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334 terms

NCLEX Review, Fourth Set

Pearson Vue
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Correction of DHD in infants less than 6 months of age involves the use of...
a Pavlik harness. Prevents hip extension or adduction and is worn continuously for about 3-6 months.
The infant grows rapidly, so the straps of the Pavlik harness should be checked every...
1-2 weeks for needed adjustments because vascular or nerve damage can occur with improper positioning.
In congenital clubfoot (talipes equinovarus), the affected foot is usually...
smaller and shorter than the unaffected foot.
Treatment of congenital clubfoot begins with the...
application of casts; cast is changed and affected limb is manipulated weekly for the first 6-12 weeks; surgical correction involves pin fixation and releast of tight joints and tendons followed by casting for 2-3 months.
The pregnant client should avoid external heat exposure, such as hot tubs and saunas, because these have been identified factors that increase the risk of...
neural tube defects.
Spina bifida: Meningocele
defect contains the meninges and spinal fluid; child has no neurological deficit
Spina bifida: Myelomeningocele
defect contains the meninges, nerve tissue, and spinal fluid; child has serious neurological deficit
Preoperative care of a client with myelomeningocele includes...
prevent injury to and or drying of the sac; sac should covered with a sterile, nonadherent dressing moistened with sterile normal saline; dressings changed every 2-4 hours
Newborn with myelomeningocele should be placed...
prone with the hips slightly flexed and elevated (low Trendelenburg) to prevent stretching of involved nerves.
Complications of myelomeningocele
hydrocephalus, UTI, meningitis, pressure sores, contractures
Symptoms of meningitis in the infant include...
temperature instability, poor feeding, high-pitched cry, and bulging fontanels.
Symptoms of meningitis in the child include...
fever, projectile vomiting, headache, and visual disturbances.
Symptoms of CHD in the infant include...
cyanosis with feeding, clubbing of the fingers and toes, dyspnea, failure to gain weight, fatigue, respiratory congestion
Early signs of CHF include...
tachycardia while sleeping, profuse sweating (especially on the scalp), fatigue, irritability, respiratory distress, and weight gain.
Acyanotic defects include...
patent ductus arteriosus, atrial septal defect, ventricular septal defect, and coarctation of the aorta
Cyanotic defects include...
transposition of the major vessels, truncus arteriosus, and Tetralogy of Fallot
Coarctation of the aorta (COA)
narrowing within the aorta that alters blood flow to the extremities
Symptoms of COA include...
elevated BP and bounding pulses in the upper extremities and dimished BP and weak or absent pulses in the lower extremities
Older children with COA might complain of...
dizziness, headache, fainting, and nosebleed, which can indicate that the BP is higher than usual.
Tetralogy of Fallot (TOF)
pulmonic stenosis, VSD, overriding aorta, right ventricular hypertrophy
Symptoms of TOF in infant include...
history of acute cyanosis and heart murmur at birth that worsens over first year of life; acute episodes of cyanosis and anoxia referred to as blue spells or tet attacks, occur during crying or feeding
Symptoms of TOF in child include...
noticeable cyanosis, clubbing of fingers, growth retardation
When oxygen is compromised in the child with TOF, the child assumes...
a squatting position.
Nursing care for the child with a tet attack includes placing the child in...
knee chest position and administering supplemental oxygen.
Phenylketonuria (PKU)
genetic disorder in which child is unable to metabolize phenylalanine into tyrosine; essential to formation of melanin (responsible for hair, skin, and eye color) and hormones epinephrine and thyroxine
Clinical manifestations of PKU include...
