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NCLEX/CGFNS REVIEW BULLETS 5

• The harness should be worn 23 hours a day and should be removed
only to check the skin, and for bathing. The hips and buttocks should
be supported carefully when the infant is out of the harness. The
harness does not need to be removed for diaper changes or
feedings.

• A complication after surgical treatment of scoliosis is superior mesenteric

artery syndrome. This disorder is caused by mechanical changes in the
position of the child’s abdominal contents, resulting from lengthening of the
child’s body. It results in a syndrome of emesis and abdominal distention
similar to that which occurs with intestinal obstruction or paralytic ileus.
Postoperative vomiting in children with body casts or those who have
undergone spinal fusion warrants attention, because of the possibility of
superior mesenteric artery syndrome.

• The most serious complication associated with skeletal traction is

osteomyelitis, an infection involving the bone. Organisms gain
access to the bone systemically or through the opening created by
the metal pins or wires used with the traction. Osteomyelitis can
occur with any open fracture. Clinical manifestations include
complaints of localized pain, swelling, warmth, tenderness, an
unusual odor from the fracture site, and an elevated temperature.

• The primary legal nursing responsibility when child abuse is suspected is to

report the case. All 50 states require health care professionals to report all
cases of suspected abuse. It is not appropriate for the nurse to file charges
against the father or mother. It is also inappropriate to ask the mother to
identify the abuser, because the abuser may be mother. If so, the possibility
exists that the mother may become defensive and leave the emergency room
with the child.

• Late signs of increased ICP include tachycardia leading to bradycardia,

apnea, systolic hypertension, widening pulse pressure, and posturing. An
altered level of consciousness is an early sign of increased ICP.

• Hydrocephalus is a condition characterized by an enlargement of the cranium

due to an abnormal accumulation of cerebrospinal fluid within the cerebral
ventricular system. This characteristic causes the increase in the weight of
the infant’s head. The infant’s head becomes top heavy. Supporting the
infant’s head and neck when picking the infant up will prevent
hyperextension of the neck area and keep the infant from falling backward.

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 Hyperextension of the infant’s head can put pressure on the neck vertebrae,
causing injury.

• Intracranial pressure and encephalopathy are major symptoms of Reye’s

syndrome.

• Safety with all activities is a priority in planning activities with the child. The
child with autism is unable to anticipate danger, has a tendency for self-
mutilation, and has sensory perceptual deficits. Although social interactions,
verbal communications, and providing familiarity with activities and
orientation are also appropriate interventions, the priority is safety.

• The adolescent should not stop taking antiepileptic medications

suddenly or without discussing it with a physician or nurse. Acne or
oily skin may be a problem for the adolescent, and the adolescent is
advised to call a physician for skin problems. Alcohol will lower the
seizure threshold and it is best to avoid the use of alcohol. Birth
control pills may be less effective when the client is taking
antiepileptic medication.

• Decerebrate posturing is an abnormal extension of the upper extremities with

internal rotation of the upper arm and wrist and extension of the lower
extremities with some internal rotation.

• The progression from decorticate to decerebrate posturing usually indicates

deteriorating neurological function and warrants physician notification.

• Cushing’s response is a late sign of ICP and consists of an increased systolic

blood pressure with widening pulse pressure, bradycardia, and a change in
the respiratory rate and pattern. Cushing’s response is usually apparent just
before or when the brain stem herniates.

• The hallmark symptoms of children with brain tumors are headache and
morning vomiting related to the child’s getting out of bed. Headaches worsen
on arising but improve during the day. Fatigue can occur but is a vague
symptom. Visual changes might occur, including nystagmus, diplopia, and
strabismus, but these signs are not the hallmark of symptoms with a brain
tumor.

• Following amputation, phantom limb pain is a temporary condition that some

children may experience. This sensation of burning, aching, or cramping in
the missing limb is most distressing to the child. The child needs to be
reassured that the condition is normal and only temporary.

• If a child is severely thrombocytopenic, with a platelet count less than

20,000/mm3, precautions need to be taken because of the increased risk of

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 bleeding. The precautions include limiting activity that could result in head
injury, using soft toothbrushes or toothettes, checking urine and stools for
blood, and administering stool softeners to prevent straining with
constipation. Additionally, suppositories and rectal temperatures are avoided.
The normal platelet count ranges from 150,000 to 400,000/ mm3.

