NCLEX review from Saunders

R hemisphere stroke

- R cerebral hemi controls movement of L side of body & spatial perception - could present as L sided functional motor loss, loss of motor skills (ataxia) and neglect From Lewis: - L sided hemiplegia (paralyses) - L sided neglect - Spatial/Perceptional deficit - tends to deny or minimize problems - Rapid performance/short attention span - Impulsive = safety - impaired judgement - Impaired concept of time

Lithium therapeutic leve

0.8-1.2

Dig therapeutic level

0.8-2

Describe the edema scale

1+ - 2mm = trace; rapid response and return of skin 2+ - 4mm = mild; 10-15 seconds 3+ - 6mm = moderate 1-2 minutes 4+ - 8mm = severe 2-5 minutes

Cushing's triad consists of:

1. Elevated systolic BP 2. Bradycardia 3. Irregular respirations

Cyclobenzaprine is prescribed for a client for muscle spasms, and the nurse is reviewing the client's record. Which disorder, if noted in the record, would indicate a need to contact the primary health care provider about the administration of this medication? 1.. Glaucoma 2. Emphysema 3. Hypothyroidism 4. Diabetes mellitus

1. Glaucoma

5 levels of Maslow's Hierarchy of Needs

1. Physiological needs (Basic needs) 2. Safety needs (Basic needs) 3. Love and Belonging needs (Growth needs) 4. Esteem Needs (Growth needs) 5. Self-actualization (Growth needs) A person must satisfy lower level needs before moving on to meet higher-level growth needs. After meeting lower levels of needs, a person scan reach the highest level of self-actualization,

Normal magnesium levels

1.3-2.1 mEq/L

Intradermal injection needle length

1/2 to 5/8 inches

Phenytoin therapeutic range

10-20 mcg/mL

Theophylline therapeutic range

10-20 mcg/mL

Vancomycin therapeutic range

10-20 mcg/mL

Expected phosphorous range

3-4.5

Expected hematrocrit range

37-47%

Calcium reference rante

9-10.5

Normal LDL levels

<130 mg/dL

normal cholesterol level

<200 mg/dL

Normal HDL levels

>40 mg/dL (45-55)

Where will glucose levels be with HHS

>600; pH will be normal d/t HHS doesn't cause ketosis

What is conversion?

A defense mechanism where the client represses their emotions related to a situation by transforming those emotions into physical responses, such as insomnia.

Sign of impending magnesium toxicity

Absent patellar reflex

How often will IV tubing be changed

According to facility policy (usually every 24-28 hours

A client has a prescription for magnesium citrate to prevent constipation after undergoing barium studies of the gastrointestinal tract. How would the nurse administer the magnesium citrate?

After it is chilled in the refrigerator Rationale: Magnesium citrate is available as an oral solution and would be served chilled to make it more palatable. The other options are incorrect.Client Needs: Physiological IntegrityClinical Judgment/Cognitive Skill(s): Take ActionCognitive Ability: ApplyingContent Area: Pharmacology: Gastrointestinal: LaxativesIntegrated Process: Nursing Process/ImplementationPriority Concepts: Elimination, Clinical JudgmentStrategies: Subject

What is needed if a child has aplastic anemia

An isolated protective environment

serious SE of ACE inhibitor drugs

Angioedema Cough Hyperkalemia Hypotension

A contraindicated condition for the use of timolol eye drops

Asthma

Thinning of skin with loss of normal skin furrow. Skin is shiny and translucent. Example: Arterial insufficiency

Atrophy

Pt education regarding diet with ARB's

Avoid foods high in potassium like salt subs, sports drinks, bananas, cooked spinach, and canteloupe

Anti-parkinsonian drugs for NCLEX

Benzatropine carbadopa-levadopa

EKG changes with hyperkalemia

Bradycardia, Tall peaked T waves, Prolonged PR intervals, Flat/absent P waves, Widened QRS, Conduction blocks, V-Fib

What area in the brain sets the respiratory rhythm?

