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NCLEX Content Review

Terms in this set (242)

Romberg Test
close eyes, raise arms, see if pt sways
Corneal Reflex
use cotton in eye, tests CN V (trigeminal)
Snellen Chart
tests optic nerve, CN II
Babinski
toes flare in adults, shows upper motor neuron disease of the pyramidal tract
Cataract High Risk Patients
exposure to UV light, eye injury, viral infections (should wear sunglasses, use eye protection)
Eye Strain causes
...
Theurapeutic Communication
confrontation after developing a relationship of trust
listen in silence to develop trust
Hallucination
sensory
Illusion
...
Delusion
false belief
Diet that promotes healing
protein, vitamins C & D
Diet to clot blood
Vitamin K
When to give abx
wound open to air
Refeeding
with TPN, check mag, phosphorus, phosphate
MAOI
used for anorexia, bulemia, anxiety
MAOI side effects
dizzy, sweat, tremors, HTN, tachycardia, slurred speech, constipation, dermatitis, anorexia, polyuria, pancytopenia, and thrombocytopenia
-administer after meals or with milk to decrease GI irritation
Oncology drugs causing cardiomyopathies
...
Oncology drugs causing ototoxicity
...
Oncology drugs causing nephrotoxicity
...
Oncology drugs causing 2nd malignancy
alkylating agents
Bulsulfan
chemo drug, effects lungs (think BLUE)
Hypocalcemia
Trousseau's sign, Chvostek's sign, tingling, short of breath, can lead to dysrthymias.
Hypercalcemia
...
Hyperkalemia
peaked T waves
BUN
8-22; indicates hydration
HCT
low indicates hemodilution from fluid overload
Meds that pass through breast milk
Benzos, Radioactive, Amphetamine, Amiodorone, Stimuland Laxatives, Tetracyclines
DVT
cover with blanket?
Risk of lots of blood transfusions
hemosiderosis (too much iron)
Hemoglobin S formation
part of gene causing condition, can't develop it
Adrenalectomy
at risk for adrenal insufficiency and hypovolemic shock (low cortisol, aldosterone, sex hormones)
Addison's
adrenal insufficiency, hyponatremia (muscle cramps, fatigue, and hypotension), dehydration, "eternal tan," decreased resistance to physical stress, alopecia
Cushing's
excess of adrenal hormones, hypertension and edema
Adrenal Crisis
...
Infant Development
solitary play
2-3 posterior fontanel closed
6 sit with support
9 pincer grasp
1 year Check-Up
triple birth weight
to 18 months, trust with dependable primary caretaker
Potty Training
begin at 20-24 months during day
Toddler Development
autonomy v shame and doubt
pounding board, cloth picture board
parallel play
Pre-School Development
initiative v guilt
tricycle, education computer games, play dress up, skates
associative play
School Aged Development
industry v inferiority
accidents on park equipment
Adolescent Development
identity v role diffusion
male - voice changes, breast enlargement
female - breast buds, irregular periods
Teen Development
intimacy v isolation
Middle Aged Development
generativity v stagnatio
Older Adult Development
integrity v despair & disgust
Assessments
Inspect, Palpate, Percuss, Auscultate
firmly press diaphragm for heart sounds
Qshift, when pt complains of s/s
-restless & confused - check meds
Tactile Fremitus
Vibration when pt says '99'
After surgical procedures
check urine & stool, bowel sounds
Infant Assessment
-dehydration
--immunization reaction less likely
S/S Alcohol Abuse
tremors, elevated temp, nocturnal leg cramps, complaints of pain
S/S Narcotic Dependence
flu sx, night sweats, elevated temp, decreased deep tendon reflexes
Position to Left Side
increases CO & venous return
reduce fetal pressure on vena cava
supine position with arms to the side, and elevate the foot of the bed
PVD
Elevate Legs
increases fetal pressure and reduces venous return to the heart
