NCLEX PN 2018
collection findings for suspected cholecystitis?
(inflammation of the gallbladder) is characterized by epigastric pain that radiates to the back and right shoulder. This pain commonly occurs after eating foods high in fat, especially those that are fried. A client with cholecystitis may also experience nausea, vomiting, and flatulence.
what is stable angina? what is unstable angina? Variant angina? Intractable angina?
- also known as exertional angina, is triggered by a predictable amount of effort or emotion. - is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. - is triggered by coronary artery spasm; the attacks are of longer duration than classic angina and tend to occur early in the day and at rest. - is chronic and incapacitating, and is refractory to medical therapy
characteristics or right sided heart failure are?
- edema - jugular vein distention - enlarged liver and spleen - anorexia and nausea - distended abdomen - swollen hand and fingers - polyuria at night - weight gain
If a patient is taking atropine for bradycardia, the nurse should question the medication if the patient has which of the following conditions?
- glaucoma ( will increase optic pressure) - pyloric stenosis - prostatic hypertrophy
what are dietary instructions for a client diagnosed with coronary artery disease?
- shoud AVOID foods high in saturated fat and cholesterol such as EGGS, WHOLE MILK, AND RED MEAT. - the use of POLYUNSATURATED OILS is recommended to control hyperlipidemia - it is not necessary to eliminate all cholesterol and fat from diet
which instructions during the discharge plan are given to client receiving chemotherapy for breast cancer?
1. Avoid people who have recently received attenuated vaccines. 2. Avoid activities that may cause bleeding 3. Wash hands frequently 4. Avoid crowded places, such as shopping malls.
nursing interventions for a burnt client?
1. IV therapy with crystalloid such as lactated Ringer's solution to prevent hypovolemic shock and maintain cardiac output. 2. administer pain medication as ordered. Usually 2-25 mg of morphine or 5-10 mg of meperidine administered IV in small increments. 3. tetanus prophylaxis be administered, as ordered DO NOT USE - hydrogen peroxide or povidone-iodine solution. Or saline soaked towels.
what are 4 interventions for a patient with pulmonary edema?
1. administer oxygen - also place client in high fowlers 2. insert a foley catheter 3. administer furosemide (lasix) - eliminate accumulated fluid overload 4. administer morphine sulfate intravenously - reduces venous return (preload), decreases anxiety, and reduces the work of breathing.
how to relieve nipple soreness in a postpartum client 2 days after breast-feeding?
1. lubricating the nipples with few drops of expressed milk before feedings 2. applying ice compresses just before feedings 3. letting nipples air dry after feedings 4. avoid the use of soap on nipples
Stages of labor: first, second and third
First: The time of the onset of true labor until the cervix is completely dilated to 10 cm. Second: The period after the cervix is dilated to 10 cm until the baby is delivered. Third: Delivery of the placenta.
what is the normal fibrinogen level? what is the critical value?
180-340 mg/dL for men 190-420 mg/dL for women Critical < 100 mg/dL *with DIC, fibrinogen level drops b/c fibrinogen is used up in the clotting process.
the 3 stages of labor
1st: onset of true labor until cervix completely dilated to 10 cm. 2nd: period after cervix dilated to 10 cm until baby is delivered. 3rd: delivery of placenta
if a patient is experiencing hyperphosphate secondary to chronic renal failure, nurse should eliminate which foods from diet?
DAIRY PRODUCTS - contain significant amounts of phosphorus
A client injures his spinal cord in a diving accident. The nurse knows that the client will be unable to breathe spontaneously if the injury site is above which vertebral level?
A client with a spinal cord injury above the level of the fourth cervical vertebra (C4) can't breathe spontaneously. With an injury below this level, diaphragmatic breathing occurs. An injury from C5 to C6 results in quadriplegia, with diaphragmatic breathing and gross arm movements.
what is epilepsy?
A disorder in which nerve cell activity in the brain is disturbed, causing seizures.
what is puerperal infection?
A puerperal infection occurs when bacteria infect the uterus and surrounding areas after a woman gives birth. It's also known as a postpartum infection. endometritis: an infection of the uterine lining myometritis: an infection of the uterine muscle parametritis: an infection of the areas around the uterus
what is diabetes insipidus?
Diabetes insipidus occurs when the body can't regulate how it handles fluids. The condition is caused by a hormonal abnormality and isn't related to diabetes. In addition to extreme thirst and heavy urination, other symptoms may include getting up at night to urinate or bed-wetting.
first signs of aging in middle life (ages 46 to 64)?
Failing eyesight, especially close vision
what is the function of ADH?
