General Bullets #3 Flashcards
While a client is receiving heparin, the nurse should monitor the:
partial thromboplastin time.
Urinary frequency, incontinence, or both can occur after __________________________. Incontinence may be manifested as:
catheter removal; dribbling
When teaching a client about colostomy care, the nurse should instruct the client to hang the irrigation reservoir 18”-22” above the stoma, insert the catheter ______ into the stoma, irrigate the stoma with ________ of water at room temperature of _____________ once a day, clean the area around the stoma with soap and water before applying a new bag, and use a protective skin covering such as a Stomahesive wafer, karaya paste, or karaya ring, around the stoma.
2-4”
17-34 oz.
105-110 degree
The first sign of Hodgkin’s disease is painless, superficial ______________, typically found under one arm or on one side of the neck in the cervical chain.
lymphadenopathy
Cyanotic skin ____________, but pigmented skin does not.
blanches
A client with a ________________ is most likely to report pain during or shortly after eating.
gastric ulcer
Widening pulse pressure is a sign of:
increasing ICP
In a burn victim, a primary goal of wound care is to prevent contamination by:
microorganisms.
To prevent _______________________ in a client who has had hip nailing, the nurse places trochanter rolls from the knee to the ankle of the affected leg.
external rotation
Severe hip pain following the insertion of a hip prosthesis indicates dislodgement. The nurse should assess for :
shortening of the leg
external rotation
absence of reflexes
______________ is a pathological, parrot like repetition of another person’s words or phrases.
Echolalia
According to psychoanalytic theory, the _______ is the part of the psyche that controls internal demands and interacts with the outside world at the conscious, preconscious, and unconscious levels.
ego
According to psychoanalytic theory, the __________ is the part of the psyche that’s composed morals, values, and ethics. It continually evaluates thoughts and actions, rewarding the good and punishing the bad.
superego (supercop of the unconscious)
According to psychoanalytic theory, the ________ is the part of the psyche that contains instinctual drives.
id (remember “I” for instinctual and “d” for drive)
According to Erikson, from birth to age 12 months, the child is in the _____________________ stage of psychosocial development.
trust-versus-mistrust
Pregnancy-induced hypertension (preeclampsia) is an increase in BP of __________ over baseline or BP of _________ on two occasions at least 6 hours apart accompanied by edema and albuminuria after 20 weeks’ gestation.
30/15
140/95
Positive signs of pregnancy include:
ultrasound evidence
fetal heart tones
fetal movement felt by examiner (after 4 mos.)
______________ is softening of the cervix.
Goodell’s sign
____________ is softening of the lower segment of the uterus.
Hegar’s sign
Quickening, a presumptive sign of pregnancy, occurs between _________________ weeks’ gestation.
16 and 19
__________ ceases during pregnancy.
ovulation
Any _______________ during pregnancy should be considered a complication until proven otherwise.
vaginal bleeding
At 12 weeks’ gestation, the fundus should be at the tope of the:
symphysis pubis
______________ are small, irregular, red spots with minute, bluish white centers that appear on the buccal mucosa of clients with measles (rubeola).
Koplik’s spots
As much as 75% of renal function is lost before ______ and __________ levels rise above normal.
BUN
serum creatinine
When compensatory efforts are present in acid-base balance, partial pressure of arterial carbon dioxide and bicarbonate always point in the :
same direction
Polyuria is urine output of ____________ with 24 hours in an adult.
2,500 mL or more
The presenting sign of ____________ is chest pain that is usually unilateral and related to respiratory movement and may be described as “stabbing” or “knifelike.”
pleuritis
If a client can’t void, the first nursing action should be _________________ to assess for bladder distention.
bladder palpation
If a client has a gastric drainage tube in place, the nurse should expect the physician to order:
potassium chloride.
___________ shouldn’t be given to infants younger than age 1 because it has low linoleic acid content and its protein is difficult for infants to digest.
Cow’s milk
An increased pulse rate is one of the first indications of _________________. It occurs because the heart attempts to compensate for a decreased oxygen supply to the tissues by pumping more blood.
respiratory difficulty
If jaundice is suspected in a neonate, the nurse should examine the infant under __________________. If that is unavailable, the nurse should examine the infant under a ___________.
natural window light
white light
Denial is a ________________ used by a client who denies the reality of an event or condition.
defense mechanism
The three phases of a uterine contraction are:
increment
acme
decrement
The client who uses a cane should carry it on the _________________ and advance it at the same time as the ________________.
unaffected side
affected side
To fit a supine client for crutches, the nurse should measure from the ____________ to the _______ and add ______ to that measurement.
axilla
sole
2”
The intensity of a labor contraction can be assessed by the _______________ of the uterine wall at the contraction’s peak.
indentability
Labor contractions are graded as _______, __________, or ____________.
mild (somewhat tense)
moderate (moderately tense)
strong (boardlike)
____________, the mask of pregnancy, is pigmentation of a circumscribed area of skin (usually over the bridge of the nose and cheeks) that occurs in some pregnant women.
