NCLEX Study Guide!

What is 0.45% NaCl?

A hypotonic crystalloid solution of sodium chloride dissolved in sterile water (unlike 0.9% NaCl which is isotonic). This fluid is designed to treat cellular dehydration, caused by such conditions such as hypernatremia or diabetic ketoacidosis.

What is a goiter?

A large mass in the neck or enlargement of the thyroid gland

What is furosemide?

A loop diuretic and is ototoxic

Which blood type can donate to A and AB?

A, but can only receive from O and A

When are hepatitis B vaccines repeated?

1 month and 6 months

30 mL equals

1 ounce

Which of the following urine outputs best indicated to the nurse that a patient's kidneys are functioning normally?

1,500 mL in 24 hours

What is an adequate fluid intake?

1,500-2,000 mL/day

What is the normal progression of labor?

1-1.2 cm cervical dilation per hour for a primigravida

What is the therapeutic level for lithium?

1-1.5 mEq/L

Short acting insulin's peak is when?

1-5 hours

What is tetanus?

Acute infectious disease of CNS, caused by exotoxin clostridium tetani; indications are painful muscle rigidity.

What is hepatitis?

Acute inflammatory disease of the liver resulting in liver cell damage. A & E transmitted by infected feces via fecal/oral route, shellfish from contaminated waters; B, C, D & G transmitted through parenteral drug abuse, sexual contact, blood and bodily fluids. Indications for all: jaundice, anorexia, right upper quadrant pain, clay-colored stools, tea-colored urine, pruritus.

Glucagon is used for...

Acute management of severe hypogylcemia when pt is unconscious or unable to swallow

What is Respiratory Syncytial Virus (RSV)?

Acute viral infection and requires contact precautions (gown and gloves) in addition to standard precautions.

What is varicella zoster (chickenpox)?

Acute, highly contagious, viral disease; prodromal: slight fever, malaise, anorexia, rash; spread by direct contact, droplet, contaminated object. Isolation until vesicle crusted. Communicable from 2 days before rash appears. Avoid use of aspirin, use acetaminophen instead.

What is varicella zoster (chicken pox)?

Acute, highly contagious, viral disease; slight fever, malaise, anorexia, rash (pruritic, begins as macule, becomes papule, then vesicle, successive crops of all three stages present at any one time). Spread by direct contact, droplet, contaminated object. Nursing considerations: isolation until vesicles crusted.

What is Tranylcypromine sulfate?

An MAO inhibitor

How would you describe Diabetes Type 1?

An absence or decrease of insulin from pancreas.

What is a Curling's ulcer?

An acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa. May develop within 24 hours after a severe burn

What is vinblastine?

An alkaloid used for lymphomas, testicular cancer, advanced breast cancer; that has potential adverse effects of loss of reflexes and peripheral neuritis, may cause stumbling and falls.

What is amikacin?

An aminoglycoside that is nephrotoxic. Anti-infective medications can eradicate normal intestinal flora and lead to superinfection of the gastrointestinal and genitourinary tracts. Nausea and diarrhea are signs of superinfection. Anti-infective medications can eradicate normal flora, reducing the amount of vitamin K produced by these bacteria and can potentiate the actions of warfarin.

What is aluminum hydroxide?

An antacid that neutralizes hydrochloric acid and reduces pepsin activity. It should be taken 1 hour after meals and at bedtime.

What is chlordiazepoxide?

An anti-anxiety and sedative/hypnotic medication used to treat anxiety and alcohol withdrawal. This medication causes drowsiness and sedation. It is important for the client to use caution when driving or operating equipment.

What is pentamidine?

An anti-protozoal agent used to prevent or treat Pneumocystis jiroveci pneumonia, a common opportunistic infection in immunocompromised clients. Therapeutic effects of pentamidine include decreased work of breathing, resolution of fever, diminishing cough, normalization of heart rate, and reduction or absence of pulmonary crackles or rhonchi.

What is sucralfate?

An anti-ulcer medication used to treat duodenal ulcers. Works best on an empty stomach.

What is trihexyphenidyl?

An anticholinergic; used for parkinson's and drug induced extrapyramidal symptoms

What is allopurinol?

An antigout agent that blocks uric acid formation; ADR: headaches, dizziness, drowsiness, GI upset, encourage fluids, monitor I/O as well as CBC and kidney function tests, give with meals.

What is simvastatin?

An antilipemic agent used to control cholesterol level when diet and exercise are not effective in keeping the level in normal range; ADE include eye lens opacities and liver dysfunction, not used to affect the blood pressure.

What is cisplatin?

An antineoplastic medication, is ototoxic.

What is Chlorpromazide?

An antipsychotic

What is Prochlorperazine maleate (Compazine)?

An antipsychotic and should be considered incompatible in a syringe with all other medications.

What is a caloric test?

An assessment of the vestibular portion of the 8th cranial nerve; sometimes, unpleasant symptoms such as vertigo, dizziness, nausea, and vomiting accompany this test; causes nystagmus

What is the defense mechanism "undoing?"

An attempt to erase an act, thought, feeling, or desire

What is Guillain-Barré syndrome?

An autoimmune disorder that manifests as an acute inflammatory polyneuropathy. Problems associated with immobility must be addressed and managed. These include diminished respiratory ventilation effort, stasis of respiratory secretions, nutritional and fluid needs, deep vein thrombosis, development of pressure injuries, and pain management.

What is cardioversion?

An elective procedure performed to treat dysrhythmias, completely depolarizes all myocardial cells so sinoatrial node can re-establish as pacemaker.

What is St. John's Wort?

An herbal supplement used for mild to moderate depression and sleep disorders; Contraindicated in major depression, transplant recipients, SSRI medications, MAOI medications, and oral contraceptives.

Signs and symptoms of hyperthyroidism are related to what?

An increased metabolic rate, possibly due to anxiety or extreme nervousness.

What is D5W?

An isotonic carbohydrate (sugar) solution that contains glucose (sugar) as the solute. Wen this is absorbed, the glucose is usually quickly grabbed up by cells and utilized for energy, leaving only water which is then a hypotonic solution.

What is folic acid used to treat?

Anemia, liver disease, alcoholism, intestinal obstruction, and pregnancy. Found naturally in foods (bran, yeast, dried beans, nuts, fruits, fresh veggies, asparagus, spinach)

What are signs of hypokalemia?

Anorexia,N/v, diarrhea, abdominal pain, confusion, paresthesias (tingling), muscle weakness, increased sensitivity to digitalis, depression of the ST segment and flattening or inversion of the T waves.

In a normal menstrual cycle of 28 days, when is ovulation usually?

Around the 14th day prior to next menstrual period

What are risk factors for intracranial bleeds?

Arteriosclerosis and hypertension

What is the most often identified ADR to MMR vaccine?

Arthritis, others include rash and fever

Where would the nurse expect to find the fundus 6-12 hours after delivery?

At umbillicus

Colchicine is used to treat inflammation with gout and is contraindicated with which medication?

Atorvastatin due to increase risk of rhabdomyolysis

The P wave represents what?

Atrial activity

What is a known risk factor for stroke?

Atrial fibrillation

What is Projection?

Attributing one's feelings, impulses, thoughts, or wishes to others.

What are positive signs of pregnancy?

Auscultating for fetal heart tones, visualization of fetus by ultrasound or x-ray, or fetal movement palpated by the examiner

What is leukemia?

Cancer of blood-forming tissues of bone marrow, spleen, lymph nodes. Abnormal, uncontrolled destructive proliferation of one type of white blood cell and its precursors. Signs/symptoms: mouth and throat ulcerations, pneumonia, septicemia, anemia, thrombocytopenia, leukocytosis, erythropenia, fatigue, bone and joint pain, bleeding gums.

What is hodgkin's lymphoma?

Cancer of lymphoid tissue; signs and symptoms include large painless lymph nodes, night sweats, fever, and unexplained weight loss; lymph node biopsy shows reed-sternberg cells

Which are medications for epilepsy?

Carbamazepine, phenytoin, valproic acid, gabapentin, pregabalin, topiramate

What is Pheochromocytoma?

Catecholamine secreting tumor of the adrenal medulla; Signs/symptoms include hx of headache, hyperglycemia, hypertension, hypermetabolism, palpitations, N/V, tinnitus, tachycardia

What is Meniere's disease?

Caused by dilation of the endolymphatic system; signs include tinnitus, unilateral sensorineural hearing loss, vertigo; treatment: salt and fluid restriction to decrease amount of endolymphatic fluid, antihistamines, antiemetics, and surgery. Avoid smoking due to vasoconstriction which decreases reabsorption of fluid.

What is important to know about lithium medication?

Causes Sodium depletion and diuretics are contraindicated.

What is the first stage, phase 3 (transition) of labor?

Cervix is dilated 8-10 cm, contractions 45-90 seconds long, 2-3 mins apart, strong, impending delivery marked by increase in dark bloody show, increased urgency to bear down, client may become anxious, apprehensive, irritable

What is the first stage, phase 2 (active) of labor?

Cervix is dilated from about 4-7 cm, contractions 30-60 seconds long, 3-5 mins apart, moderate to strong

What does the CDC recommend for tx of gonorrhea?

Cetriaxone IM plus doxycycline for 7 days by mouth

What is the earliest indication of poor cardiac output?

Change in LOC and/or alertness

What are indications of lung cancer?

Change in respiratory patterns, persistent cough, bloody or purulent sputum, unexplained dyspnea, unexplained weight loss, recurring pulmonary system problems, pain in arm or shoulder or chest, or back.

What is primary open-angle glaucoma (POAG)?

Characterized by increase intraocular pressure that is the result of decreased aqueous outflow from the anterior chamber of the eye. Most common in clients of advancing age, african american heritage, positive family hx, and coexisting diabetes or cardiovascular disease.

What are signs/symptoms of psoriasis?

Chronic recurrent thick, itchy, erythematous papules/plaques covered with silvery white scales with symmetrical distribution. Commonly found on scalp, knees, sacrum, elbows, and behind ears.

What is cirrhosis?

Chronic, progressive liver disease; caused most often by alcoholism (laenne's cirrhosis), viral infections, toxins, bile stasis or obstruction; indications include indigestion, flatulence, constipation, diarrhea, anorexia, N/v, esophageal varies, ascites, increased bleeding tendencies, edema in extremities, jaundice, dark urine, clay colored stools. Provide high-protein, high-carb diet in early stages.

What is systemic lupus erythematosus (SLE)?

Chronic, systemic inflammatory autoimmune collagen vascular disease of multiple body systems; indications: arthritis, joint swelling, butterfly rash across bridge of nose and cheeks, polymyositis, oral ulcers, pericarditis, pleural effusion, lymphedenopathy, depression; Nursing: maintain skin integrity, monitor steroid therapy, monitor for infection, relieve pain an d discomfort, monitor for cognitive abilities and emotional stability, provide emotional support.

Which are histamine 2 receptor antagonist (antacid)?

Cimetidine, famotidine, ranitidine

Which are SSRIs?

Citalopram, Sertraline, Paroxetine, Fluoxetine, Escitalopram

How does a nurse retrieve a urine specimen from an indwelling catheter?

Clamp catheter below port for 30 mins; cleans port; insert needle into port; withdraw specimen; unclamp catheter.

Which insulin should be drawn up first?

Clear (short-acting [regular]) before cloudy (intermediate-acting)

What are complex partial seizures?

Client blacks out for a few seconds, automatism may occur.

What are simple partial seizures?

Client remains conscious, often reports aura.

Which are Centrally Acting Alpha 2 agonists?

Clonidine, Methyldopa

What indicates peritonitis?

Cloudy dialsyate, N/V, anorexia, abdominal pain, tenderness, rigidity.

What is premenstrual syndrome (PMS)?

Cluster of symptoms occurring only during luteal phase of menstrual cycle; indications: breast discomfort, edema, abdominal bloating and weight gain, headache, and excessive hunger.

What is atelectasis?

Collapsed or airless lung condition: indications: dyspnea, cyanosis, cough, tachycardia, pleurtic chest pain.

What does a glascow coma scale of 5 indicate?

Coma

What is lymphedema?

Complication of mastectomy and is edema caused by obstruction of lymphatics due to removal; can be prevented by positioning each joint higher than the more proximal one.

What is arteriosclerosis?

Condition that involves thickening of the walls of the arteries, reducing the ability of the hear to contract effectively; develops over a number of years.

What is cardiogenic shock?

Condition when cardiac output decrease leads to inadequate tissue perfusion.

What is the bulge test?

Confirms presence of fluid in the knee; client leg should be extended and supported on the bed.

Long acting insulin's peak is when?

Continuous, no peak

What does myelogram test for?

Contrast medium is injected into spinal subarachnoid space through spinal puncture to identify tumors, cysts, herniated vertebral disks

The nurse understands that which statement best describes the action of glucocorticoids?

Convert protein and fat into glucose

How do you determine a heart rate with normal rhythm on a rhythm strip?

Count the number of small boxes between two R waves; 1500 divided by the number of boxes between two R waves equals the heart rate.

What is intermittent claudication?

Cramping, pain, aching experienced in lower extremity muscles during exercise; pain usually relieved by stopping activity causing it. Indication of possible other diseases

What are the diagnostic enzymes related to myocardial infarction?

Creatine kinase (CK), its isoenzyme (CK-MB), myoglobin, troponin T and I

What are the diagnostic enzymes to test for a myocardial infarction?

Creatine kinase (CK), its isoenzyme (CK-MB), myoglobin, troponin T and I.

What is an ileostomy?

Creation of a surgical passage through the abdominal wall into the ileum; nursing care: empty pouch when 1/3-1/2 full, change puch every 3-7 days during inactive period, before meals, at bedtime; check for skin irritation, be cautious of high-fiber and high-cellulose foods (popcorn, peanuts, coconut, Chinese veggies, shrimp, rice) may cause diarrhea. Don't take enteric coated medications, laxatives, enemas.

What is strabismus?

Cross-eyed

What is Bulimia Nervosa?

Binge eating behaviors frequently followed by self-induced vomiting, laxative, or diuretic use; indications include dental caries and erosion, gastric dilation, calluses or scares on hands from the vomiting, electrolyte imbalances, cardiovascular abnormalities.

What is Epistaxis?

Bleeding from the nose

Which are adverse effects of NSAIDs?

Bleeding, especially GI, heartburn, nausea, anaphylaxis, headache, dizziness; nursing considerations: observe for bleeding, give with milk/water/food, cross allergies among NSAIDs.

What is cardiac tamponade?

Blood and/or fluid collects in the pericardial sac, presses on the heart, and prevents atria and ventricles from filling adequately; cardiac output is thus reduced; emergency sternotomy and volume expanders are the treatment of choice.

Which sign or symptoms on observed when a client is hypoxic?

Blood gases;

What is important with blood transfusions?

Blood must run slowly at first (no faster than 2-5 mL/min for the first 15 mins). If no reaction, the nurse regulates the blood transfusion to the prescribed rate.

What is digoxin?

Blood pressure support and antiarrhythmic; increase the strength of the heart's contractions; can treat heart failure and heart rhythm problems.

What is Circumoral cyanosis?

Blue discoloration around the mouth only.

When an RN assigns care to another RN...

Both accountability and responsibility are transferred.

Which artery should the nurse palpate on an infant when providing CPR?

Brachial artery

What are myoclonic seizures?

Brief jerking of extremities

The nurse should explain to a client that glipizide is effective for diabetics who...

Produce minimal amounts of insulin.

Decreased production of urea nitrgoen can be achieved by restricting what?

Proetin

What is multiple sclerosis (MS)?

Progressive disorder of nerve impulse transmission characterized by demyelination of white matter throughout brain and spinal cord; periods of exacerbation and remission. Indications: paresthesias or abnormal sensations in extremities, vision changes, incoordination, bowel and bladder dysfunction, spasticity, intention tremors, chewing and swallowing difficulties, impaired speech, emotional instability, sexual dysfunction.

What is the lab used for heparin therapy?

Prolonged PTT

What are indications of hemophilia?

Prolonged internal or external bleeding, easy bruising, joint pain with bleeding, pallor; nursing interventions: assess for bleeding, recognize and control all bleeding, avoid IM injections, instruct ROM exercises after bleeding episodes, avoid contact sports.

Using a footboard _______ footdrop, by stimulating plantar flexion.

Promotes

What is tetanus immune globulin?

Promotes passive immunity and is given when a wound is treated over 24 hours after the client is wounded.

Which medication is given for hyperthyroidism?

Propylthiouracil (Suppress thyroid production)

What is the antagonist for heparin?

Protamine sulfate.

What is the Whistleblower protection act?

Protects government employees from retribution for disclosing unethical or abnormal practices in government agencies.

Ego defense mechanisms....

Provide a feeling of safety and self-worth by keeping painful unconscious material out of awareness.

What type of insulin is clear, and should be drawn up first?

Regulan insulin

What is a paracentesis?

Removal of fluid from the peritoneal cavity. To prep, encourage voiding, measure abdominal girth, weigh client. After: document drainage, assess pressure dressing for drainage, position in bed until vital signs stable.

What is paracentesis?

Removal of fluid from the peritoneal/abdominal cavity (ascites)

What is Dialysis?

Removal of fluids and waste products by other means when kidneys are not functioning.

What is a whipple procedure?

