ATI Flashcards
Osteoporosis
- Encourage weight-bearing exercises, including BRISK WALKING to prevent bone loss.
- Cottage cheese is NOT a good source of calcium d/t PROCESSING
Infant development (8, 12, 13 months)
8 months: sit up unsupported
12 months: anterior fontanel closes
13 months: walk independently
Disseminated Intravascular Coagulation (DIC) expected findings
☑ 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
Iron-rich foods
meat, fish, poultry, including BEEF LIVER
Anemia (aplastic, pernicious, sickle cell) manifestations
- 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
72 hr postop above the knee amputation (nursing actions)
☑ 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
impetigo contagiosa pnt education
☑ apply topical antibacterial ointment
☑ wash bed linens daily w/ HOT water
☑ wash hands before and after contact w/ area
ACTIVE labor pain relief (nonpharmacological)
- assisting client into a warm shower stimulates release of endorphins
- music is a distraction and relaxation in EARLY labor, NOT active
Leadership style for CPR situation
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
Stomatitis (nursing actions)
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
Chronic kidney disease diet limitations
☑ 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)
Cycloplegia expected finding after administering atropine
expected finding: BLURRED VISION after administration of atropine d/t paralysis of ciliary muscle preventing near-vision focus
Cocaine intoxication expected findings
☑ dilated pupils
☑ increased BP
☑ increased temp
RATIONALE: stimulant! fight-or-flight!
late-stage CKD nutrients to increase
increase calcium because can develop hypocalcemia d/t decreased production of active vitamin D (Needed for calcium absorption)
Superior vena cava syndrome
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
When to change tubing for TPN?
change IV tubing for TPN Q24 hrs
Brachytherapy
- 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
Newborn Vital Signs
RR: 30-60
HR: 110-160
BP: 60-80/40-50
T: 97.7-99.5
What to do when a client with an NG tube has nausea
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
Tension-building phase of cycle of violence
episodes of violence are often minor, and recipient might rationalize the episodes by taking blame
Car seat safety
☑ 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
Hydrotherapy
- 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
nephrotic syndrome nursing care
provide skin care d/t edema and r/f infection
Transient Ischemia Attack (TIA)
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!
Hypoglycemia manifestations
diaphoresis, palpitations, shakiness
Pregnancy weight gain for BMI > 30
Limit weight gain to 11-20 lbs during pregnancy
Playing Development (Infants, Toddlers, Preschool, School-age)
Infants: solitary play
Toddlers: parallel play
Preschool: associative play
School-age: cooperative play
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!
PCA Pump
- allows dosing Q6-8 min
- can use TENS while using PCA pump
Alternative restrains for confused and wandering clients
Use a rocking chair to expend some energy through rocking instead of wandering
What nutrient promotes wound healing?
Vitamin C!
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
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
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
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
steps for gastric hemorrhage and going into shock
- ) ADMINISTER O2 via NONREBREATHER
- ) INITIATE IV therapy w/ large bore catheter to support circulation by expanding intravascular fluid volume
- ) INSERT NG tube to monitor rate of bleeding and prevent gastric dilation
- ) ADMINISTER RANITIDINE when no longer bleeding to prevent a stress ulcer
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
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
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
Cushing’s Triad
What is it: bradycardia, severe HTN, widened pulse pressure
How: TBI ⇨ increased ICP ⇨ Cushing’s Triad
Kidney Transplant
- lifelong immunosuppressive therapy for organ RECIPIENT
- HEMODIALYSIS needed after getting kidney from a DEAD DONOR
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
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
Diabetes and acute bronchitis
“take insulin even if you are unable to eat your regular diet”
Take insulin even when sick to PREVENT HYPERGLYCEMIA
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
Cirrhosis (bilirubin and albumin)
expect increased bilirubin and decreased albumin because albumin is formed in the liver
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
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
What to do before feeding a pnt w/ a gastrostomy tube
- flushing w/ WATER, not 0.9% sodium chloride
- elevate HOB
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
Injury to the brain (cerebellum, hypothalamus, cerebral cortex)
difficulty w/ muscle coordination ⇨ CEREBELLUM
difficulty w/ sleeping ⇨ HYPOTHALAMUS
difficulty w/ expression ⇨ cerebral cortex
How to avoid insomnia
avoid watching TV in bed. Use bed only for sleeping and sex!
Labor & bladder distention
in bladder distention, bladder FLUCTUATES like a balloon filled with water; suprapubic, round, bulging
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
Addison’s Disease diet
Requires diet w/ low potassium and high sodium, carbs and protein!
Good = turkey and cheese sandwich
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
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
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
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”
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!
Moro Reflex
The legs move in a similar pattern of response to the arms. If the arms move up, the legs move up too!
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
Manifestation of HTN
Epistaxis, HA, dizziness, facial flushing, fainting,
NOT exophthalmos, which is caused by hyperthyroid NOT HTN
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
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
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
Monitoring FHR during Labor
♡ 1st stage of Labor: monitor Q15 min
♡ 2nd stage of Labor: monitor Q5 min
Positive and Negative symptoms (schizophrenia)
Negative: absence of something that should be present (social discomfort)
Positive: impairments in memory, dysphoria, depression, hopelessness
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!”
Burn patient care plan
- initiate ROM exercises to maintain mobility and prevent contractures
- ambulate frequently to promote mobility and improve ventilation
Conservative (noninvasive) Treatment for DVT
- body goes through fibrinolysis that eventually dissolves the clot
- heparin (anticoag.) PREVENTS future clot formation, NOT DISSOLVES the clot
purpose for gastric lavage
therapy for upper GI bleeding
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
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
interventions for manifestations of acute tubular necrosis (ATN) following a kidney transplant
☑ hemodialysis
☑ biopsy
☑ immunosuppression (essential after kidney tranplant!)
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
Play with a 9-12 month old (kinetic, auditory, visual)
kinetic: pull-push toy
auditory: making animal sounds
visual: board book with large pictures
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
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
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
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)
Infant reflexes end date (stepping, moro, extrusion, babinski)
4 weeks: stepping
3 months: moro
4 months: extrusion
1 year: babinski
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
Triage during mass casualty event: head injury with fixed dilated pupils
BLACK TAG
Nonreactive dilated pupils = poor prognostic sign and indicates severely increased ICP