Initial care of the client involves preventing further damage and rebleeding. Clients are kept at bed rest if possible, usually with the head of the bed raised. TV watching is permitted but not reading. The use of atropine, ice, and eye shields are controversial, and a nurse should not administer a pharmacologic agent or thermal therapy without a physician’s order. Safety and Infection Control

The nurse should immediately obtain a Doppler device and recheck the pulses. The dorsalis pedis and posterior tibial can be difficult to assess and might need to be verified with a Doppler. Because the client just had a surgery in which a complication is arterial insufficiency, the client must be monitored carefully. If the pulses are not found, the nurse should recognize that this is an emergent situation, and the physician must be notified immediately. If the nurse waits 30 minutes before determining if the pulses can be felt, this could compromise the viability of the client’s foot due to ischemia. Documenting the findings is important but must be performed after the nurse locates the dorsalis pedis and posterior tibial pulses or any necessary interventions are made. Health Promotion and Maintenance

Chlamydia is a sexually transmitted genital infection and is manifested in males primarily as urethritis and in

females as mucopurulent cervicitis. Clinical manifestations of urethritis are often difficult to distinguish from

gonorrhea and include mucopurulent discharges of scant or moderate quantity, urethral itching, and burning on

urination. Possible complications or sequelae of male urethral infections include epididymitis, infertility, and Reiter

syndrome. In homosexual men, receptive anorectal intercourse might result in chlamydial proctitis. In women, the

clinical manifestations might be similar to those of gonorrhea and frequently present as a mucopurulent endocervical

discharge, with edema, erythema, and easily induced endocervical bleeding caused by inflammation of the

endocervical columnar epithelium. However, up to 70% of sexually active women with chlamydial infections are

asymptomatic. Complications and sequelae include salpingitis with subsequent risk of infertility, ectopic pregnancy,

or chronic pelvic pain. Asymptomatic chronic infections of the endometrium and fallopian tubes might lead to the

same outcome. Physiological Adaptation

Even though an Alzheimer’s client might not be able to talk or communicate his needs, the family should still

communicate through talking and touching. The other statements are correct and indicate adequate understanding.

Reduction of Risk Potential

The virus makes a DNA copy of its own RNA using the reverse transcriptase enzyme, and the DNA copy is

inserted into the genetic material of the infected cell. Physiological Adaptation

Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of

Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate

impact on the infant’s development of trust and how others relate to them because of their diagnosis. The longterm

effects of hemophilia can include problems related to immobility. Altered growth and development could not

have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic

of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac. Health

Promotion and Maintenance

A urologist consult is appropriate for a client with visible blood at the urethral meatus and suspected trauma.

Choices 1 and 2 are contraindicated. A urinalysis might be ordered by the physician, but the question does not

provide enough information to make Choice 3 the correct answer. Physiological Adaptation

Parents must be careful when warming bottles in a microwave oven because the milk can become superheated.

When a microwave oven is used, the defrost setting should be chosen, and the temperature of the formula should

be checked before giving it to the baby. Refrigerated, partially used bottles should be discarded after 4 hours

because the baby might have introduced some pathogens into the formula. Returning the bottle to the refrigerator

does not destroy pathogens. Formula concentrate and water are usually mixed in a 1:1 ratio of one part concentrate

and one part water. Infants should be offered fresh formula at each feeding. Partially used bottles should not have

fresh formula added to them. Pathogens can grow in partially used bottles of formula and be transferred to the new

formula. Health Promotion and Maintenance

Preventing tissue infiltration is important to avoid tissue necrosis. Choice 1 is incorrect because hypertonic

solutions should be infused cautiously and checked with the RN if there is a concern. Choice 2 is incorrect because

potassium, mixed in the pharmacy per physician order, is mixed at a concentration no higher than 60 mEq/L.

Physiological Adaptation

Spinnbarkheit is the correct terminology to identify the cervical mucus described. This type of mucus occurs at ovulation and its assessment is used to help couples determine the time they are most likely to conceive. Ferning capacity or crystallization also increases as ovulation approaches. The only way that ferning can be identified is to place the cervical mucus on a microscope slide, let it air dry, and then examine it for a fern-type appearance. Lack of ferning cannot be determined without microscopic examination. Inhospitable cervical mucus refers to mazelike patterns of mucoid strands in cervical mucus that prohibit sperm motility. Other characteristics that make the mucus inhospitable relate to hormone levels, infection, and so on. These conditions cannot be determined by the description supplied in the question. Health Promotion and Maintenance

The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept, including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention. Psychosocial Integrity

Syphilis is an acute and chronic treponemal disease characterized clinically by a primary lesion, a secondary

eruption involving skin and mucous membranes, long periods of latency, and late lesions of skin, bone viscera, the

CNS, and the cardiovascular system. The primary lesion (chancre) appears about three weeks after exposure as an

indurated, painless ulcer with serous exudate at the site of initial invasion. Invasion of the bloodstream precedes

development of the initial lesion, and a firm, nonfluctuant, painless lymph node (bubo) commonly follows.

Infection might occur without a clinically evident chancre; that is, it might be in the rectum or on the cervix. After

four–six weeks, even without specific treatment, the chancre begins to involute, and, in approximately one-third of

untreated cases, a generalized secondary eruption appears, often accompanied by mild constitutional symptoms.

This symmetrical maculopapular rash involving the palms and soles, with associated lymphadenopathy is classic.

Secondary manifestations resolve spontaneously within weeks to 12 months. Again, about one-third of untreated

cases of secondary syphilis become clinically latent for weeks to years. In the early years of latency, infectious

lesions of the skin and mucous membranes might recur. Specific treatment includes long-acting penicillin G

(benzathine penicillin), 2.4 million units given in a single IM dose on the day that primary, secondary or early

latent syphilis is diagnosed. This ensures effective therapy, even if the client fails to return. Serologic testing is

important to ensure adequate therapy. Tests are repeated three and six months after treatment and later as needed.

In HIV-infected clients, testing should be repeated one, two, and three months after treatment, and at three-month

intervals thereafter. Any fourfold titer rise indicates the need for retreatment. Physiological Adaptation

This is the only culturally sensitive statement. Many Asian cultures have a high respect for elders, and members of these cultures might not consider placement in a long-term care facility. This is because they feel it is more respectful for them to care for the family member at home. The nurse might be able to assist the family by determining what community resources are available to assist them. Reduction of Risk Potential

For the client with an NG tube who begins vomiting, the nurse should check the tube placement because

it might be displaced, thereby leading to vomiting. The other responses are not appropriate. Reduction of Risk

Potential

Compazine is the drug that should be administered. Basic Care and Comfort