NCLEX Prep
Right lateral decubitus position
After undergoing a liver biopsy, the client should be placed in which position?
Stiff Neck
If a patient with fever reports what, then they should immediately be checked for meningitis?
-Posterior Trunk-18% -Anterior Trunk-18% -Legs-18% -Head-9% -Neck-9% -Arms-9% -Perineum-1%
Rule of 9's
-Lethargy -N/V
Signs of Lithium Toxicity
-ABD cramps -rhinorrhea -dilated pupils
Signs of opioid withdrawal
Paradoxical Chest Expansion
"The lung movement is outward during expiration and inward during inspiration."
use only pain meds to keep pt comfortable
"do not keep alive by any heroic mean"
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.When the nurse suggests they talk in the client's room, she acknowledges that the client is important and preserves the client's dignity with minimal restriction. Calling for help to escort the client to his room is inappropriate because the client hasn't yet been given a chance to go on his own. The nurse should use the least restrictive form of treatment at all times. Facing the client and demanding that he be quiet isn't incorrect because it challenges the client. Telling the client to calm down because he is safe is a placating response that will likely increase the client's anxiety.
Captopril (given to children with heart failure)
ACE inhibitors block the conversion of angiotensin I to angiotensin II in the kidney. This causes decreased aldosterone, vasodilation, and increased sodium excretion.
Oxygenation of the fetus
The nurse is gathering data on a client in the early stages of labor with an external monitor applied. The nurse interprets the monitor data as indicative of which of the following?
Muscle Biopsy
What is used to confirm muscle dystrophy?
Extended Family
Consists of the biological or adoptive parents and one or more grandparents or other family members living together.
Ishihara polychromatic plates
What is used to test for color blindness?
Sneeze with their mouth OPEN
After a stapedectomy what should the nurse instruct the patient to do if they need to sneeze?
Adrenal Cortex
Aldosterone is secreted by what?
RUQ
Appendicitis
.............................
Arthroscopy is contraindicated in clients with joint flexion of less than 50% because of technical problems in inserting the instrument into the joint to see it clearly. Other contraindications for this procedure include skin and wound infections.
Cholinergic blocker
Atropine sulfate is in which drug classification?
.......................
Broad-spectrum antibiotics that destroy aerobic and anaerobic bacteria also destroy the normal flora of the GI tract, which are responsible for absorbing water and certain nutrients (such as vitamin K). Destruction of the GI flora, in turn, leads to diarrhea
1 year
If frozen immediately plasma may be stored for how long before it has to be discarded?
Trendelenburg position.
During labor if a prolapsed cord is discovered, what position should the client be placed in?
-Resp. Depression -Hypotonia -Bradycardia
If magnesium sulfate was used during pregnancy what are the possible adverse effects for the neonate?
Yes
Can calliflower cause flatulence?
...................
Characterized by abdominal swelling from ascites, weight gain, and peripheral edema, hyperstimulation syndrome from ovulatory stimulants is an unusual occurrence. This client must be admitted to the hospital for management of the disorder. Nursing care includes emotional support to reduce anxiety and management of symptoms.
Normal Size
Children with hypopituitarism are usually of ______________ for gestational age at birth
..................
Currently, ketorolac is the only NSAID in the United States (Canada) that can be administered I.M. Ketorolac may be used for up to 5 days to control mild to moderate cancer pain.
Identity vs Role Confusion
Erikson's Stage of Development for 13-21 yoa
Initiative vs Guilt
Erikson's Stage of Development for 3-5 yoa
BUN and Creatinine
Gentamicin sulfate is toxic to the kidneys. Monitoring the _______________ levels during the course of therapy can identify nephrotoxicity before severe damage occurs.
Hyperthyroidism
Heat intolerance, nervousness, weight loss, and hair loss
Stimulates the sympathetic nervous system
How do baroreceptors respond in a client with cardiogenic shock who experiences low blood pressure?
15 Degree
In Bryant's traction the hips should be elevated off the bed at what angle?
Labyrinthitis
Inflammation of the inner ear
Amenorrhea
Lack of menstruation
..................
Lethargy is an early sign of lithium toxicity; if it goes undetected, vomiting and diarrhea soon develop
On an empty stomach in the morning
Levothyroxine should be taken how and when?
18-21 yoa
Most children with scoliosis must wear a brace until the spine matures — typically between what ages?
-Pain meds -Heat application -Physiotherapy
Nursing care for a Herniated Nucleus Pulposus (HNP)
...................
Obesity is a known cause of gallstones, and maintaining a recommended weight will help to protect against cholecystitis.
Paranoid Personality Disorders
Olanzapine is used in the treatment of what?
Be careful
Opioids suppress the respiratory center in the medulla. Both COPD and pneumonia cause alterations in gas exchange; any further problems with oxygenation could result in respiratory failure and cardiac arrest.
Depression
Paroxetine is an SSRI drug used to treat what?
8-10
Patient should perform at lest _________ sustained voluntary maximal maneuvers with an incentive spirometer during each waking hour. Less reduces the benefits of therapy.
Percuss before palpating
Percuss before palpating
Letting-Go
Phase after delivery when the client begins to accept the neonate as an individual who's separate from herself
HIV/AIDS
Pneumocystis jirovecii pneumonia is commonly seen in patient with a history of what?
Fetal Death
Pregnant are at risk for what if infected with Fifth Disease?
Fasciotomy
Procedure that involves cutting the fascia over the effected area to permit muscle expansion.
Bilateral Hearing Loss
Prolonged Aspirin use can cause what?
Lorazepam
The best choice for preventing or treating alcohol withdrawal symptoms is _____________.
Glucose
The decreased adrenal cortical function of Glucocorticoids leads to decreased ____________ availability.
3-4wks
The stepping reflex is only present until what age?
An increase in UOP
The therapeutic effect of Mannitol is diuresis, which is confirmed by what?
Temporal
The_____________ lobe regulates memory.
With a full glass of water on an empty stomach
When giving sulfamethoxazole-trimethoprim, the medication should be administered how?
Hypothyroidism
Tiredness, cold intolerance, weight gain, and constipation
press the right upper abd
To assess hepatojugular reflux, the nurse should
Balloon Angioplasty
Tx for postsurgical recoarctation
11 weeks
Using Doppler ultrasound, fetal heart tones can be heard when?
16-20wks
When is the FHT audible?
Consent needs to be obtained from the parents or legal guardian, even if the toddler has a foster family.
A 2-year-old who's admitted to the pediatric unit for a tonsillectomy is in foster care. The nurse assists the physician in gaining informed consent. Who can legally give informed consent for this elective procedure?
continuous inflow and outflow of irrigation solution.
A 3-way indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to inflating the balloon, the functions of the three lumens include
..................
A Mallory-Weiss tear is associated with massive bleeding after a tear occurs in the mucous membrane at the junction of the esophagus and stomach. There is a strong relationship between ethanol usage, resultant vomiting, and a Mallory-Weiss tear.
...............
A characteristic feature of Guillain-Barré syndrome is ascending weakness, which usually begins in the legs and progresses upward to the trunk, arms, and face. Respiratory muscle weakness is a particularly dangerous effect of this disease progression because it may lead to respiratory failure and death. Therefore, although all of the options are pertinent assessment data, those related to respiratory function and status are most significant
Bronchoscopy
A child comes to the emergency department (ED) with a cough and difficulty breathing. The parents inform the nurse that the child may have swallowed a crayon. Which diagnostic test should the nurse prepare the parents and child for?
Cardiac Catheterization
A child diagnosed with tetralogy of Fallot has been ordered to undergo testing. Which test would the nurse prepare the child for that will indicate the direction and amount of shunting in this child?
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A child who falls above or below the standard in both height and weight may not be abnormal but may reflect a genetically large or small frame. Comparing a child's growth trends with those of parents and siblings is essential in evaluating adequate growth. Although exploring the presence of metabolic disease and determining bone age can help evaluate the cause of short stature, they aren't the initial step. Evaluating baseline vital signs might assist in the assessment of an underlying metabolic cause of short stature, but taking vital signs isn't directly related to the initial evaluation of growth trends.
Hypertonic glucose solution
A child with Reye syndrome is in stage I of the illness. Which measure would help prevent further progression of the illness?
Increases Sodium Excretion
A child with heart failure is given captopril. The nurse should reinforce education of the child's parents on which action of captopril?
It increases Na excretion
A child with heart failure is given captopril. The nurse should reinforce education of the child's parents on which action of captopril?
The oxygen tubing is pinched.
A client admitted to the health care facility with acute bronchitis is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the likely cause of this sound?
