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Formal operational stage biologic processes is credited to which of the following theorists? An increased incidence of teenage ing and deductive reasoning occurs during pregnancy can be linked to substance which of the following stages of development? Which of the following are components of Freud’s theory of psychoanalytic development? Which of the following concepts are Multiple Response Questions components of Erikson’s theory of psychosocial development? Growth and development are differentiated describe the developmental stages and and integrated generic zudena 100 mg on line erectile dysfunction medications causing. Within each developmental level discount 100 mg zudena overnight delivery youth erectile dysfunction treatment, certain external control as the child learns to con- milestones can be identified. Few adults ever reach stage 6 of the the effects of environment and nutrition devel- postconventional level. Substance abuse by a pregnant woman expectations, and societal values are increases the risk for congenital anomalies adopted. Failure to thrive cannot be linked to punishment and obedience orientation, emotional deprivation. Abuse of alcohol and drugs is more prevalent or physical consequences of authority’s in teenagers who have poor family relation- disapproval. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Place the following stages of Sigmund Freud’s others’ viewpoints into his/her own theory of psychoanalytic development in the understanding of truth. Freud identified the underlying stimulus for human behavior as sexuality, which he called b. The stage of Piaget’s theory of cognitive development is characterized by the use of abstract thinking and deductive reasoning. Levinson and associates based their theory of ory of development (developmental tasks) in human development on the organizing the order in which they occur: concept of. Learning sex differences; forming concepts; Part A with the appropriate example listed in getting ready to read Part B. A 22-year-old woman picks a circle of is , meaning that growth friends with whom she spends her free progresses from gross motor movements to time. A l5-year-old boy worries about how his school years, a child imitates the religious classmates treat him. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. A 2-year-old boy expresses interest in __________________________________________ dressing himself. A 35-year-old woman volunteers Saturday aged child with increased social interaction. Stories represent religious and moral beliefs, Match the stages of faith development listed in and the existence of a deity is accepted. Note which of the following stages you __________________________________________ have personally experienced in your lifetime. Stage 4: Individuative–reflective faith ment result from two interrelated factors: e. Different aspects of growth and development Personal example: occur at the same stages and rates. According to Freud, the ego is the part of the psyche concerned with self-gratification by the easiest and quickest available means. Personal interest in gender differences, and curiosity example: about the genitals and masturbation increases. According to Havighurst, developing a gestures and behaviors of others; they follow conscience, morality, and a scale of values parental attitudes toward religious or moral should occur in middle childhood. Personal example: __________________________________________ Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. According to Gould, between the ages of 22 instrumental relativist orientation, the and 28, self-acceptance increases as the need motivation for choices of action is fear of to prove oneself disappears. Complete the following chart, using the first theorist (Sigmund Freud) as an example. Theorist and Theory Basic Concepts of Theory Stages of Development Sigmund Freud Stressed the impact of instinctual human Oral stage Psychoanalytic theory drives on determining behavior: Unconscious Anal stage mind, the id, the ego, the superego, stages Phallic stage of development based on sexual motivation Latent stage Genital stage Erik Erikson Robert J. Havighurst Jean Piaget Lawrence Kohlberg Carol Gilligan James Fowler Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Freud: “My dad told me not to moral development, and give an example of ride that thing. A 6-year-old girl with leukemia is admitted to the hospital for her first session of chemother- apy. What insight into this patient’s needs could be gained from the following theorists? Reflect on the nursing plan you would develop for a 3-year-old, a 10-year-old, and a c. How would your plan differ to take into considera- tion the age differences of the patients? Kohlberg: using a different developmental theory for each age group’s nursing plan. He has multiple fractures and several deep cuts in his face that require stitches. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. What developmental considerations may psychosexual development, Piaget’s psychoso- affect care planning for Mr. Observe children in different settings and find an example of each stage of development. Talk with classmates about how these findings would influence your nursing practice. What intellectual, technical, interpersonal, Scenario: Joseph Logan, age 70, fell and and/or ethical/legal competencies are most fractured his hip while repairing the exterior likely to bring about the desired outcome? Logan has been the traditional head of his household and is now troubled by needing others, includ- ing his wife, to care for him. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Which of the following numbers is a normal ment would a person be most likely to think score on the Apgar rating scale for newborns in the abstract and question beliefs and prac- taken 1 and 5 minutes after birth? Neonatal stage mother and uses infantile speech patterns is exhibiting which of the following behaviors? Separation anxiety ration anxiety in which of the following stages of development?

