1
Q
Osteoporosis
A
- Encourage weight-bearing exercises, including BRISK WALKING to prevent bone loss.
- Cottage cheese is NOT a good source of calcium d/t PROCESSING
2
Q
Infant development (8, 12, 13 months)
A
8 months: sit up unsupported
12 months: anterior fontanel closes
13 months: walk independently
3
Q
Disseminated Intravascular Coagulation (DIC) expected findings
A
☑ bleeding at venipuncture site
☑ petechiae on chest & arms
☑ abdominal distension
RATIONALE: the formation of large amounts of microemboli in circulation depletes the body’s platelets and clotting factors, ∴ leading to uncontrollable bleeding at venipuncture site, petechiae, and abdominal cavity
4
Q
Iron-rich foods
A
meat, fish, poultry, including BEEF LIVER
5
Q
Anemia (aplastic, pernicious, sickle cell) manifestations
A
- Aplastic: decreased RBCs, WBCs, & platelets
Manifestations: petechiae & ecchymosis - Pernicious: body can’t ABSORB vitamin B12 d/t weak stomach lining or autoimmune condition.
Manifestations: glossitis (smooth, beefy-red tongue) & weight loss (bc glossitis) - Sickle Cell Anemia manifestations: Jaundice & enlarged liver & spleen
6
Q
72 hr postop above the knee amputation (nursing actions)
A
☑ wrap residual limb w/ bandage 3x/day
☑ assist into prone position for 20-30 minQ 3-4 hrs to decrease r/f flexion contractures
☑ don’t elevate residual limb for 72 hrs after bc can lead to flexion contractures
7
Q
impetigo contagiosa pnt education
A
☑ apply topical antibacterial ointment
☑ wash bed linens daily w/ HOT water
☑ wash hands before and after contact w/ area
8
Q
ACTIVE labor pain relief (nonpharmacological)
A
- assisting client into a warm shower stimulates release of endorphins
- music is a distraction and relaxation in EARLY labor, NOT active
9
Q
Leadership style for CPR situation
A
AUTOCRATIC!
RATIONALE: We need direct commands and someone to organize/take charge for CPR. Participative leadership AKA democratic is NOT good because that leader is a resource and facilitator and non-directive
10
Q
Stomatitis (nursing actions)
A
What is it: swelling and sores inside mouth
DO: use a soft toothbrush, remove dentures except eating, rinse mouth w/ HYDROGEN PEROXIDE, warm saline, or baking soda Q2-3 hrs
DON’T: use lemon & glycerin swabs after meals bc they cause drying and irritation
11
Q
Chronic kidney disease diet limitations
A
☑ limit fluid intake (to prevent hypervolemia)
☑ limit protein intake (to prevent build-up and uremia)
☑ increase calories (so body can use protein for protein synthesis instead of energy consumption)
12
Q
Cycloplegia expected finding after administering atropine
A
expected finding: BLURRED VISION after administration of atropine d/t paralysis of ciliary muscle preventing near-vision focus
13
Q
Cocaine intoxication expected findings
A
☑ dilated pupils
☑ increased BP
☑ increased temp
RATIONALE: stimulant! fight-or-flight!
14
Q
late-stage CKD nutrients to increase
A
increase calcium because can develop hypocalcemia d/t decreased production of active vitamin D (Needed for calcium absorption)
15
Q
Superior vena cava syndrome
A
What is it: Medical emergency! Partial occlusion of the superior vena cava → decreased blood flow through the vein
Earliest manifestation: FACIAL and UPPER EXTREMITY EDEMA
16
Q
When to change tubing for TPN?
A
change IV tubing for TPN Q24 hrs
17
Q
Brachytherapy
A
- What is it: radioactive infusions or insertions into or near the tumor
- put on bedrest while radioactive implant is in place to prevent dislodgment
- there are no restrictions regarding contact with others
18
Q
Newborn Vital Signs
A
RR: 30-60
HR: 110-160
BP: 60-80/40-50
T: 97.7-99.5
19
Q
What to do when a client with an NG tube has nausea
A
FIRST: irrigate tube to determine patency. If tube isn’t patent, gastric pressure can’t decrease and increased pressure causes nausea!
DON’T clamp tube because that will worsen the nausea
20
Q
Tension-building phase of cycle of violence
A
episodes of violence are often minor, and recipient might rationalize the episodes by taking blame
21
Q
Car seat safety
A
☑ REAR-FACING until 2 Y/O
☑ place shoulder harness in the slows at level or slightly below the newborn’s shoulders
☑ place retainer clip at level of ARMPITS, NOT ABDOMEN
☑ position at 45 degree angle to prevent slumping and decrease r/f airway obstructions d/t weak neck muscles
22
Q
Hydrotherapy
A
- used for wound debrisment
- client on a shower table, constant warm water, decreases f/t infection
- use soft wash cloths or gauze to debride wounds
- leave small blisters, cut open the large ones
23
Q
nephrotic syndrome nursing care
A
provide skin care d/t edema and r/f infection
24
Q
Transient Ischemia Attack (TIA)
A
What is it: a temporary disturbance in blood supply to the brain d/t atherosclerotic plaque in the carotid arteries and HTN ∴ limit sodium to control HTN and prevent future TIAs
When discharged, teach to monitor BP!