• Once the marrow is infused, nursing care focuses on preventing the

immunocompromised child from developing a life-threatening infection until
the child engrafts and produces his or her own white blood cells with which to
fight infections.

• Sun protection is essential during radiation treatments. The child should not
be exposed to sun during these treatments.

• Orchiopexy (or orchidopexy) is a surgery to move an undescended testicle

into the scrotum. The most common complications associated with
orchiopexy are bleeding and infection. Discharge instructions should include
demonstrating proper wound cleansing and dressing and teaching the mother
to identify signs of infection, such as redness, warmth, swelling, or discharge.
The testicles will be held in a position to prevent movement, and great care
should be taken to prevent contamination of the suture line.

• Cryptorchidism is the absence of one or both testes from the scrotum. This
usually represents failure of the testis to move, or "descend. When a child
returns from surgery, the testicle is held in position by an internal suture that
passes through the testes and scrotum and is attached to the thigh. It is
important not to dislodge this suture, and this body area should be
immobilized for 1 week. The most common complications are bleeding and
infection.

• Epispadias is a congenital malformation with the absence of the upper wall of

the urethra. The urethral opening is located anywhere on the dorsum of the
penis. This anatomical characteristic leads to the easy access of bacterial
entry into the urine.

• In bladder exstrophy, the bladder is exposed and external to the body. The
highest priority is impaired tissue integrity related to the exposed bladder
mucosa.

• The “huff” maneuver (forced expiratory technique) is used to mobilize

secretions. This technique reduces the likelihood of bronchial collapse. The
child is taught to cough with an open glottis by taking a deep breath, then
exhaling rapidly whispering the word “huff.”

• Removal of foreign bodies from the respiratory tract may need to be

performed by direct laryngoscopy or bronchoscopy. After the procedure the

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 child should remain hospitalized for observation of laryngeal edema and
respiratory distress. Cool mist is provided, and antibiotic therapy is
prescribed if appropriate.

• The client undergoing cerebral angiography is assessed for possible allergy to

the contrast dye, which can be determined by questioning the client about
allergies to iodine or shellfish.

• The client undergoing LP is positioned lying on the side, with the legs pulled
up against the abdomen and with the head bent down toward the chest. This
position helps widen the spaces between the vertebrae.

• Caloric testing provides information about the vestibular portion of

CN VIII, which aids in differentiating between cerebellar and
brainstem lesions. Usually ice-cold water is inserted into the
auditory canal after patency of the ear canal is determined. If
brainstem function is intact, the eyes move in a conjugate fashion
slowly toward the irrigated side and then quickly move back to
midline. With brainstem death, this nystagmus pattern does not
occur.

• The correct technique for administering parenteral iron is deep in the gluteal
muscle using Z-track technique. This method minimizes the possibility that
the injection will stain the skin a dark color.

• Pernicious anemia can occur in a client who has not had gastric
surgery, such as when the client has a disease that involves the
ileum, where vitamin B12 is absorbed. The nurse checks the client's
history for small bowel disorders to detect this risk factor.

• Classic signs of pernicious anemia include weakness, mild diarrhea, and

smooth, sore, red tongue. The client may also have nervous system
symptoms such as paresthesias, difficulty with balance, and occasional
confusion.

• An urticaria reaction is characterized by a rash accompanied by pruritus. This

type of transfusion reaction is prevented by pretreating the client with an
antihistamine, such as diphenhydramine.

• Instructions to a femail client regarding the procedure for collecting a

midstream urine sample includes telling the client that he should cleanse the
perineum from front to back with the antiseptic swabs that are packaged with
the specimen kit. The client should begin the flow of urine, collecting the
sample after starting the flow of urine. The specimen should be sent to the
laboratory as soon as possible and not allowed to stand. Improper specimen
handling can yield inaccurate test results.

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• Sickle cell anemia is a severe anemia that predominantly affects African
Americans. It is characterized by the presence of only hemoglobin S.

