Capstone exam 2 Flashcards
Babinski Sign
When you stroke the bottom of the foot from the heel upward. The big toe bends back and the other toes spread out. Indicates CNS Disorder
Serum Ammonia Level
10-80mcg
High=severe liver disease
Mild anemia
Palpitations, dyspnea, mild fatigue. HGB 10-12
Moderate Anemia
Increased palpitations, fatigue, dyspnea. HGB 6-10
Severe Anemia
Tachycardia, anorexia, PICA, Pallor, Bone pain, Impaired thoughts, HGB below 6
Anemia Teaching
Dietary changes, Alternate rest and activity, Increase protein, B vitamins, Folic Acid, Iron, Vitamin C, Vitamin E, Blood transfusion, Erythropoietin, Oxygen therapy
Glasgow Coma Scale
Best score 15. Less than 8 severe head injury or coma, 9-12 Moderate head injury, Mild 13-15
Post craniotomy Interventions
Monitor vital signs, airway, Neuro status, pain, surgical site, fluid and electrolyte
EMG
Evaluates condition of muscles and nerves that control them. No smoking 3hrs before exam, bath or shower yo remove oils from skin, wear comfy nonobstructive clothing, low risk, client may have soreness where test was performed.
Variable Decelerations
Early Decelerations
Accelerations
Late Decelerations
Cord Compression
Head Compression
Oxygen good
Placental Insufficiency
Brudzinski’s sign
Severe neck stiffness causes patients hips and knees to flex when neck is flexed. Indicates meningitis
Biophysical profile
Combines non stress test with ultrasound
Chorioamnionitis
Intraamniotic infection, acute inflammation of membranes due to polymicrobial bacterial infection in the setting of membrane rupture
Amniotic fluid embolism
Catastrophic complication, amniotic fluids, fetal cells, hair, other debris enter into maternal pulmonary circulation causing cardiovascular collapse.
Isosorbide mononitrate
Used to prevent chest pain
Side effects: Headache, dizziness, lightheadedness, nausea, flushing. Take first thing in the AM. Headaches are a sign the med is working. Dont take with viagra or cialis
Carbamezapine
Tx epilepsy, trigeminal neuralgia, may cause steven johnson syndrome, or toxic epidermal necrolysis. Wait 14 days after stopping to take MAO
Calcitonin
Tx bone problems (pagets disease, osteoporosis) and to reduce high blood levels of calcium. Injectable causes flushing of face, hands, and feet several mins after admin. Pruritus, tingling of palms and soles, increased diuresis.
Pt with HF taking furosemide and digoxin develops muscle cramps, N/V, and anxiety. What order would the nurse expect.
Give supplemental K+
Lab value to report for DIC
Fibrinogen of 85
Multiple PVCs
indicate low potassium or low oxygen
MI Ekg findings
ST elevation, Abnormal Q wave, T wave inversion
CKD Symptoms
Decreased GFR, Azotemia, Increased BUN, Oliguria
Signs of Hypermagnesemia
Diminished DTR, Tall T waves, Decreased St elevation, bradycardia.
Lasix causes
Metabolic Alkalosis
Warfarin is prescribed for
Patients with Afib
COPD
Respiratory Acidosis
Respiratory acidosis and pnuemonia
Overproduction of hydrogen ions
Signs of acute respiratory acidosis
Lethargy, hypotension, Fatigue, decreased perfusion, impaired memory and cognition
Respiratory acidosis
Client with rib fracture
Adverse reaction to carbamazepine
WBC of 3000
Positive Brudzinski’s sign
Patient passively flexes the hip and knees in response to neck flexion and reports pain in the vertebral column
Child is unable to flex leg when the thigh is flexed anteriorly at the hip. suspect
meningitis
Signs of meningitis in CSF
Cloudy CSF, Elevated protein, Decreased glucose levels
Guillain Barre
Observe respiratory rate and effort
Guillain Barre pt reports they cant move their legs and feel tingling above waistline
Bring ECG monitor and Intubation tray
Person most at risk for Guillain Barre
Respiratory or gastro infection over the past month
Tonic clonic seizure turns cyanotic
Continue to monitor
Actions for a seizure
Loosen restrictive clothing, Remove pillow and raise padded side rails, turn to side with head flexed forward
Additional teaching about GERD is needed if pt says
I eat small meals and have a bedtime snack
Frequent complication of ileostomy
Fluid and electrolyte imbalance
Healthy Stoma
Red and moist
Additional Teaching for goiter and possible hyperthyroidism
Checks BP in one arm
Palpates neck to assess thyroid size
orders saline drops for bulging eyes
offers warm blankets for cold feet
ECG changes in hypocalcemia
QT prolongation
ST segment lengthened
DKA patient being weened off insulin reports they are lightheaded and sweaty
obtain glucose reading
Before and oral glucose tolerance test
Avoid smoking before test
several blood samples will be obtained
Fast 8 hours before test
Take levothyroxine on
an empty stomach
Dont do these with a patient with a goiter
warm blankets for feet, palpate goiter
A form of glucose should be taken if pt has
shakiness, palpitations, lightheadedness
Stoma diversion that creates the greatest risk for skin breakdown
Ileostomy
How to drain flatus from one piece drainable ostomy pouch
Open the bottom of the pouch
Empty a colostomy pouch when
its 1/3 to 1/2 full
EMG test
evaluate muscle weakness
discontinue muscle relaxants before procedure
ask if they take herbal supplements before test