25
Hypoglycemia manifestations
diaphoresis, palpitations, shakiness
26
Pregnancy weight gain for BMI > 30
Limit weight gain to 11-20 lbs during pregnancy
27
Playing Development (Infants, Toddlers, Preschool, School-age)
Infants: solitary play
Toddlers: parallel play
Preschool: associative play
School-age: cooperative play
28
What vaccines to postpone with Kawasaki Disease (KD) if they are being treated with IV immune globulin
- IV immune globulin treatment for KD has antibodies that can interfere w/ action of live-virus vaccines like measles, mumps, and rubella (MMR)
- postpone MMR for 3-6 months!
29
PCA Pump
- allows dosing Q6-8 min
| - can use TENS while using PCA pump
30
Alternative restrains for confused and wandering clients
Use a rocking chair to expend some energy through rocking instead of wandering
31
What nutrient promotes wound healing?
Vitamin C!
32
Religious practices (Judaism/Jewish, Islamic, Hindu, Buddhist) for the dead
★ Jewish (Judaism): stay with body until burial
★ Islamic: body is washed and wrapped during ritual and buried ASAP following death
★ Hindu: place body w/ head facing North following death. CREMATION, not burial
★ Buddhist: male members prepare body
33
Cushing's Syndrome
What is it: Over-secretion of glucocorticoids leading to muscle atrophy
Check for: urine specific gravity to assess for fluid volume overload and hyperglycemia because increase cortisol increases blood sugar
34
What to feed an infant with after surgical repair of cleft palate
After surgical repair, feed infant with a cup to prevent injury to suture line
35
Closed chest drainage system: when bubbling in water chamber stops
- bubbling in water seal chamber STOPS when lung RE-EXPANDS
| - Tidaling in water seal chamber is d/t INHALATION and EXHALATION
36
steps for gastric hemorrhage and going into shock
1. ) ADMINISTER O2 via NONREBREATHER
2. ) INITIATE IV therapy w/ large bore catheter to support circulation by expanding intravascular fluid volume
3. ) INSERT NG tube to monitor rate of bleeding and prevent gastric dilation
4. ) ADMINISTER RANITIDINE when no longer bleeding to prevent a stress ulcer
37
Zenker's Diverticulum
What is it: AKA pharyngeal pouch, is herniation of the esophagus occurring through the cricopharyngeal muscle in the midline of the NECK
38
Autonomic Dysreflexia (AD)
What is it: an exaggerated response to stimuli in clients who have high level spinal injuries
If untreated: can lead to stroke, organ damage, or death
Manifestations: bradycardia, severe HA, flushing, and nasal congestion
Hallmark sign: sudden increase in BP
39
Granulating wound dressing
☑ hydrocolloid and transparent film dressing
☑ use 30mL - 60 mL syringe when irrigating
DON'T apply wet-to-dry dressing because can interrupt healing tissues when removed
40
Cushing's Triad
What is it: bradycardia, severe HTN, widened pulse pressure
How: TBI ⇨ increased ICP ⇨ Cushing's Triad
41
Kidney Transplant
- lifelong immunosuppressive therapy for organ RECIPIENT
| - HEMODIALYSIS needed after getting kidney from a DEAD DONOR
42
First thing to do in ER, client c/o chest pain 8/10
FIRST: administer morphine
RATIONALE: greatest risk is myocardial ischemia, ∴ use morphine to increased O2 supply and decreased O2 demand of the heart
43
PRIORITY ACTION after 1 hour after cardiac cath and there is a hematoma at insertion site and decreased pulse in affected extremity
apply firm pressure to insertion site to STOP BLEEDING
44
Diabetes and acute bronchitis
"take insulin even if you are unable to eat your regular diet"
Take insulin even when sick to PREVENT HYPERGLYCEMIA
45
Nonrebreather mask
highest concentration of O2 (80% - 95%), but client has to breathe unassisted. Give if pulse ox is low low
use ambubag for assisted breathing during CPR
46
Cirrhosis (bilirubin and albumin)
expect increased bilirubin and decreased albumin because albumin is formed in the liver
47
Gout pnt education
- decrease intake of PURINE MEATS (organ meats and shellfish) to prevent precipitating an attack that causes pain and inflammation in joints
- what to take for ACUTE ATTACK: take COLCHICINE, INDOMETHACIN, or corticosteroid
- ALLOPURINOL: decreases uric acid after initial manifestations of acute attack have resolved
48
Specimen collection on wound
- swab back and forth over clean areas in the BASE of the wound, NOT EDGES
- cleanse wound w/ 0.9% sodium chloride irrigation to remove surface debris or old exudate
49
What to do before feeding a pnt w/ a gastrostomy tube
- flushing w/ WATER, not 0.9% sodium chloride
| - elevate HOB
50
What to avoid when using a fentanyl transdermal patch
Avoid using a heating pad on the area with the patch because heat will increase rate of absorption and lead to respiratory depression
51
Injury to the brain (cerebellum, hypothalamus, cerebral cortex)
difficulty w/ muscle coordination ⇨ CEREBELLUM
difficulty w/ sleeping ⇨ HYPOTHALAMUS
difficulty w/ expression ⇨ cerebral cortex
52
How to avoid insomnia
avoid watching TV in bed. Use bed only for sleeping and sex!