• The indirect Coombs' test detects circulating antibodies against red

blood cells (RBCs), and is the “screening” component of the order to
“type and screen” a client’s blood. This test is used in addition to
the ABO typing, which is normally done to determine blood type. The
direct Coombs' test is used to detect idiopathic hemolytic anemia, by
detecting the presence of autoantibodies against the client’s RBCs.
Eosinophil and monocyte counts are part of a complete blood count,
a routine hematologic screening test.

• The most common sites for bone marrow aspiration in the adult are the iliac
crest and the sternum. These areas are rich in marrow and are easily
accessible for testing.

• Sickle cell disease often causes pain in the bones and joints, accompanied by
joint swelling. Pain is a classic symptom of the disease and may require large
doses of narcotic analgesics when it is severe.

• The priority items in the management of sickle cell crisis are hydration
therapy and pain relief. To achieve this, the client is given intravenous fluids
to promote hydration and reverse the agglutination of sickled cells in small
blood vessels. Narcotic analgesics may be given to relieve the pain that
accompanies the crisis. Oxygen would be given, based on individual need.
RBC transfusion also may be done in selected circumstances such as aplastic
crisis or when the episode is refractive to other therapy. Genetic counseling is
recommended, but not during the acute phase of illness.

• Idiopathic autoimmune hemolytic anemia is treated with corticosteroids,

particularly prednisolone (Prelone). Other treatments that can be initiated as
necessary include splenectomy, transfusions, and sometimes
immunosuppressive agents.

• At age 15 months, the nurse would expect that the child could build a tower
of two blocks. A 24-month-old would be able to open a doorknob and unzip a
large zipper. At age 30 months, the child would be able to put on simple
clothes independently.

• Irritable bowel syndrome causes diffuse abdominal pain unrelated to meals or

activity. Alternating constipation and diarrhea with the presence of
undigested food and mucus in the stools may also be noted.

• Following pyloromyotomy, the head of the bed is elevated and the

infant is placed prone to reduce the risk of aspiration.

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• Mumps generally affects salivary glands but can involve multiple organs. The
most common complication is septic meningitis, with the virus being
identified in the cerebrospinal fluid. Common signs include nuchal rigidity,
lethargy, and vomiting. The child should be seen by the physician.

• Carditis is the inflammation of all parts of the heart, primarily the

mitral valve.

• Hypernatremia occurs when the sodium level is greater than 145 mEq/L.
Clinical manifestations include intense thirst; oliguria; agitation and
restlessness; flushed skin; peripheral and pulmonary edema; dry, sticky
mucous membranes; and nausea and vomiting.

• The two primary pathophysiological alterations associated with

hemolytic disease are anemia and hyperbilirubinemia. The red blood
cell count is decreased, because the red blood cell production cannot
keep pace with the red blood cell destruction. Hyperbilirubinemia
results from the red blood cell destruction accompanying this
disorder, as well as from the normally decreased ability of the
infant’s liver to conjugate and excrete bilirubin efficiently from the
body. Hypoglycemia is associated with hypertrophy of pancreatic
islet cells and increased levels of insulin.

• Live measles vaccine is produced by chick embryo cell culture, so

the possibility of an anaphylactic hypersensitivity in children with
egg allergies should be considered. If there is a question of
sensitivity, children should be tested before the administration of
MMR vaccine. If a child tests positive for sensitivity, the killed
measles vaccine may be given as an alternative.

• Meperidine hydrochloride is contraindicated for ongoing pain management

for a client admitted to the hospital with a diagnosis of sickle cell crisis,
because of the increased risk of seizures associated with its use.
Management of severe pain generally includes the use of strong narcotic
analgesics, such as morphine sulfate or hydromorphone (Dilaudid). These
medications are usually most effective when given as a continuous infusion
or at regular intervals around the clock.

• Dietary sources of iron that are easy for the body to absorb include meat,
poultry, and fish. Vegetables, fruits, cereals, and breads are also dietary
sources of iron but contain less iron and are harder for the body to absorb.

• Intravenous immune globulin (IVIG) will increase the platelet count. It is

thought to act by interfering with the attachment of antibody-coded platelets
to receptors on the macrophage cells of the reticuloendothelial system.

