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NCLEX > Condition > Flashcards

Condition Flashcards

0
Q

AIDS

A

Bowel programs, stool softeners and laxatives reduce intestinal stasis and bacterial overgrowth

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1
Q

Addison’s

A

Hyperkalemia

Symtoms: muscle cramps, fatigue and hypotension

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2
Q

Anxiety

A

Sleeping 7 hours a night and dreams are calm indicates major resolution of anxiety as the sleeping and dreaming both reflect and affect the body, mind, and spirit and are not conscious processes; in anxious states, insomniac symptoms of disturbed sleep pattern, sleep deprivation, fatigue are common; intrusive thoughts, worrying, fear, and/or replaying traumatic events contribute to difficulty falling asleep and/or staying asleep

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3
Q

Apnea

A

Longer than 15 seconds in a newborn should be reported
Able to leave baby for brief periods of time
Sleep by baby’s crib
Can remove monitor during bath time

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4
Q

Asthma

A

Wheezing: high pitched musical sounds heard on expiration caused by narrowing of the bronchials

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5
Q

A fib

A

Sinoatrial node no longer functions, atrial contractions reduced and stasis of blood in atria occurs
Pulse rate greater than 100 bpm, totally irregular rhythm, no definite P waves

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6
Q

Bell’s Palsy

A

Use artificial tears qid bc paralysis of eyelid allows cornea to dry; drops reduce chance of corneal damage

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7
Q

Bipolar

A

Manic: hyperactivity, poor concentration, and distractibility; redirect into activity that promotes rest, nourishment; reduce stimuli

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8
Q

Borderline personality disorder

A

Extremely angry and need help with anger management
Limit setting, including clarity and boundaries is important; they often present in a frantic, unstable, irritable, intense, impulsive manner, with frequent temper displays

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9
Q

Chronic bronchitis

A

Rhonchi: deep, low pitched rumblings are heard mainly on expiration caused by mucus in the airway

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10
Q

Cushing’s Syndrome

A

Prone to fluid overload and CHF due to sodium and water retention
Increased susceptibility to infections
Monitor patient’s blood glucose because hypercortisolism causes hyperglycemia
symptoms: fatigue, weakness, osteoporosis, cramps, edema, hypertension, decreased resistance to infection, truncal obesity, buffalo hump, moon face

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10
Q

Cystic fibrosis

A 
Autosomal recessive trait
Both parents carry recessive trait
25% chance of passing to offspring
Positive Sweat test
Increased salt in diet
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11
Q

Bulimia

A

Hoarse voice that is barely audible needs immediate referral to the physician because patient is at high risk for tracheoesophageal fistula from esophageal tear; laryngitis is danger sign

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12
Q

Buergers disease

A

Recurring inflammation of arteries and veins in upper and lower extremities, results in thrombus and occlusion
Seen in men 20-35 yo
Smoking is causative factor
Pain at rest and coldness major symptoms
Check fingers and toes every day for ulcer formation and gangrene

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13
Q

Detached retina

A

Photophobia, loss of a portion of the visual field

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14
Q

Cholecystitis

A

Symptoms: nausea, frequent belching, right upper abdominal pain
Concerning: jaundice indicates a possible stone in bile duct causing obstruction
Avoid fatty foods and gas forming foods

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16
Q

Compartmental syndrome

A

Symptoms: pale and cool to touch, complains of pain

Don’t elevate

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17
Q

Cleft lip and palate

A

Upper airway congestion: position infant on side to facilitate drainage of mucus and will promote adjustment to breathing through nose

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18
Q

Type I diabetes

A

Polyuria, polydipsia, polyphagia
Weight loss
Quivering feeling in abdomen indicates hypoglycemia
Inspect feet daily for blisters, sores, ingrown nails and cuts
Bathe feet daily in warm water
Cut toenails straight across
Don’t go barefoot
Vomiting for 24 hrs: diabetic ketoacidosis is frequently associated with dehydration so drink liquids as often as possible
At risk for heart disease

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20
Q

Type II diabetes

A

Recurrent vaginal and UTIs are an early sign in adolescents

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21
Q

Dawn phenomenon

A

Increase in blood sugar during hours of 2-8 am

Treat: stop high carb snacks before bed, adjust insulin before bed

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22
Q

DVT

A 
Deep vein thrombosis (thrombophlebitis)
Decrease inflammatory response in the affected extremity and prevent embolus formation 
Elevate foot of bed 6 inches
Warm moist packs to the affected leg
On bed rest 5-7 days -bedpan
Positive Homans sign
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25
Q

