Milestone 2 Remediation > Weaknesses > Flashcards

Weaknesses Flashcards

(57 cards)

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1
Q

What should the nurse do during the Triggering phase?

A

approach the client in a nonthreatening, calm manner in order to deescalate the
clients emotion and behavior.

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2
Q

What should the RN do if a patient has verbal threats, pacing, raised voice

A
  • Say in calm firm voice “lets go back to you room and take a time out.
  • stand in door way for easy access to leave
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3
Q

What interventions for aggression response?

A
  • Assess verbal and nonverbal ques for escalating behavior.
  • nonauthoritative approach
  • “show of force” with a child who is out of control
  • Do not ask why questions
  • use “quiet room”
    What
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4
Q

Aggression response

A
  • RN has to protect others from pts behavior
    set limits on unacceptable behavior
  • Limit setting: 1. Inform patient of rules, 2. explain consequences, 3. state
    expected behavior
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5
Q

What is the aggression 5 phase response?

A

triggering (event), Escalation (movement toward a loss of control), Crisis (loss of
control), Recovery (regain control), Postcrisis (reconciliation)

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6
Q

What is the Cycle of violence order?

A

Tension building, violence, honeymoon

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7
Q

Domestic violence screening tool- priority/

A

Don’t probe, write evidence down verbatim, provide a safe environment
- violence is increased during pregnancy
- discharge with safety plan
-looks to another person when questions are asked
- Do not refer to legal council or pt will probably not go through with it and cycle
will repeat itself

safety- priority

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8
Q

What is the highest priority for Maslow hierarchy of self care?

A

Physiologic, safety, love and belonging, self esteem , self- actualization

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9
Q

grief priority

A

based on shock

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10
Q

anorexia

A

powerlessness

encourage activities that don’t involve food

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11
Q

What should you assess for a patient Bizarre social behavior

A

physical needs
suicide risk
ensure safety AT ALL TIMES
Patient may need a 1:1 sitter case.`]

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12
Q

Bizarre social behavior-

A
  • Schizophrenia
  • Delusions
  • Hallucinations
  • How to respond: do not play with delusions
  • Speech patterns in schizo
  • Echolalia: repeating, imitating
  • Clang associations: words that sound similar
  • Preservation: Clinging to single ideas, topic and repeating same sentence over
    and over again.
  • Word salad: mixing up words that makes no sense.
  • Limit stimuli = 1:1 interaction
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13
Q

arterial htn

A

pulmonary htn

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14
Q

What Interventions are used for a patient taking allopurinol (zyloprim) for gout?

A
  • Increase fluid intake to prevent kidney stones
  • increase movement
  • avoid caffeine, alcohol, and dairy
  • may take several weeks to work
  • stop if rash develops.
    -reduce stress
  • NO HIGH PURINE FOODS (organ meats, shellfish, fructose)
  • avoid starting/ increasing med during active flare ups –> does NOT relieve active flare ups
  • bone marrow depression
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15
Q

important to acknowledge- hf

A

weight gain

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16
Q

What are the Five stages of grief in order

A

Denial, Anger, Bargaining, Depression, Acceptance

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17
Q

contributes to risk of oa

A

history of high activity= long distance runner

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18
Q

sbo

A

maintain quiet environment

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19
Q

What is the first intervention for a patient with positive small bowel obstruction?
2nd line

A

NG tube to suction placement with X-ray to confirm correct placement

Barium enema

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20
Q

what should you assess for a small bowl obstruction?

A

ausculate bowel sounds
ive fluids to replace electrolytes

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21
Q

sbo- immediately report

A

rebound tenderness in upper quadrants

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22
Q

improving rr- low

A

lower O2

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23
Q

nutritional needs throughout recovery

Study These Flashcards
A

Acute
phase: NPO, IV fluids
* Recovery phase: no fiber or foods that irritate the bowel
* Maintenance phase: high-fiber diet with bulk-forming laxatives

24
Q

What is the treatment for Diverticulitis?

Study These Flashcards
A

NPO diet or clear liquid diet to decrease exacerbations to decrease inflammation –> highest priority
- low fiber may be progressed from there
- antibiotics

