Nclex & Cgfns Review Bullets 4

8/14/2019 Nclex & Cgfns Review Bullets 4

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SOURCE: http://www.nursereview.org

NCLEX/CGFNS REVIEW BULLETS 4

The client with Addisons disease is experiencing deficits of

mineralocorticoids, glucocorticoids, and androgens. Aldosterone deficiencyaffects 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

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 noIV 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 eachmorning 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.

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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 avoidnocturia. 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, infrequentvoiding 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,

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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 andsymptoms 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

decrease in medication levels of antidysrhythmics could precipitatedysrhythmia.

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 blooddyscrasia 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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Clinical manifestations suggestive of airway obstruction include tripod

positioning (leaning forward supported by the arms, chin thrust out, and

mouth open), nasal flaring, tachycardia, a high fever, and sore throat.

Familiar objects provide a sense of security for the child in a strange hospital

environment. The child should be allowed to have a favorite toy or securityblanket while in the mist tent.

The stinger from a bee should be carefully removed by scraping it out

horizontally. The mother should be instructed to avoid squeezing the stinger

because more venom will be released. Following removal of the stinger, the

area is washed with soap and water and ice may be applied for discomfort.

Dietary changes such as salt and fluid restrictions that reduce the amount of

endolymphatic fluid are sometimes prescribed for clients with Mnires

disease.

Following mastoidectomy, the nurse should monitor vital signs and inspect

the dressing for drainage or bleeding. The nurse should assess for signs of

facial nerve injury to cranial nerve VII and assess the client for pain,

dizziness, or nausea. The head of the bed should be elevated at least 30

degrees, and the client is instructed to lie on the unaffected side. The client

would probably have sutures and an outer ear packing and a bulky dressing,

which is removed on approximately the sixth postoperative day.

Unstable angina is triggered by an unpredictable amount of exertion or

emotion, and may occur at night. The attacks increase in number, duration,

and severity over time. Variant angina is triggered by coronary artery spasm,and the attacks are of longer duration than those of classic angina and tend

to occur early in the day and at rest. Intractable angina is chronic and

incapacitating, and is refractory to medical therapy. Nocturnal angina may be

associated with dreaming that occurs with rapid eye movement (REM) sleep.

Bloody or clear watery drainage from the auditory canal indicates a

cerebrospinal leak following trauma and suggests a basal skull fracture. This

warrants immediate attention, and the physician should be notified.

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

and immobile tympanic membrane with or without perforation. Postauricularlymph 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.

Hearing loss can occur in a client with an inner ear disorder. However,

hearing loss is not the most common complaint of a client with an inner ear

disorder. Tinnitus is the most common complaint of clients with otological

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disorders, especially disorders involving the inner ear. Symptoms of tinnitus

range from mild ringing in the ear, which can go unnoticed during the day, to

a loud roaring in the ear, which can interfere with the clients thinking

process and attention span.

A hallmark sign of pemphigus is Nikolskys sign. Nikolskys sign iswhen the epidermis can be rubbed off by slight friction or injury.

Other characteristics of pemphigus include flaccid bullae that

rupture easily and emit a foul-smelling drainage, leaving crusted,

denuded skin. The lesions are common on the face, back, chest,

groin, and umbilicus. Even slight pressure on an intact blister may

cause spread to adjacent skin. Trousseaus sign is a sign for tetany

in which carpal spasm can be elicited by compressing the upper arm

and causing ischemia to the nerves distally. Chvosteks sign, seen in

tetany, is a spasm of the facial muscles elicited by tapping the facial

nerve in the region of the parotid gland. Homans' sign, a sign of

thrombosis in the leg, is discomfort behind the knee on forced

dorsiflexion of the foot.

In severe cystic acne, isotretinoin is used to inhibit inflammation. Adverse

effects include elevated triglycerides, skin dryness, eye discomfort such as

dryness and burning, and cheilitis (lip inflammation). Close medical follow-up

is required, and dry skin and cheilitis can be decreased by the use of

emollients and lip balms. Vitamin A supplements are stopped during this

treatment.

