The Annoying Crutches, Walker, and Cane Questions

Here is a great ATI video link to help you when studying for those pesky order of ambulation questions:

http://www.atitesting.com/ati_next_gen/skillsmodules/content/ambulation/viewing.html?id=undefined

ATI: Medication Administration for Pediatrics

These equations are taken from the RN ATI portal videos.




Client Weight Formula for Maintaining Daily Fluid Balance:  When running 0.9 NS IV for pediatric fluid maintenance, use this formula:

The sum of:

100 ml/kg for the first 10 kg

50 ml/kg for the second 10 kg

20 ml/kg for the remaining kg

Example: Calculate the fluid required for a 98 lb child.  Round to the ten.
 98lb / (2.2 lb/kg) = 44.54 kg  <--I noticed that for the ATI, they rounded this to 44.5 kg right away.
1st 10 kg= 10 kg x 100 ml/kg = 1000 mL
2nd 10 kg = 10 kg x 50 ml/kg= 500 mL
remaining weight = 44.5 kg - 20 kg = 24.5 kg; 24.5 kg x (20ml/kg)= 490 mL
volume required to maintain daily fluid balance for a 98 lb child is: 1000 mL +500 mL + 490 mL=1549mL






Calculating Body Surface Area:  Sometimes, a doctor will prescribe medication by BSA (body surface area) when precise administration is required, such as with highly toxic medications.  The formula is:

http://dailymed.nlm.nih.gov/dailymed/archives/image.cfm?archiveid=19085&type=img&name=norvir-equation.jpg

Example: Calculate the BSA for a child weighing 9.5 kg and 74.5 cm.  Round to the hundredth.


Sqrt ( (9.5kg x 74.5 cm)/3600)
=Sqrt (707.75 kgcm/3600)
=Sqrt (0.1965972...kgcm)
=0.4433m^2
=0.44m^2

Childhood Milestones: First 12 mos

Don't you hate it when you have that stupid question about how many teeth a child has by 12 months?  Or whether or not it's expected for a child of 10 months to be standing up without support.  Or is it with support?

And you're just staring at the computer screen like:

Seriously, who can keep that stuff straight?  Nevertheless, if you're studying pediatrics, you will need to know some version of this, so, I'll attempt to boil down chapters 3-7 of the ATI Nursing Care of Children edition 9 so that you don't have to.  Disclaimer: these are only the non-obvious facts.  So, "duh" facts like "plastic bags pose a suffocation risk," aren't included.

0-12 MONTHS

PHYSICAL CHANGES
-Posterior fontanels close at 6-8 weeks (the way I remember this is: since the baby lays on its back, it needs to close the posterior fontanels first).
-Anterior fontanels close at 12-18 mos.
-Weight: birth weight doubles by 6 mos, tripled by 12 mos.
-Teeth: 6-8 teeth normally come in around 6-10 months, and definitely before 1 year.

MOTOR REFLEXES (GROSS/FINE)
1 mos: Head lag.   Grasp reflex.
2 mos: Still has head lag.  Lifts head in prone position.  Holds hand opened.
3 mos: Slight head lag.  Can raise shoulders up in prone position.  Loses grasp reflex.
4 mos: Rolls from back to side.  Puts things in mouth.  *Discovers that thumb sucking is pleasurable.
5 mos: Rolls from prone to supine.  Palmar grasp.  (Note grasp reflex looks like palmar grasp, but one is a reflex.  The other is a conscious choice.)
6 mos: Rolls rom supine to prone.  Holds bottle.
7 mos: Stands with support.  Moves object from hand to hand.
8 mos: Sits unsupported.  Beginnings of pincer grasp.
9 mos: Pulls self to standing.  Crawling.  Coarse pincer grasp.
10 mos: Independently changes from prone to sitting.  Can grasp thin objects, like a rattle.
11 mos: Walks with help.  Can place objects in container.  Refined pincer grasp.
12 mos:  Independent sit to stand and vice versa. Tries to build a two-block tower without success.