Removal of head of pancreas, distal portion of common bile duct, the duodenum, and part of the stomach. NG tube inserted to prevent stress on anastomosis sites; drainage should be serosanguineous; clear, colorless, bile-tinged drainage or frank bleeding may indicate problem

What is a stapedectomy?

Removal of otosclerotic lesions and the creation of a tissue implant with a prosthesis to maintain adequate conduction; hearing may be impaired temporarily postoperatively due to edema and packing

What is a transsphenoidal hypophysectomy?

Removal of pituitary gland; complications could include diabetes insipidus, cerebrospinal fluid leaks, visual disturbances, syndrome of antidiuretic hormone, meningitis, pneumocephalus. Pts should not brush teeth got 1-2 weeks to allow incision to heal.

What is Hemodialysis?

Removes excessive fluids and wast products usually removed by the kidneys by circulating client's blood through semi-permeable membrane that acts as an artificial kidney; Client's circulation accessed through an AV fistula shunt, fistula, or graft; Nurse should check for "thrill" and bruit every 8 hrs, do not take BP on extremity

The T wave represents what?

Repolarization of the ventricles

What is a classic symptom of hiatal hernia?

Reports of awakening at night with heartburn

Carbon dioxide RETAINED indicates...

Respiratory acidocis

Carbon dioxide RELEASED (hyperventilation) indicates..

Respiratory alkalosis

What is acute respiratory distress syndrome (ARDS)?

Respiratory distress with progressive hypoxia; indications: hypoxia, respiratory distress (tachypnea, dyspnea, inflammatory reaction notes on chest x-ray), progressive signs of pulmonary edema, signs and symptoms of shock.

What is the most serious concern with guillain-barre syndrome?

Respiratory failure due to paralysis of the nerves that stimulate the thoracic area

Which symptoms support a diagnosis of Guillain-Barré syndrome?

Respiratory failure, flaccid paralysis, and urinary retention.

What is the Somogyi Effect?

Seen in diabetes; fall in blood glucose during the night with increased blood glucose levels in the morning. (hypoglycemia related to evening insulin injection)

What does late deceleration indicate in fetal monitoring?

Show decreasing fetal heart rates that correspond to the increasing uterine contraction; abnormal finding indicating utero=placental dysfunction.

Folic acid supplements are associated with which anemia?

Sickle cell anemia

Which are an antiflatulent?

Simethicone

What is primary intention wound healing?

Skin edges well approximated or closed; heals quickly with minimal chance of infection and scarring.

What are signs of fluid volume overload?

Slightly increased pulse that is bounding, increased RR with SOB, crackles on auscultation, JVD, decreased hematocrit and BUN

Which are indications of increased intracranial pressure?

Sluggish, dilated or unequal pupils

What are signs and symptoms of basal cell carcinoma?

Small, waxy nodule on sun-exposed areas that may ulcerate and crust

In teaching a client with Addison's disease about dietary needs, the nurse should emphasize the importance of consuming which nutrient?

Sodium

What should a client get an adequate intake of when receiving lithium?

Sodium; excretion of this medication depends on normal sodium levels, sodium reduction causes marked medication retention, leading to toxicity.

What are vesicular breath sounds?

Soft and low-pitched breezy sounds heard over most of the peripheral lung fields.

In conductive hearing loss..

Sound is heard best in the impaired ear.

What foods are a good source of magnesium?

Spinach, beet greens, green leady vegetables, whole grains, almonds, cocoa, tuna, dried peas and beans

Which are sources of oxalate?

Spinach, black tea,rhubarb, dark roughage, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, beans, chocolate, cocoa

Which organs are considered a part of the immune system?

Spleen (cleansing blood of microorganisms by macrophages and producing leukocytes, monocytes, and lymphocytes) and thymus (develops t-lymphocytes, which when mature are called T-Cells and have cytotoxic properties and can destroy "target" cells, T-helper and T-suppressors cells also exist)

Urine cultures must always be carried out before...

Starting a client on an antibiotic.

What is delirium?

State of acute confusion, rapid in onset (hours to days), short-term, and reversible (usually within 3 weeks). Indications include disorientation, decreased LOC, disorganized thinking, disturbed perceptions, impaired memory, hyperactivity or hypoactivity, emotional liability.

What is impetigo?

Steptococcal or staphylococcal, highly contagious skin infection; Indications include macules progressing to vesicles, erosions, and then characteristic honey-colored crusts, pruritus common. Nursing considerations: avoid sharing towels or other personal items; discourage touching lesions, skin isolations, careful handwashing.

The nurse performs discharge teaching for a client diagnosed with Addison's disease. It is MOST important for the nurse to instruct the client about which of the following?

Steroid replacement

Oral hypoglycemics act by...

Stimulating beta cells in the pancreas to release endogenous insulin; some also facilitate insulin's action on peripheral receptor sites; other delay the absorption of glucose in the intestinal tract (exp. include Metformin, chlorpropamide, glimepiride, glipizide, pioglitazone, Acarbose, sitagliptin)

What is dilation?

Stretching of the external cervical os from an opening a few mm in size to an opening large enough to allow the passage of the infant

What is the best position for liver biopsy?

Supine with arms above head; elevates the ribs to allow access

What is a gastrectomy?

Surgical excision of all or part of the stomach for treatment of an ulcer or removal of malignancy; Nursing responsibility: maintain NG tube with suction and observe drainage, encourage deep breathing and coughing, listen for bowel sounds, teach prevention for dumping syndrome (restrict fluids with meals, lie down after eating, eat smaller frequent meals, maintain a diet low in carbs and fiber and high in protein and fat)

What is a pyelolithotomy?

Surgical removal of a kidney stone.

What is a Cholecystectomy?

Surgical removal of the gallbladder; immediately following surgery, the stoma, which is part of the intestine, is brought out to the abdominal wall and appears beefy-red.

What is a herniorrhaphy?

Surgical repair of hernia; client ed: no lifting, pushing, straining, athletic activities, contact sports, or bicycle riding

What is a coronary artery bypass graft surgery (CABG)?

Surgically implanted shunt allowing blood to travel from the aorta to branch of coronary artery by bypassing an obstruction

What is AIDS?

Syndrome distinguished by serious deficits in cellular immune function; Opportunistic infections: pneumocystisis jiroveci pneumonia, candida albicans stomatitis and esophagitis, cytomegalovirus (CMV), kaposi sarcoma, AIDS dementia complex.

What is methadone?

Synthetic derivative similar to morphine; used for detoxification and temporary maintenance treatment of narcotic addition, relief of severe pain.

What are symptoms of hypoglycemia?

Tachycardia, palpitations, sweating, nervousness, headache, confusion, drowsiness, fatigue. Also convulsions, coma, death.

What is important to know about propranolol and insulin?

Tachycardia, which serves as a warning sign of hypoglycemia, may be masked in clients taking propranolol, resulting in beta-blocker induced hypogylcemia unawareness

What is veracity?

Telling the truth completely; intentionally deceiving a patient is a violation of this principle.

What is important to know when a client is scheduled to being ECT?

The client is being treated for glaucoma. Pupil dilation is contraindicated in glaucoma.

What is anemia?

Decrease in red blood cells or hemoglobin content or altered hemoglobin function; caused by decreased RBC production, blood loss, increased destruction of RBC or inadequate intake or excessive loss of iron. Tissue hypoxia causes fatigue, pallor of skin and mucous membranes, increased respiratory rate and depth, dizziness, difficulty concentrating, cold intolerance.

What is a way to decrease vertigo attacks with a client who has Ménière's syndrome?

Decrease movement of client's head

Which are antidiarrheal agents?

Diphenoxylate plus atropine, loperamide, rifaximin; Adverse effects: dizziness, drowsiness, dry mouth.

What is a sigmoidoscopy?

Direct visualization of sigmoid colon; prep: admin laxative night before exam, give enema or suppository morning of procedure, no dietary restrictions necessary; Post-test: allow client to rest, observe for hemorrhage, perforation, encourage fluids

What is a cystoscopy?

Direct visualization of the bladder, using cystoscope inserted through urethra.

What is ptosis?

Dropping of the upper eyelid

During peritoneal dialysis, a patient suddenly begins to breathe more rapidly. Which should the nurse do first?

Elevate the head of the bed; this will decrease pressure of the dialysate on the diaphragm, and increase the vital capacity of the lungs; draining the cavity of fluid will further decrease the pressure. Dialysate should be warmed prior to administration.

Which are proton pump inhibitors (antacids)?

Esomeprazole, lansoprazole

How often should you perform site care on a new tracheostomy?

Every 4 hours

How often is tubing changed with IV?

Every 72 hours

What is Peptic Ulcer Disease?

Excavation formed in mucosal wall of stomach, pylorus, duodenum; caused by H pylori; Indications: normal to hyposecretion of HCL, weight loss may occur, pain 1/2-1hr after a meal, vomiting. Nursing care: small frequent meals, avoid coffee/alcohol/seasonings if causes discomfort, reduce stress, administer meds 1 hr before or after meals.

What is polycythemia vera?

Excess in red blood cells; can be secondary to conditions that stimulate erythropoiesis, decreased oxygen tension in blood. Tx: remove enough blood to deplete iron stores, avoid foods and multivitamins containing iron.

What is Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?

Excessive amounts of ADH from posterior pituitary; results in water imbalance causing water intoxication; caused by fluid retention, opposition of diabetes insipidus; causes head injury, encephalitis, lung cancer, myxedema

What is postpartum hemorrhage?

Excessive bleeding after childbirth; signs: bleeding that soaks pad within 1 hour or less, boggy uterus, other symptoms of shock might not indicate major blood loss soon enough; tx; massage uterus, oxytocin, relieve bladder distention by voiding or catheterization, blood transfusion, fluid replacement, manual removal of placental pieces, dilation an dcurettage, hysterectomy

What is important for pts with COPD to avoid?

Excessive carbs as they are broken down into glucose, CO2, and water when metabolized which may render the COPD pt unable to exhale and hypercapnic (increased CO2 in blood) respiratory failure could result.

What is thrombocytopenia?

Excessive destruction of platelets. Indications: petechiae, prolonged bleeding even w/minor trauma, spontaneous bleeding, easy bruising, heavy menses.

What is tamponade?

Excessive fluid accumulates in the pericardium causing decreased venous return to heart, which decreases cardiac output causing compression to the heart; Cardinal signs include decreases systolic BP, narrowing pulse pressure, increased venous pressure and muffled heart sounds.

What is peritoneal dialysis?

Excessive fluids and wast products usually removed by the kidneys are removed through the peritoneal cavity; catheter is surgically inserted into the abdominal cavity.

What are side effects of Haldol?

Galactorrhea (excessive or spontaneous flow of milk), lactation, gynecomastia (excessive growth of male mammary glands).

What does urine with glucose and acetone present in a patient who is pregnant indicate?

Gestational diabetes, hazard of placental insufficiency.

What PPE is used for contact precautions?

Gown and gloves

Steroids should be...

Gradually withdrawn, as withdrawing suddenly the client may die of acute adrenal insufficiency

What is a pleural friction rub?

Grating sound or vibration heard during inspiration and expiration; caused by inflamed pleura, does not clear with coughing

What is a GTPAL score?

Gravida, term births, preterm births, abortions/miscarriages, living children.

What is chronic obstructive pulmonary disease (COPD)?

Group of conditions associated with obstruction of airflow entering or leaving lungs; asthma, emphysema, chronic bronchitis, cystic fibrosis; indications include change in skin color, weakness, dyspnea, cough, adventitious breath sounds

Which ABG indicates metabolic?

HCO3

What are bronchovesicular breath sounds?

Harsh sounds heard over mainstem bronchi

What is the rule of 9s?

Head and neck - 9% Each arm - 9% Each leg - 18% Anterior trunk - 18% (9% top, 9% bottom) Posterior trunk - 18% Perineum - 1%

What indicates a pending convulsion in preeclamsia?

Headache and epigastric pain

What are symptoms of hyponatremia?

Headache, apprehension, lethargy, muscle twitching. convulsions, diarrhea, fingerprinting of skin.

What are expected effects after ECT?

Headache, disrupted memory (short and long-term), and general confused state.

What are risk factors for pressure ulcers?

Impaired sensory perception, impaired mobility, altered LOC, shear, friction, moisture.

What is Cushing Syndrome?

Hypersecretion of adrenal hormones (mineralocorticoids, glucocorticoids, androgens, cortisol); indications include fatigue, weakness, osteoporosis, muscle wasting (truncal obesity but thin arms and legs due to this), cramps, edema, increased BP, hypernatremia, hypokalemia, hyperglycemia. Well known for increased fat deposits described as "moon face" and "buffalo hump"

What is Hyperthyroidism?

Hypersecretion of thyroid gland.

What is the lab for warfarin therapy?

INR

What can precipitate a sickle cell crisis?

Infection and dehydration

What is a urinary tract infection?

Infection of one or more structures in the urinary tract (cystitis, pyelonephritis, urethritis), usually caused by gram-negative bacteria, more common in females; indications include: urinary frequency and urgency, burning/pain w/voiding, possible visible blood or pus in urine.

What is Cholecystitis?

Inflammation of the gallbladder; indications: intolerance to fatty foods, indigestion, N/V, severe pain in URQ of abdomen, elevated temp. Nursing care: administer antibiotics, analgesics, antispasmodics, NPO until acute symptoms subside, instruct to avoid fatty, fried foods (gas-forming veggies such as onions, broccoli, radishes, beans, cabbage; cream butter, whole milk; chocolate, egg yolks and avocado).

What is pleurisy?

Inflammation of the pleura; nursing care: position in semi fowler to high to aid in breathing

What is Hepatitis B immune globulin?

Injection of antibodies against hep B surface antigens; provides passive immunity against infection for people who have not been vaccinated against and are exposed to the hep B virus

What is thoracentesis?

Insertion of a large bore needle through the chest wall into the pleural space to obtain specimen for diagnostic evaluation, remove pleural fluid, or instill medications into the pleural space.

What are adverse side effects of SSRIs used to treat depression and OCD?

Insomnia, dizziness, diarrhea, nausea, sexual dysfunction, lack of sex drive; monitor for suicidal tendencies.

What is warfarin?

Interferes with synthesis of vitamin K-dependent clotting factors. Nursing considerations: monitor prothrombin time (therapeutic level is 1.5-2); observe for petechiae, bleeding gums, bruises, dark stools.

What is a miller-abbott tube used for?

Intestinal decompression, often used for treatment of paralytic ileus.

What is celiac disease?

Intolerance for gluten; foods containing rye, oats, wheat, and barely should be restricted.

What does a tonometer measure?

Intraocular pressure, normal is 10-21 mm/Hg

What is acute lymphoid leukemia (ALL)?

Involves the blood-forming tissues of the bone marrow, spleen, and lymph nodes

What is ferrous gluconate?

Iron supplement, should be diluted, taken after meals, through a straw to decrease gastrointestinal upset and staining of teeth, constipation associated with iron therapy is decreased with increased fluids.

What is the most common type of anemia?

Iron-deficiency anemia

What are signs of hyperkalemia?

Irritability, N/V, intestinal colic, diarrhea, ECG changes, peaked t wave, widened QRS complex, depressed ST Segment.

What are signs of hypophosphatemia?

Irritability, apprehension, change in LOC, confusion, seizures, fatigue, bone pain, chest pain, cardiomyopathy

Which intravenous solution does the nurse use before and after administration of a blood transfusion?

Isotonic saline because it does not cause aggregation or hemolysis of RBCs

What is important to know about albumin?

It is a protein that has strong osmotic effect and prevents plasma from leaking into interstitial fluid

What is important to know about metronidazole?

It is an antibiotic and client should not drink alcohol while taking it because it could induce a reaction of N/V, headache, craps, flushing.

What is the outcome if a nurse uses a BP cuff that is too small?

It will be erroneously elevated; cuff should be 40% of the client;s arm circumference between the olecranon and the acromion

What is a common adverse effect of narcotic used in PCA pain management?

Itching

What is pruritis?

Itching

Where should the nurse stand when helping a visually impaired client walk?

Just in front of the client with elbow bent at right angle

What is an acceptable cholesterol level?

Less than 170 mg/dL

What is amyotrophic lateral sclerosis (ALS)?

Lou gehrig's disease; Signs and symptoms: are lesion specific and include fatigue, progressive muscle weakness, cramps, fasciculations, incoordination, spasticity, brisk overactive deep tendon reflexes, difficulty talking, swallowing, and ultimately breathing, inability to cough, sneeze, blow nose, and laugh, and emotional liability.

What are bronchial breath sounds?

Loud, coarse, blowing sound heard over trachea.

What is indicative of a child born with fetal alcohol syndrome?

Low birth weight, small head circumference and underdeveloped cheek bones.

Which lab finding indicates that a client diagnosed with type 1 diabetes may be developing DKA?

Low blood pH, (due to ketones accumulating in the blood, metabolic acidosis develops)

What ABG values indicate acidic?

Low pH, high, CO2, low HCO3

What are signs indicative of metabolic acidosis?

Low pH, low bicarb, normal carbon dioxide; Manifestations: decreased mental alertness, warm flushed skin, headache, hypotension, N/V. Results from: increased production of lactic acid due to cardiopulmonary arrest, DKA, medication toxicity, starvation, and acute kidney failure, loss of bicarb due to diarrhea, lower GI fistula.