25
digoxin toxity
take vs first - Loss of appetite - Lower stomach pain - diarrhea - Weakness - Blurred or yellow vision - headache - Rash
26
antidote digoxin
potassium and Digifab
27
ex of hypertonic fluids
Saline 3% or 5% 3% NaCl 5% Nacl D10W ‘D20W D50W D5LR
28
ng tube- Confirmation that obstruction is the cause of pt discomfort
us done by assessing the amount of of fluid aspirated a residual of >400 mL indicated obstruction can be placed during sx for aspirationg fluid
29
meds not to give- bph
BPH - don’t give antihistamines - do not give decongestant, anticholinergics, antidepressants
30
copd interventions
low concentrated oxygen <2-3L nasal canula No petroleum-based lip products DO NOT WANT Ph TO FALL.- resp acidosis ORAL OR IV CORTICOSTEROIDS avoid infection
31
ibs- who has highest risk tx
women - Fluids - antibiotic therapy - colloid - electrolyte replacement
32
arterial insufficienty- who has highest risk sx
men- legs - weak pedal pulses -shiny and cool skin - intermittent claudication - aching/cramping -induced fatigue - diminished pulse - diminished hair growth
33
monitoring- lithotropsy
urine output
34
What should be assessed for post anesthesia
vitals should be q15. if systolic is under 90 REPORT IMMEDIATELY.
35
thrombocytopenia labs- bleeding
-under 50,000 /LOW PLATELET COUNT normal PT/PTT prolonged Bleeding time Thrombocytopenia: Low platelet count Bleeding and petechiae usually do not occur with platelet counts greater than 50,000/mm3, although excessive bleeding can follow surgery or other trauma. -When the platelet count drops to less than 20,000/mm3, petechiae can appear, along with nasal and gingival bleeding, excessive menstrual bleeding, and excessive bleeding after surgery or dental extractions. -When the platelet count is less than 5000/mm3, spontaneous, potentially fatal central nervous system or GI hemorrhage can occur
36
sickle cell crisis prevention first signs
Vaccinations to prevent infections -hydration to prevent crisis. - Pain - Fatigue - swollen hands and feet - dehydration * Give oxygen, fluids, pain medications, infection prevention**
37
duchenne muscular dystrophy characterstics electromyogram
human genetic disease caused by X-linked recessive allele; characterized by progressive weakening and a loss of muscle tissue life extectancy usually around 30 delayed motor/speech, cognitive impairment, muscle weakness, waddle, calf enlargement, cardiomyopathy. -walk on tipy toes -trips easily soreness after test is normal- temporary
38
congenital heart defect assess interventions risk
Daily weight - watch for fluid gain color change diminished pulses- femoral - small frequent meals - oxygen - high calorie formula -KNEE TO CHEST IF CYaNOTIC suscpectible to resp infections
39
rsv assess interventions
- Grunting - Use of accessory muscle breathing - Nose flaring - increased respirations - prolonged expirations - nasal suctioning - hydration - calm - o2 as needed -standard precautions/contact
40
s/s pyloris stenosis vs intussuscpetion
Olive RUQ - Opening between stomach and small intestine is thickened - Projectile vomiting's --> electrolyte imbalance - dehydration - colic- crying - lethargic - Limp in belly - Failure to thrive - Sausage -- Part of intestine fold into the section next to it causing obstruction. - severe crampy abdomen - RUQ sausage shaped mass in upper abd - jelly stool - bloody mucus stool - fever - Weight loss
41
The 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated
weak cry wo tears
42
electrolyte imbalance- vomiting
met alk
43
The nurse is caring for an infant scheduled for reduction of intussusceptions. The day before the scheduled procedure the infant passes a soft-formed brown stool. Which intervention should the nurse implement?
tell dr
44
What are the signs of placenta abruption
uterine irritability - Dark red blood - knife like pain -broad rigid abdomen - hypovolemic shock
45
what should the nurse do for a placental abrution
c-section, bedrest start 2 large IV lines. one for fluid and medications and the other for blood replacement. -IMMEDIATELY NOTIFY HCP, & NO ABD OR VAG MANIPULATION OR EXAMS -ADMIN O2 BY FACEMASK -MONITOR FOR BLEEDING AT IV SITE & GUMS B/C OF ↑ RISK FOR DIC
46
What is not good when looking fetal heart tracings?
- Recurrent decelerations
47
While in labor at 39 weeks’ gestation, a primigravida develops a temperature of 38.2°C (100.7°F), and fetal tachycardia is noted at 170 beats per minute. The student nurse asks the experienced nurse what this could indicate. How should the experienced nurse respond?
ANSWER- A temperature of 38.2°C (100.7°F) may indicate an infection such as chorioamnionitis, and the practitioner should be notified
48
What should the nurse do for a patient with prolapse cored
push up on fetal presenting part to remove pressure. - look for cord in vagina - use hand to remove pressure - KNEE TO CHEST POSITION - TRINDELINBURG POITION - IF CORD IS CLAMPED BABY LOOSING O2 - DO NOT PUT ON LEFT SIDE( FOR BP) How should the nurse handle a patient with a prolapsed cord? 1. Call for assistance- medical emergency 2. Sterile gloves, insert 2 fingers into vagina & elevate the fetal presenting part off cord. 3. Apply warm sterile saline soaked towels over cord. 4. Oxygen 5. Prepare for birth
49
Shoulder dystocia actions How can you tell a patient is experiencing shoulder dystocia?
supra pubic pr and mcroberts maneuver Delivery of the head and then retracts immediately.
50
Variable deceleration actions
1. Change maternal position TO SIDE 2. Stimulate fetus if indicated. 3. Discontinue oxytocin (Pitocin) if infusing. 4. Administer oxygen (O2) at 10 L by tight facemask. 5. Perform a vaginal examination to check for cord prolapse. 6. Report findings to physician and document.
51
What should the nurse do for a patient with a boggy uterus? assessment?
empty bladder uterine massage MEDICAL EMERGENCY give oxytocin fundus is higher than expected when palpated -excessive lochia
52
Mother brings infant complaining of vomiting and diarrhea to ER that’s been breastfeeding and introducing formula
ANSWER- Ask what kind of water are you mixing with formula
53
How is symmetric IUGR diagnosed signs
By serial ultrasound, which is the reason for 1st trimester ultrasound amniotic fluid levels. assess babies growth and cord prolapse fetal size fetal weight under 10th % fetal distress
54
what should a patient do if they have engorged breasts but wants to breast feed? pump, and skin to skin contact What should a patient do for engorged breasts but doesnt want to breast feed?t
pump, and skin to skin contact cold compress and tight clothing what
55
A new mother reports breast engorgement and nipple pain on day 2 after the delivery of a healthy newborn. The mother tells the nurse, “I’m not sure that breastfeeding the baby is for me.” What should the nurse advise the mother to do to help relieve discomfort and encourage persevering with breastfeeding? -
ANSWER- Inform the mother that breastfeeding the newborn more frequently will help treat these symptoms
56
A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide?
breastfreed q2hr
57
Milestone 2 Remediation
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