QT1 Flashcards
When does motor reflex end?
after 3-4 months
When does infant have pincer grasp?
9mo
When can infant sit with support?
6mo
When does birth weight triple for infant?
by 1 year (5-7oz/wk or double by 5mo)
When does posterior fontanelle close?
by 2-3 mo
When does anterior fontanelle close?
by 18 mo
What is projection?
attributing one’s thoughts or impulses to another (involved in phobias)
What is displacement?
shifting of emotion concerning person or object to another neutral or less dangerous person
What is sublimination?
diversion of unacceptable drives into socially acceptable channels
what is Internalization?
incorporation of someone else’s opinion as one’s own
what is rationalization?
attempt to make behavior appear to be the result of logical thinking
What is intellectualization?
excessive reasoning or logic used to avoid experiencing disturbing feelings
What is reaction formation?
development of conscious attitudes and behavior patterns into opposite of what one really wants to do
What is symbolization?
something represents something else (involved in phobias)
expected findings of infant with fetal alcohol syndrome?
small head circumference, low birth weight, undeveloped cheekbones, difficulty feeding and poor sucking ability; respiratory distress may be related to preterm birth, neurologic damage, small trachea, floppy epiglottis
Type 1 DM and elderly, why is urine test for sugar and ketones not preferred?
The renal threshold is elevated, meaning the level at which glucose starts to appear increases giving false-negative readings. Will show negative if 0-180 mg/dL
What can amniocentesis determine?
evaluate baby’s lungs, any spinal cord problems, or issues with baby’s blood
pediculosis capitis (head lice)
very hot water and a special detergent (RID) need to be used for cleansing clothing and personal belongings, 1% gamma benzene hexachloride (Kwell) shampoo is an organic solvent, can be toxic, absorbed through scalp; may be repeated 5 to 7 days after first application which is necessary after eggs hatch; permethrin 1% crème rinse (Nix) kills both lice and nits after one application
What is position for administering enema?
patient left side-lying (Sim’s) with knee flexed; allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution
Which type of breathing and signs characterize edema and inflammation of the airways?
inspiratory stridor and restlessness
Extrapyramidal side effects
side effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing)
chlorpromazine hydrochloride (Thorazine)
mood disorders (eg, schizophrenia), the manic phase of manic-depressive disorder, anxiety and restlessness before surgery; s/e is EPS and if this occurs antiparkinsonian drug like Cogentin may be ordered
Hypoparathyroid signs and diet requirements
indications include tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia, and laryngeal spasm
High in calcium since it’s not producing, and low in Ca means the body is high in phosphorus so the diet should be low in P.
Early signs of preeclampsia
hypertension, facial swelling, proteinuria (the triad)
Signs of eclampsia
blurred vision, oliguria; epigastric pain and h/a are signs before a seizure
Why might a person with CVA and facial paralysis have a corneal abrasion?
client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect eye
early signs of lithium toxicity
include fine tremors of fingers, wrists, and hands; and nausea, vomiting, and diarrhea
severe lithium toxicity
Ataxia, confusion, seizures.
s/e of antipsycotic agents
Elevated white blood cell count, fever, orthostatic hypotension
Hiatal hernia and reflux
Hiatal hernia is a condition in which part of the stomach sticks upward into the chest, through an opening in the diaphragm.
instruct pt to withhold food and fluids just before going to bed b/c full stomach is more likely to slide (reflux) through the hernia, causing regurgitation and heartburn; and pt less likely to awaken during the night
When is solid food for infant started?
Rice cereal is usually the first solid food and is started around 4 to 5 months.
primary reason elderly adults have problems with constipation
reduced gastrointestinal motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, side effect of medications, emotional problems, insufficient fluid intake, and excessive dietary fat
Types of play: solitary vs parallel vs associative
solitary-infant; parallel-toddler; associative-preschool (4y)
S/S of addison’s disease
Muscular weakness and fatigue.
Dark pigmentation of the skin.
Gastrointestinal disturbances and anorexia
indicative of crisis: Restlessness and rapid, weak pulse.
During the mother’s fourth stage of labor, the nurse should palpate the client’s fundus?
uterus is normally contracted and palpable at the umbilicus
cholecystitis
Right upper abdominal pain.
