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Quick Facts > page 31-40 > Flashcards

page 31-40 Flashcards

1
Q

Immunizations
What do you get at each age?

BIRTH (1 vaccine)

A

Hep B #1

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2
Q

Immunizations
What do you get at each age?

2 months (5 vaccines)

A 
Hep B #2 (some resources say it can be given at 1 mo.)
DTap
Hib Haemophilus influenzae type b
IPV Inactivated polio vaccine
PCV Pneumococcal conjugate vaccine
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3
Q

Immunizations
What do you get at each age?

4 months (4 vaccines)

A

All 2-month immunizations except Hep B

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4
Q

Immunizations
What do you get at each age?

6 months (5 vaccines)

A 
All 2-month immunizations:
Hep B #2 
DTap
Hib
IPV
PCV
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5
Q

Immunizations
What do you get at each age?

12 months

A

MMR #1

Hib Haemophilus influenzae type b

PCV

Varicella

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6
Q

Immunizations

Tetanus & diptheria are optional vaccinations; what is the earliest age they can be given?

A

2 months

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7
Q

Immunizations

What is a booster shot?

A

An additional dose of vaccination to increase effectiveness.

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8
Q

Immunizations

What are the side effects of immunizations?

A

low-grade fever, tenderness, swelling at the site, child may become irritable

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9
Q

Immunizations

What medications should be given for these effects?

A

Acetaminophen

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10
Q

Immunizations

Never give ______ to children experiencing side effects of immunization.

A

Aspirin

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11
Q

Immunizations

When should the meningitis vaccination be given?

A

Before going to college

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12
Q

Immunizations

If an adult woman receives an MMR shot, what should you teach her?

A

Wait three months before pregnancy

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13
Q

Immunizations

How soon can a child get the influenza vaccination?

A

Not until six months

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14
Q

Immunizations

Do not give MMR if the client is allergic to _____ or _____.

A

Eggs or neomycin

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15
Q

Immunizations

Do not give the influenza vaccination if the client is allergic to ______.

A

Eggs

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16
Q

Immunizations

What is active immunity?

A

Stimulating the body to produce antibodies by giving a vaccine

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17
Q

Immunizations

What is passive immunity?

A

Antibodies that are formed in another body but passed down for short-term use (breastmilk)

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18
Q

Inflammatory Bowel Disease

Crohn’s Disease vs Ulcerative Colitis

Location: Anywhere in the digestive tract from mouth to anus

A

Crohn‘s Disease

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19
Q

Inflammatory Bowel Disease
Crohn’s Disease vs Ulcerative Colitis

Location: Primarily colon

A

Ulcerative Colitis

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20
Q

Inflammatory Bowel Disease (Crohn’s Disease vs Ulcerative Colitis)

Signs: 3-4 semi-soft stools, no blood, anorexia, fistulas

A

Crohn’s Disease

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21
Q

Inflammatory Bowel Disease
Crohn’s Disease vs Ulcerative Colitis

Signs:

  1. Bloody diarrhea
  2. Weight loss
A

Ulcerative Colitis

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22
Q

Inflammatory Bowel Disease
Crohn’s Disease vs Ulcerative Colitis

Lifestyle: Associated with smoking

A

Crohn’s Disease

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23
Q

Inflammatory Bowel Disease
Crohn’s Disease vs Ulcerative Colitis

Lifestyle: Non-smokers

A

Ulcerative Colitis

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24
Q

Inflammatory Bowel Disease

Treatment: Anti-inflammatory steroids

NPO Status- bowel rest

Surgery will not help; disease will reoccur

A

Crohn’s Disease

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25
Q

Inflammatory Bowel Disease

Treatment: Anti-inflammatory steroids
NPO Status -bowel rest
Surgery to remove affected area

A

Ulcerative Colitis

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26
Q

Incentive Spirometry

Incentive Spirometry is a method of _____ that helps maximize lung inflation.

A

Deep breathing

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27
Q

Incentive Spirometry

Instruct the client to place _______ tightly around the mouth piece.

A

Lips

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28
Q

Incentive Spirometry is used after surgery to prevent _______.

A

Atelectasis

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29
Q

Increased intracranial pressure (ICP)

what is the normal intracranial pressure range?

A

5-15 mmHg

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30
Q

Increased intracranial pressure (ICP)

What are the common causes of ICP?

A

Trauma
Hemorrhage
Edema
Tumors

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31
Q

Increased intracranial pressure (ICP)

This the earliest sign of ICP.

A

Decreased level of consciousness

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32
Q

Increased intracranial pressure (ICP)

The client will often appear?

