Mometrix Flashcards
Which need immediate attention
- Respiration 20
- HR 122 thready
- Sunken eyes
- Temperature 98.9
- Lethargy
- Reported vomiting/ diarrhea
- HR 122 thready
- Sunken eyes
- Lethargy
- Reported vomiting/ diarrhea
Hypovolemia/Hypervolemia
- Orthostatic Hypotension
- Crackles in the base of lungs
- Bounding pedal pulse
- Decreased skin turgor
- +2 edema bilateral upper extremities
Hypovolemia
- Orthostatic Hypotension
- Decreased skin turgor
Hypervolemia
2. Crackles in the base of lungs
3. Bounding pedal pulse
5. +2 edema bilateral upper extremities
Apixaban is this type of medication
Used to treat
a novel oral anticoagulant
Nonvalvular atrial fibrillation to reduce the risk of stroke and blood clots
Client who stops taking apixaban for their A fib is at risk for what type of stroke?
Secondary to….
Ischemic stroke
Secondary to an embolism
Stopping apixaban (novel blood thinnner) can cause clots to form which can travel to the brain and cause a stroke
What is VAN positive mean…
0
1-4
5-15
16-20
21-42
Deficit in vision, aphasia, or neglect (VAN) categories
Large artery stroke
0 (No Stroke)
1-4 Mild
5-15 Moderate
16-20 Moderate/ Severe
21-42 Severe
How would a patient get a hemorrhagic stroke?
Head Trauma/ Falls
For a suspected ischemic stroke
Which of the following should the nurse consider a priority
- Blood sugar sample
- Order CBC, BMP, trophin level
- Obtain EKG
- Education on medication compliance
- CT scan of head
- Administer IV labetalol
- Blood sugar sample (Hypo/Hyperglycemia resemble stroke symptoms)
- CT scan of head (<25 mins arrival ED - Rules out hemorrhagic stroke)
- Administer IV labetalol ( Contraction for thrombolytics is Systolic BP > 185)
No priority
- Order CBC, BMP, trophin level
- Obtain EKG
- Education on medication compliance
newborn’s average blood pressure is ____
Between one month and two years old is ___
New born 64/41
1 month- 2 years = 95/58
Most common symptoms with Influenza
- Fever
- Cough
- Diarrhea
- Loss of appetite
- Rhinorrhea
Influenza colonizes the Respitory Tract
Fever, Cough, Rhinorrhea
Most common symptoms with UTI
- Fever
- Cough
- Diarrhea
- Loss of appetite
- Rhinorrhea
Fever
Also, pain / frequent urination
Maybe blood in urine
Most common symptoms with gastroenteritis
- Fever
- Cough
- Diarrhea
- Loss of appetite
- Rhinorrhea
Diarrhea & loss of appetite
May also have vomiting & abdominal pain
Which is a potential nursing action for a 2 year old who had a fever induced seizure and is dehydrated from vomiting & diarrhea
- Adding safety padding to the sides of the clients bed
- Request that acetaminophen order be given via rectal suppository
- Request an order for 1,000mL IV fluid bolus
- Provide client with juice or popsicle
- Provide client with cold compression for forehead / neck
Indicated
- Adding safety padding to the sides of the clients bed
- Provide client with juice or popsicle
- Provide client with cold compression for forehead / neck
Not indicated
- Request that acetaminophen order be given via rectal suppository
- Request an order for 1,000mL IV fluid bolus (Standard IV bolus for pediatrics = 20 mL / kg over 20 - 30 mins) 1000mL is way too much and dangerous
2 year old being discharged for hospital for stroke induced by fever & dehydration. Which statements indicate understanding by mother.
- My child was diagnosed with epilepsy today.
- Rectal is the most accurate location to measure my child’s temperature.
- I will alternate between acetaminophen & Ibuprofen to control my child’s temp.
- Place a platic biting pad in mouth during seizures to prevent damage.
- I will monitor my child’s intake of fluids & have him seen again if there is a decrease in wet diapers or crying without tears.
Understanding:
- Rectal is the most accurate location to measure my child’s temperature.
- I will alternate between acetaminophen & Ibuprofen to control my child’s temp.
- I will monitor my child’s intake of fluids & have him seen again if there is a decrease in wet diapers or crying without tears.
Not Understanding:
- My child was diagnosed with epilepsy today.
- Place a platic biting pad in mouth during seizures to prevent damage.
Children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin.
Due to this serious complication….