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Scenario: Billy Collins generic zudena 100 mg amex erectile dysfunction doctors huntsville al, a 9-year-old with a his- tory of allergies zudena 100mg fast delivery erectile dysfunction radiation treatment, including an allergy to insect stings, is spending a week at summer camp. What resources might be helpful for this suddenly reports to the camp counselor that he family? The counselor rushes Billy to the nearest emergency health center after helping him self-inject epinephrine. He presents with itching and hives, difficulty breathing, nausea, and palpitations. When his parents arrive, they ask you what more they can do, if anything, to prevent this situation from occurring in the future. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. The safety event report becomes a part of Circle the letter that corresponds to the best the medical record. When deciding whether to use restraints on a patient, the nurse should consider which of 4. According to a recent study, unrestrained older patients were three times more likely a. There is no evidence linking a relationship to sustain fall-related injuries than between childhood sexual abuse and certain restrained older patients. There are no physiologic hazards associated with the proper use of restraints on older b. Generally, a physician’s order is not neces- accidents involve the use of alcohol and/or sary to apply restraints. According to Pillitteri, ribavirin, used for respiratory infections in infants and a. Most people who die in house fires do not children, may be harmful to a developing die from burns, but from smoke inhalation. Fire is the major safety problem in hospitals expose residents to potentially unhealthy and the leading cause of accidental death substances. Stressful situations are more devastating to got out of bed and fell, restraints were applied. Which of the following statements reflect con- following would be the most appropriate nurs- siderations a nurse should keep in mind when ing intervention for Mrs. A medication regimen that includes diuret- to the use of restraints for ensuring patient ics or analgesics places an individual at risk safety and preventing falls? Allow the patient to use the bathroom expected of another nurse in a similar independently. Which of the following statements accurately will not attempt to get out unassisted. Inhalation anthrax produces fever, fatigue, Multiple Response Questions cough, dyspnea, and pain; the patient’s condition may progress to meningitis, sep- Circle the letters that correspond to the best ticemia, shock, and death. Which of the following statements accurately include a characteristic rash that progresses describe factors affecting safety in the general to crusted scabs in 5 days. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Check agency policy for the application of that progresses symmetrically in a descend- restraints and secure a physician’s order. Choose the most restrictive type of device result abruptly in respiratory failure. Smallpox produces fever, myalgias, conjunc- that a finger cannot be inserted between tival symptoms, mild hypotension, and the restraint and the patient’s wrist or petechial hemorrhages; the patient’s condi- ankle. Remove the restraint at least every 2 hours cause diarrhea, nausea, and respiratory or according to agency policy and patient distress. Remove restraint at least every 2 hours; reassure patient at regular intervals and 6. Which of the following would be an age-appro- assess for signs of sensory deprivation. Childproof the house to ensure that poisonous products and small objects are out of reach. Provide drug, alcohol, and sexuality Match the type of poisonous agent in Part A education. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Falls, fires, and motor vehicle crashes are significant hazards for this age group, a. Acetaminophen (products containing Tylenol) and safety measures should be directed b. Education for this group must focus on safe driving skills, the dangers of drug c. Hydrocarbons (gasoline, kerosene, furniture and alcohol use, and creation of a polish, lamp oil) healthy lifestyle as a way to respond to d. Nausea, vomiting, diarrhea, abdominal drug use, and exposure to dangers in the pain, melena, hematemesis, lethargy, environment. Vigilant supervision by parents and Treatment: guardians is required to anticipate hazards and provide protection for this 4. Safety care for this group entails never leaving them unattended, using crib rails, and monitoring objects that may 5. Adult caregivers must use at least two patient iden- tifiers (neither to be the patient’s room num- g. This age group needs assistance to evalu- True False ate activities that are potentially danger- 3. A person with a history of falling is at great ous and to discuss specific interventions risk to fall again. True False Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Asphyxiation may occur in any age group, but the incidence is greatest among older adults. A rear-facing safety seat is recommended for infants who are younger than 1 year old and weigh less than 20 pounds. Limitation in mobility: parental responsibility is on childproofing the environment. As the primary reason for applying restraints, nurses consistently cite the risk for injury to e. Limitation in knowledge: patients and healthcare workers from irrational behavior. Using a restraint on an older person who tends to wander is justified to ensure his/her safety. The number of deaths from accidental is necessary when assessing the patient for poisoning has decreased over the years. School-aged child: Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