53
Labor & bladder distention
in bladder distention, bladder FLUCTUATES like a balloon filled with water; suprapubic, round, bulging
54
Breathing patterns (Cheyne-Stokes, Kussmaul, Orthopnea, Paradoxical)
Cheyne-stokes ⇨ deep to shallow breaths followed by periods of apnea
Kussmaul ⇨ deep, rapid hyperventilation
Orthopnea ⇨ SOB in supine position
Paradoxical ⇨ (flail chest) chest wall contracts during inspiration and expands during expiration
55
Addison's Disease diet
Requires diet w/ low potassium and high sodium, carbs and protein!
Good = turkey and cheese sandwich
56
Erikson's Development (early childhood, adolescence, young adulthood, older adults)
Early adulthood ⇨ Initiative vs. guilt
Adolescence ⇨ identity vs. role confusion
Young adulthood ⇨ intimacy vs. isolation
Older adults ⇨ integrity vs despair
57
TB Test
- Mantoux test determines if the client had an exposure to TB
- X-ray or sputum test confirms if the client has active TB
58
Hormonal Therapy (TH) with estrogen and progestin
- estrogen + progestin can be prescribed for menopause
- short-term HT can assist with managing manifestations like urogenital atrophy
- progestin can protect against estrogen-induced cancer of the uterus, but estrogen INCREASES r/f estrogen-induced BREAST CANCER
59
Thought-stopping
- non pharmacological chronic pain management
- repeat memorized facts about the painful event such as "the pain will be gone soon" or "I'll be home by this time tomorrow"
60
Healing by secondary intention
Meaning: wound will be left open (instead of stitched up) to heal by itself and closing naturally
REPORT TO PROVIDER: halo or ring of erythema on surrounding skin, indicating underlying infection
- Pink, shiny tissue w/ a grainy appearance = granulation tissues and indicates WOUND HEALING!
61
Moro Reflex
The legs move in a similar pattern of response to the arms. If the arms move up, the legs move up too!
62
Therapeutic response to a client who is concerned about how her partner will react to mastectomy
Right: "Would you like me to have a member of a breast cancer support group visit you? This is advocating!
Wrong: "This is a common concern..." This is a stereotypical remark and isn't empowering or therapeutic
63
Manifestation of HTN
Epistaxis, HA, dizziness, facial flushing, fainting,
NOT exophthalmos, which is caused by hyperthyroid NOT HTN
64
Postpartum Diuresis
Weight loss of 5 lb from excess urination and perspiration of the remaining pregnancy-induced increase in blood volume after 12 hrs post partum
65
Toxoplasmosis
"Avoid gardening during pregnancy" because toxoplasmosis is a teratogenic infection to the fetus
Transmitted via contact with CAT FECES, which can be found in gardens, and via contact with UNCOOKED MEAT
66
Preventing dumping syndrome
- Eliminate simple sugars (sugar, honey) and sugar alcohols (sorbitol, xylitol) from diet because they propel food through intestines faster
- Drink BETWEEN, NOT WITH, meals about 1 hour after eating
- Eat several smaller meals that have 1-2 foods, instead of less meals with much more food
67
Monitoring FHR during Labor
♡ 1st stage of Labor: monitor Q15 min
| ♡ 2nd stage of Labor: monitor Q5 min
68
Positive and Negative symptoms (schizophrenia)
Negative: absence of something that should be present (social discomfort)
Positive: impairments in memory, dysphoria, depression, hopelessness
69
Displacement defense mechanism
What is it: redirecting thoughts, feelings, and impulses from an object that causes to anxiety to a safer, more acceptable one
Example: Client redirecting anxiety about cancer diagnosis to the staff members who are providing care "This staff has been terrible and they haven't been taking care of me!"
70
Burn patient care plan
- initiate ROM exercises to maintain mobility and prevent contractures
- ambulate frequently to promote mobility and improve ventilation
71
Conservative (noninvasive) Treatment for DVT
- body goes through fibrinolysis that eventually dissolves the clot
- heparin (anticoag.) PREVENTS future clot formation, NOT DISSOLVES the clot
72
purpose for gastric lavage
therapy for upper GI bleeding
73
MRI pnt education
- client can have a mild sedative to help w/ clausterphobia and anxiety
- have to lie still for 45-60 min
- there is no radiation
74
Manifestations of...
Protein-calorie malnourishment
Vitamin C deficiency
Iron deficienacy
Protein-calorie: dry, brittle hair, edema (when albumin levels are low), and poor wound healing
Vitamin C: gingivitis
Iron: Spoon-shaped nails
75
interventions for manifestations of acute tubular necrosis (ATN) following a kidney transplant
☑ hemodialysis
☑ biopsy
☑ immunosuppression (essential after kidney tranplant!)