Brainstem

Pagets dz is r/t an imbalance in which electrolyite

Calcium

Unique side effect of beta blockers

Can mask signs of low blood sugar so check glucose often

What part of the brain controls balance and coordination

Cerebellum

What area of the brain facilitates complex behaviors like expression, learning, memory, and language

Cerebral cortex

Beta blockers have what effect on afterload?

Decrease

How do ace inhibitors affect preload and afterload?

Decrease both

Side effect of dilantin

Dental hyperplasia - get regular dental check-ups

What condition would improve as a result of taking hydrochlorothiazide (HCTZ)?

Diabetes insipidus Rationale: A thiazide diuretic is used to reduce urine production. Diabetes insipidus causes an overproduction of urine

A group of postmenopausal women are learning to do breast self-examination (BSE) in a teaching session at the clinic. The clinic nurse would teach the group which point about this procedure?

Do the exam on the same day every month Rationale: Women who are postmenopausal are taught to do BSE on the same day every month. Before menopause, women would do the procedure 7 days after the start of the menstrual cycle, when the breasts are least tender. Each breast is examined with the opposite hand. The pads of the fingers, not the fingertips, would be used for palpation. The client may use a circular, up and down, or wedge method of assessment. Consistency of use of the same method is more important than the actual method used.

The nurse is monitoring a client with leukemia who is receiving doxorubicin by intravenous infusion. The nurse would monitor for which finding that would indicate doxorubicin toxicity?

ECG changes

cholecystitis. Which of these clinical manifestations support this diagnosis?

Fever C/o indigestion Pain in RUQ after a fatty meal

how often will IV fluid bag be changed

Every 24 hours

What is insensible fluid loss

Fluid loss that cannot be measured

Antidote: Benzodiazepines

Flumazenil (Romazicon)

What food should be avoided with MAOI's?

Food with tyramine

Teaching point for desmopressin nose spray

Gently blow the nose prior to admin to avoid diluting med w/nasal secretions.

What should be tested periodically if taking quietapine furmarate

Glucose

Definition of radiation

Heat given off without contact

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds. On the basis of these laboratory values, the nurse anticipates which prescription?

Hold the next dose of Warfarin Rationale: The normal PT is 11 to 12.5 seconds (conventional therapy and SI units). A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the value of 35 seconds is high, the nurse would anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.Client Needs: Physiological IntegrityClinical Judgment/Cognitive Skill(s): Generate SolutionsCognitive Ability: AnalyzingContent Area: Foundations of Care: Laboratory TestsHealth Problem: Adult Health: Cardiovascular: DysrhythmiasIntegrated Process: Nursing Process/PlanningPriority Concepts: Clinical Judgment, ClottingStrategies: Subject Rationale Strategy Reference

What electrolyte values will be present in Addison's dz

Hyperkalemia; hypercalcemia

What area of the brain serves as the sleep center

Hypothalamus

The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder?

Increased calcium level Rationale: Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.Client Needs: Physiological IntegrityClinical Judgment/Cognitive Skill(s): Recognize CuesCognitive Ability: AnalyzingContent Area: Adult Health: OncologyHealth Problem: Adult Health: Cancer: Multiple MyelomaIntegrated Process: Nursing Process/AssessmentPriority Concepts: Cellular Regulation, Clinical JudgmentStrategies: Subject

What is conversion disorder?

Involuntary loss of sensory motor function

What is the best position for picking up extra heart sounds?

L sidelying

L sided hemisphere stroke

Language facts logical reasoning

Manifestations of a hemolytic transfusion reaction

Low back pain HA Chest pain Tachypnea Tachycardia Dark urine

Nonpalpable, skin color change, smaller than 1 cm Examples: Freckle, petechiae

Macule

What metabolic d/o is a/w DKA

Met. acidosis

Nursing considerations for ACE inhibitors

Monitor K+ levels Monitor BP Monitor for facial swelling Cough suppressant for cough Monitor kidney fxn

Palpable, circumscribed, deep, firm, 1 to 2 cm Example: Wart

Nodule

What is a situational crisis

One that is an unexpected but regular part of life such as a serious illness or financial loss

What should be monitored with warfarin

PT/INR

Palpable, circumscribed, solid elevation of skin, smaller than 1 cm Example: Elevated nevus

Papule

What are expected elevated lab values in chronic kidney disease?

