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NCLEX PN 2020
Terms in this set (264)
What is adenosine used for?
Antiarrhythmic used to treat supraventricular tachycardia.
What is dopamine used for?
A vasopressor used to treat symptomatic hypotension.
What is metoprolol used for?
Metoprolol is a beta blocker used for heart rate control in tachyarrhythmias.
Torsades de pointes
"Twisting of the points" usually do to a prolonged QT interval which is the result of electrolyte imbalances especially hypomagnesemia.
- Intubation and suction supplies should always be available at the bedside during GL in case the client develops aspiration or respiratory distress
- Performed through large bore (36 to 42 french)
- Client should be placed on side with HOB elevated.
- Should be initiated within one hour of overdose.
Done to detect the patency of ulnar artery.
CPR (cardiopulmonary resuscitation)
- 3O compressions to two rescue breathes.
- Hand placement is in the center of chest on lower half of the sternum.
- Compression rate of 100 to 120/min
AED placement for ≤ 8 years old
One AED pad on chest and one on back.
Why is suprapubic pressure applied during pregnancy?
It helps dislodge an impacted anterior shoulder from under the client's pubic bone in the event of shoulder dystocia.
A systematic approach to palpating the pregnant abdomen to identify fetal presentation.
Consists of sharply flexing the thigh onto the maternal abdomen to straighten the sacrum. It is used for shoulder dystocia.
How does the palm of your hand appear during negative Allens test?
It does not turn pink and remains pale.
What food allergies increase the risk for latex allergies?
Avocado, Banana and tomato.
Gravida, Term, Preterm, Abortion, Living.
The number of times a woman has been pregnant regardless of outcome.
The number of pregnancies delivered at 37 w 0 d gestation & beyond.
The number of pregnancies delivered from 20 w 0 d gestation through 36 w 6 d gestation.
The number of pregnancies ending before 20 w 0 d gestation; these may be spontaneous (miscarriage) or induced abortions.
The number of currently living children.
Peripheral cyanosis that is considered normal during the first day of life or up to 7-10 days after birth if the infant becomes cold.
A system for the assessment and rating of cervical favorability and readiness for induction of labor.A higher Bishop score indicates an increased likelihood of successful induction that results in vaginal birth.
What is the average newborn head circumference?
13-14 inches (33-35cm)
S/S of pyelonephritis
- Fever and chills
- Flank pain
- Costovertebral tenderness
Important foods during pregnancy.
Foods containing folic acid, protein, whole grains, iron, and omega-3 fatty acids are especially important.
Supine hypotensive syndrome
Occurs when the weight of the abdominal contents compresses the vena cava, causing decreased venous return to the heart.
A systemic disease characterized by hypertension and proteinuria after the 20th gestational week with unknown etiology.
The onset of convulsions or seizures that cannot be attributed to other causes in a woman with preeclampsia. Delivery is the only cure for preeclampsia-eclampsia syndrome.
A central nervous system depressant used to prevent/control seizure activity in preeclampsia/eclampsia clients. Therapeutic level is 4-7 mEq/L.
Medication used to lower bp during preeclampsia.
- Hydralazine (Apresoline)
- methyldopa (Aldomet)
- labetalol (Trandate) is used to lower blood pressure (BP) if needed (usually considered when BP is >160/110 mm Hg).
Medications used to suppress contractions in preterm labor. Examples: terbutaline, magnesium sulfate, indomethacin, nifedipine.
A severe form of preeclampsia.
Hemolysis,Elevated Liver enzymes,Low Platelet count.
s/s of HELLP syndrome
RUQ pain, nausea, vomiting, and malaise.
A benign skin discoloration most often seen in newborns of ethnicities with darker skin tones (eg, African American, Native American, Hispanic, Asian).
*Fade over first 1-2 years of life.
*Measure and document area.
VBAC (vaginal birth after cesarean)
Have a slightly increased risk for uterine rupture due to previous surgical scarring of the uterus.
Signs of uterine rupture
-Abnormal fetal heart rate patterns.
-Constant abdominal pain.
-Loss of fetal station.
- Sudden cessation of uterine contractions.
What is an immediate intervention to help control ADHD?