Performing mouth care
A client admitted with a high fever mentions that his mouth is very dry. Scheduled diagnostic testing restricts him from consuming anything by mouth. Which action by the nurse is best?
Methylprednisolone
A client admitted with a spinal cord injury at the level of T12 reports loss of movement of lower extremities. Which medication would the nurse anticipate will be administered to control edema of the spinal cord?
When the client has the urge to void, assist her to a sitting position on the bedpan.
A client admitted with deep vein thrombosis of the left leg is prescribed bed rest . The client states that she's unable to void in the bedpan. Which action should the nurse take?
Dystonia.
A client begins taking haloperidol . After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as:
osteoporosis
A client diagnosed with systemic lupus erythematosus and taking daily prednisone reports severe back pain after manually opening a garage door. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?
Eye Pain (eye pain is NOT normal after cataract surgery)
A client had cataract surgery. Which sign or symptom should the nurse tell the client to report immediately to the health care provider?
N/V
A client has just taken a dose of trimethobenzamide (Tigan). The nurse evaluates that the medication has been effective if the client states relief of which problem(s)?
Assist with positioning the client.
A client in labor receives epidural anesthesia. Which nursing action should the nurse take?
Prolonged dyspareunia
A client in labor requires an episiotomy. Which complication should the nurse have the client report to the health care provider after the procedure?
Reposition the client to left lateral position.
A client in the first stage of labor is being monitored with an external fetal monitor. The nurse notes variable decelerations on the monitoring strip. Which action should the nurse take?
C4
A client injures his or her spinal cord in a diving accident. Which cerebral vertebral level would the nurse associates the injury site if the client is unable to breathe spontaneously?
-MRI -CT scan -Myelography
A client is admitted to the emergency department with severe lower back pain, weakness, and atrophy of leg muscles. For which diagnostic tests should the nurse prepare the client? Select all that apply.
Hypokalemia
A client is admitted to the hospital disoriented and weak, has an irregular pulse, and takes hydrochlorothiazide. Which imbalance should the nurse suspect as the underlying cause for the client's symptoms?
Drug Toxicity
A client is admitted with a diagnosis of acute renal failure. The nurse monitors the client closely for which sign or symptom?
Methotrexate
A client is diagnosed with an unruptured ectopic pregnancy. Which medication does the nurse expect to administer to the client?
pain that occurs when the pinna of the ear is pulled
A client is diagnosed with otitis externa. Which finding should the nurse anticipate during data collection?
Fever, chest discomfort, and elevated erythrocyte sedimentation rate (ESR)
A client is diagnosed with pericarditis. The nurse anticipates that the client may exhibit which signs and symptoms?
Autoimmune disorders include connective tissue (collagen) disorders.
A client is diagnosed with rheumatoid arthritis , an autoimmune disorder. When teaching the client and family about autoimmune disorders, the nurse should provide which information?
-Numbness -Tingling -Muscle twitching and spasms
A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms?
Sedation
A client is prescribed diazepam to treat severe skeletal muscle spasms. During this therapy, the nurse monitors the client closely for adverse reactions. Which adverse reaction is most likely to occur?
2-3hrs
A client is prescribed flecainide to treat atrial fibrillation. How soon after administering flecainide orally can the nurse expect the drug to reach its peak concentration?
Lactic Acidosis
A client is prescribed metformin to control type 2 diabetes. The nurse should monitor for which life-threatening adverse reaction?
Morning administration of prednisone mimics the body's natural corticosteroid secretion pattern
A client is prescribed prednisone daily. Which statement best explains why the nurse should instruct the client to take this drug in the morning?
BP
A client is receiving nitroglycerin ointment to treat angina pectoris. The nurse evaluates the therapeutic effectiveness of this drug by assessing the client's response and checking for adverse effects. Which vital sign is most likely to reflect an adverse effect of nitroglycerin?
Eating
A client is scheduled for a bronchoscopy. Pre-procedure, the nurse should instruct the client to avoid which activity?
Succinylcholine
A client is scheduled for electroconvulsive therapy (ECT). Before ECT begins, the nurse reviews the client's chart and prepares to administer which neuromuscular blocking agent?
Pulmonary angiogram
A client is suspected of having a pulmonary embolus. Which test should the nurse prepare the client for that is definitive?
Decreased hearing acuity
A client must take streptomycin for tuberculosis . Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs?
"Have you noticed a change in your memory?"
A client presents to the emergency department with a closed head injury. What would the nurse ask the client to help assess cerebral function?
Obtain VS (The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored.)
A client presents to the emergency room with abdominal pain and blood in the stool. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time?
Increased serum glucose and free fatty acid protein levels
A client recently had a myocardial infarction (MI). Which finding does the nurse identify to be a normal metabolic change occurring after an MI?
Panic Disorders
A client tells a nurse that he feels like he's losing his mind. This fear is most commonly associated with which disorder?
Encourage the client to be out of bed the first postoperative day
A client undergoes an L4-L5 laminectomy. Which nursing action would be best to prevent postoperative complications?
Notify the physician. (The nurse should notify the physician, who will likely order an eye patch. Patching one eye at a time relieves diplopia.)
A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is the most appropriate?
2" to 4"
A client with a history of colon cancer has a permanent colostomy. The nurse must irrigate the colostomy to prepare the client for diagnostic testing. When irrigating, how far into the stoma should the nurse insert the lubricated catheter?
Figure-eight
A client with a sprained ankle comes to the emergency department. When bandaging the client's ankle, the nurse should use which technique ?
Risperidone
A client with a tic disorder has tried to use stress reduction techniques without success. Which medication does the nurse anticipate the client may be prescribed for treatment?
Vision Changes (bc these may be irreversible)
A client with advanced breast cancer is prescribed tamoxifen. When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately ?
Increased intraocular pressure.
A client with an inflammatory ophthalmic disorder has been receiving a ½-inch ribbon of corticosteroid ointment in the lower conjunctival sac four times per day as directed. The client reports a headache and blurred vision . The nurse suspects that these symptoms represent:
Heart Failure
A client with chronic alcoholism may be predisposed to develop which condition?
Manual resuscitation bag
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?
atelectasis.
A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor him closely for
Questioning
A client with dependent personality disorder has difficulty expressing personal concerns. Which communication technique is best to teach the client?
Risk for Infection (The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body. Therefore, the client is at risk for infection.)
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis . Which nursing diagnosis is most appropriate for this client?
Preparations containing salicylates
A client with type 1 diabetes takes 15 units of isophane insulin suspension before breakfast and 8 units before dinner. During a follow-up visit, the nurse reevaluates the client's knowledge about insulin therapy and self-administration skills and learns that the client is unaware that certain over-the-counter (OTC) preparations and other medications may interact with insulin. The nurse should advise the client to avoid which OTC preparations?
Atrophy of the gastric mucosa
A client, age 82, is admitted to an acute care facility for treatment of an acute flare-up of a chronic GI condition. In addition to assessing the client for complications of the current illness, the nurse monitors for age-related changes in the GI tract. Which age-related change increases the risk of anemia?
Explain that these are expected problems for the latter stages of pregnancy.
A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath and is unable to sleep unless she places three pillows under her head. After listening to her concerns, the nurse should take which action?
A clinical pathway
A clinical management tool that organizes the major interventions for a multidisciplinary health care team
Sensory Overload
A condition in which the central nervous system receives much more auditory, visual, or other environmental stimuli than can be processed effectively
activating dopamine receptors in the CNS
A dopamine receptor agonist such as bromocriptine relieves muscle rigidity caused by antipsychotic medication by
activating dopamine receptors in the CNS.
A dopamine receptor agonist such as bromocriptine relieves muscle rigidity caused by antipsychotic medication by:
Vesicular
A healthy client comes to the clinic for a routine examination. When auscultating lower lung lobes, the nurse anticipates which type of breath sound?
Stop the medication at once and see the health care provider immediately.(The client should stop the medication and see the health care provider immediately because fever can be a sign of agranulocytosis, which is a medical emergency.)
A homebound client taking clozapine tells the nurse he has been feeling tired for 5 days. Temperature is 99.6° F (37.6° C); pulse 110 beats/minute; and respirations 20 breaths/minute. Based on the client's report, which instruction would be most appropriate?
Inform the RN
A licensed practical nurse/licensed vocational nurse is caring for a client with trigeminal neuralgia who reports severe stabbing pain on one side of the face. Which action should the LPN/LVN perform first?
The child returns to a level of behavior that increases his sense of security. (The stress of starting nursery school may cause the child to regress to a level of behavior that increases his sense of security. A child's skills remain intact, although increased stress may prevent the child from using these skills. Growth occurs when the child doesn't regress. Parents rarely desire less mature behaviors.)