irritability, frequent vomiting, failure to thrive, and seizures; older children have bizarre behaviors such as head banging, screaming, arm biting, and other psychotic behaviors
Screening test for PKU
Guthrie blood test; side of heel; most reliable if newborn has ingested source of protein
Treatment of PKU
low-phenylalanine diet continued through adolescence; partial breast feeding allowed if monitored; solid food such as cereal, fruits, and vegetables added according to recommended schedule; most high-protein foods restricted; artificial sweeteners containing aspartame should be avoided
Galactosemia
infant appears normal at birth, but within a few days of ingesting a formula containing lactose, she begins to vomit and lose weight
Symptoms of galactosemia
jaundice, cirrhosis, portal hypertension, cataracts by 1-2 months of age, lethargy and hypotonia with brain damage
Treatment of galactosemia
eliminate all milk- and lactose-containing foods, including breast milk; fee a soy-protein formula
Symptoms of acute otitis media (AOM)
high fever (103 degrees-104 degrees F), anorexia, vomiting, and pain; rubbing or pulling at affected ear or rolling head side to side
If rupture of eardrum occurs...
pain and fever subside.
Treatment of AOM
antibiotics (amoxicillin, sulfonamides, erythromycin, or cephalosporins); antipyrectics (ibuprofen or acetaminophen) for fever and pain
Complications of AOM
mastoiditis, meningitis, and hearing loss
Hearing evaluation is recommended for a child who has bilateral OM for a total of...
three months.
Symptoms of tonsillitis
difficulty swallowing and breathing, enlargement of the tonsils, inability to smell and taste, mouth breathing, snoring
Postoperative tonsillectomy
child should be observed for continual swallowing, which is an indication of bleeding
Postoperative tonsillectomy, foods that should be avoided include...
citrus foods, hot foods, and foods with rough textures, as well as foods that are red, orange, or brown in color
Upon discharge of a tonsillectomy, parents should be instructed to...
keep the child out of crowds for 1-2 weeks.
Symptoms of laryngotracheobronchitis (LTB) (croup)
upper respiratory infection and low-grade fever, restless and irritable, noticeable hoarseness and brassy cough
The symptoms of hoarseness, cough, and inspiratory stridor can be relieved by providing...
high humidity with cool mist; frequently offer fluids; steroids or epinephrine to reduce bronchial swelling
The American Academy of Pediatrics recommends that all children receive the H. influenza B conjugate vaccine beginning at...
two months of age as part of the routine childhood immunization series.
Symptoms of acute epiglottitis
awaken complaining of sore throat and pain on swallowing, drooling, muffled phonation, inspiratory stridor, and sitting in tripod position; cherry red epiglottitis
Only the MD should exam a child's throat with epiglottitis because...
visualization can precipitate immediate airway obstruction; tracheostomy set or endotracheal intubation set should be readily available
Symptoms of bronchiolitis
dyspnea, nonproductive cough, wheezing, nasal flaring, intercostal and sternal retractions, emphysema
Treatment of bronchiolitis
oral fluids may be withheld until respiratory function improves; cool mist vaporizers with or without supplemental oxygen and respiratory therapy with Virazole (ribavirin)
Ribavirin should be administered within
3 days of the infection; pregnant healthcare workers should avoid direct care of the client receiving aerosolized Virazole (ribavirin)
Symptoms of CF
meconium ileus, frequent upper respiratory infections, malabsorption, failure to gain weight, heat prostration; reoccurring nasal polyps and rectal prolapse
Diagnosis of CF
sweat test
The sweat test in CF will reveal...
elevated sodium and chloride levels
In CF, the absence of pancreatic enzymes results in...
malabsorption and steatorrhea or undigested fat in stools
Treatment of CF
antibiotics to treat respiratory infections and pancreatic enzyme replacement to improve absorption and decrease weight loss
Diet for a client with CF
high in carbohydrates, high in protein, moderate in fat; extra salt is allowed; supplemented vitamins A, D, E, and K
Pancreatic enzymes are given...
with each meal and snack, and are best tolerated when given in applesauce because it disguises the taste
Gastroenteritis or...
acute diarrheal disease
Treatment of gastroenteritis
determine cause, assess for signs of fluid and electrolyte imbalance, ensure adequate hydration, adequate diet
Treatment of gastroenteritis of children
clear liquids with progression to BRAT diet (bananas, rice, applesauce, and toast)
Treatment of formula for infants with gastroenteritis
half-strength soy formula, full-strength soy formula, and (if tolerated) a return to regular formula
Potassium replacement should be instituted only after...
assessing for the presence of urinary output.