What is the drug of choice for treating ADHD. Not used on a PRN basis. Administered daily in 2-3 divided doses 30 -45 min before meals.
What is the legal criteria for involuntary admission?
- The individual appears to be an imminent danger to self or others.
-The individual has a grave disability(unable to adequately care for basic needs) as a result of a mental illness.
borderline personality disorder(BPD)
To avoid being abandoned, they use manipulation and control, often unconsciously, to prevent a person from leaving. The manipulative behavior may be of a positive nature, such as the use of flattery, or a negative nature, such as distancing from the other person.
Caregiver role strain
A caregiver's perception of the multifactorial difficulties associated with providing care to another person (usually a family member).
What are some signs of caregiver role strain?
*All physical, emotional and social
Fatigue, depression, isolation etc.
How do you choose activities for children with intellectual disabilities.
Based on the child's developmental age with consideration given to size, coordination, physical fitness, maturity, likes and dislikes, and health status.
A positive symptom of schizophrenia. Delusions are false beliefs that have no basis in reality and are unrelated to a client's culture or intelligence.
Delusion of grandeur (grandiose)
The false belief in one's own superiority, greatness, or intelligence. Ex: "I need to get to Washington for my meeting with the president."
Delusion of control
False belief that a person's will, thoughts, or feelings are being controlled by external forces. Ex: "Don't drink the tap water. That's how the government controls us."
The individual has a false idea that the self, a part of the self, others, or the world is nonexistent. Ex: "It doesn't matter if I take my medicine. I'm already dead."
He or she believes that he or she has a physical defect or medical problem. Ex: "The doctor said I'm fine, but I really have lung cancer."
When someone experiences some perception related to touch when it is not really there
Hearing voices, noises, music, or sounds that are not there.
False, persistent beliefs that one is being pursued by other people
Delusions of reference
Delusions of reference cause clients to feel as if songs, newspaper articles, and other events are personal to them. Ex: "That song is a message sent to me in secret code."
Clinical Manifestations of anorexia nervosa
Extreme weight loss, amenorrhea, bradycardia, cold intolerance, dry skin, and lanugo.
What are the three categories of PTSD symptoms?
Reexperiencing the traumatic event, Avoiding reminders of the trauma, increased anxiety and emotional arousal.
An atypical antipsychotic medication used to treat schizophrenia. Associated with a risk for agranulocytosis. *Pretreatment assessment and ongoing monitoring of WBC and absolute neutrophil counts are critical.
What are some potential side effects of clozapine?
Prolonged QT interval, orthostatic hypotension, Hyperglycemia, dyslipidemia, and weight gain.
Nursing care plan for clients with acute mania include:
Providing a quiet, structured, non-stimulating environment; engaging the client in one-on-one and physical activities; limiting contact with other people; and providing foods of high nutritional value that are easy to eat.
Helpful strategy for client with suicide ideation:
Safety planning is a helpful strategy to support a client with suicidal ideation. The safety plan should include strategies for making the environment safe, how to identify and cope with signs of an impending crisis, and carrying a list of people, mental health agencies, and hotlines the client can contact for help.
Stages of Change Model
Precontemplation, contemplation, preparation, action, maintenance and Termination
Major depressive disorder
Also known as unipolar depression is a subtype of depressive disorder, classified by specific symptoms that interfere with the ability to perform activities of daily living, work, sleep, and enjoy activities that are usually pleasurable to the client.
S/S of major depression
Sleep (increased or decreased)
Interest deficit (anhedonia)
Guilt (worthless, hopeless)
Appetite (increased or decreased)
Psychomotor retardation or agitation
What are the 2 key clinical features of major depressive disorder?
Depressed mood or loss of interest or pleasure. *Must be present everyday for atlas 2 weeks to dx.
Borderline Personality Disorder (BPD)
Clients diagnosed with borderline personality disorder (BPD) often make suicidal threats, gestures, and attempts. They may use these behaviors to bring about a response when there is a real or perceived risk of abandonment from a significant other.
Made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: "I would like to have a phjinox."
literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, "The grass is always greener on the other side," would be interpreted to mean that the grass somewhere else is literally greener.
Rapid shifting from one idea to another, with little or no connection to logic or rationality
Repetition of words, usually uttered by someone else
Going from one topic to the next without getting to the point of the original idea or topic.