A mother asks the nurse how to handle her 4-year-old child, who recently started wetting his pants after being completely toilet trained. The child just started attending nursery school 2 days a week. Which principle should guide the nurse's response?
10mo
A mother is playing with her infant, who's sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. What age would the nurse estimate the infant to be?
Hyperbilirubin
A neonate with ABO incompatibility is at the highest risk for developing what?
Weighing would be done first so that a baseline weight can be established and weight changes can be assessed
A nurse admits an infant diagnosed with pyloric stenosis. Which nursing intervention should the nurse complete first?
Weight the infant so that a baseline weight is established
A nurse admits an infant diagnosed with pyloric stenosis. Which nursing intervention should the nurse complete first?
Chest Pain
A nurse is caring for a 16-year-old adolescent with aortic stenosis. Which finding is associated with aortic stenosis when the teen is active?
Burning on urination Green vaginal discharge
A nurse is caring for a client in the clinic. Which sign or symptom may indicate that the client has gonorrhea?
sterile gloves and sterile saline solution
A nurse is caring for a client with a tracheostomy. Which equipment should the nurse gather to perform tracheostomy care?
"Give the solution immediately after feedings."
A nurse is caring for a client with thrush. Which instructions would be anticipated for treatment of this disorder?
Maintain the client on strict bed rest-HOB raised no more than 15 degrees
A nurse is caring for a female client having intracavitary radiation for cancer of the cervix. Which nursing intervention is most important for this client?
Tachypnea Hypoglycemia Lethargy
A nurse is caring for a neonate and suspects the development of early-onset sepsis. Which finding would indicate to the nurse that this is occurring?
Microcephaly
A nurse is caring for a neonate diagnosed with fetal alcohol syndrome (FAS). When gathering data on this neonate, which craniofacial change would the nurse most likely find?
Prone position with hips abducted
A nurse is caring for a neonate who has been found to have developmental dysplasia of the hip (DDH). Which position is best for this neonate?
Client is scheduled to have a myelogram within 48 hours of admission (The dye used in myelography may cause severe neuron reaction if given within 48 hours of starting a new antipsychotic medication)
A nurse is caring for a newly admitted client diagnosed with schizophrenia and is started on antipsychotic medication. When reviewing the client's file, which notation would alert the nurse to notify physician before implementing?
Report the symptom so that the infusion can be stopped immediately.
A nurse is monitoring a client who's receiving a blood transfusion for volume replacement. The client reports itching about 20 minutes after the infusion begins. What is the priority action by the nurse?
Provide close supervision due to the client's impulsiveness and poor judgment. (The primary symptoms of a client who experienced a right-sided stroke are left-sided weakness, impulsiveness, and poor judgment.)
A nurse is planning care for a client who suffered a stroke in the right hemisphere of the brain. What intervention is appropriate for this client's care?
Bronchopulmonary dysplasia
A nurse is providing care to a neonate who has received prolonged mechanical ventilation following birth. For which condition should the nurse carefully monitor this neonate
inhales slowly and deeply through the mouthpiece
A nurse is reinforcing education with a client on use of an incentive spirometer. The nurse identifies the teaching as successful when the client demonstrates which technique?
Blinking
A nurse is reviewing a client's chart. Which documentation does the nurse expect to find to indicate that the client's reaction is a normal response to a corneal sensitivity test?
Constriction and convergence
A nurse is testing a client's pupils for accommodation . Which findings should the nurse interpret as normal ?
Help the client dangle the legs. (After placing the client in high Fowler's position and moving the client to the side of the bed, the nurse should help the client sit on the edge of the bed and dangle the legs. The nurse should then face the client and place the chair next to, and facing, the head of the bed.)
A nurse is transferring a client from a bed to a chair. What action should the nurse take during client transfer?
Watery Stools
A physician prescribes phototherapy for a neonate with jaundice. The nurse should monitor the neonate for which common adverse effect of phototherapy?
Oxytocin Carboprost Methylergonovine
A postpartum client experiences postpartal hemorrhage. Fundal massage has failed to maintain uterine contraction and the client continues to experience hemorrhage. The nurse would anticipate which medication to be prescribed?
Contact the MD for pain meds (its there right)
A pregnant women in labor who attended natural birth classes asks for something for pain, what do you do?
Vesicular lesions that ooze, forming crusts on the face and extremities
A school nurse is examining a student at an elementary school. Which finding would lead the nurse to suspect impetigo?
Proteinuria
A toddler is admitted to the hospital with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip. Which finding is the nurse most likely to report?
Stress Urinary Incontinence
A urinary problem associated with cystocele — herniation of the bladder into the vagina
Cardiac tamponade
A victim of a motor vehicle crash with blunt chest trauma and no obvious signs of bleeding has a heart rate of 132 BPM, a blood pressure of 82/54 mm Hg, and muffled heart sounds. Which condition does the nurse suspect the client is experiencing?
..........................
A woman with a history of diabetes has an increased risk for perinatal complications, including hypertension, preeclampsia, and neonatal hypoglycemia; therefore, she needs to be more closely monitored
-HTN -Pre-Eclampsia -Neonatal Hypoglycemia (Should be monitored more frequently)
A women with type 1 DM has in increased risk for what prenatal complications?
Epispadias
Abnormal finding when the urinary meatus is located on the dorsal surface
The day after surgery
After a leg amputation, exercise of the remaining limb should begin when?
May take as long as 6wks
After a stapedectomy how long before hearing improves?
90 Degrees
After hip surgery you should not flex the hips more than what?
q 15min
After placing a client in full leather restraints, how often should the nurse check the client's circulation?
The client is demonstrating signs of hyperstimulation syndrome.
After receiving large doses of an ovulatory stimulant such as menotropins, a client comes in for her office visit. Data collection during the nursing assessment reveals the following findings: Weight gain of 6 lb (3 kg), ascites, and pedal edema. How does the nurse interpret these findings?
Hypospadias
An abnormal finding that's characterized by the location of the urinary meatus on the ventral surface of the penis
Administering multiple doses of insulin
An adolescent with type 1 diabetes mellitus is experiencing a growth spurt. Which treatment approach would be most effective for this client?
Atleast 2hrs after a meal
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?
Anterior MI
An anterior MI causes left ventricular dysfunction and can lead to manifestations of heart failure, which include pulmonary crackles and dyspnea
Osteoarthritis (Osteoarthritis of the hip is associated with joint pain that worsens with activity, diminished ROM, joint crepitus, and difficulty arising after long periods of rest.)
An older adult client is seen in the clinic with reports of right hip pain that worsens after activity, decreased range of motion (ROM) of the right hip, and difficulty getting up after sitting for long periods. The nurse hears crepitus in the right hip upon movement and determines that these symptoms are associated with which condition?
The Tongue
An unconscious client is admitted to the emergency department. The nurse suspects which source is the cause of airway obstruction in this client, as it is the most common source of airway obstruction in the unconscious victim?
Urine Retention
Anticholinergic meds given before surgery put the patient at risk for what?
Muscle Strength
Anticholinesterase drugs like, neostigmine, are given to improve what in Myasthenia Gravis patients?
Question the order
Anticholinesterase drugs like, neostigmine, potentiate the effects of Morphine. What should the nurse do if these meds are given together?
Panic Disorder
Anxiety severe enough to cause the client to fear he's losing his mind occurs with _______________.
................
Aortic stenosis can result from rheumatic fever, which can damage the aortic valve in the first 8 weeks of pregnancy. It accounts for about 5% of all congenital heart defects. It causes a decrease in cardiac output. It's classified as an acyanotic defect with obstructed flow from the ventricles.
Yes
Are DID patients at risk for self-harm?
No
Are patients doing clinical trials a candidate for hospice care?
No this is abnormal
Are urine retention and incontinence normal in a 2 day postop laminectomy patient?
Ginkgo biloba
Aspirin may increase the bleeding when taken with which herbal supplement?
12
At what age should males be taught to perform testicular self-exams?
Respiratory System
Based on the nurse's knowledge of petroleum distillates, which system would be most affected?
Kawasaki Disease
Because of the risk of coronary artery involvement and possible aneurysm development, repeat echocardiography and electrocardiography will be required the first few weeks and at 6 months
Joint flexion of less than 50%
Before a client undergoes arthroscopy, the nurse reviews the data collection findings for contraindications for this procedure. Which finding is a contraindication ?
Bc these contain Iodine and can alter the results of the test
Before the patient undergoes any thyroid functioning tests the nurse should determine whether the patient is applying any topical antiseptics and taking any multivitamins, why?