What are signs of respiratory acidosis?

Low pH, normal bicarbonate, elevated CO2. High potassium. Manifestations: lethargy, confusion, hyporeflexia, hypotension, variable respirations, pale to cyonatic skin. Results from: respiratory depression due to anesthetics, medication, trauma, airway obstruction, skeletal abnormalities.

What are the dietary considerations for someone with chronic kidney disease?

Low protein, low potassium, low sodium. Sample foods include unsalted vegetables, white rice, canned fruits, sweets.

Which diet is recommended for preop parathyroidectomy?

Low-calicum diet

Why is vitamin B6 (pyridoxine) given along with isoniazid?

Neuritis is a potential complication of isoniazid tx, pyridoxine is given to help prevent neuritis

For a chest tube, the fluid in the water-seal chamber does not fluctuate with respirations indicates what?

No more air is leaking into pleural space

What is angioplasty?

Nonsurgical invasive technique to widen vessel lumen to increase blood flow; may include balloon compression of plaque against vessel wall, stent insertion, or plaque removal via laser atherectomy (cauterize and remove plaque)

What is a sickle cell crisis?

Pain that can begin suddenly and last several hours to several days. It happens when sickled red blood cells block small blood vessels that carry blood to your bones. You might have pain in your back, knees, legs, arms, chest or stomach.

What are signs and symptoms of pyrogenic reaction to IV therapy?

Pain, redness, edema at the site, systemic symptoms include chills, fever, and general malaise.

What is placenta previa characterized by?

Painless vaginal bleeding.

What are braxton hicks contractions?

Painless, irregular contractions that do not change in frequency, duration, or intensity, do not produce cervical changes, may occur throughout pregnancy, "false labor", may become more evident, frequent, and painful as true labor approaches.

What is good to know about diabetes and illness?

Illness can cause glycogen to be released from the liver and it cannot be metabolized unless insulin in present; Client should always take the prescribed dose of insulin. Physical illness and surgery alter insulin requirements and blood glucose levels.

How do you palpate uterine contractions?

Palpate with fingertips; mild contractions (fudus easy to indent with fingertips); moderate contractions (feels like toughing the tip of your nose), strong contractions (fundus difficult to indent; feels like touching chin); severe contractions (fundus board like and almost impossible to indent, like touching forehead)

What do lumbar lesions cause?

Paresthesia, pain, muscle weakness, and atrophy in the lower extremities

The PR interval represents what?

Passage of impulse through AV Node

Which are antibiotics?

Penicillins, cephalosporins, carbapenems, tetracyclines, macrolides, aminoglycosides, fluoroquinolone

Organic failure to thrive (OTT) arises from..

Physical causes such as congenital heart defects, cerebral palsy, kidney failure.

What are indications of Conversion disorder?

Physical symptoms with no organic basis; symptoms may include blindness, paralysis, convulsions without loss of consciousness, stocking and glove anesthesia; lack of concern about symptoms.

What are the 5 levels of Maslows Hierarchy of Needs?

Physiologic needs (basic); safety or security needs; love and belonging needs; esteem; self-actualization

What does a positive sweat test indicate?

Positive finding for cystic fibrosis; enzyme replacement therapy is necessary.

What are probable signs of pregnancy?

Positive pregnancy test, braxton hicks contractions, chadwick's sign (bluish-gray violet discoloration of vaginal mucous membrane and cervix), and hegar's sign (softening of uterine isthmus)

What is abruptio placenta?

Premature separation of a normally implanted placenta leading to hemorrhage; fluid volume deficit is a major nursing concern with these clients.

What is diagnostic of rheumatic fever?

Presence of C-reactive protein in serum

What is Klinefelter syndrome?

Presence of one or more additional X chromosomes in males. Clinical manifestations include tall with long legs, hypogenitalism, sterility, gynecomastia, and poor psychosocial adjustment.

What foods are not allowed on a low sodium diet?

Preserved meats, cheese, fried foods, milk products, canned foods, added salt.

What does a pulmonary artery wedge pressure (PAWP) measure?

Pressure of the pulmonary artery; normal range is 4-12 mm Hg

What is loratadine?

Prevents effects of histamine released during allergic reaction; excitability is a paradoxical effect.

What is the purpose of continuous bladder irrigation after a TURP?

Prevents formation of clots that can lead to obstruction and spasm in the postoperative client

What is hemolytic disease of the newborn?

Primary cause of hperbilirubinemia; due to Rh or ABO incompatability; jaundice occurs within 24 hours of birth; nursing care: phototherapy, assist with exchange transfusion

What is 0.9% Normal Saline (NaCl)?

This is one of the most common IV fluids because it works for most hydration needs due to vomiting, diarrhea, hemorrhage, or even shock; isotonic

How does a nurse retrieve a urine specimen from an 24-hour specimen?

Time begins after client urinates; discard this sample; collect all urine for 24 hrs; may require refrigeration of specimen during collection

What are symptoms of aspirin overdose?

Tinnitus and gastric distress

What are symptoms of Aspirin overdose (salicylism)?

Tinnitus, uticaria, bronchospasm.

What are signs of low oxygen levels in the body?

Tiredness and exertional dyspnea, pallor and dizziness, malaise and tachycardia

Why is it important to have a client void before a paracentesis?

To avoid puncturing the bladder.

What is terbutaline used for?

To delay delivery in preterm labor

What is the primary purpose of tun, cough, and deep breathe?

To improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis.

What are low doses of heparin used for?

To keep IV patent (Heparin flush), solution is dilute and will not cause systemic anticoagulation effects.

What is the main purpose of a tracheostomy?

To provide and maintain an airway, which permits the removal of tracheobronchial secretions when the patient is unable to cough productively; also permits the use of positive pressure for ventilation, and prevents aspiration of secretions in the unconscious or paralyzed patient.

When is Fresh Frozen Plasma (FFP) used?

To treat post-surgical hemorrhage and shock. Adverse effects include hypocalcemia (usually with multiple transfusions).

What is isoniazid used for?

To tx tuberculosis; side effect is peripheral neuropathy

Parallel play describes play for a..

Toddler

What are generalized seizures?

Tonic clonic seizure, begins with tonic phase and immediate loss of consciousness, followed by clonic phase, rhythmic jerking of all extremities.

What is a full thickness or third degree burn?

Total destruction of epidermis and dermis, decreased blood flow due to eschar. Painless, varied color (white, red-brown, black, charred), dry, leathery, edema. Exp. Scalds, flames, grease, chemicals, extensive contact with hot objects, electrical shock.

What does gravida refer to?

Total number of pregnancies regardless of duration, includes present pregnancy

What is recommended weight gain in pregnancy?

Total: 25-35lbs; 1st trimester 3-5lbs; 2nd trimester 12-15lbs; third trimester 12-15 lbs

What is carbon monoxide poisoning?

Toxicity from inhaling carbon monoxide fumes; signs: headache, dizziness, fatigue, cherry red lips and face, difficulty concentrating, seizures, coma, death

The nurse cares for the client admitted with a diagnosis of acute hypoparathyroidism. It is most important for the nurse to have which item available?

Tracheostomy set because of the safety risk for laryngospasm

What is bismuth subsalicylate?

Treats diarrhea, heartburn, Nausea, and upset stomach

What is Down Syndrome?

Trisomy 21; clinical manifestatiosn include brachycephaly, inner epicanthal folds, broad, short hands with transverse crease, and intellectual disability.

What is levothyroxine sodium?

Tx for hypothyroidism; it can also treat an enlarged thyroid gland and thyroid cancer. Can increase metabolic processes of body, including glomerular filtration, edema will decrease as water is excreted.

Diabetic ketoacidosis (DKA) is a life-threatening condition found in which type?

Type 1, caused by a lack of insulin and body drawing on fat and protein stores for energy when no insulin is being produced. Ketones accumulate in blood, lower pH, and metabolic acidosis develops.

You should avoid which food when taking an MOAI such as phenelzine?

Tyramine, can cause a hypertensive crisis, can be corrected with antihypertensive

What is disorientation?

Unable to identify self, place, time, location, direction, and/or situations.

What is Brachytherapy?

Use of internal radiation or radium implants at the treatment site, usually a malignant lesion. Nursing considerations: save all dressings and linens until the source is removed and discard as usual, organize care so limited time is spent in room, encourage client to do as much self-care as possible, pt must remain on bed-rest while implant is in place.

What is vernix?

White cheesy substance that acts as protective covering for the infant's skin, describes full-term infant

What is an advance directive?

Written statement by a competent person that specifies decisions for an individual's treatment in the event of serious illness or injury.

Intimacy versus isolation is appropriate for...

Young adults

Immune thrombocytopenia purpura (ITP) is most common in who?

Young children, especially after a viral infection.

What is colchicine?

a drug given to treat acute attacks of gout.

What is probenecid?

a drug that prevents the reoccurrence of gouty arthritis

What is imipramine?

a tricyclic antidepressant medication; Sore throat, fever, increased fatigue, vomiting, and diarrhea are possible adverse effects

Generativity versus stagnation is appropriate for...

ages 45-64 yo

What is cholestyramine?

an antilipemic agent. Constipation is an adverse effect of the medication. Encourage a diet high in fiber and fluids to help relieve the constipation.

What is zidovudine?

an antiviral, which is used to prevent the replication of HIV in the bloodstream. Because the medication suppresses bone marrow function, the client is prone to developing a deficiency in red and white blood cell production.

What is the best source of information about the patient's pain?

The patient

What is hypophysectomy?

the removal of a part or the entire pituitary gland, which controls specific hormones.

What is a myringotomy?

incision in tympanic membrane to insert tympanostomy tubes due to recurrent and chronic otitis media; nursing considerations: no diving/jumping, or submerging in water without earplugs; keep bath water and shampoo out of ear; inform parents that tubes will eventually fall out (notify provider); should keep mouth open when sneezing or coughing to avoid upper respiratory infection and keep ears dry for 6 weeks.

What is stomatitis?

inflammation of the oral mucosa

What is pericarditis?

inflammation of the pericardial sac; indications: chest pain is sharp, occurs suddenly, severity varies with position changes, pericardial friction rub auscultated, fever may be present.

What are the most common causes of hypercalcemia?

malignancies and hyperparathyroidism

Which foods are high is phosphate?

milk, milk products, organ meats, nuts, fish, poultry, whole grains

Why is temporary control by insulin needed after surgery?

oral agents not effective due to surgically induced metabolic changes, being NPO before and after surgery, and the infusion of IV fluids.

What are symptoms of graft verse host disease?

rash, diarrhea, and pruritus

What is epoetin alfa?

recombinant EPO, prescribe with anemia

Which fetal presentation is associated with breech position?

sacrum anterior; fetal heart rate can be determined above the umbillicus

Fat embolism syndrome (FES) is most commonly associated with?

trauma, long bone and pelvic fractures, and orthopedic surgery; Clinical manifestations include pulmonary insufficiency, neurologic symptoms, anemia and thrombocytopenia, tachypnea, dyspnea, and tachycardia. Petechiae appears on the trunk of the body, face, and in the axillary folds

What is alendronate?

used for treatment and prevention of osteoporosis. This medication causes photosensitivity and should utilize sunscreen.

What is sodium polystyrene sulfonate?

used to treat hyperkalemia

The parathyroid controls what?

Calcium balance

What is dysphagia?

Difficulty swallowing

Solitary play describes play for an..

Infant

What is hydroxyzine?

Antipruritic; reduces anxiety, nausea, uticaria, alcohol withdrawal. Avoid alcohol.

What does increased serum osmolality mean?

Dilute urine (usually due to urinary frequency/diabetes insipidus)

What should the nurse monitor for when a client is taking ceftriaxone?

Overgrowth of organisms; surface of the tongue

What does hemoglobin measure?

Oxygen-carry capacity of the blood

Which foods have high cross sensitivity to iodine-based contrast medium?

Shellfish, high in iodine (include oysters)

What is evisceration?

When the abdominal organs protrude or come out of an incision (dehiscence)

What is the brudzinski sign?

When the client flexes the head, the hip and knee also flex; sign of meningeal involvement

Which are foods high in potassium?

Bananas, citrus fruits, dried fruit, potatoes, pumpkins, salt substitute, tomatoes, melons, spinach, avocado, meats.

The nurse cares for a client admitted with a dx of DKA. The nurse anticipates the health care provider will order which type of insulin?

Short-acting (regular) insulin

What is orthopnea?

Shortness of breath (dyspnea) that occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair.

What is important to know about oxytocin?

Should always be a secondary infusion controlled by an IV pump.

What is important to know about colostomy irrigation?

Should be done at the same time each day to assist in establishing a normal pattern of elimination.

What is good pt education for a pt to prevent urolithiasis?

Should drink sufficient quantity of fluid to produce a dilute urine; limit protein intake, monitor sodium intake; avoid oxalate-containing foods (spinach, chocolate, cocoa, peanuts, tofu, soy, VEGETARIAN); avoid activity conducive to temperature that may induce sweating and dehydration

What is ipsilateral?

"on the same side of the body"

How is neuropathic pain generally described?

"shooting," sharp, burning

Which are gliptins for diabetes?

(-gliptin) Sitagliptin, saxagliptin

Which are antihistamines?

(-ine) loratadine, cetirizine, diphenhydramine, hydroxyzine

Which are Beta Blockers?

(-lol) Metoprolol, atenolol, bisoprolol, Carvedelol, Propranolol, Lavetalol

Which are Calcium Channel Blockers?

(-pine) Amlodipine, Felodipine, Diltiazem, Verapamil

Which are proton pump inhibitors?

(-prazole) omeprazole, pantoprazole

Which are ace-inhibitors?

(-pril) Lisinopril, Enalapril. Captoril, Ramipril

Which are Angiotensin II Receptor Blockers (ARBs)?

(-rtan) Losartan, Valsartan, Candesaratan

Which are HMG-CoA Reductase inhibitors/statins?

(-statin) Atorovastatin, Fluvastatin, lovastatin, Simvastatin

Which are thiazolidinediones for diabetes?

(-tazone) Pioglitazone, rosiglitazone

Which are long acting beta 2 agonists?

(-terol) Salmeterol, formeterol, indacaterol

Which are H2 receptor antagonists?

(-tidine) Ranitidine, famotidine, cimetidine

Which are Direct Acting Fact Xa inhibitors?

(-xaban) Apixaban, Rivaroxaban

Which are Alpha 1 Blockers?

(-zosin) Prazosin, Doxazosin, Terazosin

How much protein is expected in urine?

0-8 mg/dL

What is the maintenance dose range for digoxin?

0.125-0.5 mg

What is a therapeutic level of digoxin?

0.5 and 2 ng/mL

What is a normal lactic acid level?

0.5 to 2.2 mEq/L; Elevated levels indicate inadequate oxygenation in the body or the presence of shock

What is a therapeutic digoxin level?

0.5-2.0 ng/mL

Rapid acting insulin's peak is when?

0.5-2.5 hours

What are normal digoxin plasma levels?

0.8-2 ng/mL

What is cesium 137?

A form of bradytherapy (internal radiation implant)

What is gout?

A form of inflammatory arthritis that develops in some people who have high levels of uric acid in the blood. The acid can form needle-like crystals in a joint and cause sudden, severe episodes of pain, tenderness, redness, warmth and swelling.

What is a boggy uterus and deviated to the right indicate?

A full bladder, encourage client to void.

What is acute myeloid/myelogenous leukemia (AML)?

Any of a group of hematological malignancies in which neoplastic cells develop from myeloid, monocytic, erythrocytic or megakaryocytic precursors. Common in adults.

What is the location of fundus for the first 12 hours postpartum?

At or 1cm/fingerbreadth above the umbilicus; descend by one fingerbreadth each succeeding day

Tube feedings are usually given...

At room temperature to minimize intestinal cramping.

What is normal specific gravity?

1.010-1.030, low indicates diabetes insipidus

When do tricyclic antidepressants begin to take effect?

10-14 days after tx has been initiated. Client's may have physical and emotional energy to act on suicidal thoughts at this time.

What is a normal AST (liver)?

10-40 U/L

What is a therapeutic level of phenobarbital?

10-40 mcg/mL

What is a normal apical rate for newborns when they are asleep?

100 bpm

What is a normal blood pressure for a child 5-12 years old?

100-110 mm Hg/56-60 mm Hg

What is a normal LDH (liver)?

100-200 units

When conducting CPR, what is the rate of compressions?

100/minute

When is a fundus palpable just above the symphysis pubis?

12-14 weeks

When do anterior fontanels close?

12-18 mo of age

Associative play describes play for a...

4 year old

What is the maximum daily dose of acetaminophen?

4,000 mg/day

What is an elevated adult BP?

120-129 mm Hg/80 or less

What is a normal apical rate for newborns when they are awake?

120-160 bpm

What is a normal bilirubin level?

13-15mg/dL @ 72 hours of age

What is a stage 1 hypertension BP?

130-139/80-89

What is a stage 2 hypertension BP?

140 or more/90 or more

An adolescent female requires how much iron per day?

15 mg

What is a normal platelet level?

150,000-400,000

What is a normal BMI?

18.5-24.9

Intermediate acting insulin's peak is when?

4-12 hours

What is the amount of time between each mark on a rhythm strip?

