SAUNDERS NCLEX REVIEW ( 1 )
Contraction stress test
A contraction stress test (CST) is performed near the end of pregnancy to determine how well the fetus will cope with the contractions of childbirth. The aim is to induce contractions and monitor the fetus to check for heart rate abnormalities using a cardiotocograph. Negative: (Normal finding) within 10 min period, three uterine contractions & no decels. Positive: (Abnormal finding) persistent and consistent decelerations on more than half the contractions. Cord or fetal head compression present.
Disequilibrium syndrome
Disequilibrium syndrome occurs most often in clients who are new to dialysis. It is characterized by headache（考）, mental confusion, decreasing level of consciousness（考）, nausea, vomiting, twitching, and possible seizure （考）activity. It results from rapid removal of solutes from the body during hemodialysis, with a higher residual concentration gradient in the brain because of the blood-brain barrier. Water goes into cerebral cells because of the osmotic gradient, causing brain swelling and the onset of symptoms. It is prevented by dialyzing for shorter times or at reduced blood flow rates.
Care of the client with mania
The client in the manic phase of the bipolar disorder needs to have limits set on behavior. During this phase, the client cannot understand reasoning. This also indicates a need for redirection or distraction when the client engages in inappropriate behavior. Decreasing stimulation will allow the client to rest. Because the client is constantly in motion, small frequent meals and finger foods are needed. DO NOT: Provide information on medications.(cos During this phase, the client cannot understand reasoning.)
drip factor calculation (一定要记住）
Volumn * drop factor(gtt/ml) ----------------------------------- = gtts/min Time in minutes
escharotomy
an incision made through burned skin to help with healing (the scab or crust that forms after a third degree burn is called 'eschar')
Signs/symptoms of a circulatory overload include:
1.dyspnea, precordial心前区 pain, wheezing, cyanosis, dry cough（考）, and distended neck veins（考）. （注：why can lead to dry cough: Congested lungs. A weak heart causes fluid to back up in the lungs. ... Lung congestion can also cause a dry, hacking cough or wheezing. Fluid and water retention.） 2.The licensed practical nurse is assisting the registered nurse (RN) in the care of a child who is receiving a blood transfusion and notifies the RN if the child displays which signs/symptoms of fluid overload? Select all that apply. --ANS: Dry cough(考） Disdended neck veins(考） 注： 没有chill, itching, back pain (见下方transfusion reaction) 3. Signs/symptoms of a transfusion reaction include chills, itching, rash, fever, headache, and pain in the back.
Client teaching points regarding the cardiac catheterization procedure.
A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms? --ANS: Chest pain(考） The client is taught before cardiac catheterization to immediately report chest pain or any unusual sensations. The client is taught that a warm, flushed feeling may accompany dye injection, occasional palpitations may occur, and the urge to cough（记） may occur as the catheter tip touches the cardiac muscle. The client may be asked to cough or breathe deeply from time to time during the procedure. Because a local anesthetic is used, the client should feel pressure, but not pain, at the insertion site.
epoetin alfa (Epogen).
Antianemic. Stimulates production of RBC's. Monitor bone pain The nurse is reinforcing instructions to a client regarding epoetin alfa (Epogen) that will be administered subcutaneously by the client at home. The nurse tells the client to do which action? --ANS: Refrigerate the medication(考）. The medication should be refrigerated but not frozen. The client should be instructed not to shake the medicine bottle. Syringes with a ⅝-inch needle are used to administer subcutaneous injections.
The complications of gastroesophageal reflux disease (GERD).
Aspiration（考） The primary symptom of GERD is heartburn, which is also called pyrosis胃灼热. Another symptom is regurgitation. The client reports the feeling of warm fluid traveling up the throat. If the fluid reaches the level of the pharynx, the client notes a sour or bitter taste in the mouth. This effortless regurgitation frequently occurs when the client is in the upright position. If regurgitation occurs when the client is recumbent, the client is at risk for aspiration. Belching may be a symptom of the disease.
