NCLEX 2 Flashcards

Hemoglobin
Terms Definitions
myopia
nearsightedness
DIGOXIN
.5-2.0
Dilantin
10-20
TB: Precautions
Airborne
Electrolytes:
Parallel
Inverse
Parallel
Sodium/Calcium/Magnesium/Chloride
Inverse

Sodium/Potassium
Calcium/Phosphate
Hydrogen/Potassium
monocytes
4%; 0-800 cells/mm3
Ketoacidosis: S/S
Kussmaul respirations
Lethargy
CONDYLE
A ROUNDED PROJECTION
Gravid
A pregnant woman.
ammonia
35 - 65 mcg/dL
Laminectomy: Side rails
Don't use
FOUR NEGATIVES IN URINE
GLUCOSE,RBC,WBC,ALUMBIN.
Normal RBC Level
4.5-5.0 million
Hepatomegaly
Enlargement of the liver.
EXCESSIVE DRYNESS
BENZOYL PEROXIDE MAY CAUSE...
Evacuating Children: Should Not
LEAVE ALONE
docusate (Colace)
Laxative, stool softener
Problems include dependency, bowel damage, electrolyte imbalance
Cholecystitis
patients with cholecystitis should adhere to a diet low in fat and gas forming foods should be avoided.
s/sx of hemorrhage
tachycard & hypotension
CHEMISTRY VALUES

CPK
21 - 232 U/I
Incompatibility
Unsuitability for combination, often due to antagonistic action.
Addison's disease
A life-threatening condition characterized by fatigue, hypotension, loss of appetite and weight, nausea or vomiting, and increased hyperpigmentation of the skin and mucous membranes. It results from partial or complete loss of glucocorticoid, mineralocort
cream of wheat, blueberries, coffee
Thiamine
isocarboxazid (Marplan)
SSRI's (selective serotonin reuptake inhibitor
Cannabis Derivatives: S/S of Withdrawal
Insomnia
Hyperactivity
Decreased appetite
Ear infections
Often cause vertigo
Priority client due to safety
propranolol (Inderal)
Beta blocker
Used as antianginal, anti-arrhythmic, anti-hypertensive
S/E: Weakness, hypotension, bronchospam and depression
What is a possible complication associated with nasogastric tube feeding?
Aspiration
respiratory acidosis
Caused by reduced alveolar ventilation; is marked by increased partial pressure of arterial carbon dioxide, excess carbonic acid, and increased plasma hydrogen-ion concentration. Hypoventilation inhibits the excretion of carbon dioxide, which consequently produces excessive carbonic acid and thus lowers blood pH.
CN X
Vagus- pharynx, respiratory, cardiac and circulatory reflexes
Pilocar Eye Drops
eyedrops that promote constriction.
Nephritic syndrome
A clinical classification including all kidney diseases characterized by marked proteinuria, hypoalbuminemia, and edema.
Clinical depression
Syndrome characterized by persistent sadness and dysphoria accompanied by disturbances in sleep and appetite, lethargy, and an inability to experience pleasure.
Sensory perceptions
Awareness of one's surroundings through the use of vision, hearing, taste, touch, and smell.
IV 0.45%NaCl or 0.9%NaCl, encourage fluids, lasix, calcitonin, Mobilization, restrict diet (Ca), Inc PO fluid, maintain acidic urine
Magnesium
Bacillus anthraciss
contracted thru digestive system, abrasions in skin, or inhaled thru lungs
Newborn Assessment:Head
-general apperance, facial bruising is caused by birth trauma and should be noted.
-norm shape- flattened over forhead, raises to a point
-norm circumference- between 33& 38 cm
-Fontanelle size- the posterior fontanelle can be already closed at birth= NOT ABNORMAL, should feel soft yet spongy
-sunken fontanelle= dehydration
-over riding suture lines is a normal finding
-widely spaced suture lines=RED FLAG
Ear: Infection S/S
Priority client
Temperature of 100
C/O hearling loss in R ear
Wilms tumor
Most common intraabdominal and kidney tumor in childhood
Swelling or mass in abdomen
Manipulation of tumor may cause cancer cells to metastasize to other sites
Scoliosis: S/S
Arms appear different in length
Slight limp during ambulation
12. Parallel play for toddlers develops in this age range?
24-48 months
SIADH
patients with SIADH you'd expect low sodium levels because of water retention a dilutional hyponatremia occurs. Seen with patients that have Lung CA.
What condition will manifest in blast cells being present in the bone marrow?
Leukemia
bacteria's that cause meningitis
Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, or Escherichia coli.
Tofranil facts:
Tofranil S/E:
Anti-depressant that also treats neuropathic pain

Postural HOTN
Sore throat
fever
increased fatigue
V/D
VITAL SIGNS OF ADULT

RR
12 - 20 RPM
Effacement
Shortening of the vaginal portion of the cervix and thinning of its walls during labor due to stretching and dilation caused by the fetus. Full effacement obliterates the constrictive neck of the uterus. The extent of effacement is expressed as a percenta
Acute nephritis
Acute inflammation of the kidney, possibly involving the glomerulus, tubules, and interstitial tissues.