A

Restless, agitated, complaining of headaches

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33
Q

Increased intracranial pressure (ICP)

What will babies physically present with?

A

Bulging fontanelles

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34
Q

Increased intracranial pressure (ICP)

Late signs of ICP

A

Unilateral pupil dilation
Hypertension or hypotension
Bradycardia

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35
Q

Increased intracranial pressure (ICP)

Client may complain of ________.

A

Projectile vomiting without nausea.

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36
Q

Increased intracranial pressure (ICP)

How will the vital signs appear with ICP?

A

B/P (up)
Temp (up)
Resp (up then down)
HR (up)

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37
Q

Increased intracranial pressure (ICP)

What is widening pulse pressure & how it is related?

A

When systolic bp goes up & diastolic continues to go down so that they become further apart (eg 135/40 is a bad sign)

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38
Q

Increased intracranial pressure (ICP)

What is Cushing’s Triad?

A

3 things
Widening pulse pressure
Cheyne stokes respirations
Bradycardia

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39
Q

Increased intracranial pressure (ICP)

Initiate _____ precautions.

A

Seizure

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40
Q

Increased intracranial pressure (ICP)

Elevate hob to?

A

10 to 30 degrees; to promote jugular venous outflow

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41
Q

Increased intracranial pressure (ICP)

What medications will be prescribed?

A

Anti convulsants
BP medications
Corticosteroids
Diuretics

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42
Q

Increased intracranial pressure (ICP)

Tell the client not to ________,_____,or ______.

A

Strain, cough or sneeze

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43
Q

Increased intracranial pressure (ICP)

Nursing interventions would be to?

A

DECREASE environmental stimuli.
Maintain body temperature.
LIMIT fluid intake.
Monitor intake & output.

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44
Q

Instillation of Ear Medications

Medication should be________ temperature?

A

Room - too hot or cold will have side effects (nausea dizziness etc)

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45
Q

Instillation of Ear Medications

What position should the client be in when receiving ear medications?

A

Supine, with AFFECTED EAR UP

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46
Q

Instillation of Ear Medications

When administering ear meds to an adUlt, draw the pinna back and ______.

A

Up

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47
Q

Instillation of Ear Medications

When administering ear meds to an chilD, draw the pinna back and ______.

A

DOWN

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48
Q

Instillation of Ear Medications

How long should the head be tilted to allow medication to travel the ear canal? _____ minutes

A

5 minutes

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49
Q

Instillation of Eye Medications

When giving eye medications, do this to prevent meds from going into the nasal passage.

A

Apply pressure

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50
Q

Instillation of Eye Medications

Pull the _____ eyelid down against the ______.

A

Lower, cheek

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51
Q

Instillation of Eye Medications

Squeeze the drop in the _____.

A

Conjunctiva sac

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52
Q

Instillation of Eye Medications

If more than one drop is prescribed, wait ___ to ___minutes before applying another drop.

A

3 to 5 minutes

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53
Q

Instillation of Eye Medications

Do not let the ____ touch the ___.

A

Medication bottle, eyeball

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54
Q

Intravenous therapy

Why are IV fluids used?

A

They are a quick way to replace nutrients, water, and electrolytes.

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55
Q

Instillation of Eye Medications

What are the 3 types of IV fluid?

A

Isotonic
Hypotonic
Hypertonic

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56
Q

Increased intracranial pressure (ICP)

Initiate _____ precautions.

A

SEIZURE PRECAUTIONS

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57
Q

Increased intracranial pressure (ICP)

Elevate hob to?

A

10-30 degrees, to promote jugular venous outflow

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58
Q

Increased intracranial pressure (ICP)

What medications will be prescribed?

A

Anticonvulsants
Blood pressure medications
Corticosteroids
Diuretics

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59
Q

Increased intracranial pressure (ICP)

Tell the px not to _____,____, or_____.

A

Strain, cough, or sneeze

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60
Q

Increased intracranial pressure (ICP)

Nursing interventions would be to?

A

Decrease environmental stimuli
Maintain body temperature
Limit fluid intake
Monitor intake & output

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61
Q

Instillation of Ear Medications

Medication should be ______ temperature?

A

Room

-too hot or cold will have side effects (nausea, dizziness etc)

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62
Q

Intravenous Therapy

Describe Isotonic fluid/give examples.

A

Isotonic fluid is the same as the inside of the cell.
0.9% normal saline
Lactated Ringer
D5W

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63
Q

Intravenous Therapy

Why would you give isotonic fluids?

