NCLEX-RN Facts Flashcards
What are manifestations of autonomic dysreflexia?
Severe pounding HA, profuse sweating, nasal congestion
What kind of PPE is necessary for an acute viral infection?
Contact precautions - gown and gloves
What diagnostic measure can be used to determine hemolytic disease of the NB?
Amniocentesis - maternal Abs destroy fetal RBCs; bilirubin secreted b/c of hemolysis
What is the kcal/day requirement for women?
1200-1500 kcal/d
What is the daily Kcal requirement per day for men?
1500-1800 kcal/d
What is the required intake of Fe for pregnant versus non-pregnant females?
15 mg/day nonpregnant and 30 mg/day pregnant
What are the symptoms of a hemolytic reaction?
Hypotension, backache, low back pain, fever, chills, dyspnea
What is the main psychosocial problem with anorexia nervosa?
Self-identity and self-esteem
“This test will show how well my blood sugar has been controlled over the past 6-8 wks”
HbA1C - when RBCs are being formed, sugar attached (glycosylated) and remains attached throughout the life of the RBC (about 2 mo) - normal is 4-6%
What are the manifestations of a panic attack?
Palpitations, decreased perceptual field, diaphoresis, fear of going crazy, increased HR, increased BP (sANS)
What are the manifestations of Graves’ Dz?
Restlessness and hyperactive reflexes; heat intolerance, wt loss, and increased appetite d/t increased metabolic rate
What group is characterized by trust versus mistrust?
Birth to 18 mo - results from interaction with dependable, predictable primary caretaker
What age group is characterized by Autonomy vs Shame and Doubt?
Toddlers - 18 mo to 3 y/o
What age group is characterized by Initiative vs Guilt?
Preschoolers - ages 3-6 y/o
What age group is characterized by Industry vs Inferiority?
Latency/School Age - 6-12 y/o
What age group is characterized by Identity vs Role Confusion?
Adolescence - 12-19 y/o
What age group is characterized by Intimacy vs Isolation?
Young Adulthood (19-35 y/o)
What age group is characterized by Generativity vs Stagnation?
Middle Adulthood (35-65 y/o)
What age group is characterized by Ego Integrity vs Despair?
Late Adulthood (>65 y/o)
What is the primary goal of a reminiscing group for residents of a LT care facility?
Provides environment for social interaction and companionship
What sign is associated with hypocalcemia?
Trousseau’s sign - indicative of neuromuscular hyperreflexia
What manifestations are associated with hypercalcemia?
Constipation, depressed reflexes, decreased muscle strength
What labs may be noted with bacterial meningitis?
CSF cloudy and increased WBCs
What labs may be noted with viral meningitis?
CSF clear and increased WBCs
What is the purpose of a Miller-Abbott tube?
Provides intestinal decompression; intestinal tubes often used for Tx of paralytic ileus
What should parents be told about the accuracy of a PKU (phenylketonuria) test?
The initial specimen should be collected as close to DC as possible but not after 7 d; if collected before 24 h old, a repeat test should be done 2 wks of age
What may be seen with Buerger’s disease?
Vasculitis of vessels in upper and lower ext - digital sensitivity to cold, intermittent claudication
What is the best method to use when evaluating the effectiveness of tracheal suctioning?
Auscultation of chest for changes or clearing of adventitious breath sounds
What is an important consideration in care of NB with FAS?
Replace vitamins depleted as result of poor maternal diet, esp. vitamin B complex (CNS Fx)
What will the skin of a pt with Addison’s Dz look like?
Darker skin that is more pigmented b/c increased MSH
What is an indication of intestinal obstruction?
Distended and painful abdomen
When is best time to start toilet training a child?
24 mo - able to achieve daytime bladder control
What is the highest priority when caring for pt with hypoparathyroidism?
Dealing with cardiac dysrhythmias b/c hypocalcemia
What is the purpose of continuous bladder irrigation (CBI)?
Prevents formation of clots that can lead to obstruction and spasm in the postop TURP pt - Enables urine to keep flowing
When does a pt with an adjustment disorder/reactive depression have the highest physical and psychic energy?
In the morning hours
What is the earliest sign of an obstructed urinary catheter?
