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Nursing Process > Final Exam > Flashcards

Final Exam Flashcards

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1
Q

airborne precautions

A
  • negative pressure room, mask, gloves, gown

- TB, measles, chicken pox, herpes zoster, SARS

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2
Q

droplet precautions

A
  • private room, mask when within 3 feet of the client, gloves, gown
  • mumps, pertussis, pneumonia
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3
Q

contact precautions

A
  • private room, gloves, gown

- impetigo, C. diff

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4
Q

hematocrit and dehydration

A

HCT goes up with dehydration, down with fluid overload

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5
Q

types of play in relation to ages

A

-infancy: onlooker and solitary
-toddlers: parallel play
-3-4: associative
4-6+: cooperative

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6
Q

negativism

A
  • toddlers
  • doing the opposite of what others want; closely related to autonomy… the toddler wants to do things independently
  • negative toward anyone that tries to take away their independence
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7
Q

ages of stranger anxiety

A

8 or 9 months to 2 years

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8
Q

3 C’s of tracheoesophageal fistula

A
  • coughing and choking during feedings

- unexplained cyanosis

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9
Q

maintenance of tracheoesophageal fistula

A
  • NPO
  • suction accumulated secretions
  • maintain supine, upright position of at least 30 degrees to facilitate drainage of secretions
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10
Q

iron supplements

A
  • start at 6 months if only breastfed
  • never with milk because it binds free iron
  • Vit C helps absorption
  • can cause constipation
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11
Q

vitamin D supplements

A
  • deficiency leads to rickets

- 400 IU/day shortly after birth

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12
Q

Meckel’s diverticulum

A
  • fibrous band connecting SI to umbilicus
  • most common congenital malformation of the GI tract
  • painless rectal bleeding
  • currant jelly stool or dark red
  • can cause hypotension because of blood loss
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13
Q

3 C’s of measles and other telling sign

A
  • coryza (inflammation of the mucus membranes in the nose
  • cough
  • conjunctiva
  • other: Koplik spots
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14
Q

erythema infectuosum

A
  • Fifth Disease
  • asymptomatic before rash, possible mild fever, malaise, headache, runny nose
  • face-slap rash develops and disappears by 1-4 days
  • rash progresses to extremeties
  • common with sickle cell
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15
Q

immunization schedule

A
  • Birth: Hep B
  • 1 month: hep B
  • 2 months: inactivated poliovirus vaccine (IPV), DTaP, Hib, pneumococcal (PCV), rotavirus (RV)
  • 4 months: DTaP, Hib, IPV, PVC, RV
  • 6 months: DTaP, Hib, HepB, IPV, PVC, RV
  • 12-15 months: Hib, PVC,MMR, HepA first dose (second dose given 6-18 months after first dose, varicella
  • 15-18 months: DTaP
  • 18-33 months: HepA (second dose)
  • 4-6 years: DTaP, IPV, MMR, varicella
  • 11-12 years: MMR (if not administered at 4-6 years, Tdap, meningococcal vaccine (MCV4) with a booster at age 16, HPV (first dose to girls at age 11 to 12, second dose 2 months after first dose, and third dose 6 months after firsts dose
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16
Q

aphthous stomatitis

A
  • canker sore
  • painful, small, whitish ulcerations surrounded by a red border
  • healthy adjacent tissues, absence of vesicles, and no systemic illness
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17
Q

herpetic gingivostomatitis

A
  • cold sores/ fever blisters
  • caused by HSV
  • fever, pharynx becomes edematous and erythematous; vesicles erupt on the mucosa, causing severe pain
  • exacerbated by emotional stress, trauma, immunosupression, or exposure to excessive sunlight
18
Q

rule of 5s

A

takes a drug 5 half lives to build to a steady state in the body, by the time the five half-lives have occurred, the body has eliminated a single dose

19
Q

somatoform disorder

A
  • persistent worry or complains regarding physical illness without supportive physical findings
  • increases with psychological stressors
  • identify alternative methods of coping
  • assist the pt to relate feelings and conflicts to the physical symptoms
  • convey understanding that the physical symptoms are real to the client, but avoid responding with positive reinforcement about physical symptoms
20
Q

what to monitor with a pt on TPN

A
  • glucose q6h
  • weight qd with same linens
  • I&O
21
Q

GERD education

A
  • avoid foods that cause irritation: peppermint, chocolate, coffee, fried or fatty foots, carbonated beverages, alcohol, smoking
  • low-fat, high-fiber diet
  • elevate head of the bed
  • avoid anticholinergics and NSAIDS
  • instruct on use of antacids
22
Q

prevalence of eating disorders

A
  • both: 1 - 4% of US population
  • 89% of pts hospitalized are women
  • 2:1 women to men for anorexia; 3:1 for bulimia
23
Q

nephrotic syndrome

A 
-proteinuria and hyperlipidemia 
NAPHROTIC:
N - Na+ decrease
A - Albumin decrease
P - Proteinuria >3.5 g/day
H - Hyperlipidemia 
R - Renal vein thrombosis
O - Orbital edema
T - Thromboembolism 
I - Infection
C - Coagulability
24
Q

glomerulonephritis

A
  • 2 to 3 week after strep infection
  • decreased urinary output
  • cloudy, smoky, brown-colored urine (hematuria)
  • headaches, abdominal pain or flank pain, dysruia
  • HTN
  • proteinuria with foam
  • azotemia
25
Q

talipes varus

A

inversion

26
Q

talipes valgus

A

eversion

27
Q

talipies equinus

A

plantar flexion with the toes lower than the heel

28
Q

talipes calcaneus

A

plantar flexion with the toes higher than the heel

29
Q

avoiding contractures

A

place limb flat on firm bed after 24 hours of elevations

30
Q

wound care for burns

A
  • reposition

- change every 8-12 hours

31
Q

3-point gait

A

both crutches and foot of affected extremity are advanced together, followed by the foot of the unaffected extremity

32
Q

oliguric phase of acute renal failure

A
  • sudden decrease in urine output; less than 400 ml/day
  • signs of excess fluid volume
  • restrict fluid intake
33
Q

diuretic phase of acute renal failure

A

excessive urine output indicates that damaged nephrons are recovering their ability to excrete waste
-IV fluids to maintain fluid and electrolyte balance

34
Q

sign of end stage renal disease

A

GFR less than 15 ml/min

35
Q

management of anemia r/t chronic kidney disease

A

administer epoetin alpha (Epogen, Procrit) to promote maturity of the RBCs

36
Q

Cast care

A

-examine the cast for pressure areas… check for unrelieved pain; pale, dusky, or edematous tissue distal to the involved area; parasthesias; pulselessness

37
Q

cast education for children

A
  • big toys
  • instruct parents and child not to stick objects down the cast
  • teach parents and child to keep cast clean and dry
  • instruct parents and child in isometric exercises to prevent muscle atrophy
38
Q

position for BPH surgery

A

lithotomy

39
Q

meds associated with refractory mania

A
  • refractory mania is bipolar mania that does not respond well to meds
  • treated with clozapine (or other atypical antipsychotics) and ECT
40
Q

3-way catheter

A

Transurethral Resection of Prostate (TURP)

  • microscope
  • scissors
  • foley

Nursing Process (4 decks)

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