Chloasma or melasma
The gynecoid pelvis is most ideal for delivery. Other types include:
platypelloid (flat)
anthropoid (apelike)
android (malelike)
Pregnant women should be advised that there is no safe level of _______________.
alcohol intake
In an adult, a hemoglobin level below ________ suggests iron deficiency anemia and the need for further evaluation.
11 mg/dL
The normal partial pressure for oxygen in arterial blood is ________ (plus or minus 5 mm Hg).
95 mm Hg
Vitamin C deficiency is characterized by:
brittle bones
pinpoint peripheral hemorrhages
friable gums with loosened teeth
Clinical manifestations of pulmonary embolism are variable, but common signs include:
increased RR
tachycardia
hemoptysis
In a psychiatric setting, ______________ is used to reduce overwhelming environmental stimulation, protect the client from self-injury or injury to others, and prevent damage to hospital property.
seclusion
Seclusion is used for clients who don’t respond to less restrictive interventions. Seclusion controls _______________ until the client can assume self-control and helps the client to regain self-control.
external behavior
__________________, such as aged cheese, chicken liver, avocados, bananas, meat tenderizer, salami, bologna, Chianti wine, and beer may cause severe hypertension in a client who takes a ______________.
Tyramine-rich food
monoamine oxidase inhibitor
A client who takes a monoamine oxidase inhibitor should be weighed ___________ and monitored for _____________.
bi-weekly
suicidal tendencies
If the client who takes a monoamine oxidase inhibitor has ___________, _____________, or severe _______________, the nurse should withhold the drug and notify the physician.
palpitations
headaches
orthostatic hypotension
Normally, the intraocular pressure is ___________. It can be measured with a _________________ tonometer.
12-20 mm Hg
Schiotz
The frequency of uterine contractions, which is measured in minutes, is timed from the ___________ of one contraction to the ______________ of the next.
beginning
In early _________________, blood pressure may be normal, but RR & HR are rapid. The client may report ________ and may have _________ and piloerection.
hemorrhagic shock
thirst
clammy skin
_______________ begins with the nurse’s first encounter with the client and continues throughout the client’s stay.
Assessment
The nurse obtains assessment data through the:
health history
physical examination
review of diagnostic studies
Cool, moist, pale skin, as occurs in shock, results from diversion of blood from the skin to the __________.
major organs
Capillary refill indicates ______________, which decreases in shock, thereby lengthening refill time. Normal capillary refill time is _______.
perfusion
Except for clients with renal failure, urine output of
dehydration
The appropriate needle size for insulin injection is ______ and ______ long.
25g
1/2”
Residual urine is urine that remains in the bladder after _________. The amount of residual urine is normally ________.
voiding
50-100 mL
In elderly clients, the most common fracture is:
hip fracture
_____________- weakens the bones, predisposing elderly clients to fracture, which usually results from a fall.
Osteoporosis
Molting and tenting of the skin are signs of severe ____________; intravenous fluids are required to rehydrate.
dehydration
Before _____________, the nurse should ask the client whether he’s allergic to the dye, shellfish, or iodine and advise him to take nothing by mouth __________ before the procedure.
angiography
8 hours
During myelography, ~__________ of CSF is removed for laboratory studies and an equal amount of contrast media is injected.
10-15 mL
Vitamin K is administered to neonates to prevent hemorrhagic disorders because a neonate’s ___________ can’t synthesize Vitamin K.
intestine
After ________________, the puncture site is covered with a pressure dressing and the affected part is immobilized for _____________ to decrease the risk of bleeding.
angiography
8 hours
If a water-based medium was used during myelography, the client remains on bed rest for _________, with the head of the bed elevated ______________.
6-8 hours
30-45 degrees
If an oil-based medium was used, the client remains _____ in bed for ____________.
flat
6-24 hours
The level of ____________ is determined by estimating the maximum viable tissue (tissue with adequate circulation) needed to develop a functional stump.
amputation
Before internal fetal monitoring can be performed, a pregnant client’s cervix must be dilated at least _____, the amniotic membranes must be ruptured, and the fetus’s presenting part (scalp or buttocks) must be at station ______ or lower, so that a small electrode can be attached.