A mix of words and/or phrases having no meaning except to the client. Example: "Here what comes table, sky, apple."
Rhyming words in a meaningless, illogical manner. Example: "The pike likes to hike and Mike fed the bike near the tyke."
Repeating the same words or phrases in response to different questions.
Lifestyle measures that help prevent GERD.
- No alcohol, caffeine, chocolate, peppermint and high fat foods.
- Small frequent meals.
- Discontinue tobacco products.
What are some potential complications of acute diverticulitis.
- Abcess formation (continuous fever despite antibiotics and palpable mass)
- intestinal perforation resulting in diffuse peritonitis (progressive pain in other quadrants of the abdomen, rigidity, guarding and rebound tenderness)
S/S to expect with acute diverticulitis.
-Bleeding with bright red blood in stool.
- Fetal position.
-leukocytosis (11,000 wbc)
What position does a person with peritonitis prefer?
They prefer to lie still and take shallow breaths to avoid stretching the inflamed peritoneum.
The client may experience acute pain (usually in the left lower quadrant) and systemic signs of infection (eg, fever, tachycardia, nausea, leukocytosis).
What is RAI?
RAI is the primary treatment for nonpregnant adults with hyperthyroid disorders such as Graves' disease (a type of autoimmune hyperthyroid disease). RAI damages or destroys the thyroid tissue, thereby limiting thyroid secretion, and can result in hypothyroidism. Clients need to take thyroid supplementation (levothyroxine) for life. The use of RAI is contraindicated in pregnancy and could cause harm to a fetus.
What may occur after an RAI treatment?
Radiation thyroiditis and parotitis, which cause dryness and irritation to the mouth. The nurse can teach the client to take sips of water frequently or to use a salt and soda gargle solution 3-4 times daily to relieve these symptoms.
S/S of acute appendicitis
-Pain: Beginning in the per umbilical region, moves to right lower quadrant centering at Mcburney's point.
- GI symptoms: Anorexia, nausea and vomiting.
- Rebound tenderness and guarding.
How do clients with acute appendicitis attempt to decrease pain?
By avoiding intrabdominal pressure from coughing, sneezing, and deep inhalation and lying still with right leg flexed.
What is the best way to prevent unwanted pregnancy after a vasectomy?
By using alternative birth control until cleared by a health care provider.
S/S of dumping syndrome
This results in hypotension, abdominal pain, nausea/vomiting, dizziness, generalized sweating, and tachycardia. The symptoms usually diminish over time.
What are some atypical symptoms of a heart attack.
Nausea, vomiting, belching, indigestion, diaphoresis, dizziness, and fatigue.
Where is the point of maximal impulse in a cardiac pt.
4th and 5th intercostal space.
What is the purpose of thiamine?
It is prescribed to alcoholic pt's to prevent Wernicke encephalopathy.
What are some classic symptoms of a DVT?
- Unilateral leg edema.
- local warmth.
- Low grade fever.
In the rule of nine's what percentage is the front/back of the head and neck?
In the rule of nines what percentage is the front/back of chest down to the buttocks.
In the rule of nines what percentage is the front/back of leg
In the rule of nines what percentage is the front/back of arms?
In the rule of nines what percent is the private area?
How do you calculate fluid resuscitation in a burn pt?
4 mL x kg of body weight x TBSA(total body surface area).
A client with a hip fracture is placed in Buck traction. Which activities are appropriate for the nurse to include in the client's plan of care?
- Assess for skin breakdown of the limb in traction.
- Ensure adequate pain relief.
- Keep the limb in a neutral position.
- Perform frequent neuromuscular checks on the limb in traction.
Bronchial breathe sounds at lung periphery could indicate?
Laryngo spasm or edema of the upper airway is consistent with?
Diffuse bilateral crackles at lung base indicates?
What is the function of parietal lobe?
Integrates somatic and sensory input. Injury to the parietal lobe could result in a deficit with sensation.
What is the function of the frontal lobe?
Controls higher-order processing, such as executive function and personality. Injury to the frontal lobe often results in behavioral changes.
What is the function of the temporal lobe?
Integrates visual and auditory input and past experiences. Temporal lobe injury clients cannot understand verbal or written language.
