Lecture 4 exam 3

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  1. Family influence on obesity
    • inconsistent eating patterns
    • one or both parents overweight
    • poor dietary choices
  2. Definition of obese
    • BMI of 30+
    • exceeds 95%
  3. Who's most likely to be obese?
    • Hispanic males
    • Black girls
    • Poor
  4. Complications of childhood obesity....describe
    Metabolic syndrome-insulin resistance

    • elevated lipids
    • increased bp
    • elevated fasting blood glucose
  5. Which type of diabetes will an obese person get?
    Type II
  6. Pulmonary complications from being obese
    • asthma
    • sleep apnea
    • exercise intolerance
  7. GI problems from being obese
    • risk for cirrhosis of the liver
    • risk for colon cancer
  8. What is kept in a food diary?
    • time
    • place
    • type and amt eaten
    • why they ate
  9. What is key for success in weight reduction?
    ownership by the child to accept the plan and be on board
  10. When do kids get type I dm?
    • incidence peak 4-6 yo
    • second peak at 10-14
  11. What causes Type I DM
    • viral infections
    • dietary toxins
    • hx of obesity
    • chemicals
  12. What causes Type II DM
    • overweight
    • insulin resistance
    • genetics
    • race
    • *maternal gestational dm
    • Intrauterine growth retardation
    • lack of physical activity
  13. Patho of DM I
    Inflammatory process/autoimmune causes destruction of islet cells making the pancreas unable to make and secrete adequate amounts of insulin
  14. Patho of DM II
    Pancreas makes insulin, but not enough to overcome chronic hyperglycemia
  15. Clinical manifestations of DM I
    • 3P's-polyuria, polydipsia, polyphagia
    • dehydration
    • wt. loss....despite eating
    • fatigue
    • blurred vision
  16. Clinical Manifestations of DM II
    • fatigue
    • yest infections
    • blurred vision
    • frequent urination
    • HTN
    • High triglycerides and LDL's
    • Polycistic ovary syndrome
    • Acanthosis Nigricans (dark skin/back/neck)
  17. Who gets DKA?
    Glucose #
    • DM I
    • urine ketones
    • RR
    • Fruity breath
    • dehydration
    • hypokalemia

  18. 3 tests for DM...what are the levels?
    • Fasting Glucose=126
    • Random serum glucose=200
    • HbA1c= <7%
  19. For Type II DM what is a pre diabetic?  What is a diabetic?
    • Fasting glucose test 140-199 pre diabetic
    • 200+ is diabetic
  20. How do you manage Type I DM
    • continuous insulin therapy
    • nutrition therapy
    • physical activity
    • blood glucose monitoring
  21. How do you manage Type I DM with nutrition?
    count carbs

    • 15g = 1 carb
    • 1 unit of insulin for 5-20 carbs
  22. How do you manage Type II DM
    • Nutrition
    • regular/moderate exercise
    • Insulin therapy to reverse metabolic imbalances
    • blood glucose monitoring
    • Metformin oral meds
    • Follow up with HgA1c tests
  23. Weird things that cause hyper and hypoglycemia
    Hyperglycemia-infection, illness, stress

  24. Behaviors when you have hypo and hyperglycemia
    hypo-irritable, shaky, weak, confused

    hyper-drowsy, lethargic, weak, confused
  25. Pulse/HR for a person with hypo/hyperglycemia
    hypo-full, bounding, rapid

    hyper-weak, rapid
  26. Breathing for a person with hypo/hyperglycemia
    hypo-shallow, no odor

    hyper-deep, labored, rapid, fruity
  27. Onset of hypo vs. hyperglycemia
    hypo-rapid onset and progression

    hyper-slow onset and progression
  28. How do you treat hypo and hyperglycemia?
    hypo-carb liquids/food

