Professional Documents
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• Bone marrow aspiration biopsy is a key diagnostic tool for confirming the
diagnosis of leukemia and for identifying malignant cell types. Lumbar
puncture may determine the presence of blast cells in the central nervous
system. Radiographic tests may detect lesions and sites of infection. A
lymphangiogram may be performed to locate malignant lesions and
accurately classify the disease.
• When the neutrophil count is less than 500/mm3, the client is at risk for
infection; therefore, monitoring the oral temperature is a critical nursing
intervention.
• When the neutrophil count is less than 1000/mm3, the client is at risk for
infection. A platelet count less than 20,000/mm3 would place the client at
risk for hemorrhage.
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• Vaginal discharge called leukorrhea is common in pregnant women because
of the increased mucus production by the endocervical gland. The mucus
should be clear or slightly whitish and mucoid in appearance.
• To evaluate the deep tendon reflexes, the client’s lower leg is exposed, and
one hand is placed under the knee to raise it slightly off the bed. A percussion
hammer is used to strike the patellar tendon just below the patella. The
normal response is extension and thrusting of the foot upward.
• The facial nerve (CN VII) has both motor and sensory divisions. Common
symptoms of dysfunction of this nerve include an inability to close the eye
and to blink automatically, facial asymmetry, drooling and inability to swallow
secretions, loss of the ability to form tears, and possible loss of taste on the
anterior two thirds of the tongue. Bell’s palsy, fracture of the temporal bone,
and parotid lacerations or contusions are often responsible for these
symptoms.
• The vestibulocochlear nerve (CN VIII) is responsible for auditory acuity as well
as bone and air conduction. The audiometer assesses the client’s hearing,
whereas the tuning fork tests bone and air conduction.
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strength that might not otherwise be noted. Hyperreflexia is an excessive
reflex action.
• With an impaired corneal (blink) reflex, the client is at risk for the eyes
becoming dry and also for corneal abrasions if foreign matter comes in
contact with the eye. Use of sterile saline drops helps keep the eyes
lubricated. An eye patch would have to be used carefully because corneal
abrasion could result if the cornea comes in contact with the patch.
Introduction of a foreign object (a cotton ball) inside the lower eyelid also
risks corneal abrasion. Taping the eye shut could impair the client’s vision,
putting the client at risk for another injury, such as a fall.
• After the acute phase of Ménière’s disease, remission occurs, but symptoms
of the disease will recur with two or three acute attacks occurring per year.
As this pattern of attacks and remissions develops, fewer symptoms occur
during the acute phase. A complete remission eventually occurs with some
degree of hearing loss, varying from slight to complete. It takes several
weeks before all symptoms subside after an attack, leaving a loss of hearing
in the involved ear.
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vasodilators, and diuretics may be prescribed for the client. A low-salt diet is
prescribed for the client to reduce fluid retention. The major goal of
treatment is to preserve the client’s hearing, and careful medical
management helps achieve this in most clients with Ménière’s disease.
• After stapedectomy, the client is instructed to keep water out of the ear canal
for at least 3 weeks and to avoid swimming for 6 weeks. The client also is
instructed to avoid coughing and sneezing and to avoid bending and lifting
heavy objects or other strenuous activities for at least 3 weeks. Air travel is
avoided for 4 weeks. If sudden hearing loss, fever, or severe persistent
vertigo or dizziness develops, the physician should be notified.
• The client with urethritis from chlamydial infection should not engage in any
form of sexual activity (intercourse, as well as oral-genital or oral-anal
contact) until the client is fully cured. At that point, the client also should use
condoms to prevent reinfection.
• To conduct a hearing test, The examiner should stand 1 to 2 feet away from
the client and ask the client to block one external ear canal. The nurse quietly
whispers a statement and asks the client to repeat it. Each ear is tested
separately.
• Insects that make their way into an ear are killed before removal unless they
can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted
alcohol is instilled into the ear to suffocate the insect, which is then removed
by using ear forceps. When the foreign object is vegetable matter, irrigation
is not used because this material expands with hydration, and the impaction
becomes worse.
