Gracious NCLEX PREP Final

muscle strength

- 0 is the worst: no contractility - 5 is the best: normal ROM

cranial nerves

- 12 pairs of nerves that carry messages to and from the brain oh, oh, oh! To to touch and feel a Good Velvet Such Heaven

Sodium

- 135-145 - Critical <120, >160 - may indicate low or high neuro symptoms

5 heart sounds (A PET MAN)

- Aortic: right 2nd intercostal - Pulmonic: left 2nd intercostal (murmer) - Erbs point: S1, S2 sound best - Tricuspid: Left 4 Intercostal - Mitral: Left 5th intercostal ( listen to apical pulse and aortic and regurgitation)

cervical spine

- C1-C7 - nerves controls breathing, arms, and neck movement

Order of assessment

- Inspection - Palpation - Percussion - Auscultation

Lumbar

- L1-L5 - nerves control the lower abdomen, buttock, and leg strength

What is the last resort treatment for tonsilitis and adenoiditis?

- Last resort treatment for tonsilitis and adenoiditis is surgery to remove the tonsils and adenoids.

coarse crackles

- Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration

How is a child positioned after a tonsillectomy and adenoidectomy?

- On their side or prone to promote drainage of secretions.

Sacral and coccyx

- S1- S5 - nerve control the thighs, lower leg strength, and genitals

thoracic spine

- T1-T12 - nerves control the chest, back, and abdomen

Describe: Tonsillitis and Adenoiditis

- Tonsillitis and Adenoiditis are infections and inflammations of the tonsils that are in the back of the throat. - It is caused by an infection, especially from strep throat.

heart murmur

- abnormal heart sound - whooshing, swishing, and clicking noise

S3 and S4

- abnormal heart sounds - associated with cardiac disease

diminshed lung sounds

- an area the lung sounds cannot be heard well

Medication: Otitis media

- analgesics or antipyretics to decrease pain and fever - antibiotics PO or ear drops

signs of poorly controlled pain

- decreased cough, oliguria, hypo-ventilation

hypoactive bowel sounds

- diminished or absent bowel sounds - 1 sound every 3-5 minutes

Percussion sounds

- dull tone: spleen, liver - flat tone: bone - hypersonance: lungs - tymphany: abdomen

FLACC pain scale

- for nonverbal or ages 2-10 years old F: Faces. L: Legs. A: Activity. C: Cry C: Consolability

febrile

- has a fever/high temperature

Interventions: Conjunctivitis

- if conjunctivitis is from a bacterial infection, give antibiotic eye drops - If it's viral, it will improve without treatment - If it's from allergies, give an antihistamine eye drops such as Visine

Heparin Sodium therapy

- monitor Activated partial thromboplatin time (aPTT) level of 1.5 to 2.5

Cerebellum

- movement, gait, and balance

Bell's Palsy

- one sided facial paralysis caused by the compression of the facial nerve assessment findings include: facial drooping, increased lacrimation, painful sensations in the eye, face, or behind the ear, difficulty chewing

frontal lobe

- personality changes - speech - behavior - emotions - intellectual function

Define conjunctivitis

- pink eye. it can be from allergies or from an infection - if it's from an infection, it is highly contagious and requires contact precautions

supratentorial craniotory

- position in semi-fowler's - elevate head 30 degrees to promote venous outflow

Treatment of strabismus

- possible glasses - patch the good eye to strengthen the bad eye

Secondary = Screening

- preventing cancer: mammograms, colonoscopy, pap smear, stopping smoking

Signs and symptoms of conjunctivitis

- purulent drainage and eye crusts

fine crackles

- short high pitched sounds during inspiration - a little bit of fluid in the lungs

deep tendon reflexes

- tested with a reflex hammer that is used to strike a tendon - 0: no response, always abnormal - 1+: slight but present response, may or may not be normal - 2+: brisk response, normal -3+: a vert brisk response may or may not be normal -4+ a tap elicits a repeating reflex (clonus) always normal

4 main functions of the liver are:

- to make clotting factors to prevent bleeding - to make proteins so all the organs and cells can function - to metabolize toxins and cholesterol - to make bile for digestion

Tertiary = Treatment

- to maximum functions of a client that already has the disease, support groups, cardiac rehab MI, skin care for diabetics

how to document

- use black ink -Date/time of insertion/ name on each entry - document right after yo do something - be factual - document refusal, calls to HCP - don't leave blank spaces on forms

Teachings for Conjunctivitis

- wash hands and don't share towels - don't rub your eyes - throw away used contacts and makeup

jaundice

- yellowing of the skin - increased liver failure/ cirrhosis

ateletasis

-Collapse or incomplete lung expansion -Result of mucus, hyperventilation of the alveolar, or compression by tumors/enlarged lymph nodes

Romberg test

-ask the client to stand with feet at a comfortable distance apart, arms at sides, and eyes closed -expected finding: client should be able to stand with minimal swaying for at least 5 seconds

pulse strength

0-ABSENT 1-WEAK 2-NORMAL 3-FULL 4-BOUNDING

Interventions: Otitis media

1. Encourage fluid intake to break up secretions 2. Can be painful - apply heat or cold to the ear - lie with the affected ear down

Abdominal assessment

1. Inspection 2. Auscultation 3. Percussion 4. Palpation

Teaching to parents to prevent otitis media in an infant?