Symptoms of pyloric stenosis
projectile vomiting and a palpable olive-shaped mass in the right upper quadrant
Intussusception
invagination or telescoping of one portion of the bowel into another; most common site is ileocecal valve or where large and small intestines join
Symptoms of intussusception
colicky abdominal pain, sausage-shaped mass in abdomen, passage of currant jelly stools
Treatment of intussusception
conservative measures of air pressure or water-soluble contrast, surgical intervention
Celiac
malabsorptive disorder of proximal small intestine caused by intolerance to gluten
Gluten is found in...
grain of wheat, oats, barley, and rye
Symptoms of celiac
malabsorption, steatorrhea, abdominal distention, muscle wasting (in buttocks and extremities)
Treatment of celiac
replacement of gluten-containing grains with corn, rice, and millet
Rheumatic fever is an autoimmune response to...
Group A beta hemolytic streptococcal infection; affects skin, joints, brain, serous surfaces, and heart; damange to valves of heart (mitral)
In rheumatic fever, appearance of...
hemorrhagic lesions (Aschoff bodies) found in all affected tissues
Symptoms of rheumatic fever
carditis (heart) includes presence of apical systolic murmur, aortic regurgitation, tachycardia, cariomegaly, complaints of chest pain, development of mitral stenosis; polymigratory arthritis (joints) red, swollen, painful joints (larger, knees, elbows, hips, shoulders, wrists); erythema marginatum (skin) red macule with clear center found on trunk and proximal extremities; subcutaneous nodules (serous surfaces) small, painless swellings, bony prominences of feet, hands, elbows, vertebrae, scalp, scapulae; Syndeham's chorea (brain) aimless, jerking movements of extremities; involuntary facial grimacing; speech disturbances; emotional lability; muscle weakness
Minor symptoms of rheumatic fever
fever, arthralgia, elevated ESR, positive C-reactive protein
Supporting evidence of preceding Group A beta hemolytic streptococcal infection includes...
positive throat culture and positive ASLO titer
Treatment of rheumatic fever
eradicating hemolytic streptococcal infection, prevent cardiac damage, make child comfortable, prevent recurrences of Group A beta hemolytic infection
Kawasaki's disease is an...
acute systemic vasculitis; dilation of coronary arteries, which results in aneurysm formation
Symptoms of Kawasaki's disease
high fever that lasts five or more days and fails to respond to antipyretics or antibiotics, redness or bulbar conjunctiva, inflammation of pharynx and oral mucosa, red cracked lips, "strawberry tongue," swelling of cervical lymph nodes; swelling in weight-bearing joints; increased platelet counts and increased coagulation
One of the most notable symptoms of Kawasaki's disease
desquamation that begins at fingertips and toes and gradually spreads, leaving soles and palms red and swollen
Diagnosis of KD
no specific; diagnosis based on symptoms and lab work that reveals decreased number of RBC, increased number of immature WBC, increased ESR
Treatment of KD
IV immunoglobulin and aspirin
Signs of MI in infant or young child
abdominal pain, vomiting, restlessness, inconsolable crying, pallor, and shock
Signs of CHF in infant or child
respiratory distress, tachycardia, and decreased urinary output
Symptoms of aspirin toxicity
tinnitus, dizziness, headache, confusion
The nurse should instruct the parents to discontinue aspirin and notify the MD if the child is...
exposed to influenza or chickenpox
Treatment of scoliosis
use of Milwaukee brace or Boston brace and exercise; surgical correction with Harrington rods and Luque wires
A client treated surgically with Harrington rods should be...
logrolled when turning
Legg-calve-perthes disease
aseptic necrosis of the head of the femur
Symptoms of legg-calve-perthes disease
soreness, aching, stiffness, and appearance of limp on affected side; pain and joint dysfunction most evident on arising or at end of day
Treatment of legg-calve-perthes disease
bed rest, non-weight-bearing activity; abduction brace, leg casts, leather harness sling
Clinical manifestations of muscular dystrophy
delayed walking; wide-based waddling gait; lordosis; weak, hypertrophied leg muscles; use of Gower's maneuver to stand erect
Children with Duchenne muscular dystrophy lose the ability to walk by...