Describe it…
Reyes syndrome
Early:
diarrhea, rapid breathing, vomiting, and severe fatigue.
Symptoms such as confusion, seizures, and loss of consciousness need emergency treatment
Brain Swelling/ Damage Most serious complication
What duration of apnea in a neonate is of concern?
- All periods of apena
- 2 - 3 seconds
- 6 - 8 seconds
- > 15 - 20 seconds
- > 15 - 20 seconds
Periodic breathing are normal in neonates. Usually 2-3 seconds long
If episodes are frequent or accompanied by Pallor, cyanosis, bradycardia, or hypotonia alert physician
Following a Lumbar puncture client has sever headaches lasting >24 hrs & not relieved by bedrest or fluids.
Which intervention does the nurse anticipate
- Bedrest 3 days
- Opiod analgesia
- Epidural blood patch
- IV fluids
- Epidural blood patch
Persistent headaches indicate a hole in the Dura Mater, Epidural Blood Patch creates a Blood Clot to “seal the hole”
Headaches occur in 1/5 post Lumbar Puncture aka spinal tap
Used to diagnose bacterial, fungal and viral infections, including meningitis, encephalitis and syphilis.
Bleeding around the brain, known as subarachnoid hemorrhage.
HbA1c levels
Pre-diabetic
Diabetic
*must occur on 2 separate occasions
Pre-diabetic: 5.7 - 6.4
Diabetic: > 6.5
Describe Parkinsons gait
Slight flexion of hips & knees
Short shuffling steps
Trunk leaning forward
No arm swing
RN team leader has a staff of 1 LPN & 2 CNA’s. Which assignment would you give to the LPN
- Dressing change on foot ulcer
- Insert Foley catheter
- Enema as prep for radiological procedure
- Bed bath for four clients
- Checking vital signs
LPN
- Dressing change on foot ulcer
- Insert Foley catheter
CNA
- Enema as prep for radiological procedure (YES, they can give enemas)
- Bed bath for four clients
- Checking vital signs
State Naegele’s rule for estimating pregnancy
When would be the due date for a client whose last menstrual cycle started June 10
Ended June 14
Naegeles rule states:
Date of onset of (LMP -Last menstrual period) + 9 months + 7 days
June 10th + 9 months = March 10th
March 10th + 7 days = March 17th
Immune system attacks the nerves.
The condition may be triggered by an acute bacterial or viral infection.
Early: weakness and tingling in the feet and legs that spread to the upper body. Paralysis can occur. (Lung paralysis)
Special blood treatments (plasma exchange and IV immunoglobulin therapy) can relieve symptoms.
Physical therapy is needed.
Guillain barré syndrome
autoimmune disease that occurs when the body’s immune system mistakenly attacks and destroys the pancreas’ insulin-producing beta cells.
Name the disease
DM type 1
In _____ arthritis, the body’s immune system attacks its own tissue, typically in the hands and feet. In some people, the condition can damage body systems including the skin, eyes, lung, heart and blood vessels.
rheumatoid
Hashimoto disease describe:
Describe disease in general.
How you contract it?
Symptoms/ Complications
Treatment
Hashimoto is an Auto Immune disorder that attacks the Thyroid (butterfly shapped organ Located below Adam’s Apple)
Contracted Auto Immune
S&S: Same as hypothyroidism (Tired, Sleepy, muscle weakness & aches)
Complications: Goiter - which can cut off airway
Myxedema coma: Exposure to Stress, Cold, Infection or Sedation
Treatment: levothyroxine aka Synthroid
Client with schizophrenia has frequent hallucinations and is becoming withdrawn. Which are appropriate interventions to hallucinations
- Communicate frequently and present to reality
- Use distraction techniques
- Ask client to describe hallucinations
- Encourage the client to participate in reality-based activities, ie. Playing Cards
- Tell client to ignore hallucinations
- Communicate frequently and present to reality
- Ask client to describe hallucinations
(Helps determine if Client or Others are at risk due to the hallucinations) - Encourage the client to participate in reality-based activities, ie. Playing Cards
Do Not
Use distraction techniques
Tell client to ignore hallucinations
Ischemic stroke ( From Clot ) in the Right Hemisphere. What type of problems do you anticipate?
Left sided paralysis and visual disturbances
Raynauds disease 35 yr female.
Which is appropriate education?