Sleeping
Biofeedback is useful in the treatment of what disorder?
10 days
Bone marrow depression is most likely to occur how long after administering methotrexate?
...................
Caffiene must be avoided because it is a stimulant that will further irritate the pancreas. A client with pancreatitis must avoid all alcohol because chronic alcohol use is one of the causes of pancreatitis. The diet should be low in fat and high in calories, especially carbohydrates.
Yes
Can Metoprolol alter the insulin requirements in previously stabilized clients?
NO!!!
Can the LPN perform IV push medications?
Yes, it will not effect the neonate
Can you still breast feed if you have Mastitis?
Children with a myelomeningocele have a 90% chance of having a Chiari II malformation. This may lead to respiratory function problems, such as respiratory stridor associated with paralysis of the vocal cords, apneic episodes of unknown cause, difficulty swallowing, and an abnormal gag reflex
Children with a myelomeningocele have a 90% chance of having a Chiari II malformation. This may lead to respiratory function problems, such as respiratory stridor associated with paralysis of the vocal cords, apneic episodes of unknown cause, difficulty swallowing, and an abnormal gag reflex
.......................
Children with a myelomeningocele have a 90% chance of having a Chiari II malformation. This may lead to respiratory function problems, such as respiratory stridor associated with paralysis of the vocal cords, apneic episodes of unknown cause, difficulty swallowing, and an abnormal gag reflex.
Clients taking steroids on a long-term basis lose subcutaneous fat under the skin and are especially vulnerable to skin breakdown and bruising. Such clients should take great care when performing tasks that may injure the skin and should anticipate delayed healing when injuries occur. Clients taking long-term steroids are likely to have hyperglycemia. Prolonged steroid use can cause depression.
Clients taking steroids on a long-term basis lose subcutaneous fat under the skin and are especially vulnerable to skin breakdown and bruising. Such clients should take great care when performing tasks that may injure the skin and should anticipate delayed healing when injuries occur. Clients taking long-term steroids are likely to have hyperglycemia. Prolonged steroid use can cause depression.
-spinach -beef -liver -prunes -pork -broccoli -legumes -whole wheat bread and cereals
Common food sources of iron include:
Necrotizing Entercolitis
Components specific to breast milk have been shown to lower the incidence of _____________________________ in premature neonates
Nuclear Family
Consists of a husband, wife, and children.
Frontal
Damage to the ___________ lobe affects personality, memory, reasoning, concentration, and motor control of speech and regulates thinking, planning, and judgment.
Visual Disturbances
Damage to the occipital lobe cause what?
Hearing and Speech Problems
Damage to the temporal lobe causes what complications?
ARDS
Decreased PaO2 indicates hypoxemia, which is a universal finding in ARDS. PaCO2 level is low early in the disease due to hyperventilation and then elevates later in the disease due to fatigue and worsening clinical status. In later stages, HCO3- level may be low in ARDS due to reduced tissue oxygenation, but not in the early stages.
Ototoxicity
Decreased hearing acuity indicates ________________, a serious adverse effect of streptomycin therapy. The client should notify the physician immediately if it occurs so that streptomycin can be discontinued and an alternative drug can be prescribed.
Roseola
Discrete, rose-pink macules or maculopapules that blanch on pressure and usually last 1 to 2 days
No
Does suctioning require a MD order?
To increase cardiac output
Dopamine given post-op is most likely given for what?
-Cardiac Output -HRT -Cardiac Contractility
Dopamine is a cardiac stimulant that increases what?
Paralyzing the diaphragm reduces the space left by the pneumonectomy
During a pneumonectomy, the phrenic nerve on the surgical side is typically cut to cause hemidiaphragm paralysis. What is the best explanation for the nurse to use when reinforcing teaching the client about this procedure?
........................
During an adolescent growth spurt, a regimen of multiple insulin doses achieves better control of the blood glucose level because it more closely simulates endogenous insulin release.
Digoxin
During digoxin therapy, the nurse should closely monitor the client's serum potassium and magnesium levels. This is because hypokalemia or hypomagnesemia can predispose the client to digoxin toxicity
.......................
During retinal detachment repair, an air bubble is typically injected into the eye to provide added pressure. Postoperative positioning of the client is critical because the injected bubble must float into position over the area of detachment. The client must maintain a prone position which allows the bubble to act as a tamponade for the retinal detachment. The position should be maintained until the health care provider evaluates how well the retina is adhering to the choroid
"8 days after conception"
During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse's best response?
8 days after conception
During routine preconception counseling, a client asks how early a pregnancy can be diagnosed. What is the nurse's best response?
During Diastole
During which phase do coronary arteries primarily receive blood flow?
Autonomy vs Shame & Doubt
Erikson's Stage of Development for 18mo-3yrs
Intimacy vs Isolation
Erikson's Stage of Development for 21-39 yoa
Generativity vs Stagnation
Erikson's Stage of Development for 40-65 yoa
Industry vs Inferiority
Erikson's Stage of Development for 5-13 yoa
Ego Integrity vs Despair
Erikson's Stage of Development for 65yoa -death
Trust vs Mistrust
Erikson's Stage of Development for Infants-18mo
Menorrhagia
Excessive menstrual period
Blended Family
Family in which children from previous marriages live together.
Myctophobia
Fear of the dark
.......................
Female neonates may have some vaginal bleeding in the first or second day after birth because they no longer have the high levels of female hormones that they were exposed to while in the uterus. The physician needn't be called. This bleeding is normal and doesn't indicate dehydration or hematuria.
Following through with promises
Fidelity
Latent Phase
First stage of labor is associated with irregular, short, mild contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort
-Yogurt -Aged Cheese -Smoked or Processed Meats -Red Wines -Avocadoes -Raisins -Figs
Foods containing Tyramine:
-organ meats -anchovies -sardines -shellfish -chocolate -meat extracts
Foods high in purine
High Fowler's
For a client with impaired gas exchange, which position is best?
Decreased
For a pregnant diabetic mother are the insulin requirements usually increased or decreased during the first trimester?
Adding air prevents the drug from flowing back into the needle track.
For which rationale, when administering a Z-track injection, the nurse measures the correct medication dose and then draws a small amount of air into the syringe?
...................
Formative (or concurrent) evaluation occurs continuously throughout the teaching and learning process. One benefit is that the nurse can adjust teaching strategies as necessary to enhance learning.
..................
Gentamicin sulfate is toxic to the kidneys. Monitoring BUN and creatinine levels during the course of therapy can identify nephrotoxicity before severe damage occurs. Gentamicin sulfate is also toxic to the ears. Evaluating the client for tinnitus, dizziness, vertigo, and hearing loss can prevent damage from ototoxicity.
-Raisins -Dates -Figs -Prunes -Cabbage -Mushrooms -Strawberries
Good sources of Potassium
Gustatory Hallucination
Hallucination where the client reports experiencing a peculiar tastes?
.......................
Haloperidol can cause photosensitivity and precipitate severe sunburn, so the nurse should instruct the client to apply a sunscreen before exposure to the sun. The nurse should also teach the client to take haloperidol with meals, rather than 1 hour before, to prevent gastric upset and should instruct the client not to decrease or increase the dosage unless ordered to do so by the physician
Check MM
How do we check for cyanosis in a dark skinned person?
Respiratory Secretions
How is Fifth Disease transmitted?
Fine Needle Aspiration
How is a dx of breast cancer confirmed?
Within 1hr
How long after administration does Loperamide begin to work?
3-5qts
How much fluid should a patient with multiple myeloma consume daily?
1lb/wk
How much weight should the pregnant client gain during the second trimester?
q 15-30 min
How often should a hospitalized dissociative identity disorder (DID) patient be checked on?
By shaking it so that all the drug particles are dispersed uniformly
How should the nurse prepare a suspension before administration?
On the left side with the right knee flexed
How should the patient be positioned when self-administering an enema?
Top inside, through wounds, and then out
How to irrigate wound:
-osteopenia -hypotony -renal calculi
Hyperparathyroidism is characterized by _________, ____________, and ____________.
...........................
If a radioactive implant becomes dislodged, the nurse should pick it up with long-handled forceps and place it in a lead-lined container, then notify the radiation therapy department immediately. Minimizing radiation exposure for the client and the nurse is the first priority, so the nurse must not delay removing the implant from the bed
NG Patency
If the NG tube isn't draining properly or is kinked, the child will experience nausea. Therefore, the nurse should check the tube's patency and irrigate it as ordered.
Void
If the fundus is boggy and deviated to the right, what should the nurse instruct the patient to do to help with uterine involution?
Notify the MD of the concerns to determine whether these concerns should be expected with this procedure
If the patient has concerns after surgery what should the nurse do?