What is the function of the occipital lobe?
Registers visual images. Injury to the occipital lobe could result in a deficit with vision.
What action should be taken if a foreign body becomes accidentally embedded in the eye?
Both eyes should be shielded to prevent eye movement and additional injury. The nurse should immediately refer the client to an ophthalmologist for further evaluation and treatment.
What is the function of ACE inhibitors?
ACE inhibitors (eg, captopril, enalapril, lisinopril) help reduce the risk of future MIs by reducing blood pressure and cardiac workload and inhibiting ventricular remodeling.
Informed consent can only be obtained by whom?
The health care provider.
T/F, a client should be placed on NPO status for a paracentesis.
False, an NPO status is not required for this procedure.
What does a urine output of <30ml/hr indicate?
May indicate low vascular volume (dehydration, blood loss), decreased renal perfusion (low cardiac output), intrinsic kidney injury, or urine outflow obstruction (enlarged prostate, kinked Foley catheter).
peak flow meter
A handheld device used to measure peak expiratory flow rate (PEFR) and is most helpful for clients with moderate to severe asthma.
This device measures the volume of air that a client can exhale in one breathe.
Peak flow meter.
How do you record peak flow value in asthma pt's?
Using a peak flow meter, exhaling quickly and forcibly 3 consecutive times and recording the highest volume.
What immediate action should be taken for ocular chemical burns?
copious eye irrigation with sterile saline or water.
* Irrigation is continued until ph returns to normal (6.5-7.5) which typically requires 30-60 min depending on the chemical.
What eye chart is commonly used to assess visual acuity?
What is the first thing you test after cast placement?
What is phenelzine?
MAO inhibitor; antidepressent.
What foods should be avoided when taking phenelzine?
Foods high in tyramine (eg, aged cheese, yogurt, cured meats, fermented foods, broad beans, beer, red wine, chocolate, avocados) need to be restricted to reduce the risk of hypertensive crisis.
How are bladder spasms treated after a TURP
The spasms are typically treated with belladonna-opium suppositories or other antispasmodics (eg, anticholinergics such as oxybutynin [Ditropan]). The nurse should remind the client to refrain from trying to void around the catheter as this can trigger the spasms.
A productive cough that is annual and seasonal, particularly occurring in the winter may indicate?
When performing cpr what is the time limit on interrupting chest compressions?
Chest compressions should not be interrupted for more than 10 seconds when assessing for a pulse and chest rise/fall.
In car if a client has a pulse but is not breathing how often do you give rescue breaths?
Every 5-6 seconds.
Why might the jaw thrust maneuver be used in CPR?
The jaw-thrust maneuver is used instead of the head-tilt/chin-lift method in clients who may have a head/spinal injury. Repositioning the jaw forward opens the airway to allow for assessment and delivery of rescue breathing.
What do you do if the AED says no shock advised?
The nurse should resume high-quality chest compressions immediately.
May be prescribed to increase the excretion of bile salts in feces, thereby decreasing pruritus. It is packaged in powdered form, must be mixed with food (applesauce) or juice (apple juice), and should be given 1 hour after all other medications.
What is the recommended initial treatment for PUD?
The recommended initial treatment is 7-14 days of triple-drug therapy with omeprazole (Prilosec), amoxicillin, and clarithromycin (Biaxin).
overflow urinary incontinence
Involve incomplete bladder emptying and urinary retention, which lead to overdistension and overfilling of the bladder and frequent involuntary dribbling of urine.
normal serum calcium
S/S of hypocalcemia
Tetany(overactive neurological responses such as tingling in the hands, feet, and around the mouth; spasms or cramps that can occur even in the larynx; positive Trousseau or Chvostek sign).
Arm/carpal spasm associated with hypocalcemia
Cheek twitching associated with hypocalcemia.
How does bleeding usually occur post thyroidectomy?
Blood typically trickles and pools behind the client's neck.
When can you resume sexual activity after an uncomplicated MI?
What agents is contraindicated when consuming any form of nitrates?
The use of erectile agents (eg, sildenafil).
palpable vibration over chest wall.
Normal fasting cholesterol
S/S of hyperglycemia
Excessive thirst, increased urination, abdominal pain, headache, fatigue, and blurred vision.