    • hyper-non sugar IV fluids
    • insulin
    • electrolytes
  29. Insulins
    • Very short acting-Lispro
    • Short acting-Regular
    • Intermediate-NPH
    • Long Acting-Ultra lente
    • Very Long Acting-Glargine
  30. Which type of DM is more likely to lead to PICU admission when not controlled?
    Type I for hyperglycemia and ketoacidosis
  31. Primary focus for discharge teaching/ed with parents for kids with DM
    • insulin admin-draw up correct dose and admin
    • how to monitor blood sugar and read results
    • other areas....diet, exercise
  32. Age related concerns for infants/toddlers with DM
    • rapid growth/varying metabolic rate affects blood glucose levels and insulin needs
    • picky eater
    • hard to get urine samples from diapers
    • can tell you how they feel-hypo/hyperglycemia
    • afraid of needles
    • don't understand why cant eat things and having painful procedures done
  33. Age related concerns for pre school aged child with DM
    • afraid of body mutilation associated with needles
    • can now tell when they don't feel right
    • have high energy which can affect blood glucose levels
    • compliance and adjustments r/t special occasion with food (Halloween/birthday)
  34. Age related considerations for the school aged kid with DM
    • mastery of own glucose testing/injections
    • now can discuss fears
    • concerns about being different, activity limitations and dietary restrictions
    • noncompliance with junk food
    • anticipate needs for more glucose r/t sports
    • **many get insulin pump**
  35. Age related considerations for adolescents with DM
    • activity, puberty and growth spurts affect glucose and insulin
    • feel isolated from peers related to having DM
    • start experimenting with alcohol/drugs
    • non compliance with diet etc...to be normal
    • **anorexia-purposefully withhold insulin and allow BG to increase to prevent weight gain**
  36. Infants/kids are more vulnerable to alterations in F&E cuz
    • have more water than adults
    • have a higher metabolism
    • greater surface area than adults
    • inadequate fluid conservation with dehydration
    • more vulnerable to fluid overload
    • dependent on others for fluids and can be stubborn
  37. Because infants have a higher concentration of water in their ECF, they can lose fluid equal to their ECF in how long?
    2-3 days
  38. What makes infants less able to concentrate their urine?
    immature renal function...which also makes them more susceptable to acidosis
  39. Infants have a immature lower esophageal sphincter....what's the result?
    they are prone to GERD which can lead to dehydration and electrolyte imbalance
  40. List all infection/diseases that make kids susceptible to F&E  disturbances
    • fever
    • gastroenteritis
    • respiratory infection
  41. Body weight loss for dehydration...mild, moderate, severe
    • mild-4 to 5% (40-50mL/kg)
    • moderate-6-9%
    • severe 10%
  42. With all dehydration the HR will increase....but at severe it....
    increases then drops
  43. What happens to BP during severe dehydration?
    it drops significantly and collapses
  44. How does LOC change with the different stages of dehydration?
    • mild-alert, irritable, restless and THIRSTY
    • moderate-alert, irritable, but lethargic
    • severe-apprehensive, lethargic, COMA
  45. What happens to the anterior fontanelle with the different stages of dehydration?
    • mild-normal
    • moderate-depressed
    • severe-sunken
  46. What happens to skin color with the different stages of dehydration?
    • mild-normal
    • moderate-pale
    • severe-gray and mottled
  47. What happens to peripheral pulses with the different stages of dehydration?
    • mild-normal to slight decrease
    • moderate-weak
    • severe-very weak to absent
  48. What happens to a childs extremity temp with dehydration?
    • mild-warm to cool
    • moderate-cool
    • severe-cold
  49. What happens to capillary refill when a child is severely dehydrated?
    >2 seconds
  50. What happens to urine output when a childs dehydrated?
    • mild-normal, slightly decreased
    • moderate-decreased, dark and inc. USG
    • severe-significantly lower UO to none
  51. What happens to serum levels for a child with dehydration?
    • mild-normal BUN And Cr
    • moderate-increased BUN
    • severe-increased Bun and Cr
  52. Priorities for treating dehydration
    • correct the fluid and electrolyte imbalance
    • treat the cause
    • keep sin intact
    • get the person adequate nutrition....thru an IV if necessary
  53. Vascular access for a dehydrated person
    try peripheral then go intra-osseous
  54. How do you replace fluids for a kid with mild dehydration?
    oral rehydration with Pedialyte....1mL for 1mL replacement
  55. How do you rehydrate a kid with moderate dehydration?
    • rapid oral rehydration with pedialyte (50-100mL/kg over 3 h
    • reevaluate rehydration status every 1-2 hrs
  56. How do you rehydrate a kid with sever dehydration?
    • IV bolus of fluids 20/mL kg of NS or LR
    • when stable start oral rehydration 100mL/kg over 2-4 hrs
    • *continuous evaluation after each bolus of IV solution
  57. What causes diarrhea?
    • intestinal infections
    • food intolerances
    • malabsorption
    • meds
    • colon disease
    • IBS
    • intestinal obstruction
    • emotional stress
    • infectious diseases
  58. List infectious diseases that cause diarrhea
    • otitis media
    • URI
    • UTI
  59. What do you assess with a person who has V/D?
    • frequency
    • amount
    • characteristics
  60. What do you test on stool when a person has diarrhea?
    • ova and parasite
    • occult blood
    • fecal fat
    • pH
  61. What do you test on a persons vomit
    • occult blood
    • pH
  62. What do you test on a persons blood with V/D?
    • Hgb
    • Hct
    • Bun
    • Creatinine
    • CBC
    • Electrolytes
  63. Dx tests done when a person has V/D to rule out other causes
    • pH-GERD
    • upper GI/Endoscopy
    • Radiological-xray/CT
  64. How do you treat a person with diarrhea
    • oral rehydration....avoid juice, milk ok, but need electrolytes...not just water!
    • BRAT diet
    • NPO
    • NG tube
    • perineal care
  65. How do we treat a person who's vomiting?
    • observe vomit
    • assess for associated problems
    • admin antiemetics
    • NPO
    • sips of fluid of not NPO
  66. If a baby is vomiting when do you admit and when do you treat and send home?
    send home if >3 mo or >5kg, alert and mild dehydration