9-12 years of age.
Gower's maneuver
child places his hands on his knees and moves his hands up his legs until he's standing erect
Wims tumor (nephroblastoma)
renal cancer; confined to one side; firm and nontender; encapsulated, responsive to chemotherapy
With a wilms tumor the nurse should not...
palpate the abdomen
Symptoms of leukemia
anemia, fatigue, lethargy, fever, joint and bone pain, pallor, petechiae, enlargement of spleen, liver, and kidneys
Acute lymphoid leukemia is most prevelant in...
males 1-5 year of age
Treatment of leukemia
cytotoxic drugs and possible bone marrow transplantation
Osteogenic sarcoma
most common site is epiphyseal plate of long bones, particularly the femur
Managment of osteosarcoma
amputation of affected extremity and intensive chemotherapy
Salicylate, or aspirin overdose, results in...
an acid/base imbalance.
Symptoms of salicylate overdose
nausea, vomiting, dehydration, tinnitus, hyperpnea, hyperpyrexia, bleeding, convulsions, coma
Treatment of salicylate overdose
removal through emesis, lavage, activate charcoal; sodium bicarbonate transfusions to correct metabolic acidosis, vitamin K to control bleeding, diazepam to control seizures
Initial drug levels for acetaminophen overdose are drawn...
4 hours after the drug is ingested, but treatment should begin before the lab value is back
Treatment of acetaminophen overdose
IV acetylcysteine; plasma levels of 300 mcg/ml occuring 4 hours after ingestion or 50 mcg/ml occuring 12 hours after ingestion are associated with hepatotoxicity
Lead poisoning results in...
irreversible damage to the brain
Lead poisoning affects the...
hematopoietic, renal, and neurological systems
Low-dose lead exposure symptoms
impulsivity, hyperactivity, distractibility
High-dose lead exposure symptoms
mental retardation, paralysis, blindness, convulsions, and death
Treatment of lead poisoning
Chelation therapy with calcium disodium edetate (EDTA), calcium disodium versenate (Versenate), British anti-Lewisite (BAL/Dimercaprol), and Succimer (orally)
The client receiving Versenate should be assessed for signs of...
cerebral edema
Treatment of cerebral edema
IV mannitol or dexamethasone
Symptoms of iron poisoning
vomiting of blood and blood in stools; if left untreated, restless, hypotensive, tachypneic, cyanotic; hepatic injury, coma, death within 48-96 hours after ingestion if left untreated
Treatment of iron poisoning
emesis or gastric lavage; severe cases require chelation therapy with deferoxamine
CF affects the...
exocrine glands
The child with Syndeham's chorea has...
facial grimacing, jerking movements of the extremities, and rapidly changing mood.
ABCD assessment
airway, breathing, circulation, deficits
Only relief of airway obstruction and care of sucking wounds would take priority over the immediate control of...
bleeding.
Deficits include...
fractures, burns, wounds, and neurological injuries
Symptoms of partial obstruction of airway
noisy breathing and coughing
Clients who need airway management
scores less than 8 on GCS, maxiofacial injuries, aspirated, inhalation injuries from burns
A client with a partially obstructed airway should be encouraged to...
cough forcefully.
Always provide C spine immobilization before...
opening the airway of any client with undeteremined or suspected neck injuries
RR adults
12-20
RR children
15-30
RR infants
28-50
Tourniquets or inflated blood pressure cuffs are applied to an extremity only if...
hemorrhage cannot be controlled by direct pressure; should be loosened periodically
Infusion of LR helps...
restore circulation and allows time for blood typing and screening.
Resuscitative efforts continue until the client has a serum lactic acid level lower than...
2.5 mmol/L within 24 hours after the injury and there are no further signs of hemorrhage.
To test for responsiveness, note AVPU
alertness, verbal stimuli, pain, unresponsiveness
Rapid head-to-toe approach for trauma after ABCD, includes DCAP--BTLS
deformities, contusions, abrasions, punctures or penetrations, burns, tenderness, lacerations, swelling
Coup (site of impact) injuries occur in the...
frontal area of the brain.
