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By O. Ballock. State University of New York College of Agriculture and Technology, Cobleskill.

Antibody-Dependent Cellular Immunity and Natural Killer Cells Lymphocytes can nonspecifically bind IgG antibodies by means of Fc recep- tors sildigra 100mg visa, then specifically attack targets cells (e discount sildigra 100 mg otc. This recognition process functions via special receptors that are not expressed in a clonal manner buy 100mg sildigra fast delivery. Humoral, Antibody-Dependent Effector Mechanisms The objectives of the immune response include: the inactivation (neutraliza- tion) and removal of foreign substances, microorganisms, and viruses; the rejection of exogenous cells; and the prevention of proliferation of patho- logically altered cells (tumors). The systems and mechanisms involved in these effector functions are largely non-specific. Specific immune recognition by B and T cells directs these effector mechanisms to specific targets. Usage subject to terms and conditions of license 86 2 Basic Principles of Immunology digestion. Opsonization involves the coating of such microbes with Fc-ex- pressing antibodies which facilitates their phagocytosis by granulocytes. Many cells, particularly phagocytes (and interestingly enough also some bac- teria like staphylococci), bear surface Fc receptors that interact with different Ig classes and subclasses. Mast cells and basophils bear IgE molecules, and 2 undergo a process of degranulation following interaction with allergens against which the IgE molecules are directed. It is made up of a co-operative network of plasma proteins and cellular receptors, and is largely charged with the following tasks: & Opsonization of infectious pathogens and other foreign substances, with the aim of more efficient pathogen elimination. Bound complement factors can: enhance the binding of microbes to phagocytozing cells; result in the activation of inflammatory cells; mediate chemotaxis; induce release of inflammatory mediators; direct bactericidal effects; and induce cell lysis (Fig. The pro- duction of a C3 convertase, which splits C3 into C3a and C3b, is common to both pathways. C3b degradation products are recognized by recep- tors on B lymphocytes; they stimulate the production of antibodies as well as pathogen phagocytosis. The cleavage products C3a and C4a are chemotactic in their action, and stimulate expression of adhesion molecules. Nomenclature: the components of the alternative pathway (or cascade) are desig- nated by capital letters (B, D, H, I; P for properdin), those of the classical pathway (or cascade) plus terminal lysis are designated by “C” and an Arabic numeral (1–9). Component fragments are designated by small letters, whereby the first fragment to be split off (usually of low molecular weight) is termed “a” (e. Molecules often group to form complexes; in their designations the indi- vidual components are lined up together and are usually topped by a line. Usage subject to terms and conditions of license Immune Responses and Effector Mechanisms 87 & Solubilization of otherwise insoluble antigen-antibody complexes. Over 20 proteins of the complement system have been identified to date, and are classified as either activation or control proteins. C3 is not only present in the largest amount, but also represents a central structure for complement activation. Usage subject to terms and conditions of license 88 2 Basic Principles of Immunology Immunological Cell Death 2 Fig. During classic activation of complement, C1q must be bound by at least two antigen-antibody immune complexes, to which C4 and C2 then attach themselves. Pentameric IgM represents a particularly efficient C activator since at least two Ig Fc components in close proximity are required for C1q binding and activation. During alternative activation of complement, the splitting of C3 occurs directly via the action of products derived from microorganisms, endotoxins, polysaccharides, or aggregated IgA. C3b, which is produced in both cases, is activated by the factors B and D, then itself acts as C3 convertase. Subsequent formation of the lytic complex, C5–C9 (C5–9), is identical for both classic Kayser, Medical Microbiology © 2005 Thieme All rights reserved. Usage subject to terms and conditions of license Immune Responses and Effector Mechanisms 89 and alternative activation, but is not necessarily essential since the released chemotaxins and opsonins are often alone enough to mediate the functions of microbe neutralization and elimination. Some viruses can activate the complement system without the intervention of antibodies by virtue of their ability to directly bind C1q. Importantly, without a stringent control mechanism complement would be activated in an uncontrolled manner, resulting in the lysis of the hosts own cells (for instance erythrocytes). Complement Control Proteins The following regulatory proteins of the complement system have been character- ized to date: C1 inhibitor, prevents classic complement activation. This protein is lacking in patients suffering from paroxysmal nocturnal hemoglobinuria. This is a glycolipid anchored within the cell surface which prevents C9 from binding to the C5b-8 complex, thus protecting the cell from lysis. Those complement components with the most important biological effects include: & C3b, results in the opsonization of microorganisms and other antigens, either directly or in the form of immune complexes. C5a initi- ates the chemotactic recruitment of granulocytes and monocytes, promotes their aggregation, stimulates the oxidative processes, and promotes the re- lease of the thrombocyte activating factor.