A

D.K.A, Burns to replace sodium chloride

*0.9% NS always hung with blood

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64
Q

Intravenous Therapy

Describe hypotonic fluids/give examples.

A

Hypotonic fluid is less concentrated than the cell.
This would cause water to move into the cell.
0.45% NS

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65
Q

Intravenous Therapy

Why would you give hypotonic fluids?

A

Dehydration, HYPERnatremia; lowers blood pressure.

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66
Q

Intravenous Therapy

Why should hypotonic fluids be closely monitored?

A

Because a rapid increase in fluid shifting into the cells can cause cellular & cerebral edema.

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67
Q

Intravenous Therapy

Describe HYPERtonic fluid/give examples.

A

Hypertonic fluid is more concentrated than the cell.
This would cause water movement out of the cell.
5% NS
D5%NS
D5%LR

68
Q

Intravenous Therapy

WHY would you give HYPERtonic fluids?

A

Hyponatremia, nutrition

69
Q

Intravenous Therapy

Why would HYPERTONIC fluids be closely monitored?

A

Because it can cause electrolyte imbalance & dehydration.

70
Q

Intravenous Therapy

Before you start IV fluids, assess client’s ______.

A

IV; make sure it is patent

71
Q

Intravenous Therapy

If the IV is infiltrated, what would you see?

A

Cool, swollen, tender, painful at the site

72
Q

Laminectomy

Surgery is the removal of ______ so the spinal cord can be seen.

73
Q

Laminectomy

To move the client after surgery, ______ this client!

74
Q

Lead Poisoning

What is the highest risk factor in ingesting lead?

A

Age; younger kids put things in their mouth

75
Q

Lead Poisoning

What is the most likely ingested item to cause lead poisoning?

A

Lead paint chips

76
Q

Lead Poisoning

The MOST dangerous side effect of ingesting lead is ________.

A

Mental retardation

77
Q

Lead Poisoning

What are the signs of lead poisoning?

A 
Signs more serious if larger amounts are ingested:
headache, 
abdominal pain,
fatigue, 
muscle weakness, 
respiratory depression
78
Q

Lead Poisoning

How do you treat lead poisoning?

A

Chelating agents

79
Q

Lead Poisoning

How are these chelating agents given?

A

By receiving many IM injections

80
Q

Lead Poisoning

Do not give ______ to induce vomiting.

81
Q

Legal Issues

Negligence is when a nurse does _______.

A

NOT provide appropriate care according to set standards

82
Q

Legal Issues

If a nurse does a treatment without consent, it is example of ______?

83
Q

Legal Issues

If your client falls out of bed because you forgot to put up the side rails, this is _________.

84
Q

Legal Issues

Any NCLEX question that has the word ‘‘threat’’, think?

85
Q

Legal Issues

Advanced directives are important because they _____.

A

Allow the client to direct how/what care they are to receive if they become unable to make decisions in the future.

86
Q

Legal Issues

Are advanced directives mandatory for a client?

87
Q

Legal Issues

The document that specifically names a person to make decisions on another person’s behalf is_______.

A

Durable power of attorney

88
Q

Legal Issues

The client must be of ______ to write a will.

A

Sound mind

89
Q

Lung Sounds

What is the cause of crackles?

A

Fluid or secretions in the airway

90
Q

Lung Sounds

When do you hear crackles?

A

On inspiration (sounds like Rice Crispies in milk)

91
Q

Lung Sounds

What are some possible causes of crackles?

A

pneumonia

edema

bronchitis

92
Q

Lung Sounds

What is another name for crackles?

93
Q

Lung Sounds

What are the characteristics of wheezes?

A

High-pitched musical sounds

94
Q

Lung Sounds

When do you hear wheezes ?

A

On inspiration & expiration

95
Q

Lung Sounds

What are possible causes of wheezing?

A

asthma

smoking

allergic reactions

96
Q

Lung Sounds

Wheezes can often be heard without a _______.

A

Stethoscope

97
Q

Lung Sounds

What are characteristics of stridor?

A

High-pitched harsh sound heard in UPPER airway.

98
Q

Lung Sounds

Stridor is often confused with _____.

99
Q

Lyme Disease

This type of infection is caused by?

A

Bite from a tick

100
Q

Lyme Disease

How long after a bite can you test for this disease?

A

Between 4 to 6 weeks

101
Q

Lyme Disease

What is the treatment plan?

A

Take antibiotics:
Doxycycline (Adults)
Amoxicillin (Children)

102
Q

Maslow’s Hierarchy of Needs

What are the most important factors in order?