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One way to describe this process is to say that the antigen selects the corresponding B-cell type to which it most effi- ciently binds purchase zudena from india impotence organic. However buy genuine zudena online erectile dysfunction caused by guilt, as long as the responding B cells do not proliferate, the specificity of the response is restricted to a very small number of cells. For an effective response, clonal proliferation of the responsive B cells must be induced. After several cell divisions B cells differentiate into plasma cells which release the specific receptors into the surroundings in the form of soluble antibodies. B-cell stimulation proceeds with, or without, T cell help depending on the structure and amount of bound antigen. Antigens can be divided into two categories; those which stimulate B cells to secrete antibodies without any T-cell help, and those which require additional T-cell signals for this purpose. These include paracrystalline, identical epitopes arranged at approximately 5–10 nm intervals in a repetitive two-dimensional pattern (e. Either type of antigen can induce B cell activation in the absence of T cell help. These antigens are less stringently arranged, and are usually flexible or mobile on cell surfaces. These are monomeric or oligomeric (usually soluble) antigens that do not cause Ig cross-linking, and are unable to induce B-cell proliferation on their own. In this case an additional signal, provided by contact with T cells, is required for B-cell activation (see also B-cell tolerance, p. Receptors on the surface of B cells and soluble serum antibodies usually re- cognize epitopes present on the surface of native antigens. For protein anti- gens, the segments of polypeptide chains involved are usually spaced far apart when the protein is in a denatured, unfolded, state. A conformational or structural epitope is not formed unless the antigen is present in its native configuration. So-called sequential or linear epitopes—formed by contigu- ous segments of a polypeptide chain and hidden inside the antigen—are lar- gely inaccessible to B cell receptors or antibodies, as long as the antigen mol- ecule or infectious agent retains its native configuration. The specific role of linear epitopes is addressed below in the context of T cell-mediated immunity. B cells are also frequently found to be capable of specific recognition of sugar molecules on the surface of infectious agents, whilst T cells appear to be in- capable of recognizing such sugar molecules. As mentioned above, contact between one, or a few, B-cell receptors and the correlating antigenic epitope does not in itself suffice for the induction of B-cell proliferation. Instead proliferation requires either a high degree of B cell receptor cross-linking by antigen, or additional T cell- mediated signals. Proliferation and the rearrangement of genetic material—a continuous process which can increase cellular numbers by a million-fold—occasionally Kayser, Medical Microbiology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license Immune Responses and Effector Mechanisms 69 result in errors, or even the activation of oncogenes. The results of this process may therefore include the generation of B-cell lymphomas and leukemia’s. Uncontrolled proliferation of differentiated B cells (plasma cells) results in the generation of monoclonal plasma cell tumors known as multiple mye- 2 lomas or plasmocytomas. Occasionally, myelomas produce excessive amounts of the light chains of the monoclonal immunoglobulin, and these proteins can then be detected in the urine as Bence-Jones proteins. Such proteins represented some of the first immunoglobulin components acces- sible for chemical analysis and they revealed important early details regard- ing immunoglobulin structure. It is possible to isolate a single cell from such a polyclonal immune response in an experimental setting. Fusing this cell with an “immortal” proliferating myeloma cell results in generation of a hybridoma, which then produces chemically uniform immunoglobulins of the original specificity, and inwhatever amounts are required. This method was developed by Koeler and Milstein in 1975, and is used to produce mono- clonal antibodies (Fig. Many monoclonal antibodies are still produced in mouse and rat cells, making them xenogeneic for hu- mans. Attempts to avoid the resulting rejection problems have involved the production of antibodies by human cells (which remains difficult), or the “humanization” of murine antibodies by recombinant insertion of the variable domains of a murine antibody adjacent to the constant domains of a human