Nclex Tips Flashcards
Rule of Nines
Head and Neck 9% Each upper ext 9% Each lower ext 18% Front trunk 18% Back trunk 18% Genitalia 1%
Birth weight doubles
by 6 months and triples by 1 year
Cranial Nerves
O lfac Some O ptic Say O cul Marry T roch Money T trig But A abd My F acial Bro A udit Says G glossoph Big V agus Bras A ccessory Matter H ypoglo More
Dumping Syndrome
Increase fat and protein, small freq meals
wait 1 hour after meals to drink
Allen Test
Occlude Ulnar and Radial until hand blanches then release ulnar.
if hand pinks up then ulnar is good for ABGs
Chest Tube
Collection chamber Far Right
Continuous bubble far left = suction chamber
Water chamber seal = bad if it is bubbling (air leak)
tiding is normal
If the tube detaches - Putin sterile water
Hirchsprung’s
Bile obstruction
No bile is upper obstruction
Ribbon like Stool
Cane walking
COAL
Cane
Opposite
Affected
Leg
Late Decels
- LLR position
- O2 @ 8-10 LPM
- Increase IV Fluid
- Pit off
- Call MD
Bacterial meningitis
is inflammation of the meninges of the brain and spinal cord caused by infection.
infants and children age <2 include fever, restlessness, and a high-pitched cry.
hydrocephalus, an increase in intracranial pressure (ICP) resulting from obstruction of cerebrospinal fluid flow.
permanent hearing loss, learning disabilities, and brain damage.
Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children. Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis.
Insulins
RALG.I.DG regular insulin (fast) aspart (fast) lispro (fast) glulisine (fast) NPH - Isophane (intermediate) detemir (long) glargine (long)
- Insulins
- Main hormone in the
metabolism of glucose - All Type 1 diabetics,
Type 2 uncontrolled by diet
and oral anti-diabetics
Risk for hypoglycemia, hypokalemia
- Regular Insulin can be pushed
for hyperkalemia, follow-up with D5
Fast Acting - 30min
Intermediate - 2-4 hours
Long Acting - 6-8 hours
Neologisms
impaired thought processes seen in individuals with schizophrenia include the following:
made-up words or phrases usually of a bizarre nature; the words have meaning to the client only. Example: “I would like to have a phjinox.”
Echolalia
impaired thought processes seen in individuals with schizophrenia include the following:
repetition of words, usually uttered by someone else
Tangentiality
impaired thought processes seen in individuals with schizophrenia include the following:
going from one topic to the next without getting to the point of the original idea or topic
Clang associations
impaired thought processes seen in individuals with schizophrenia include the following:
rhyming words in a meaningless, illogical manner. Example: “The pike likes to hike and Mike fed the bike near the tyke.”
Word salad
impaired thought processes seen in individuals with schizophrenia include the following:
a mix of words and/or phrases having no meaning except to the client. Example: “Here what comes table, sky, apple.”
Loose associations
impaired thought processes seen in individuals with schizophrenia include the following:
rapid shifting from one idea to another, with little or no connection to logic or rationality
Perseveration
impaired thought processes seen in individuals with schizophrenia include the following:
repeating the same words or phrases in response to different questions
Concrete thinking
impaired thought processes seen in individuals with schizophrenia include the following:
literal interpretation of an idea; the client has difficulty with abstract thinking. Example: The phrase, “The grass is always greener on the other side,” would be interpreted to mean that the grass somewhere else is literally greener
Sickle Cell Anemia
Vaso-occlusive crisis Lab results
elevated reticulocytes
elevated bilirubin
Anemia.
Ulcerative colitis who has abdominal distension, bloody diarrhea, and fever
likely has toxic megacolon. This is a common, life-threatening complication of inflammatory bowel disease and is seen more frequently in ulcerative colitis than in Crohn disease. Toxic megacolon can also be associated with Clostridium difficile infection and other forms of infectious colitis.
Statin medications
…the client’s liver function tests should be assessed.
Prior to starting therapy with statin medications (eg, rosuvastatin, simvastatin, pravastatin, atorvastatin), the client’s liver function tests should be assessed. The drug is metabolized by the hepatic enzyme system and could cause drug-induced hepatitis and increased liver enzymes. Liver function tests should be assessed prior to the start of therapy.
Hepatic encephalopathy (HE)
is a frequent complication of liver cirrhosis. Precipitating factors include hypokalemia, constipation, gastrointestinal hemorrhage, and infection. It results from accumulation of ammonia and other toxic substances in blood.
Clinical manifestations of HE range from sleep disturbances (early) to lethargy and coma. Mental status is altered, and clients are not oriented to time, place, or person (Option 1). A characteristic clinical finding of HE is presence of asterixis (flapping tremors of the hands). It is assessed by having the client extend the arms and dorsiflex the wrists (Option 2). Another sign is fetor hepaticus (musty, sweet odor of the breath) from accumulated digestive byproducts.
Spider angiomas
(eg, small, dilated blood vessels with bright red centers), gynecomastia, testicular atrophy, and palmar erythema are expected findings in cirrhosis due to altered metabolism of hormone in the liver.
Jaundice
occurs when bilirubin is 2-3 times the normal value. Jaundice can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is not related specifically to encephalopathy.
Amylase and lipase are enzymes
from pancreatic tissue. Alanine aminotransferase and aspartate aminotransferase are liver enzymes. They would be elevated with hepatitis and are not unique to cirrhosis or HE. Elevated ammonia levels would be more specific to cirrhosis.
Acute urinary retention
is best treated with rapid, complete bladder decompression rather than the intermittent urine drainage that is limited to 500 to 1000 mL at a time. Rapid decompression can be associated with hematuria, hypotension, and postobstructive diuresis (Option 2). However, these are rarely clinically significant if appropriate supportive care is administered, whereas inability to relieve the obstruction can be associated with infection and kidney injury (Option 3).
pulsus paradoxus
To measure the pulsus paradoxus, place a blood pressure cuff on the patients arm and very very slowly deflate the cuff while listening for brachial pulsations. Note the pressure that you first hear with pulsations during expiration (which will be the highest).
Place client in semirecumbent position
Have client breathe normally
Determine the SBP using a manual BP cuff
Inflate the BP cuff to at least 20 mm Hg above the previously measured SBP
Deflate the cuff slowly, noting the first Korotkoff sound during expiration along with the pressure
Continue to slowly deflate the cuff until you hear sounds throughout inspiration and expiration; also note the pressure
Determine the difference between the 2 measurements in steps 5 and 6; this equals the amount of paradox
The difference is normally <10 mm Hg, but a difference >10 mm Hg may indicate the presence of cardiac tamponade.
A low-residue diet
, which avoids all high-fiber foods, may be used in treating acute diverticulitis. However, after symptoms have resolved, a high-fiber diet is resumed to prevent future episodes.