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Examples include sumatriptan (Imitrex) discount 100mg sildigra with visa, rizatriptan (Maxalt) generic 100 mg sildigra mastercard, naratriptan (Amerge) cheap sildigra 100mg otc, and zolmitriptan (Zomig). There are drugs that can be taken regularly to prevent migraines (reduce the frequency). Examples include beta-blockers (propranolol), calcium channel blockers (verapamil), and antidepres- sants (amitriptyline and nortriptyline). These drugs can cause serious side effects, so speak to your doctor and pharmacist. Foods to avoid: • Food additives, preservatives, and dyes can trigger migraines (benzoic acid, tartrazine). Limit foods high in salt (snack foods, deli meats) and avoid using the salt shaker. Try an elimination diet to determine if food sensitivities are triggering your migraines (see Appendix D). This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses, such as muscle tension. Do moderate-intensity activities (walking, swimming, and cycling) and warm up slowly because sudden, intense activity can trigger a headache. Record what you ate that day and any 334 factors that you feel could have triggered the event, such as stress, reaction to a smell, or light. This information will also be helpful to your doctor in determining a treatment strategy. Top Recommended Supplements M Butterbur: Reduces inflammation and spasms in cerebral blood vessels. Two studies have found that it significantly reduces the frequency of migraine attacks. Look for a product standardized to contain at least 15 percent pet- asins, the main active ingredient. Feverfew: Several studies have shown that it can reduce the severity and frequency of migraines. It may work by modulating serotonin release and reducing production of inflammatory substances in the brain. Magnesium: Those with migraines often have low magnesium levels, which can lead to cerebral artery spasm and increase the release of substances that cause pain. Three studies have found that magnesium supplements can significantly reduce migraine attacks. Complementary Supplements Fish oils: Reduce inflammation and blood vessel spasms and support healthy brain function. Preliminary research shows the supplements can reduce frequency and severity of migraines. Vitamin B2 (riboflavin): Shown to reduce the frequency and severity of migraine head- aches. Eat small, frequent meals and include more whole grains, nuts, seeds, and fish in your diet. When suffering with a migraine, use cold packs on the head and neck, rest in a dark room, and use medications only if necessary. This results in inflammation and injury to the sheath and M ultimately to the nerves that it surrounds. Over time this damage can slow or block the nerve signals that control muscle coordination, strength, sensation, and vision, causing fatigue, numbness, loss of balance, impaired vision, and disability. It is thought that several factors may be involved, such as genetic predisposition, environment, and exposure to a viral infection. It is known that lifestyle factors, such as stress and poor nutrition, can exac- erbate symptoms. There are medications, dietary approaches, and supplements that can help reduce symptoms and promote remission. One of the proteins in milk mimics a particular protein affiliated with human myelin. These drugs are classed as “partially effective” in reducing relapses and worsening of the disease. Examples include: Beta interferons: Interferon beta-1b (Betaseron) and interferon beta-1a (Avonex, Re- bif) are genetically engineered copies of proteins that occur naturally in your body. They are taken by injection and help fight viral infection and regulate your immune system. These drugs reduce but don’t eliminate flare-ups, they don’t reverse damage, and they haven’t been proven to significantly alter long-term development of perma- nent disability. Some people develop antibodies to beta interferons, which may make them less effective.