antibody. The generation of a transgenic mice, in which the Ig genes have been replaced by human genes, has made the production of hy- bridoma’s producing completely human antibodies possible. However, if the antigen is in a monomeric, or oligomeric, soluble form the B cell can only mount a response if it undergoes the process of T-B collaboration. Many infectious pathogens carry surface antigens with polyclonal activation properties (e. They then receive a second, in- travenous, dose of antigen twoto four days before cell fusion. Those spleen cells that fail to fuse to a myeloma cell die within one day of culture. Aminopterin blocks specific metabolic processes, but with the help of the intermediary metabolites (hypoxanthine and thymidine) spleen cells are able to complete these processes using auxiliary pathways. After this time, the cell culture is diluted such that there is, ideally, only one hy- bridoma within each well. If the result is positive, the hybridoma cells are subcloned several times to ensure clonality; with the specificity of the produced antibody being checked following each round to subcloning. Production of purely human mono- clonal antibodies is carried out using mice whose Ig genes have been completely replaced by human Ig genes. Immune Responses and Effector Mechanisms 71 repeated in a regular pattern (linear e. These paracrystalline-patterned antigens are capable of inducing B-cell responses without contact-dependent T cell help. Such B-cell responses are usually of the IgM type, since switching to different 2 isotype classes is either impossible or very inefficient in the absence of T cell help. The IgM response is of a relatively brief duration (exhibiting a half-life of about 24 h), but can nonetheless be highly efficient. Examples of this effi- ciency include IgM responses induced by many viral envelope antigens which bear neutralizing (“protective”) determinants accessible tothe corresponding antibodies, and responses to bacterial surface antigens (e. This is often mediated by the binding of the bacterial or viral product to the constant segment of certain Vb chains (and possibly Va chains) with a low level of specificity (see Fig. Endogenous superantigens are derived from components of certain retroviruses found in mice, and which display superantigen-like be- havior (e. Foreign antigens, whose three-dimensional structures are recognized by B cells, also contain linear peptides. ClustersofBcells(so-calledprimary follicles) are located in the cortex, where following antigen-stimulation, secondary follicleswithgerminalcentersdevelop(rightside).

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There is scope for improved methods trihexyphenidyl discount zudena 100mg free shipping erectile dysfunction due to zoloft, orphenadrine) commonly cause side effects of packaging to reduce over- or under-dosage cheap zudena master card whey protein causes erectile dysfunction. Glaucoma regimens are confusing and increase the risk of adverse inter- may be precipitated or aggravated and confusion may occur actions (see Chapter 13). Cerebral function in old people is easily disturbed, resulting in disorientation and confusion. It is shorter time, their sleep is more likely to be broken and they are important to start with a low dose and monitor carefully. Before hypnotics are commenced, other possible factors likely to suffer severe consequences, such as falls/fractures should be considered and treated if possible. Hypokalaemia due to decreased potassium intake (potassium-rich foods are often expensive), faulty homeo- Diabetes is common in the elderly and many patients are static mechanisms resulting in increased renal loss and the con- treated with oral hypoglycaemic drugs (see Chapter 37). It is comitant use of diuretics is more common in the elderly, and is best for elderly patients to be managed with diet if at all possi- a contributory factor in some patients. In obese elderly diabetics who remain symptomatic on prescribed when there is no indication for it (e. In one drugs because of the risk of hypoglycaemia: chlorpropamide series of geriatric patients on digoxin, the drug was withdrawn (half-life 36 hours) can cause prolonged hypoglycaemia and is in 78% of cases without detrimental effects. Brisk diuresis in patients with mental impairment or reduced The decline in renal function must be borne in mind when an mobility can result in incontinence. For many patients, a thia- antibiotic that is renally excreted is prescribed, especially if it is zide diuretic, such as bendroflumethiazide, is adequate. Appendix 3 diuretics, such as furosemide, should be used in acute heart of the British National Formulary is an invaluable practical guide. Broad-spectrum drugs including uncommon with low doses of diuretics, but plasma potassium cephalosporins and other beta-lactams, and fluoroquinones are should be checked after starting treatment. If clinically important common precursors of Clostridium difficile infection which has a hypokalaemia develops, a thiazide plus potassium-retaining high mortality rate in the elderly. Amoxicillin is the most com- diuretic (amiloride or triamterene) can be considered, but there mon cause