ADH stimulates the renal tubules to reabsorb water, thereby concentrating urine
in which conditions might the nurse auscultate crackles?
Acute respiratory distress syndrome, pneumonia, pulmonary edema
One minute after birth, a neonate has an Apgar score of 7. What should the nurse do?
An Apgar score of 5 to 7 (out of a total possible score of 10) indicates mild respiratory depression. To correct this problem, the nurse should stimulate breathing by rubbing the neonate's back or by gently but firmly slapping the neonate's soles. The nurse should also provide oxygen (at 100% concentration) but should administer it by bag and face mask rather than nasal prongs. CPR only if the neonate's Apgar score is between 0 and 2
what is croup?
An upper airway infection that blocks breathing and has a distinctive barking cough.
what is amniotomy?
Artificial rupture of membranes, also known as an amniotomy, may be performed by a midwife or obstetrician to induce or accelerate labor common complication: cord prolapse
After delivering a neonate, a client delivers the placenta. At this time, where does the nurse expect to palpate the uterine fundus?
At the midline, 0.4" to 0.8" (1 to 2 cm) below the umbilicus
which area usually takes longer to evaluate in a child than in an adult?
Because children undergo rapid physiologic and psychological changes that affect growth and development, evaluating development usually takes longer in a child and involves more detail
which herbal supplement is used in treatment for varicose veins?
Bilberry - also to treat cataracts, retinopathy, diabetes, peripheral vascular disease
4th degree burn?
Black, eschar, dry, painless, no blanching
what is a vesicle?
Circumscribed, elevated, and filled with serous fluid
a client is color blind. the nurse understands that this client has a problem with?
Cones provide daylight color vision, and their stimulation is interpreted as color
With gastric ulcers, pain is?
Intensified with meals due to the release of gastric acid
symptoms of diabetes?
MIGHT HAVE SOME OR NONE - frequent urination - excessive thirst - unexplained weight loss - extreme hunger - sudden vision changes - tingling or numbness in hands or feet - feeling very tired much of the time - very dry skin - sores that are slow to heal more infections than usual
a child with acute nephritis (swelling and inflammation of kidney) should be given which electrolyte for this condition?
Magnesium sulfate
A 3½-year-old Vietnamese child with a fever, decreased urine output, wheezing, and coughing is brought to the emergency department. On data collection, the nurse discovers red, round, weltlike lesions on the child's upper back and chest. The nurse would interpret these lesions to be caused by which of the following
Many Vietnamese perform coining, a cultural practice in which a coin is repeatedly rubbed lengthwise on the oiled skin to rid the body of a disease. Coining can produce weltlike lesions on the child's back or chest, and children subjected to the practice are often thought to have been abused.
Paralytic ileus is?
Obstruction of the intestine due to paralysis of the intestinal muscles
which organ produces insulin?
Pancreas, near the stomach - produces the insulin to help glucose get into the cells of our bodies.
The nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client?
Prinzmetal's angina is generally treated with calcium channel blocking agents.
Which physiologic response should the nurse expect during the early postpartum period?
Rapid diuresis (ncreased or excessive production of urine.)
actions taken when administering Sertraline (Zoloft)?
SSRI - treats depression, obsessive compulsive disorder, posttraumatic stress disorder (PTSD), premenstrual dysphoric disorder (PMDD), social anxiety disorder, and panic disorder. Sertraline should be administered once daily, either in the morning or evening (but not at bedtime). The oral concentrate should be mixed with 4 oz of water, ginger ale, or lemon-lime soda, and it should be administered immediately after mixing. The client should be advised to check with the prescriber or pharmacist before taking any over-the-counter preparations. The nurse should also advise the client to use caution when performing hazardous tasks that require alertness.
A client states that he has 20/40 vision. what does it mean?
The client can read from 20' (6 m) what a person with normal vision can read from 40'. The numerator, which is always 20, is the distance in feet between the vision chart and the client. The denominator indicates from what distance an eye with normal vision can read the chart. Normal vision is defined as 20/20.
teaching plan for patient with SLE?
