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statistics for nursing a practical approach
Fundamentals Of Nursing: Standards And Practices 2nd Edition Sue C. DeLaune, Patricia Kelly Ladner - Solutions
Change in level of consciousness
Emotional lability
Irritability
Aphasia
Vague behavioral complaints (by significant others if client unaware or denies behavioral changes)
Confusion
Memory deficits
Suspected brain lesion (new seizures, headaches, behavioral changes)
Known brain lesion (stroke, tumors, trauma)
Instruct the client to report any findings that deviate from normal such as lumps and nodules, especially if they are nonmobile.
Instruct the client to perform the examination during a warm shower using the thumb and first two fingers to gently feel each testicle and the epididymis. The testicles should move freely within the scrotum and have a smooth surface; the epidiymis should be softer.
Review the anatomy of the scrotum by describing that the testicles are ovoid structures that feel firm and rubbery and that the epididymis, located behind the testicles, is softer and feels rope-like.
Explain to the client that monthly TSE will allow for early detection of testicular cancer.
Ask the client if monthly TSE is performed.
Tinea cruris: erythematous plaques with scaling, papular, lesions with sharp margins caused by fungal infections of the groin
Chancroid: tender, ulcerated, exudative, papular lesion with an erythematous halo surrounding edema and a friable base that results from small breaks in epidermal tissue and inoculation of Hemophilus ducreyi
Candidiasis: multiple, discrete, flat pustules with scaling and surrounding edema that are superficial mycotic infections of moist cutaneous sites associated with diabetes mellitus, deficiencies in systemic immunity, and antibiotic therapy
Configuration: pattern that the murmur makes over time; described as crescendo (soft to loud), decrescendo (loud to soft), crescendo-decrescendo(soft to loud to soft
Pitch: high, medium, or low (auscultated with the bell of stethoscope for low-pitched murmurs and the diaphragm for high-pitched murmurs).
Quality: sound produced (harsh, rumbling, blowing, or musical).
Intensity: the loudness or intensity (see the display for a grading of murmurs).
Timing: phase in the cardiac cycle. If the murmur occurs simultaneously with the pulse, it is a systolic murmur. If the murmur is not related to the pulse, it is a diastolic murmur.
Thrombophlebitis: inflammation of a vein with a formed blood clot
Myocardial infarction: necrosis of the heart muscle
Ischemia: local and temporary lack of blood supply to the heart
Coronary artery disease: any abnormal condition that may affect the arteries of the heart
Congestive heart failure: circulatory congestion caused by a cardiac disorder
Bundle branch block: conduction abnormality of the cardiac impulse through the bundle of His fibers
Buerger’s disease (thromboangiitis obliterans): an occlusion of a medium to small artery in the leg or foot that becomes inflamed and thrombotic
Atrial fibrillation: rapid, random contractions of the atria with irregular ventricular beats
Arteriosclerosis: buildup of plaques in the inner layers of the walls of large-to-medium-sized arteries
Angina: pain in the chest, neck, and/or arm resulting from myocardial ischemia
Aneurysm: localized (aortic) abnormal dilation of a blood vessel wall
Thrombophlebitis: inflammation of a vein with a formed blood clot
Myocardial infarction: necrosis of the heart muscle
Ischemia: local and temporary lack of blood supply to the heart
Coronary artery disease: any abnormal condition that may affect the arteries of the heart
Congestive heart failure: circulatory congestion caused by a cardiac disorder
Bundle branch block: conduction abnormality of the cardiac impulse through the bundle of His fibers
Buerger’s disease (thromboangiitis obliterans): an occlusion of a medium to small artery in the leg or foot that becomes inflamed and thrombotic
Atrial fibrillation: rapid, random contractions of the atria with irregular ventricular beats
Arteriosclerosis: buildup of plaques in the inner layers of the walls of large-to-medium-sized arteries
Angina: pain in the chest, neck, and/or arm resulting from myocardial ischemia
Aneurysm: localized (aortic) abnormal dilation of a blood vessel wall
Pneumothorax: collection of air in the pleural space that causes lungs to collapse