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 Corticosteroids can be prescribed to enhance vascular stability and decrease
the production of antiplatelet antibodies.

• Koplik spots appear approximately 2 days before the appearance of the rash
of rubeola. These are small, blue-white spots with a red base found on the
buccal mucosa. The spots last approximately 3 days, after which time they
slough off

• A bulging anterior fontanel indicates an increase in cerebrospinal fluid

collection in the cerebral ventricle.

• Ductus arteriosus is described as an artery that connects the aorta

and the pulmonary artery during fetal life. It generally closes
spontaneously within a few hours to several days after birth. When
patent, it allows abnormal blood flow from the high- pressure aorta
to the low-pressure pulmonary artery, resulting in a left-to-right
shunt.

• Discharge instruction to the parents of a child who has had heart surgery
includes the child may return to school the third week after hospital
discharge, but should go for half days for the first few days. The child should
avoid crowds of people for 1 week after discharge, including day care centers
and churches. Play outside should be avoided for several weeks, although
inside play is allowed. If any difficulty with breathing occurs, the parents
should notify the physician.

• A toddler derives comfort and security from familiar routines and people. The
new sights, sounds, and smells are a source of anxiety during hospitalization.

• The crisis of Autonomy vs Shame and Doubt is related to the developmental

task of gaining control of self and environment as exemplified by toilet
training. Initiative vs Guilt is the crisis of the preschool and early school-
aged child. Initiative vs Inferiority is the crisis of the 6- to 12-year-old, and
Trust vs Mistrust is the crisis of the infant.

• The Somogyi effect is a rebound hyperglycemia that occurs as a result of the

secretion of counter regulatory hormones such as epinephrine, growth
hormone, and corticosteroids. The 3:00 a.m. blood glucose level is low,
followed by a high level a few hours later, demonstrating the rebound effect.

• Children suspected of having acute rheumatic fever are tested for the
presence of recent streptococcal infection antibodies. An increased antibody
level, evidenced by an elevated or rising antistreptolysin-O (ASO) titer, will
assist in confirming the diagnosis. An increased erythrocyte sedimentation
rate would occur in acute rheumatic fever. A leukocyte count and hemoglobin
count will not confirm the diagnosis of acute rheumatic fever.

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• A diarrhea stool has an alkaline pH that can cause skin breakdown. A damp
washcloth is an ineffective way to clean the skin. The mother should be
taught to thoroughly clean the skin, using a mild soap.

• Spina bifida occurs during fetal growth and development and has genetic
predispositions. Parents who have children with congenital defects blame
themselves for the child’s defects. Parents, at times, have difficulty bonding
with their newborn because they are grieving the loss of their perfect baby.
Integrating the new baby with special needs into the parent’s life is a
stressful adjustment.

• Complications from pertussis include pneumonia, atelectasis, otitis media,

convulsions, and subarachnoid bleeding. Decreased breath sounds are
indicative of both pneumonia and atelectasis.

• Clubbing, a thickening and flattening of the tips of the fingers and

toes, is thought to occur because of a chronic tissue hypoxia and
polycythemia.

• In hemophilia A, the partial thromboplastin time is prolonged. The

white blood cell count, sedimentation rate, and clot retraction time
are unrelated to the diagnosis of hemophilia A.

• The stools of a child with celiac disease are characteristically malodorous,

pale, fatty, large (bulky), and soft (loose). Excessive flatus is common, and
bouts of diarrhea may occur.

• Rehydration is the initial step in resolving diabetic ketoacidosis

(DKA.) Normal saline is the initial IV rehydration fluid. Regular
insulin will be administered by continuous IV infusion. Dextrose
solutions are added to the treatment regime when the blood glucose
levels reach an acceptable level. IV potassium may be required,
depending on the potassium levels, but would not be part of the
initial treatment. Glucagon hydrochloride is used to treat severe
hypoglycemia.

• If a child is being treated with propylthiouracil, the increased risk for

neutropenia and hepatotoxicity exists. Contact sports should be
limited to decrease the possibility of injury and damage to the liver.
If the child develops a sore throat or fever, the physician should be
notified, because these signs could indicate neutropenia. A yellow
discoloration of the skin could indicate the presence of liver damage
or hepatitis, and if this occurs, it is not normal and the physician
must be notified.