What might alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness?
subtle symptoms of an alcohol-related problem; client who has several complaints of pain that do not appear to be correlated to the admissions problem requires further investigation; tremors, elevated temperature, nocturnal leg cramps and pain symptoms are indicative of an alcohol-related problem
pituitary dwarfism clinical manifestations
see small size but normal body proportions
usually have delayed sexual maturity
appear younger than chronological age (delicate features)
usually see fine, smooth skin
Identity versus role diffusion
adolescent
Intimacy versus isolation
young adult
Generativity versus stagnation
older adult aged 45 to 64 years of age
Integrity versus despair and disgust
ages 65 and older
ceftriaxone sodium (Rocephin)
cephalosporin, long-term use of Rocephin can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended
lient with hypothyroidism to avoid which medications?
narcotics, barbiturates, and anesthetics
Hypothyroidism diet
requires high fiber, high cellulose foods to prevent constipation
the Weber test
The stem of a vibrating tuning fork is held in the middle of the forehead, and the girl’s hearing is assessed in both ears.
Rinne test
The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal.
type 1 diabetes complaining of decreased vision
caused by gradual destruction and degeneration of the retina b/c of deterioration of the retinal vessels, as well as edema, occurs
clomiphene citrate (Clomid)
induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum
cortisol is responsible for?
Converting proteins and fat into glucose, also an anti-inflammatory agent
epinephrine is responsible for?
Preparing the body for “flight or fight.”
norepinephrine is responsible for?
Enhancing musculoskeletal activity
delusions of persecution
delusion is a strongly held belief that is not validated by reality
Command hallucinations.
hallucinations are sensory perceptions that take place without external stimuli; most common are auditory, or hearing voices; other types of hallucinations are tactile, visual, gustatory, and olfactory; command hallucinations involve client experiencing auditory hallucinations that are telling him/her to do something; for example, to kill someone
Delusions of reference
delusions of reference are a false belief that public events or people are directly related to the individual
verapamil
This medicine is a calcium channel blocker.
Treats high blood pressure, severe chest pain (angina), and irregular heartbeat (arrhythmia). A lower blood pressure will reduce the risk of stroke and heart attack.
breast-feeding mother should increase her daily caloric intake by how many calories?
500
What does a continuous bubbling in the water-seal chamber indicate?
air leak; need to check for location of leak; clamp tubing close to chest and check for bubbling, and then clamp tubing close to container and check for bubbling
The nurse determines the lung has re-expanded if what occurs in the three-chamber water-seal drainage system (Pleur-evac)?
The fluid in the water-seal chamber does not fluctuate with respirations, indicates no more air leaking into pleural space
3-month-old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is MOST appropriate for the nurse to take which of the following actions?
Make the infant NPO for 3 hours.
hemolytic transfusion reaction
Hypotension, Chills, Lower back discomfort
allergic reaction
wheezing, urticaria (hives), facial flushing, and epiglottal edema
What is the purpose of digoxin?
Increases the force of myocardial contraction
primary purpose of the pacemaker
acts to regulate cardiac rhythm, increasing CO
plasma cholesterol screening instructions
only sips of water are permitted for 12 hours before plasma cholesterol screening to achieve accurate results, alcohol intake will interfere with test results, normal diet week before test
BEST fluid to offer toddler with lead poisoning?
milk provides a large amount of vitamin D; vitamin D optimizes deposition of lead in the long bones; purpose of the treatment is to remove lead from the blood and soft tissues
process of a normal adjustment to a terminal illness
1- denial 2- anger 3- bargaining 4- depression 5- acceptance
intravenous pyelogram (IVP)
x-rays of entire urinary tract taken, evaluates kidney function
Natural passive immunity
occurs when antibodies are passed from mother to fetus via placenta, colostrum, and breast milk
Artificial active immunity
small amounts of specific antigens are used for vaccination; body responds by actively making antibodies
Artificial passive immunity
involves injection with antibodies that were produced in another person or animal; used to protect person exposed to serious disease
Natural active immunity
antigen enters the body without human assistance; body responds by actively making antibodies
support group called SIDS
support group for parents who have had an infant die from sudden infant death syndrome
support group called SHARE
support group for parents who have lost a newborn or have experienced a miscarriage
support group called RESOLVE
support group for infertile clients
support group called CANDLELIGHTERS
support group for families who have lost a child to cancer
BEST way for a nurse to assess the fluid balance of an elderly client?
Maintain an accurate intake and output. BP is not reliable b/c may be elevated d/t age-related hypertension
nephrotic syndrome diet
Adequate protein, low sodium intake.
colostomy irrigations
colostomy irrigation should be done at once a day at the same time each day to assist in establishing a normal pattern of elimination; use body temp solution, do not insert catheter more than 4in
Apraxia
loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly
Ataxia
Uncoordinated movement is due to a muscle control problem that causes an inability to coordinate movements. It leads to a jerky, unsteady, to-and-fro motion of the middle of the body (trunk) and an unsteady gait (walking style). It can also affect the limbs.
How would pt’s leg present if there is a hip fracture?
The leg appears to be shortened and is adducted and externally rotated.