...................
Immune globulin provides a temporary immunity that's passively acquired. Antibodies from one person are recovered and administered to another person to help prevent him from being infected. Since the recipient's immune system didn't make the antibodies, the immunity is considered to be passively acquired. Immunizations and actual disease processes, such as chickenpox, cause the body to manufacture antibodies against future exposure to these specific antigens; this is called active immunity. Active immunity produces antibodies that are either permanent or longer lasting than passively acquired immunity.
.........................
In Schilling test, a radioactive vitamin B12 is given PO and then urine is collected over the next 24 hours to measure whether vitamin B12 is normally absorbed
Excessive Drooling
In type III/C tracheoesophageal fistula, the proximal end of the esophagus ends in a blind pouch and a fistula connects the distal end of the esophagus to the trachea. Saliva will pool in this pouch causing what to happen?
-fetuses -neonates -infants
In which populations are premature atrial contractions common?
Increase
Incidence of Ovarian Cancer ________________ in women who have never been pregnant.
!!!!!!!!!!!!!!!
Infants and children with heart defects tend to have poor nutritional intake and wt. loss, indicating poor cardiac output, heart failure, and hypoxemia. The child appears lethargic/tired bc of the heart failure or hypoxia. Gray, pale, or mottled skin may indicate hypoxia or poor cardiac output.
Respiratory stridor, apneic periods, and difficulty swallowing
Infants with myelomeningocele must be closely observed for manifestations of Chiari II malformation. Which finding would indicate this manifestation?
10mm Hg
Intra-arterial readings should be at least __________ higher than cuff readings.
Intertrigo
Irritation of opposing skin surfaces caused by friction
Yes
Is Bupropion used as an antidepressant?
Yes
Is ECT (electro-convulsion therapy) indicated for depression?
Yes
Is Testicular Cancer highly curable?
No
Is hypnosis used to treat depersonalization/derealization disorder?
Surgeon/MD
It is the responsibility of who to get the informed consent signed?
...........
Keeping objects close to the body's center of gravity by carrying them close to the body lessens strain on the back.
Performing BSE
Lie down with one arm behind the head. Place the hand over the breast to be examined (use the right hand for the left breast and vice versa). Use the finger pads of the three middle fingers and touch the breast. Use a circular motion to feel the breast tissue (with light, medium, and firm pressure). Palpate the breast in a perpendicular motion, going across the breast from side to side and top to bottom
Anxiety and Insomnia
Lorazepam is a benzodiazepine used to treat various forms of what?
Anxiety
Lorazepam is used to treat what?
respiratory depression, hypotonia, and bradycardia.
Magnesium sulfate crosses the placenta, and adverse neonatal effects include:
...............
Many older adults already have diminished hearing, and salicylate use can lead to further or total hearing loss
Hirschsprung's disease
Many older adults already have diminished hearing, and salicylate use can lead to further or total hearing loss what?
65>, and some ppl younger than 65 with disabilities
Medicare is a national health insurance program for people in what age group?
.......................
Meningeal irritation may cause seizures and heightens a child's sensitivity to all stimuli, including noise, lights, movement, and touch
NO!!!!
Missed doses of Risperdone (Risperdal) should NOT be doubled!!!!!!!!!!!
4-12hrs
NPH is an intermediate-acting insulin that peaks ______________ after administration
97.7-99.5 ax
Normal Infant Temp.
Major surgery
On a visit to the gynecologist, a client reports urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?
Thrombocytopenia
Oprelvekin is given to a client with __________________________ to stimulate the production of platelets.
Platelets
Oprelvekin is given to a client with thrombocytopenia to stimulate the production of ____________.
Dyspareuria
Painful intercourse
-Prednisone 1/day q day -Wt. in the "AM" and keep a logbook -"AM" urine with a 2+ protein for 2 days in a row, CALL MD
Parent teaching for a child with Nephrosis
Taking Hold (Dependent-Independent)
Phase after delivery, which may last from 3 days to 8 weeks, the client vacillates between seeking nurturing and acceptance for herself and seeking to resume an independent role
Phenytoin
Phenytoin can cause hypertrophy of the gums and gingivitis; therefore, regular dental checkups are essential. Phenytoin needs to be taken with food or after meals to decrease adverse GI reactions, and should never be discontinued unless ordered by the health care provider. Some drowsiness is expected initially; however, this usually decreases with continued use.
..........................
Prelabor contractions are usually felt in the abdomen. In contrast, true labor contractions are regular, start in the back and radiate to the abdomen, and become more intense during walking.
Airborne
Pulmonary TB requires what type of isolation?
........................
Pulmonary edema, a life-threatening complication of heart failure, can develop in minutes, secondary to a sudden fluid shift from the pulmonary vasculature to the lungs' interstitial alveoli.
..................
Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low.
Strawberry Hemangiomas
Rapidly growing vascular lesions that reach maximum growth by age 1 year. The growth period is then followed by an involution period of 6 to 12 months. Lesions show complete involution by age 2 or 3 years. These benign lesions don't need surgical or oncologic referrals.
Apraxia
Refers to the client's inability to use objects properly
Tidal Volume
Refers to the volume of air inspired and expired with a normal breath.
DID
Repeated exposure to a childhood environment that alternates between highly stressful and then loving and supportive can be a factor in the development of DID. Many children grow up in a household without a father but don't develop DID. Because of disso-ciation from the trauma, a client with DID usually can't recall traumatic childhood events. Clients with DID commonly have low self-esteem.
-Drowsiness -Dizziness -Tremors -Wt. Gain -Dry Mouth
S/E of Gabapentin
-Irritability -Shaky Feeling -Hunger -HA -Dizziness
S/S of Hypoglycemia
-Sudden onset of incapacitating vertigo -N/V
S/S of Labyrinthitis
-HA -Weakness -Renal Insufficiency -Renal Calculi -HTN -Arrhythmias -Muscle pain -Conjunctivitis -GI Upset -Metallic Taste
S/S of Vitamin D Toxicity
-pallor -tachycardia -sore tongue -anorexia -wt. loss -smooth, beefy red tongue -wide pulse pressure -palpitations -angina -weakness -fatigue -paresthesia of the hands and feet
S/S of pernicious anemia
Proliferative
Scabs appear during which stage of healing?
Myxedema Coma
Severe hypothyroidism may result in ________________, in which a drastic drop in the metabolic rate causes decreased vital signs, hypoventilation (possibly leading to respiratory acidosis), and nonpitting edema.
No
Should ECT be used for severe agitation, antisocial behavior, or noncompliance?
Yes
Should an increase in BP during contractions be reported?
No, it should be given with a full glass of water on an empty stomach
Should doxycycline be given with food?
Empty, the nurse should teach the patient to void before procedure
Should the bladder be full or empty when performing an Amniocentesis?
Russell Traction
Skin traction applied to a lower extremity, with the extremity suspended above the bed
Russell's Traction
Skin traction applied to a lower extremity, with the extremity suspended above the bed
B12
Smooth, bright red tongue is a sign of what vitamin deficiency?
Hypertonic
Solution that causes fluids to be absorbed into the intravascular space until equal pressure is established on both sides of the blood vessel
Hypotonic
Solution that causes fluids to move from the intravascular space into the interstitial space
Transitional Phase
Stage of labor when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60 seconds' duration occur every 1½ to 2 minutes.
Active Phase
Stage of labor when the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds' duration occur every 2 to 5 minutes
Highest
Survival rates with Wilms Tumors are the ____________ among childhood cancers.
Thyroid Hormones
T3 and T4 are what type of hormones?
Fasciotomy
TX for Compartment Syndrome
Decreases
Taking an antipsychotic medication with milk, nicotine, or caffeine _______________ its effectiveness.
-MRI -CT scan -Myelography
Tests used to diagnose a herniated nucleus pulposus (HNP) include:
....................
The Hib vaccine provides protection against serious childhood infections caused by H. influenzae type B virus, such as meningitis and bacterial pneumonia
5mo
The Moro Reflex is present up until what age?
4mo
The Palmer Grasp Reflex is typically present until what age?
9
The Plantar Grasp Reflex is typically present until what age?
Parietal
The ________ lobe regulates sensory function, which would include the ability to sense hot or cold objects.
Occipital
The __________ lobe is primarily responsible for vision function.
C-Cut Down A-Annoyed by criticism G-Guilty about drinking E-Eye-opener drinks
The acronym CAGE stands for:
Beneficent
The act of doing good for the benefit of others
.....................