3 seconds

When does the tonic neck reflex disappear?

3-4 mo of age

What is a normal newborn blood pressure?

60-80 mm Hg/40-50 mm Hg

What is the max dose per day for ibuprofen?

3.2 grams/day

What is a normal albumin?

3.5-5 g/dL

What is a normal level of potassium?

3.5-5 mEq/L; Main ion involved in cardiac rhythm, nerve transmission.

What is a normal serum albumin level?

3.5-5.0 g/100 mL blood

What is the minimum output suggested for urine?

30 mL in 1 hour

What is the max amount of acetaminophen one should have in one day?

4 grams; adverse effects include liver failure, kidney failure, leukopenia, neutropenia, pancytopenia, rash.

What is the normal range of gastric aspirate pH?

4 or less

What is the time frame that thrombolytic therapy is effective?

4.5-6 hours

What is the range of pH of urine?

4.5-8, tends to be primarily acidic

How many sounds are heard per minute in "normal bowel sounds?"

5-30

What is a normal pH?

7.35-7.45

What are neutropenic precautions?

AKA reverse isolation; used for clients at increased risk for infection, immunosuppressed with neutrophil count under 500 mm3. Procedure: private room scrupulously cleaned, meticulous handwashing and use of personal protective equipment by all, restriction of visitors, no fresh fruit or vegetables, and avoid invasive procedures.

Which blood type is the universal RECIPIENT?

AB, but can only donate to AB

Which are inhaled corticosteriods?

Beclomethason, mometason

What is the antidote for acute acetaminophen poisoning?

Acetylcysteine, given orally every 4hrs for 18 doses, all doses must be given.

What is beneficence?

Action promotes good; requires nurse to help patients meet al of their needs.

What is Addisonian Crisis/Adrenal Crisis?

Acute adrenocortical insufficiency precipitated by stress, surgery, trauma, and infection; treated with hormone replacement therapy and requires rapid infusion of IV fluids to prevent vascular collapse and hypoglycemia.

What are premature ventricular contractions?

AV node blocks all electrical impulses to ventricles resulting in AV dissociation; signs and symptoms: dizziness, palpitations, dyspnea, disorientation, syncope, cyanosis, and random P and QRS waves on ECG

What is the most widely accepted examination to test for the presence of tardive dyskinesia?

Abnormal Involuntary Movement Scale (AIMS)

What is glaucoma?

Abnormal increase in intraocular pressure leading to visual disability and blindness; indications: cloudy or blurry vision, artifical lights appear to have rainbows or halos around them, decreased peripheral vision; medically treated with eye drops for the remainder of the life

What is nystagmus?

Abnormal, involuntary rapid oscillating eye movements; may be horizontal, vertical, rotary, or mixed in direction

What is flail chest?

Abnormality of chest wall, occurs when two or more ribs fracture; area moves in with inspiration and out with expiration.

What is the incubation period for chickenpox?

About 10-21 days (approx. 2-3 weeks)

Lithium is used to control manic episodes of bipolar psychosis. What is a toxic level of lithium?

Above 1.5 mEq/L

Which medication is given for an acetaminophen overdose?

Acetylcysteine

What is Naegele's rule for determining fetal due dates?

Add 7 calendar days to the date of the client's last menstrual period and then subtract 3 months.

What is a priority with any client with sickle cell crisis?

Adequate hydration

What is nursing care for burn injury?

Administer IV Lactated Ringers and plasma, use an IDC to monitor hourly output (should be at least 30 mL/hour), check for signs of fluid overload versus dehydration, monitor BP, monitor serum electrolyte, high carb and high protein diets, wound care at least once a day (administer pain meds 30 mins before)

Identity versus role diffusion is appropriate for...

Adolescents

What are Potassium-Sparing Diuretics?

Antagonize aldosterone in distal tubules to decrease potassium loss during diuresis, block sodium reabsorption by the kidney. Adverse effects hyperkalemia. Exp. Spironolactone, eplerenone

What are potassium-sparing diuretics?

Antagonize aldosterone in distal tubules to decrease potassium loss during diuresis, block sodium reabsorption in kidney; exp. Spironolactone. Nursing considerations: monitor electrolyte imbalance, I/o, avoid salt substitutes, LIMIT foods in potassium

What is vitamin K?

Anti-hemorrhagic factor, necessary for synthesis of clotting factors. Food sources: alfalfa, fats, oats, wheat, and rye

Which medications are generally used to for delirium tremens?

Anticonvulsants such as phenobaritol and sedatives such as chlordiazepoxide. Sedation is used to control anxiety and agitation, and anticonvulsants are used to prevent withdrawal seizures.

What is diphenoxylate hydrochloride with atropine sulfate?

Antidiarrheal medication, a synthetic narcotic w/atropine; it increases intestinal done and decreases peristalsis.

What is promethazine?

Antiemetic and adverse effects include anorexia, dry mouth and eyes, constipation and orthostatic hypotension. Client is at risk for dehydration due to vomiting, which exacerbates the orthostatic hypotension.

What is amphotericin B?

Antifungal.

What is diphenhydramine hydrochloride?

Antihistamine, blocks the effects of histamine on bronchioles, GI tract, and blood vessels, thereby preventing or decreasing symptoms of allergic response.

What is Valproic acid?

Antiocnvulsant medication used for both convulsive disorders and as a mood stabilizer in bipolar disorders: ADR: sedation, N/V, indigestion, prolonged bleedings. Do not take with carbonated beverages.

Which medications are different types of insulin?

Aspart, gluisine, lispro, isophane, Detemir, glargine

What is a bone marrow biopsy?

Aspiration/removal and examination of #, size, and shape of RBCs, WBCs, and platelet precursors in the bone marrow; assess and identify blood dyscrasias; specimen obtained from iliac crest or sternum; after test, cleanse site with alcohol to remove providine iodine and apply pressure dressing for several minutes, apply sterile pressure dressing.

Which medication is contraindicated during pregnancy?

Aspirin, can cause fetal hemorrhage

What is a cardiac stress test?

Assess cardiovascular response to increased workload; stress induction by medications or physical exercise using treadmill or bicycle to target heart rate or development of adverse symptoms.

What are important nursing considerations for a client with an endotracheal tube?

Assess for bilateral breath sounds and bilateral chest excursion; mark tube at level it touches mouth or nose; secure w/tape to stabilize; encourage fluids to facilitate removal of secretions; offer alternative methods of communication.

UAPs can be delegated what tasks?

Assist with direct client care activities: bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, ht/wt, intake and output, housekeeping, transporting, stocking supplies.

LPNs can be delegated to do what?

Assist with implementation of defined plans of care; performs procedures according to protocol; differentiates normal from abnormal; cares for physiologically stable clients with predictable conditions; has knowledge of asepsis and dressing changes; ability to administer medications varies with education background and state nurse practice act.

How is an apgar score performed?

At 1 and 5 mins; 0-2 points given for a cardiac rate, respirations, muscle tone, reflexes, and color

When do posterior fontanels close?

At 2 mo of age

What is the best age to start toilet training?

Average begins at 20 months, by 24 months achieved

What is important client education for those taking MOAIs?

Avoid foods with tyramine (alcohol, aged cheese, avocados, bananas, liver, processed meats, sausage, caffeine, chocolate, meat tenderizer, miso soup, yeasts, yogurt, raisins, raspberries, peanuts, over-ripe fruits, soy cause, sauerkraut, shrimp paste), may precipitate a hypertensive crisis

How should you treat infection of the eyes?

Avoid touching or rubbing them, always wash hands before and after med amin, treat each eye separately if infection in both, the less affected eye should be treated first, then the more infected

Which blood type can donate to B and AB?

B, but can only receive from O and B

Metformin and contrast media are contraindicated because?

Can cause life-threatening lactic acidosis

The cerebellum maintains what?

Balance

Which foods are high in potassium?

Bananas, citrus fruits, dried fruit, potatoes, pumpkins, salt substitute, tomatoes, melons, avocado, meats, spinach

Which type of beverages are restricted prior to an electroencephalogram (EEG) for 1-2 days?

Caffeine (stimulants)

Respiratory paralysis occurs with spinal cord injuries....

C4 and above

What type of medication is nifedipine?

Calcium Channel blocker, bradycardia is an adverse effect

What are nursing considerations for eye trauma?

Chemical: flood immediately with saline or running tap water; foreign object: do not remove or bump, apply eye shield or stiff small inverted paper cup, do not cover eye tightly, administer tetanus immunization

What is 5-fluorouracil?

Chemotherapy agent

What is acute epiglotitis?

Childhood bacterial or viral inflammation of the epiglottis leading to swelling above the epiglotis causing airway obstruction; Sitting in tripod position with mouth open, Drooling, agitation, and absence of spontaneous cough; do not attempt throat inspection unless immediate intubation can be performed (laryngospasm may occur)

Which populations are at high risk for latex allergy?

Children diagnosed with spina bifida, clients dx with urogenital abnormalities or spinal cord injuries, client with hx of multiple surgeries, and health care workers.

Which are antipsychotics?

Chlorprmazine, Risperidone, Olanzapine

What is Korsakoff's psychosis and what is it's symptoms?

Chronic central nervous system disorder usually associated with chronic alcoholism; symptoms include loss of memory, confabulation, disorientation, hallucinations, illusions, progressive mental deterioration, and polyneuritis. Tx includes thiamine (vitamin B1)

What are indications of Schizophrenia?

Chronic illness resulting in psychotic behavior: symptoms include inappropriate or no display of feelings; hypochondriasis and depersonalization, hallucinations, delusions, short attention span, regression, inability to meet basic survival needs

What is prednisone?

Corticosteriod used in varied conditions, to reduce inflammation and lessen complications; It has CNS adverse effects which affect mental status, even to the point of causing psychosis and/or seizures, others include mood swings, behavioral changes, sleep disturbances, and psychomotor alterations.

What is Glomerulonephritis?

Damage to glomeruli resulting in proliferative and inflammatory changes within the glomerular structure; An immunologic reaction to beta-hemolytic streptococcal infection elsewhere in the body, occurs 10 days after skin or throat infection; Indications include: fever, chills, hematuria, poteinuria, weakness, pallor, dyspnea, lung rales, weight gain, fluid overload, oliguria

What is glomerulonephritis?

Damage to glomeruli resultingin proliferative and inflammatory changes within the glomerular structure; Caused by an immunologic reaction to beta-hemolytic streptococcal infection elsewhere in he body, occurs 10 days after skin or throat infection; indications: fever, chills, hematuria, proteinuria, weakness, pallor, dyspnea, lung rales, weight gain, fluid overload, generalized edema, hypertension, oliguria with fixed specific gravity.

What is linea nigra?

Dark, pigmented line in middle of abdomen during pregnancy

What is agranulocytosis?

Decreased to absent granulocytic WBCs (basophils, eosinophils, neutrophils); symptoms include fatigue and weakness immediately, within 203 days the client develops sore throat, fever, chills, ulcerations of the upper airway mucosa and weak rapid pulse.

What is good to know about antacids?

Decreases bonding to gastrointestinal mucosa so you should avoid giving them within 30 minutes of other medication (especially magnesium ones)

The nurse knows the purpose of the cuff on the tracheostomy tube includes which reason?

Decreases the chance of aspiration into the trachea

The client is admitted with a diagnosis of subdural hematoma and cerebral edema after a motorcycle accident. Which symptoms should the nurse expect to see initially?

Decreasing LOC, ipsilateral pupil dilation, headache

What are deep thickness or 4th degree burns?

Deep wounds to muscle or bone. No pain or edema, black color, monitor for shock, amputation or grafting possible. Exp extensive contact with electrical or other burning situations.

What is Addison's Disease?

Deficiency of adrenocortical hormones and is indicated by weakness, hypoglycemia, hypotension, emaciation, dark pigmentation of skin, low serum sodium (hyponatremia), high serum potassium (hyperkalemia); Exogenous glucocorticoid therapy is used for the rest of the life.

What is the earliest indication of cerebral palsy?

Delayed gross motor development: signs include stiff or rigid arms or legs, arching back, floppy or limp body posture, poor head control after 3 months

What are the stages of grief?

Denial, anger, bargaining, depression, acceptance.

Magnesium has a CNS.....

Depressant effect; reflex hammer needed for monitoring deep tendon reflexes and IV calcium gluconate can block the effects of hypermagnesemia.

What are symptoms of amphetamine withdrawal?

Depression, disturbed sleep, restlessness, disorientation.

What is defibrillation?

Discharge of electricity causing depolarization of myocardial cells, when repolarized, SA nodes resumes as pacemaker. Most effective method for terminating ventricular fibrillation.

Pyridium is a spasmolyic that has an anesthetic action on urinary mucosa and...

Discolors urine red or orange and may stain fabrics. Alert your patients!

The nurse observes late decelerations of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. Which actions should the nurse take?

Discontinue the oxytocin, turn client to left side to aide in blood flow to the placenta, give oxygen to help provide additional oxygen to the fetus, and increase the fluid infusion by giving more volume for transfer of oxygen to the fetus.

What are nursing interventions for conversion & Somatization disorders?

Discuss feelings w/client rather than symptoms; promote therapeutic relationships; recognize and avoid supporting secondary gains of client.

How do you convert pounds to kg?

Divide by 2.2

Applying warm packs to the breast will..

Enhance the flow of milk

What is lymphadenopathy?

Enlargement of lymph nodes in the body to the point where they are palpable; the nodes function as a filter of foreign material, fight infection, and increase in number when infection is present.

What is a predominant sign associated with bladder cancer?

Hematuria, others include change in voiding or urine, back and/or pelvic pain

What would be the result if a Rh-negative receives ph-positive blood?

Hemolysis (breakdown of RBC) and anemia

What are post-op complications to look out for?

Hemorrhage, paralytic ileus, atelectasis, pneumonia, embolism, infection of wound, dehiscence, evisceration, venous thromboembolis, psychosis.

What are possible complications of a thyroidectomy?

Hemorrhage, respiratory distress, tetany caused by parathyroid injury, and damage to laryngeal nerves.

What is Tetrology of Fallot (TOF)?

Includes 4 defects: ventricular septal defect, pulmonic stenosis, overriding aorta, and right ventricular hypertrophy acquired due to increased pressure within right ventricle; indications: cyanosis at birth, mild cyanosis that progresses during first year of life, heart murmur, poor weight gain, poor feeding habits, clubbing of fingers, delayed physical growth and development, child squats or assumes knee-chest position.

What is Inflammatory Bowel Disease (IBD)?

Includes Crohn disease and ulcerative colitis; indications: abdominal pain, diarrhea, fluid imbalance, weight loss. Nursing considerations: high protein, high calorie, low fat, low fiber diet, may require TPN to rest bowl, maintain fluid/electrolyte balance, promote rest.

What is the primary purpose of a pacemaker?

Increase cardiac output.

What is a pneumothorax?

Lung collapse; caused by accumulation of air or fluid in the pleural cavity; indications include pleuritic pain, tachypnea, diminished breath sounds; tx chest tube.

Which medication is given for seizure prevention in pregnancy?

Magnesium sulfate, given IV

What is carbidopa-levodopa?

Mainstay drug therapy to slow the progression of parkinson's disease.

What is an autocratic leadership style?

Maintains full control of decision-making, planning, and issuing of directive; discourages independence; uses coercion; emphasizes status differences.

What are cheyne-stokes breathing?

Marked by a regular pattern of rapid breathing which builds from shallow to very deep respirations and then back to shallow, followed by a period of apnea.

What PPE is used for droplet precautions?

Mask.

What is Anasarca?

Massive generalized edema that develops when there is a decreased kidney function and fluid lost to interstitial spaces

What is Isoproterenol?

May accelerate the ventricular escape rhythm and facilitate conduction. This is a temporary measure and is not used if active ischemic heart disease is present

What is central venous pressure (CVP)?

Measurement of effective blood volume and ability of right side of heart to manage a fluid load. Normal is 2-8 mm Hg. Over 8 indicated hypervolemia or poor cardiac contractility, under 2 indicates hypovolemia.

Which foods are high in iron?

Meat, liver, oysters, egg yolks, carrots, apricots, raisins and leafy green vegetables.

What is the best source of dietary iron?

Meats, fish, poultry

The nurse provides care for a client with an ileostomy. For which acid-base disorder does the nurse monitor the client?

Metabolic acidosis; Intestinal secretions are high in bicarbonate that may be lost through enteric drainage tubes, an ileostomy, or diarrhea. This causes metabolic acidosis.

Which are antiemetics?

Metoclopramide, ondansetron, promethazine, prochlorperazine; Adverse effects: headache, constipation, drowsiness, extrapyramidal effects. Administer 30 mins before chemo or meals.

What is the earliest sign of diabetic nephropathy?

Microalbuminuria

What foods are included in a full liquid diet?

Milk and milk products (pudding, custards), all vegetable juices, pureed vegetables, all fruit juices, refined or strained or cooked cereals, eggs in custard,butter, margarine, and cream.

Which are common allergens associated with eczema?

Milk, wheat, egg whites

How do you time labor contractions?

Minutes from the beginning of one contraction to the beginning of the next contraction; duration: time in seconds from the beginning of a contraction to its completion

Electrical burn injuries are typically..

More injurious to underlying tissue, such as nerve and vascular tissue,which require complex and timely treatment

What is parietal pain?