Occurs as a result of compartment syndrome associated with distal humerus fractures.
What are some characteristics of macular degeneration?
Distortion (blurred or wavy visual disturbances) or loss of the central field of vision, whereas the peripheral vision remains intact
What are some ways to slow progression of macular degeneration?
Smoking cessation, intake of specific supplements (eg, carotenoids, vitamins C and E), laser therapy, and injection of antineoplastic medications.
What are some risk factors for macular degeneration?
Advanced age, family history, hypertension, smoking, and long-term poor intake of carotenoid-containing fruits and vegetables.
What is seeing small flashes of light associated with?
The inability to see things close up is knows as?
aka poor peripheral vision, can result from optic nerve damage seen in glaucoma.
What are the clinical manifestations of TB?
- Low-grade fever
- Night sweats
- Anorexia and weight loss
S/S of pulmonary TB
- Purulent or blood-tinged sputum (hemoptysis)
- Shortness of breath
What is a cardiac tamponade?
Muffled or distant heart tones, hypotension, jugular venous distension. Requires emergency pericardiocentesis.
What are some things to expect in acute pericarditis.
- Pain that worsens with deep breathing or when supine.
- ST segment elevation.
-Pericardial friction rub.
What type of insulin is Aspart (NovoLog)?
What is the onset, peak, and duration of Lispro, Aspart and glulisine insulin?
Onset: 10-15 min
Peak: 30min -3hr
Normal Platelet count
What should you asses prior to admin of ACE inhibitors?
Potassium and bp. Can cause hyperkalemia and hypotension.
What are some expected SE of albuterol?
Insomnia, nausea and vomiting, palpitations (from tachycardia), and mild tremor.
Urge incontinence (overactive bladder)
Occurs when the bladder contracts randomly, causing a strong, sudden urge to urinate that is followed by urine leakage.
Characteristic of V-fib
chaotic irregular waveforms of varying shapes and amplitude and no identifiable P, QRS or T waves.
Characteristic of AFIB
Characterized by disorganized electrical activity in the atria and an irregular pulse rate.
Characteristics of PVC's
Abnormal electrical impulses in the ventricles that may occur spontaneously or in response to heart irritants (eg, stimulant medications, electrolyte alterations, pain). This arrhythmia is typically not harmful but requires monitoring by the nurse.
Characteristic of V-tach
Characterized by organized, rapid firing of electrical activity within the ventricles, may impair perfusion and often leads to cardiac arrest and/or VF
controls language expression - an area, usually in the left frontal lobe, that directs the muscle movements involved in speech.
controls language reception - a brain area involved in language comprehension and expression; usually in the left temporal lobe
the inability to use speech that is distinct and connected because of a loss of muscle control after damage to the peripheral or central nervous system
Glucocorticoid medication used to reduce airway inflammation in asthma.
T/F glucocorticoids can cause in elevation in WBC count during initiation of treatment.
Continued use of albuterol can cause low what?
What are some common adverse side effects of Beta 2 Adrenergic Agonists?
Ex: Albuterol, Salmeterol
Adverse SE are hypokalemia and tachycardia.
Associated with increased water reabsorption and excessive intra- and extracellular fluid, which result in hypervolemia from fluid retention and dilutional hyponatremia.
Caused by prolonged exposure to excess corticosteroids, especially glucocorticoids.
An antiemetic that promotes the relief of nausea/vomiting, which helps minimize further fluid loss.
A barrier method of contraception used with spermicide (eg, nonoxynol-9). The reusable, cup-shaped cap is placed over the cervix before intercourse to block sperm from the uterus.
How long should a cervical cap remain in place after intercourse?
≥6 hours after intercourse but should not remain for more than 48 hours.
Where is spermicide placed on a cervical cap?
Spermicide should be applied inside the cap, along the rim of the cap, and in the groove on the underside of the cap.
T/F it is ok to use a cervical cap during menses
False. This will increase the risk of toxic shock syndrome.
Addison disease (primary adrenal insufficiency)
Is due to decreased function of the adrenal gland, which is responsible for the secretion of glucocorticoids, androgens, and mineralocorticoids.