    admit if <3mo or <5kg, prolonged illness and not urine output
  67. Describe failure to thrive
    • weighs <5% for age
    • DD or behind in milestones
    • hypotonia-decreased muscle mass
    • listlessness/fatigue
    • thin hair
    • brittle nails
    • abdominal distention
    • abnormal bowel habits
    • anemia, calcium and or v. deficiencies
    • self stimulating behaviors
    • F&E imbalances
    • decreased immune function
  68. How can a baby be FTT due to inadequate caloric intake?
    • fatigue/weak cuz respiratory, congenital heart, neuromuscular disease
    • Nausea from chemo
    • Poor suck/swallow-premie abnormal jaw shape
    • Cleft/lip palate
    • GI abnormalities-SBO
    • Metabolic/malabsorption syndromes
  69. Examples of ways to supplement ordinary foods with calories
    • MCT oil
    • avocado
    • corn oil
    • breast milk fortifier
    • carnation instant breakfast supplement to milk
    • sour cream
    • peanut butter
  70. What causes GERD?
    incompetent lower esophageal sphincter
  71. Result of GERD
    reflux of gastric contents in to the esophagus leading to ulceration, lung damage, apnea and pulmonary aspiration
  72. If interventions don't happen with GERD what will the child die of?
    respiratory complications
  73. What do 90% of babies do with GERD?
  74. How does esophageal irritation present?
    • fussy after feeds
    • older kids complain of substernal burning
    • dysphagia
  75. Complication after feeds when you have GERD?
  76. Tuttle Test
    • dx of GERD
    • pH monitoring of distal esophagus
    • *pH probe inserted nasoesophageally and sits above stomach
    • pH of 4 or less is diagnostic-ACID
  77. If a baby has GERD how do I burp them?
    over the should and keep upright after feeds
  78. With severe GERD how does a baby lay?
    prone with head elevated....avoid infant seats cuz compresses the abdomen
  79. What is a complication of Reglan for GERD?
    Tardive Dyskinesia-involuntary repetitive body movements
  80. Surgery for GERD
    Nissen Fundoplication...stomach wrapping
  81. When do cleft palate/lip form?
    in utero at 4-9 weeks.....congenital
  82. Cleft palate
    feeding problem
    small or large split involving both the soft and large palate

    poor sucking, choking, respiratory distress, apnea
  83. Cleft Lip

    slight indentation to complete separation that can involve the nose and or floor of nose

    poor latch and sucking
  84. How do you feed a child with a cleft palate/lip?
    • feed upright
    • special bottle to squeeze and nipple that has a x hole
  85. If the cleft palate/lip is severe they may need....
    GT for feeds
  86. When do you see surgery performed on a child with a cleft palate, lip?
    palate before speech of possible by 1-2 yo

    lip shortly after birth
  87. Post op considerations after a cleft lip repair
    • elbow restraints
    • positioning....don't lay prone
    • rinse mouth after feeds
    • sterile water cleaning of wounds
    • antibiotic ointments
    • oral feeds on side of mouth away from sutures with soft nipple
    • pain man
  88. Post cop considerations after a cleft palate repair
    • elbow restraints
    • rinse mouth
    • soft nipple
    • pain man
    • *sucking restrictions-no straws, eat soft foods
    • respiratory assessment looking for airway obstruction
    • follow up with orthodontist, speech therapy
    • possible need for myringotomy tubes
  89. What is esophageal artesia?
    pathological closure of the esophagus
  90. What is Traheo-esophageal fistula?
    abnormal formation of the trachea and esophagus....or maybe no connection at all
  91. Kids with Esophogeal artesia  and tracheoesophogeal fistula are at risk for?