Cushing's syndrome
A metabolic disorder caused by chronic, excessive production of adrenocortical hormones or by prolonged high-dose glucocorticoid therapy. It’s characterized by such signs and symptoms as hypertension, diabetes mellitus, dusky complexion with purple striae
Controlled substance
Any substance that is strictly regulated or outlawed because of its potential for abuse or addiction.
Type 2 diabetes
An endocrine disorder involving disturbances in carbohydrate, protein, and fat metabolism; characterized by insulin resistance with varying degrees of insulin secretory defects. May be treated with diet, exercise, and oral antidiabetic agents. Exogenous i
Pancreatitis
Acute or chronic inflammation of the pancreas.
Agonsia
can't recognize sounds, tastes & other sensations, familiar objects
diabetic ketoacidosis
rehydrate with NS is initial step
magnesium
1.6 - 2.6 mg/dL used to determine metabolic activity and renal function; needed for blood clotting process, regulates neuromuscular activity
A nurse is taking the nursing history of a client with silicosis. The nurse checks whether the client wears with of the following items during periods of exposure to silica particles?
Mask
Tinnitus
Pt C/O ringing in ears and occasional vertigo
Cause for tinnitus should be determined
FAT EMBOLISM
ORIGINATES IN THE BONE MARROW AND OCCURS AFTER A FX WHEN A FAT GLOBULE IS RELEASED INTO THE BLOODSTREAM
What is effleurage?
Massage of the abdomen during contractions
Diuretic / Recovery phase of Acute Renal Failure
Urinary output > ?
4-5 liters/day
Lower Right Quadrant
An acute attack for appendicitis localizes as pain and tenderness in the LRQ.
Evisceration
1. Pushing out or removal of the viscera, especially through a surgical incision. 2. In ophthalmology: excision of the contents of the eyeball (except the sclera).
Cystic fibrosis
An inherited disorder of the exocrine glands that affects multiple organ systems, causing such conditions as chronic pulmonary disease, pancreatic deficiency, sweat gland dysfunction, malabsorption, and liver obstruction.
Ototoxicity
Harmful effect on the function of the eighth cranial nerve or hearing organs; most commonly associated with prescribed drugs.
aspirates feeding
suction airway to provide a patent airway
HYPOCHLOREMIA
IN A PT WITH 2ND-3RD DEGREE BURN, THE NURSE SHOULD MONITOR FOR FLUID IMBALANCE AND WHICH ELECTROLYTE IMBALANCE?
newborn abnormal cries at birth
-high pitch cry= abnormal
-to stimulate a cry- rub soles of feet. Trendelenburg or side laying position
Folic acid (Vitamin B9)
Prevent neural tube defect in fetus
Supplementation is recommended for all women capable of becoming pregnant
Abdominal aortic aneurysm (AAA): Lifting
Do not lift heavy objects
Chronic Renal Failure
patients with CRF should not consume foods high in potassium because they are at risk for hyperkalemia.
what is ulcerative colitis
colon is ulcerated chronically and recurrently. abd cramping. rectal bleeding. diarrhea c blood, pus, mucus.
Chvostek's Sign
this is a sign of hypocalcemia its abnormal facial msucle and nerve spasms elicitied when the facial nerve is tapped.
Vaso-occlusive crisis
The most common type of sickle cell crisis resulting from blood vessel obstruction by rigid, tangled sickle cells leading to tissue anoxia and possibly necrosis. Also called a painful crisis or infarctive crisis.
Allen's test
A test designed to evaluate a client's collateral circulation in the arm before an invasive arterial procedure such as arterial blood gas analysis. While the client's radial and ulnar arteries are occluded, he clenches his fist, causing the hand to blanch
PVD (Peripheral Vascular Disease)
hematemesis--> bright red/or dark red with coffee grounds
Diabetic Ketoacidosis: Discharge Teaching
-Signs and symptoms may include fast, deep breathing, increased urination, fruity-smelling breath, or weakness and confusion. The high sugar level, ketones, and acid can cause you to become very sick. High sugar levels also can lead to dehydration (loss of body fluids and salts)
A client is to receive three doses of potassium chloride 10 mEq in 100 mL of 0.9% normal saline to infuse over 30 minutes each. Which action is a priority assessment to perform before a nurse gives this medication?
"Urine output"
Phototherapy: Jaundice around eye disappearing
Indicates eye patches are not adequately placed
Eyes must be shielded to prevent light exposure, which could result in eye damage
Homans Sign
the nurse asks the woman to extend her legs flat on the bed. The nurse grabs the foot and dorsiflexes if forward. if this causes any discomfort on resistance. Homan's sign is present.
Talipes equinovarus Interventions:
Casting; changed Q1-2 wks for 8-12 wks w/progressive correction
Cardiac output
The volume of blood ejected by the heart per minute (normally ranging from 4 to 8 L). Cardiac output equals the stroke volume (the difference between end-diastolic volume and end-systolic volume) multiplied by the heart rate.
inc BP, protein in urine, weight gain greater than 1 lb/week or edema
Digoxin in infant
Wet to Dry Dressing: Clean wound
Clean wound with saline solution
Clean from least contaminated to most contaminated area of the wound to decrease potential for infection
What do normal hemoglobin levels mean?
iron and protein intake is sufficient.