The client with SLE should stay out of direct sunlight and avoid other sources of ultraviolet light because they may precipitate severe skin reactions and exacerbate the disease. The client should monitor his temperature, because fever can signal an exacerbation, which he should report to the physician. Corticosteroids must be tapered gradually once symptoms are relieved because they can suppress the function of the adrenal glands
characteristics of decerebrate posture
Wrist pronation, Stiff extension of the arms and legs, Plantar flexion of the feet, Opisthotonos (spasm of the muscles causing backward arching of the head, neck, and spine)
what is theophylline?
a high potent bronchodilator used to relieve asthma symptoms
high-pitched gurgles over the lower right quadrant indicate?
a normal finding
appropriate toy for a 10-month old?
a push toy promotes development of an infant's gross and fine motor skills and aids cognitive development.
what is pericardiocentesis? when preparing client for procedure, which position does the nurse place client in?
also called a pericardial tap, is a procedure in which a needle and catheter remove fluid from the pericardium, the sac around your heart. The fluid is tested for signs of infection, inflammation, and the presence of blood and cancer supine with the head of the bed elevated at a 45- to 60- degree angle.
what is angioplasty?
also known as balloon angioplasty and percutaneous transluminal angioplasty, is a minimally invasive, endovascular procedure to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis.
what is ADH?
antidiurectic hormone that helps your kidney manage the amount of water in the body - made by the hypothalamus in the brain and stored in the posterior pituitary gland.
negative symptoms of schizophrenia? positive?
apathy, blunted affect, lack of motivation Positive: delusions, hallucinations
what is raynaud's disease?
causes some areas of your body — such as your fingers and toes — to feel numb and cold in response to cold temperatures or stress. In Raynaud's disease, smaller arteries that supply blood to your skin narrow, limiting blood circulation to affected areas (vasospasm). happens more in women
Transition phase of labor
cervix dilated 8-10 cm contractions last 60-90 secs with 30 sec-2 min rest in between
latent phase of labor
cervix dilated from 0-3 cm. mild to moderate contractions every 5-20 mins. contractions feel like aching in lower back, menstrual cramps, pressure/tightening in pelvic area. longest section of labor
Expulsive phase
begins immediately after birth and ends with separation and expulsion of placenta.
therapeutic modalities used to treat generalized anxiety disorder?
biofeedback; Buspirone (BuSpar) therapy; relaxation techniques
definition of diabetes
body does not process food for use as energy.
what are the "water hammer" or Corrigan's pulse characteristics?
bounding, with a rapid rise and fall
steps to collecting 24 hr urine sample
client should void, discard the urine, and record the time. This assures that the client starts the collection period with an empty bladder. At the end of the 24-hour collection period, the client should void and save the urine. The first voiding isn't used because it isn't known how long the urine has been in the bladder. The urine sample should be refrigerated or kept on ice to keep it fresh. It isn't necessary to clean the perineum for a 24-hour urine sample
which client is at risk for developing a wound infection?
clients who are undernourished
Asphyxia is?
condition of severely deficient supply of oxygen to the body that arises from abnormal breathing. An example of asphyxia is choking.
what is hypertonic solution?
causes fluids to be absorbed into the intravascular space until equal pressure is established on both side of the blood vessel.
what is hypotonic solution?
causes fluids to move from the intravascular space into the interstitial space
Adverse effects of oxytocin in the mother include?
hypertension, fluid overload, and uterine tetany
levothyroxine sodium (Synthroid) is used for? name side effects associated with the medication?
hypothyroidism Insomnia, weight loss, mild heat intolerance
a direct complication for a patient with scoliosis is?
if left untreated, the thoracic spinal curvature can impinge on the lungs and affect pulmonary function.
what is crohn's disease?
is an inflammatory bowel disease (IBD). It causes inflammation of your digestive tract, which can lead to abdominal pain, severe diarrhea, fatigue, weight loss and malnutrition
what is thrombophlebitis?
is an inflammatory process that causes a blood clot to form and block one or more veins, usually in your legs. The affected vein might be near the surface of your skin (superficial thrombophlebitis) or deep within a muscle (deep vein thrombosis, or DVT). Causes include trauma, surgery or prolonged inactivity.
what is external radiation and the adverse effects?
most common form of radiotherapy. The patient sits or lies on a couch and an external source of ionizing radiation is pointed at a particular part of the body adverse effects: causes stomatitis (irritation of the oral mucous membranes), xerostomia (dry mouth), and dysgeusia (a diminished sense of taste)
a client with a diagnosis of myocardial infarction should not have the following beverages?
not consume caffeinated beverages. lemonade acceptable
Dark, concentrated urine, DRY mucous membranes, and a urine output of less than 30 mL/hr (720 mL/hr in 24 hrs) are symptoms of what?
dehydration or deficient fluid volume
The nurse should teach the client that myasthenia gravis is caused by:
destruction of acetylcholine receptors at the postsynaptic membrane of the neuromuscular junction
what is the name of a rare water metabolism disorder called? what are the symptoms of this disorder?