76
Play with a 4 month old infant (tactile, kinetic, auditory, visual,)
tactile: splashing in bath tub
kinetic: gentle bouncing on parent's lap
auditory: rattle
visual: put a toy in hand
77
Play with a 9-12 month old (kinetic, auditory, visual)
kinetic: pull-push toy
auditory: making animal sounds
visual: board book with large pictures
78
Airborne Precaution (AirS MTV)
AirS: shingles (herpes zoster)
M: Measles (rubella)
T: TB
V: Varicella (chicken pox *uncrusted lesions = contact*)
PPE: N95, gloves, gown, goggles
Isolation: negative pressure room
79
Contact Precaution (DORMS)
D: Diarrheal → c. diff, e. coli, rotavirus
O: Other → conjunctivitis, salmonella
R: Respiratory → RSV, adenovirus, parainfluenza
M: Multidrug Resistant → MRSA, VRF
S: Skin wound → scabes, lice, herpes, varicella (uncrusted chicken pox), shingles
PPE: gown, gloves, private room
80
Droplet Precaution (SPIDERMAN)
```
S: Sepsis - streptococcal pharyngitis
P: Pneumonia/ pertussis
I: Influenza
D: Diphtheria
E: Epiglotitis
R: Rubella
```
M: Mumps/ meningitis, meningeal pneumonia
A: Adenovirus
N: Neisseria meningitis
PPE: mask, gloves, gown, goggles, private room
81
What med can be administered with Lithium?
Valproic acid because it also treats bipolar disorder.
NOT
- ibuprofen (↑ kidney absorption of Lithium)
- haloperidol (↑ r/f extrapyramidal ADRs and tardive dyskinesia)
- hydrochlorothiazide (promotes sodium loss → lithium toxicity)
82
Infant reflexes end date (stepping, moro, extrusion, babinski)
4 weeks: stepping
3 months: moro
4 months: extrusion
1 year: babinski
83
Rh(D) immune globulin
- administer to client who is pregnant and is Rh-negative at 28 weeks gestation
- administer if pregnant client has Rh-negative blood to prevent maternal antibody production due to having a Rh-positive newborn
- administer following a mismatched blood transfusion
84
Triage during mass casualty event: head injury with fixed dilated pupils
BLACK TAG
| Nonreactive dilated pupils = poor prognostic sign and indicates severely increased ICP
85
Dinoprostone vaginal insert pouch
What is it: Put in vagina and gives off prostaglandin which body makes to start labor
Pnt edu: lie on back for at least 2 hours without getting up
86
Arthroscopy
What is it: helps with diagnosing musculoskeletal disorders like rheumatoid arthritis, osteoarthritis, and internal joint injuries
After: keep leg elevated 12-24 hr to decrease pain and swelling. Have short-term activity restrictions
87
Adjustment Disorder
What is it: Response to a stressful death, treated with antidepressant meds
Manifestations: guilt, depression, anxiety, anger, social withdrawal
Example: "I could have done something to prevent his death"
88
Ventricular Septal Defect (VSD)
What is it: a hole in the septal wall between the ventricles. When the oxygenated blood goes to the left ventricle to be pumped out the aorta, some exits thought the septal hole and mixes in with the deoxygenated blood in the right ventricle, so mixed blood goes to body and lungs and the heart and lungs work harder
Expected Finding: murmur at left sternal border
89
Renal Biopsy pnt edu
need to be on bedrest supine with a back roll for support 2-24 hours after procedure to decrease r/f bleeding
90
safest IM injection site for adults
Ventrogluteal because has thick gluteal muscles and no major nerves or blood vessels
91
Thrombocytopenia care plan
measure abdominal girth DAILY to monitor for manifestations of internal bleeding
92
Manifestations of...
Respiratory Obstruction
Tension pneumothorax
Flail chest
Respiratory Obstruction: intercostal retractions, high-pitch inspiratory (stridor), call RRT! Caused by laryngospasm and edema
Tension pneumothorax: tracheal deviation, distended neck veins, absent breath sounds on 1 side
Flail chest: paradoxical chest movement, dyspnea, and cyanosis
93
Urine specific gravity
1.005 to 1.030
94
Expected findings for isotonic dehydration
increased hematocrit d/t hemoconcentration caused by decreased plasma fluid volume
95
Types of enemas (oil retention, carminative, hypertonic, sodium polystyrene sulfate)
Oil retention ⇨ SOFTEN stool before removing fecal impaction
Carminative ⇨ expel FLATUS
Hypertonic ⇨ CLEANSE bowels (prep for surgery)
Sodium polystyrene sulfate ⇨ give to client who has high potassium
96
A client has hemophilia and reports pain and swelling in a joint following an injury. What is the nursing action?
Prepare for replacement of the missing clotting factor.
What is hemophilia: hereditary bleeding disorder in which blood clots slowly and abnormal bleeding occurs d/t deficiency in most common clotting factors, factor VIII (hemophilia A). AGGRESSIVE FACTOR REPLACEMENT is initiated to prevent hemarthosis, which can lead to long-term loss of ROM
97
Hypertonic uterine dysfunction + 3 cm dilation (full = 10cm) Nursing actions
- offer hydrotherapy to relax
| - therapeutic rest measures should be initiated to relieve pain and prevent early exhaustion
98
1 oz = x mL
| 1 pint = x mL
1 oz = 30 mL
| 1 pint = 480 mL
99
ABG withdrawal from radial artery nursing action
perform Allen's Test before obtaining specimen by ensuring that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured (the radial artery is the most common site for ABG withdrawal)
100
Genital herpes self-management
- apply warm compress to the lesions to relieve discomfort
| - AVOID sexual activity when lesions are present
101
weight gain (1 lb body fat = x calories)
3,500 calories
102
infant nutrition
allow infant to try finger foods, like crackers, after SIX months
103
toddler development
toddlers maintain bowel and bladder control during daytime by 30 months (2.5 years)
104
Baby feedings
- feed baby 8-12 times/day or Q2-3 hours
| - after 1st week of life, baby should have 6-9 heavy wet diapers per day
105
Acute angle-closure glaucoma manifestations
severe eye pain, halos around lights, blurred vision, HA, brow pain, N/V
106
what to administer for 12 hr postop & preventing DVT (enoxaparin, warfarin, or aspirin?)