• Clients with meniere's disease are instructed 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. Clients are advised to stop smoking because of its
vasoconstrictive effects.
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bowel sounds, weak and irregular pulse, and cardiac dysrhythmias
(tachycardia or bradycardia). Clinical manifestations also may include
hypotension, ileus, irritability, and fatigue. Nausea may or may not occur.
• The ventral gluteal site may be used for intramuscular injections in older
children. In children who have not yet developed the gluteal muscle (those
younger than 2 years), the preferred site for intramuscular injections is the
anterolateral aspect of the thigh. The deltoid muscle can be used in children
18 months or older; however, in an 11-year-old child, the ventral gluteal
muscle is the preferred site.
• When giving DPT, Hib, and hepatitis B vaccines simultaneously, the nurse
should administer the most reactive vaccine (DPT) in one leg and inject the
others, which cause a smaller reaction, into the other leg.
• Any immunization may cause an anaphylactic reaction. All offices and clinics
administering immunizations must have epinephrine 1:1000 available.
Pediatric syringes are needed to administer the immunization. Generally, a
needle that is 2/8-inch or longer is adequate to administer immunizations for
a normal 4-month-old infant.
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lung tissue or the pleural cavity, but these problems are not likely to occur
after the first 24 to 48 hours after the injury.
• Rubeola has an infectious period that ranges from 1 to 2 days before the
onset of symptoms to 4 days after the rash appears.
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Articles that are contaminated should be bagged and labeled before
reprocessing.
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• Discharge instructions to a mother regarding the care of her 10-year-old child
who has pharyngitis includes antibiotics should be taken for the entire
prescribed course, even if the child is feeling better and is free of symptoms.
The older child may gargle with saline. Warm or cool compresses may be
applied to the throat. A follow-up with a repeat throat culture should be done
3 to 5 days after completing the course of the antibiotics.
• Clear, cool liquids are provided when the child is fully awake. Citrus,
carbonated, and extremely hot or cold liquids are avoided because they
irritate the throat. Milk and milk products, including puddings and ice cream,
are avoided initially until the child has tolerated clear liquids well. This is
done because milk products can coat the throat and cause the child to clear
it, thus increasing the risk of bleeding.
• Atrial septal defect is an opening between the two atria that allows
oxygenated and unoxygenated blood to mix. Left-to-right shunting of blood
occurs because of the higher pressure on the left side of the heart.
Ventricular septal defect is an opening between the two ventricles allowing
oxygenated and unoxygenated blood to mix. Patent ductus arteriosus
involves an artery that connects the aorta and the pulmonary artery during
fetal life. Atrioventricular canal defect occurs as a result of inappropriate fetal
development of endocardial cushions.
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because the abnormal communication, or opening, sends more blood to the
right side of the heart through the opening than is normal.
• In some children with patent ductus arteriosus, no symptoms occur, and the
defect closes spontaneously. Measures to reduce symptoms of congestive
heart failure (CHF) must be undertaken. Surgical closure, if performed, is
done via a left thoracotomy and without cardiopulmonary bypass.
Indomethacin (Indocin) is sometimes used to promote ductal closure in
premature infants.
• A limited fluid intake can predispose the client to dehydration and respiratory
infection. This is because dehydration impairs the action of the cilia in the
respiratory tree.
• Typically, seizure assessment includes the time the seizure began, part(s) of
the body affected, the type of movements and progression of the seizure,
changes in pupil size, eye deviation or nystagmus, client condition during the
seizure, and postictal status.
• Generalized seizures are seizures that are bilaterally symmetric and have no
focal point of onset. Partial seizures are seizures that begin locally and
include simple partial seizures (without impaired level of consciousness),
complex partial seizures (with impaired level of consciousness), and partial
seizures secondarily generalized.
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• Positioning the client on one side with the head flexed forward allows the
tongue to fall forward and facilitate drainage of secretions, which could help
prevent aspiration. The nurse would also remove restrictive clothing and the
pillow and raise the padded side rails, but these would not decrease the risk
of aspiration. Rather they are just general safety measures to use during
seizure activity. The nurse would not raise the client’s head of bed.