diabetes insipidus aka ADH deficiency - excessive urination (polyuria) - extreme thirst (polydipsia)
With duodenal ulcers, pain is relieved by?
during meal time due to the closure of the pyloric sphincter. Pain will manifest about 2-3 hours after a meal, when the pylorus opens and releases gastric contents into the small intestine
AU - medical term means?
each ear or both ears
what are the characteristics of a vesicular rash and are associated with which conditions?
elevated, round, blisterlike lesions that are filled with clear fluid contact dermatitis, herpes zoster, and the late stages of smallpox
client with pneumonia experiencing thick mucous secretions would need the following to help liquefy secretions?
encourage increased fluid intake
data collection in a client abusing opiates such as morphine include?
euphoria (a feeling or state of intense excitement and happiness) and constricted pupils.
what is pulmonary edema? what causes it?
excess fluid in the lungs making it difficult to breath. causes: pneumonia, exposure to toxins and meds, trauma to chest wall, exercising or living at high elevations
HIV infection - CD4+ levels are measured to determine the?
extent of immune system damage
what are characteristics of pulmonary edema?
extreme breathlesness, dyspnea, air hunger, production of frothy pink-tinged sputum
symptoms of opioid withdrawal?
flushing, goosebumps, nausea, vomiting, abdominal cramps
what is isotonic solution?
has no effect on the cell
serious diabetes health complications include?
heart disease, blindness, kidney failure, and lower extremity amputations. 7th leading cause of death in US
which type of insulin is an intermediate-acting insulin?
humulin NPH onset: 1.5 hrs peaks: 4-12 (hypoglycemic occurs during peak time) duration of action: 24 hrs
what is disseminated intravascular coagulation (DIC)?
rare, life-threatening condition. In the early stages of the condition, DIC causes your blood to clot excessively. As a result, blood clots may reduce blood flow and block blood from reaching bodily organs. As the condition progresses, platelets and clotting factors, the substances in your blood responsible for forming clots, are used up. When this happens, you will begin to experience excessive bleeding.
Deep partial thickness (2nd degree) ?
red and white, blood blisters, moist, painful, less blanching
Superficial partial thickness (2nd degree)?
red, clear blisters, moist, painful blanches
describe superficial (1st degree) burn?
red, dry, painful
Which term refers to the primary unconscious defense mechanism that keeps intense anxiety-producing situations out of a person's conscious awareness?
repression
characteristics of decerebrate posture?
results from damage to upper brain stem adduction and stiff extension of the arms/legs; wrist pronation; plantar flexion of the feet; opisthotonos
rheumatic endocarditis also called rheumatic carditis is a major indicator of which disease?
rheumatic fever - which is a complication of infection with group A b-hemolytic streptococcal infections. It is frequently triggered by streptococcal pharyngitis.
Identify the area where the nurse would expect the pain to localize for a patient with severe appendicitis?
right lower quadrant, midway between the umbilicus and the crest of the ilium.
cardiovascular findings for increased intracranial pressure (ICP)?
rising blood pressure, bradycardia, widening pulse pressure (aka cushing's triad) , bounding pulse
The nurse is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg's position. The nurse interprets that the client is likely being treated for which condition?
shock A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat and slightly elevating the head and shoulders. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm, which is vital to the treatment of shock
An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action?
should be placed on continuous cardiac monitoring so myocardial perfusion and presence of dysrhythmias can be most accurately assessed.
scabs indicate which phase of healing?
the LAG phase - the fibrin network dries out and forms a scab. The fibrinoplastic phase concludes with a scar, and the contraction phase is demonstrated by sloughing and shrinking of the scar. Inflammation is the first stage of wound healing and includes hemostasis, edema, and drawing of leukocytes to the wound area.
what does asepsis mean?
the absence of bacteria, viruses, and other microorganisms
A client is scheduled for amniocentesis. What should the nurse do to prepare the client for the procedure?
the nurse should ask the client to empty her bladder to reduce the risk of bladder perforation. Prior to the procedure, the nurse should also assess fetal heart rate and maternal vital signs to establish baselines. The client should be supine during the procedure; afterward, she should be placed on her left side
nurse is collecting data on a newly admitted client. who should the nurse consider to be a part of the client's family?
the nurse should consider family members to be all the people whom the client views as family. Family members may also include those people who provide for the physical and emotional needs of the client.
Active labor phase
time to head to hospital cervix dilated 4-7 cm contractions 45-60 sec with 3-5 min rest in between
Full thickness burn (3rd degree)?
white/brown, dry, leathery, painless, no blanching