Contrecoup injuries occur...
away from the site of impact (frontal and temporal areas of the brain).
The use of opiates for a client with a head injury is...
contraindicated because they cause CNS depression.
Flail chest
unequal chest movement
Blood tends to collect in these areas
anterior abdomen, flanks, back, genitalia, and rectum
Cullen's sign
ecchymosis around umbilicus; indicates retroperitoneal bleeding
Turner's sign
ecchymosis on either flank; indicate retroperitoneal bleeding
Ballance's sign
with client lying on left side, right flank is percussed, resonance indicates rupture of spleen
Kehr's sign
pain in left shoulder is seen in client with ruptured spleen
Pain in right shoulder indicates...
lacerations of the liver
Do not try to insert an NG if there is...
suspected skull fracture.
Vomiting is never induced in a client who has ingested...
corrosive or petroleum distillates.
Management of a client with a sting includes...
removing stinger and washing area with soap and water; discourage from scratching because it releases histamine; oral antihistamines and analgesics
In anaphylaxis or severe allergic reaction, give...
epinephrine and massage the site to speed absorption
Venomous snake bites is a medical emergency and the client should...
lie down; constricting items should be removed; affected area immobilized below the level of the heart; antivenin given (most effective when given within 12 hours of snake bite)
Corticosteroids are contraindicated in the first...
6-8 hours after bite because they can interfere with action of antivenin.
Symptoms of antivenin allergic reaction
feeling of facial fullness, itching, rash, and apprehension; followed by tachycardia, dyspnea, hypotension, and shock
Nerve agents
Tabun; Sarin; Soman; VX
Symptoms of nerve agents
salivation; lacrimation; urination; defecation; gastric emptying; pinpoint pupils (everything looks dark); seizures
Treatment of nerve agents
atropine (will not reverse miosis); Pralidoxime chloride; benzodiazepines for seizure control
Cyanides
hydrogen cyanide; cyanogen chloride
Symptoms of cyanides
nonspecific including anxiety, hyperventilation, respiratory distress; lactic acidosis and increased concentration of venous oxygen
Treatment of cyanides
antidote kit; amyl nitrite ampule inside BVM resuscitator; sodium nitrite; sodium thoisulfate
Vesicants
mustard; lewisite
Symptoms of vesicants
redness and blisters; inhalation injury can result in respiratory distress; leukopenia; pancytopenia
Treatment of vesicants
topical antibiotics; systemic analgesics; fluid balance; bronchodilators and steroids for pulmonary symptoms
Pulmonary intoxicants
chlorine; phosgene
Symptoms of pulmonary intoxicants
delayed onset of noncardiogenic pulmonary edema
Treatment of pulmonary intoxicants
hypertension with fluid; no diuretics; ventilate with PEEP, bronchodilators
Symptoms of riot control agents
ear, nose, mouth, and eye irritation
Treatment of riot control agents
irrigate; bronchodilators and steroids as needed
Anthrax symptoms
I: 1-6d; FLS; possibly widened mediastinum
Treatment of anthrax
delayed 24 hours until cultures are available; ciprofloxacin or doxycycline po 8 weeks
Cholera symptoms
I: 4h-5d; severe gastroenteritis with rice water diarrhea
Treatment of cholera
oral rehydration with WHO solution or IV hydration; tetracycline, doxycycline po for three days if resistant strain
Plague symptoms
I: 2-3d; FLS; CXR; patchy inflitrates or consolidation; gram stain of lymph node aspirate, sputum, or CSP
Treatment of plague
isolation. doxycycline or ciprofloxacin for 7 days; if symptomatic: gentamicin or doxycycline IV for 10-14 days; meningitis: chloramphenicol
Tularemia symptoms
I: 2-10d; FLS
Treatment of tularemia
gentamicin for 10-14 days
Q fever symptoms
I: 10-40d; FLS
Treatment of Q fever
most selflimited; tetracycline or doxycycline po 5-7 days
Smallpox symptoms