A 
Physiological Needs
Safety & Security
Love & Belongingness
Self-Esteem
Self-Actualization
103
Q

Mastectomy

This surgery is to remove ______ or _____.

A

Breast tissue or nipple

104
Q

Mastectomy

After surgery, ______ the affected arm to prevent _______.

A

Elevate, lymphedema

105
Q

Mastectomy

No ______ or _____ in the affected arm.

A

BP, venipuncture

106
Q

Mastectomy

Always assess site for signs of _____ after surgery.

107
Q

Mastectomy

List signs of infection.

A 
● swelling
● redness
● fever
● chills 
● elevated WBC count
108
Q

Mastectomy

Encourage client to do ______ on the remaining breast.

A

Self breast exam

109
Q

Medication Administration

What are the six rights of medication administration?

A

Right:

  1. Client
  2. Medication
  3. Time
  4. Documentation
  5. Dose
  6. Route
110
Q

Medication Administration

What two verifiers do you ask a client before giving a medication?

A

Name & birthdate

111
Q

Medication Administration

Do not give medication if _____.

A

You don’t know what it does.

Clients will ask. If you can’t answer them, they won’t trust you!

112
Q

Medication Administration

DO NOT STORE medications _____.

A

At the bedside

113
Q

Medication Administration

Can you give medication prepared by other RN?

A

No, never do this. This is ILLEGAL!

114
Q

Medication Administration

What does it mean if a medication is PRN?

A

It means to give only when necessary.

115
Q

Medication Administration

Do not _______ sustained-release capsules or enteric-coated tablets.

116
Q

Medication Administration

What should a nurse do if she/he administers the wrong medication?

A

Notify physician
DO NOT document on px’s chart & complete an incident form.
This is not part of client records.

117
Q

Meniere’s Syndrome

What are the symptoms?

A

Tinnitus

Unilateral hearing loss

dizziness

118
Q

Meniere’s Syndrome

What are the causes?

A

Viral, bacterial infections & allergic reactions

119
Q

Meniere’s Syndrome

Describe Meniere’s attacks.

A

Severe, sudden attacks that may cause permanent hearing loss.

Nausea & vomiting can also be present.

120
Q

Meniere’s Syndrome

What is the best environment for a client with this syndrome?

A

Bed rest in a quiet room, moving head slowly, sedatives can be given to keep client calm.

Low playing music helps with tinnitus.

121
Q

Meniere’s Syndrome

What diet should be?

A

Low sodium

122
Q

Meningitis

What is meningitis?

A

Inflammation of arachnoid & pia mater of the brain/spinal cord

123
Q

Meningitis

How it is transmitted?

A

Direct Contact

Droplet

124
Q

M E N I N G I T I S

What are the signs & symptoms?

A 
M E N I N  G I T I S
● nuchal rigidity (Brudzinki's sign)
● tachycardia
● headache 
● nausea & vomiting
125
Q

Meningitis can also cause ______.

A

Increased intracranial pressure

126
Q

Meningitis

What two physical signs are positive?

A

Positive Kernig’s & Brudsinki’s

127
Q

M E N I N G I T I S

What are the nursing interventions?

A
  1. Monitor LOC
  2. Vitals
  3. Initiate seizure precautions
  4. Maintain isolation
  5. Elevate HOB
128
Q

Meningitis

What medications are prescribed?

A

Antibiotics & analgesics

129
Q

Mongolian Spots

What do these spots look like?

A

Bluish-black spots on body

130
Q

Mongolian Spots

Where can you find these spots?

A

On the back & buttocks of newborns

131
Q

Mongolian Spots

In what race are these spots mostly seen?

A

Asian & African American

132
Q

Mongolian Spots

Are they harmful & how long do they appear?

A

No. They are normal in newborns & they gradually

133
Q 
Multiple Sclerosis (MS)
True or false? MS is a chronic, progressive, degenerative disease of the nervous system.
134
Q 
Multiple Sclerosis (MS)
What part of the nervous system is affected?
A

The problem is with demyelinization of the white matter of the brain & spinal cord.

135
Q 
Multiple Sclerosis (MS)
Is there a cure for MS?
136
Q 
Multiple Sclerosis (MS) - is a chronic, progressive, degenerative disease of the nervous system
What are the signs of MS?
A
  • muscle spasms
  • weakness
  • bowel/bladder dysfunction
  • numbness in the extremities
  • visual disturbances

MULTIPLE SCLEROSIS

137
Q 
Multiple Sclerosis (MS)
What medication will be given for spasms?
138
Q 
Multiple Sclerosis (MS)
What medication will be given to reduce amount of time a client experiences exacerbated symptoms?
A

Corticosteroids

139
Q 
Multiple Sclerosis (MS)
If you were at a MS conference, what would you teach?
A
  1. start regular bladder bowel program
  2. avoid stressful situations
  3. eat a well-balanced diet
  4. initiate speech/physical therapy
  5. remove safety hazards in home
140
Q

Munchausen Syndrome

What is the definition of this syndrome?