2 cm
-1
Fetal alcohol syndrome presents in the first 24 hours of life and produces:
lethargy seizures poor suckling reflex abdominal distention respiratory difficulty
Variability is any change in the ______ from its normal rate of _______________.
FHR
120-160 bpm
_________ is increased FHR.
Acceleration
_________ is decreased FHR.
Deceleration
Heparin sodium is included in the ________ used for renal dialysis.
dialysate
In a neonate, the symptoms of heroin withdrawal may begin ____________ to _______ after birth.
several hours
4 days
In a neonate, the cardinal signs of narcotic withdrawal include:
coarse flapping tremors sleepiness restlessness prolonged, persistent, high-pitched cry irritability
The nurse should count a neonate’s respirations for __________.
1 full minute
Paroxysmal nocturnal dyspnea may indicate:
heart failure
A client who takes a cardiac glycoside, such as ____________, should consume a diet that includes high-potassium foods.
digoxin
The nurse should limit tracheobronchial suctioning to _______ and should make only ______ passes. The client should be hyperventilated between each pass.
10-15 seconds
two
Before performing tracheobronchial suctioning, the nurse should ventilate and oxygenate the client _______ with a resuscitation bag and _______ oxygen. This procedure is called __________.
5-6 times
100%
bagging
Signs and symptoms of pneumothorax include:
tachypnea
restlessness
hypotension
tracheal deviation
The cardinal sign of toxic shock syndrome is rapid onset of a
high fever.
A key sign of peptic ulcer is ___________ hematemesis, which can be bright red or dark red, with the consistency of coffee grounds.
hematemesis
Signs and symptoms of a perforated peptic ulcer include:
sudden, severe upper abdominal pain
vomiting
extremely tender, rigid (boardlike) abdomen
_____________ is a common adverse reaction to aluminum hydroxide.
Constipation
For the first 24 hours after a __________, the client should use a bedside commode and then progress to walking to the toilet, bathing, and taking short walks.
myocardial infarction
After a myocardial infarction, the client should avoid ________ and add a new activity daily, as tolerated without dyspnea.
overexertion
In a client with a recent MI, frothy, blood-tinged sputum suggests:
pulmonary edema
In a client who has acquired immunodeficiency syndrome, the primary purpose of the drugs is to prevent
secondary infections
In a client with AIDS, suppression of the immune system increases the risk of opportunistic infections, such as:
cytomegalovirus
Pneumocystis carinii pneumonia
thrush
A client with AIDS may have rapid weight loss, a sign of
wasting syndrome.
Between the ages of ___________, a child begins to show emotions, such as affection, jealousy, and anger.
10-12 months
Chlorpromazine (thorazine) is used to treat neonates who are addicted to
opioids
The nurse should use ____________ to protect an infant with eczema, a scalp vein infusion, or who’s recovering from cleft lip repair or eye surgery.
elbow restraints
The nurse should provide a dark, quiet environment for a neonate who’s experiencing ___________.
opioid withdrawal
Difficulty ___________ is a common complaint of a client who has just undergone a thyroidectomy.
swallowing
If the body doesn’t use glucose for energy, it metabolizes fat and produces:
ketones.
In infants ages _________ months, separation from the mother evokes a more intense response than any other stimulus.
6-12
Because __________ mask symptoms of infection, they should be administered to children with extreme caution.
steroids
Steroids should be administered with ________ to a child.
food
Approximately 20% of clients with ______________________ have residual deficits, such as mild motor weakness or diminished lower extremity reflexes.
Guillan-Barre syndrome
In children, signs and symptoms of leukemia include:
fatigue, anorexia, low-grade fever, and decreased WBC, RBC & platelet counts
In children with leukemia, the most common causes of death include:
hemorrhage
infection
In a child, anemia is the first sign of :
lead poisoning
A ______________ frame is commonly used to immobilize a child who has a spica cast.
Bradford
In a premature neonate, signs of respiratory distress include:
nostril flaring
substernal retractions
inspiratory grunting
Hypertension and hypokalemia are the most significant clinical manifestations of primary:
hyperaldosteronism
In a child age _____, having and frequently speaking to an imaginary friend are normal behaviors.
3
By age _______, an infant with normal motor development should be able to lift and control his head.