Trendelenburg or knee to chest
decrease pressure on umbilical cord
Elevate HOB
decrease venous return, GERD, breathing
Supine
doesn't change venous return
Standard Precautions
lyme disease, kawasaki, mono (not transmitted through touch)
Contact Precautions
mask & gloves: acute viral infection
Negative Pressure
TB, chicken pox
Passive ROM
assists elderly to carry out ADLs
Navajo Indians
present focused, may not be on time
Patients to Transfer to another floor
non-infectious, auto-immune (lupus, RA)
NO: if on abx
Diet for Crohn's Disease
low residue (fiber), low fat, high protein
Diet for Gastrectomy
monthly B12 injections, small frequent meals, concentrated sweets, limit fluids with meals
Diet for Hypoparathyroidism
foods with high Ca and low phosphorus
Diet for Lead Poisoning
milk removes lead from blood and soft tissues
Diet while Breastfeeding
extra 500 cals
If appetite is reduced
find favorite foods, megace
Low Na Diet
Yes: lemonade, treat vertigo
NO: tomato juice, ginger ale
Diet for Renal Failure
Low fat
Calories/Iron for Women
1200-1500 and 15g iron
Calories/Iron for Men
1500-1800 and 10g iron
Inserting IV
soft/elastic veins, distal portion of arm, away from joint, hold the skin taut to stabilize vein
Removal of Dressing of Peritoneal Dialysis Catheter
clean insertion site with sterile cotton swab with povidone-iodine, apply 2 sterile 4x4s to insertion site with paper tape, clean insertion site in a circular motion toward outer abdomen
Ileostomy Teaching
skin around stoma should be cleansed with warm water and dried, appliance should fit snugly around opening, irrigation done at same time each day
NO: coated, capsules, osmotic laxative
Water Seal Drainage System
When no more are leaks in pleural space: fluid in water seal chamber doesn't fluctuate with each respiration
-continuous bubbling indicates air leak
Pre-eclampsia
facial swelling, HTN, peripheral edema, proteinuria
Folic Acid
reduce risk for neural tube defects
Active Labor
check for fetal distress, not monitor
1st Trimester
n/v is r/t elevation in hormones
Meds that cause birth defects
carbamazepine, valproic acid
FHR during contractions
110 at peak, 158 baseline
Normal Contractions
3-4 min apart, last 60 seconds
Ultrasound
determines gestational age
Amniocentesis
lung development, look in spinal cord, baby blood disorders
Purpose of internal fetal monitor
monitor oxygen status of fetus during labor
4th stage of labor
fundus at umbilicus
Timing of PKU test
near discharge but before 7 days, if less than 24 hrs then repeat at 2 wks of age
Normal head circumference
33-35 cm (chest 31-33)
Newborn weight
6-9 lbs (lose 5-15% in week 1)
Newborn length
18-21 in
Suction bulb
mouth then nose
Newborn vitals
97.7-99.99.4
110-160
30-60
80/50
Umbilical Cord
1 vein, 2 arteries
Fontanel
bulging indicates increased ICP
Fetal Alcohol Syndrome
small head, low weight, underdeveloped cheekbones, feeding difficulty, sucking difficulty, need B vitamins for CNS
Infant Solid Foods
start with rice cereal at 4-6 months
Infant Respiratory Distress
expiratory stridor, substernal retractions, tachypnea (hypoxia), tachycardia, anxious, restless
Rinne Test
hearing test on child, on mastoid bone then in front of auditory canal
Head Lice
special shampoo kills nits, 1 week later gets eggs and new
Blood Transfusions
Allergic Reaction: wheezing, urticaria (hives, facial flushing, epiglottal edema
Hemolytic Reaction: chills, hypotension, low back pain
Fever/pyrogenic Reaction: fever & chills about 1 hr after start
PNA
Risks: immunosuppression, older, lung disease, bedridden, postop
COPD priority
increase ventilation to reduce levels of CO2 and increase levels of O2.