Administer ENOXAPARIN bc it is a low-molecular-weight heparin
Not warfarin because it has a delayed onset and it is for long-term prophylaxis
Not aspirin because it suppresses platelet aggregation, not anticoagulant
107
Complete vs incomplete proteins
Complete: eggs, soybeans, yogurt
Incomplete: lentils, veggies, gains, nuts, seeds (missing 1+ essential amino acids)
108
when a pregnant client needs a biophysical profile
- when a non-stress test is nonreactive
| - when there are < 10 kicks in 12 hours (the minimum number of kicks in 12 hrs is 10 kicks)
109
schizophrenia symptoms (cognitive, affective, negative)
- cognitive: impaired memory, impaired concentration, impaired judgement
- affective: feelings of hopelessness; mood or emotional responses dissonant w/ behavior "I just feel so hopeless"
- negative: absence of normal behaviors r/t motivation or interest (inability to experience joy) "I no longer enjoy the activities i used to love"
110
Binge-eating disorder
- expected abdominal pain
| - repeated episodes of binging w/o using compensatory behaviors such as laxatives
111
Tracheal stenosis
What is is: abnormal narrowing of the trachea d/t inflammation and scarring that follows intubation
Manifestations: increased coughing/ inability to cough up secretions/ difficulty talking or breathing
112
Burn lab values during resuscitation phase (sodium, hemoglobin, albumin, potassium)
Resuscitation phase: replacement of fluids
Sodium: ↓ because it is trapped in interstitial space
Albumin: ↓
Hemoglobin: ↑ d/t loss of fluid volume
Potassium: ↑
113
End-stage liver failure expected labs (PT, lactate dehydrogenase, ammonia, albumin)
Prothrombin time: ↑ d/t inadequate supply of clotting factors, ∴ prolonged PT
Lactate dehydrogenase: ↑ = liver cell destruction
Ammonia: ↑
Albumin: ↓
114
DVT Treatment
- continuous heparin therapy
- can take acetaminophen, NOT ASPIRIN
- warm, moist heat & elevation for comfort
115
Communication problems
| Receptive Aphasia, Expressive Aphasia, Dysarthria
Receptive Aphasia: unable to understand words or sentences they hear
Expressive Aphasia: cannot name simple objects or formulate sentences or phrases
Dysarthria: difficulty articulating correctly d/t weakness or paralysis of muscles that produce speech
116
Effective uterine contractions
should occur every 2-3 minutes
117
Prevention
Primary: vaccines / education to healthy people that are in danger of getting ill; seatbelts, bike helmets
Secondary: preventing illness from getting severe via regular exams and screenings (mammograms)
118
Who can take oral contraceptives?
Yes: 4 weeks after childbirth
No: smoking, anticonvulsants & systemic anti-fungals, anti-HIV protease inhibitors, anti TB meds
119
Tympanostomy tubes
- allow drainage from and ventilation to middle ear
| - fall out on their own within 6-12 months
120
Nursing actions for fever
- keep bed linen dry to maximize heat loss
| - do not ice groin because this leads to shivering and increased energy expenditure
121
Postop urinary diversion to treat bladder cancer
Nursing care: change collection pouch in early morning when urine output is low
Expect no delay in urinary output after surgery
122
gross motor mobility of a 3/yo
stand on 1 foot for a few seconds
123
Nursing actions for 8 hrs postpartum hemorrhage
☑ massage the fundus to expel clots and help uterus contract
☑ administer 10 L/min O2 via nonrebreather face masks
☑ add oxytocin to IV fluids
☑ insert indwelling urinary catheter to monitor urinary output and perfusion to kidney
☑ place in lateral position w/ legs elevated 30 degrees
124
When to discontinue Swaddling
D/C swaddling once baby is able to roll over (~2 months) because rolling over can tighten the swaddle and keep baby from breathing properly
125
Polyhydramnios
What is it: presence of excessive amniotic fluid surrounding unborn fetus
Expected: GI malformations and neuro disorders
126
Female Structures (graafian follicle, fallopian tube, corpus luteum)
Graafian follicle: expels mature ovum
Fallopian tube: where egg moves from ovaries to uterus
Corpus luteum: structure within the ovary that produces the progesterone needed to establish and maintain pregnancy
127
Vacuum-assisted birth
inform the client that caput succedaneum (swelling of scalp d/t suction) resolves in a few days
128
Otosclerosis (sclerosis of the ossicles)
Overgrowth of the tissue of the bones in the middle ear, which can cause tinnitus and conductive hearing loss
129
Diet when client has acute diverticulitis active inflammation
Low fiber (white bread, low-fat milk, yogurt w/ active cultures, poached eggs, and canned soft fruit)
130
Borderline Personality Disorder
- Splitting is a common defense mechanism in which the client plays one staff member against another. First, they cling towards a certain staff member and then abruptly complains about them to another staff.