Antipsychotics Psychosis is a disorder that is characterized by a number of symptoms discount sildigra 100 mg free shipping. These include difficulty processing information and reaching a conclusion; experienc- ing delusions or hallucinations; being incoherent or in a catatonic state; or demonstrating aggressive violent behavior purchase sildigra 100mg without a prescription. Schizophrenia is a chronic psychotic disorder where patients exhibit either positive or negative symptoms buy 100mg sildigra mastercard. Positive symptoms are exaggeration of normal function such as agitation, incoherent speech, hallucination, delusion, and paranoia. Negative symptoms are characterized by a decrease or loss of motiva- tion or function such as social withdrawal, poor selfcare, and a decrease in the content of speech. Psychosis is caused by an imbalance in the neurotransmitter dopamine in the brain. Antipsychotic medication, also known as dopamine antagonists, block the D2 dopamine receptors in the brain thereby reducing the psychotic symptoms. A number of antipsychotic medications block the chemoreceptor trigger zone and vomiting (emetic) center of the brain. Although blocking dopamine improves the patient’s thought processes and behavior, it can cause side effects. These include symptoms of Parkinsonism (see Parkinsonism previously dis- cussed in this chapter). Patients who undergo long-term treatment for psychosis using antipsychotic medications also might be prescribed drugs to treat the symptoms of Parkinsonism. The typical category of antipsychotic med- ication is further subdivided into phenothiazines and nonphenothiazines. Phenothiazines block norepinephrine causing sedative and hypotensive effects early in treatment. Nonphenothiazines include butyrophenone haloperidol (Haldol) whose phar- macologics are similar to phenothiazines as it alters the effects of dopamine by blocking the dopamine receptor sites. Included in this group are prochlorperazine (Compazine), fluphenazine (Prolixin), perphenazine (Trilafon), and trifluoperazine (Stelazine). These have replaced sedatives that were traditionally used because they have fewer and less potent side effects, especially if an overdose of the medication is given to the patient. Anxiolytics are prescribed when the patient’s anxiety reaches a level where the patient becomes disabled and is unable to perform normal activities. Anxiolytics have a sedative-hypnotic effect on the patient, but not an antipsychotic effect. Primary anxiety is not caused by a medical condition or drug use but may be sit- uational. Anxiolytics are usually not administered for secondary anxiety unless the sec- ondary cause is severe or untreatable. Benzodizepines include chlordiazepoxide (Librium), diazepam (Valium), chlorazepatge dipotassium (Tranxene), oxazepam (Serax), lorazepam (Ativan), and alprazolam (Xanax). Depression About 20% of Americans are depressed; however, one-third receives medical or psychiatric help for their depression. Depression is characterized by mood changes and loss of interest in normal activities. Patients who are depressed might have insomnia, fatigue, a feeling of despair, and an inability to concen- trate. Depression is caused by a number of factors including genetic predisposition, social and environmental factors, and biologic conditions such as insufficient monoamine neurotransmitter (norepinephrine and serotonin). Causes of major depression can include genetic predisposition, social and environmental factors, and biologic conditions. Antidepressants are used to treat depressions, however they also can mask sui- cidal tendencies (Table 15-3). They do not cause hypotension, sedation, anticholinergic effects, or cardiotoxi- city. A n t i c h o l i n e r g i c I n s o m n i a / C a t e g o r y e f f e c t S e d a t i o n H y p o t e n s i o n G I d i s t r e s s C a r d i o t o x i c i t y S e i z u r e s A g i t a t i o n T r i c y c l i c A n t i d e p r e s s a n t s A m i t r i p t y l i n e ( E l a v i l ) + + + + + + + + + + + – + + + + + + + – C l o m i p r a m i n e ( A n a f r a n i l ) + + + + + + + + + + – + + + + + + – D e s p r a m i n e ( N o r p r a m i n ) + + + + + – + + + + + D o x e p i n ( S i n e q u a n ) + + + + + + + + + – + + + + – I m i p r a m i n e ( T o f r a n i l ) + + + + + + + + + + + + + + + + + N o r t r i p t y l i n e ( A v e n t y l ) + + + + + – + + + + + – P r o t r i p t y l i n e ( V i v a c t i l ) + + + + + + – + + + + + T r i m i p r a m i n e ( S u r m o n t i l ) + + + + + + + + + + – + + + + + + – S e l e c t i v e S e r o t o n i n R e u p t a k e I n h i b i t o r s F