1. feed infants sitting upright to prevent formula or breast-milk getting into middle ear 2. avoid getting upper respiratory infections get vaccinations 3. avoid irritation avoid smoking and allergens around infant

Bowel sounds assessment order

1. left upper quadrant 2. right upper quadrant 3. right lower quadrant 4. left lower quadrant

Magnesium

1.6-2.6 - muscle, neuro symptoms

Phosphate

2.5-4.5 - decreased poor nutrition

Potassium

3.5-5.0 - critical level (<3, >6) - may indicate low or high dysrhythmia, muscle symptoms

normal bowel sounds

5-30 clicks or gurgles per min

Calcium

8.5-10.5 - muscle, neuro symptoms

Chloride

98-106 mEq/L - goes with sodium

How are ear drops administered in a child?

< 3 years old, pull earlobe down and back > 3 years old, pull pinna up and back

temporal lobe

A region of the cerebral cortex responsible for hearing and language.

pallor

Extreme or unnatural paleness

Tachycardia

Fast heart rate (HR greater than 100bpm)

syncope

Loss of consciousness; to faint

skin turgor

Measure of hydration, which tests how quickly the skin returns to its normal position after being pinched (pinch the skin folds of the sternum and forearm

musculoskeletal assessments

Movement and range-of-motion of joints and extremities Strength of hand grips and foot flexion Ability to stand and walk; balance Continuous passive motion machine Splints, casts, traction, over-the-bed trapeze bar Walker, cane use

S1 and S2

Normal heart sounds; also known as the lub-dub

Blood flow through the heart

SVC --> Rt atria --> Tricuspid --> Rt ventricle --> Pulmonic valve --> Lungs --> Lt atria --> Mitral valve --> Lt ventricle --> aortic valve --> aorta --> Body

Define: Strabismus

Strabismus is "cross-eye". It is normal for children less than 4 months old.

Wong-Baker FACES scale

a pain assessment tool that asks patients (often children) to select one of several faces indicating expressions that convey a range from no pain through the worst pain

petechiae/purpura

a small red or purple spot caused by bleeding into the skin.

Scoliosis

abnormal lateral curvature of the spine

Minimum urine output

adults: 30 mL/hr Infants: (up to 1 year) at 2 mL/kg/hour

capillary refill

after blanching nail bed, color should return to normal withing <3 secs

partial lobe

analyze senses and allows you to feel sensations such as temperature, pressure, and pain, and movement

Chene-Stokes

apnea lasting 10-60 seconds followed by hyperventilation; indicates a dying client but may be normal in babies

melena

black, tarry stools; feces containing digested blood

Ecchymosis

bruising

Dyspnea

difficulty breathing

changes in older adults

eyes: decreased vision, yellowing of lens, issues w/ glare and darkness ears: hearing loss, thickening of tympanic membrane mouth: decreased sense of taste, gum disease, tooth loss, decreased salivation, pale gums voice: increased vocal pitch nose: decreased sense of smell

crackles

heard in pneumonia, asthma, COPD, pulmonary edema

wheeze

high-pitched, musical, squeaking adventitious lung sound

Define: Otitis media

infection of the middle ear caused by cold, allergies, or other respiratory infections

hyperactive bowel sounds

loud, high-pitched, rushing, tinkling sounds that signal increased motility

pleural friction rub

low-pitched grating sound from pleurisy (inflammation of lung surfaces)

medium crackles

lower, more moist sound heard during the midstage of inspiration; not cleared by a cough

cachexia

malnutrition, wasting away

absent bowel sounds

no sounds in 3-5 minutes

apnia

not breathing

tacypnea

rapid respiration > 20

erythema

redness of the skin due to capillary dilation

bradypnea

slow breathing <12

Bradycardia

slow heart rate (less than 60 bpm)

Rhonchi

sounds like snoring, may clear with cough

Functions of the gallbladder

stores and concentrates bile

stridor

strained, high-pitched sound heard on inspiration from obstructive airway

Primary= prevention

teach about health lifestyle - diet, exercise, teeth brushing, car seats, helmets, vitamins, vaccines, sunscreen, limiting/ eliminating alcohol

Modifiable risk factors

things the client can change - diet, exercise

Non-modifiable risk factors

things the client cant change - age, gender, family history, sex, genetics

exocrine organs

to release enzymes for food digestion

endocrine organ

to release insulin so the body can regulate glucose/ sugar

emaciated

unnaturally thin

Pulse

use the radial to get standard pulse

occipital lobe

vision

hematemesis

vomiting blood

ptosis

when one eye droops

Afebrile

without fever