Surgery induced diabetes insipidus

A

4000 ml in 24 hrs

Increased urine output with pale colored urine and low specific gravity

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26
Q

Dumping syndrome

A

Include foods with fat and increase calories
Lie down or sit in recliner for 30-60 min after eating
Wait 1 hr before drinking

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27
Q

Chronic glomerulonephritis

A

May be treated with peritoneal dialysis if end stage renal disease develops

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28
Q

Acute Glomerulonephritis

A

Occurs secondary to other infections
Meds: antibiotics, corticosteroids, antihypertensive, immunosuppressive agents; restrict sodium intake, restrict water if oliguric; dialing weights, monitor I and O, bed rest, high calorie, low protein diet

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29
Q

Droplet

A

Private room, maintain spatial separation of 3 ft between patient and visitors
Pertussis
Wash hands, remove mask and throw trash in container in room

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30
Q

Hip fracture

A

Abduction wedges
No more than 90 degrees
Don’t cross legs

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34
Q

Hypoglycemia

A

Tachycardia
Cold and clammy skin
Weakness and pallor
Treat at home: drink 1/2 c fruit juice followed by protein snack

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35
Q

Evisceration

A

Immediately cover open area with sterile gauze soaked in normal saline and notify physician

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36
Q

Impetigo

A

Honey colored crusted lesion
Notify parents first
Loosen scab with burrow’s solution compress
Systemic antibiotics, antibacterial soap
Possible complication is peri orbital edema indicative of poststreptococcal glomeruli nephritis

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39
Q

ICP

A

Normal 7-15;
3 mo old with high pitched cry indicates increased ICP
5 yo with closed head injury- assess orientation to person, place and time every hour to detect early signs of increased ICP
Determine cough reflex and ability to swallow prior to administering PO fluids
Increased systolic pressure and widening pulse pressure indicates increased ICP

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40
Q

Hepatitis A

A

Communicable for 2-3 weeks before onset of jaundice and about 1 wk after onset of jaundice
Eat small frequent meals
Increase calories to 2000-3000 per day to meet energy needs
No alcohol
Eat protein sources
Spead by oral rectal route
Practice good hand washing
Caution about taking any drugs not approved by doc bc it may become dangerous bc of livers inability to detoxify and excrete them

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41
Q

HHNK (hyperglycemic hyperosmolar nonketotic syndrome)

A

Seen after 50 yo

Age-related changes in thirst perception result in dehydration and decrease in urine-concentrating abilities of kidney

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42
Q

Hepatic encephalopathy

A

Early sign: impaired thought process

Late sign: hyperventilation, stupor, decerebrate/decorticate posturing

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43
Q

Hypoparathyroidism

A

Symptom: tetany

Treatment successful if denies numbness and tingling

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44
Q

Herpes simplex virus abscess

A

Clean lesions twice daily with diluted solution of povidone-iodine (betadine) and leave open to air

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46
Q

Age related macular degeneration

A

Causes permanent loss of central vision

Smokers at risk

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47
Q

Hypertension is silent killer

A

CVAs can be related to long term hypertension

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48
Q

Hyperthyroidism

A

Exophthalmos-requires ophthalmic drops
Provide calm, restful environment
Frequent high calorie snacks

49
Q

Systemic lupus erythema

A

Auto immune

Joint pain, malaise, weight loss

50
Q

Hypothyroidism

A

Symptoms: Tired, coarse hair and skin, persistent weight gain

51
Q

MI

A

Most common complication following MI is dysrhythmias, ventricular types most serious
Generally related to coronary artery disease

52
Q

Pneumonia

A

Crackles: Soft high pitched interrupted sounds heard on inspiration caused by fluid in the alveoli

53
Q

Hyperparathyroidism

A

Abdominal discomfort, muscle weakness, diaphoresis

Report hematuria, sign of renal calculi

54
Q

Opisthotonos

A

condition in which the body is held in an abnormal position. The person is usually rigid and arches the back, with the head thrown backward. If a person with opisthotonos lies on his or her back, only the back of the head and the heels touch the supporting surface.