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• Signs of infection include fever (greater than 100° F), increased pulse and BP,
high WBC count with a shift to the left (indicating rapid proliferation of
WBCs), and positive cultures, such as from wound drainage, urine, sputum, or
blood. If the client meets expected outcomes, the client is free of signs and
symptoms of infection.

• TB is spread by droplet nuclei, which become airborne when the infected

client laughs, sings, sneezes, or coughs. An individual must inhale the droplet
nuclei for the chain of infection to continue.

• The client taking isoniazid is at risk for hepatotoxicity. For this

reason, the client’s hepatic enzymes are measured before and
periodically during therapy with this medication. BUN and creatinine
are measured during therapy with streptomycin, which is a
nephrotoxic medication. Vision testing is done during treatment with
ethambutol (Myambutol).

• The most common symptom of Pulmonary embolism (PE) is a sudden-onset

chest pain. The next most frequent symptoms are dyspnea and tachypnea.
Other manifestations include tachycardia, diaphoresis, cough, fever,
hemoptysis, and syncope.

• When a client is severely depressed, the client should be involved in quiet

one-to-one activities. Because concentration is impaired when the client is
severely depressed, these types of activities maximize the potential for
interacting and may minimize anxiety levels.

• It is important to ask the client to identify preferred foods and drinks and to
offer choices when possible. The client is more likely to eat the foods
provided if choices are offered. The client should be offered high-calorie,
high-protein fluids and snacks frequently throughout the day and evening.
When possible, it is best to remain with the client during meals. This action
reinforces the idea that someone cares, can raise the client’s self-esteem,
and can serve as an incentive to eat.

• In a depress client who has trouble sleeping, the client should be provided
rest periods after activities during the day because fatigue can intensify
feelings of depression. The nurse should spend more time with the client
before bedtime to help allay anxiety and increase feelings of security.
Reduced environmental and physical stimuli should be provided in the
evening, such as soft lights, soft music, and quiet activities. Exercise should
be avoided before bedtime. The client should be encouraged to get up and
dress and stay out of bed during the day because this routine minimizes
sleep during the day and increases the likelihood of sleep at night.

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• Eskalith is the medication of choice for treating the manic phase of a bipolar
disorder. It is a mood stabilizer and is the prototypical antimanic medication.
Often it can calm manic clients, prevent or modify future manic episodes, and
prevent future depressive episodes.

• A normal diet and normal salt and fluid intake should be maintained while the
client is taking lithium. This agent decreases sodium reabsorption by the
renal tubules, which could cause sodium depletion. A low-sodium intake
causes a relative increase in lithium retention, which could lead to toxicity.
The client should avoid taking any over-the-counter medications without
checking first with the physician. Lithium is irritating to the gastric mucosa;
therefore the client should take the medication with meals. Because
therapeutic and toxic dosage ranges are so close, lithium blood levels must
be monitored very closely, more frequently at first, and then once every few
months thereafter.

• A flat affect is an immobile facial expression or blank look. A blunted

affect is indicated by a minimal emotional response. An
inappropriate affect refers to an emotional response to a situation
that is not congruent with the tone of the situation. A bizarre affect
is especially prominent in the disorganized form of schizophrenia
and is characterized by grimacing, giggling, or mumbling to one’s
self.

• A bizarre affect is especially prominent in the disorganized form of

schizophrenia. Grimacing, giggling, and mumbling to one’s self are included
in this description. A bizarre affect is marked when the client is unable to
relate logically to the environment. A flat affect is an immobile facial
expression or blank look. A blunted affect is a minimal emotional response,
commonly seen in schizophrenia. In schizophrenia, the client’s outward affect
may not coincide with inner emotions. An inappropriate affect refers to an
emotional response to a situation that is not congruent with the tone of the
situation.

• Thought-blocking occurs when a client stops talking in the middle of

a sentence and remains quiet. Poverty of speech occurs when there
is a restriction in the amount of speech and answers consist of brief,
often monosyllabic or one-word answers. Speech that is adequate in
amount but conveys little information because of vagueness, empty
repetitions, or the use of stereotypes or obscure phrases is
described as poverty of content of speech.