l u o x e t i n e ( P r o z a c ) – + – + + + – 0 / + + + F l u v o x a m i n e ( L u v o x ) – + + – + + + – – + + P a r o x e t i n e ( P a x i l ) – + – + + + – – + + S e r t r a l i n e ( Z o l o f t ) – + – + + + – – + + T a b l e 1 5 - 3. The enzyme monoamine oxidase inactivates norepinephrine, dopamine, epinephrine, and serotonin. Examples of these drugs includes isocarboxazid (Marplan), phenelzine sulfate (Nardil), and tranycypromine sulfate (Parnate). A list of drugs utilized in the treatment of depression is provided in the Appendix. Summary There are many medications that either interfere with impulses transmitted over the neural pathways or stimulate those impulses. Medications that interfere with impulses are called inhibitors and usually compete with neurotransmitters for receptor sites. That is, the medication gets to the receptor site before the neurotransmitters blocking the neurotransmitters from delivering the impulse to the receptor site. There are four major groups of medications that stimulate the central nervous system.

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Use of toluidine blue increased the detection rate of posterior fourchette lacerations from 4 to 58% in adult (older than 19 years) complainants of nonconsensual vaginal intercourse order 100 mg sildigra overnight delivery, from 4 to 28% in sexually abused adolescents (11–18 years old) cheap sildigra 100mg without a prescription, and from 16 purchase 100mg sildigra visa. The same frequency of posterior fourchette lacerations has been identi- fied by use of the stain in adolescents after consensual penile penetration and nonconsensual sexual acts (129). In contrast, adult complainants of nonconsensual vaginal intercourse and sexually abused children had signifi- cantly more lacerations demonstrable by toluidine blue staining than control groups (130), although such staining does not identify lacerations that cannot be detected using a colposcope (123). Therefore, if a colposcope is not avail- able, toluidine blue may be an adjunct to the genital assessment of prepubertal and adult complainants of vaginal penetration (129,130). Furthermore, some centers use the stain during colposcopy to provide a clear pictorial presenta- tion of the injuries for later presentation to juries (123). Toluidine blue (1%) is then painted on the posterior fourchette, using Sexual Assualt Examination 93 a swab, before any instrumentation. After a few seconds, the residual stain is removed with lubricating jelly and gauze (128). The time parameters within which the use of toluidine blue is beneficial in highlighting injuries have not been identified. Injuries Little information is available regarding the incidence and type of geni- tal injuries that result from consensual sexual acts involving the female geni- talia. Although penile–vaginal penetration is the most frequent sexual act performed by heterosexual couples, anecdotal reports from doctors who regu- larly conduct nonforensic assessments of the female genitalia (general prac- titioners, gynecologists, or genitourinary physicians) suggest that injuries resultant from sexual activity are rarely identified. However, this may be explained by the nature of routine assessments, which are usually limited to naked-eye inspection or because of the rapid and complete resolution of minor injuries (90). On the other hand, there are reports describing genital injuries in complainants of sexual assault, although, unfortunately, few have matched the findings with the specific complaint or the subsequent outcome in court. To date, no case-control study has compared the genital findings in complainants of sexual assault with those in a sexually active control popu- lation. External Genitalia For penile penetration of the vagina to occur, the penis must first pass between the labia minora and through the hymenal opening. The apposition of the penis and the posterior fourchette in the majority of sexual positions means that this area may be stretched, rubbed, or receive blunt trauma as vaginal penetration is achieved. Lacerations, abrasions, or bruises at the posterior fourchette have all been described after consensual sexual activity, although in all these cases, the examinations were enhanced by the use of toluidine blue or a colposcope (90,128,129). Wilson (131) has also described macroscopi- cally visible hematomata of the labia with consensual sexual activity. Among 311 postpubertal females (age range 11–85 years) who made a “valid” (defined as “police investigation corroborated the victim’s history and the victim did not recant”) complaint of