Meningitis

55
Q

Rheumatoid arthritis

A

Contributes to mitral valve disease
Plan of care: Heat, range of motion exercises, weight reduction, firm mattress
Symptoms: symmetrical joint swelling, rheumatoid nodules

56
Q

Orthostatic hypotension

A

Teaching: Arise slowly from bed and avoid standing still for long periods
Lower limb compression devices aid in prevention

57
Q

Schizophrenia

A

Inappropriate affect, expressions of feelings bizarre for situation
Ex: client laughs while talking about being raped

58
Q

Intermittent claudication

A

Pain in calf during exercise that disappears at rest

Ankle-brachial index

59
Q

Respiratory acidosis

A

Treat: high fowlers, encourage coughing and deep breathing, evaluate airway patency

60
Q

Pericardial friction rub

A

Harsh grating sounds heard best during inspiration

61
Q

Shock

A

Low BP, high pulse, low resp
Cool, clammy skin, and tachypnea
Weak thready pulse
Cyanotic, short of breath, complaining of pain
Lower head of bed and place patient on left side -air will rise to right atrium, minimizes chance of air bubbles entering cerebral circulation

62
Q

MS

A

Visual disturbances, weakness in extremities, muscle tremors
Risk for Falls, skin breakdown, fatigue
Avoid overexposure to heat (sauna, hot tubs, sunbathing) or cold
Ambulated as tolerated
ROM, stretching and strengthening
Avoid alcohol
Avoid crowded places (May cause infection)

63
Q

Osteomalacia: adults
Rickets: peds

A

Poor vitamin D and calcium

Bones become soft and weak

64
Q

Respiratory alkalosis

A

Administer anti anxiety agent, assist patient with rebreathing device to increase O2 levels

65
Q

Spina bifida

A

Spinal nerves destroyed by myelomeningocele can’t be corrected

66
Q

MVA don’t leave pt alone if

A

Disorientation and irregular vital signs

67
Q

Chronic renal failure

A

Increase intake of carbs to help maintain energy requirements

68
Q

Rupture of membranes (ROM)

A

Assess for prolapsed cord
If so, position patient supine with foot of bed elevated. Nurse would place 2 gloved fingers to push on presenting part to take pressure off cord. Prepare for csection.

69
Q

Third trimester

A

Epigastric pain most concerning because indicative of an impending convulsion
Shortness of breath expected
Increased rectal pressure expected
Diabetic: check blood sugar before meals, 2 hrs after meals and bedtime CONCERN if client taking less insulin than 2 mo ago bc would indicate placenta not functioning

70
Q

Scoliosis

A

Brace ordered

Hold on rail down stairs to prevent falls

71
Q

Thermal injury (burns)

A

Most concerning: Increased respiratory rate and decreased BP bc may indicate burn wound sepsis
Muscle weakness and lethargy are signs of hypokalemia, which can occur on the third day after a burn; hypokalemia is caused by diuresis
Report to doc if gastric pH is less than 5 bc client at risk for Curling’s ulcer. May develop 24 hrs after severe burn injury (gastric pH 1-5)

72
Q

Positive pregnancy

A

Fetal HR detected by Doppler 10-12 wks
Active fetal movements palpable by examiner
Outline of fetus by radiography or ultrasonography

73
Q

SIADH

A

Low sodium

Weight increase

74
Q

Shingles

Herpes zoster

A

Can care for non high risk clients, cover lesions, can’t care for immunosuppressed clients until lesions have crusted
Disseminated: airborne and contact precautions

75
Q

Thumb sucking

A

Peaks at 18-20 mo, normal behavior, usually subsides after 24 mo
Malocclusion occurs if thumb sucking persists past 4 yo or when permanent teeth erupt

76
Q

Transition phase of labor

A

Pant with pursed lips to allow patient to control pain and urge to push and promotes oxygenation of fetus
Cervix is 8-19 cm dilated with complete effacement; increased pressure in pelvis causes intense desire to urinate

77
Q

Somogyi effect

A

Blood sugar goes down at 3 am and then high in am

Treat: bedtime snack with insulin

78
Q

Wilm’s tumor

A

Blood in urine, pain, fever
Childhood (5yo) kidney cancer
Don’t palpate it or massage bc it may cause dissemination of cancer cells

79
Q

Pyloric stenosis

A

Infant fussy and seems hungry all the time

Lethargic, dehydrated and malnourished

80
Q

Infant with reflux

A

Head of bed at 30 degrees

Small volume, frequent feedings

81
Q

Presumptive Pregnancy

A 
Amenorrhea
N/V
Increased breast size and fullness
Pronounced nipples
Urinary frequency
Quickening
Fatigue
Discoloration of vaginal discharge
82
Q

Peripheral vascular disease (PVD)

A

Decreased blood flow
Low tolerance for exercise
Increased venous pressure
Mottled skin, coolness, loss of hair, dry skin
Slow, steady walking to stimulate development of collateral circulation
Walk until experiences pain, rest, resume walking