More localized, more severe and steady.

What are cold stress symptoms?

Mottling of the skin, acrocyanosis, and irregular respirations at the rate of 60 breaths per minute

What does para refer to?

Number of past pregnancies beyond period of viability (20 weeks or greater) regardless of number of fetuses or whether infant was born alive or dead

Which drinks promote acidic urine and minimizes the risk of urinary tract infections and calculus formation?

Prune juice, cranberry juice, blueberry juice

What is important to know about ECT?

Pt given general anesthesia, NPO after midnight

What is the best position to obtain an accurate BP reading on the adult client's lower extremity?

Pt is on abdomen and the nurse places the cuff around the thigh and the stethoscope at the popliteal artery

What is pernicious anemia?

RBC that are large, have abnormally shaped nuclei, contain normal amounts of hemoglobin; caused by intrinsic factor causes decreased absorption of vitamin B12 in gastric mucosa, autoimmune destruction of the gastric mucosa (maybe surgery?); Symptoms: pallor, glossitis, fatigue, paresthesia of the hands and feet; tx: B12 injections taken for the rest of one's life 1x month due to inability to absorb B12 in stomach due to absence of an intrinsic factor.

What does variable decelerations on fetal monitoring indicate?

Rapid in decent and commonly do not correspond to the uterine contraction pattern; found with cord compression.

What is atrial fibrillation?

Rapid irregular atrial contractions leading to ineffective atrial emptying of blood into the ventricles; blood pools in atria possibly forming clots that can embolize to the body; indications: irregular HR, ventricular response determines rapidity, dizziness, dyspnea, palpations, syncope.

What does hematocrit measure?

Ratio of RBC to fluid volume

What are indications of chest pain?

Retrosternal (or slightly to the left of sternum) chest pain that radiates usually to left shoulder and upper arm and proceeds down arm into fingers; may also radiate to right shoulder, neck, jaw, or epigastrium

What is Glucagon?

Reverses hypoglycemia by stimulating hepatic production of glucose from glycogen store to increase blood glucose.

What is autonomy?

Right to choose and freedom to make decision for oneself, accomplished by providing information and supporting patient's choices.

What is cor pulmonale?

Right ventricle fails as a result of pulmonary condition. Signs: exertional dyspnea, productive cough, fatigue, weakness, JVD, and peripheral edema.

What is normal lochia day 1-3 postpartum?

Rubra-bloody with fleshy odor, may have clots

What is dehiscence?

Separation of wound edges, experienced 5-6 days postoperative. Nursing care: place client in low fowlers, no coughing, NPO, cover viscera with sterile saline dressing, notify HCP

What is anaphylaxis?

Serious multiple-system response (vasogeneic shock) to an antigen-antibody reaction; occurs usually upon subsequent exposure (rarely first) to a substance for which a person has developed a severe hypersensitivity. Nursing considerations: establish airway, administer epinephrine, start IV, monitor I?O, oxygen, suction, and life support as needed.

What is normal lochia 4-9 days postpartum?

Serosa- pink/brown with fleshy odor

What are symptoms of cocaine withdrawal?

Severe cravings, depression, fatigue, hypersomnia

The nurse recognizes which symptoms are characteristic of impending diabetic ketoacidosis?

Severe hyperglycemia, confusion, Hot, flushed, dry skin, increased temperature, thirst, anorexia, increased pulse, and possibly vomiting. Pt becomes lethargic and develops acetone breath and kassumals respirations.

What is thyrotoxicosis?

Severe hyperthyroidism (over secretion of thyroid gland); indicated by hyperpyrexia (high fever), cardiac dysrhythmias, and altered mental status. .

What is Pruritus?

Severe intense itching, tingling, burning sensation

There is a strong relationships between iodine allergy and...

Shellfish allergy

What is Passive Immunity?

Temporary and results from introduction of antibodies from a source other than the individual (e.g., gamma globulin, breastfeeding).

Transient ischemic attacks typically cause....

Temporary unilateral neurologic symptoms (parasthesia, muscle weakness, aphasia, dizziness) lasting from several minutes to several hours.

What are indications of hypocalcemia?

Tetany (muscle twitches), positive trousseau's sign, positive chvostek's sign, seizures, confusion, paresthesia, irritability

What are signs of hypoparathyroidism?

Tetany, muscular irritability, carpopedal spasm, paresthesia, laryngeal spasm, tachycardia, positive chvostek's sign, positive trousseau's sign.

Which immunizations are due at 12-15 mo of age and again at 4-6 yo?

Varicella and MMR

What is Kaposi Sarcoma?

Vascular malignancy associated with depressed immune status; possible etiology herpes virus, involves skin surface, especially face and thorax, similar appearance to ecchymosis or purpura.

Which are SNRIs?

Venlafaxine, Duloxetine

The QRS complex represents what activity?

Ventricular depolarization

What is the earliest sign of heart failure?

Ventricular gallop

What is HIV?

Virus that causes immunodeficiency that can lead to AIDS. Transmitted via blood and body fluids. Signs: early stages of infection-asymptomatic, later as immune system deteriorates, symptomatic, opportunistic infections.

Which are foods high in saturated fats and is a diet to avoid in cardiac disease?

Visible sources of fat in or on meat, palm-kernel oil, coconut oil, cocoa butter, lard, solid shortening

What is a colposcopy?

Visualization of the cervix with a stereoscope binocular microscope

What is the antidote for warfarin?

Vitamin K

What does blanching of the skin indicate?

Warning sign of pressure ulcer

What is sodium responsible for?

Water balance

What are signs of Cushing's syndrome (hypersecretion of adrenal hormones)?

Weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections

When does the Moro reflex disappear?

by 4 mo of age

What are course rales?

expected with the pulmonary edema that accompanies a myocardial infarction

What is abduction?

movement away from the midline

What is adduction?

movement toward the midline

What does a fixed and dilated pupil represent?

A neurological emergency, symptoms of increased intracranial pressure.

Which immunizations are due at 2 mo of age?

Rotovirus, DTap, Haemophilus influenzae type b, and inactivated polio

Which diagnoses require droplet precautions?

Rubella (German Measles), meningitis, streptococcal pharyngitis, pneumonia, mumps

What is zolmitriptan?

A neurological medication used to treat acute migraines with or without aura; does not prevent headaches; side effects include dizziness, drowsiness, dry mouth, and dyspepsia.

What is osteomyelitis?

A potential complication of bone marrow aspirations; fever and yellow, purulent discharge from the site is noted.

What is an intravenous pyelogram (IVP)?

A procedure in which an x-ray is taken of the entire urinary track to evaluate kidney function.

When does delirium occur after not ingesting alcohol?

2-3 days and symptoms include tremors, anxiety, panic, disorientation, confusion, paranoia, delusional symptoms, generalized tonic-clonic seizures, coma, and death

What is normal weight gain during the first trimester of pregnancy?

2-5 lbs (2.2 lbs per month)

Preschool age is considered what?

2-5 yrs of age, prior to beginning school

What is a normal CVP range?

2-8 mm Hg

What is Buerger's disease?

A rare disease of the arteries and veins in the arms and legs. Also called thromboangiitis obliterans — your blood vessels become inflamed, swell and can become blocked with blood clots (thrombi)

What are indications of bipolar disorder?

Elevated or expansive mood, agitation, accelerated speech, thought, and movement, distractibility, self-confidence, aggression, sarcasm, inappropriate dress, inattention to personal hygiene, constipation, insomnia. Nurses should set limits, and be consistent, redirect.

What are signs of hypernatremia?

Elevated temperature, weakness, disorientation, delusions, hallucinations, thirst, dry swollen tongue, sticky mucous membranes, hypotension, tachycardia.

What is a myocardial infarction?

formation of localized necrotic areas within the myocardium; indications: severe crushing chest pain, may radiate to arms and/or jaw and/or neck and/or back, dyspnea, nausea, vomiting, gastric discomfort, indigestion, apprehension, restlessness, fear of death.

What are indications of arterial insufficiency?

Rubor, cool, shiny skin, cyanosis, ulcers, gangrene, impaired sensation, intermittent claudication; Nursing care: monitor peripheral pulses, maintain good foot care; client ed: avoid crossing legs, regular exercises, place legs in the dependent position to relieve pain at rest, smoking cessation.

What are symptoms of heroin withdrawal?

Runny nose, yawning, fever, muscle and joint pain, diarrhea.

What does clear fluid draining from the ear indicate?

Rupture of meninges and presents a potential complication of meningitis.

Which diagnoses require contact precautions?

S. Aureus; Respiratory syncytial virus (RSV); infected decubitus ulcer

What are common allergy reactions?

SOB, wheezing, inflamed airways, itching, congestion, and erythema

Nonorganic failure to thrive (NFTT) arises from..

Factors such as inadequate parental knowledge of nutrition, family poverty, family stress, feeding resistance.

What is anxiety?

Feeling of dread or fear in the absence of external threat or disproportionate to the nature of the threat.

Which pulse site is most commonly used during shock or cardiac arrest?

Femoral

What does meconium-stained amniotic fluid (greenish-colored) alert the nurse to which possibility?

Fetal distress and perinatal asphyxia; could indicate hypoxia-induced peristalsis and sphincter relaxation; normally seen in breech deliveries

What is status asthmaticus?

A severe condition in which asthma attacks follow one another without pause.

What is hemophilia?

A sex-linked disorder, recessive x-gene, bleeding disorder (A is a deficiency of factor VIII most commonly) commonly seen in males

What is the lithotomy position?

A supine position of the body with the legs separated, flexed, and supported in raised stirrups.

What is dependent edema?

A term that doctors use to describe gravity-related swelling in the lower body. Gravity has the effect of pulling fluid down toward the earth, causing it too pool in the lowest parts of your body, such as your feet, legs, or hands

What is phenazopyridine?

A urinary analgesic and spasmolytic, not an antiinfective.

What is hydralazine?

A vasodilator that works by relaxing the muscles in your blood vessels to help them dilate (widen). This lowers blood pressure and allows blood to flow more easily through your veins and arteries. Is used to treat high blood pressure/headaches (hypertension). Over the counter medications should be avoided.

What is epinephrine?

A vasopressor that is used to maintain cardiovascular function. Vasopressors act on the blood vessels and induce vasoconstriction to raise blood pressure. Evidence that treatment has been effective includes a blood pressure WNL, a heart rate WNL, and capillary refill of less than 2 seconds.

What is hyperresonance?

A very loud, booming, low-pitched sound of long duration heard in conditions of over-inflated air-filled tissues such as occurs in pulmonary emphysema

Why would a newborn born to a mother with diabetes be at risk for hypoglycemia?

Fetus produces increased insulin to mate mother's increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia.

What are early signs of lithium toxicity?

Fine motor tremors, N/v, diarrhea

When is the first trimester of pregnancy?

First 12-13 weeks; Discomforts include: N/V, urinary frequency, fatigue, breast tenderness, and increased vaginal discharge

What are indications of Somatization disorders?

Frequent seeking and obtaining of tx for multiple somatic reports; begins before 30 yo; reports not explainable by a doctor or substance use; must include hx of certain # of symptoms in different categories.

What is the third stage of labor?

From birth of the baby to expulsion of placenta

What is the second stage of labor?

From full dilation of cervix to the delivery of the baby

What is normal range for phosphate?

2.5-4.5 mg/dL

What is a normal Hemoglobin A1C?

2.5-6%

What size needle is used to deliver blood products?

20-gauge or larger

Intake and output should be within...

200-300 mL of each other

When is the fundus palpable at the umbilicus?

22-24 weeks

What is transfusion-related acute lung injury (TRALI)?

The leading cause of transfusion related deaths, arises during or within 6 hrs of transfusion. Signs and symptoms: fever, chills, hypotension, tachypnea, frothy sputum, dyspnea, hypoxia, respiratory failure, and noncardiogenic pulmonary edema. Leukoreduction diminishes this risk with a known history of transfusion reactions.

A grade IV ulcer involves...

The muscle, bone, and joint tissues.

A grade III ulcer involves...

The muscular tissue.

What is placenta previa?

The placenta is implanted near or over the cervical os. Sx include painless, sudden, profuse bleeding in the third trimester.

Which finding indicates to the nurse that the client's Salem sump tube (nasogastric) is functioning effectively?

The presence of hissing sound from the blue lumen tube; indicative that air is freely exiting the airway, purpose is to provide continuous steady suction without pulling gastric mucosa.

A client has hemodynamic monitoring using a Swan-Ganz catheter. The nurse is aware this type of monitoring will provide which information?

The pressure in the ventricles (CVP reading)

When does alcohol withdrawal begin after last drink?

4-6 hours; symptoms include tremors, agitation, anxiety, insomnia, mild tachycardia, hypertension

What is a normal respiratory rate for a neonate?

30-40 breaths per minute

What are normal respirations for a newborn?

30-60

What is a normal respiratory rate for a new born?

30-60 per minute, may be short; less than 20 seconds of apnea; obligatory nose breather

How many additional calories are suggested during pregnancy?

300/day

For CPR, what is the compression to ventilation rate adult/infant/child?

30:2

What is the average head circumference of a neonate?

32-36 cm

What is the maximum daily dose of ibuprofen?

3200 mg/day

When is a fundus palpable at the xiphoid process?

38 weeks

For CPR, what is the compression ventilation rate for neonate??

3:1 for one rescuer and 30:2 for 2 rescuers

What is considered a high-fluid intake?

3L/day

What is a significant side effect of nitroglycerin?

Hypotension

What are signs of hypermagnesemia?

Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, paralysis, shallow respirations. Caused by CKD, excessive magnesium admin (OTC meds)

A client with a hemolytic transfusion reaction would experience what symptoms?

Hypotension, low back pain, elevated temp.

Oxygen therapy prevents...

Hypoxemia, which is secondary to hypovolemia.

What is rheumatic fever?

Inflammatory disease that occurs after group A beta-hemolytic streptococcal infection. Indications include: carditis, polyarthritis, erythema marginatum, subcutaneous nodules, chorea. Tx: penicillin

What is lyme disease?

Inflammatory disorder caused by a spirochete, spread by tick bites; Symptoms: flat, slightly raised red lesion, fever, fatigue, chills, muscle pain, progresses to joint pain, persistent fatigue, headache, stiff neck (flu-like symptoms). Tx w/antibiotic

What is pneumonia?

Inflammatory process resulting in edema of lung tissues, extravasation of fluid into alveoli causing hypoxia; indications: fever, leukocytosis, cough producing rust-colored, green or whitish-yellow sputum, dyspnea, pleuritic pain, tachycardia

What are the stages of wound healing?

Inflammatory response, epithelial proliferation, migration, remodeling; Complications: hemorrhage, infection, dehiscence, evisceration, fistula formation.

What is hepatic encephalopathy?

A brain dysfunction and damage caused by increase ammonia in the blood, results from severe liver disease. Eliminating dietary protein and administering abx decreases serum ammonia; Indications: progressive mental (thought process, insomnia) and motor disturbances (hand tremors); nursing care: assess neurological status, I/O, for infection, electrolytes, decrease protein in diet.

What is montelukast?

A bronchodilator used for the long-term control of asthma by decreasing the frequency of asthma attacks; is a leukotriene antagonist that decreases airway edema and smooth muscle constriction; not used to treat acute asthma attacks; takes several weeks to lessen the effects of chronic asthma.

What is magnesium sulfate?

A central nervous system depressant; side effect is oliguria

What is the earliest sign of increased ICP?

A change in level of consciousness

What is doxorubicin hydrochloride?

A chemotherapy drug; causes bone marrow depression. A fever is a sign of an infection and should be reported to the health care provider.

Diabetes insipidus is...

A deficiency of antidiuretic hormone (ADH) produced by posterior pituitary or decreased kidney response; symptoms include excessive urine output, excessive thirst, chronic, severe, dehydration

What are danger signs with pregnancy?

Leaking amniotic fluid, vaginal bleeding, severe headaches, abdominal pain, persistent vomiting/fever/chills, swelling in face and fingers.

What is an oculogyric crisis?

A dystonic reaction to certain drugs characterized by a prolonged involuntary upward deviation of the eyes. A healthcare provider should order an anticholinergic agent to correct this reaction.

What is wilms tumor?

A malignant neoplasm of the kidney and is the most common intra-abdominal tumor in children

What is edrophonium?

A medication that facilitates the transmission of impulses at the myoneural junction. Immediate but temporary relief of symptoms after an edophonium injection is diagnostic of myasthenia gravis.

How long should a nurse listen to bowel sounds before determining they are absent?

5 minutes in each quadrant

A client with Lupus should be in remission for how long prior to conceiving?

5 months, and 2 years after diagnosis

What is a normal ALT (liver)?

5-35 units

What is an appropriate amount of bloody drainage?

50 mL

How many extra calories a day does the nurse advise the clients to consume to support breastfeeding?

500

What is a normal calcium range?

8.5-10.6 mg/dL

Contractions should less than..

90 seconds in duration

What is a normal blood pressure for a child 1-4 years old?

90-99 mmHg/60-65 mmHg

What is phenelzine sulfate?

A monoamine oxidase inhibitor (MAOI). A hypertensive crisis may be precipitated by foods containing tyramine. A client should be taught to report problems associated with hypertension, such as a severe headache, dizziness, and fatigue.