SIADH
abnormal secretion of ADH; will cause a decreased HGB and WBC, BUN would be decreased with hypervolemia due to increased ADH secretion, may cause pulmonary edema and crackles
-lung cancer is a common cause, confused, reduced urinary output
Priority: low Na (dilutional hyponatremia) from increased water absorption
Risks: Seizures
Grave's
Hyperthyroidism, females, puberty/pregnancy/or 3-5th decades, exophthalamos (wide eyes), goiter (enlarged thyroid gland), Pretibial myxedema (reddish thickening of the skin in front of the shin bones), photophobia (sensitivity to light), eyelid and globe lag and impaired vision, tachycardia, palpitations, weight loss, diarrhea, nervous/anxious, exhausted
Thyroid Storm
tachy, fever, altered mental status
Allen Test
...
Battle Sign
...
Calcitriol (Rocaltrol)
vitamin d deficiency
Calcitonin (Calcimar)
hypercalcemia
Plicamycin (Mithracin)
hypercalcemia
hypothyroid
fatigue, some increasing constipation, and weight gain, serum TSH level is elevated, hypothermia, bradycardia, decreased CO
Cataracts
lens loses moisture and becomes more dense, partial or total opacity of the normally transparent crystallin lens; there is a general decrease in ability of client to see environment clearly, there is an annoying glare; pupil changes from black to gray to milky white
Fluid overload
restless, difficulty breathing, bibasilar crackles
Myasthenia Gravis
Ptosis (drooping eyelids), impaired speech, dysphagia, diplopia (double vision), muscle weakness that improves with rest (caused by acetylcholine deficiency)
Nephrotic Syndrome Potential Risks
DVT
Lidocaine (Xylocaine)
v tach
Reduce risk of falling
exercise, lamps, check meds, shoes with thin, nonslip soles, vision checked
Vitamin B6
given to prevent the peripheral neuropathy, dizziness, and ataxias that can occur with TB drugs
Vitamin B12
if pt has pernicious anemia
Vitamins for Chronic Alcoholism
needs supplementation with all B vitamins, especially thiamine (vitamin B1); thiamine deficiency is the primary cause of alcohol-related changes such as Wernicke's encephalopathy and Korsakoff's syndrome
Vitamins for pregnancy
12 weeks - folic acid (vitamin B9) to prevent neural tube defects in the fetus
Alcohol Withdrawal
begin a few hours after reduction of alcohol intake and peak in 24-48 hours - Tremors, elevated pulse, anxiety, startles easily
Judaism Dietary Restrictions
dairy/meat combination is prohibited
On left side, lower HOB
for 30 min after insert CVC pt is pale and dyspneic, and has tachycardia (air embolism)
Evacuator drainage system rapidly inflates
air leak
Adrenocortical insufficiency
hyponatremia, hypoglycemia, and hyperkalemia
After laminectomy
pillow should be placed longitudinally between legs to prevent hip and lower leg adduction and spinal torque
Loop Diuretics (Lasix, Edecrin)
potassium wasting; encourage client to increase intake of potassium-rich foods
Potassium Rich foods
OJ, banana
Glaucoma
cloudy, blurry vision, or loss of vision, artificial lights appear to have rainbows or halos around them, decreased peripheral vision, pain, headache, nausea, vomiting
Glaucoma Teaching
periodic tonometer readings to check IOP
Ginko
not to be taken with NSAIDs
Straight Cath
Only 300 - 500ml
11 months
like to throw toy on floor
UA
indicate renal disease
Hip Replacement Surgery
abduction prevents dislocation of the hip
Birth Control
if pill is missed 2 days in a row, instruct to take 2 tablets a day for the next 2 days, continue on regular dosing schedule; use another form of contraceptive for remainder of cycle
Autonomic Dysreflexia
spinal injury with headache
Bowel Obstruction
frequent small amounts of watery diarrhea with abdominal pain and nausea
Not good for breast milk
benzo, r, e, a, sex hormones/birth control, t
Semi-fowlers
drain lochia
Postpartum Assessment
Breast, Uterus, Bladder, Bowels, Lochia, Bowel, Episiotomy/laceration/incision
Chronic Ear Infections
vertigo is safety concern before mastoidectomy
1 yr
say 3-5 words, 2 block tower, hug on command
9 months