83
Q

Placenta previa

A

Cannot deliver vaginally

84
Q

Myelomeningocele

A

After repair: Head circumference measurement is important because of risk of hydrocephalus following surgery
At risk to develop infection (meningitis) because of myelomeningocele sac; monitor for elevated temperature, irritability and lethargy

85
Q

Ostomy

A

Change bag at least 1x/wk

86
Q

Urinary catheter

A

If urine appears cloudy and foul-smelling, encourage client to increase fluid intake

87
Q

Newborn cord

A

Clean it several times a day and expose it to air frequently

Should be dry with no redness

88
Q

Meningitis

A

Isolation can be stopped 24 hrs after start of antibiotic therapy

89
Q

Probable pregnancy

A 
Uterine enlargement
Hagar sign: softening of the uterine
Goodells sign: softening of the cervix
Chadwick's sign: blue cervix
Ballotment: rebound of fetus
Braxton hicks
Positive test
89
Q

Myasthenia gravis

A

Sudden inability to swallow or maintain patent airway
Muscle weakness
Precipitating factors: infection, stress

89
Q

Ectopic pregnancy

A

Needs to be evaluated if 4 wks gestation reporting unilateral, dull abdominal pain
If ruptured, fluid most important

89
Q

Radical mastectomy

A

Position client in semi-fowler with the arm of the affected side elevated bc it facilitates removal of fluid from venous pathways and lymphatic system through gravity; arm elevated to enhance circulation and prevent edema

89
Q

Pregnancy

A 
2-5 lb first trimester
.66-1.1 lb/wk in second and third trimester 
Heart beat 3 wks
Organs, circulatory 8 wks
Formed 12 wks
89
Q

Kaposi sarcoma lesions

A

Large, painful, purplish-brown open areas: Clean carefully with soap and water every day and cover with sterile dressing

89
Q

Withdrawal

A

Pulse rate is good indicator of client’s progress through withdrawal
Increasingly elevated pulse signals impending alcohol withdrawal delirium, requiring more sedation

89
Q

Parkinson’s

A

Tremors, shuffling gait, rigidity

Stage IV: client is immobile-ROM exercise to all extremities 4x/day

89
Q

Osteoarthritis

A

Warm up exercises should be done prior to exercising

89
Q

Phantom pain

A

“Staying active will help decrease the episodes”
Activity helps reduce frequency and degree of phantom pain
Majority of clients feel pain for several months

90
Q

Korsakoffs psychosis

A

Symptom: confabulation (in order to fill memory gaps, client invents elaborate, improbable happenings

91
Q

Wernickes syndrome

A

Form of dementia that results from thiamine deficiency

symptoms: diplopia, nystagmus

92
Q

Hantavirus pulmonary syndrome (HPS)

A

Caused by rodents
symptoms: fever, aching, and nausea, may cause severe cardiopulmonary disease
observe for hematuria, hematemesis, bleeding gums and melana

93
Q

Supra ventricular tachycardia (SVT)

A

If child experiences another episode of sudden chest pain and dizziness, child should stick thumb in the mouth, close the mouth around it and then blow on the thumb as if it were a trumpet. This is a form of a vagal or Valsalva maneuver. Another possible vagal maneuver would include ice to the face, holding the breath and then bearing down, massaging the carotid artery on only one side of the Neck.

94
Q

Acute epiglottis

A

Three-year-old leaning forward with mouth open, tongue protruding and drooling indicates acute epiglottitis. Sitting upright to breathe better, tongue protrusion increases pharyngeal movement; drooling caused by difficulty swallowing because of pain and excessive secretions.

95
Q

Open angle glaucoma

A

Glaucoma is abnormal increase in intraocular pressure, leading to visual disability and blindness; obstruction of outflow of aqueous humor
Symptoms: cloudy, blurry vision, or loss of vision, artificial lights appear to have rainbows are halos around them, decreased peripheral vision, pain, headache, nausea, vomiting
Periodic to nonmotor readings 1 to 2 times a year; normal IOP is 10 to 21mm Hg
Mydriatic eyedrops contra indicated

96
Q

Emphysema

A

Perform pursed lip breathing

97
Q

Dissociative identity disorde

A

At least two or more distinct alternative or subpersonalities; each of these has its own name and patterns of thinking, feeling, and behaving; patient spontaneously turning when name is called indicates that subpersonalities are not in control

NCLEX (8 decks)

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