Regular Insulin onset:
Peak:
Onset - 30 minutes
Peak: 2 - 4 hrs
Duration: 6 - 8 hrs
see how well pt can absorb vit B12, check see if pt have pernicous anemia
prevents kidney rejection
Instructions when giving a client nitro
Store meds in a dark container
*place tablet under tongue
*burning sensation indicates tablet is fresh
*position supine with elevated legs to manage hypotension
What medicine would be given to a client with a calcium level of 12 mg/dl
Calcitonin to decrease calcium levels
black tarry stools are a sign of
bleed high in the GI tract
Insulin needs dec in 1st trimester
b/c inc insulin production by pancreas & inc peripheral sensitivity to insulin.
What will be elevated in people with neuroblastoma?
Vanillymandelic acid levels in the urine.
A 45-year-old male returned to his room an hour ago following a bronchoscopy. He is requesting some water. The nurse must:
C. Check the gag and swallowing reflexes.
A 45-year-old male returned to his room an hour ago following a bronchoscopy. He is requesting some water. The nurse must:
A. Keep the client NPO until an order is written.
B. Check the vital signs first.
C. Check the gag and swallowing reflexes.
D. Encourage coughing and deep breathing.
A. A Guthrie test can check the necessary lab values. B. The urine has a high concentration of phenylpyruvic acid C. Mental deficits are often present with PKU. D. The effects of PKU are reversible.
The effects of PKU are reversible
The nurse's teaching plan for a rape prevention class should include which of the following regarding Flunitrazepam (Rohypnol)?
a. ingestion of the drug accelerates intoxication
The nurse's teaching plan for a rape prevention class should include which of the following regarding Flunitrazepam (Rohypnol)?
a. ingestion of the drug accelerates intoxication
b. a white sediment develops in the drink laced with Rohypnol
c. always smell your drinks because adding the drug to a drink creates a citrus aroma.
d. after ingestion, the client may become hyperactive
A nurse is providing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic periods. Which position will the nurse instruct the client to assume.
Sitting on the side of the bed, leaning on an overbed table.
The nurse needs to obtain a clean catch urine specimen from a client who presented to this women's health clinic with symptoms of gonorrhea. What instructions will the nurse give?
a. place a cotton ball into your vagina prior to obtaining the urine specimen
The nurse needs to obtain a clean catch urine specimen from a client who presented to this women's health clinic with symptoms of gonorrhea. What instructions will the nurse give?
a. place a cotton ball into your vagina prior to obtaining the urine specimen.
b. obtain the 1st stream of urine as the specimen
c. you will have to drink one pint of fluid prior to collection of the specimen
d. the catheter will be removed as soon as I gather the specimen
A 45-year old client has recently been told that she has acute nyelocytic leukemia. She seems quite happy and laughs and jokes about everything. The nurse should:
C. Wait and allow her to explore her feelings.
A 45-year old client has recently been told that she has acute nyelocytic leukemia. She seems quite happy and laughs and jokes about everything. The nurse should:
A. Remind her of the seriousness of her diagnosis.
B. Encourage her to continue with her laughter and joking.
C. Wait and allow her to explore her feelings.
D. Reprimand her for not taking her treatment seriously.
MYCIN
ANTIBIOTICS
TSH
.2-5.4
Calcium
Ca++
CAINE
LOCAL ANESTHETICS
Phosphorus
2.5-4.5 mEq/L
Psychosis
Withdrawal from reality
Cardioversion: Assess
Heart Rhythm
Anticholenergics
Decrease oral secreations
clindamycin HCl (Cleocin)
Macrolide
Patient with headache
Stable patient
Blaming
Indicate dysfunctional family process
Substance abuse is primary cause
Cushings
hypersecretion of adrenal hormones;moon face, buffalo hump, hurutruism, hyperglucemia/hypernatremia/inc wbc, hypocalcemia/kalemia
Cranial nerve I
optic- vision
9.0 to 10.5
Hypocalcemia s/s
Crutches: Shoes
Nonslip soles
Leather is unsafe
MMR, IVP, Varicella Vaccine: Allergies
Neomycin
OTHER WORDS ASSOC. WITH EVALUATION
MONITOR,EXPAND,SYNTHESIZE,CONSIDER,QUESTION,
Hyperthroidism
metabolism inc, goiter, exopathalum; thyroid storm
Pedi immunization schedule!
needs an answer
CHEMISTRY VALUES

LDH
100 - 190 U/I
Stridor
A high-pitched respiratory sound, usually heard during inspiration, caused by an obstruction of the trachea or larynx.