What is neostigmine bromide?

A muscle strengthener; used to tx myasthenia gravis. Can also reverse the effects of anesthesia.

How do you determine the heart rate from a rhythm strip?

A 6 second strip (3 marks at the top) is obtained; the number of complexes is counted, then multiplied by 10

What is aminophyline?

A CNS stimulant, known to cause tachycardia, nervousness, restlessness, and nausea; must be used cautiously in clients with cardiac impairment

What is verapamil?

A Calcium channel blocker that sometimes causes headache, constipation, fatigue, and dizziness; non-narcotic analgesia is often prescribed to treat the headache; this adverse effect seems to diminish over time.

What is myelomeningocele?

A birth defect in which the backbone and spinal canal do not close before birth (Aka Spina bifida)

What is Butorphanol tartrate?

A narcotic; decreases rate and depth of respirations.

What is systemic inflammatory response syndrome (SIRS)?

May result from a variety of life-threatening conditions and the inflammatory response is activated, resulting in the release of inflammatory mediators, direct damage to the endothelium, hypermetabolism, increased vascular permeability, and activation of the coagulation cascade.

What is aortofemoral bypass?

Means of circumventing a clot in the femoral artery; blood flow is shunted from the proximal aorta to the distal femoral artery bypassing the clotted area.

What is a femoropoliteal bypass?

Means of circumventing a clot in the femoral artery; blood from is shunted from the proximal femoral to the distal popliteal artery bypassing the clotted area.

What diagnoses require airborne precautions?

Measles (rubeola), TB, varicella, disseminated zoster (shingles), All personnel wear N95-type respirator mask in room

What are signs of hypomagnesemia?

Weakness,irritability, tetany, ECG changes, delirium, convulsions, confusion, growth failure (children); caused by kidney impairment, malnutrition due to alcohol abuse or insufficient protein intake, prolonged diarrhea/vomiting, endocrine disorders.

What is Rubeola?

Measles, german measles; transmission by direct contact; indications: prodromal fever and malaise; followed by cough and koplik's spots on buccal mucosa 2 days before rash, erythematous maculopapular rash with face first affected, turns brown after 3 days when symptoms subside. Isolate until 5th day, maintain bedrest during first 3-4 days, airborne precaustion

What does MMR vaccinate against?

Measles, mumps, and rubella

What is presbyopia?

Affects client's over age 40, permanent loss of accommodation of crystalline lens of eye.

When does the Babinski reflex disappear?

After 1 year of age

What is macular degeneration?

Age related phenomenon that is imprecisely defined; characterized by the loss of central vision, the presence of yellowish exudate beneath the retinal pigment epithelium, blurred vision, and distortion of vision

Which foods have tyramine?

Aged cheese, yogurt, beer, wine

Integrity verses despair is appropriate for..

Ages 65 and older

What is venous thromboembolism (VTE)?

Aggregate of platelets attached to a vein wall; indications: pain in affected limb, localized edema of one extremity, possible warm skin over the affected area, possible fever, chills, and perspiration.

What are signs of serotonin syndrome?

Agitation, confusion, disorientation, anxiety, hallucinations, myoclonus, hyperreflexia, poor concentration, excessive sweating, fever, tremor, incoordination, death.

What is a complication of central catheters?

Air embolism; place client on left side and in Trendelenburg to trap air in right ventricle.

For a chest tube, when there is continuous bubbling in the water-seal chamber, it is indicative of what?

Air leaks, and need to check for location of leak, clamp tubing close to chest and check for bubbling, and then clamp tubing close to container and check for bubbling. Gentle bubbling is normal.

What is normal lochia 10 days postpartum?

Alba-yellow-white

What is aplastic anemia?

All formed elements of the blood depressed. Tx: bone marrow transplant.

What is indomethacin?

NSAID, can be ototoxic

If a client has carbon monoxide poisoning, what should you monitor for?

Altered mental status, decreased blood pressure, depressed ST segment on EKG, coma, pale-to reddish-purple skin, convulsions, and death

What is a holter monitor?

Ambulatory ECG monitoring; Pt is encouraged to resume normal activities during monitoring period

What does hypersecretion of the pituitary express itself?

Acromegaly, gigantism, and Cushing disease

What should you know about high-ceiling (loop) diuretics?

Act at loop of Henle to inhibit reabsorption of sodium, chloride, potassium, water; Adverse effects include agranulocytosis (decreased wbc), hypokalemia, orthostatic hypotension; Nursing considerations: admin in morning to prevent noctoria, monitor bp, I/o, potassium supplements, diet high in potassium

What are Heigh-Ceiling (loop) diuretics?

Act on the loop of henle to inhibit reabsorption of sodium, chloride, potassium, water; Hypokalemia is an adverse side effect; exp. Bumetanide, Ethancrynic acid, furosemide, torsemide

Which medications are contraindicated in head injuries?

Narcotic analgesics, causes CNS and respiratory depression, masks signs of increased intracranial pressure.

What is aortic stenosis?

Narrowing of the aortic valve.

What is pulmonic stenosis?

Narrowing of the entrance to the pulmonary artery

What is peripheral arterial disease?

Arterioclerosis, raynauds, buerger; indications: rubor, cool, shiny smooth hairless skin, cyanosis, ulcers, gangrene, impaired sensation, intermittent claudication, deceased peripheral pulses, bruit or thrill over site of occlusion.

What is rhinoplasty?

Nasal reconstruction (improve airway or cosmetic); often include packing to prevent bleeding, packing removed day after surgery; client must understand that breathing will be through mouth during recovery

What are symptoms of barbiturate withdrawal?

Nausea and vomiting, tachycardia, coarse tremors, seizures.

What is benztropine?

Antiparkinonian agent used to counteract the extra pyramidal adverse effects of antipsychotics

What is chlorpromazine?

Antipsychotic medication; complete blood counts, fasting blood glucose; cholesterol, and liver function studies should be monitored periodically; ADE: sedation, blurred vision, dry mouth, constipation, urinary retention, photosensitivity, and orthostatic hypotension. Pink urine is also expected.

What is Zidovudine?

Antiretroviral used to treat HIV infection; ADR: anemia, headache, anorexia, diarrhea, nausea, GI pain, paresthesia, and insomnia (temporary at start of therapy)

What is isoniazid?

Antitubercular used as first line therapy to treat active TB or as a prophylactic to treat clients exposed to TB. Do not combine with phenytoin, causes phenytoin toxicity

What is an obese BMI?

Anything over 30

How long must a diaphragm remain in place after intercourse?

At least 6 hours to be effective; can be inserted up to 6 hours before intercourse, but spermicide must be inserted into vagina with every intercourse

What are signs of hyponatremia?

Nausea, muscle cramps, increased intracranial pressure, confusion, muscular twitching, convulsions.

What is an initial adverse effect of estrogen?

Nausea; will subside after weeks of medication use, encourage to stick it out

The nurse explains insulin needs during pregnancy will change in which way?

Needs increase during pregnancy due to hormonal interference in glucose metabolism, decrease after delivery

Which are loop diuretics?

Bumetanide, Ethacrynic Acid, furosemide, torsemide

What should the nurse know about restraints?

Needs to assess and document need for restraints; consider and document use of alternative measures; health care provider's order required specifying duration and circumstances under which restraints may be used; remove restraints every 2 hours; assess for redness or excoriation.

A deceleration occurs when the FHR falls below...

Baseline for 15 seconds or more, followed by a return to baseline; An early deceleration occurs simultaneously with the contraction and is a reassuring sign

What is a sitz bath?

Bathing of perineum in warm or cool water; aids in healing and reduced discomfort; frequently used after childbirth for the episiotomy and may be used after perineal trauma or surgery

Which is a stimulant laxative?

Bisacodyl

What is one of the earliest signs of obstructed drainage tubing (urinary catheter)?

Bladder distention

What is Magnesium responsible for?

Bone formation, nerve conduction, smooth muscle relaxation, protein synthesis, enzyme activity, carbohydrate metabolism, cell membrane transportation.

What are adverse effects of chemotherapy?

Bone marrow suppression, N/V, altered immunologic response, impaired oral mucous membrane, stomatitis, fatigue; nursing considerations: monitor bleeding, avoid injections and rectal temps, prophylactic antiemetics

Which are LATE signs of increased ICP?

Bradycardia, decreased response to commands, decorticate posturing, decerebrate posturing, widening pulse pressure

What is respiratory distress syndrome?

Breathing disorder in newborn caused by underdeveloped lungs; signs and sx: expiratory grunt, nasal flaring, intercostal and xiphoid and chest wall retractions, tachypnea, tachycardia, cyanosis, seesaw respirations, fine inspiratory crackles; nursing considerations: place in prone position, administer oxygen

What are absence seizures?

Brief periods of loss of consciousness like daydreaming, more common in children

What is aminophylline?

Bronchodilator; It can treat asthma and other lung diseases. Causes rapid pulse and dysrhythmias.

Which medications are contraindicated with glaucoma??

Over the counter appetite suppressants, antihistamines, topical corticosteriods

What is methyldopa?

Centrally acting sympatholytic that reduces peripheral vascular resistance; adverse effects include drowsiness, sedation, orthostatic hypotension, bradycardia, and loss of libido; do not discontinue abruptly, ay cause hypertensive crisis; monitor for fluid retention.

What is the first stage, phase 1 (latent) of labor?

Cervix dilates 0-3 cm; contractions 10-30 seconds long, 5-30 mins apart, mild to moderate

Which ABG indicates respiratory?

CO2

What is the initial action when someone develops Vfib?

CPR

Which are food that promotes growth of footers?

Cabbage, turnips, spinach, and seafood.

What is important to know about gonorrhea?

Can cause pelvic inflammatory disease, which is one of the most common causes of sterility; tx w/ antibiotics

Which nursing measure is most important following cardiac catheterization?

Check extremities for pulses; following procedure, trauma to the vessels is a major concern

When the amniontic membrane ruptures, what is the nurses priority?

Check fetal heart tones to assess for fetal distress; assess for prolapsed cord

Cortisol is responsible for what action?

Converting proteins and fat into glucose, also an anti-inflammatory agent

What are nursing interventions for UTIs?

Culture and sensitivity, force fluids to 3,000 mL/day, encourage cranberry juice or other urinary acidifiers, administer antibiotics, teach females to void following intercourse, teach proper cleaning after defecation (front to back), void every 4 hrs even without urge

What is chloasma?

Darkened skin over forehead and around eyes during pregnancy

What is megaloblastic anemia?

Decrease in RBC that cause hemoglobin levels to be lower than normal; caused by deficiency of folic acid and vitamin B12

How would you describe Diabetes Type 2?

Decrease in ability of body to respond to insulin because of insulin resistance, decreased sensitivity of tissues to insulin.

What are symptoms of hypothyroidism?

Decreased activity level, sensitivity to cold, impaired skin integrity, decreased perception of stimuli, weight gain, alopecia, bradycardia, decreased metabolism, constipation, and fatigue.

What are indications of Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?

Decreased level of consciousness (cerebral edema, increased intracranial pressure), seizures, coma, sodium less than 120 mEq/L

What is preload?

Determined by the amount of blood returning to the ventricles from the venous and pulmonary systems; an increase in preload will increase contractility by increasing the stretch of the myocardial fibers

What is Reaction Formation?

Develops behaviors or emotions opposite from current, unacceptable emotions or behaviors; way of controlling unacceptable emotions or behaviors and keeping them out of awareness.

What is autonomic dysreflexia?

Develops in individuals with a neurologic level of spinal cord injury at or above T6; Causes an imbalanced reflex sympathetic discharge, leading to potentially life-threatening hypertension. Symptoms include severe headache, profuse sweating, and nasal congestion.

What is Dementia?

Develops slowly, causes impaired memory, poor judgment, impaired abstract thinking.

What is Hemoglobin A1C ?

Diagnostic test of serum to monitor the control of blood glucose levels over the past 120 days; no need to fast; normal value is less than 6% w/o diabetes, and over 7 indicates uncontrolled diabetes.

What symptoms is often associated with the onset of myasthenic crisis?

Difficulty speaking

What does DTaP protect against?

Diptheria, teatanus toxoid, and pertussis

What is nonmalefience?

Do no harm; requires nurses to protect patients from danger and to protect patients who cannot protect themselves.

What is important client education of SSRIs?

Do not stop abruptly; do not take with MOAIs; may take several weeks for effects.

Which is a surfactant laxative?

Docusate

What is preoxygenation?

Done before anesthetic induction and tracheal intubation is a widely accepted maneuver, designed to increase the body oxygen stores and thereby delay the onset of arterial hemoglobin desaturation during apnea.

What is bromocriptine?

Dopamine promoter. It can treat menstrual problems, growth hormone overproduction, Parkinson's disease, and pituitary tumors. Should be taken with meals to prevent GI upset.

What is diplopia?

Double vision, seeing two images of everything at the same time.

What is a drain?

Drainage system (open or closed) placed to provide exit route by gravity or vacuum for air, blood, and other material following surgery; Nursing considerations: monitor characteristics, record I/O, secure placement.

What are indications of anorexia nervosa?

Dramatic weight loss, distorted body image, fear of obesity, anemia, amenorrhea, endocrine dysfunction, hypothermia, electrolyte imbalance, gastric complications, denial/fear of sexuality. 4-40% clients with this diagnosis die from self-imposed starvation and its sequelae, involving fluid electrolyte imbalance and multiple organ system failure.

Which are adverse effects of anti anxiolytics?

Drowsiness, sedation, lethargy, confusion, orthostatic hypotension, increased depression, leukopenia, anemia, delirium, abdominal cramping.

What are adverse effects of SNRI used to treat depression, GAD, panic disorder, social anxiety and ADHD?

Dry mouth, constipation, decreased appetite, N/V, weight loss, suicidal thoughts, behavior changes, mood swings, urinary retention, fatigue, orthostatic hypotension, hypertension, erectile dysfunction, dysmenorrhea, hallucinations, and prolonged QT interval.

What is atherosclerosis?

Due to accumulation of fat, neutrophils, macrophages, and platelets in the intima and media layers of the arteries; nursing care: identification of risk factors, education about lifestyle changes, and education about medications.

What complication should you attempt to prevent after a gastrectomy?

Dumping syndrome (occurs when food, especially sugar, moves from your stomach into your small bowel too quickly)

What are indications of hypopituitarism (hyposecretion of the pituitary gland)?

Dwarfism, hypogonadism, diabetes insipidus, Addison disease, syndrome of inappropriate antidiuretic hormone; Pts usually have fine skin and delicate features.

What are signs of left-sided heart failure?

Dyspnea, orthopnea (discomfort with breathing), cough, crackles, tachycardia, fatigue, anxiety, restlessness, confusion. (left flows to body, but backs up in lungs)

What is left sided heart failure symptoms?

Dyspnea, orthopnea, cough, crackles, tachycardia, fatigue, anxiety, confusion, restlessness

It is important for the nurse to monitor a client with Addison's disease for the development of which condition?

Dysrhythmias due to hyperkalemia

What are indications for a cesarean birth?

Dystocia, repeat cesarean, breech presentation, fetal distress, active gonorrhea or herpes type 2 infection, placenta previa, abruptio placenta

What does a central venous pressure (CVP) measure?

Effective blood volume and efficiency of cardiac pumping. Normal range is 2-8 mm Hg. High indicates hypervolemia or fluid volume overload.

What is calcium gluconate?

Electrolyte replacement and used in hypocalcemia; ADE: dysrhythmia, constipation, cardiac arrest.

What is a cardiac pacemaker?

Electronic apparatus used to initiate heartbeat when the SA node is seriously damaged and unable to act as a pacemaker.

How to promote bowel elimination?

Encourage diet high in fiber (fruits, vegetables, nuts, whole grains) and cellulose for bulk (whole wheat bread, fruits, other grains), daily fluid intake of 2,000-3,000 mL, engage in exercise to improve muscle tone and GI motility, encourage client to establish regular time for defecating.

What is the procedure for enteral tube feeding?

Ensure feeding is at room temp, elevate head to at least 30 degrees, verify tube placement, check for gastric residual, return residual to stomach unless greater than 100 mL, flush tubing w/30 mL water, initiate feeding, flush tubing with 30 mL water.

What is a deep partial-thickness or second degree burn?

Epidermis affected deeper than 1/3 of dermis. Painful, red/white, moderate edema, blisters are rare. Exp. Scalds, flames, grease, chemicals, prolonged contact with hot objects.

What is a superficial partial-thickness or second degree burn?

Epidermis affected to 1/3 of dermis, intact blood supply. Painful, red, exudes fluid, edema, blistered. Exp Scalds, flames, brief contact with hot objects.

What is a superficial or 1st degree burn?

Epidermis affected, blanches with pressure. Painful, red, dry, minimal or no edema. Exp sunburn, flash burns.

What is a duodenal ulcer?

Erosion of the mucosal wall of the duodenum; epigastric pain is the most common symptom; pain occurs 2-3 hours after eating, and food intake relieves the pain. Nursing care: eat 3 meals a day, avoid coffee/alcohol/caffeine, decrease stress, stop smoking.

What is cold stress?

Excessive heat loss in newborns; indications: increased respirations, mottling of skin or cyanosis, abnormal blood gases (metabolic acidosis); nursing considerations: maintain heated environment

What is a laissez-fair leader?