    describe assessment
    aspiration-respiratory issues

    • 4 c's
    • cough
    • choke
    • cyanosis
    • copious oral secretions

    abdominal distention
  92. How do you dx esophageal artesia and tracheosophageal fistula?
    • NG tube unable to pass or comes back out
    • radiography
  93. Prior to surgery of a kids with esophageal artesia and tracheosophageal fistula what are you managing?
    • proper nutrition-parental/GT or JT
    • keep airways clear...suction and O2 as needed
    • antibiotics to prevent aspiration pneumonitis
  94. How do you surgically repair an esophageal artesia and tracheosophageal fistula?

    Ligate the fistula with an end to end anastamosis
  95. Post op interventions for an esophageal artesia and tracheoesophageal fistula
    • monitor airways
    • promote nutrition slowly
    • prevent infection
    • pain man
  96. Pyloric stenosis
    hypertrophied pyloric muscle that prevents movement of stomach contents in to the jejunum
  97. S/S of pyloric stenosis
    • projectile vomiting shortly after feeds of partially digested foods and gastric contents
    • always hungry even after feeds
    • wt. loss
    • dehydration
    • metabolic alkalosis
  98. What does the abdomen look like when a child has pyloric stenosis?
    olive shaped mass in right epigastrium
  99. Dx of pyloric stenosis
    • X ray
    • barium swallow w/ delayed gastric emptying
    • string sign-threadlike pylorus
  100. How do you manage pyloric stenosis?
    • NPO
    • IV F&E replacement
    • NG for decompression
    • **surgery only after stabilization of F&E
  101. Surgical repair of pyloric stenosis
  102. Post op care after a pyloromyotomy for pyloric stenosis
    • NG tube with decompression
    • slow and gradual resumption of feeds
    • vomiting can occur....so position upright and on right side
    • pain man
  103. Hirschsprungs disease
    colon is not innervated by ganglion cells resulting in a lack of peristalsis of food causing a dilation of the colon and an alteration in F&E
  104. S/S of Hirschsprungs
    • constipation
    • ribbon like stool
    • abdominal distention
    • bile stained emesis
    • FTT
    • Englarged colon
  105. Cardinal sign of Hischsprungs in a neonte
    failure to pass the first meconium
  106. Pre op management for Hirschprungs
    • NGT for decompression and decrease abd. distention
    • sline enemas to empty bowel
    • antibiotics
    • measure abdominal girths
  107. How do you support the parents of a baby with Hirschsprungs?
    prep for colostomy and surgeries....probably exhausted from this disorder
  108. Intussusception
    an invagination of a section of the intestine in to the distal bowel that causes an obstruction
  109. S/S of baby/child with Intussusception
    • healthy child with sudden, sever abdominal pain
    • blood diarrhea
    • drawing up knees
    • inconsolable
    • guarding abdomen
    • *currant jelly stools
  110. Intussusception shows up as what in abdomen
    sausage shaped mass in the RUQ or epigastrium
  111. Goal for treatment of Intussusception?
    How do it?
    restore bowel to normal position and function ASAP

    admit to hospital to admin IV fluids, NG tubes and pain man. 