COGNITIVE DEVELOPMENT: Piaget-Sensorimotor (birth-24 mos)
-reflexes mature into intentional imitative activities
-separation from others
-object permanence (9 mos)
-recognizes symbols
-Languages:
  -Discovers that people respond to smiling, cooing, crying.
  -Turns head to aural stimuli.
  -Pronounces single-syllable words, up to 3 word phrases made up of 5 word vocabulary.
  -Understands "no" by 12 months.

PSYCHOSOCIAL: Erikson-Trust vs Mistrust (0-12 mos)
-Trust if needs are met, mistrust if need are inconsistently or inadequately met, OR if needs are continuously med BEFORE being vocalized by the infant.  (Capable of learning delayed gratification.)
-Attachment/bonding (Reactive attachment disorder results from maladaptive or absent attachment between the infant and a caregiver, like if the child undergoes a long-term hospitalization.)
-Separation anxiety 4-8 mos.
-Stranger fear 6-8 mos.

AGE APPROPRIATE ACTIVITIES:
Short attention spans, solitary play, activates senses--rattles, pat-a-cake, balls, reading very short books, mirrors, playing blocks, brightly colored toys.

IMMUNIZATIONS (per CDC):

http://www.cdc.gov/vaccines/parents/downloads/parent-ver-sch-0-6yrs.pdf

NUTRITION:
-Breast feeding provides complete diet up to 6 months, and continues to supplement through 12 mos.  Supply iron if breastfeeding.
-Give vit D starting at birth.
-Solids are introduced around 4-6 months IF there is control of head and neck, disappearance of extrusion, and interest in solid foods.  Appropriate to switch to table foods at 9 months.  Examples are: bananas, toast, graham crackers, cheese cubes, noodles, peeled chunks of apples, pears, or peaches.
-DO NOT GIVE citrus, meat, or eggs until after 6 mos.
-Bedtime feedings are the last to be stopped.

SLEEPING:
-Sleep 14-15 hours a day with 9-11 of it at night.  Pattern is established by 3-4 mos.
-Sleeps throughout the night, and takes 1-2 naps daily by 12 mos.
-Cribs: slats should be no more than 6 cm apart (2.375 inches).  Remove mobiles by 4-5 mos.


BATHING:
-Temp set at maximum of 49C  (or 120F).

SAFETY:
-REAR facing until 2 y-o or surpassing height requirement.

Unnecessarily Complicated

Leopold Maneuver Video by ATI

http://www.atitesting.com/ati_next_gen/skillsmodules/content/maternal-newborn/viewing/leopold.html

Cramming for exams: Prioritizing at its finest

Quick.  You have, for whatever reason, not kept up with the reading for a class.  Tomorrow is the final, and you don't know what you're doing.

(Bear with me.  I pulled an involuntary all-nighter--my brain just would not stop racing.  Granted, that's not all that uncommon while in school, still, I am not sure I'll write what I mean to write, so, if something sounds nonsensical, it probably is.  Hopefully that'll add to the post since I'm assuming you're reading this post because you're cramming, probably with an all-nighter.)

I've been reading my Asinine Testing Insanity book for this OB test tomorrow, trying to cram the whole thing into one night of reading, which, I'll admit, isn't the best plan I've had this year, but, we do what we gotta do.  (I mean, they did say it doesn't count, right?)  By now, you've taken at minimum, one test, usually more like 4, and you know where your weak spots are.   For example, I know that the question about normal neonate head circumference always gets me (it is, by the way, 32-36.8 cm or 12.6-14.5 in, which sound like numbers people made up just to make me mad, but they aren't), and I always forget what "telangiectatic nevi" is (stork bites, or flat red marks that blanch, found around the infant's face, that are benign and fade by second year).

Lab values are maddening, but one of the best things to capitalize on.  They change from source to source.  My tip?  Memorize the ATI values (vs the professor's values) because these questions will only pop up once or twice on a 50 question exam from your professor, and you can afford to miss 2 points on a unit exam, but you don't want to mess up on the ATI and have to repeat the course--and standardized tests love to screw you on lab values.