The activity which has the preschooler take a deep breath in and blow out such as blowing a tissue to allow the nurse to assess the lung fields. This activity is fun and developmentally appropriate for the preschooler and accomplishes the nursing goal
Medicate the client for pain.
The assessment of a client on the first day after a thoracotomy shows a temperature of 100°F (37.8°C); heart rate, 96 beats/minute; blood pressure, 136/86 mm Hg; and shallow respirations at 24 breaths/minute, with rhonchi at the bases. The client reports incisional pain. Which nursing action has priority?
..................
The average incubation period for localized genital herpes simplex infection is 3 to 7 days. (For generalized herpes simplex infection, the average incubation period is 2 to 12 days.)
Stomach
The client with a peptic ulcer is prescribed an antacid. After administering the medication, the nurse assesses the pH of which organ contents to determine effectiveness?
Oliguria. Azotemia. Acidosis. Severe hypocalcemia.
The first symptom of acute renal failure is oliguria (urine output less than 1 mL/kg of the child's body weight per hour). The inability to produce urine causes azotemia, an accumulation of nitrogen waste in the bloodstream, which leads to rising blood urea nitrogen levels. This leads to acidosis because of the body's inability to excrete H+ ions. The acidotic state results in hyperphosphatemia (high phosphorus levels), which in turn causes hypocalcemia (low calcium levels). When hypocalcemia is severe, muscle twitching and tetany can occur.
Sodium and Excess Water
The kidneys respond to a rise in blood pressure by excreting __________________________________. This affects systolic blood pressure by regulating blood volume. Sodium and water must travel across the kidney membrane together; one can't travel without the other
Resolve the immediate problem
The major goal of therapy in crisis intervention is to what?
Muscle Weakness (may depress liver function or cause idiosyncratic hepatitis)
The most common adverse reaction to dantrolene is what?
abdominal aorta, just below the renal arteries.
The most common site of aneurysm formation is in the:
Hypertensive Crisis
The most serious adverse reaction associated with high dosages of MAO inhibitors is ______________________.
........................
The most serious adverse reaction associated with high dosages of MAO inhibitors is hypertensive crisis, which can lead to death. Although not a crisis, orthostatic hypotension is also common and may lead to syncope with high dosages.
Large, immune Liver
The nurse caring for a 3-day-old neonate notices that he looks slightly jaundiced. Although not a normal finding, it's an expected finding of physiologic jaundice and is caused by which of the following?
Independent
The nurse complies with a client's request to administer his medication at 9 p.m. instead of 10 p.m. so he can go to sleep earlier. Which type of nursing intervention is the nurse utilizing?
Barely detectable depression when the thumb is released from the swollen area; normal foot and leg contours
The nurse documents the severity of pitting edema as +1. What is the best description of this type of edema?
Gamma aminobutyric acid (GABA)
The nurse educator is teaching a a group of nursing students about baclofen therapy. The nurse educator will include baclofen as an analogue of which neurotransmitter ?
Establish unresponsiveness
The nurse finds an adult client collapsed in the hallway. Which action should the nurse take first when arriving to assist this client?
Kidneys
The nurse has just administered a drug to a child. Which organ is most responsible for drug excretion in children?
Remove the warm compress after 20 minutes for at least 15 minutes.
The nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse would:
Fine Crackles
The nurse is assessing a client with heart failure. The breath sounds commonly auscultated in clients with heart failure are:
Press the Right Upper ABD
The nurse is assessing a client with heart failure. To assess hepatojugular reflux, the nurse should:
Use birth control for 1 year
The nurse is caring for a client after evacuation of a hydatidiform mole. The nurse should tell the client to:
Orient the client to the surroundings.
The nurse is caring for a client immediately after the client has received electroconvulsive therapy for the treatment of severe depression. What is a priority intervention for this client?
Echocardiography
The nurse is caring for a client suspected of having cardiac tamponade. Which diagnostic test will the nurse prepare the client for?
Monitor blood glucose closely and look for signs of hypoglycemia
The nurse is caring for a client who vomits 1 hour after taking a morning glyburide? What is the priority nursing action?
destroys the odor-proof seal.
The nurse is caring for a client with a colostomy and notices small holes in the bag. The client tells the nurse that he makes small pin holes in the drainage bag to help relieve gas. The nurse includes in her teaching plan that this action:
Hold pressure to the site for 5-10 minutes.
The nurse is caring for a client with acute respiratory insufficiency that requires arterial blood gas analysis (ABG). The client has been taking warfarin for several months. What intervention should be provided after the ABG is drawn?
Calcium-channel antagonists
The nurse is caring for a pregnant client with cardiovascular disease. Which classification of medication may be used safely for the client?
Administer after meals by swabbing the mouth
The nurse is caring for an infant diagnosed with thrush. Which instruction should the nurse give to a client's mother who will be administering nystatin oral solution?
Undescended testes
The nurse is caring for an infant with hypospadias. Which anomaly would the nurse assess the infant for that commonly accompanies this condition?
diarrhea.
The nurse is collecting data on a client suffering from stress and anxiety. A common physiological response to stress and anxiety is:
Notify the charge nurse. (Because bleeding gums are an adverse effect of heparin that may indicate excessive anticoagulation, the nurse should notify the charge nurse, who will evaluate the client's condition.)
The nurse is obtaining vital signs for a client who is receiving a heparin infusion to treat deep vein thrombosis. The client reports that the gums bleed when brushing the teeth. What should the nurse do first?
Hypoactive
The nurse is performing an assessment on a client who has developed a paralytic ileus. The nurse expects the client's bowel sounds will be:
It will assess for central nervous system infiltration.
The nurse is preparing a child newly diagnosed with leukemia for a spinal tap. The parents state, "Why is the health care provider doing this? What is the best response by the nurse?
Vertex Position
The nurse is providing care to a pregnant woman in early labor. Which position is the fetus in that will provide an easy passage through the birth canal?
Foot (Distal-Proximal)
The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's
Collection of cerebrospinal fluid (CSF) and blood for culture
The nurse should anticipate that antibiotic therapy to treat meningitis will be instituted immediately after which event?
Call the MD for a different route of administration bc demopressin is given Intranasally and the excessive nasal mucous will interfere with the absorption
The nurse should include which in-home management instruction for a child who's receiving desmopressin acetate for symptomatic control of diabetes insipidus?
a corticotropin-secreting pituitary adenoma.
The nurse would respond that "Cushing's syndrome is most likely caused by:
-30min -4-6hrs
The onset of action of kaolin and pectin occurs within _________ after oral administration. Duration of action is_____________________.
-Biopsy of the lesions -Colonoscopy
The parents of a 13-year-old child being evaluated for possible Crohn's disease asks the nurse how Crohn's is positively diagnosed. Which diagnostic tests would the nurse correctly identify as providing confirmation of Crohn's disease?
slows the conduction of impulses through the atrioventricular (AV) node
The physician has ordered digoxin for a client with pulmonary edema. The nurse knows that digoxin has a direct and beneficial effect on myocardial contraction in the failing heart. This effect:
lethargy, vomiting, and diarrhea.
The physician prescribes lithium carbonate for a client who has just been diagnosed with bipolar disorder . Now the nurse is teaching the client about signs and symptoms of lithium toxicity , which include:
-This is an allergic reaction. -Based on the location, it is likely that detergents in the bed linens caused the rash. -Oatmeal (Aveeno) baths are a good treatment for a rash of this type because of the large area
The physician's diagnosis is an allergic contact dermatitis. Which teaching points about contact dermatitis are important?
.........................
The prostate gland has alpha-adrenergic receptors. Thus, alpha-adrenergic blockers relax the smooth muscle of the bladder neck and prostate, so the urinary symptoms of BPH (frequency, urgency, hesitancy) are reduced in many clients.
............................
Theoretical and conceptual models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren't frameworks for nursing education and practice.
Seated Upright
To check the fontanels, how should the nurse position an infant?
Mastitis
To help relieve mastitis, the nurse should advise the client to massage the affected area gently during breast-feeding; breast-feed at least every 2 to 3 hours; apply a warm, wet washcloth to her breast before each feeding; and wear a supportive brassiere.
At bedtime
To minimize the risk of adverse drug reactions, the client should take benztropine as a single dose when?
"I will avoid using soap and water on the affected area and will apply an emollient cream on this area frequently."
To treat a child's atopic dermatitis , a physician prescribes a topical application of hydrocortisone cream twice daily. After medication instruction by the nurse, which statement by the parent indicates effective teaching?
Diarrhea
To treat a urinary tract infection (UTI), a client is prescribed sulfamethoxazole-trimethoprim. The nurse should teach the client that sulfamethoxazole-trimethoprim is most likely to cause which adverse effect?