I: 7-17d; FLS. later erythematous rash to pustular vesicles; electron or light microscopy of pustular scrapings, PCR
Treatment of smallpox
isolation; PEP: vaccinia vaccine scarification, immune globulin IM
Viral encephalitides symptoms
I: 1-6d; FLS; immunoassay
Treatment of viral encephalitides
supportive
Viral hemorrhagic fever symptoms
I: 4-21d; FLS; easy bleeding and petechiae; enzyme immunoassay
Treatment of viral hemorrhagic fever
isolation and supportive; ribavirin
Botulism symptoms
I: 1-5d; descending bulbar, muscular, and respiratory weakness
Treatment of botulism symptoms
supportive; PEP: Toxoid, symptomatic: anti-toxin
Staphylococcus enterotoxin B symptoms
I: 3-12h; FLS
Treatment of staphylococcus enterotoxin B
supportive
Ricin symptoms
I: 18-24h: FLS, pulmonary edema, severe respiratory distress
Treatment of ricin
supportive
T-2 mycotoxins symptoms
I: 2-4h; skin, respiratory, and GI symptoms
Treatment of T-2 mycotoxins
supportive
Incorporation
client requires immediate medical management because cells, tissues, and susceptible organs (kidneys, bones, liver, and thyroid) have taken up radioactive material
Symptoms of acute radiation syndrome (ARS)
decreased WBCs, RBCs, and platelets; headache, nausea, vomiting; redness of skin, desquamation, necrosis
Green
minimal---injuries are minor and treatment can be delayed
Red
immediate--injuries are life-threatening but survivable with minimal care
Yellow
delayed--injuries are significatn and require medical care
Black
expectant--injuries are extreme, and survival is unlikely
Before administering antivenin, the nurse should...
check for an allergic response; perform the skin or eye test
Hispanic people believe that disease is caused by an imbalance in...
hot and cold.
Hispanic people often use a healer, referred to as...
santero/santera
In hispanic, the male is considered...
the head of the household; decisions should be discussed with the husband or father
In hispanic, the evil eye (mal de ojo) is thought to cause...
fever, crying, and vomiting in the infant
Treatment of evil eye
sweep body with eggs, lemons, and bay leaves
In hispanic, susto symptoms
brought on by emotional trauma; fever, vomiting, or diarrhea
Treatment of susto
brush body with ruda, rough ouject, for nine consecutive nights
In hispanic, bilis
disease of intestinal tract brought on by anger
Mangement of hispanic empacho
client lies face down with back bare; pinch piece of skin at waist, listening for snap as skin is released
Hispanic, eye contact is...
often avoided.
In childbirth, the hispanic client might...
not complain of pain; might remain stoic
Hispanic clients do not believe that colostrum is...
good for the infant.
Native Americans use...
medicine men, known as shaman.
For Native Americans, decisions regarding healthcare should be directed to the...
male members of the family.
For Native Americans, eye contact often is considered...
disrespectful.
Native Americans tend to be very...
quiet.
For Native Americans, the extended family...
typically attends the birth. The umbilical cord is given to the family after the birth to be buried near a tree.
Asian-Americans may nod in agreement...
even though they have questions or may not understand.
Asian medicine includes therapies such as...
acupuncture, acupressure, herbs, and dietary supplements.
Asian theory
yin (cold) and yang (hot)
Asian hot foods include
beef, chicken, eggs, fried foods, red foods, and foods served hot
Asian cold foods include
pork, most vegetables, boiled foods, foods served cold, white foods
In Asian culture, eye contact is a sign of...
disrespect.
In Asian culture, shaking hands with a person of the opposite sex is considered...
forward and inappropriate.
Asian clients are often...
stoic.
In Asian culture, birth is seen as a...
hot time and the family often takes the infant to allow the mother to rest and recover.