- Stop smoking
- Wear gloves outside during cold weather
- Handle foods from the refrigerator or freezer for brief periods
- Avoid calcium channel blockers
- Avoid beta blockers
- Avoid birth control pills
- Avoid vasodilatadors
Raynaud’s disease is intermittent digital arteriolar vasoconstriction, affects hands & feet: Result Ulceration or Gangrene
- Stop smoking
- Wear gloves outside during cold weather
- Handle foods from the refrigerator or freezer for brief periods
- Avoid beta blockers
- Avoid birth control pills
It’s the opposite
4. Avoid calcium channel blockers
7. Avoid vasodilatadors
Calcium channel blockers & vasodilatadors improve symptoms of Raynaud’s disease
Flumazenil is….
a benzodiazepine antagonist typically used in overdose emergencies.
Benzodiazepine overdose and postoperative sedation from benzodiazepine anesthetics
Client mistakenly takes 4, 80mg doses of baclofen (to relieve muscle spasms) instead of his 4, 10mg dose. The overdose results in a overdose and pronounced CNS depression.
Which of the following does the nurse anticipate
- Administer Naloxone
- Administer atropine
- Supportive care only
- Administer flumazenil
- Supportive care only
There is no antidote to muscle relaxants such as: Carisoprodol (Soma), Cyclobenzaprine (Flexeril), Metaxalone (Skelaxin), Methocarbamol (Robaxin), Baclofen (Lioresal)
- Give atropine for Bradycardia
- Give flumazenil for Benzodiazepine OD
Carisoprodol
Cyclobenzaprine
Metaxalon
Methocarbamol
Carisoprodol (Soma), Cyclobenzaprine (Flexeril), Metaxalone (Skelaxin), Methocarbamol (Robaxin), Baclofen (Lioresal
Brain damage can happ3n from birth but is more often due to lack of oxygen than from compression of the skull.
During birth mother has a narrow boney Pelvis. What is the most likely result?
- Cerebral Palsy
- Intracranial hemorrhage
- Cranial molding
- Epilepsy
- Cranial molding
____ can occur before, during, or shortly after birth, or in the first few years of life, when the brain is still developing.
The majority of cases (85%–90%) are congenital, which is related to events before or during birth.
A congenital disorder of movement, muscle tone, or posture.
Exaggerated reflexes, floppy or rigid limbs, and involuntary motions.
Medications: Valium, Ativan, Dilantin, and Versed.
Cerebral Palsy
4 yr old child with autism reaches for a stuffed animal and says “bunny”. Which of the following is the best example of Incidental Teaching?
- Nurse asks, “What color is the bunny?” And waits for response before giving the child the toy
- Nurse states, “that’s right, it’s a bunny” and gives child the toy
- Nurse gives child toy without comment, because child correctly ID the toy
- Nurse states, “before you get the bunny, you need to answer some questions “
- Nurse asks, “What color is the bunny?” And waits for response before giving the child the toy
Incidental teaching involves using a child’s interest as teaching opportunities
Which vaccine is needed <12 hrs after birth?
- Polio
- Heptavalent pneumococcal Conjugate
- Hep B
- Rotavirus
Hep B. It can be passed from mother to children during birth
Vaccine consists of 3 doses. One at birth, second 1 - 2 months, third about 24 weeks.
If mother test positive for Hep B what interventions are done to the child
- Monovalent hepB vaccine
- HepB immune globulin
<12 hrs after birth
TBI treated in ICU
Which interventions does the nurse anticipate
- Elevate HOB
- Admin Ox maintain PaO2 >85mmHg
- Maintain neutral alignment of head
- Admin sedative to reduce Agitation
- Maintain body temp below normal
- Elevate HOB
- Maintain neutral alignment of head
- Admin sedative to reduce Agitation
Not
2. Admin Ox maintain PaO2 >85mmHg - Should be maintain >90
5. Maintain body temp below normal
(Maintain body at normal temperature)
Rumack-Matthew nomogram….
Serum acetaminophen concentration, in relation to the time after ingestion, to assess potential hepatotoxicity after a single, acute ingestion of acetaminophen.
15 yr old took bottle of Tylenol (Acetaminophen) 5 hrs prior to arrival at ED. Serum level is 180mcg/ mL Which of the following interventions does the nurse anticipate
- Antidote: 72 hr N-acetylcysteine (NAC) protocol
- Supportive care
- GI decontamination with activated charcoal
- Monitor hepatic function
- Psychiatric consultation
- Antidote: 72 hr N-acetylcysteine (NAC) protocol
- Supportive care
- Monitor hepatic function
- Psychiatric consultation
- GI decontamination with activated charcoal - Only with in 1 hr of ingestion.