peripheral edema, JVD, organomegaly
Allen's Test
potassium food sources
avacado's, bananas, cantalopes, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, tomatoes
platelets
4units/hr, 0/9 ns, nonwettable filter, give quickly
metformin (Glucophage)
Antidiabetics
Take with meals to reduce side effect of drug
Does not cause weight gain
Halo traction: Screws
Determine tightness of screws
warfarin (Coumadin): INR
Anticoagulent
Prolongs PT
Maintains INR at 2-3
LAMINECTOMY
EXCISION OF LAMINA TO REMOVE DISKS
Hypomagnesium S/S
depresses ST segments, shallow respirations, positive Trousseaus and Chvostek sign, tetany
sensitivity to cold; claudication; more severe at night; decreased pulses
Buerger's disease
Cranial nerve V
Trigeminal- chewing, facial movement
THERAPEUTIC DRUG LEVELS

THEOPHYLLINE
10 - 20 MCG/DL
Myeloma
Osteolytic neoplasm consisting of a protrusion of cells typical of the bone marrow.
Crackles
Short, explosive or popping sounds usually heard during inspiration. They may be coarse (loud and low in pitch) or fine (less intense and high in pitch) and resemble the sounds heard when rolling hair between the fingers near the ear.
*high-pitched course sound, that is heard wit stetho over trachea.
Hemorrhoids
Po2
80-100 mm Hg partial pressure of oxygen
Sickle Cell: Crisis
Hydration is important
Priority for fluids
Nosebleed: Cause
Allergies
Frequent use of nasal sprays to relieve symptoms can result in vasoconstriction that causes atrophy of nasal membranes
Results in decreased integrity of blood vessels
Appendicitis: S/S
Pain prior to nausea and vomiting
Defibrillation: Joules
Set at 200 joules
then 200-300 joules
then 360 joules
Lumbar puncture: Headache
ASSESS
Assess puncture site for leakage of CSF or presence of hematoma
INTERNAL FIXATION
INVOLVES THE APPLICATION OF SCREWS, PLATES,PINS, OR RODS TO HOLD THE FRAGMENTS IN ALIGNMENT
Hemoglobin
Males: 14 to 16.5

Females: 12 to 15
Thyroid
controls rate of body metabolism and growth
what's cushing's syndrome
metabolic disorder r/t chronic, excessive production of adrenocortical hormones or by prolonged high-dose glucocorticoid tx.
BSE while pregnant
During breast-feeding, the client should examine each breast after neonate has emptied the breast. Women must continue to examine their breasts, even if they're lactating.
Graham Steell's murmur
A pulmonary regurgitation murmur resulting from pulmonary hypertension; usually loud with a blowing quality and variable in duration, it’s heard best along the left sternal border over the third and fourth intercostal spaces.
Mastectomy
The surgical resection of a breast; usually performed to remove a malignant tumor.
Croup
An acute viral infection of the respiratory tract that causes acute upper airway obstruction. Characterized by stridor, a barking cough, and hoarseness, it primarily affects infants and young children ages 3 months to 3 years and follows an upper respirat
Supratentorial
Located above the tentorium of the brain.
Trousseau's sign
An assessment technique for evaluating neuromuscular irritability (tetany) associated with hypocalcemia. When Trousseau's sign is positive, the client develops a carpopedal spasm (adducted thumb, flexed wrist and metacarpophalangeal joints, and extended i
Peritonitis
An inflammation of the peritoneum; can be produced by bacteria or irritating substances introduced into the abdominal cavity by a penetrating wound or perforation of an organ.
hypermagnesemia s/s
depresses CNS, dec cardiac impulse transmission, hypotension, facial flushing, muscle weakness, absent DTRs, paralysis, shallow respirations
Buck's Traction
elevate foot of bed for counter-traction
at 18 weeks for nulliparousat 14-16th week for multiparous
preeclampsia
Antiarrhythmics Indication
Preventing or treatment of atrial or ventricular arrhythmias including those secondary to MI or digitalis toxicity
Skeletal traction
Should never be removed without an order
Wilms tumor: Treatment
Surgery, followed by radiotherapy and chemotherapy
Chronic alcoholism: Need
Supplementation with all B vitamins, especially thiamine (vitamin B1)
Broken leg
Priority is to prevent further injury to leg
Splinting the joint above and below the fracture
Uninjured leg can be used as splint
"Bandage legs together"
Fluid Volume overload: S/S
Difficulty breathing in supine position or with minimal activity
Skin is pale and cool to touch with pitting edema in dependent areas
Decrease in LOC and moderate ascites
Appendencitis
The sequence of symptoms is the most reliable information from the history. When assessing for possible diagnosis, the clinical symptoms with pain usually come prior to Nausea and Vomiting. NVD that come before abdominal pain indicate gastroenteritis.
what are c-section babies at risk for
respiratory distress
Brain-frontal lobe
broca's area, aids in formulation of words
BETA ADRENERGIC BLOCKERS
GENERIC NAMES INCLUDE THE SYLLABLE "OLOL"
Action: blocks the sympathetic vasomotor response lowering B/P, Pulse rate, cardiac output
S.E. orthostatic HTN, bradycardia, N/V, diarrhea, CHF, blood dyscrasias.