3-4 months
Head lag is common in infants younger than:
3 months
________ is candidiasis (Candida albicans) of the oral mucous membranes.
Thrush
Thrush is characterized by aphthae, or small _______, in the mouth.
ulcers
Common causes of child abuse are:
poor impulse control by the parents
lack of knowledge of growth and development
Allopurinal (Zyloprim) is used in children with leukemia to prevent accumulation of:
uric acid
Allopurinal =
Zyloprim
Before administering any “as needed” pain medication, the nurse should ask the client to indicate:
the location of the pain
At age ___ months, an infant should begin to receive solid foods one at a time and ____ week apart.
6
1
After percutaneous aspiration of the bladder, the client’s first void is usually ________; urine containing ___________ should be reported to the physician.
pink
frank blood
A urine culture that grows more than ____________ colonies of bacteria per milliliter of urine indicates infection.
100,000
The most appropriate toy for a toddler age 18 months is one that helps to develop
motor coordination
When administering an _____________ to an infant, the nurse should ask another nurse (not the parent) to divert the child’s attention and assist as needed.
injection
Respiratory distress syndrome (hyaline membrane disease) develops in premature infants because their pulmonary alveoli lack:
surfactant
A client who’s undergoing dialysis should take a vitamin supplement and eat food that are:
high in calories
but low in protein, sodium and potassium
The nurse should lower her profile to communicate at eye level with a
child.
An infant who has phenylketonuria should be fed a ________________ formula and should have plasma phenylalanine levels monitored frequently.
low-pheylalanine
When caring for an infant who has had six to eight episodes of diarrhea a day for 4 days, the nurse should assess for
electrolyte imbalance
The nurse may offer finger foods to a child age ____ who has a poor appetite.
3
When in a mist tent (Croupette), a child may require
soft restraints
In a client who has COPD, the most effective ways to reduce thick secretions are to
increase fluid intake to 2,500 mL/day
encourage ambulation
The nurse shouldn’t administer a drug to a child at ____________ unless it’s specifically prescribed because it may stimulate the child.
bedtime
Medulloblastoma, the most common brain tumor in children, is characteristically found in the
cerebellum
Clubbing of the digits and a barrel chest may develop in a client who has
COPD
In a client who’s undergoing dialysis, desired outcomes are :
normal weight
normal serum albumin level (3.5-5.5 mg/dL)
adequate protein intake (1.2-1.5g/kg of body wt daily)
Intermittent peritoneal dialysis consists of ____ cycles per night.
6
Isoetharine (Bronkosol) can be administered with a handheld nebulizer or by
intermittent positive-pressure breathing
Isoetharine =
Bronkosol
_______________ decreases body secretions and is used before surgery such as tonsillectomy.
Atropine sulfate
Continuous ambulatory peritoneal dialysis requires ____ exchanges per day, 7 days a week, for a total of 168 hours per week.
4
The classic adverse reactions to antihistamines are
dry mouth
drowsiness
blurred vision
Because of the risk of ______________, a client who has received a general anesthetic can’t take anything by mouth until active bowel sounds are heard in all abdominal quadrants.
paralytic ileus
_______________ believe that they shouldn’t receive blood components donated by other people but can receive an organ transplant if the donor organ has had the blood removed.
Jehovah’s Witnesses
The level of alpha-fetoprotein, a tumor marker, is elevated in clients who have
testicular germ cell cancer
Clinical manifestations of orchitis caused by bacteria or mumps include
high temp
chills
sudden pain in involved testis
The level of prostate-specific antigen is elevated in clients with
BPH
or prostate CA
The level of prostatic acid phosphatase is elevated in clients with advanced
stages of prostate CA
Phenylephrine (Neo-Synephrine) a mydriatic, is instilled in a client’s eye to __________ the eye.
dilate
Phenylephrine =
Neo-synephrine
To test ___________, the nurse should ask the client to cover each eye separately and to read the eye chart with glasses and without, as appropriate.
visual acuity
To promote fluid drainage and relieve edema in a client with epididymitis, the nurse should elevate the scrotum on a
scrotal bridge
Fluorescein staining is commonly used to asses ________________ because it outlines superficial epithelial defects
corneal abrasions
____________ is loss of near vision as a result of the loss of elasticity of the crystalline lens.
Presbyopia
When providing _____________ for an unconscious client, to minimize the risk of aspiration, the nurse should position the client on his side.
oral care
During assessment of distance vision, the client should stand ______ from the chart.
20’
A sign of acute appendicitis, __________________ is tenderness at ___________ (about 2” from the right anterior superior iliac spine on a line between the spine and the umbilicus)
McBurney’s sign
McBurney’s point
The diagnosis of _____________ is based on clinical findings of two or more cognitive deficits, progressive worsening of memory, and the results of a neuropsychological test.