Undercooked fresh meats
Toxoplasmosis comes from what?
Bryant's Traction
Traction that is used to tx femoral fx or congenital hip dislocation in children younger than 2yoa who weighs less than 30lbs.
86
Using the formula systolic blood pressure = 80 + (age in years × 2), the estimated blood pressure for a 3-year-old child is
Taking-In (Dependent)
Usually lasts 1 to 2 days after delivery, the client usually is exhausted and dependent on others, focusing on her own needs
Metrorrhagia
Uterine bleeding from a cause other than menstruation
Telling the truth
Veracity
......................
Vesicular breath sounds are soft, low-pitched sounds normally heard over the lower lobes of the lung. They are prolonged on inhalation and shortened on exhalation. Bronchial breath sounds are loud, high-pitched sounds normally heard next to the trachea; they are discontinuous and loudest during exhalation. Tracheal breath sounds are harsh, discontinuous sounds heard over the trachea during inhalation or exhalation. Bronchovesicular breath sounds are medium-pitched, continuous sounds that occur during inhalation or exhalation and are best heard over the upper third of the sternum and between the scapulae.
N/V
What are some early signs of alcohol withdrawal?
-Congenital abnormalities -DM
What are some secondary causes of osteoarthritis?
-Altered LOC -Bradycardia
What are some signs of neurologic deficit in an infant?
-Limit Caffeine -Avoid Smoking -Follow a regular schedule for sleep and rest
What are some things the nurse should teach a Narcolepsy patient?
-Overuse of joints -Aging -Obesity
What are the causes of Primary osteoarthritis?
Antipsychotic Agents
What class of drug is Haloperidol?
Atypical Antipsychotic
What classification is Bupropion?
Honey-color, crusted lesions
What does impetigo look like?
Decreases the workload of the heart
What effect does Enalapril have on the heart?
To help reduce the sx of alcohol withdrawal
What is Chlordiazepoxide (Librium) used for?
A topical med applied nightly for Acne Vulgaris
What is Tretinoin (retinoic acid)?
To help expel flatus to relieve distention
What is a carminative enema used for?
Uremia
What is a clinical finding associated with Chronic Renal Failure?
Seizures
What is a common risk when taking Bupropion in doses of 450mg or more daily?
Malignant Neuroleptic Syndrome
What is a dangerous adverse reaction of neuroleptic drugs, like: Fluphenazine)?
Granulocytopenia
What is a major adverse effect of Clozapine?
0-15
What is a normal ICP?
Give foods to eat while active
What is a nursing intervention for a patient with bipolar disorder to help maintain adequate nutrition?
Erectile Dysfunction
What is a potential adverse reaction for male clients taking beta blockers?
No ABD pain
What is a short term goal for a patient with acute pancreatitis?
Blurred Vision (requires no action)
What is an expected effect associated with the open-angle glaucoma drug, Pilocarpine?
Calcium Gluconate
What is the antidote for magnesium toxicity?
3-7 Days
What is the average incubation period for Genital Herpes Simplex?
It's unknown
What is the cause of Pyloric Stenosis?
A Scale
What is the characteristic secondary lesion occurring in psoriasis?
Gastroscopy
What is the diagnostic test for gastric cancer?
Acromegaly occurs after puberty and gigantism before puberty.
What is the difference between acromegaly and gigantism?
Osteoarthritis is localized and rheumatoid arthritis is systemic
What is the difference between osteoarthritis and rheumatoid arthritis?
Haloperidol
What is the drug of choice for treating Tourette syndrome?
Edrophonium
What is the drug of choice to diagnose myasthenia gravis?
To remove the cancerous lung tissue that has tumor in it while preserving as much surrounding tissue as possible
What is the goal of surgical lung resection?
Agnosia
What is the inability to recognize familiar objects?
10-20 Days
What is the incubation period for varicella?
S. aureus
What is the most common causative pathogen of osteomyelitis?
Arrhythmias
What is the most common complication of an MI?
Burning and tingling genital discomfort
What is the most common initial finding in clients with primary genital or type 2 herpes simplex?
Dust Mites
What is the most commonly inhaled allergen that can cause asthma attacks?
Slows conduction of impulses through the atrioventricular (AV) node
What is the most direct effect on myocardial contraction due to digoxin in the failing heart?
Vertex position (flexion of the fetal head)
What is the optimal position for passage through the birth canal?
Permethrin
What is the recommended treatment for scabies in a child who's younger than age 1?
Compression Garments
What is worn for up to 1 year to control hypertrophic scarring?
Cones
What part of the eye is responsible for color vision?
Antacids
What should be avoided when taking iron supplements as it will interfere with absorption of the iron?
Provide frequent early formula feedings
What should be done for a neonate of a mother with poorly controlled DM to prevent hypoglycemia?
Carotid Artery
What should be used to assess for a pulse when performing CPR on children and adults?
Brachial Pulse
What should be used when performing CPR on an infant?
-Whether they know the appropriate dosage and administration -Whether they know the correct reason for taking this med -Whether they know the proper route of administration
What should the nurse ascertain to determine the safety of a patient who takes OTC meds regularly?
Place infant in warmer and notify charge nurse
What should the nurse do if the infant has an AX temp. below 97.7?
-Pursed-lip Breathing -Low-Flow O2 -Alternating activity with rest -Postural drainage and chest physiotherapy
What should the nurse teach the patient with Emphysema?
It is associated with seizures
What should we educate the client about when using Lindane lice shampoo?
Change diaper frequently and allow to air-dry when possible
What should we teach parents to do for diaper dermatitis?
That this is a normal healing stage of a head injury
What should we tell the parents of an infant with a head injury who is showing inappropriate behavior and combative violent outbursts?
Use a Doppler to find it and if you still can not find it notify the MD
What should you do if you can not find a dorsalis pedal pulse?
Dryness of the lips (this is d/t dehydration and is common with pyloric stenosis)
What symptom would the nurse most likely find in an infant dx with Pyloric Stenosis?
Schilling Test
What test is performed to evaluate vitamin B12 absorption. It is used to diagnose pernicious anemia.
Diaphragmatic Breathing
What type of breathing exercises are you most likely to teach a bronchitis patient?
Low-Sodium (d/t corticosteroids causing fluid retention)
What type of diet should be followed when taking corticosteroids?
Moist Sterile Saline Gauze
What type of dressing should the nurse apply to and open ulceration with visible granulation?
Standard
What type of isolation is required for botulism?
Droplet
What type of isolation is required for mumps of streptococcal pharyngitis?
Contact
What type of isolation is required for scabies and multidrug-resistant organisms?
Respiratory Isolation
What type of isolation is used for Measles?
Droplet
What type of isolation is used for bacterial meningitis?
N95 Respirator (NOT an isolation mask)
What type of mask is required when taking care of a TB pt?
Enteric
What type of precaution is used for Norwalk Virus?
-Hematuria -Proteinuria
What would the nurse expect to see in an urinalysis for a patient with Glomerulonephritis?
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When a client is ambulating, gravity causes the drainage to flow downward. Covering the base of the wound with extra dressing will contain the drainage. Reinforcing the dressing at the top, in the middle, or over the total wound won't contain the drainage.
Missed Dosage
When a nurse has accidentally omitted an ordered medication, she should first notify the prescriber, nursing supervisor, and pharmacist. She should then document the omission and the reason in the client's chart and, depending on facility policy, write an incident report. The nurse shouldn't give an extra dose at the next scheduled time because adverse reactions or toxicity could occur.
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When a spinal cord lesion exists at birth, it commonly leads to altered development or function of other areas of the CNS. Spina bifida is a complex neurologic defect that heavily impacts the physical, cognitive, and psychosocial development of the child, and involves collaborative, lifelong management due to the chronicity and multiplicity of the problems involved.
Menstrual irregularities and decreased libido
When administering spironolactone to a client who has had a unilateral adrenalectomy, the nurse should instruct the client about which possible adverse effect of the drug?
Full glass of water
When administering sulfamethoxazole-trimethoprim be sure to instruct the patient to take this medication with what?
She should report the finding as hypospadias.
When assessing a male neonate, the nurse notices that the urinary meatus is located on the ventral surface of the penis. How should the nurse report this finding?
maintaining the client's fluid, electrolyte, and acid-base balance.
When assisting with developing a plan of care for a client recovering from a serious thermal burn, the nurse knows that the most important immediate goal of therapy is:
28wks
When can the fetus open their eyes?
20wks
When can the fetus suck and swallow?
Multiple Myeloma
When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration.
Prevent infection
When caring for a neonate with Myelomeningocele what is a top priority?