sit unsupported, pull up to standing, responds to simple verbal commands, compare blocks
Raise HOB
prevents increased IOP
African Americans
risk of MI, stroke, BB (olol) & ACE (pril) less effective
Heat Stroke
hypotension, tachypnea, tachycardia, temperature of 105°F or above; skin is hot and dry; behavior is bizarre, confused, delirious, or comatose
Tricyclic Antidepressants
imipramine (Tofranil)
Tricyclic Antidepressant Side Effects
Sore throat, fever, increased fatigue, vomiting, diarrhea
View of Death
Pre School - Death is temporary and gradual
7 yrs - punishment
9 - Death is inevitable and irreversible
Adolescent - Death as a concept based on past experience
CF Diet
High protein, low fat, and high calories
Temporal Lobe
auditory center, loss of hearing would involve CN VIII acoustic
Taste
CN IX, glossopharyngeal
Electromyography
electrodes are attached to legs, length of time for impulse transmission is measured, noninvasive, about 30 min
Inguinal Hernia
A bulge in the lower right quadrant, pain at the umbilicus radiating down into the groin
Stages of Play
5 yrs - The boy talks on a toy telephone and imitates his father
School Aged - The boy plays with a large truck with another child
TDAP Immuniization
first dose of the DPT may be given at 2 months of age, the second is given around 4 months
MMR Immunization
15 months
Polio Vaccine
2, 4, 12 months
Cushings
Buffalo hump, hyperglycemia, hypernatremia, weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections
Myelogram
The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal; identifies tumors, cysts, herniated vertebral discs
Prepare 3 yr old for procedure
Describe the procedure to the child in short, concrete terms while talking calmly.
Naegele Rule
add 7 days to first day of last menstrual period and subtract 3 months
Hypovolemic Shock
vasoconstriction compensates for the loss of fluid, resulting in cool, clammy skin, tachycardia, tachypnea, and pale color
Tube Feeding
Rinse the bag and change the formula every 4 hours
Duodenal Ulcers
have an increased association with clients who experience increased psychological pressures, the pain usually occurs 2 to 4 hours after meals, antacids given
Gastric Ulcers
clients with gastric ulcer may be malnourished because food may cause nausea or vomiting
Minor Head Injury
Unexpected: vomiting, blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache
Expected: nausea and dizziness for 24 hours
Symptoms of infant cold stress
mottling of the skin with irregular low respirations
Infant Hypoglycemia
cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, coma
Hypoglycemia Symptoms
Irritability, tachycardia, and diaphoresis
Hyperglycemia Symptoms
Headache, nervousness, polydipsia, tenseness, tachycardia, anorexia, fruity acetone odor to the breath, polyuria, and flushed skin
3 years old
child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet
able to jump
2 1/2 years
-azoles
cream that inhibit cell growth
Flagyl - no ETOH, headache, dry mouth
Tetracycline
bacteria infection, PNA, lyme - not with milk
Penicillin/Amoxicillin
bacterial med - can cause anaphylaxis
Isoniazid (INH)
no ETOH, check LFT, B6 deficiency - for TB
Cipro
treats bacteria infections, 18+, not with seizures/theophylline, phototoxicity
Cephalosporin
bacteria infections, no if penicillin allergy, 4 generations (keflex, ceftin, claforan/rocephin - nephrotoxic, maxipime)
Azithromycin (zithromax)
bacterial infections
ARV
HIV treatment - retrovir, sustiva, invirase, fuzeon, seizentry
Aminoglycosides
potent bacteria, nephro/ototoxicity
Lower Cholesterol
Welchol, Lopid
Doppler Ultrasound
probe should be at a 45-degree angle, pressing snugly can compress the artery if done, should move distal to proximal, conductive gel applied to the skin to decrease resistance to sound transmission; it also protects the crystals in the probe, which are what transmit and receive signals; warming the gel is important because if the gel were cold it would promote vasoconstriction, making it difficult to detect a signal
Acute Renal Failure