Alzheimer’s disease
Signs and symptoms of ____________ include rectal bleeding, change in bowel habits, intestinal obstruction, abdominal pain, weight loss, anorexia, nausea & vomiting.
colon cancer
To help calm a child who’s frightened of a mist tent, the nurse may suggest that a parent
lie with the child in the tent
Symptoms of prostatitis include
frequent urination
dysuria
The male sperm contributes an __________ chromosome, the female ovum contributes an ____.
X or Y
X
Fertilization produces a total of ___ chromosomes, including an XY combination (male) or an XX combination (female).
46
A _________ is a painless, ulcerative lesion that develops during the primary stage of syphilis.
chancre
During the __________ stage of syphilis, spirochetes invade the internal organs and cause permanent damage.
tertiary
Normal room humidity is _____.
30-60%
In TPN, ____________ is the most reliable indicator of a positive response to therapy.
weight gain
The nurse may administer an IV fat emulsion through a central or peripheral catheter, but shouldn’t use an ___________ because the fat particles are too large to pass through the pores.
in-line filter
A positive Homan’s sign may indicate
thrombophlebitis
If a client who has a prostatectomy is using a ________________, instruct him to wash and dry his penis before applying the clamp.
Cunningham clamp
A Cunningham clamp should be applied ______________ and removed every 4 hours to empty bladder to prevent infection.
horizontally
______________ is the loss of train of thought because of a defect in mental processing.
Thought blocking
A Bradford frame is used for ___________ of a child, such as a client with extensive burns or meningocele.
long-term immobilization
During delivery, ________________ is safest for the mother and baby. This includes a pudendal block of the perineal tissue.
local anesthesia
If a woman has signs of UTI during menopause, she should be instructed to
drink 6-8 glasses of water per day
urinate before and after intercourse
perform Kegel exercises
_____________ causes fissures at the angles of the mouth and may indicate a Vitamin B12, riboflavin, or iron deficiency.
Cheilosis
Tetany may result from ______________ caused by hypoparathyroidism.
Hypocalcemia
Dietary fiber (roughage), which is derived from ____________, supplies bulk, maintains intestinal motility, and helps to establish regular bowel movements.
cellulose
Alcohol is metabolized primarily in the _______. Smaller amounts are metabolized in the kidneys and lungs.
liver
A client who has cervical cancer may experience vaginal bleeding for 1-3 months after
intracavitary radiation
___________ is the accumulation of fluid, containing large amounts of protein and electrolytes, in the abdominal cavity.
Ascites
Ascites is commonly caused by
cirrhosis
To measure ascites, use a centimeter tape and measure at the _________________ or the ___________.
superior iliac crest
umbilicus
Normal pulmonary artery pressure is
10-25 mmHg
Normal pulmonary artery wedge pressure is
5-12 mmHg
After cardiac catheterization, the site is monitored for bleeding and hematoma formation, pulses distal to the site are palpated every _______ minutes for an hour, and the client is maintained on bed rest with the extremity extended for ____ hours.
15
8
The third stage of labor begins after the neonate’s birth and ends with
expulsion of the placenta
In full-term neonates, skin creases appear over two-thirds of the neonate’s feet. Preterm neonates have heel creases that cover less than ____________ of the feet.
two-thirds
The _____________ stage of labor (postpartum stabilization) lasts up to 4 hours after the placenta is delivered. This time is needed to stabilize the mother’s physical and emotional state after the stress of childbirth.
fourth
At 20 weeks’ gestation, the fundus is at the level of the
umbilicus
At 36 week’s gestation, the fundus is at the lower border of the
rib cage
A premature neonate is one born before the end of the
37th week of gestation
The ___________ isoenzyme level increases 4-8 hours after a MI, peaks at 12-24 hours and returns to normal in 3 days.
CK-MB
Phase I (orientation phase) of nurse-client relationship:
nurse obtains initial history
nurse & client agree to a contract
Phase II (working phase) of nurse-client relationship:
client discusses his problems
behavioral changes occur
self-defeating behavior is resolved/reduced
Phase III (termination or resolution phase) of nurse-client relationship
nurse terminates therapeutic relationship
and gives client positive feedback
___________________ is a leading cause of maternal death in the U.S.
Gestational hypertension
A _________________ is a woman who has had three or more consecutive spontaneous abortions.
habitual aborter
____________________ occurs when bleeding is present without cervical dilation.
Threatened abortion
A ________________ occurs when all products of conception are expelled.
complete abortion