Nursing Considerations: Monitor for changes in lab values (protein, BUN, creatinine)that would indicate nephrotic syndrome, B/P, HR and rhythm, signs of edema.
Battle's sign
Discoloration of the skin behind the ear after the fracture of a bone in the lower skull.
Osteoporosis
A disorder in which bone mass is reduced and fractures occur after minimal trauma. It occurs most commonly in postmenopausal women, sedentary or immobilized individuals, and persons on long-term steroid or heparin therapy.
20 to 39 seconds
1.5 to 2.5 times normal
pain that is relieved by food intakepain in midepigastric area
Ileostomy complication
Normal Physiological changes of pregnancy:Pyrosis
pyrosis=heartburn, experienced in mid to late part of pregnancy
Hypothermic Patients
Need to be handled gently and with caution
5. Object permanence for toddlers develops in this age range?
5 to 10 months
What are symptoms of iodine toxicity
abdominal pain, vomiting, diarrhea.
Digoxin maintenance dose:
0.125 - 0.5 mg/day
administer over at least 5 min
Check apical pulse
Apgar Scores
Apgar scores are used to indicate a need for resuscitation at birth.
n/v, ab pn, fever, extreme weakness, severe hypoglycemia & dehydration (acute), bp falls, shock/coma/death
Addisonian Crisis TX
In 2nd/3rd --> insulin dose need is increased (hyperglycemia)
Variable deceleration
Ergonomic Principles: Reinforcing Teaching about the use of a Standartized Walker
-check for correct height. Have client stand inside of walker with arms at their sides. Walker handles should be even with client's wrists
-used with client's that have unilateral or bilateral weakness or an inability to bear weight on one leg
-it requires arm strength and balance
Defibrillation: First action
Place gel pads on chest
Gel, cream, or saline-soaked gauze pads used
Better contact, prevents burns
8 stages of Erik Erikson's Psychosocial Theory
Oral sensory, Muscular Anal, Locomotor, Latency, Adolescence, Young Adulthood, Middle Adulthood, Maturity.
The community health nurse discusses with a client how her husband makes her feel like a servant. The client states that her husband demands all childcare and housework be done completely by her with no help whatsoever from him. The nurse understands her
A. Psychological abuse
The community health nurse discusses with a client how her husband makes her feel like a servant. The client states that her husband demands all childcare and housework be done completely by her with no help whatsoever from him. The nurse understands her
a. psychological abuse
b. physical abuse
c. sexual abuse
d. sociological abuse
Spinal Cord Injuries
Injury in the cervical areas of the spine (C) result in quadraplegia. Injury in the Thoracic cord (T) and below result in paraplegia.

C 4= diaphragm location
Heart failure
Inability of the heart to pump an adequate amount of blood to the tissues.
CNS depression, fatigue, depression, confusion
Heart sends out how much blood/min
A nurse assigned to care for a client following a left pneumonectomy. The nurse would avoid positioning the client:
On the side.
Visitor slumped to floor
Shake patient and shout "Are you all right?"
Assess unconsciousness
Open airway with head tilt of chin lift (jaw thrust if neck injury is suspected)
A 46-year old client has just had a femoral-distal bypass. It would be most importnt for the nurse to assess:
C. Pedal pulses
A 46-year old client has just had a femoral-distal bypass. It would be most importnt for the nurse to assess:
A. Serum cholesterol levels
B. Popliteal pulses
C. Pedal pulses
D. Cardiac enzyme levels
Debridement for Burn Patient
When debriding a burn the RN should adminster analgesics 30 minutes before wound care, that may be proceded by hydrotherpay. It is important to organize time for the dressing change and provide emotional support.
Detection of HIV confirmed by
p 24 antigen assay, virus culture, polymerase
Infant with cleft plate: Feeding
Rubber tip syringe can be placed at side of mouth to avoid the operative area and prevent sucking on tubing
A 49-year old client with cancer of the lung just had a throacentesis. The nurse would position the client:
C. on the unaffected side
A 49-year old client with cancer of the lung just had a throacentesis. The nurse would position the client:
A. On the affected side
B. Sitting
C. On the unaffected side
D. In Fowler's position
DEFINE TORCHS SYNDROME IN THE NEONATE?
THIS IS A COMBINATION OF DISEASES INCLUDING
TOXOPLASMOSIS
RUBELLA (GERMAN MEASLES)
CYTOMEGALOVIRUS
HERPES
SYPHYLIS
The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for TB. Choose the instructions that the nurse will include on the list.
Activities should be resumed gradually, A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated, Respiratory isolation is not neccessary because family members have already been exposed, Cover mouth and nose when coughing or sneezing and confine the use of tissues to plastic bags.
The nurse understands that clarification of knowledge is necessary when a female client who is suspected to have been raped states:
a. just because he made me have oral sex doesn't mean I was raped.