In Asian culture, the postpartum period is considered a...
cold time and the client may refuse peri-care, but might allow a heat lamp; 30-40 days is thought to provide healing
Hindu believe placing honey in the mouth of infant ensures a sweet life. However, this can cause
botulism
For Arab-Americans, the bed should be positioned
towards Mecca (southeast)
During Ramadan, Muslims must...
fast from sunrise to sunset (pertains to IV therapy and most injections as well)
Arab-Americans prefer to be treated by...
a healthcare worker of the same sex.
The body of an Arab-American who has died should be positioned...
east.
Milk is seldom consumed in the...
hispanic culture and chinese culture.
Devout Buddhists restrict...
meats and do not eat beef.
Do not consume most fruits
Japanese
Jewish dietary
pork is forbidden; fish without scales are forbidden; blood is forbidden; milk products should not be eaten at the same meal that contains meat and meat products
Beef, pork, and some fowl are restricted
Arab-Americans
For Hindu, a priest is called for consultation...
prior to treatments. Amputations of limbs might be refused.
Might refuse blood transfusions and surgery or treatments
Jehovah's witness
The best indicator of understanding of teaching is...
demonstration.
Alcohol is forbidden
Islamic religion
In the Islamic religion, the left hand is reserved for...
toileting; the right hand is considered clean and is used to eat and touch others
Negligence
lack of reasonable conduct and care; fails to perform an act
Malpractice
professional negligence, misconduct, or unreasonable lack of skill that results in injury or loss of professional services; medication errors, carelessness, failure to assess symptoms
Tort
legal wrong against a person or his property; intentional or unintentional; assault, battery, slander
Assault
unjustifiable threat or attempt to touch or injure another person
Battery
actual touching of another without consent
Fraud
intent to mislead in any form; recording vital signs that were not taken
The RN is the only personnel who can...
apply restraints; interpret CVP monitoring; start, manage, and discontinue IV infusions; blood transfusion
The LPN can...
collect specimens; insert NG; administer medications orally or by injection; change sterile dressing; tracheostomy care/endotracheal care; urinary catheters
Do not assign a nursing assistant to...
calculate hourly intake and output, take post-operative vital signs, or care for an unstable client.
Which client should be assigned to a private room
client with Cushing's disease; adrenocortical hypersecretion; increase in cortisone causes the client to be immune-suppressed
Vanillymandelic acid test is done to detect
pheochromocytoma; adrenal tumor that often leads to malignant hypertension
Collection of a 24-hour urine is required for a...
VMA level
Foods that should be avoided two days before a VMA test
coffee, tea, bananas, cocoa products, vanilla products, aspirin, and medications containing aspirin
Drainage of more than this is considered excessive and should be reported immediately to the provider
100 mls per hour
A client taking Phenelazine (Nardil) an MAO inhibitor should avoid foods high in...
tyramine to prevent hypertensive crisis; figs, chocolate, and eggplant
Unilateral neglect
leaning to left when believes he is sitting upright; washing or dressing only one side of the body
To assist a blind client with ambulation, the nurse should walk...
to the side and slightly in front of the client while the client holds onto the nurse's arm
A client receiving cyclosporine should be instructed to...
dilute the solution in chocolate milk and drink it immediately
Imipramine and other tricyclic antidepressants can cause...
cardiac dysrhythmias and should not be used in those with known cardiac disease
Signs of osteomyelitis
infection of the bone; fever, redness at the site, pain, signs of cardiac adjustment such as tachycardia
A complication of renal disease is...
anemia due to lack of erythropoetin; this leads to chronic hypoxia and heart enlargement
Cardioversion is synchronized with the...
QRS complex
Overuse of antacids composed of calcium carbonate or sodium bicarbonate can cause...
metabolic alkalosis
Acetaminophen and aspirin can cause...
acidosis
A client receiving cortisone retains...
sodium and water; should avoid a high-sodium diet
Smoking prior to surgery is not permitted because it...
stimulates stomach secretions.
Therapeutic APTT
60-90 seconds
A moribund client
one who is dying
Cross-sensitivity exists between
cephalosporin and penicillins
The woman who has delivered several term infants is more likely to experience...
extreme pain after delivery because the uterus is contracting with more difficulty in an attempt to decrease bleeding.