Acute spinal cord edema due to spinal cord injury. Drug to best control edema?
- Aspirin
- Mannitol
- Morphine
- Methylprednisone
Methylprednisone
Is a steroidal Anti-inflammatory which reduces edema
Mannitol is an osmotic diuretic to control brain edema
Central catheter is inserted for administration of parental nutrition. X-ray shows the catheter tip is in the right Atrium. Which action is correct
- Hold infusion and notify MD
- Gently withdraw catheter 2-3 “
- Begin the infusion catheter is placed correctly.
- Gently insert catheter 2-3”
- Hold infusion and notify MD
Superior vena cava is the correct placement
Which is correct for a toxic (not caustic) substance in the right eye.
- Posistion client on their left side with head flat on surface
- Irrigate with bulb syringe tip about .5” above eye.
- Flush for 5 minutes
- Hold eye open while flushing
- Hold emesis basin against left side of clients face to contain the irrigant
- Irrigate with bulb syringe tip about .5” above eye.
- Hold eye open while flushing
Incorrect:
1. Posistion client on their left side with head flat on surface (Place client on right side with head elevated 20°)
- Flush for 5 minutes (mometrix says 1 minute)
- Hold emesis basin against left side of clients face to contain the irrigant
Stages of wound repair
Profileration, Maturation, Inflammation, Hemostasis
1st stage: First few minutes platelets seal off vessels, Vasoconstriction, Thrombin stimulates clotting mechanism forming fibrin mesh
2nd over 1 - 4 days inflammatory response & phagocytosis occurs
3rd Over 5 - 20 days. Fibroblasts produce collagen & granulation tissue starts to form
4th. After 21 days - 2 years. Collagen tightens to reduce scars. Tissue gains tensile strength
Hemostatis
1st stage: First few minutes platelets seal off vessels, Vasoconstriction, Thrombin stimulates clotting mechanism forming fibrin mesh
Inflammation
2nd over 1 - 4 days inflammatory response & phagocytosis occurs
Profileration
3rd Over 5 - 20 days. Fibroblasts produce collagen & granulation tissue starts to form
Maturation
4th. After 21 days - 2 years. Collagen tightens to reduce scars. Tissue gains tensile strength
An epileptic taking phenytoin will be educated about these long-term SE
- Gingival hypertrophy
- Hirsutism
- Hypertrophy of facial subcutaneous tissue
- Dementia
- Anemia
- Gingival hypertrophy
- Hirsutism
- Hypertrophy of facial subcutaneous tissue
Long-term use of phenytoin includes condition call “Dilantin facies” characterized by Gingival hypertrophy, hirsutism (hair growth on unexpected areas of the body, such as on the face, chest, and back) and Facial SQ fat loss.
Additionally, they may develop osteoporosis, Vitamin D is prescribed.
Clients with low albumin (renal disease or malnutrition) may have more severe side effects
Client taking anticholinergic (benztropine mesylate) aka Cogentin to relieve tremors & muscle spasms associated with Parkinsons disease are advised to avoid
- Overheating
- Overeating
- Excessive fluid intake
- Skipping meals
Overheating
Anticholinergics “dry you up” and affect the ability to sweat
Which is correct when taking a telephone order
- Write down orders directly into clients record as given
- Write orders in their entirely and read back to confirm
- Repeat each order 1 at a time and confirm each before proceeding
- Insist the physician email or fax a copy of the orders for confirmation
- Write orders in their entirely and read back to confirm
Repeating each order and confirmation before proceeding may cause MD to lose their train of thought
Alzheimer’s patient has repeatedly eloped by walking out the front door at night. Which of the following might be helpful
- Hang curtain over the front door
- Place a latch at the top or bottom of the door.
- Lock client into their room.
- Place motion detector with loud alarm on clients bedroom door
- Place bed restraints on client
- Hang curtain over the front door
- Place a latch at the top or bottom of the door.
NOT
A motion detector with loud alarm will scare client and make them want to escape
Type of cancer that kills most women between 15 - 34
Breast also highest in 35 - 54
Breast cancer is more aggressive & harder to detect in young women due to denser breast tissue
Eye opening, verbal response, and motor response are all the criteria for this scale.