Data you just need to know cold.  There's no way around it.  Some data you're just going to have to route memorize.  For me it was just repeating it, writing it, posting it next to light switches and on bathroom mirrors over and over and over, one fact per day, like memorizing a series of phone numbers (remember back in the day when people actually had to remember phone numbers?  I can still recite my childhood home number from over 20 years ago: 312-985-4715).  And sure, I forget it, but if I glance at them before an exam I can still recall them.

And that's not to say I've got everything memorized.  Like today, I've only got 20% of neonatal data memorized.  But you know what?  Honestly, there are general things you should know, like VS, and the rest will come on a printout when you're at work, so don't sweat it.

Speaking to my classmates, I don't have these memorized, and I'm betting not many of you have these memorized either, so here's the ATI version:

For term babies
Expected VS:
BP: 60-80/40-50mmHg** NOTE: this is different than our professor's ranges of 60-80/45-55mmHg
HR: 100-160/min ** NOTE: this is different than our professor's range of 110-160bpm
Resp: 30-60 c up to 15 seconds of apnea
Temp: 36.5-37.2C or 97.7-98.9F axillary

Expected reference ranges of physical measurements:
Weight: 2,500-4,000 g
Length: 45-55cm
Head circumference: 32-36.8cm (or about 2-3 cm larger than chest circumference due to cephalocaudal development)
Chest circumference: 30-33cm

Expected lab values: 
Hgb: 14-24 g/dL
Hct: 44-64%
RBC: 4,800-7,100,000/mm3
Leukocyte: 9,000-30,000mm3
Platelets: 150,000-300,000/mm3
Glucose: 40-60
Bilirubin: 0-6 mg/dL on day 1; 8mg/dL or less on day 2; 12 mg/dL or less on day 3

Good luck today!

Cracking this Asinine Testing Insanity

Acronym notwithstanding, standardized testing for nursing sucks because there's always more than one right answer, but only one is the most right answer.  To make matters worse, one test prep company, like say, Lippincott, will tell you one answer is the most right answer, and another, like Assessment Technologies Institute will tell you the other.  And worst of all, sometimes the same company just can't seem to make up its mind (ahem, you know which I'm talking about).  Take for example, suspected domestic abuse--this questions ALWAYS gets me.

It's usually a question like: "You are a nurse working in the ER bay, and a child comes in with multiple bruises on her hands and thighs.  You suspect abuse.  What is your nursing priority?"

a) Obviously wrong answer.
b) Obviously wrong answer.
c) Some variation of calling DCFS.
d) Some variation of assessment.

I got this question as part of a test prep engine from a company and the answer was (d) because you have to finish assessing for all signs of abuse and then I took a test for class from the same company today and I picked the same answer and I got it wrong.

And I was just like:

Here's another annoying one:

You're a nurse on a mental health inpatient floor and a patient with panic disorder presents with tachypnea, diaphoresis, paleness, and is sliding down a wall into a seated position.  Your priority is to:
a) Obviously wrong answer.
b) Obviously wrong answer.
c) Some variation of give him a paper bag to breathe into.
d) Some variation of tell the patient he is in a safe place, and to slow down his breathing.

My medsurg brain flew to "respiratory alkalosis, give him a bag to breathe into," but no, apparently I was supposed to tell a panicked patient that he is in a safe place and to slow down his breathing.  Keep in mind that panic, as opposed to severe stress, is qualified by the person losing control of himself, so, trying to teach (keyword) someone to slow down his breathing is kind of futile, right?  I don't know.  (But then again, my professor made this question up so, who knows, maybe she was wrong.  I digress.)

I always ALWAYS get these wrong.  I swear, the same online test will say one answer for one question and the other answer for a procedurally and situationally similar question later down the line.
It's infuriating.
It's brain fuckery.
I confess.  Depending on how confident I feel on the rest of the test, if a test has two similar question, I'll pick "c" for one question, and "d" for the other just to negate the wrong answer rather than gamble and potentially get both questions wrong.

So let me ask you, how do you reason through questions like these?

Tangentially related material:
State Child Abuse Reporting Numbers
5 Reasons Why Feminism Needs to Address Child Abuse