- Underlying cause of splitting: fear of abandonment and inability to accept both + and - feelings. ∴ the client demonstrates only + or - feelings towards others.
131
Alcohol withdrawal manifestations
6-8 hrs after cessation: "the shakes" and HTN
12-24 hrs after cessation: generalized and tonic-clonic seizures
Within the 1st 72 hrs: delirium tremens
132
Antacids
Take antacids 1 hr apart from other meds because antacids increase gastric pH and interferes with absorption of various meds
133
Types of grief (acute, anticipatory, delayed, disenfranchised)
Acute: have somatic and psychological manifestations of distress like waking up early/inability to sleep well + profound sadness
Anticipatory: an expected response before an actual loss. Client might be preoccupied w/ impending loss, make extensive funeral arrangements, etc.
Delayed: unable to accept the reality of a loss. Client remains in denial and can't express sorrow and loss
Disenfranchised: can't openly acknowledge the loss because of societal or religious norms
134
Digestive proteins (pepsin, amylase, lipase)
Pepsin: breaks down PROTEINS
Amylase: breaks down STARCHES into GLUCOSE
Lipase: breaks down TRIGLYCERIDES into MONOGLYCERIDES
135
Fetus in occipital brow presentation
What is it: this presentation increases diameter of the presenting part, which may prevent the fetal head from descending into the pelvis
Can cause PROLONGED LABOR, forceps- or vacuum- assisted birth, or a C-section
136
Post-streptococcal glomerulonephritis
Expect hematuria, normal potassium, and increased BP
137
Priority finding for 13 weeks and has hyperemesis gravidarum
Priority: Ketones 2+
Rationale: the greatest risk is malnutrition → risk to developing fetus. Ketonuria indicates that the client is breaking down FAT and PROTEIN STORES for energy, and can't give fetus essential nutrients
NOT priority: hypotension, dehydration, hyponatremia
138
Expected findings for newborns
- acrocyanosis: within 24-48 hrs after birth
- erythema toxicum: macular, papular, vesicular rash on torso; within 24-72 hrs after birth
- blood sugar >40 mg/dL
- NOT axillary temp 96.9F because r/f cold stress which can decrease pulmonary perfusion
139
How to decrease allergen exposure
apply a hypoallergenic mattress cover
140
How to prevent the onset of Raynaud's disease
Smoking cessation
141
mL to tbsp
1 tbsp = 15 mL
142
HELLP Syndrome
This syndrome is a severe form of preeclampsia (3 manifestations)
HELLP = hemolysis (H), elevated liver enzymes (EL), and low platelet count (LP)
143
Neonatal Abstinence Syndrome
Usually exhibits hyperactivity within the CNS
144
Nursing action for infant with unrepaired myelomeningocele
- palpate the abdomen for bladder distention d/t possibility of incomplete emptying
- a neurogenic bladder is a common complication
145
Bile (gallbladder, liver, intestines, bile duct)
- gallbladder STORES bile
- liver MAKES bile for digestion
- GI tract ELIMINATES bile
- small amount of bile continuously enters the duodenum
- bile duct is a series of thin tubes that carry bile from the gallbladder into the small intestine to help digest the fats in food
146
Commercial formula for newborn
Cow's milk-based formula is recommended for healthy newborns because it is similar to human breast milk.
Conditions that need alternative formula W/O milk: galactosemia
147
Labor Terms (lightening, quickening, effacement)
Lightening: engagement of fetal head into pelvis. Breathing becomes easier, but urination is more frequent
Quickening: 1st fetal movement
Effacement: thinning of cervical tissue
148
VEAL CHOP (fetal accelerations and decelerations)
V: variable decels C: cord compression
E: early decels H: head compression
A: acceleration O: okay
L: late decels P: placental insufficiency
149
amnioinfusion
prepare an amnioinfusion to decrease cord compression
150
Leuk- (-openia, -emia, -ocyosis, -oplakia)
Leukopenia: decreased WBC
Leukemia: uncontrolled production of blast cells or immature WBC in bone marrow (cancer)
Leukocytosis: increased circulating WBC in response to WBC exiting from the blood vessels in response to inflammation
Leukoplakia: thick white patches in mucosa of the mouth (precancerous, seen in heavy smokers)
151
Disease manifestations (varicella, measles, fifth disease, tetanus)
Varicella (chicken pox): maculopapular rash → vesicles on erythemous bases, which will eventually rupture and crust over
Measles: Koplik spots (a transient cephalocaudal rash of maculopapular eruptions of upper trunk and face) → spreads to lower body
Fifth disease: begins w/ bright red cheeks, "slapped-cheek," then a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) look
Tetanus: lockjaw and muscle rigidity. DTap vaccine prevents
152
Defense mechanisms (compensation, conversion, projection)
Compensation: coveres/blocks a problem.
Example: blocks anxiety by drinking alcohol (maladaptive); avoid anxiety by working hard to excel in some way (adaptive)
Conversion: unconscious transformation of anxiety into physical manifestations w/no organic cause
Projection: unknowing rejection of emotionally unacceptable feelings by attributing those feelings to others
153
ADHD parent education
"ignore your child's attention-seeking behaviors that are not dangerous" so the child will learn the the behavior does not get the desired response and does the behavior less.