The nurse understands that clarification of knowledge is necessary when a female client who is suspected to have been raped states:
a. just because he made me have oral sex doesn't mean I was raped.
b. I'm going to learn self-defense and fight back next time
c. I thought he was a polite guy who was interested in me. Guess you can't be too careful because a rapist doesn't have any identifying characteristics.
d. I didn't have anything to drink and my clothes were modest, so no one could accuse me of leading him on.
what's kernig's sign and what does it indicate?
tests for meningitis: Elicitation of resistance & hamstring pain when you extend the knee while the hip and knee are both flexed 90 degrees.
client with TB asks a nurse about precautions to take after discharge from the hospital to prevent infection of others. The nurse develops a response to the client's question based on the understanding that:
The disease is transmitted by droplet nuclei
A 26-year old client is having a chest tube inserted into the left upper chest wall posteriorly. The nurse anticipates that which of the following will be used to cover the incision?
D. Sterile petrolatum (Vaseline) gauze
A 26-year old client is having a chest tube inserted into the left upper chest wall posteriorly. The nurse anticipates that which of the following will be used to cover the incision?
A. Sterile Gauze
B. Kerlix
C. A sterile sealant
D. Sterile petrolatum (Vaseline) gauze
Lindy states that she uses douching as a method of birth control. Which of the following statements should the nurse make?
B. Douching may actually facilitate a pregnancy.
Lindy states that she uses douching as a method of birth control. Which of the following statements should the nurse make?
a. Douching can be an effective method if used appropriately.
B. Douching may actually facilitate a pregnancy
C. The timing of douching following intercourse is very important.
D. Combining doughing with the use of condoms may assist you in avoiding prenancy and a STI
a nurse working on a respiratory nursing unit is caring for several clients with respiratory disorders. The nurse would identify which of the following clients as being the least risk for developing infection with TB?
A man who is an inspector for the U.S. Postal Service.
HEMATOCRIT/FEMALES
37-48%
Librium
.8-2.1
reboxetine (Vestra)
atypical
PIVOT
ALLOWS ROTATION
Amnesia
memory loss
HIV Patient: Precautions
Standard
TOTAL PROTEIN
6.0-8.0 GM/DL
Benzodiazepines:
Ativan? or
Haldol? or
Valium?
Ativan
Valium
avoid Tyramine
Schilling test
Oral contraceptives: Antibiotics
Effectiveness decreases
2 anti coagulants
Coumadin, Heparin
ABG VALUES

PAO2
80% - 100%
Sx: Pallor, coolness, swellingIntervention: Remove cath & start IV line at another site
Phlebitis
glipizide (Glucotrol)
Oral hypoglycemic
Decreases blood sugar by stimulating insulin release from beta cells of pancrease
Beta blocker
Decreases excitability of heart
Reduces cardiac workload and oxygen consumption
Decreases release of renin
Lowers blood pressure by reducing SNS stimuli
PROCESS
LARGE PROJECTION OF A BONE
Anti-Infectives
Used for treatment of infections
menigitis assessment findings
headache
photophobia
fever and chills
lethargy
confusion, malaise, irritability, vomiting
nuchal rigidity
kernigs sign
brudzinskis sign
SERUM ELECTROLYTE

MAGNESIUM
1.5 - 2.5 MEQ/L
Milieu
A therapeutic environment, typically used as part of inpatient psychiatric therapy.
Cholelithiasis
Causes enlarged edematous gallbladder with multiple stones & an elevated bilirubin level.
Intracavitary radiation for cancer of the cervix, what is # 1 risk
DEHYDRATION
Vesicular
Soft low pitched breezy sounds
Heard over most of peripheral lung fields
Cardiac problems: S/S
Widening pulse pressure
Bradycardia
Alcohol: Early S/S of Withdrawal
Hyper-alert
Startles easily
Anorexia
Albumin
deficits in albumin indicate a decrease in oncotic pressure and fluid shifts from vascular area to tissue resulting in edema.
Normal value : 3.5 to 5.0

Low Albumin indicated poor nutritional status.
Brochodilators
Dilate Large ari passages in asthma/lung disease
Lithium depends upon what body chemical to be normal for lithium to be effective?
Sodium
Pentamidine Isethionate
clients with AIDS receiving pentamidine isethionate should have their blood sugar levels monitored frequently because that drug can cause permanent diabetes mellitus.
Urinary incontinence
Inability to prevent urine discharge.
Paralysis
An abnormal condition characterized by the loss or impairment of motor function or the impairment of sensory function.
Bruit
An abnormal vascular "swishing" sound heard on auscultation as a result of turbulent blood flow through dilated, irregular, torturous, or stenotic vessels.
Polyphagia
Voracious or excessive eating before becoming satiated.
dehydration b/c of hemoconcentrationHeart failure & COPD inc hemoglo as result of body's need for more oxy-carrying capacity
Renal failure diet
SOLAR RADIATION
MAJOR EITIOLOGICAL FACTOR IN BASAL CELL CARCINOMA
Pleural friction rub
Grating sound or vibration
Heard during inspiration and expiration
Z-track
Variation of IM technique for meds highly irritating to subcutaneous and skin tissues
Role of charge nurse
To support agency decisions
isoniazid (INH): Need
Antitubercular
Need vitamin B6 to prevent S/E of peripheral neuropathy, dizziness and ataxias
Pain
Is body's signal that there is potential for harm
Withdrawal from situatoin
miconazole (Monistat 7)
Antifungal (Topical)
Full doses should be taken, even if period
Given for vulvovaginal candidiasis
Platypelloid pelvis
Pelvis type characterized bye a transverse oval inlet, is often noted a flat pelvis.