sexual assault, 200 had colposcopically detected injuries at one or more of the following sites on the external genita- lia: posterior fourchette, labia minora, hymen, and fossa navicularis (90). Although all categories of injuries (“tears,” bruises, abrasions, redness, and 94 Rogers and Newton swelling) were described at all sites, the predominant injuries described were site dependent; for example, tears were most frequently described on the pos- terior fourchette (n = 83) and fossa navicularis (n = 28), whereas abrasions were most frequently described on the labia minora (n = 66) and bruises were the most frequent injuries seen on the hymen (n = 28) (90). Adams and col- leagues found similar types and distributions of injuries among the adoles- cent complainants (14–19 years) they examined (132). In this population, tears of the posterior fourchette or fossa navicularis were the most common find- ings (40%). The studies of macroscopic findings among complainants of sexual assault have also found that most of the injuries detected are located on the external genitalia (133,134). Healing of lacerations of the posterior fourchette is predominantly by first intention, with no residual scarring being detected at follow-up assess- ments (90). Nonetheless, scarring may occur occasionally in these areas, but it is important not to mistake a linear vestibularis, a congenital white line iden- tified in the fossa navicularis (present in 25% of neonates), for a scar (135). Accidental injuries of the external genitalia of female children are well documented in the literature. The site and nature of the injury will depend on the type of trauma and the conformation of any object involved (136,137). Hymen The hymen must be examined in detail after an allegation of a nonconsensual penetrative act. When the hymen is fimbriated, this assess- ment may be facilitated by the gentle use of a moistened swab to visualize the hymenal edges. When the hymenal opening cannot be seen at all, application of a few drops of warm sterile water or saline onto the hymen will often reveal the hymenal edges. Foley catheters are also a useful tool to aid hymenal visu- alization in postpubertal females (138). A small catheter is inserted through the hymenal opening, the balloon is then inflated with 10–20 mL of air, and the catheter is gently withdrawn so that the inflated balloon abuts the hymen. Obviously, in the acute setting, none of these maneuvers should be attempted until the relevant forensic samples have been retrieved. There is little specific information available regarding the type and fre- quency of acute hymenal injuries after consensual sexual acts, particularly regarding the first act of sexual intercourse. They found lac- erations (tears) with associated bruising at the 3-o’clock and 9-o’clock posi- tions on the hymen of a 14-year-old and bruises at the 6-o’clock and 7-o’clock Sexual Assualt Examination 95 positions on the hymens of two other females (aged 13 and 33 years). Unfortunately, no details regarding pre- vious sexual experience are recorded on their pro forma.

Key points Key points Bisphosphonates and bone disease Management of acute hypercalcaemia • Used to treat malignant hypercalcaemia order sildigra 100 mg otc, bone pain from • Avoid thiazides buy sildigra 100 mg cheap, vitamin D (milk) sildigra 100mg lowest price, any calcium metastatic cancer (breast, prostate) and Paget’s disease, preparations and, if possible, immobilization. It is contraindicated in absorbed dose is excreted unchanged in the urine, but the patients with other metabolic bone diseases, including hyper- remainder is excreted over many weeks. This is a 32-amino-acid polypeptide hormone secreted by thy- roid parafollicular C-cells. This is accom- used to lower the plasma calcium concentration in hypercal- panied by a modest reduction in plasma calcium and phos- caemia, especially from malignancy, and in the treatment of phate. It is given by mouth for secondary hyperparathyroidism and for post-menopausal osteoporosis (together with calcium in patients on dialysis for end-stage renal disease and for and vitamin D supplements, if diet is inadequate). Plasma calcium, phosphate, alkaline phos- phatase and if possible urine hydroxyproline excretion are Case history monitored. A 52-year-old woman has had epilepsy since childhood, treated with phenytoin 300mg/day and her fits have been Mechanism of action well controlled. Since the loss of her job and the death of her husband she has become an alcoholic. In the kidney, it decreases the reabsorp- has no sensory symptoms in her limbs and no sphincter prob- 2 