Scabies can be identified by the multiple straight or wavy threadlike

lines noted beneath the skin. The skin lesions are caused by the

female mite, which burrows beneath the skin and lays its eggs. The

eggs hatch in a few days and the baby mites find their way to the

skin surface where they mate and complete the life cycle.

The client with any renal disorder, such as renal failure, may become angry

and depressed because of the permanence of the alteration. Due to the

physical change and the change in lifestyle that may be required to manage

a severe renal condition, the client may experience Disturbed Body Image.

Athletes often have sinus bradycardia because exercise increases the stroke

volume of the heart. Since the cardiac output is a product of stroke volume

and heart rate, fewer beats are needed per minute at rest to maintain the

normal cardiac output. The vital signs are normal for this client.

With classic presentation of herpes zoster, the clinical examination is

diagnostic. A viral culture of the lesion provides the definitive diagnosis.

Herpes zoster is caused by a reactivation of the varicella zoster virus, the

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cause of the virus for chicken pox. In a Woods light examination, the skin is

viewed under ultraviolet light to identify superficial infections of the skin. A

patch test is a skin test that involves the administration of an allergen to the

skins surface to identify specific allergies.

The primary lesion of herpes zoster is a vesicle. The classicpresentation consists of grouped vesicles on an erythematous base

along a dermatome. Because they follow nerve pathways, the

lesions do not cross the bodys midline.

Squamous cell carcinomas are malignant neoplasms of the epidermis. They

are characterized by local invasion and have a potential for metastasis.

Melanomas are pigmented malignant lesions originating in the melanin-

producing cells of the epidermis. This type of skin cancer is highly metastatic,

and a persons survival depends on early diagnosis and treatment. Basal cell

carcinomas arise in the basal cell layer of the epidermis. Early malignant

basal cell lesions often go unnoticed, and although metastasis is rare,underlying tissue destruction can progress to include vital structures.

A melanoma is an irregularly shaped pigmented papule or plaque

with a red, white, or blue-toned color. Basal cell carcinoma appears

as a pearly papule with a central crater and rolled waxy border.

Squamous cell carcinoma is a firm, nodular lesion topped with a

crust or a central area of ulceration. Actinic keratosis, a

premalignant lesion, appears as a small macule or papule with a dry

rough adherent yellow or brown scale.

Premature ventricular contractions are generally easily recognizable on theECG. They occur early in relation to the timing of previous normal beats, have

no visible P wave, and have a characteristically wide and bizarre QRS

complex. There is a compensatory pause.

With onset of ventricular fibrillation, the client loses consciousness

and becomes pulseless and apneic. There are no heart sounds or

blood pressure. Death will occur if not treated.

Assessment findings in frostbite include a white or blue color, and the skin

will be hard, cold, and insensitive to touch. As thawing occurs, the skin

becomes flushed, blisters or blebs develop, or tissue edema appears.

Gangrene develops in 9 to 15 days.

Acute frostbite is ideally treated with rapid and continuous rewarming of the

tissue in a water bath for 15 to 20 minutes or until flushing of the skin occurs.

Slow thawing or interrupted periods of warmth are avoided because this can

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contribute to increased cellular damage. Thawing can cause considerable

pain, and the nurse administers analgesics as prescribed.

Chvosteks sign, seen in tetany, is a spasm of the facial muscles elicited by

tapping the facial nerve in the region of the parotid gland. Trousseaus sign is

a sign for tetany in which carpal spasm can be elicited by compressing theupper arm and causing ischemia to the nerves distally. A hallmark sign of

pemphigus is Nikolskys sign. In Nikolskys sign, the epidermis can be rubbed

off by slight friction or injury. Homans' sign, a sign of thrombosis in the leg, is

discomfort behind the knee on forced dorsiflexion of the foot.