    Post reduction-observe for passage of barium, note stools and keep NPO till normal bowel function is achieved
  112. What does the bowel do?
    • digestion
    • absorption of nutrients, vitamins, minerals, electrolytes, iron, bile acids
    • bacterial barrier and controls production of lactic acid
  113. What can cause a loss of a portion of the bowel?
    • necrotizing enterocolitis
    • Crohns disease
    • SBO
    • trauma
  114. How much bowel do you need to lose of the bowel to have malabsorption issues
    • +50%
    • this causes a decreased mucosal surface area leading to inadequate absorption of fluids, electrolytes and nutrients
  115. Nursing assessments for a person with SBS
    • Alteration in F&E and acid base balance
    • Malabsorption from diarrhea
    • Feeding intolerance-gas, abd dist, vomit, gas
    • osmotic diarrhea
    • skin break down from diarrhea and acidic stools
    • malnutrition/FTT
    • DD
    • Liver disease
    • *bacterial overgrowth, translocation of bacteria from the intestine to the blood stream
  116. How will you see bacterial overgrowth, translocation of bacteria from intestines in to the blood stream in a child with SBS?
    • infection
    • foul smelling stool
    • diarrhea
    • lactic acidosis
  117. Most common symptom of SBS
    watery diarrhea

    **also see steatorrhea, bloating, excessive gas, foul smelling stool, poor appetite, vomiting, wt loss, fatigue
  118. Complications of SBS
    • Protein-caloric malnutrition
    • Dehydration
    • Electrolyte imbalance
    • Gallstones/kidney stones
    • High levels of bacterial in the intestines
    • vitamin/mineral deficiencies
  119. Nursing considerations for a child with SBS
    • Provide IV nutrition-TPN
    • Careful intro of enteral nutrition...but advancement is from IV-NG/Gt-PO SLOWLY
    • Monitor wt gain
    • Monitor F&E
    • Strict I&O
    • Meds
    • Vitamins
    • antibiotics
    • Promote normal G&D
  120. Meds for child with SBS
    • Antacids
    • H2R blockers
    • PPI's
    • antimobility agents
  121. Vitamins for child with SBS
    ADEK...water soluble
  122. What is given to a child with SBS to stimulate intestinal mucosal growth?
    glutamine and growth horomones
  123. What is Celiacs disease?
    when a person eats wheat, rye, oats and barley and the small intestine breaks it down in to gliadin, but this cant be digested.  An accumulation of glutamine occurs which has a toxic effect on the mucosal cells.
  124. What is the result of the toxic accumulation of glutamine with celiacs disease
    villi atrophy causing malabsorption of fat, calories, carbs and vitamins.
  125. S/S of celiacs crisis
    • severe diarrhea--foul smelling
    • dehydration
    • vomiting
    • poor perfusion
    • edema
    • change in VS
  126. Dx of celiacs
    IgA anti tissue transglutaminase antibody test
  127. Nursing assessment of a child with celiacs disease
    • can see as early as 4-6 mo...upon addition of gluten in to diet
    • FTT
    • Muscle wasting
    • Abdominal distention
    • Chronic Diarrhea
    • Anemia
    • Steatorrhea
    • Bruising
    • Osteoporosis
    • Dermatitis
    • Apathy, irritability, fatigue, weakness, depression
  128. What causes bruising
    inability to absorb v. K
  129. How do you manage celiacs disease?
    • gluten free diet....feel better in 1 week!
    • eat a high calorie, high protein, low fat diet
    • vitamin supplements
  130. Patho of Biliary Artesia?
    begins prenatally, but appears healthy at birth

    it is an obstruction of the extrahepatic bile ducts causing an obstruction of the normal flow of bile out of the liver and in to the gallbladder and small intestine
  131. Result of biliary artesia.....leading to....
    obstruction causes bile to form plugs and a back up of bile in to the liver causing inflammation, edema and hepatic degeneration

    liver will become fibrotic and cirrhosis and portal hypertension develops leading to liver failure
  132. How do you dx biliary artesia?
    • Liver biopsy....but it can cause hemorrhage
    • LFT
  133. S/S of a child with biliary artesia
    • clay colored stools
    • jaundice
    • dark urine stained diapers
    • hepatomegaly
    • FTT
    • icterus
  134. What causes FTT in a child with biliary artesia?
    bile isn't present in the intestines so fat and fat soluble vitamins cant be absorbed which will cause malnutrition, and deficiencies in fat soluble vitamins
  135. Describe Kasai procedure for Biliary Artesia
    a portion of the jejunum is used to reestablish bile flow, this allows the bile to drain from the liver directly in to the intestines.