Check urine specific gravity (normal 1.01-1.03)
Acute Abdominal Aneurism
avoid straining, including during bowel movements and avoid lifting
Malignant Hyperthermia
life-threatening complication of general anesthesia; indications include tachycardia, dysrhythmias, tachypnea, hyperthermia, hypotension; treatment includes dantrolene sodium (Dantrium)
Incentive Spirometer
held upright at eye level so patient can observe the ball, purpose is to promote complete lung expansion and prevent respiratory complications in the post-op patient, should inhale and hold breath for 3 seconds, allows sustained maximal inspriation to prevent atelectasis; patient is able to see efforts registered on spirometer, done when awake; encourage patient to cough after using spirometer
P. jiroveci pneumonia
opportunistic infection associated with AIDS; causes progressive hypoxemia and cyanosis
R sided heart failure
dependent edema (hands and feet swollen at end of day), liver enlargement and abdominal girth, anorexia, nausea, bloating, anxiety, fear, and depression
Pulmonary Edema
manifested as dyspnea; fluid remains in the vessels of the lung instead of going into the left side of the heart; decreased cardiac output results in tissue congestion; fluid passes from the pulmonary capillaries to the alveoli, causing cough and shortness of breath; dyspnea may occur or become worse with physical exertion
irritation of the parietal pleura/pericarditis
pain in chest when coughing
Wilms Tumor
most common childhood intraabdominal/kidney tumor, manipulation of tumor may cause cancer cells to metastasize to other sites, assess the size of the tumor; treatment is surgery followed by radiotherapy and chemotherapy, hypertension may occur due to excessive renin production
Indocin
nonsteroidal anti-inflammatory; use cautiously in clients with peptic ulcer disease
Gout Meds
Colchicine (Colsalide), Allopurinol, Probenecid (Benemid)
Renal Colic
pale and diaphoretic, who is complaining of sudden and severe pain radiating from the flank to the scrotum
Appendicitis
right lower quadrant (RLQ) abdominal pain of 24 hours' duration and which is relieved by drawing the legs up and remaining still, treatment is appendectomy within 24-48 hours to avoid rupture causing peritonitis
Chronic Cholecystitis
jaundiced and nauseated, clay colored stools, who is complaining of pain in the right shoulder and has a temperature of 100°F (37.8°C).
Acute Gastritis
vomiting and hematemesis may be seen with gastritis stemming from alcohol abuse; other symptoms are epigastric pain or discomfort, cramping, nausea and vomiting
Immune System Complex disease
occurs about 10 days after a skin or throat infection; symptoms include fever, chills, hematuria, dyspnea, weight gain, edema, hypertension, headache, decreased level of consciousness, confusion, abdominal or flank pain
Glomerulonephritis
occurs secondary to other infections or systemic diseases such as systemic lupus erythematosus, cirrhosis, sickle-cell disease, and infective endocarditis (streptococcus)
-UA: a large amount of protein and a large number of red blood cells
-Treatment: antibiotics, corticosteroids, antihypertensives, immunosuppressive agents; restrict sodium intake, restrict water if oliguric; dialing weights, monitor I/O, bed rest, high-calorie, low protein diet
Post Surgery
encouraged to perform early ambulation to prevent thromboembolism; cough and deep breath, incentive spirometry, avoid heavy lifting or strenuous activity
Lupus
proteinuria, hyperlipidemia
CPR Compressions
elbows should be locked, arms straight, shoulders directly over hands; heel of hand should be on the lower half of the sternum; presence of pulse should be re-checked after every minute
Impetigo
honey-colored crusts, vesicles, and reddish macules around mouth (monitor for acute glomerulonephritis - complication of untreated impetigo)
Tinel Sign
indicates carpal tunnel syndrome; nurse percusses lightly over median nerve on inner aspect of wrist (+ - numbness, tingling, and pain when the nurse taps lightly over the inside of her wrist)