Exerts little or no control or direction in planning, decision-making, or action; gives support when it is requested; emphasizes the group.

What is decerebrate posturing?

Extensor response: Hands pushed to sides and body hyper-extended. Arms are stiffly extended, adducted & hyperpronated. Hyperextension of the legs with plantar flexion of the feet. (May indicate more serious brainstem damage.)

A diet high in calories includes....

Extra servings of carbs, found in whole grains, vegetables, legumes (peas and beans), potatoes, fruits, honey, starches, and refined sugar

Which are adverse effects of antipsychotics?

Extrapyramidal symptoms, pseydoparkinsonism, akathisia (inability to sit still), tardive dyskinesia, agranulocytosis (low WBC)

What is a swan-ganz catheter?

Flexible catheter inserted into pulmonary artery to determine intracardiac pressures, oxygen saturations, and other hemodynamic parameters. Normal pulomary artery pressure 20-30 systolic, 8-12 diastolic

What is decorticate posturing?

Flexion and adduction of upper extremities, extension and internal rotation of lower extremities, plantar flexion of feet, flexion of hands

Which are sulfonylureas for diabetes?

Flipizide, glimepiride, glyburide

The nurse cares for the client diagnosed with type 1 diabetes. The nurse identifies which is the primary cause of dehydration in the client with DKA?

Fluid loss due to osmotic diuresis

What is the treatment for Syndrome of Inappropriate Antidiuretic Hormone (SIADH)?

Fluid restriction (500-600mL/24hrs); sodium replacement; diuretics; Nursing considerations include daily wt, neuro checks, I/o, check electrolytes, position flat in bed.

How might dyes make one feel?

Flushing, warmth, metallic taste

What is Salmonellosis?

Food borne illness caused by improperly cooked shrimp, eggs, beef, pork, lamb. Onset is 1-3 days. Indications: N/V, diarrhea, abdominal cramps, fever, and chills.

Why are newborns given vitamin K at birth?

For bleeding due to newborn's inability to produce vitamin K the first few days, vitamin K produced in GI tract after microorganisms introduced, able to produce vitamin K by day 8

The nurse understands that risk management, within the context of managed care, focuses on which principle?

Prevent and minimize institutional and treatment factors that could lead to legal liability.

What is hordeolum (sty)?

Furuncle of the margin of the eyelid originating in the sebaceous gland of an eyelash; encourage pt to see healthcare provider for treatment

What are somatic indications of depression?

GI distress, change in appetite, pain, irritability, sleep disturbances, lack of energy, changes in sex drive, palpitations, dizziness.

Extensive burns results in...

Generalized body edema in both burned and non-burned tissue, an increased heart rate due to catecholamine release and the hypovolemia and dehydration due to the evaporative fluid loss.

What is Turner Syndrome?

Genetic abnormality resulting from a female having only one X chromosome. Clinical manifestations include short stature, webbed neck, low posterior hairline, and shield-shaped chest.

What is Phenylketonuria (PKU)?

Genetic disorder caused by a deficiency in liver enzyme phenylalanine hydroxylase. The body cannot metabolize the essential amino acid phenylalanine and is allowed to accumulate in the blood. Treatment includes dietary restrictions of foods containing phenylalanine: meat, milk, eggs, beans, bread.

What is a long-term side-effect of phenytoin?

Gingival hyperplasia

What is sickle cell disease?

Hereditary (Autosomal recessive), chronic, severe condition of abnormal hemoglobin distorting erythrocytes, increasing fragility, causing cells to become sickled in shape and rigid. Indications include, systemic, chronic anemia (6-9 g/dL), possible growth retardation, delayed sexual maturity, pain often in joints, swelling, jaundice, priapism, impaired kidney function, cardiac murmurs, altered pulmonary function, increased susceptibility to infection. Nurse considerations: promote adequate hydration

What is Cystic Fibrosis (CF)?

Hereditary dysfunction of exocrine glands causing obstructions because of flow of think mucus; diet should be high in protein; pancreatic enzymes need to be replaced.

What diet promotes wound healing?

High in protein, fat, carbs, vitamins (especially A, C, E), and minerals (including zinc).

What ABG values indicate bases?

High pH, low, CO2, high HCO3

What are signs of respiratory alkalosis?

High pH, normal bicarb, low CO2; Results from hyperventilation due to anxiety or response to respiratory stimulant; Indications: deep, rapid breathing, lightheadedness, spasms of hands and feet, muscle weakness.

What is one of the first signs of an increase in the intracranial pressure in infants?

High pitched cry

What is a diet needed for a client with cystic fibrosis?

High protein and calories

Which nutrition plan is indicated after surgery to promote wound healing?

High protein, vitamin c, and high calories

What are indications of substance withdrawal in the newborn?

High-pitched cry, hyperreflexia, decreased sleep, diaphoresis, tachypnea, restlessness, tremors, uncoordinated sucking; withdrawal occurs from 12-24 hours up to 7-10 days after birth

When using gravity drip, piggyback fluid level needs to be...

Higher than primary infusion

What is the most common cause of mitral valve problems?

Hx of rheumatic fever with a subsequent complication of carditis, which affects the valve

What are symptoms of hyperthyroidism?

Hyperthermia, heat intolerance, hypermetabolism (avoid stimulants), increased appetite, frequent mood swings (irritability and nervousness). 75% caused by graves disease which leads to exophthalmos so must keep eyes moist or sunglasses to protect cornea.

The emergency room nurse knows which cause most frequently is associated with tetany (involuntary contraction of muscle)?

Hypocalcemia

What can precipitate digoxin toxicity?

Hypokalemia

What is a major adverse reaction of thiazide diuretics?

Hypokalemia

What is hypothyroidism?

Hyposecretion of thyroid hormone; may develop myxedema (non-pitting edema in periorbital area, hands, feet). Causes slowed physical and mental functions.

What is important to know about prednisone?

Important to increase and decrease this medication gradually to minimize the reaction to the body to the sudden gain or loss of exogenous steroids.

What the medical definition of infertility?

Inability to conceive after at least one year of unprotected intercourse.

What is Introjection?

Incorporation of outside world into perception of self.

An acceleration is...

Increase in fetal heart rate above baseline by 15 or more beats for 15 or more seconds for 2 minutes or less with return to baseline- usually indicates fetal well-being

What is multiple myeloma?

Increase in plasma cells; increased number in bone marrow causes overproduction of antibodies. Manifestations: bone pain, fractures, and infiltration and necrosis of vital organs; complications: infection, kidney injury or disease, bleeding problems.

What are physiological signs that a patient is in pain?

Increased blood pressure and pulse, rapid irregular respirations, pupil dilation, increased perspiration, increased muscle tension, apprehension and irritability, grimacing, guarding, verbalizations of pain, crying in infants and children.

What are signs indicative of metabolic alkalosis?

Increased pH, elevated bicarb, rising partial pressure of CO2; Manifestations: anxiety, irritability, tetany, seizures, paresthesia, hyperreflexia, muscle cramping and twitching, decreased respiratory effort. Results from: excessive intake of bicarbs, carbonates, admin of blood transfusion, TPN, prolonged vomiting, NG suctioning, thiazide diuretics.

What is chronic lymphocytic leukemia (CLL)?

Increased production in blast cells causes abnormal WBCs to outspace the production of normal blood cells in the bone marrow and lead to spleen and liver enlargement. Signs/symptoms: leukocytes exceeding 100,000, painful splenomegaly and hepatomegaly, decreased perfusion leading to the brain causing confusion and restlessness, SOB, malaise

What are symptoms of hypovolemic shock?

Increased pulse, decreased BP, pallor, diaphoresis, moist cold skin, oliguria, hyperpnea, metabolic acidosis, and altered sensorium. Nursing responsibilities: ensure patent airway, maintain breathing and circulation, IDC, lab tests, elevate feet slightly, maintain body temp.

Which factor contributes to increased insulin resistance in type 2 diabetes?

Increased waist size

Client's with chronic kidney disease are in danger of...

Increasing their blood urea nitrogen (BUN) due to the inability of the kidneys to excrete the by-products of protein metabolism.

What is "third spacing"?

Indication of movement of fluid from the two main fluid compartments of the body (intracellular and intravascular) into the "third space" known as the interstitial area.

What is infective endocarditis?

Infection of the heart lining and valves; Signs include fever, malaise, back and joint pain, splinter hemorrhages under fingernails and toenails, petechiae in conjunctiva and mucous membranes, heart murmur.

What is otitis media?

Infection of the middle ear; often proceeded by upper respiratory infection; indications: fever, chills, headache, sense of fullness in ear, sharp pain, head rolling, irritability, N/V; nursing considerations: position on side of involved ear to promote drainage, bottle or breast feed with infant in upright position

What is tuberculosis?

Infectious disease of insidious onset, primarily affects lungs; Indications: fatigue, lethargy, anorexia, weight loss, low-grade fever, and productive cough with mucopurulent sputum. Tx 9 month regimen of isoniazid combined with streptomycin, ethambutol, rifampin, or pyrazinamide.

What is diverticulitis?

Inflamed intestinal diverticula; indications: LLQ abdominal pain increasing with coughing, lifting, and bending, fever, vomiting, diarrhea, abdominal distention, elevated WBC count; Nurse care: bed rest, avoid increased intra-abdominal pressure, NPO status progressing to clear liquid, progressive to high fiber diet.

What is mastitis?

Inflammation of milk duct of breast

What is peritonitis?

Inflammation of part or all of parietal and visceral surfaces of abdominal cavity; indications: abdominal pain, abdominal rigidity and distention, rebound tenderness, N/v, increased temp, leukocytosis, paralytic ileus.

What is acute epiglottitis?

Inflammation of the epiglotitis. Life threatening concern; drooling occurs because of difficulty swallowing. Child may be apprehensive or anxious, should be transported to hospital sitting in an upright position to aid in breathing

What is gastroenteritis?

Inflammation of the mucous membrane of the stomach and intestinal tract. Symptoms: diarrhea of varying intensity, abdominal distention, pain, cramping, N/V, anorexia, hyperactive bowel sounds. Nursing care: admin fluids and electrolytes

What is pancreatitis?

Inflammation of the pancreas; indications include severe abdominal pain, often radiating to the back, N/V, fever, jaundice, confusion, hyperglycemia, weight loss (chronic), diabetes (chronic), and steatorrhea (oily stool) (chronic); nursing considerations: NPO, monitor NG tube, F/E, place in semi-fowler for pain relief, knees flexed, encourage bedrest to decrease metabolic rates.

What is mastoiditis?

Inflammation or infection of the mastoid sinuses, often follows otitis media, causes pain behind the ear; mastoidectomy is the removal of the mastoid sinuses to tx infection not responding to medication (complications may include facial nerve damage, paralysis, or swallowing difficulty)

What is Ulcerative Colitis?

Inflammatory condition of colon characterized by eroded areas of mucous membrane and tissues beneath it. Indications: rectal bleeding, blood, pus, mucus in stool, may have 20-30 diarrhea stools daily, abdominal pain occurs pre-defecation, nutritional deficit.

Cystic fibrosis is ..

Inherited by an autosomal recessive gene

What are thiazide diuretics?

Inhibit reabsorption of sodium, chloride, potassium, water; lower diuresis than loop diuretics. Exp. Hydrochlorothiazide, Metolazone

What are osmotic diuretics?

Inhibit reabsorption of water in the kidney by creating osmotic pressure. Exp. Mannitol. Adverse effects: seizures, rebound increased ICP

What is good to know about thiazide diuretics?

Inhibits reabsorption of sodium, chloride, potassium, water; causes increase in uric acid and glucose; lower diuresis; INCREASE foods in potassium; Need to monitor for dysrhythmias if client taking digoxin. exp: hydrochlorothiazide

A primigravida diagnosed with type 1 diabetes reviews the insulin regimen with the nurse. The nurse reinforces the importance of regular prenatal care and explains changes in include requirements will include which changes?

Insulin requirements will increase during pregnancy and decrease after delivery.

What is parenteral nutrition?

Intensive nutritional support, excess of 2,500 kcal/day; usually given when client cannot ingest, digest, or absorb nutrients in oral foods. If given too rapidly, client experiences glucose overload and excessive diuresis with excretion of glucose, which pulls water with it by osmosis. May develop dehydration and shock, seizures.

What are indications of lead poisoning?

Irritability, sleepiness, N/V, abdominal pain, constipation/diarrhea, decreased activity, increased ICP (seizures and motor dysfunction), hematologic, kidney, CNS system effects; interventions: chelating agents, hydration, identify and remove source, preventive teaching

What is lactated Ringers?

Isotonic cystalloid that contains NaCl, KCl, CaCl, and Sodium lactate in sterile water. It is most similar tot he body's plasma and serum concentration and is especially great for burn victims or those with hypovolemia due to fluid shifts.

What is important to know about metoprolol?

It can mask the symptoms of hypoglycemia

What is important to know about Oxycodone terephthalate (Percodan)?

It contains aspirin (containdicated with bleeding disorders).

What is important to know about warfarin?

It has a prolonged action, duration is 2-5 days

What is right sided heart failure symptoms?

JVD, dependent edema, hepatomegaly, URQ tenderness, increasing hepatic dysfunction, ascites, anorexia, nausea, weight gain, weakness, respiratory distress, abdominal pain, altered liver function test, GI distress.

What are signs of right-sided heart failure?

JVD, dependent edema, hepatomegaly, right upper quadrant tenderness, increasing hepatic dysfunction, ascites, respiratory distress, GI distress. (right goes to lungs, but backs up in body)

What is the drug of choice for treatment of candidiasis (fungal infection due to any type of Candida (a type of yeast). When it affects the mouth, it is commonly called thrush.)?

Ketoconazole (Nizoral)

What is precipitous labor?

Labor pattern that progresses quickly and ends less than 3 hours after it began. The physiological risks include hemorrhage and amniotic fluid embolism.

Which is an osmotic laxative?

Lactulose, magnesium salts

What type of nutrition do burn patients require?

Large amounts of fluid, electrolytes, and protein. Increase calorie intake by 3-5 times (should increase baseline weight by up to 20%)

What type of acceleration/deceleration in relation to FHR is concerning?

Late deceleration (begins after a contraction has been established, usually at or after a peak) and indicates fetal hypoxia and acidosis usually results. As well as variable decelerations indicate cord compression (administer oxygen and discontinue oxytocin)

Which foods should a client avoid while taking warfarin?

Leafy vegetables that contain vitamin K.

What is tertiary intention wound healing?

Left open for several days before closure; allowed to finish closing by primary intention.

What is secondary intention wound healing?

Left open; closes, filling in from bottom up with scar tissue; severe scarring; longer time frame to heal.

What is a democratic leader?

Less controlling than autocratic leader; encourages participative planning and decision-making; offers suggestions; encourages independence; motivates with economic and personal satisfaction rewards.

What is normal capillary refill time?

Less than 3 seconds, anything greater indicates poor perfusion

When does the palmar grasp reflex disappear?

Lessens after 3 months

Which medication is given for hypothyroidism?

Levothyroxine (hormone replacement/augmentation)

Which medication is the drug of choice for premature ventricular contractions (PVC) occurring in excess of 6-10 per minute?

Lidocaine

What are nursing interventions after a myelogram?

Lie flat for several hours, encourage oral intake, and monitor vital and neurological signs.

A grade I pressure ulcer is...

Limited to the superficial epidermal and dermal layers.

Which are rapid acting insulins?

Lispro (humalog), aspart (novolog), glulisine (apridra)

What do albumin levels indicate?

Long-term nutritional status

Contractions should occur...

Longer than 2-minute intervals

Which type of insulin is cloudy, and should be drawn up second (clear before cloudy)?

Longer-acting insulin

Which are antianxiety medications?

Lorazepam, Oxazepam

What is apraxia?

Loss of purposeful movement in the absence of motor or sensory impairment; can affect ADLs

What is a continuous positive airway pressure (CPAP)?

Mode of ventilation for spontaneously breathing client; slight pressure is administered throughout respiratory cycle; prevents alveolar collapse during expiration.

What is a vaso-occlusive crisis?

Most common complication of sickle cell disease; painful due to hypoxia and necrosis of tissues or organ; occurs when sickled cells block blood flow to an organ or body part.

What is Pneumocystis jiroveci pneumonia (PJP)?

Most common opportunistic infection among individuals diagnosed with HIV. This form of pneumonia may be lethal and does not respond to typical antifungal treatment. Pentamidine is administered as a nebulized or injectable medication.

How do you calculate a drip rate?

Multiply the flow rate by the drop factor, divide by 60 mins.

What are indications of hypercalcemia?

Muscle weakness, lack of coordination, constipation, abdominal pain/distention. confusion, dysrhymthias

What are symptoms of hyperkalemia? (>5.0 mEq/L)

Muscle weakness, paralysis, nausea, diarrhea, dysrhythmias, EKG changes include heart block, prolonged PR intervals, flattened or absent P waves, and widened QRS complex.

The 3rd heart sound known as S3 is indicative of what condition?

Myocardial infarction

What PPE is used for airborne precautions?

N95 or higher respirator for healthcare professional

Damage to the parathyroids may cause a decrease in calcium (hypocalcemia), which could be manifested by...

Numbness, also causes tetany, seizures, and confusion.

Which blood type is the universal DONOR?