Potassium Magnesium Phosphates

EKG changes with hypocalcemia

Prolonged QT intervals Other manifestations: Tetany Tingling Seizures Laryngospasms

Drug used to treat myasthenia gravis

Pyridostigmine (Mestinon)

Which antipsychotic is used in the treatment of Alzheimer's

Quietapine

Dopamine agonist

Ropinirole (Requip)

How do you treat phlebitis

Stop the IV DC the line Apply warm compresses

How do you treat infiltration

Stop the IV infusion Discontinue the line Elevate and apply warm or cold compresses per facility policy

The nurse provides care for a client in chronic kidney disease (CKD). Which topics should the nurse provide in the teaching session to help this client control phosphorus levels?

Take an aluminum based antacid before or afterm meals, this will bind phosphorous for easier removal from the body

When teaching the client with adrenal insufficiency about cortisone, the nurse would include which items?

Take with food Stay away from people with infections Notify HCP if surgery or illness occurs Take in potassium rich foods Rationale: Rationale:Glucocorticoids would not be abruptly discontinued because acute adrenal insufficiency could occur. Because glucocorticoids cause sodium and water to be retained while causing loss of potassium, the client would limit sodium intake and increase potassium intake. These medications can increase the risk of infection; therefore, the client would avoid contact with clients who are ill. Taking the medication with food helps prevent stomach upset. Individuals may need an increase in dosage during illness or times of stress (surgery).Client Needs: Physiological IntegrityClinical Judgment/Cognitive Skill(s): Generate SolutionsCognitive Ability: ApplyingContent Area: Pharmacology: Endocrine: CorticosteroidsHealth Problem: Adult Health: Endocrine: Adrenal DisordersIntegrated Process: Teaching and LearningPriority Concepts: Safety, Patient EducationStrategies: Subject

most accurate temperature

The tympanic membrane

A client has been prescribed cyclobenzaprine for the treatment of painful muscle spasms accompanying a herniated intervertebral disk. The nurse would withhold the medication and question the prescription if the client has a concurrent prescription for which medication?

Tranylcypromine Rationale: Rationale:The client would not receive cyclobenzaprine if the client has taken monoamine oxidase inhibitors such as tranylcypromine or phenelzine within the last 14 days. Otherwise, the client could experience hyperpyretic crisis, seizures, and possibly death. The medications in the remaining options are not contraindicated.Client Needs: Physiological IntegrityClinical Judgment/Cognitive Skill(s): Take ActionCognitive Ability: AnalyzingContent Area: Pharmacology: Musculoskeletal: Muscle RelaxantsHealth Problem: Adult Health: Neurological: Intervertebral Disc ProblemsIntegrated Process: Nursing Process/ImplementationPriority Concepts: Collaboration, SafetyStrategies: Subject

Solid mass, deep, larger than 1 to 2 cm

Tumor

How often is IV site changed?

Usually every 72 hours

Serous fluid-filled, smaller than 1 cm Examples: Blister, herpes simplex, varicella

Vesicle

Antidote to Warfarin (Coumadin)

Vitamin K

Palpable, irregular borders, edematous Example: Insect bite

Wheal

What is paternalism

When a HCP believes they know what is best for the client. An example is a NP withholding info in order to not distress the client, denying the client the right to be informed.

Which food is allowed if taking an MAOI

Yogurt - Does not contain high amounts of tyramine

What should be monitored w/heparin

aPTT

Causes of hypophosphatemia

antacids, heat stroke, low potassium, and hepatic encephalopathy.

CCB affect ________________not the ___________________

blood vessels heart

Chlorpromazine

controls manifestations of schizophrenia

Cardiac Glycosides

drugs used to improve heart output by increasing the muscular contraction, such as digoxin

Indications for cardian glycosides

heart failure a-fib a-flutter

Sign of hypocalcemia

paresthesia; starting with tingling in hands and feet

What is the antidote to heparin

protamine sulfate

Education about self administration of THR

take on an empty stomach

Conduction

transfer of heat by direct contact

signs of benzodiazepine overdose

unresponsiveness bluish fingernails