Baclofen (Lioresal)--Muscle relaxant
Baclofen is dispensed in 10- and 20-mg tablets for oral use. Dosages are low initially and then gradually increased. Maintenance doses range from 15 to 20 mg administered 3 or 4 times a day.记：15 mg 4 times a day（考）
Addison's disease（与cushing 相反）
a condition that occurs when the adrenal glands do not produce enough cortisol or aldosterone
The procedure for assessing circulation in a newborn infant.
To assess circulation in an infant younger than 1 year, the nurse should check the brachial pulse（考）. If the child is older than 1 year, the carotid pulse（记） is palpated. The popliteal and femoral areas are not easily palpated in an infant because of the infant's body mass.
The purpose of an escharotomy 焦痂切开术.
Which should be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn? --ans: The return of distal pulses(考） Escharotomies are performed to alleviate the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn.
Boutonniere deformity 纽扣畸形（手指或脚趾）
can occur in rheumatoid arthritis. A boutonniere deformity is a deformed position of the fingers or toes, in which the joint nearest the knuckle is permanently bent toward the palm while the farthest joint is bent back away.
hallux valgus 拇指（脚趾）外翻 ['hæləks] 大拇指（脚趾） valgus ['vælgəs] 外翻
can occur in rheumatoid arthritis. A hallux valgus deformity is a deformity characterized by lateral deviation of the great toe. It is commonly called a bunion.
Swan neck deformity 天鹅颈畸形（手指）
can occur in rheumatoid arthritis. A swan neck deformity is a deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it.
Ulnar drift（考）小指（手指）偏移
can occur in rheumatoid arthritis. Ulnar drift occurs when synovitis stretches and damages the tendons, and eventually the tendons become shortened and fixed. This damage causes subluxation半脱位 (drift) of the joints.
Signs/symptoms of a transfusion reaction include
chills, itching, rash, fever, headache, and pain in the back.
Cellulitis.（compare to erysipelas)
is a skin infection into the deeper dermis and the subcutaneous fat（考）, usually caused by Streptococcus pyogenes
Belching 嗳气
the expulsion of gas from the stomach through the mouth.
Nissen fundoplication--for GERD 胃底折叠术
A surgical procedure to wrap the fundus of the stomach around the distal esophagus to prevent reflux of the stomach contents to the esophagus.
Signs/symptoms of ovarian cancer
include abdominal distention(考）, urinary frequency and urgency, pleural effusion胸腔积液, malnutrition, pain from pressure caused by the growing tumor and the effects of urinary or bowel obstruction, and constipation. Ascites with dyspnea and ultimately general severe pain will occur as the disease progresses. 注： Abnormal bleeding, often resulting in hypermenorrhea, is associated with uterine cancer.
Erysipelas [,erɪ'sɪpɪləs]("St. Anthony's Fire") 丹毒
is an acute, superficial, rapidly spreading inflammation of the dermis and the lymphatics. Occurs mostly on face and legs Predisposing factors: diabetes, alcoholism, HIV, immunocompromised
confrontational test
tests peripheral vision（考） （Confrontation visual field exam (Donders' test): having the patient looking directly at your eye or nose and testing each quadrant in the patient's visual field by having them count the number of fingers that you are showing. This is a test of one eye at a time.）
Inner ear problems
A client is diagnosed with a disorder involving the inner ear. The nurse caring for the client understands that which is the most common client complaint associated with a disorder involving the inner ear? --ans：Tinnitus（考） Tinnitus is the most common complaint of clients with otological耳科的 disorders, especially disorders involving the inner ear（记）. Symptoms of tinnitus range from mild ringing in the ear that can go unnoticed during the day, to a loud roaring in the ear that can interfere with the client's thinking process and attention span. Hearing loss may or may not occur. Pruritus and burning in the ear are not specifically associated with inner ear problems.
Procedures to follow for blood transfusion reaction
A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? --ANS: The blood bank( 考 ） （This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented）
Blood administration procedure
The nurse assesses the client's vital signs before the procedure to obtain a baseline（考) After beginning the transfusion, assess VS every 15 minutes (记）for the first half hour and every half hour thereafter.