lems. Neurological examination of her legs is normal apart tion of both Ca and phosphate in the proximal tubules. Clinical investigations reveal that haemoglobin, white Adverse effects blood and platelets are normal, but her erythrocyte sedi- mentation rate is 30mm per hour, her blood glucose level is Adverse effects include the following: 5. Answer Strontium is a bone-seeking element; it was widely used for This patient has hypocalcaemia with hypophosphataemia and a raised alkaline phosphatase, but no evidence of renal osteoporosis in the 1950s, but there were concerns that it dysfunction. This is the clinical picture of a patient with osteo- inhibited calcitriol synthesis and might cause defective bone malacia. The mechanism of these effects is complex and calcium-deficient diet and incorrect dosing. Phenytoin is a potent indicates that strontium ranelate reduces bone reabsorption inducer of hepatic drug metabolizing enzyme systems, including the enzymes involved in vitamin D metabolism, and increases bone formation, and reduces vertebral and hip specifically metabolism of calciferol to 25 -hydroxycholecal- fractures in women with post-menopausal osteoporosis. It is ciferol by the liver, and its further metabolism to inactive given by mouth at night to older women with osteoporosis products. It also impairs the absorption of vitamin D from the and a history of bone fracture when bisphosphonates are gut. Treatment of this form of drug-induced osteomalacia consists of giving the patient oral Ca2 supplements together contraindicated or not tolerated. Recombinant human parathyroid hormone: osteoporosis is proving amenable to treatment. The adrenal cortex secretes: Adverse effects Adverse effects of glucocorticosteroids are common to all 1. Glucocorticosteroids • osteoporosis; influence carbohydrate and protein metabolism, and play a • glucocorticosteroid therapy is weakly linked with peptic vital role in the response to stress. Glucocorticosteroids stimu- ulceration, and can mask the symptoms and signs of late the mobilization of amino acids from skeletal muscle, bone gastrointestinal perforation; and skin, promoting their transport to the liver where they are • mental changes: anxiety, elation, insomnia, depression converted into glucose (gluconeogenesis) and stored as glyco- and psychosis; gen. Fat mobilization by catecholamines is potentiated by • posterior cataracts; glucocorticosteroids. The major therapeutic uses of the gluco- • proximal myopathy; corticosteroids exploit their powerful anti-inflammatory and • growth retardation in children; immunosuppressive properties. Applied topically to skin or mucous membranes, after prolonged glucocorticosteroid administration. Gradual potent steroids can cause local vasoconstriction and massive tapered withdrawal is less hazardous. However, even in doses administered systemically can cause hypertension due to patients who have been successfully weaned from chronic treat- generalized vasoconstriction. The receptor–glucocorticosteroid unusual if the daily glucocorticosteroid dose is lower than the complex translocates to the nucleus, where it binds to gluco- amount usually secreted physiologically. This increases the transcription of various their underlying condition and also on the dose and duration of signal transduction proteins. Sodium and water retention, potassium loss Haematological Lowers lymphocyte and eosinophil counts; Florid complexion and increases neutrophils, platelets and polycythaemia clotting tendency Alimentary Increases production of gastric acid and pepsin Anorexia and nausea Dyspepsia; aggravation of peptic ulcer Cardiovascular system Sensitizes arterioles to catecholamines; Hypotension, fainting Hypertension, enhances production of angiotensinogen. High-dose intravenous hydrocortisone is used short term At physiological concentrations, it plays little if any part in to treat acute severe asthma (usually followed by oral pred- controlling blood glucose, but it does cause hyperglycaemia nisolone) or autoimmune inflammatory diseases (e. Hydrocortisone cream is relatively low in potency and Glucocorticosteroids – major side effects is of particular use on the face where more potent steroids are contraindicated. Hydrocortisone is rapidly absorbed from the gastro-intestinal • Metabolic effects including hyperglycaemia and tract, but there is considerable inter-individual variation in hypokalaemia occur rapidly, as does insomnia and mood disturbances. Treatment must therefore inflammatory potency of synthetic glucocorticoids be re-evaluated regularly and if long-term use is deemed essen- increases.