Histoplasmosis usually starts as a respiratory infection in the client

with AIDS. It then becomes a disseminated infection, with

enlargement of lymph nodes, spleen, and liver.

The client who suffers a spinal cord injury experiences spinal shock at the

time of the injury. The client loses all motor, bowel, bladder, and sexualfunction, and loses all reflexes below the level of the injury. Spinal shock

resolves in 7 days to 3 months. Indications of resolving spinal shock include

hyperreflexia and positive Babinski reflex.

As the first symptom, the client with Pneumocystis carinii infection usually

has a cough that begins as nonproductive and then progresses to productive.

Later signs include fever, dyspnea on exertion, and finally dyspnea at rest.

If the results of two ELISA tests are positive, the Western Blot is done to

confirm the findings. If the result of the Western Blot is positive, then the

client is considered to be positive for HIV, and infected with the HIV virus. TheCD4 count identifies the T-helper lymphocyte count and is performed to

determine progression and treatment.

Hyperglycemia is characteristic of newly diagnosed diabetes mellitus. Newly

diagnosed diabetics present a variety of symptoms, which may include

polydipsia, polyuria, polyphagia, weakness, weight loss, dehydration. The

definitive diagnosis is verified by hyperglycemia.

Renal biopsy is a definitive test that gives specific information about whether

the lesion is benign or malignant. An ultrasound discriminates between a

fluid-filled cyst and a solid mass. Renal arteriography outlines the renalvascular system. While some types of cancer grow more quickly than others,

it is not possible to determine this by biopsy.

Radiation therapy to the brain can cause cerebral edema. Clients may also

experience nausea and vomiting because of the effects of the radiation on

the brains chemoreceptor trigger zone. Because hair follicles are destroyed

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by radiation, clients receiving radiation to the head may also experience hair

loss.

Anxiety varies with an individual's perception, which in turn depends on a

person's psychosocial makeup, education, degree of maturity, and life

experiences. The nurse should know that anxiety is exhibited in many variousforms. People can communicate their anxiety both verbally and nonverbally.

The nurse needs to identify cues, interpret them, and seek to validate them.

Oral, subcutaneous, and intramuscular routes for administering medications

are contraindicated for the burned client because of the poor absorption.

When fluid balance is stabilized, oral narcotic agents can be used.

A hydrocele is an abnormal collection of fluid within the layers of the tunica

vaginalis that surrounds the testis. It may be unilateral or bilateral and can

occur in an infant or adult. Hydrocelectomy is the excision of the fluid filled

sac in the tunica vaginalis. The client needs to be instructed that the suturesused during the hydrocelectomy are absorbable.

The client undergoing a radioactive iodine uptake test needs to be reassured

that the amount of radioactive iodine used is very small, that it is not harmful

to the client, and that the client will not be radioactive.

Since tuberculosis is transmitted by droplet, it cannot be carried on clothing,

eating utensils, or other possessions. It is important to perform proper hand

washing after contact with body substances, tissues, or facemasks. The client

should cover the mouth with a tissue when laughing, coughing, or sneezing,

and dispose of tissues carefully.

The client with tuberculosis usually experiences cough (either productive or

nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest

discomfort or pain, chills and sweats (which may occur at night), and a low-

grade fever.

The signs identified in the question indicate an occlusion of the femoral

artery. Prior to the procedure, the nurse should mark the peripheral pulses

distal to the catheter insertion site with a felt-tipped pen, and record the

quality of the pulses in the chart. This will aid in locating the pulses after the

procedure. Pulses are checked before the procedure for post-procedurecomparisons and to detect possible occlusion of the vessel undergoing

cannulation. The physician is notified immediately if the client experiences

numbness or tingling in the affected extremity, if the extremity becomes

cool, pale, or cyanotic, or if sudden loss of peripheral pulses occurs. These

manifestations represent serious impairment of circulation.