Parity
The number is pregnancies that have been carried to viability.
population with highest incidence of esophageal cancer
black males
Oliguric phase of renal failure:
Daily urinary output < ?
400 ml/day
Ticlopidine
this drug prescribed to prevent a thromboembolic stroke it inhibits platlet aggregation by interferring with adenosine diphosophate releases in the coagulation cascade and is used to prevent thrombomblic stroke.
Hemogram
Written recording of the blood count differential.
Crystalloid fluid
Clear solutions (usually in reference to I.V. solutions) containing electrolytes and water.
Wilms' tumor
A rapidly growing malignant kidney tumor that occurs most commonly in children younger than age 5, although it sometimes develops before birth. Rare cases occur later in life. Also called adenomyosarcoma.
Pressure ulcer
Localized area of skin breakdown occurring secondary to prolonged pressure. Necrotic tissue develops because the vascular supply to the area is diminished.
hairless dry scaly & dependent ruber
PVD- venous
cryoprecipitate
treat bleeding form hemophilia or DIC b/c it is rich in clotting factor
Immobilizing Interventions: prioritizing care for a client with a long arm cast
*use sling for arm/cast support,
*keep arm raised above heart for first 48hrs
*raise arm over head throughout day to prevent shoulder stiffness
*monitor skin color and warmth of skin, keep dry and move fingers frenquently
Kegel exercises
2-3 times a day
Best done while sitting, standing, or lying down
Breathing should be relaxed and normal
Volkmann contracture
In cast with fingers and wrist contracted
Type of compartment syndrome
Caused by obstruction of arterial blood to forearm and hand
Can't straighten fingers, severe pain, s/s of diminshed circulation
Impaired immune system
Relaxation can help system repair itself
Genu varum (Bowleg)
Bowleg
Caused by lateral bowing of tibia and last until all leg and lower back muscles are well developed
By 2 years of age
4. Which of the following months matches with an infant first having the ability to sit-up independently?
6 months
Dupuytren Contracture
a slow progressive contracture of the palmar fascia causing flexion of the 4th and 5th fingers resulting from inherited autosomal dominant trait, occurs most often in men over 50 years of age, of Scandinavian or Celtic descents. Also associated with diabetes mellitus, gout, arthritis, and ETOH use.
Anorexics have problems with what feelings?
self-identity & self-esteem
Condom Catheter
A condom catheter can be an appropriate intervention for an elderly male client who is incontinent of urine because it used a condom-type device to drain urine away from the client.
Erythroblastosis fetalis
Hemolytic anemia of the neonate caused by placental transmission of maternally formed antibodies against the incompatible antigens of fetal blood. It results from maternal-fetal blood group incompatibility, specifically involving the rhesus (Rh) factor an
Anticipatory guidance
Information about a disorder or about the normal growth and development expectations of a specific age-group given at an appropriate time before an event in order to provide the client with support and strategies for dealing with potential problems before
Rectal route
Use of the rectum to administer medication
Hemolytic reaction
Type of blood transfusion reaction occurring when the donor's blood is incompatible with the recipient's blood; the most serious type of transfusion reaction.
Synergistic effect
Administration of two drugs producing the same qualitative effect together to produce a greater response than either drug alone.
Lochia serosa
A pink or brownish discharge persisting for 5 to 7 days postpartum.
preferred agents to treat constipation in children
Hyperbilirubinemia in newborn
congenital anomaly,
absence of ganglion cells in rectum. chronic constipation, ribbon like stools that are foul smelling
Meningitis: Expected findings: (Brainspine Infection)
s/s fever, chills, confusion, nausea, vomiting, sensitivity to light, often SEVERE HEADACHE, stiff neck, may have infection in blood, nose, or ear.
*monitor for DEHYDRATION, maintain dim lighting and assist with ADL'S
Dirty bomb: Actions
Turn off air conditioners and forced air into building
Close and lock all doors
Move to an inner room or basement
Peptic Ulcer Disease:Diet
Avoid diets rich in milk and cream
Stimulates acid secretion
Anti-Social Personality Disorders
These patients usually do not progress well, they move from a situation in an opportunistic fashion, and experiences problems with authority.
A 66-year old client with congestive heart failure takes both Digoxin and Lasix daily. The nurse would want to know the results of the following laboratory test:
D. Electrolyte panel
A 66-year old client with congestive heart failure takes both Digoxin and Lasix daily. The nurse would want to know the results of the following laboratory test:
A. Complete blood count
B. Blood urea nitrogen and createnine
C. Coagulation times
D. Electrolyte panel
these three cranial nerves control eye movement
III, IV, VI
SCHEDULE IV DRUGS
REQUIRES A NEW PRESCRIPTION AFTER SIX MONTHS.