Clients with Addison's disease may develop...
hypovolemia, hyponatremia, and hyperkalemia
What are some manifestations of Addison's disease.
Slow, progressive onset of weakness and fatigue
Anorexia and weight loss
Nausea and vomiting
Depression and irritability
Bronze hyperpigmentation of the skin in sun-exposed areas is commonly associated with what disease?
intermittent attacks of vasoconstriction in the fingers and toes often triggered by exposure to cold (the digits will go from pink, to blue, to white, back to pink as blood flow is restricted and then restarted)
High pitched wheezing is usually found in clients with?
Asthma and anaphylactic allergic reactions.
lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax
acute angle closure glaucoma
Sudden onset of severe eye pain
Reduced central vision
Report of seeing halos around lights
Chronic open angle glaucoma
Gradual loss of peripheral vision and difficulty adjusting to different lighting.
Pursed lip breathing
Inhale deeply for 2 seconds through the nose with the mouth closed.
Exhale for 4 seconds through pursed lips, as if blowing through a straw. If unable to exhale for this long, practice regularly until you can exhale for twice as long as you inhale.
What are some benefits of pursed lip breathing?
Helps to decrease shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease (COPD).
Results from excess fluid accumulation inside the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness.
A client with Menieres Disease should restrict what in their diet.
Early signs of ICP
confusion, drowsiness, flat affect.
Late signs of ICP
Cushing triad (eg, bradycardia, widening pulse pressure [increasing systolic/decreasing diastolic], altered respiratory pattern); fixed, dilated pupil(s); and decreased motor function.
three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation
What are some classic signs of retinal detachment?
A curtain coming across the vision, floaters or lightning flashes in the vision field, and "gnats/hairnet/cobweb" throughout the vision.
Refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy, stupor) that may progress to a comatose state.
Many women are asymptomatic but can have profuse frothy gray or yellow-green vaginal discharge with a fishy odor. Small red lesions (strawberry color) may be present in the vagina or cervix. Pruritus is common.
What is the drug of choice for treating trichomoniasis?
What should clients avoid while taking metronidazole
Clients should avoid alcohol while taking metronidazole and for 24 hours after completion of the therapy due to the risk of a reaction that includes flushing, nausea/vomiting, and abdominal pain.
This medication can have a metallic taste and turn the urine a deep red brown color.
A client diagnosed with trichomonal vaginal infection (trichomoniasis) is prescribed metronidazole. Which directions are essential for the nurse to reinforce?
- Avoid alcohol while taking this medication.
- Your partner(s) must be treated simultaneously.
- Your urine can turn a deep-red brown color.
Atrial paced rhythm
spike before P wave
First degree heart block
The practical nurse is assisting the registered nurse in preparing the room for a client with new-onset tonic-clonic seizures. It is important to ensure that what equipment is in the room?
-Oxygen delivery system.
- Padding on the bed side rails
- Suction equipment
A chronic disorder in which the bone marrow produces too many RBCs, causing blood to become viscous and sluggish and leading to venous stasis. Clients are at increased risk for thrombosis, embolization, and decreased tissue perfusion.
A surgical procedure to remove part of the pituitary; it involves the insertion of an endoscope through the inner aspect of the upper lip all the way to the pituitary.
What class of drugs are usually held before dialysis?
Unless otherwise indicated by the health care provider, antihypertensives and other blood pressure-lowering medications (eg, furosemide), antibiotics, digoxin, and water-soluble vitamins (B, C, and folic acid) should be held prior to dialysis.
Why would vitamin E be given to someone undergoing dialysis?
To prevent leg cramps.
A client has characteristic silver plaques on reddened skin that may be found bilaterally on the elbows, knees, scalp, lower back, and/or buttocks. What is this condition?
What is the best way to manage psoriasis?
- Avoidance of triggers (stress, trauma, infection)
- Topical therapy ( corticosteroids, moisturizers)
- Phototherapy (Ultraviolet light)
- Systemic medications including cytotoxic (methotrexate) and biologic (infliximab agents)
- DON'T scratch and avoid alcohol.
Immune Thrombocytopenic Purpura (ITP)
An autoimmune condition in which antibodies bind to and cause destruction of platelets. Clients with ITP have a platelet count <150,000/mm3 (150 x 109/L) and are at increased risk of bleeding.