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Vaccines for hepatitis A using live activated and inactivated virus have been

tested and seem safe and effective. Havrix, a vaccine containing the inactive

virus of hepatitis A, is available and can replace gamma globulin for travelers.

A single dose of this vaccine is given intramuscularly. For maximum antibody

titer, a booster dose is recommended 6 to 12 months after the initial

injection. The hepatitis B vaccine (Engerix-B, Recombivax-HB) provides activeimmunity to hepatitis B.

Subcutaneous emphysema can follow a thoracentesis, because air in the

pleural cavity leaks into subcutaneous tissues. The tissues feel like lumpy

paper and crackle when palpated (crepitus). Usually, subcutaneous

emphysema causes no problem unless it is increasing and constricting vital

organs, such as the trachea.

In Bells palsy, the client experiences weakness on an entire half of the face.

The client is unable to close the eye on the affected side and experiences

paralysis of the ipsilateral facial muscles. The client also experiences pain,drooling, decreased taste, and increased tearing. Tinnitus, vertigo, and

deafness are not associated with Bells palsy but can be seen in Mnires

disease. Muscle spasms in the jaw and cheek area are most likely associated

with trigeminal neuralgia.

Therapeutic management for the client with Bells palsy includes providing

moist heat packs to the affected area. The client is instructed to eat small

meals and soft foods frequently, and to protect the affected eye by using an

eye patch. The client is also instructed to use artificial tears four times daily

and to manually close the affected eye from time to time.

For the first 24 hours postoperatively, the nurse should elevate the stump as

prescribed to decrease swelling and promote comfort. Stumps with

compromised circulation must not be elevated. A lower extremity stump is

elevated at intervals, because elevation for long periods of time can cause

flexion contractures of the hip. To prevent flexion hip contractures, the client

should be positioned on the abdomen for a 30-minute period every 4 to 6

hours.

In general, only the area in the treatment field is affected by radiation. Skin

reactions, fatigue, nausea, and anorexia may occur with radiation to any site,whereas other side effects occur only when specific areas are involved in

treatment. A client receiving radiation to the neck is most likely to experience

a sore throat.

Pallor is best seen in the buccal mucosa or conjunctiva, particularly in dark-

skinned clients. Cyanosis is best seen in the nail beds, conjunctiva, and oral

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mucosa. Jaundice is best seen in the sclera, the junction of the hard and soft

palate, and over the palms.

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, therebydecreasing pancreatic stimulation.

Usually, one tooth erupts for each month of age past 6 months up to 30

months of age. Proper dental care includes adequate cleaning, removal of

plaque, use of fluoride, and good nutrition. The child should not be allowed to

have a bottle in bed. A diet that is low in sweets and high in nutritious food

promotes dental health.

The normal respiratory rate for a 3 year old is 20 to 30 breaths per minute.

The nurse would document the findings.

The normal blood pressure of a 3-year-old child ranges from 72 to 110 mm

Hg systolic and 40 to 73 mm Hg diastolic.

Age-related activities for adolescents include sports, videos, movies, reading,

parties, hobbies, listening to favorite music on video or compact disc, and

experimenting with makeup and hair styles.

The normal apical rate for a newborn infant is 120 to 160 beats per minute

A toddler has the skills required to feed himself or herself. The mother should

be instructed not to feed a child who can feed herself and to never force-feed

the child. To increase nutritious intake, the mother is instructed to limit juice

intake to 6 ounces per day, and milk intake to 16 to 24 ounces per day.

Additionally, the mother should limit the child to 2 nutritious snacks per day

and should only provide the snacks at the toddlers request.

Vomiting, pain, and an irreducible mass at the umbilicus are signs of a

strangulated hernia. The parents should be instructed to contact the

physician immediately if strangulation is suspected.

McBurneys point is usually the location of greatest pain in the child with

appendicitis. McBurneys point is midway between the right anterior superioriliac crest and the umbilicus.