O, but can only receive O

What are nursing responsibilities for seizures?

Observe and document type and progress of seizure activity and postictal behavior; administer oxygen; suction at bedside. Post- position on back with head turned to side or position on side to prevent aspiration and promoting drainage of secretions.

What is pyloric stenosis?

Obstruction caused by hypertrophy and hyperplasia of pylorus; seen soon after birth. Indications: projectile vomiting, weight loss, diminished stools, palpable olive-shaped mass in epigastrium, peristaltic waves.

What is a pulmonary embolism?

Obstruction of the pulmonary artery; indications: pleuritic or anginal chest pain, acute dyspnea, restlessness, apprhension.

What does early deceleration on fetal monitoring indicate?

Occurs in response to compression of fetal head; uniform in shape corresponds to rise in intrauterine pressure as uterus contracts, does not indicate fetal distress.

What is fetal hypoglycemia?

Occurs most often due to gestational diabetes, mother has hyperglycemia and high levels of glucose cross the placenta, stimulates fetal pancreas to release insulin, and hyperinsulinemia results; indications: jitteriness, irregular respiratory effort, cyanosis, lethargy, twitching, seizure

A grade II ulcer involves...

Only the subcutaneous adipose tissue.

What is disseminated intravascular coagulation (DIC)?

Pathological form of coagulation that involves both bleeding and thrombosis; precipitated by septic shock, fate emboli, infection, trauma, cancer, abruptio placenta, retained expired fetus, toxins.

What is the best way to decrease joint pain in a vaso-occlusive crisis (Sickle cell crisis)?

Perform passive range of motion (to prevent contracture) and apply warm compress (vasodilate and increase circulation)

What is active immunity?

Permanent and results from an antigenic substance stimulating an individual's own antibody formation (e.g., tetanus)

What is preeclampsia?

Persistent elevation of systolic BP above 140 mm hg and diastolic above 90 mm Hg. Occurs between 20-40th week of pregnancy; indications 2+ to 3+ proteinuria, generalized edema; Promote bed rest, seizure precautions, adequate protein intake (restores osmotic pressure).

Which medication is for weightloss?

Phentermine (adipex-P)

Which are antiepileptic drugs?

Phenytoin, fosphenytoin, carbamazepine, valproic acide, gabapentin, lamotrigine, pregabalin

What is a known adverse effect of tetracycline?

Photosensitivity and client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure.

What is the most common cause of hypoglycemia?

Physical activity without food.

What is conjunctivitis?

Pinkeye; inflammation of the conjunctiva; indications: discharge, scratching or burning sensation, photophobia; nursing care: moistened compresses, instruct client to avoid sharing towels/toys/linens, wash hands before and after med admin

What is legionnaires' disease?

Pneumonia caused by legionell pneumophil found in warm, stagnant water and is spread by aerosolized route from environmental source to client.; nursing care: careful respiratory monitoring, assess for shock, provide oxygen, semi-fowlers, isolation not required

What is a potential complication of insertion of any central venous pressure line?

Pneumothorax especially a subclavian line

What is the primary cause of iron deficiency anemia?

Poor nutrition

What is venous insufficiency?

Poor venous return from the lower extremities to the heart; signs: edema, cool, brown skin, ulcers, pain, normal or decreased pulses.

What is visceral pain?

Poorly localized and dull, aching, burning, or cramping.

What are indications of fluid volume deficit?

Rapid weak pulse, rapid respirations, hypotension, weight loss, emaciation (state of being excessively thin and wasted), dry mucous membranes, increased urine specific gravity, increased hematocrit, sunken fontanels (infants), tenting (except in elderly), sunken eyes (children)

What is serotonin syndrome?

Rare, life-threatening event caused by SSRI. Sx include: abdominal pain, fever, tachycardia, hypertension, delirium, myoclonus, irritability, mood changes, and death.

What is methylphenidate?

Ritalin- Used to treat ADHD; Stimulates a portion of brian that helps a person pay attention and reduce hyperactivity

Which characteristics are most common in a pre-term newborn?

Red (due to lack of subq fat), wrinkled skin, lanugo (downy fine hair found on shoulders, forehead, cheeks), and hypotonic muscles (floppy, poor head control, limp extremities)

What foods should someone with gout avoid?

Red and organ meats, shellfish, oily fish with bones (should be on low-purine diet)

What food is high in B12?

Red meats, especially liver

What are indications of wound infection?

Redness beyond line of incision; increased pain; warmth, swelling; increased drainage may be purulent or foul smelling; fever, anorexia, malaise, leukocytosis; positive wound culture. Nursing considerations: monitor temperature, give broad-spectrum antibiotics, culture results, use contact precautions and aseptic technique, monitor drainage.

What is the goal of managed care?

Reduce health care costs; the focus is in client outcomes, it uses an interdisciplinary approach, employs clinical or critical pathways (Care maps) as foundations for care activities and timelines; monitoring activities pervade managed care.

What does positioning on the left side do for pregnant women?

Reduces compression on vena cava and aorta.

What happens approximately 48 hours after thermal injury?

Remobilization phase; the capillary permeability stabilizes and the interstitial fluid shifts back in the vascular compartment. Client then becomes hypervolemic and date for the client indicates this is happening: slightly increased bounding pulse, increased RR with SOB, crackles on auscultation, JVD, and a decreased hematocrit and BUN.

What is important to do after use of an inhaled glucocorticoid?

Rinse mouth to decrease the risk of candida infection.

What is the Dawn Phenomena?

Seen in diabetes; early morning fasting blood glucose elevation caused by nocturnal secretion of growth hormone

What potentially develops 24-48 hours following a thermal injury?

Shock; CVP and urine output decrease when a person is in shock. Normal CVP is 2-8 mm HG.

What is important to know about lead poisoning?

Should offer child milk as it contains calcium, calcium binds to lead and inhibits its absorption.

What materials should the nurse have at the bedside with a patient who has a chest tube?

Sterile connecter (to re-establish drainage system if disconnected), gauze pad (if chest tube dislodges, forming a seal so atmospheric air cannot get into the negative pressure thoracic cavity), and a padded clamp (briefly and with extreme caution to assess for possible air leaks and prior to removing chest tube)

What is Crohn disease?

Sub-acute and chronic inflammatory bowel disease involving segments of the terminal ileum and proximal colon, restrict absorption of nutrients. Symptoms include colicky lower right quadrant pain not relieved by defecation, diarrhea, weight loss, low-grade fever, nutritional deficit, fistulas (anorectal fissure or fistula).

What is an iridectomy?

Surgical procedure to manage glaucoma by removing part of the iris of eye to create new route for flow of aqueous humor through trabecular network and thereby decrease intraocular pressure.

What is a carotid endarterectomy?

Surgical procedure to remove obstruction from lower portion of internal carotid artery.

What should you know about infant cord care?

Surrounding skin needs to be kept clean, dry; keep open to air until falls off (usually 7-14 days); diaper folded below base; no baths until healed; report redness, edema, purulent drainage

What is myasthenia gravis?

Systemic disturbance of nerve impulse transmission, deficiency of acetylcholine at myoneural junction; indications: muscular weakness after repeated or sustained movements, muscles regain strength after rest, diplopia, weakness of facial muscles, dysphagia, respiratory distress in cholinergic crisis. Nursing intervention: patch eye in diplopia, give good eye care, provide environment free of stress, avoid precipitating factors, recognize symptoms of crisis (sudden inability to swallow, speak, or maintain patent airway).

What is a normal blood pressure for an adult?

Systolic less than 120 mm Hg and diastolic less than 80 mm Hg

What is important information about taking vitamins?

Taking the with something acidic increases the absorption of iron; taking them with food at bedtime decreases the possibility of nausea as the client will be sleeping.

What are signs of hyperphosphatemia?

Tetany, tachycardia, anorexia, N/V, hyperreflexia, muscle weakness, tingling in fingertips and circumoral, bone and joint pain, soft tissue calcification in lungs, heart, kidneys, cornea.

Which medication is an opthalmic vasoconstrictor and contraindicated with angle-closure glaucoma and should be used cautiously with hypertension?

Tetrahydrozoline

What is removed in a modified radical mastectomy?

The breast, axillary nodes, and superior apical nodes; major and minor pectoral muscles are preserved

What is basal body temperature?

The change in body temperature related to ovulation and discharge of the ovum; a slight drop occurs at the time of ovum discharge followed by a rise in temp when ovulation occurs (approx. 14 days prior to next menstrual period)

The visiting nurse instructs a client how to use esophageal speech following a total laryngectomy. Which of the following actions, if performed by the client, indicates teaching is effective?

The client swallows air and then eructates it while forming words with his mouth.

What is a normal pulse pressure?

The difference between systolic and diastolic BP and is 30-40 mm Hg

What is pulse pressure?

The difference between systolic and diastolic BP readings; serves as an indirect measure of cardiac output; a difference of 30-40 is considered normal

What is amiodarone?

The drug of choice for hemodynamically unstable ventricular tachycardia. This medication inhibits adrenergic stimulation and prolongs repolarization, allowing for a normal rhythm to occur.

What is a peer review?

The evaluation of an individual's practice by colleagues who have similar education and experience; purpose is to provide the individual with feedback from staff members who best understand the job requirements.

What is the fourth stage of labor?

The first 2 hours after the birth of the baby

When suctioning a bronchus in a pt with a trach....

The head should be position to the side opposite from that of the bronchus being suctioned

What is a general rule for spinal cord injuries?

The higher the injury, the more severe dysfunction/limitation (Cs in wheelchair, and inability to care for self at c4 and above) (Ts some independence but requires wheelchair) (Ls may use cane or crutches for ambulation)

What is oxytocin used for?

The induction of labor; It is extremely important for the nurse to continually assess contractions from client receiving this drip; if contractions occur too frequently (at interval of less than 2 mins) or last two long (more than 90 seconds) they may endanger client and fetus and infusion should stop

Which information does the nurse provide regarding the accuracy of a PKU (phenylketonuria) test?

The initial specimen should be collected as close to discharge as possible but not later than 7 days.

What is myocardial contractility?

The innate ability of the heart muscle to contract; produces changes in force

What is cardiac catheterization?

The insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes. May feel burning sensation when dye is injected, on bed rest for 8-12 hours after procedure with pressure dressing applied over catheter insertion, peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then every 4h, NPO after midnight before procedure

In sensorineural hearing loss...

The sound is heard better in the normal ear.

An acute kidney injury is...

The sudden cessation of kidney function caused by failure of renal system circulation or by glomerular or tubular damage. Three phases: oliguric (urine output less than 400 mL/day), diuretic phase, recovery phase

What is effacement?

The thinning and shortening or obliteration of the cervix

What is tactile fremitus?

The tremulous vibration, palpable over the posterior chest wall, which is produced when client says "99", it increases when lung consolidation exists such as pneumonia, and decreased when pleural effusion, pneumothorax, bronchial obstruction, and air-trapping occurs; Use ulnar and palmar surfaces.

What is important to know about penicillins and cephalosporins?

There is a cross sensitivity between the two

What is good to know about salt substitutes?

They often replace sodium with potassium, which can cause hyperkalemia

What is a mantoux test?

Tuberculin skin test; read in 48-72 hours; induration of 5 or more mm considered positive in high risk pts, induration of 10 mm or more in residents or employees of high risk places

What are Kaposi's sarcoma lesions?

Type of cancer that forms in the lining of the blood and lymph vessels. Tumors typically appear as painless purplish spots on the legs, feet, or face. Should be cleaned and dressed daily.

What is a myelogram?

Type of radiographic examination that uses a contrast medium to detect pathology of the spinal cord, including the location of a spinal cord injury, cysts, and tumors.

What is Sublimation?

Unconscious, replacing improper, immature, and damaging behaviors and impulses with socially appropriate, productive, and responsible behaviors.

What is a normal apical rate for newborns when they are crying?

Up to 180 bpm

What is important to know about carbonyl iron used to prevent iron deficiency in pregnancy?

Upright posture reduces the likelihood of esophageal corrosion; do not take the medication less than one hour before bedtime for the same reason.

What is the best way to teach a preschooler about a procedure?

Use puppet or doll.

What is lidocaine?

Used as an antidysrythmIc medication, decreases myocardial irritability and decreases myocardial automaticity.

What is controlled ventilation?

Used for clients who are unable to initiate a breath, such as clients with polio or Gillian barre; it delivers a set tidal volume of oxygen at a set rate; simpliest mode but is used less frequently than others

What is heparin?

Used for short-term therapy (IV or Subq); inactivates thrombin and prevents conversion of fibrinogen to fibrin; ADR: hemorrhage, thrombocytopenia, hypersensitivity. Nursing considerations: leave needle in place for 10 seconds after injection, don't massage

What is a clear liquid diet?

Used for surgical clients, clients experiencing vomiting or diarrhea; maintains fluid balance and requires minimal digestions; Exp. gelatin, ice pops, tea w/lemon, ginger ale, bouillion, fruit juice without pulp

What is metronidazole?

Used for trichomoniasis, bacterial infections, acne, rosacea. Avoid any alcohol, may have dark or red/brown urine, may have metallic taste, concurrent treatment for sexual partners

What is pursed lip breathing?

Used in COPD; as air i pushed against the small opening between the lips, the resistance created goes backwards and through the airways and pushes them open throughout expiration, also prolongs exhalation.

What is the lecithin/sphingomyelin (L/S) ratio?

Used to determine fetal lung maturity. A ratio of 2-2.5 indicates maturity

What is a schillings test?

Used to diagnose pernicious anemia; clients fast for 12 hours, given small dose of B12 orally followed by a large nonradioactive dose IM, 24 hour urine collected; if urine is not radioactive, the radioactive B12 stayed in the GI tract. Discard first void, and save all urine in one container thereafter and refrigerate or keep on ice. label container. If intrinsic factor is not secreted by the body, vitamin B12 cannot be absorbed.

What is an incentive spirometer used for?

Used to maximize lung expansion by opening closed alveoli and mobilizing secretions; prevents atelectasis

What is azathioprine?

Used to suppress immune function. It can prevent organ rejection after a transplant. It can also treat rheumatoid arthritis.

What is synchronized intermittent mandatory ventilation?

Used with clients who can breath spontaneously; tidal volume and ventilatory rate are pre-set; it differs from assist-control ventilation in that it allows spontaneous breathing at the rate and tidal volume of the clients themselves in between the mandatory ventilator breaths; ventilator breaths are synchronized to inspiratory efforts of client.

What is assist-control ventilation?

Used with clients who can breathe spontaneously but have weak muscles of respiration; tidal volume and ventilatory rate are pre-set; will deliver oxygen without client effort, but if client does inspire, it will respond to that effort.

What is cetirizine?

Used with seasonal and perennial allergic rhinitis, chronic uticaria. Give on empty stomach.

What is important to know about nitroglycerin?

Usually a total of three tablets are given in intervals of 3-5 minutes for chest pain; if there is no relief after the third dose, the client should seek medical attention immediately as they may be experiencing an MI.

What is toxic shock syndrome (TSS)?

Usually occurs in women less than 30 years of age, menstruating, using tampons; caused by staphylococcus aureus; indications: sudden fever, vomiting, diarrhea, myalgia, hypotension, diffuse rash.

Which medications, when taken with furosimide, can cause ototoxicity?

Vancoycin and digoxin

Which foods are allowed on a low-residue diet?

Well-cooked tender meats (lamb), fish, and poultry, milk and cheeses, juices without pulp (no prune juice), canned fruit and ripe bananas, white bread or refined bread.

What is the diagnostic test for HIV?

Western blot

An allergic reaction to blood transfusion would include what?

Wheezing, uticaria (hives), facial flushing, and epiglottal edema.

The nurse administers Rho(D) immune globulin to prevent complications in which client situation?

When a Rh-negative mother who delivers an Rh-positive baby when the baby has a negative coombs test.

What is an air embolism?

When air enters the circulatory system; in addition to respiratory distress, client may complain of chest pain, be hypotensive, and tachycardic; Administer O2, clamp catheter, place client on left side with head down and notify healthcare provider.

When are packed red blood cells transfused?

When blood RBCs are need but not the fluid (plasma)

When is platelets transfused?

When blood clotting is problematic.

What is digoxin toxicity?

When digoxin use leads to hypokalemia, leading to toxicity; Symptoms include abdominal pain, weakness, anorexia, nausea, vomitic, cardiac dysrythmias, and visual changes (blurred vision, haloes, diplopia); Eat foods high in potassium.

What is kernig's sign?

When hip is flexed to 90 degrees, complete extension of the knee is restricted and painful

When is it recommended to give sodium bicarbonate?

When pH is less than 6.9

What is Disulfiram?

When taken with alcohol, causes flushing, increased pulse, difficulty swallowing, headache, N/V, palpitations, hyperventilation, hypotension, respiratory depression. Used to manage chronic alcoholism.

What is neuroleptic malignant syndrome?

a life-threatening reaction that can occur in response to neuroleptic or antipsychotic medication. Symptoms include pallor, tachycardia, hypertension/hypotension, diaphoresis, fever, convulsions, loss of bladder control, respiratory distress, severe muscle stiffness, tiredness.

What level of theophylline is considered toxic?

above 20 mcg/L, 10-20 is normal

What is cystitis?

the medical term for inflammation of the bladder