NCLEX PN Notes 4

Question 1

( life threatening inhibited sympathetic response of nervous system to a noxious stimulus- patients with spinal cord injuries at T-7 or above) is usually caused by a full bladder.

Answer 1

autonomic dysreflexia

Question 2

= myelin sheat destruction, disruption in nerve impulse conduction.

Answer 2

Multiple sclerosis

Question 3

= decrease in receptor sites for acetylcholine. Since smallest concentration of ACTH receptors are in cranial nerves, expect fatigue and weakness in eye, mastication, pharyngeal muscles.

Answer 3

myasthenia gravis

Tensilon test given if muscle is tense in myasthenia gravis.

Question 4

= ascending paralysis. Keep eye on respiratory system.

Answer 4

Guillain-Barre syndrome

Question 5

= RAT: rigidity, akinesia (loss of muscle mvt), tremors. Treat with levodopa.

Answer 5

parkinson’s

Question 6

mini stroke with no dead brain tissue

Answer 6

TIA (transient ischemic attack)

Question 7

mini stroke with dead brain tissue.

Answer 7

CVA (cerebrovascular accident)

Question 8

= cancer of lymph is very curable in early stage.

Answer 8

Hodgkin’s disease

Question 9

Rule of NINES for burns 
Head and Neck= 9% 
Each upper ext= 9% 
Each lower ext= 18%
Front trunk= 18% 
Back trunk= 18% 
Genitalia= 1% ?

Answer 9

Birth weight doubles by 6 month and triple by 1 year of age.

Question 10

if HR is <100 do not give dig to children.

Answer 10

first sign of cystic fibrosis may be meconium ileus at birth. Baby is inconsolable, do not eat, not passing meconium.

Question 11

heart defects. Remember for cyanotic -3T’s( Tof, Truncys arteriosus, Transposition of the great vessels). Prevent blood from going to heart. If problem does not fix or cannot be corrected surgically, CHF will occur following by death.

Answer 11

with R side cardiac cath=look for valve problems

with L side in adults look for coronary complications.

Question 12

rheumatic fever can lead to cardiac valves malfunctions.

Answer 12

ICP (intracranial pressure) should be <2. measure head circonference.

Question 13

= poor muscle control due to birth injuries and/or decrease oxygen to brain tissues.

Answer 13

cerebral palsy

Question 14

dilantin level (10-20). Can cause gingival hyperplasia

Answer 14

for Meningitis check for Kernig’s/ Brudzinski’s signs.

Question 15

Wilm’s tumor is usually encapsulated above the kidneys causing flank pain.

Answer 15

hemophilia is x-linked. Mother passes disease to son.

Question 16

when phenylalanine increases, brain problems occur.

Answer 16

Buck’s traction= knee immobility

Question 17

Russell traction= femur or lower leg

Answer 17

Dunlap traction= skeletal or skin

Question 18

Bryant’s traction= children <35 lbs with femur fx.

Answer 18

place apparatus first then place the weight when putting traction

Question 19

placenta should be in upper part of uterus

Answer 19

eclampsia is seizure.

Question 20

a patient with a vertical c-section surgery will more likely have another c-section.

Answer 20

perform amniocentesis before 20 weeks gestation to check for cardiac and pulmonary abnormalities.

Question 21

Rh- mothers receive rhogam to protect next baby.

Answer 21

anterior fontanelle closes by 18 months. Posterior 6 to 8 weeks.

Question 22

= diffuse edema of the fetal scalp that crosses the suture lines. Swelling reabsorbs within 1 to 3 days.

Answer 22

caput succedaneum

Question 23

pathological jaundice= occurs before 24hrs and last 7 days.

Physiological jaundice= occurs after 24 hours.

Answer 23

placenta previa = there is no pain, there is bleeding.

Placenta abruption = pain, but no bleeding.

Question 24

bethamethasone (celestone)

=surfactant. Med for lung expansion.

Answer 24

dystocia

= baby cannot make it down to canal

Question 25

pitocin med used for uterine stimulation

Answer 25

Magnesium sulfate(used to halt preterm labor) is contraindicated if deep tendon reflexes are ineffective. If patient experiences seizure during magnesium adm. Get the baby out stat (emergency).

Question 26

Do not use why or I understand statement when dealing with patients

Answer 26

milieu therapy= taking care of patient/environment

Question 27

cognitive therapy= counseling

Answer 27

crisis intervention=short term.

Question 28

FIVE INTERVENTIONS FOR PSYCH PATIENTS -safety

• setting limits
• establish trusting relationship
• meds
• least restrictive methods/environment.

Answer 28

SSRI’s (antidepressants) take about 3 weeks to work.

Question 29

Obsession is to thought. Compulsion is to action

Answer 29

if patients have hallucinations redirect them. In delusions distract them.

Question 30

Thorazine, haldol (antipsychotic) can lead to EPS (extrapyramidal side effects)

Answer 30

Alzheimer’s disease is a chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of all dementias