Final Exam Flashcards
Visual soothing mental picture?
Guided imaginary
What do vitamins A,C, & E have in common?
They are antioxidants
Physiological change, anaphylactic reaction- causing what to lungs?
Bronchoconstiction
Gunshot wound, left femoral Artery- what kind of shock?
Hypovolemic
With Acute pain, no meds what’s the best CAM to teach a client ?
Relaxation
Assessing client for medication list? What is an essential question to ask ?
Any allergies ? Vitamins and herbs are you taking any?
Hypovolemic leads to an adequate tissue perfusion and what?
Hypoxia ?
And eventually organ failure
Cariogenic shock, Hypotension- placed in what position?
Talenberg or supine with feet elevated
Fluid treatment for hypovolemic shock ?
0.9% normal saline
Teaching client self administrating Epi pen - placement of injection
Subcutaneous in outer thigh
Relationship between sepsis and age
Increase chances with age
Dyspneic, crackles in lungs, fluid volume excess , CHF - what physiologic symptom will be present
Increase in blood pressure
Med allergy most at risk for anaphylactic shock?
Penicillin
Nursing responsibility for prevention on shock ?
Know potential risks for each patient
Warm flushed skin fever increase respiratory rate and heart rate - what diagnosis ?
Stage one of septic shock
First line treatment for anaphylactic shock ?
Epinephrine
Primary treatment for hypovolemic shock
Fluid replacement
Most serious complication for anaphylactic shock
Death
Hypovolemic shock - risk for what electrolyte imbalance
Hypokalemia
Chemical ware fare agent , extent of injury - what else ?
Amount used and time exposed
1st symptoms of radiation sickness
Nausea and vomiting and diarrhea and headache
Describe an emergency in health care
Medical condition of people who need immediate attention
Triage in ER- what to triage first ?
Red tags – severity of illness or injury
CPR in the hospital , promote respiration- what will you use
BVM, defibrillator, CAB
Abdominal pain assessment- what 4 things to asses?
PQRST ??
Provokes , quality, radiates, severity, timing
Penetrating trauma bowel loops protruding - what do you do?
What sterile gauze with dry sterile gauze over
Terrorists attack/triage - multiple choice
Loss of consciousness, chest pain, chest Wound , 3rd° burn wound
Terminal cancer and CAM
?Relaxation, biofeedback, healing touch, imagery
Epi pen-?
Avoid sun and heat, don’t inject IM or butt , thighs preferred
Positive homans sign ?
Embolis
A-fib more likely to happen that what?
Five times more likely of stroke
D/c teaching with a pacemaker
Medical IDs no contact sports ?
You can set off medical detectors
DVT and bedrest
Wear compression stockings SCD
D/C teaching thrombophlebitis?
Anticoagulant such as Coumadin. Drink 2-3 quarts of h2o daily
Do not cross legs, elevate legs while sitting, avoid sitting or standing long periods, wear support, shift weight back and forth or circulation. Notify PCP ASAP if assumed DVT or PE.
Bradycardia- what is it?
Slow heart rate below 60- treat with atropine
Pacemaker - d/c teaching
Teach client to take accurate apical and radial pulses
Inform client to report dizziness, fainting , or fever
Regular pacemaker checks or trans telephonic monitoring
Treatment for ventricular fibrillation?
?shock only and atropine
Treatment for ventricular fibrillation
Defibrillation and CPR
Oxygen, amiodarone (cordarone) given through IV, lidocaine hydrochloride, mag sulfate, can also be cardioverted if peripheral pulses are present or defib if peripheral pulses are absent
Treatment for tachycardia
Depends on cause
Placement of defibrillation paddles
Upper right below clavicle at apex of heart and lower left
Heparin therapy and lab values
DPPT or APTT lab values ??
Partial thromboplastin time. Serum test the identifies abnormalities in clotting pathway.
