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