What are the “brackets” in this scale
Glasgow coma scale
16 = Fine
15 - 13 = mild head injury
9 - 12 = Moderate head injury
<8 = Severe head Injury
3 - 8 = Coma
Client has episodes of Constipation with fecal impaction. The nurse assisting with bowels training regimen will include which interventions
- Scheduled toileting
- Stool softeners
- High Fiber Diet
- Daily Laxatives
- Periodic enemas
- Routine exercise
- Scheduled toileting
- Stool softeners
- High Fiber Diet
- Routine exercise
Not
- Daily Laxatives
- Periodic enemas
Best body mechanics for moving a heavy medication cart
- Push cart both hands, head up and back straight
- Pull cart 1 hand leaning slightly forward
- Push cart with shoulders
- Pull cart with 1 hand, head up and back straight
Push cart both hands, head up and back straight
Avoid pulling or twisting when moving items. Stand close to item
Tracheostomy client needs these teachings before discharge
- Bowel care
- Pulmonary hygine
- Dietary supplements
- Tracheostomy care
- Exercise program
- Bowel care
- Pulmonary hygine
- Tracheostomy care
Bowel care is needed due to client cannot “bear down” for Valsalva maneuver & may need daily stool softeners
Nulliparous client is fully effaced and dilated 3cm after 12 hrs of mild contractions at home. How long should it take to get to 10 cm dilation
7hrs
Nulliparous dilate at a rate of 1 cm per hour
The latent phase of stage 1 usually last 10- 14 hrs the client went through this phase and now is in the active phase
Client had 4 pregnancies
1 miscarriage at 12 weeks
2. Still born at 34 weeks
3. Healthy son at 38 weeks
4. Healthy daughter at 40 weeks
What is her Gravida / Para number
Gravida 4
Para 3
Gravida = confirm3d pregnancies
Para = number of births after 20 weeks
What is a concern of using Naloxone on a longtime opiod addict?
Withdrawal & Seizures
What is a normal TUG (Timed up & go)
What is considered a fall risk
Normal 7 - 10 seconds
Fall risk >14
Which is most appropriate for stage II pressure ulcer with moderate exudate
- NS on guaze (Wet-to-Dry)
- Transparent film
- Hydrocolloid
- Hydrogel
Hydrocolloid - contains gelling agents to absorb exudate
Wet - to - Dry No longer recommended Disrupt the graduation process.
Transparent is used to IV ports
Hydrogels are designed to hydrate dry wounds Not for Exudate
Is it ever appropriate to “milk” blood clots out of the tubing of a JP drain before emptying it?
Yes, this is how one removes blood clots
Which B vitamin does a woman need to start taking before she gets pregnant to prevent neural tube defects
B9 folate
Which are Contradicted for Parkinsons patient who has been prescribed levodopa (Precursor to Dopamine) helps with ADL’s
- Narrow angle glaucoma
- Macular degeneration
- Pregnancy
- Melanoma
- Cataracts
- Narrow angle glaucoma
- Pregnancy
- Melanoma
Also not for clients with psychosis & monitor if there is a heart problem
How long is the incubation period for measles?
When can a person with measles pass it to another person (how long into the disease)
Incubation period 7 - 21 days
May spread measles 4 days prior to rash & 4 days after
Match the following
Brain stem, Frontal Lobe, Cerebellum, Occipital, Parietal, Temporal
Changes in mood & personality, as well as hemiparesis
Visual disturbances & Hallucinations
Loss of memory, speech abnormalities, and lack of coordination
Loss of sensation, difficulty with fine motor skills, Loss of half body awareness
Lack of balance and coordination
Dysphagia, facial pain, weakness and cranial nerve dysfunction
Frontal
Changes in mood & personality, as well as hemiparesis
Occipital
Visual disturbances & Hallucinations
Temporal
Loss of memory, speech abnormalities, and lack of coordination
Parietal
Loss of sensation, difficulty with fine motor skills, Loss of half body awareness
Cerebellum
Lack of balance and coordination
Brain stem
Dysphagia, facial pain, weakness and cranial nerve dysfunction
Study macule, papule, nodule, patch in your nursing class stuff
Infact study all of that stuff
11 yr old autistic is hospitalized. When parents not present he hits his head on the wall, screams, get violent. Which is the most effective method to control his behavior
- Ask the parents for advice
- Ask physician for a sedative
- Place child in restraints
- Ask for psych referal
Ask the parents for advice
Cranial molding is a common, abnormal head shape in newborns that occurs when pressure is applied to the baby’s head during childbirth.
Cause the skull bones to shift
Treatments
Helmet therapy to reconform head shape
