction
defects, abnormal impulses and rhythms due to escape mechanisms,
and in myasthenia gravis. It is used with caution in clients with
preexisting asthma, muscle weakness, infection with fever, and
hepatic or renal insufficiency.

Ganciclovir causes neutropenia and thrombocytopenia as the most frequent

side effects. For this reason, the nurse monitors the client for signs and
symptoms of bleeding, and implements the same precautions that are used
for a client receiving anticoagulant therapy. These include providing a soft
toothbrush and electric razor to minimize the risk of trauma that could result
in bleeding. Venipuncture sites should be held for approximately 10 minutes.
The medication does not have to be taken on an empty stomach. The
medication may cause hypoglycemia, but not hyperglycemia.

Diarrhea, nausea, vomiting, loss of appetite, and dizziness are all common
side effects of quinidine. If these should occur, the physician should be
notified; however, the patient should not discontinue the medication. A rapid

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decrease in medication levels of antidysrhythmics could precipitate

dysrhythmia.

Benzonatate (Tessalon) is a locally acting antitussive. Its

effectiveness is measured by the degree to which it decreases the
intensity and frequency of cough without eliminating the cough
reflex.

Drowsiness, dizziness, nausea, and vomiting are frequent side effects

associated with Carbamazepine (Tegretol). Adverse reactions include blood
dyscrasias. If the client developed a fever, sore throat, mouth ulcerations,
unusual bleeding or bruising, or joint pain, this might be indicative of a blood
dyscrasia and the physician should be notified.

Parlodel is an antiparkinson prolactin inhibitor used in the treatment of

neuroleptic malignant syndrome. Vitamin K is the antidote for warfarin
(Coumadin) overdose. Protamine sulfate is the antidote for heparin overdose.
Vasotec is an angiotensin-converting enzyme (ACE) inhibitor and an
antihypertensive that is used in the treatment of hypertension.

Hematological reactions can occur in the client taking clozapine, and

include agranulocytosis and mild leukopenia. The white blood cell
count should be assessed before treatment is initiated and should
be monitored closely during the use of this medication. The client
should also be monitored for signs indicating agranulocytosis, which
may include sore throat, malaise, and fever.

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