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A nurse attains a master’s degree in nursing door of a patient who is receiving oxygen purchase 100mg sildigra with visa. The most important of all basic human needs members of a group home would not be is discount 100 mg sildigra otc. The family is a buffer between the needs of human needs buy sildigra 100mg, physical activity and rest are individual members and society. Relatives such as aunts, uncles, and grandpar- ents are part of what is known as the d. The nuclear family is composed of two member meet his or her basic needs by provid- parents and their children. Which of the following is a developmental institutions and services would be considered task of the family with middle-aged adults? Maintain ties with younger and older Match the correct risk factor category listed in generations Part A with the appropriate example of family c. Place the following list of human needs in order from highest-level needs to lower-level d. Biologic human needs: Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Families in a city ghetto area fear walk- ing to school/work because of gang activity on their street. A first-time mother-to-be is taken to the surgi- ily cannot tolerate what she feels is inad- cal unit for an emergency cesarean birth. A mother returns home from the hospi- an example of how each of the following basic tal with a premature baby for whom she needs can be met by the nurse in caring for must provide care. Physiologic needs: pregnancy tells you she didn’t think she could become pregnant the first time she had sexual relations. Self-actualization needs: cancer finds a lump in her breast during her monthly breast examination. Describe how each tions and explain how each meets the needs family differs from one another. Which fami- of individual family members and society as a lies do you feel have been most effective in whole. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Identify their risk factors, and give an example of a character at risk for each of the following: a. List typical questions that should be part of a Scenario: Samuel Kaplan is an 80-year-old man family assessment. Volunteer some of your time at a local home- less shelter or any other service-oriented organization. Explain how you could attempt to provide Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. What resources might be helpful for and/or ethical/legal competencies are most Mr. Study Guide for Fundamentals of Nursing: The Art and Science of Nursing Care, 7th Edition. Which of the following statements accurately describes a characteristic of a system? A system is an entity in itself and cannot communicate with or react to its Circle the letter that corresponds to the best environment. A theory is based on facts and contains allow energy, matter, or information to absolute or direct proof. Each system is independent of its subsystems that gives meaning to a series of events. When a nursing theorist identifies a specific through which of the following processes? Which of the following theorists believed that a person is a biopsychosocial being who is c. According to Levine’s theory of nursing, nurs- ing practice should focus on which of the d. The human and the complexity of his or when using the quantitative research process? State the research problem as a general to the behavioral system, when illness problem, as opposed to focusing narrowly occurs on the problem being studied.

Its principal cavity generic 100 mg sildigra, the sinus venarum cavarum buy sildigra 100mg without prescription, is between the two vena cavae and the atrioventricular (between an atrium and a ventricle) openings buy sildigra 100 mg with visa. The point where the right atrium’s auricle joins with its principal cavity is marked externally by the sulcus terminalis and internally by the crista terminalis. Openings into the right atrium include the following: The superior vena cava, which has no valve and returns blood from the head, thorax, and upper extremities and directs it toward the atrioventricular opening The inferior vena cava, which returns blood from the trunk and lower extremities and directs it toward the fossa ovalis in the interatrial septum, which also has no valve The coronary sinus, which opens between the inferior vena cava and the atrio- ventricular opening, returns blood from the heart, and is covered by the ineffec- tive Thebesian valve An atrioventricular opening covered by the tricuspid valve Chapter 10: Spreading the Love: The Circulatory System 167 The fossa ovalis is an oval depression in the interatrial septum that corresponds to the foramen ovale of the fetal heart. If the foramen ovale does not close at birth, it causes a condition known as “blue baby. The ventricles The heart’s ventricles are sometimes called the pumping chambers because it’s their job to receive blood from the atria and pump it back to the lungs and out into the body’s network of arteries. More force is needed to move the blood great