Bladder distention
What manifestations would be noted if TPN were abruptly DC’d?
Insulin levels remain high while glucose levels decline; results in hypoglycemia (diaphoresis, confusion, tachycardia); will also see restlessness, HA, weakness, irritability, apprehension, lack of muscle coordination
When will pain occur if pt has a gastric ulcer?
1/2 - 1 hr p meal, unrelieved by ingestion of food
When will the pain occur if pt has a duodenal ulcer?
2-3 hr p meal, prior to ingestion of food, often during night; relieved by ingestion of food
Why does N/V occur during 1st Tmx?
B/C increased estrogen, progesterone, and hCG
What is an early sign of hypoxia/respiratory distress?
Tachypnea, restlessness, anxious - tachycardia occurs in early resp distress
What is the most important consideration for the pt with myasthenia gravis?
Increased muscle fatigue, esp toward the end of the day
What manifestations are noted in Mania?
agitation, grandiose delusions, euphoria, difficulty concentrating
What is the problem with Meniere’s syndrome?
Vertigo attacks - stand directly in front, avoid shifting positions
What is most reliable assessment to determine effectiveness of diuretic therapy?
Daily wts
What is the purpose of play therapy?
children have difficulty putting feelings into words; play is how they express themselves
How long does an MRI usually take?
90 min
In preparing for an IVP, which medication should be DC’d 48 h prior to proc?
Metformin (Glucophage), b/c contrast media can cause life-threatening lactic acidosis
What symptoms are noted in DI?
Signs of dehydration, increased UO, low SG
What manifestations are noted in low intestinal obstruction?
N/V, abd distention - distention occurs above level of obstruction and initially hypoactive BS; no stool
After a lumbar laminectomy, what muscles need to be strengthened?
Abdominal - contributes to supporting lumbar spine
When assessing orientation of an elderly pt, what principle should be noted by the nurse?
The stress of an unfamiliar environment may cause confusion
What manifestations are noted with Cushing’s syndrome?
Thin ext (b/c wt loss in legs) with easy bruising, BP increases, wt gain in general, K+ decreases
What occurs in 65% of AIDS pts?
Dementia - cognitive confusion and disorientation
Removal of a cataract allows for correction of refraction for what type of vision?
Distant vision
What signifies liver involvement?
Yellow casting - jaundice
What is an important post-Wilm’s tumor assessment?
Measure abd girth - assesses size of tumor
What is the purpose of a non-stress test for a pregnant client?
The non-stress test is looking for the baby’s heart beat to increase with activity. A favorable result is 2 or more FHR accelerations of 15 bpm lasting 15 sec over 20 min interval
What is an important consideration when preparing for a bone scan?
Drink lots of fluids between tracer injection and test - time interval 1-3 h; fluids maintain hydration and decrease radiation dose to bladder; void immediately before scan to prevent distention
Considerations for crutches
Support wt on hand pieces, 8-10 inches in front with each step, arms at 35 degree angle
Hemorrhoidectomy concern
Lower abd enlarged and dull on percussion - poss. Urinary retention. Occurs b/c closeness of bladder to surgical site and occurrence of rectal spasms and anorectal tenderness; catheterization to empty bladder
Phototherapy Considerations
Eye patches; loose, green stools and increased UO reflect increased excretion of bilirubin and are possible minor SE; turn off lights to draw blood
Low back pain positioning
HOB elevated 45 degrees and knees moderately flexed - relieves pressure on sciatic nerve and disk
What is noted in scoliosis?
Asymmetry or prominence of rib cage and scapulae, curvature of spine; Tx is bracing and spinal fusion surgery
What are the manifestations of ALS?
Dysphagia and aspiration, fatigue while talking, tongue atrophy, weakness of arms and hands, fasciculations of face, retains bowel and bladder Fx
Dumping syndrome considerations
Decrease CHO; undigested food is dumped into jejunum, resulting in distention, cramping, pain, diarrhea 30-60 min p eating; causes diaphoresis, diarrhea, and hypotension; eat small frequent meals, increase fat and protein, lie down after eating to delay gastric emptying; avoid high-fiber, no fluids 1 h a, 2 h p meals
Risks for prostate cancer
Age >50, African American, occupation (urban areas and industrial)