The vegetations growing on the valves can break off and embolize to various organs, resulting in life-threatening complications
What are some common symptoms of IE (Infective Endocarditis)?
Fever, arthralgias (multiple joints pains), weakness, and fatigue.
Can occur with infection of the heart valves (endocarditis).
Hyperosmolar hyperglycemic state (HHS)
A serious complication of type 2 diabetes mellitus (DM). In HHS, the pancreas can produce enough insulin to prevent the breakdown of fats that would result in diabetic ketoacidosis (DKA) but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
Gonorrhea and Chlamydia.
What STD's are referred to as silent infections?
Gonorrhea and chlamydia.
Toxoplasma gondii treatment
Sulfadiazine + pyrimethamine
Parasite found in cat litter.
T/F it is ok to raise the residual limb after an above knee amputation.
False. Doing this could cause hip flexion contractures.
How do you manage edema with an AKA (above knee amp)
Using a figure 8 compression bandage.
How do you avoid hip flexion contractures after an AKA.
- Figure Eight compression bandage.
- Prone position with hip extension 30 minutes 3 or 4 times a day.
What are some common asthma triggers?
Allergen inhalation (eg, mold, pollen, dust mites, animal dander)
Air pollutants (eg, tobacco smoke)
Infections - viral upper respiratory infections are the most common
Pharmacological agents (eg, beta blockers, aspirin, nonsteroidal anti-inflammatory drugs)
Clinical Manifestations of asthma exacerbations
- Accessory muscle use
- Chest tightness
- Diminished breathe sounds
- High pitched expiratory wheezes
What is the primary factor contributing to bladder cancer?
Cigarette smoking or tobacco use.
s/s of acute respiratory failure
altered mental status (eg, confusion, agitation, somnolence), paresthesias, dyspnea, tachypnea, and hypoxemia.
Von Willebrand Disease
A genetic bleeding disorder caused by a deficiency of von Willebrand factor (vWF), which plays an important role in coagulation.
Common causes of SIADH?
-CNS disruption (stroke, neurosurgery, infection)
-Meds (desmopressin, carbamazepine)
-Pulmonary disorders (pneumonia)
T or F? NSAIDS are contraindicated in pt's with heart failure.
True, they contribute to sodium retention.
Client teaching for mitral valve prolapse
- Stay hydrated.
-Avoid caffeine and alcohol.
- Reduce stress.
-Take beta blockers.
Guillain-Barré syndrome (GBS)
an acute, immune-mediated polyneuropathy most often accompanied by ascending muscle weakness and absent deep-tendon reflexes. Many clients have a history of recent viral respiratory tract or gastrointestinal infection.
What is the gold standard for assessing ventilation?
Measurement of forced vital capacity (FVC).
What are early signs of impending respiratory failure in GBS (Guillain-Barré syndrome)?
Inability to cough
Dyspnea and hypoxia
Inability to lift the head or eyebrows
Symptoms of Guillain-Barré syndrome
- Diaphoresis/ facial flushing
- Hypoactive/absent bowel sounds.
Symptoms of ovarian cancer
Bloating, early satiety, urinary symptoms (pressure on the bladder), and pelvic pressure.
s/s of autonomic dysreflexia
Hypertension, bradycardia, pounding headache, diaphoresis, nausea
An acute, life-threatening response to noxious stimuli (eg, bladder distention, tight clothing) in clients with spinal cord injuries above T6.
Ruptured cerebral aneurysm
"The worst headache of my life". Severe headache with changes in or loss of consciousness, neurologic deficits, diplopia, seizures, vomiting, or a stiff neck.
Where is the apex of the heart?
5th intercostal space
histrionic personality disorder
Characterized by persistent attention-seeking behavior and exaggerated emotionality. The client with this disorder demands immediate gratification and has little tolerance for frustration.
schizoid personality disorder
Social detachment and an inability to express emotion. They do not enjoy close relationships and prefer to be aloof and isolated.
antisocial personality disorder
Disregard for and violation of the rights of others. They manipulate others for personal gain and lack empathy.
NI for manipulative behaviors.