distances, so the myocardium of the ventricles is thicker than that of either atrium, and the myocardium of the left ventricle is thicker than that of the right. The right ventricle only has to move blood to the lungs, so its myocardium is only one- third as thick as that of its neighbor to the left. Roughly triangular in shape, the right ventricle occupies much of the sternocostal (front) surface of the heart and forms the conus arteriosus where it joins the pulmonary artery, or trunk. The right ventricle extends downward toward where the heart rests against the diaphragm. A circular opening into the pulmonary trunk is covered by the pulmonary semilunar valve, so- called because of its three crescent-shaped cusps. When the ventricle relaxes, the blood from the pulmonary artery tends to flow back toward the ventricle, filling the pockets of the cusps and causing the valve to close. The atrial surface of the tricuspid valve is smooth, but the side toward the ventricle is irregular, forming a ragged edge where the chordae tendineae attach. These fibrous cords, which are attached to nipple-shaped projec- tions called papillary muscles in the ventricle’s wall, prevent blood from flowing back into the atrium. Cardiac muscle in the ventricle’s wall is in an irregular pattern of bun- dles and bands called the trabeculae carneae. Longer and more conical in shape, the left ventricle’s tip forms the apex of the heart. This ventricle’s chordae tendineae are fewer, thicker, and stronger, and they’re attached by only two larger papillary muscles, one on the front (anterior) wall and one on the back (posterior). Its opening to the aorta is protected by the aortic semilunar valve, composed of three half-moon cusps that are larger, thicker, and stronger than the pulmonary valve’s cusps. Between these cusps and the aortic wall are dilated pockets called aortic sinuses, which are openings for the coro- nary arteries. Use the terms that follow to identify the heart’s major vessels shown in Figure 10-2. The cavity in the heart that contains the areas called the sinus venarum cavarum and a blind pouch called the auricle is the a. The atrioventricular opening between the right atrium and right ventricle is covered by the a. Four structures play key roles in this dance — the sinoatrial node, atrioventricular node, atrioventricular bundle, and Purkinje fibers. Rather than both contracting and conducting impulses as other cardiac muscle does, these structures specialize in conduction alone, setting the pace for the rest of the heart. Following is a bit more information about each one: Sinoatrial node: This node really is the pacemaker of the heart. Located at the junction of the superior vena cava and the right atrium, this small knot, or mass, of specialized heart muscle initiates an electrical impulse that moves over the musculature of both atria, causing atrial walls to contract simultaneously and emptying blood into both ventricles. Atrioventricular node: The impulse that starts in the S-A node moves to this mass of modified cardiac tissue that’s located in the septal wall of the right atrium. Also called the A-V node, it directs the impulse to the A-V bundles in the septum. Atrioventricular bundle: From the A-V node, the impulse moves into the atri- oventricular bundle, also known as the A-V bundle or bundle of His (pronounced “hiss”). The bundle breaks into two branches that extend down the sides of the interventricular septum under the endocardium to the heart’s apex. Purkinje fibers: At the apex, the bundles break up into terminal conducting fibers, or Purkinje fibers, and merge with the muscular inner walls of the ventricles. The pulse then stimulates ventricular contraction that begins at the apex and moves toward the base of the heart, forcing blood toward the aorta and pulmonary artery. One of the best ways to detect cardiac tissue under a microscope is to look for undu- lating double membranes called intercalated discs separating adjacent cardiac muscle fibers. Gap junctions in the discs permit ions to pass between the cells, spreading the Chapter 10: Spreading the Love: The Circulatory System 171 action potential of the electrical impulse and synchronizing cardiac muscle contrac- tions. Potential problems include fibrillation, a breakdown in rhythm or propagation of the impulses that causes individual fibers to act independently, and heart block, an interruption that causes the atria and ventricles to take on their own rates of contrac- tion. Left atrium Sinoatrial node (pacemaker) Purkinje fibers Atrioventricular node Figure 10-4: Right atrium The conductive Purkinje fibers system of the heart. Wolters Kluwer Health — Lippincott Williams &Wilkins A healthy heart makes a “lub-dub” sound as it beats. The first sound (the “lub”) is heard most clearly near the apex of the heart and comes at the beginning of ventricu- lar systole (the closing of the atrioventricular valves and opening of the semilunar valves).

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