(DIAZEPAM)
Eschar
A thick scab or dry crust that appears after a thermal or chemical burn.
Phototherapy
The treatment of disease by the use of light, especially ultraviolet light or other concentrated rays; used to treat acne, psoriasis, and hyperbilirubinemia.
Cystic fibrosis Diet
diet low in fat, high in Na
hyperinflation of alveoliflattening of diaphragm
dyspnea c prolonged expiration hyperresonant lungs to percussion
Client Rights: Refusing Treatment
arguement among family, or doubt on healthcare team, treatment must be given until case is resolved in court.
-Only time a person does not have right to make decision to refuse treatment is when greater public interest would be in danger
Infant: Tetralogy of Fallot
Enlarge hole in nipple of formula bottle
Allows child to obtain nourishment easily
Feed on 3 hour schedule and feed soon after awakening so infant doesn't cry
Signs of Volume Defecit
* Increase pulse rate with thready quality.
* Decreased blood pressure
* Fever
* Increased rate and depth of respirations.
when is contact isolation used
gi infx, diarrhea, wound infections, draining abscesses
Lung CA
this is a common cause of SIADH, which results in increased water absorption, and dilutional hyponatremia. Diuretics are used to promote fluid loss.
Postterm neonate
A neonate born after the onset of the 43rd week of pregnancy.
MRI, CT scan, ultrasound
visulaize the mass but not confirm diagnosis of malignancy
Colorectal Cancer: Risk Factors
> 50 years of age
High protein, high fat, low fiber diet
Family Hx (first degree relative) of colorectal cancer or polyps
Hx of chronic inflammatory bowel disease
Special Rules for ECT
patients receiving ECT are at risk if they are taking any drugs for osteoporosis ( i.e. Fosamax)
Nardil is what type of drug?

Should NOT be taken with what foods?
MAO inhibitor
Antidepressent & anxiolytic
DONT TAKE W/TYRAMINE FOOD
S/E = dizz, blurred vision, dry mouth, HA, lethargy, the gamut
Electroconvulsive therapy (ECT)
The induction of a brief seizure and loss of consciousness by applying a low-voltage alternating current to the brain through scalp electrodes. ECT is used in the treatment of affective disorders (primarily acute depression), especially in clients resista
What is considered adequate urinary output for perfusion of kidney, heart, and brain?
A rate of 30ml/hr is considered adequate.
Peripheral vascular disease: Avoid
Using warm or cold packs on hands or feet
Decreased sensitivities may result in burns
Should use gloves and socks instead
The nurse working on the sexual assault response team (SART) will begin acquisition of medical and forensic data by first:
c. obtain a detailed hx of the event
The nurse working on the sexual assault response team (SART) will begin acquisition of medical and forensic data by first:
a. photograph any physical injuries
b. scrape under the victim's fingernails
c. obtained a detailed hisotry of the event
d. mark clothing and seal in an airtight bag
* Private room or cohort gloves gown
Glycerin suppositories
Use of nasal decongestant spray: Position
Should be seated with head erect or tilted slightly backward
Contagious Infection Period for TB
After 4 weeks of treatment for TB the disease is no longer considered infectious but the client must continue to take their medication.
Why would a nurse assess for gastric residual prior to administering a tube feeding?
to check to confirm weather undigested formula from a previous feeding reaminas and therby evaluates absorption of the last feeding
The nurse is taking a neurologic health history from a female client who is concerned with symptoms of premenstrual syndrome. Which of the following symptoms should the nurse inquire about?
b - vertigo
The nurse is taking a neurologic health history from a female client who is concerned with symptoms of premenstrual syndrome. Which of the following symptoms should the nurse inquire about?
a - urinary retention
b - vertigo
c - edema
d - acne
Diet for Regimen to prevent Dumping Syndrome
* Avoid Simple Sugars
* Avoid Fiber
* Eat a diet high in proteins
* Avoiding stimulating your metabolism by exercising right after eating.
A 29-year old client has been taking prednisone 60 mg daily for an inflammatory condition for the past 6 months. The physician just wrote an order to discontinue the medication. The nurse should:
C. Call the physician and question the order
A 29-year old client has been taking prednisone 60 mg daily for an inflammatory condition for the past 6 months. The physician just wrote an order to discontinue the medication. The nurse should:
A. Stope the medication as ordered
B. Continue the medication until the physician is available
C. Call the physician and question the order.
D. Hold the medication until the physician is available
A client admitted to the er for a broken leg confides to the nurse that her boyfriend pushed her down the stairs. The client asks the nurse, "why would he bo so cruel to me?" The nurse's best response would be:
c. men who abuse women are insecure and feel powerless
A client admitted to the er for a broken leg confides to the nurse that her boyfriend pushed her down the stairs. The client asks the nurse, "why would he bo so cruel to me?" The nurse's best response would be:
a. i guess you did something to provoke him and he overreacted.
b. i bet this is a family trend for you. were you battered as a child?
c. men who abuse women are insecure and feel powerless
d. was your boyfriend drinking? alcohol causes domestic violence.
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Term:
Definition:
Definition:

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