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Capstone > Capstone exam 2 > Flashcards

Capstone exam 2 Flashcards

1
Q

Babinski Sign

A

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

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2
Q

Serum Ammonia Level

A

10-80mcg
High=severe liver disease

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3
Q

Mild anemia

A

Palpitations, dyspnea, mild fatigue. HGB 10-12

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4
Q

Moderate Anemia

A

Increased palpitations, fatigue, dyspnea. HGB 6-10

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5
Q

Severe Anemia

A

Tachycardia, anorexia, PICA, Pallor, Bone pain, Impaired thoughts, HGB below 6

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6
Q

Anemia Teaching

A

Dietary changes, Alternate rest and activity, Increase protein, B vitamins, Folic Acid, Iron, Vitamin C, Vitamin E, Blood transfusion, Erythropoietin, Oxygen therapy

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7
Q

Glasgow Coma Scale

A

Best score 15. Less than 8 severe head injury or coma, 9-12 Moderate head injury, Mild 13-15

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8
Q

Post craniotomy Interventions

A

Monitor vital signs, airway, Neuro status, pain, surgical site, fluid and electrolyte

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9
Q

EMG

A

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.

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10
Q

Variable Decelerations
Early Decelerations
Accelerations
Late Decelerations

A

Cord Compression
Head Compression
Oxygen good
Placental Insufficiency

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11
Q

Brudzinski’s sign

A

Severe neck stiffness causes patients hips and knees to flex when neck is flexed. Indicates meningitis

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12
Q

Biophysical profile

A

Combines non stress test with ultrasound

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13
Q

Chorioamnionitis

A

Intraamniotic infection, acute inflammation of membranes due to polymicrobial bacterial infection in the setting of membrane rupture

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14
Q

Amniotic fluid embolism

A

Catastrophic complication, amniotic fluids, fetal cells, hair, other debris enter into maternal pulmonary circulation causing cardiovascular collapse.

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15
Q

Isosorbide mononitrate

A

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

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16
Q

Carbamezapine

A

Tx epilepsy, trigeminal neuralgia, may cause steven johnson syndrome, or toxic epidermal necrolysis. Wait 14 days after stopping to take MAO

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17
Q

Calcitonin

A

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.

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18
Q

Pt with HF taking furosemide and digoxin develops muscle cramps, N/V, and anxiety. What order would the nurse expect.

A

Give supplemental K+

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19
Q

Lab value to report for DIC

A

Fibrinogen of 85

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20
Q

Multiple PVCs

A

indicate low potassium or low oxygen

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21
Q

MI Ekg findings

A

ST elevation, Abnormal Q wave, T wave inversion

22
Q

CKD Symptoms

A

Decreased GFR, Azotemia, Increased BUN, Oliguria

23
Q

Signs of Hypermagnesemia

A

Diminished DTR, Tall T waves, Decreased St elevation, bradycardia.

24
Q

Lasix causes

A

Metabolic Alkalosis

25
Q

Warfarin is prescribed for

A

Patients with Afib

26
Q

COPD

A

Respiratory Acidosis

27
Q

Respiratory acidosis and pnuemonia

A

Overproduction of hydrogen ions

28
Q

Signs of acute respiratory acidosis

A

Lethargy, hypotension, Fatigue, decreased perfusion, impaired memory and cognition

29
Q

Respiratory acidosis

A

Client with rib fracture

30
Q

Adverse reaction to carbamazepine

A

WBC of 3000

31
Q

Positive Brudzinski’s sign

A

Patient passively flexes the hip and knees in response to neck flexion and reports pain in the vertebral column

32
Q

Child is unable to flex leg when the thigh is flexed anteriorly at the hip. suspect

A

meningitis

33
Q

Signs of meningitis in CSF

A

Cloudy CSF, Elevated protein, Decreased glucose levels

34
Q

Guillain Barre

A

Observe respiratory rate and effort

35
Q

Guillain Barre pt reports they cant move their legs and feel tingling above waistline

A

Bring ECG monitor and Intubation tray

36
Q

Person most at risk for Guillain Barre

A

Respiratory or gastro infection over the past month

37
Q

Tonic clonic seizure turns cyanotic

A

Continue to monitor

38
Q

Actions for a seizure

A

Loosen restrictive clothing, Remove pillow and raise padded side rails, turn to side with head flexed forward

39
Q

Additional teaching about GERD is needed if pt says

A

I eat small meals and have a bedtime snack

40
Q

Frequent complication of ileostomy

A

Fluid and electrolyte imbalance

41
Q

Healthy Stoma

A

Red and moist

42
Q

Additional Teaching for goiter and possible hyperthyroidism

A

Checks BP in one arm
Palpates neck to assess thyroid size
orders saline drops for bulging eyes
offers warm blankets for cold feet

43
Q

ECG changes in hypocalcemia

A

QT prolongation
ST segment lengthened

44
Q

DKA patient being weened off insulin reports they are lightheaded and sweaty

A

obtain glucose reading

45
Q

Before and oral glucose tolerance test

A

Avoid smoking before test
several blood samples will be obtained
Fast 8 hours before test

46
Q

Take levothyroxine on

A

an empty stomach

47
Q

Dont do these with a patient with a goiter

A

warm blankets for feet, palpate goiter

48
Q

A form of glucose should be taken if pt has

A

shakiness, palpitations, lightheadedness

49
Q

Stoma diversion that creates the greatest risk for skin breakdown

A

Ileostomy

50
Q

How to drain flatus from one piece drainable ostomy pouch

A

Open the bottom of the pouch

51
Q

Empty a colostomy pouch when

A

its 1/3 to 1/2 full

52
Q

EMG test

A

evaluate muscle weakness
discontinue muscle relaxants before procedure
ask if they take herbal supplements before test

Capstone (2 decks)

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