Adjust activity based on level of child's attention
ADRs of ADHD meds: decreased appetite and weight loss
154
Heberden's nodes
hard, bony lumps or nodules in the finger joints
155
Systemic Scleroderma
Sclerodroma: chronic disease that can cause thickening, hardening, or tightening of the skin, blood vessels, and internal organs
Patho: body produces and deposits too much collagen → thickening and hardening, including skin and extremities
Localized scleroderma: mainly affects the skin
Systemic scleroderma: can affect internal organs
Manifestations: skin changes, Raynaud's, arthritis, muscle weakness, dry mucous membranes, contractures develop with advanced s.s. unless clients do ROM and muscle-strengthening
156
Hematocrit levels during dehydration
They increase.
When a person does not drink enough, their plasma levels drop, while the number of RBCs packed in it stays the same and this increases the proportion of red blood cells in their blood volume.
157
celcius to farenheit
F = (C x 9/5) + 32
158
A client is at risk for a latex allergy if they are allergic to these foods...
avocados, bananas, chestnuts, mangos, kiwi, pineapple, and passion fruit
(abc MK, pp)
159
manifestations for client w/ ADHD and addicted to amphetamines
will eat excessively, exhaustion, depression, prolonged sleep, craving amphetamines
160
Dialysis Disequilibrium Syndrome (DSS)
What is it: CNS disorder that can develop in clients who are new to dialysis d/t the rapid removal of solutes and changes in blood pH
Manifestations: HA, N/V, decreased LOC, seizures, and restlessness
161
Lithium
Expected: hand tremors (will subside), nausea (will subside), weight gain (diet and exercise will help
Toxicity Manifestation: poor motor coordination
162
APGAR
A: appearance
0 = blue/pale
1 = pink body; blue extremities
2 = pink
P: pulse
0 = absent
1 = < 100
2 = > 100
G: grimace (reflex irritability)
0 = floppy
1 = minimal response to stimulation
2 = prompt response to stimulation
A: activity (muscle tone)
0 = absent
1 = flexed arms and legs
2 = active
R: respiration
0 = absent
1 = slow and irregular
2 = vigorous cry
163
Administering a cleansing enema
- insert tip of tubing 7-10 cm (3-4 in) along rectal wall to prevent dislodging of the tube and avoid injury to rectal mucosa
- position on the left side in sims' position to allow solution to flow downward into sigmoid colon and rectum and promote retention of the enema
164
rheumatoid arthritis meds
Daily management: celecoxib (NSAID)
Short term treatment d/t ADRs or severe R.A.: prednisone (corticosteroid)
165
Pravastatin
the only statin that isn't affected by CYP3A4 inhibitors ∴ you CAN drink grapefruit juice with this med
166
ADHD meds side effects
stimulants
Will see weight loss, tachycardia, HTN
167
Caring for a client with recent stroke and history of GERD. What is this client at risk for?
Aspiration pneumonia
Rationale: GERD → gastric reflex from stomach to lower esophagus. When regurgitation occurs, client is at high risk for PNEUMONIA d/t aspiration of gastric contents in airway.
Recent stroke increases risk for dysphagia.
168
Esophageal varices
What is it: enlarged veins in the esophagus develop when blood flow to the liver is blocked. They often occur in people with advanced liver disease.
169
duodenal ulcer disease
ulcers in duodenum, not esophagus, and are r/t stress, COPD, pancreatic disease, and chronic renal failure
170
Administering otic antibiotics
holder dropper 1 cm (0.5 in) above the ear canal during administration
171
spinal anesthesia hypotension ADR
nursing action: position client in a head-down position to rapidly promote venous return to the heart and increase BP
172
nicotine gum ADRs
throat irritation, aching jaw muscles, dyspepsia
173
an expected view of death from a preschooler
a preschooler typically views death as temporary and interchangeable with life
174
basic needs of older adult clients
- caloric needs are decreased because metabolic rate decreases by 10%
- deep sleep is decreased because they spend less time in stages of deep sleep, but this can delay healing
175
Diaphragm
What is it: a flexible rubber cup that is filled with spermicide and inserted over the cervix before sex
Prescription fitted by a provider
Replace Q2 years
176
mucolytic drugs for bronchitis
such as hypertonic saline solution or acetylcysteine
ADR: bronchospasm because it can irritate the airways by producing a cough and thinning mucus secretions
177
Otitis media manifestations
low-pitched (NOT high) sound in ear, feeling of fullness, ear pain, cracking sound when yawning or swallowing, mild dizziness
178
Foot care for patient with diabetes
- test water temp with wrist because client may have peripheral nerve damage from diabetes
- trim toenails straight across, NOT round the edges because can create in ingrown toenail
179
Nursing actions for extravasation of tissues surrounding IV
1. ) stop infusion
2. ) elevate extremity
3. ) notify provider
4. ) remove IV line last because treatment may include infusion of antidote through IV line, ∴ don't remove until prescription is initiated
180
Toddler should be able to
remove their own shoes
181
IV problems and manifestations (infiltration, infection, phlebitis, not intact)
- infiltration: taut skin around IV catheter site that is cool to touch. Stop IV, elevate extremity, warm moist or cold compress
- infection: redness at IV catheter entry site. Remove IV, clean site with alcohol, start IV in a different location
- phlebitis: palpable cord along the vein d/t inflammation of inner layer of the vein. Discontinue infusion and start a new IV in a different location
- Not intact: bleeding at insertion site. See if IV is intact and if the catheter is in the vein. If still bleeding, start a new IV in a different location
182
Removing sutures from a client's laceration
"I will clip each suture close to the skin and pull it through from the other side" so it doesn't disrupt the wound-healing process
183
Indication of an acute INTRAVASCULAR hemolytic reaction
sudden oliguria because this reaction causes AKI
184
Late decelerations nursing action
- place client in a left lateral position to improve blood flow to the uterus because late decels = placental insufficiency (veaL choP) = decreased fetal oxygenation.