A

A psychiatric disorder that causes a person to self-inflict injury/harm to his/her own body.

The person may also say that he/she has a mental disorder.

141
Q

Munchausen Syndrome

What is Munchausen by proxy?

A

An individual, typically a mother, intentionally causes or makes up an illness in a child under their care for attention.

142
Q

Munchausen Syndrome

Notes for NCLEX

A

The child will have issues with no explained etiology.

Treatment of the issue does not help.

Assessments indicate child is healthy, symptoms get better when child is away from the caregiver.

Nursing priority: Protect the child

143
Q

Myasthenia Gravis
True or false?
It is an autoimmune disease that results in extreme fatigue & muscle weakness.

144
Q

Myasthenia Gravis

What is the malfunction of the body?

A

Body produces antibodies that block acetylcholine receptors

145
Q

Myasthenia Gravis

Is there a cure for myasthenia gravis?

146
Q

Myasthenia Gravis

What are the signs & symptoms?

A 
S/Sx MG
• difficulty talking 
• chewing 
• weak eye muscles 
• visual disturbances 
• unsteady gait
147
Q

Myasthenia Gravis

Do the symptoms of myasthenia gravis worsen with activity?

A

YES, they do.

148
Q

Myasthenia Gravis

The _______ test is performed to diagnosis Myasthenia Gravis.

149
Q

Myasthenia Gravis

If the px muscle strength is increased, the test is ______.

150
Q

Myasthenia Gravis

What medication will be given?

A

Anticholinesterase/Plasmapheresis

151
Q

Myasthenia Gravis

What would you teach at a myasthenia gravis conference?

A

M G
• Take meds 30 mins before eating.
• Cough/deep breathe
• Exercise
• Conserve energy by doing multiple short tasks
• Try to decrease stress, infections, & unhealthy habits.

152
Q 
Myocardial Infarction (MI)
What is the cause of MI?
A

Decreased oxygen supply to heart

153
Q 
Myocardial Infarction (MI)
Where is the pain felt?
A

Substernal (sudden, crushing radiating to jaw, shoulders, back) & lasting longer than 30 minutes

154
Q 
Myocardial Infarction (MI)
The pain is not relieved by \_\_\_\_\_\_ or \_\_\_\_\_\_.
A

Rest or nitroglycerin

155
Q 
Myocardial Infarction (MI)
What changes would you see on an EKG?
A

ST elevation, inverted T waves

156
Q 
Myocardial Infarction (MI)
What lab values will be elevated?
A
  1. CK-MB Creatine kinase-MB
  2. CPK Creatine kinase
  3. Troponin
  4. LDH Lactate dehydrogenase
  5. WBC
157
Q 
Myocardial Infarction (MI)
What medications are given for an MI?
A 
MONA
Morphine
O2
Nitroglycerin
Aspirin

*MI=MONA

158
Q 
Myocardial Infarction (MI)
What activity is prescribed for this client?
159
Q 
Myocardial Infarction (MI)
What is angina pectoris?
A

Chest pain due to heart not receiving enough oxygen

160
Q 
Myocardial Infarction (MI)
Where is the pain located? (angina pectoris)
A

The same area of the chest as seen in MI

161
Q 
Myocardial Infarction (MI)
What are common causes of angina pectoris?
A

early-morning activity (shoveling snow), heavy meals, stress, exercise and smoking

162
Q 
Myocardial Infarction (MI)
How is stable angina different from an MI?
A

Chest pain that has a typical onset location, lasts for 3 to 5 minutes & is relieved by nitroglycerin/rest

163
Q 
Myocardial Infarction (MI)
What is UNSTABLE angina?
A

It is chest pain that occurs while the client is resting.

164
Q 
Myocardial Infarction (MI)
How is angina diagnosed?
A
  1. cardiac cath
  2. coronary artery bypass
  3. exercise/thallium stress test
  4. EKG with no ST elevation
165
Q 
Myocardial Infarction (MI)
What should you teach a client who has angina?
A
  • How to take nitro for pain (can take up to 3 tablets SL)
  • Diet modification (low cholesterol)
  • Exercise & stop smoking

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