    should do at 2 mo. old
  136. Treatment options for a child with Biliary Artesia
    • Liver transplant
    • Kasai
    • treat malnutrition and sumptoms.
  137. After a child has had Kasai procedure for Biliary Artesia, what do I monitor them for?
    portal hypertension
  138. What do I teach the parents of a child after Kasai procedure
    • monitor BP always
    • watch for GI bleeding
    • severe edema
    • ascites....may need diuretics, low sodium diet and IV albumin
  139. What will a child take to assist with the secretion of bile salts and decrease pruritis?
  140. Inborn Error of Metabolism
    child eats carbs, proteins, fats and they cant be broken down in to energy due to a defect in specific enzymes (proteins) that help break down food parts
  141. What is the result of inborn error of metabolism?
    build up of toxic chemicals in the body
  142. Dx of Inborn Error of Metabolism
    heel stick done at 12 hours old.. and before the 6th day of life on all newborns.  Tests for 45 metabolic disorders
  143. S/S of Inborn Error of Metabolism?
    • fatigue
    • hypoglycemia
    • agitation
    • tachypnea
    • poor feeding
    • vomiting
    • altered LOC
    • irritability
    • developmental regression
    • seizures, coma death
  144. Why is inborn error of metabolism hard to dx?
    they cant talk and it they sleep a lot when normal
  145. A toxic amount of this causes irritability
  146. Clinical Management of inborn error of metabolism
    protein restrictions + medications
  147. Fatty acid oxidation defect
    • fat restricted diet
    • no fasting greater than 4 hours
  148. Organic Acidemias
    • avoid fasting
    • low protein and high carb foods
    • supplement with Carnitine
  149. Amino Acid disorders
    Most common is PKU

    • low protein foods
    • amino acid replacement-sodium benzoate
  150. Carbohydrate disorders
    most common is Galactosemmia

    • eliminate galactose and lactose from the diet
    • have patient drink Duart Galactosemia soy for the first year, check blood and then introduce dairy as tolerable
  151. Nursing considerations for patient with Inborn Error of Metabolism
    • med admin
    • formula admin
    • daily/hourly lab draws....reporting all abnormal labs to Dr. on call
    • excellent assessment skills looking for decompensation
  152. When do you discontinue NG tube feeds
    • signs of respiratory distress
    • cyanosis
    • abdominal distention
    • vomiting
  153. While kids are on tube feedings what is important to give them....
    paci to associate sucking with feedings

    or if older have child sit at table to promote socialization during feedings
  154. When do you do gavage feeds?
    in pre term infants prior to starting oral feeds....

    small catheter is inserted through the nose or mouth to provide intermittent/continuous feeds
  155. Describe bolus feeds
    given over 30-60 min
  156. Who should get Continuous feeds?
    • infants with SBS
    • congenital heart disease
    • intolerance of bolus feeds
  157. Position child is placed in to receive continuous or bolus feeds
    on back or right side with HOB elevated
  158. Which kind of feeding is at greater risk for aspiration?
  159. After a bolus feed what do I do?
    flush the tube with sterile water and clear it by injecting 1-5 mL of air

    place child on right side with HOB elevated for 30-60 min and watch for signs of nausea, emesis and respiratory difficulties
  160. TPN
    IV infusion of solutions containing the major nutrients needed for metabolism and growth...it provides calories, amino acids, fatty acids and minerals specific to that child
  161. Munchausen by Proxy definition

    injury falsified or inflicted by caretaker and they bring them to hospital/doctor for attention/care

    • decreased LOC
    • bleeding
    • infection
    • apnea
    • seizures
    • diarrhea
    • vomiting
    • fever
    • rash
  162. Shaken baby syndrome
    vigorous shaking causing severe whiplash type of injury and leding to intracranial damage and intraocular damage

    brain injury and brain death
  163. Families at risk for abuse
    • isolated
    • competitive environment for emotions
    • altered family roles
    • lack of trust
    • drug abuse
    • aggression used for conflict resolution
    • altered communication patterns-threats
    • dominant/controlling family member
    • family hx of abuse
  164. Children at risk for abuse
    • premies-altered bonding
    • chronic illnesses
    • frustrating behavior-irritable baby, cant feed, cries a lot, ADHD, DD
    • Aggressive/defiant/disobediance
    • emotional disturbances
    • birth order/gender
    • passive child
    • family scapegoat
  165. What do adolescents who are abused need?
    • Encouragement to.....
    • stay in school
    • have dreams
    • want to live

    someone will listen and can be trusted
Card Set:
Lecture 4 exam 3
2014-02-17 17:26:49
Same stuff different lecture
obesity, diabetes, fluid and electrolytes, GI, Nutrition, abuse
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