- 8-10 L/min nonrebreather mask
185
A kid has strabismus. How to prevent amblyopia?
wear an eye patch on the stronger/unaffected eye (to strengthen the weak eye muscle on affected eye)
186
ALZ Disease
Expect personality changes and confusion that develops SLOWLY
187
hypercalcemia manifestations
depressed deep-tendon reflexes, N/V, bone pain, lethargy, weakness
NOT muscle tremors (hypo)
** it's kinda like hypercalcemia = depressed symptoms (opposite)
188
Allergy contraindications to vaccines
allergy to EGGS, don't take INFLUENZA vaccine
allergy to GELATIN or NEOMYCIN, don't take VARICELLA vaccine
189
using a nonpunitive approach
verbal reminder
190
Concept to discuss in Termination phase in a nurse-patient relationship
Loss
Rationale: loss is an expected feeling for both client and nurse. Must end relationship w/o guilt or anxiety
191
Pericarditis
What is it: swelling and irritation of thin, saclike tissue surrounding the heart.
Manifestations: dyspnea, hiccups, nonproductive cough... can indicate HF from pericardial compression d/t constrictive pericarditis or cardiac tamponade
- chest pain increases w/ deep inspiration d/t increased pressure on pericardial sac
- chest pain decreases when sit upright or lean forward bc will relieve pressure
192
Ways to decrease flatus and odor
Eat crackers, toast, and yogurt because they can help decrease flatus, which contributes to odor
193
Successful surgery for bile duct obstruction
clay-colored stool (obstruction) → yellowish-brown stool (successful surgery)
194
Cons of ORAL glucocorticoids for kids
Chronic use of oral glucocorticoids in high doses can → decreased linear growth
While inhaled glucocorticoids go directly to the local target area (airways) → decreased r/f adrenal suppression
195
Fat embolism syndrome
Manifestations: neuro changes, petechial rash, and hypoxemia occur when fat globules occlude small blood vessels
Risk factors: multiple fractures and a long bone fracture, male clients
196
Nurse to intervene in AP's actions when turning patient to the right side
when AP places a pillow under right arm. The AP shouldn't do this. Place pillow under LEFT arm to prevent internal rotation of the L shoulder
197
Placenta problems (abruptio placentae and placenta previa)
Abruptio placentae: premature separation of placenta from the uterus
Expect: persistent uterine contractions, board-like abdomen, and DARK red vaginal bleeding
Placenta previa: placenta is covering the cervix (outlet of uterus)
Expect: a relaxed uterus and BRIGHT red vaginal bleeding
198
Foods to eat if client has uric acid calculi
YES: citrus fruits
NO: food w/ purine (chicken, organ meats, red wine)
199
Plasma infusion nursing actions
☑ enter plasma product # into client's medical record
☑ transfuse fresh frozen plasma immediately to maintain integrity of the clotting factors
☑ admin. each unit over 30-60 min. Slow infusion rate if the client shows indication of fluid overload
200
What to do if IV pump for TPN is unavailable
Use manual drip tubing to give dextrose 10% in water at the same rate
DON'T admin TPN using a manual drip tubing because it increases r/f hyperglycemia!
201
Pressure injury (stage II and III)
Stage II: partial-thickness skin loss or blister
| Stage III: visible subcutaneous tissue
202
Significant head trauma and agonal breathing (gasping for air)
Black tag!
203
Disaster management plan
includes prevention, preparedness, response, recovery)
Response: perform a rapid needs assessment
Recovery: conduct home visits, identify lack of safe shelter or clean water and any other potential hazards
204
Colostomy care
- activate the adhesive in the skin barrier by holding it in place over the stoma for 30 seconds
- cut the skin barrier opening no more than 0.3 cm (0.13 in) larger than the stoma
205
tunneled central venous catheter w/o a pressure-sensitive valve
- flush catheter daily w/ heparin when not using it regularly
- keep the catheter clamped when not in use to prevent blood backflow.
206
Nursing actions for early decels at 39 weeks, 2nd stage labor
continue to monitor FHR
Rationale: this is an expected finding for progression of labor
207
multiple sclerosis manifestation
nystagmus (involuntary eye movements and muscle spasticity)
208
trach care order
1. Remove inner cannula
2. Remove soiled dressing
3. Clean stoma with 0.9% sodium chloride
4. Change trach collar
209
How to clean vomit on a reusable BP cuff
place BP cuff in a labeled bag and send for decontamination NOT chlorine bleach (blood spills)
210
Reporting to local health department
chlamydia, syphilis, gonorrhea, chancroid, and HIV/AIDS
do NOT tell hospital chaplain the pnt's diagnosis d/t HIPAA
211
obstructive sleep apnea complication
- hypoxia → HTN
- HF
- dysrhythmias
NCLEX
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