Piece of equipment that should be kept at the bedside of a client immobilized with Crutchfield tongs
torque wrench
Suppression
conscious forgetting
Repression
unconscious forgetting, revealed through slips of the tongue, dreams, or hypnosis
Ordered prior to an IVP
laxatives; to evacuate the bowel and provide for better visualization of the kidney
Aminophylline toxicity symptoms
nausea, jitteriness, tachycardia, hypotension, irritability
Conversion reaction
development of physical symptoms in response to emotional distress
Nipride in D5W is expected to be...
light brown in color.
Manipulation of objects in their environment enables the toddler to learn...
about spatial relationships.
Physiological responses to sensory alterations include...
increased urinary levels of catecholamines, 17-ketosteroids, and lutenizing hormones.
Healing by second intention results in...
excessive scar formation because the wound is left open and allowed to heal from the inside out.
Healing by first intention inolves the use of...
staples or sutures.
Drug of choice for managing status epilepticus
Diazepam (Valium)
Opiates such as morphine should not be used in clients with...
pancreatitis because they cause spasms in the sphincter of Oddi.
Highly suggestive of impaired hearing in an infant
absence of babbling by age 7 months
Vincristine or other antineoplastic drugs can cause...
changes in taste during or after administration.
A child with Syndeham's chorea will exhibit...
irregular movements of the extremities, facial grimacing, and labile moods.
Therapeutic digoxin
0.5-2.0 ng/ml
Therapeutic lithium
0.6-1.5 mEq/L
Therapeutic dilantin
10-20 mcg/dl
Therapeutic theophylline
10-20 mcg/dl
HR
80-100 bpm
Newborn HR
100-180 bpm
RR
12-20 respirations per minute
BP systolic
110-120 mm Hg
BP diastolic
60-90 mm Hg
Newborn BP systolic
65 mm Hg
Newborn BP diastolic
41 mm Hg
Temperature
98.6 +/-
Coumadin PT
12-20 sec
INR
2-3
Heparin PTT
30-60 sec
FHR
120-160 bpm
Variability
6-10 bpm
Frequency of contractions
every 2-5 minutes
Duration of contractions
less than 90 sec
Intensity of contractions
less than 100 mm Hg
Amniotic fluid amount
500-1200 ml
Airborn precautions
tuberculosis, measles (rubella), and chickenpox
Droplet precautions
influenza, mumps, pertussis, rubella (German measles), diphtheria, pneumonia, scarlet fever, streptococcal pharyngitis, meningitis
Contact precautions
RSV, scabies, colonization with MRSA, and VRE
Compensation
development of attributes that take the place of more desirable ones
Conversion reaction
development of physical symptoms in response to emotional distress
Displacement
transference of emotions to another other than the intended
Projection
transferring of unacceptable feelings to another person
Rationalization
dismissal of one's responsibility by placing fault on another
Reaction formation
expression of feelings opposite to one's true feelings
Repression
unconscious forgetting of unpleasant memories
Sublimation
channeling of unacceptable behaviors into behaviors that are socially acceptable
Suppression
conscious forgetting of an undesirable memory
1 minim
1 drop
1 fluid dram
60 minims
1 fluid ounce
8 fluid drams
1 dram
60 grains
30 ml
2 tbs
15 ml
1 tbs
5 ml
1 tsp
1 tsp
60 drops
2 tbs
1 ounce
1 cup
8 ounces
2 cups
1 pint
2 pint
1 quart
4 quart
1 gallon
1 pound
16 ounces
1 tsp
15-16 minims; 1 ml
2.2 lbs
1 kilogram
1 gr
60-65 mg
1 gm
15 gr
Folic acid
B9; client should be taking B9 three months prior to becoming pregnant
Renal diet
high calorie, high carbohydrate, low protein, low potassium, low sodium, fluid restricted to intake=output +500 ml
Gout diet
low purine; omit poultry; medication for acute episodes: Colchicine; maintenance medication: Zyloprim
Maslow's hierarchy of needs
physiological needs proceeds to safety and security, then love and belonging, self-esteem and, finally, self-actualization