Pneumonia: inflammation of the lungs
Pleurisy: inflammation of the pleura
Pleural effusion: accumulation of fluid in interstitial and air spaces of lungs
Hemothorax: accumulation of blood and fluid in the pleural cavity
Empyema: accumulation of pus in a body cavity such as a pleural cavity
Emphysema: loss of alveolar elasticity and decreased gas exchange
Bronchiectasis: dilatation and destruction of the bronchial walls
Atelectasis: collapse of lung tissue and decreased gas exchange
Asthma: recurring episodes of labored breathing, wheezing on expiration, and a productive cough of viscous mucoid bronchial secretions
Aortic aneurysm: localized dilatation of the aortic wall
Stridor: heard predominantly on inspiration as a continuous crowing sound
Pleural friction rub: heard on either inspiration or expiration over the anterior lateral lungs as a continuous creaking, grating sound
Wheezes: heard predominantly on expiration all over the lungs as a continuous sonorous wheeze(low-pitched snoring) or sibilant wheeze (highpitched musical sound)
Rhonchi: heard predominantly on expiration over the trachea and bronchi as a continuous, lowpitched musical sound
Crackles: heard predominantly on inspiration over the base of the lungs as an interrupted fine crackle(dry, high-pitched crackling, popping sound of short duration) that sounds like a piece of hair being rolled between the fingers in front of the ear or a coarse crackle (moist, low-pitched
Parkinson’s disease causes decreased facial mobility and expressions, producing a masklike face; results from progressive, degenerative, neurologic disorders.
Clients with chronic renal failure have pale, swollen tissue around their eyes.
Cushing’s syndrome is a round or “moon” face with excessive hair growth (mustache and sideburns); it occurs in clients with excessive production of adrenal hormones or in clients taking adrenal hormone medications.
Acromegaly is characterized by an elongated head with prominent forehead, nose, and lower jaw and enlarged nose, lips, and ears resulting from excessive growth hormone.
Exophthalmos is the protrusion or bulging of the eye that results from an increased pressure in the eye’s orbit (e.g., from tumor or inflammation).
History of childhood or adult sexual trauma, rape, or domestic abuse
Current or past contraceptive methods
Desire for parenting, at present or in the future
History of sexually transmitted diseases (STDs)
Concerns regarding sexuality or sexual identify
Satisfaction in current relationship
Number of current sexual partners
History of sexual activity with women, men, or both
Age at which sexual history began
Identify the need for additional testing or examination
Confirm alterations, disease, or inability to perform the activities of daily living
Identify factors placing the client at risk and to determine areas of preventive nursing
Ascertain the client’s level of health and physiological function
A cuff that is deflated too slowly
A cuff that does not fit snugly around the extremity
A cuff too narrow for the extremity
18.Lower bed, raise side rails, place call light in easy reach.
17.Record reading.
16.Inform client of reading.
15.Remove cuff or wait 2 minutes before taking a second reading.
14.Deflate cuff rapidly and completely.
Abrupt, distinctive muffled sounds
Intense sound (phase III).
Swishing sound (phase II).
A faint, clear tapping sound appears and increases in intensity (phase I).
Injury or disease to the shoulder, arm, or hand, such as trauma, burns, or application of a cast or bandage
Surgery involving the breast, axilla, shoulder, arm, or hand
Venous access devices, such as an intravenous infusion or arteriovenous fistula for renal dialysis
l. Record reading and indicate site as “OT.”
k. Remove and dispose of gloves in receptacle.Wash hands.
j. Shake thermometer down, and cleanse glass thermometer with soapy water, rinse under cold water, and return to storage container.
i. Read at eye level and rotate slowly until mercury level is visualized.
h. Remove thermometer and wipe with a tissue away from fingers toward the bulb’s end.
g. Leave in place as specified by agency policy, usually 3–5 minutes.
f. Place thermometer in mouth under the tongue and along the gumline to the posterior sublingual pocket. Instruct client to hold lips closed.
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