Kidney function tests should be monitored, because EDTA is nephrotoxic. The

calcium level should also be monitored, because EDTA enhances the

excretion of calcium.

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Clinical manifestations of iron deficiency anemia will vary with the

degree of anemia but usually include extreme pallor with a

porcelain-like skin, tachycardia, lethargy, and irritability.

The mother should be instructed to administer oral iron supplements

between meals. The iron should be given with a citrus fruit or juice high invitamin C, because vitamin C increases the absorption of iron by the body.

The major complication of chronic transfusion therapy is hemosiderosis. In

order to prevent organ damage from too much iron in the blood, chelation

therapy with a medication called deferoxamine (Desferal) is used. Desferal is

classified as an antidote for acute iron toxicity.

Oral iron supplement should be administered through a straw or medicine

dropper placed at the back of the mouth because it will stain the teeth. The

parents should be instructed to brush or wipe the teeth after administration.

Iron is administered between meals because absorption is decreased if thereis food in the stomach. Iron requires an acid environment to facilitate its

absorption in the duodenum.

High fevers and severe illnesses are reasons to delay immunization, but only

until the child has recovered from the acute stage of the illness. Minor

illnesses such as a cold, otitis media, or mild diarrhea without fever are not

contraindications to immunization.

Diagnoses of pinworm is confirmed by direct visualization of the worms.

Parents can view the sleeping childs anus with a flashlight. The worm is

white, thin, about inch long, and moves. A simple technique, thecellophane tape slide method, is used to capture worms and eggs.

Transparent tape is lightly touched to the anus and then applied to a slide for

examination. The best specimens are obtained as the child awakens, and

before toileting or bathing.

Roseola is transmitted via saliva; therefore, others should not share

drinking glasses or eating utensils.

IPV is devoid of serious adverse effects. As with other injected

medications, local soreness may occur at the injection site. IPV

contains trace amounts of streptomycin, neomycin, and bacitracin.Therefore, the nurse should ask the mother about allergies to these

medications.

HBV is one of the safest vaccines. The most common reactions are soreness

at the injection site and mild to moderate fever. Acetaminophen (Tylenol)

may be used to relieve discomfort, but aspirin should be avoided. The only

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contraindication to HBV is a previous anaphylactic reaction to either the HBV

immunization or to Bakers yeast.

Care to the child with rubella involves contact isolation. Contact isolation

requires the use of masks, gowns, and gloves for contact with any infectious

material. Contaminated articles are also bagged and labeled per agencyprotocol. Goggles are not necessary to care for the child with German

measles.

Asymmetry of the gluteal skin folds when the infant is placed prone and the

legs are extended against the examining table is noted in hip dysplasia.

Asymmetric abduction of the affected hip, when the client is placed supine

with the knees and hips flexed, would also be an assessment finding in hip

dysplasia in infants beyond the newborn period. An apparent short femur on

the affected side is noted as well as limited range of motion.

SGA infants are at risk for developing hypocalcemia. The normal range fortotal serum calcium is 7.0 mg/dL to 8.5 mg/dL.

The classic picture of Osgood-Schlatter disease is that of a very active

adolescent boy involved in sports activities. The child will complain of

bilateral knee pain that is exacerbated by running, jumping, or climbing

stairs. The child will point to the tibial tubercle as the site of pain.

Dunlop traction is used to treat supracondylar fractures of the

humerus. A pin is inserted through the distal humeral fragments.

The elbow is flexed at a 90-degree angle, with the forearm in neutral

position. Correct alignment needs to be maintained to preventcontractures. Circulation should be assessed at least every 2 to 4

hours to monitor for vascular compromise. Pain, pallor, and cyanosis

are indications of Volkmann's ischemia. The child should be asked to

wiggle the finger to check for numbness, tingling, and decreased

sensation.

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Nclex & Cgfns Review Bullets 4

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