• Accupril is an angiotensin-converting enzyme inhibitor. It suppresses the

renal angiotensin-aldosterone system and reduces peripheral arterial
resistance and blood pressure (BP). It is used in the treatment of

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 hypertension, either alone or in combination with other antihypertensive
agents.

• Quinidine gluconate (Duraquin) is an antidysrhythmic medication.

The BP should be monitored before administering the medication.
Although pulse oximetry, temperature, and respirations may be
components of the assessment, monitoring the BP is specific to the
administration of this medication.

• Quinine sulfate is an antimalarial, antimyotonic medication. Its

antimalarial effect elevates the pH in intracellular organelles of
parasites, producing parasitic death. It relaxes the skeletal muscle
by increasing the refractory period, decreasing excitability of motor
end plates, and affecting distribution of calcium within muscle fiber.

• The catheter should be advanced for 1 to 2 more inches beyond the point
where the flow of urine is first noted. This ensures that the balloon is fully in
the bladder before it is inflated.

• Anorexia nervosa is an eating disorder characterized by a determination to

lose weight mainly by restricting food intake, even when emaciated. It
generally occurs in young adults who have distorted views of the body’s
shape and weight and the self. Through dieting and weight loss, these
persons believe they will experience control, autonomy, and competence.
Bulimia nervosa is characterized by eating binges followed by maladaptive or
inappropriate reparative behaviors, such as dieting and purging, occurring at
least two times each week for 3 or more months.

• A desirable target weight should be discussed with the client with anorexia
nervosa. A weekly weight gain of 1 pound is generally acceptable for the
emaciated client. In the client with bulimia, a desirable goal is weight
stabilization without binge-purge behavior.

• Nitrofurantoin (Macrodantin) is specifically indicated for the treatment of

urinary tract infections when due to susceptible strains of Escherichia coli,
enterococci..

• During the immediate postpartum period, vital signs are taken every
15 minutes during the first hour after birth, every 30 minutes for the
next 2 hours, and every hour for the next 2 to 6 hours. Vital signs
are monitored thereafter every 4 hours for the first 24 hours and
every 8 to 12 hours for the remainder of the hospital stay.

• During the first week after birth, transient episodes of bradycardia are
common. The woman’s pulse may be as low as 40 to 50 BPM the first 1 to 2
days after delivery. It is not necessary to notify the physician.

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• The position of the fundus should be midline. Displacement to the side
indicates that the bladder may be full. It is not necessary to notify the
physician. Fundus massage is performed when the uterus is soft and boggy.

• The presence of cyanosis can be best seen in the nailbeds, the

conjunctivae, and the oral mucosa. Pallor is best seen in the buccal
mucosa or the conjunctivae, particularly in dark-skinned clients.
Jaundice can be best assessed in the sclera near the limbus at the
junction of the hard and soft portions of the palate and over the
palms.

• After elbow arthroplasty, elbow-flexion and elbow-extension

exercises are allowed as tolerated. The client should not lift more
than 5 pounds and should not begin triceps- and biceps-
strengthening exercises for 3 months. The client will not be able to
lift heavy items or play sports with the operative arm.

• To assess cutaneous nerve status, flexion of the biceps is checked by having

the client raise the forearm. Poor biceps flexion may indicate compromise of
the cutaneous nerve

• The client is at risk for impairment of skin integrity owing to the presence of
the catheter, exposure to moisture, and irritation from tape and cleansing
solutions. The client should be instructed to use paper or nonallergenic tape
to prevent skin irritation and breakdown. It is proper procedure for the client
to use aseptic technique and to self-monitor vital signs and weight on a daily
basis.

• A client with anemia should be taught the basics of good nutrition and
encouraged to consume a diet high in protein, iron, and vitamins. The nurse
should encourage the client to consume foods cooked in iron pots and to
ingest foods such as liver, which has the highest source of iron of the foods
identified in the options. Other foods that may provide high sources of iron
include oysters, lean meats, kidney beans, whole-wheat bread, kale, spinach,
egg yolks, turnip tops, beet greens, carrots, apricots, and raisins.

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