Normal time is 60-70 sec clot time. If >100 higher clot risk. If taking heparin, do PTT test 30-60 mins before dose
Heparin will prolong PTT
Rheumatic fever
Mitral valve prolapse
Mitral stenosis
Valve becomes and the leaflets are thicken which prevents blood flow from flowing freely
Hemophilia/bleeding into joints- treatment
Immobilize and put pressure apply ice
DIC and treatment
Deseminated intravascular coagulation condition that alternates clotting and hemorrhaging. Administer platelets and packed red blood cells.
RBCs and function
Carry oxygen
Blood transfusion with what fluid IV?
0.9 % normal saline
Platelets and function ?
Clotting factor
Anaphylactic reaction- what to give first?
Epinephrine
Immunosuppressive (what at risk first)?
Infection
Bee sting (what will you ask first)
Ask if hey have ever been stung before
SLE- the characteristic sign?
Systemic lupus erythematosus - butterfly rash on face
Anaphylactic shock to shellfish (what is most important ?)
Airway
SLE- what is it?
Inflammatory disease of collagen contained in connective tissues
RBC blood transfusion- signs to tell patient to report immediately?
Hives, trouble breathing, feeling sick malaise
Function of skin
Protection , sensation , temp, regulator
Brown/dark colored skin- where to asses for pallor ?
Mucus membranes
PPE to wear when caring for burn patient ?
Gown, mask, gloves, bonnet
Severe burn, less than desirable client status
Hourly urine less than 30mL
Diet for atrial dysrhythmias/foods to avoid
No salt , no alcohol , no caffeine
Most common cause of altered wound healing
Infection
Burns nursing diagnoses
Ineffective airway clearance
Lice interventions ?
Shampoo ever 9-10 days
Burn and effect on survival
Inhalation injury
Dietary and wound healing
Increase protein and calorie intake
Contact dermatitis?
Pruritus/ rash
Carbuncle
Boil
Glasgow coma scale - scoring
Lowest:3-deep coma - 15 is best
Stroke/TIA- risks
Hypertension increase risk
Parkinson’s - meal safety measurements
Dysphasia - monitor for choking
Encephalitis and meningitis- diagnostic testing and nursing interventions
Lumbar puncture
CBC
Anticonvulsants- client teaching
Use good oral hygiene
Head injury and ICP?
ICP-Device used for draining and maintaining adequate O2 levels and perfusion in brain after head injury
Closed wound - swelling in brain
Open wound - fluid through ears - cerebral fluid
S/s- ICP
Headache nausea vomiting confusion , increased bp, pupils don’t respond to light , coma, seizures,shallow breathing
Back surgery - how to reposition ?
Log roll- supine
MS - goals and what causes exacerbations
Periods of emotional or physical stress
Spinal cord injuries - what kind of paralysis it can cause ?
Monoplegia - arms and legs
Quadriplegia- all four limbs
Hemiplegia- arm and leg on same side
Paraplegia- both legs
T-8?
Autonomic dysreflexia - nursing intervention
Fowler’s position - asses bp every few min
Hearing aides- what do they help with?
Increase sound and speech but not necessarily clarity
Sensorineural, conductive and mixed hearing loss
Inner ear loss
Ménière’s disease
State of hearing loss caused by tinnitus or vertigo
Internal radiation therapy- nursing interventions
Wear lead apron , prepare everything outside room , several nurses , wear shield , limit time of exposure with pt
Tonic clonic seizures- nursing interventions
Asses respiratory status, note time, document if unconscious, prepare suction cover side rail with blankets , loosen clothing
PNS- SNS - flight or fight
?pg 791
SNS - Prepares the body for intense physical activity (fight or flight response)
PNS-
Relaxes the body and inhibits it slows high energy functions ? (Conserves and restores)
Fight or flight-
Response to stress and prepares the body to react to danger part of the autonomic nervous system. Maintains homeostasis
Mental status - what to look for in change of mental status ?
Loc- loss of consciousness