of drug rash in the elderly. Flucloxacillin induced is a risk of hyperkalaemia due to renal impairment, especially cholestatic jaundice and hepatitis is more common in the elderly. Thiazide-induced gout and Case history glucose intolerance are important side effects. An 80-year-old retired publican was referred with ‘congest- ive cardiac failure and acute retention of urine’. His other medication included ketoprofen for osteoarthritis and fre- These drugs plays an important part in the treatment of chronic quent magnesium trisilicate mixture for indigestion. He heart failure, as well as hypertension (see Chapters 28 and 31), had been getting up nearly ten times most nights for a year and are effective and usually well tolerated in the elderly. During the day, he frequently passed small However, hypotension, hyperkalaemia and renal failure are amounts of urine. The possibility of atheroma- were due to the fact that he drank two pints of beer each tous renal artery stenosis should be borne in mind and serum day since his retirement seven years previously. On physical examination he was clinically anaemic, but Potassium-retaining diuretics should be co-administered only not cyanosed. Rectal examination revealed an enlarged, symmetrical prostate and black tarry faeces. Initial laboratory results revealed that the patient had acute on chronic renal failure, dangerously high potassium 5. Drugs should seldom be used to treat symptoms without urinary catheterization, furosemide and haemodialysis. Drugs should not be withheld because of old age, but it doxazosin and ranitidine, and paracetamol as required. Do not use a drug if the symptoms it causes are worse Answer Co-amilozide – hyperkalaemia: amiloride, exacerbation of than those it is intended to relieve. It is seldom sensible to treat the side effects of one drug Chlorpromazine – urinary retention by prescribing another. Ketoprofen – gastric ulcer, antagonism of thiazide diuretic, salt retention, possibly interstitial nephritis In the elderly, it is often important to pay attention to mat- Magnesium trisilicate mixture – additional sodium load ters such as the formulation of the drug to be used – many old (6mmol Na /10mL). Supervision of drug taking may be necessary, as Iatrogenic disease due to multiple drug therapy is common in the elderly. The use of amiloride in renal impairment an elderly person with a serious physical or mental disability leads to hyperkalaemia. This patient’s confusion and rest- cannot be expected to comply with any but the simplest drug lessness were most probably related to his renal failure. Containers require especially clear labelling, and Chlorpromazine may mask some of the symptoms/signs and should be easy to open – child-proof containers are often also delay treatment of the reversible organic disease. The sodium content of some antacids can adversely affect cardiac and renal failure. A proton pump inhibitor should be A previously mentally alert and well-orientated 90-year-old woman became acutely confused two nights after hospital considered as prophylaxis against upper gastro-intestinal admission for bronchial asthma which, on the basis of peak complications in those most at risk. Improper prescription of drugs is a common cause of morbid- Answer ity in elderly people. Common-sense rules for prescribing do Prednisolone, cimetidine, digoxin and nitrazepam. Comment not apply only to the elderly, but are especially important in If an H2-antagonist is necessary, ranitidine is preferred in the this vulnerable group. It is likely that the patient no longer requires digoxin (which accumulates in the elderly). Take a full drug history (see Chapter 1), which should not be used for sedation in elderly (or young) asthmatics. The implications of a angiotensin receptor blockers in heart failure and high cardiovas- growing evidence base for drug use in elderly patients. British Journal of Clinical Pharmacology 2006; 61: Vitamin D and bisphosphonates for fractures and osteoporosis. Drugs and Aging ers in heart failure and thrombolytics in acute myocardial infarc- 2000; 17: 353–62. Three further minor cat- egories of adverse drug reaction have been proposed: Adverse drug reactions are unwanted effects caused by nor- mal therapeutic doses. The classification proposed by Rawlins nephropathy); and Thompson (1977) divides reactions into type A and type B 2. They are dose-related and usually treatment with benzodiazepines or β-adrenoceptor mild, although they may be serious or even fatal (e. The term ‘side effects’ is often applied to minor type products available directly or on prescription. Exposure to drugs in the the drug’s main pharmacological action, are not dose-related population is thus substantial, and the incidence of adverse and are severe, with a considerable mortality. Type A reactions are pathophysiology of type B reactions is poorly if at all under- reported to be responsible for 2–3% of consultations in general stood, and often has a genetic or immunological basis. In a recent prospective analysis of 18820 hospital reactions occur infrequently (1:1000–1:10000 treated subjects admissions by Pirmohamed et al.

E. Kor-Shach. University of Hawai`i, West O`ahu.