- Setting limits that are realistic, nonpunitive, and enforceable
- Using a nonthreatening, matter-of-fact tone when discussing limits and consequences of unacceptable behaviors
- Enforcing all unit, hospital, or center rules (Option 4)
- Ensuring consistency from all staff members in enforcing set limits
What are some nursing actions for clients experiencing panic attacks?
- Maintaining a calm, matter-of-fact approach
- Speaking calmly and using simple, clear words and phrases when providing information on emergency department procedures
- Placing the client in a room with as few stimuli as possible
- Administering an anti-anxiety medication such as a benzodiazepine (per health care provider prescription)
- Having the client take slow, deep breaths if hyperventilation is a problem
A peptide that causes natriuresis. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure.
Serum lactate level
Provides information about anaerobic tissue metabolism (perfusion).
Prodromal seizure phase
the period with warning signs that precede the seizure (before the aural phase).
Aural seizure phase
The period before the seizure when the client may experience visual or other sensory changes. Not all clients experience or can recognize a prodromal or aural phase before the seizure.
After the seizure.
What does fine crackles in the lungs indicate?
Chronic Venous Insufficiency (CVI)
Occurs when the valves in the veins of the lower extremities fail to keep blood moving forward. Chronic edema and inflammatory changes lead to brownish, thickened skin on the extremities and venous leg ulcers (commonly on the inside of the ankle).
S/S of pancreatic abcess
High fever, increasing abdominal pain, and leukocytosis
What to expect with acute pancreatitis
Severe midepigastric abdominal pain, elevated blood glucose levels, and steatorrhea.
How is Hep B primarily transmitted?
Through contact with blood, semen and vaginal secretions.
Hold breath tightly to close the vocal cords
Place food in mouth and swallow while continuing to hold breath
Cough to dispel remaining food from vocal cords
Swallow a second time before breathing
What are the clinical manifestations of opioid withdrawal in a newborn?
Irritability, jitteriness, high-pitched cry, sneezing, diarrhea, vomiting, and poor feeding.
The fetal effects of congenital rubella syndrome
congenital cataracts, deafness, heart defects (patent ductus arteriosus), and cerebral palsy.
What meat should be avoided during pregnancy due to high amounts of vitamin A?
Occurs when a fertilized ovum implants outside the uterine cavity. The majority of ectopic pregnancies occur in the fallopian tubes.
Clinical Manifestations of an Ectopic pregnancy
lower-quadrant abdominal pain on one side,
mild to moderate vaginal bleeding, and missed or delayed menses.
S/S of ruptured ectopic pregnancy
Dizziness, hypotension, and tachycardia, severe abdominal pain, shoulder pain.
What is a common adverse effect of misoprostol?
Signs of endometrial infection
Foul smelling lochia, fever, tachycardia, and uterine pain/tenderness
If the funds is elevated above the umbilicus and deviated to the right what does this suggest?
A distended bladder.
LMP - 3 months + 7 days
What is a classic sign of VSD?
Holosystolic murmur at the left lower sternal border.
When should you avoid ibuprofen during pregnancy?
It must be avoided starting at 30 weeks gestation due to the risk of causing premature closure of the ductus arteriosus in the fetus and prolonged labor in the client.
What are some potential complications of oxytocin?
- Water intoxication.
- Uterine tachysystole.
- Non reassuring fetal heart rate.
A rare, life-threatening inherited muscle abnormality triggered in susceptible clients by certain drugs used to induce general anesthesia.
Characteristics signs of MH (Malignant Hyperthermia)
- Hypercapnia (extra CO2 in blood)
- Generalized muscle rigidity
Acute mental status changes that fluctuate and inattention with disorganized thinking and/or altered level of consciousness.
What type of nutrition should clients with mania receive?
Energy- and protein-dense foods that are easily carried and consumed (eg, sandwiches, shakes, hamburgers, pizza slices, burritos, fruit juices, granola bars).
Clinical manifestations of acute glomerulonephritis
Periorbital and facial/generalized edema, hypertension, and oliguria, which are primarily due to fluid retention (decreased kidney filtration). The urine is tea-colored and cloudy due to the presence of protein and blood.
- Bilious vomiting
- Abdominal Distension
- Failure to pass meconium
- Tight anal sphincter
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