Dupuytren contracture
slow, progressive contracture of the plantar fascia (ex: fourth and fifth fingers are contracted onto the palm)
Volkmann Contracture
type of compartment syndrome caused by obstruction of arterial blood flow to the forearm and hand; cannot straighten fingers, has severe pain, and there may be signs of diminished circulation (ex: in an arm cast with fingers and wrist contracted)
Crede Maneuver
applying manual pressure to bladder aids in emptying the bladder completely; results in reduced risk for infection; performing at the same times every day can result in bladder control
Test for showing glomerulonephritis
Elevated serum antistreptolysin O (ASO) titer
Test showing UTI
Urine c/s with E. coli, UA with leukocytes
To limit dumping syndrome
decrease intake of carbohydrates, eat 5-6 small meals, increase fat and proteins, avoid high-fiber foods, no fluids 1h before, with, or 2 h after meal
Using heat packs
-don't use with decreased sensitivity in hands/feet
Amputations
-3 days out, prone to avoid contractures
S/S ICP
-slowing of speech, changes in LOC, restlessness, and confusion
-pupillary changes, increased BP, decreased pulse
Dangers during development
toddlers: in danger of aspirating large pieces of meat and hot dogs, nuts, dried beans, chewing gum (cut hot dog into small, irregular shapes)
-S/S: wheezing on inspiration
Asthma
wheezing on expiration
When showing S/S of SVT (dizziness, chest pain)
Vagal/Valsalva Maneuver can reverse SVT
-stick the thumb in the mouth, close the mouth around it, and then blow on the thumb as if it were a trumpet for 30-60 secs
-ice to the face
-holding the breath and then bearing down
-massaging the carotid artery on only one side of the neck
BUT - if vagal maneuvers do not work, IV adenosine (antidysrhythmic) given
To relieve hypoxia
squatting position with the arms wrapped around the legs
Pt with Bell's Palsy
-use moist heat on affected side
-cover affected eye with patch at night (prevent corneal irritation)
-not go out when there is a cold wind (sensitivity of nerve endings)
Main functions of lobes of brain
-parietal: primary center for sensation
-temporal: auditory reception area
-frontal lobe: concerns personality, behavior, emotions, and intellectual function
-occipital: primary visual receptor center
Prednisone
-don't just stop taking
-need to increase with surgery
--monitor vital signs, blood sugar, infection
M é ni è re's disease diagnosis
H/P (no blood test) - eval of CN VIII
Paracentesis
shock may occur after removal of fluid
Anaphylactic Reaction
sneezing and coughing, is flushed, has generalized hives, and complains of feeling warm (need to start IV w/NS)
Prenatal precautions
-avoid cats (toxoplasmosis)
When ASA is contraindicated
-babies/children
-allergy to yellow dye #5 (tartrazine)
Dystonic Reaction
sneezing and coughing, is flushed, has generalized hives, and complains of feeling warm
Neurasthenia
unexplained chronic fatigue with nervousness, anxiety, and irritability
Conversion Hysteria
motor or sensory neurological symptoms with no identifiable physiological cause
Waxy Flexibility
abnormal posturing
Conversion Reaction
instinctive drives and their accompanying anxiety are repressed and converted into a physical symptom (repression)
Identification
unconscious process in which one assumes the characteristics of an authority or parent figure
Displacement
redirecting emotion or feelings to a subject that is more acceptable or less threatening
Introjection
one symbolically takes the characteristics of another
Development at age 40
self-questioning occurs, reappraises the past, discards unrealistic goals, potential mid-life crisis (compares accomplishments against goals)
Topamax
anti-convulsant, use non-hormonal contraceptives
Infant increased ICP
high pitched cry, irritability, poor feeding, increased frontal occipital circumference
S/S TB
dry cough for several weeks with frequent night sweats
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