• Cerebral thrombosis does not occur suddenly. In the few hours or days
preceding a thrombotic CVA, the client may experience a transient loss of
speech, hemiplegia, or paresthesias on one side of the body. Signs and
symptoms of thrombotic CVA vary, but may include dizziness, cognitive
changes, or seizures. Headache is rare, but some clients with CVA experience
signs and symptoms similar to cerebral embolism or intracranial hemorrhage.
In addition, most clients do not have repeated episodes of loss of
consciousness. The client does not complain of difficulty with night vision as
part of this clinical problem.
• After CVA, the client often experiences periods of emotional lability, which is
characterized by sudden bouts of laughing or crying, or by irritability,
depression, confusion, or being demanding. This is a normal part of the
clinical picture for the client with this health problem, although it may be
difficult for health care personnel and family members to deal with
• Hemiparesis is a weakness of the face, arm, and leg on one side. The client
with one-sided hemiparesis benefits from having objects placed on the
unaffected side and within reach
• Before the client with dysphagia is started on a diet, the gag and swallow
reflexes must have returned. The client is assisted with meals as needed, and
food is placed on the unaffected side of the mouth. The client is given ample
time to chew and swallow and should not eat quickly because this could
cause choking. Liquids are thickened to avoid aspiration.
• Homonymous hemianopsia is loss of one half of the visual field. The client
with homonymous hemianopsia should have objects placed in the intact field
of vision, and the nurse also should approach the client from the intact side.
The nurse instructs the client to scan the environment to overcome the visual
deficit and does client teaching from within the intact field of vision.
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• Unilateral neglect is an unawareness of the paralyzed side of the body, which
increases the client’s risk for injury. The nurse’s role is to refocus the client’s
attention to the affected side. Personal care items, belongings, bedside chair,
and commode are all placed on the affected side. The client is taught to scan
the environment to become aware of that half of the body and is approached
on that side by family and staff as well.
• Clients with aphasia after CVA often fatigue easily and have a short attention
span. General guidelines when trying to communicate with the aphasic client
include: speaking more slowly and allowing adequate response time, listening
to and watching attempts to communicate, and trying to put the client at
ease with a caring and understanding manner. The nurse also suggests to
avoid shouting (because the client is not deaf), appearing rushed for a
response, and allowing family members to give all the responses for the
client.
• Placing an eye patch over one eye in the client with diplopia removes the
second image and restores more normal vision. The patch is alternated on a
daily basis to maintain the strength of the extraocular muscles of the eyes.
• The client with myasthenia gravis has weakness after periods of exertion and
near the end of the day, and medication is prescribed to alleviate weakness,
particularly at these times. The nurse works with the client to space out
activities to conserve energy and regain muscle strength by resting between
activities. The client also is instructed to take medication as prescribed.
• The client with myasthenia gravis experiences dysphagia and a nasal quality
to speech when the muscles of chewing and swallowing are involved. The
nurse listens attentively and verbally verifies what the client has said. Other
helpful techniques are to ask questions requiring a yes or no response and to
develop alternative communication methods (letter board, picture board, pen
and paper, flash cards).
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• Signs and symptoms of cholinergic crisis in a client with myasthenia gravis
include general weakness and difficulty chewing, swallowing, speaking, and
breathing. Nausea and vomiting, abdominal cramping, diarrhea, and
increased production of body secretions also occur. It is due to
overmedication and is treated by withholding all medications and supporting
the client’s respiratory function until symptoms improve.
• The client with Parkinson’s disease has a tendency to become withdrawn and
depressed, which can be limited by encouraging the client to be an active
participant in his or her own care. The family also should give the client
encouragement and praise for perseverance in these efforts. The family
should plan activities intermittently throughout the day to inhibit daytime
sleeping and boredom.
• The major dietary source of calcium is from dairy foods, including milk,
yogurt, and a variety of cheeses.
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