Wt. Loss
When collecting data on a neonate diagnosed with diabetes insipidus, which finding would indicate the need for intervention?
"It is given into the rectum to help expel flatus to relieve distention."
When discussing the plan of care with the nurse mentor, which appropriate information would the graduate state that provides an understanding of a carminative enema?
21-28wks
When does a fetuses nostrils open?
7-9 weeks
When does menses typically return after delivery?
9-18 mo old
When does the anterior fontanel close?
3-4 wks
When does the stepping reflex cease?
Hematuria and proteinuria
When evaluating the urinalysis report of a child with acute glomerulonephritis, the nurse would expect which result?
Use the smallest needle possible
When giving a patient with thrombocytopenia an injection, what is the best way to protect them from complications?
Instruct the client to breathe deeply. (Breathing deeply relaxes the urinary sphincter, making urinary catheter insertion easier)
When inserting a urinary catheter on a male client, which action should the nurse take to facilitate the insertion?
When the lesions have crusted over
When is a child with varicella no longer contagious?
The nurse loosens the wet-to-dry dressing with normal saline. (Loosening the wet-to-dry dressing with any solution defeats the purpose - to debride)
When observing a newly hired nurse change a wet-to-dry dressing, which action by the nurse would indicate to the nurse mentor that further teaching is needed?
CPR with a child
When performing CPR on a child between ages 1 and 8, the nurse should use the heel of one hand to compress the chest 1" to 1½" (2.5 to 3.75 cm).
At the base of the wound
When preparing a client with a draining vertical incision for ambulation, where should the nurse apply reinforced dressings?
Standard Written Order
When reviewing a client's file, the nurse reviews the following medication order "Vitamin K 10 mg intramuscular (I.M.) daily × 3 days?" The nurse recognizes this as which type of order?
Rejection by peers
When reviewing the mental health chapter, the nursing student recognizes which psychosocial influence has been causally related to the development of aggressive behavior and conduct disorder?
ASAP and then again in 3mo
When to get tested with a needle stick injury?
Palms of the hands
When using crutches what part of the body should bear the weight?
Ventrogluteal muscle (however, the preferred site is the Vastus Lateralis)
Which I.M. injection site might the nurse use for a 2-year-old child?
Enhance myocardial oxygenation.
Which action by the nurse is the priority care for a client exhibiting signs and symptoms of coronary artery disease?
Tricyclic antidepressants (Tricyclic antidepressants can create fatal cardiac arrhythmias.)
Which classification of drugs is the most potentially fatal if the client takes an overdose?
Hypocalcemia
Which condition should the nurse closely monitor that may occur during chelation therapy in a child with lead poisoning?
The urinary meatus opens close to the scrotum.
Which data collected by the nurse would indicate to the health care provider the need for a staged repair of a hypospadias rather than a single repair?
Voiding pattern
Which factor should the nurse evaluate when determining the effectiveness of an alpha-adrenergic blocker given to a client with benign prostatic hyperplasia (BPH)?
IgE
Which immunoglobulin is specific to an allergic response?
Restrict Exercise (In a child with symptomatic aortic stenosis, exercise should be restricted due to low cardiac output and left ventricular failure)
Which instruction by the nurse would be most appropriate for a child with symptomatic aortic stenosis?
Weighing infants daily
Which intervention provides the most accurate information about an infant's hydration status?
Human immunodeficiency virus (HIV) testing
Which intervention should be done first for a client who has an antisocial personality disorder and a history of polysubstance abuse?
Handle the infant minimally after feedings
Which intervention should the nurse perform to help prevent vomiting in an infant diagnosed with pyloric stenosis?
Sleep 8hrs/night
Which measure should the nurse emphasize when reinforcing education for a client with multiple sclerosis (MS) to avoid exacerbation of the disease?
Amantadine
Which medication can control the extrapyramidal effects associated with antipsychotic agents?
Lithium Carbonate
Which medication is a nonantipsychotic that may be used to treat a client with schizoaffective disorder?
Helping the client identify and express feelings of anxiety and anger
Which nursing action is most appropriate when trying to diffuse a client's impending violent behavior?
Elevate the head of the bed 45 to 90 degrees. (To facilitates diaphragmatic movement and lung expansion)
Which nursing action takes priority when admitting a client with right lower lobe pneumonia?
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
Which nursing diagnosis takes highest priority for a client with Parkinson's crisis?
Auscultating breath sounds
Which nursing intervention takes priority for a client infected with Pneumocystis carinii pneumonia?
The hips are slightly elevated off the bed
Which observation by a nurse indicates that an 18-month-old in Bryant traction is properly positioned?
Tetanus and diphtheria toxoids
Which of the following immunizations should an adolescent, age 12, receive as a component of preventative care?
Promote and participate in community health projects such as free clinics, health fairs, and blood pressure clinics.
Which of the following would be the role of the licensed practical nurse (LPN) in community nursing?
Frontal Plane
Which plane would divide the body longitudinally into anterior and posterior regions?
Reduces Acid Secretions
Which process best describes the mode of action of medications such as ranitidine, which are used in the treatment of peptic ulcer disease?
Low T4 level and high TSH level
Which results would indicate to the nurse the possibility that a neonate has congenital hypothyroidism?
"Pulmonary edema, a life-threatening condition, can develop in minutes."
Which statement by a nurse to an unlicensed assistive personnel (UAP) best explains the need to promptly report changes in respiratory rate for a client diagnosed with heart failure?
"By examining the retina in your eyes, an ophthalmologist can detect changes in the arteries in your eyes."
Which statement by the nurse accurately explains the need for a client with hypertension to obtain an annual eye exam?
"This disease occurs after a streptococcal infection."
Which statement regarding acute glomerulonephritis indicates that the parents of a child with this diagnosis understand the education provided by the nurse?
Heat Intolerance
Which symptom should the nurse expect to find in a client with increased blood plasma levels of thyroxine?
Restlessness
Which symptom would the client with generalized anxiety disorder (GAD) most likely display when assessed for muscle tension?
Stools that have an oily consistency
Which symptoms, if reported by a client, should lead the nurse to suspect Crohn's disease affecting the small intestine?
Call for help
While administering morning medications, a nurse enters the room of a client who recently had a thyroidectomy. She observes that the client is sitting up in bed but appears unresponsive. After confirming unresponsiveness, what should the nurse do next?
As a third heart sound (S3)
While auscultating the heart sounds of a patient with heart failure the nurse hears and extra heart sound immediately after the 2nd heart sound. How should the nurse document this?
Prolonged bleeding time
While collecting data, a nurse should recognize which symptom as the primary clinical manifestation of hemophilia?
Hypoactive bowel sounds
While monitoring a client with hypothyroidism, which symptoms would the nurse anticipate observing?
"It occurs in children who have ancestors with adult height in the lower percentiles and whose height during childhood is appropriate."
While reinforcing education with the parents of a child of short stature, the nurse discusses familial short stature. Which statement by the nurse about this condition is most accurate?
Lorazepam
While shopping at a mall, a woman experiences an episode of extreme terror accompanied by anxiety, tachycardia , trembling, and fear of going crazy. A friend drives her to the emergency department, where a physician rules out physiological causes and refers her to the psychiatric resident on call. The nurse caring for this client would expect the health care practitioner to prescribe which medication to control the client's anxiety ?
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While taking metronidazole to treat trichomoniasis, adolescents shouldn't consume alcohol for at least 3 days following the last dose because the drug is similar to disulfiram and may lead to a psychotic reaction.
The client and nurse
Who is involved in writing a behavioral contract?
Bc it is a stimulant and increases anxiety
Why is caffeine contraindicated when taking Lorazepam?
Metabolic Alkalosis
Will bulimia cause Metabolic alkalosis or Metabolic acidosis?
Nephrotoxicity
With Gentamicin Sulfate the BUN and Creatinine level should be monitored to look for signs of what?
Bc this allows them to be less fearful in their room
With a Down's Syndrome child why should we always take them to an exam room for a procedure?
Yes
With a chest tube drainage system, is bubbling in the suction chamber normal?
YES
With syndrome of inappropriate antidiuretic hormone (SIADH) should fluids be restricted?
Hypothyroidism
Wt. gain, lethargy, bradycardia, with decreased levels of T3 and T4 indicate what?
Aphasia
___________ is characterized by an impaired ability to speak.
Acetylcholine
______________ is a neurotransmitter contained in the axon terminal vesicles. It is the substance that, when broken down, provides energy for muscle contraction
Autonomy
________________ ascribes the right of the individual to make his own decisions.
Cholinesterase
____________________ is an enzyme that breaks down acetylcholine and prevents continuous stimulation of skeletal muscle
