Saunders Review CD Flashcards
For what group are herbal therapies contraindicated?
Children; especially without professional supervision.
Procedure for assisting with preparation of kosher meal for a client.
Allow the client to unwrap the plastic utensils and prepare their own meal for eating. Do not transfer food from one dish to another.
Herbal therapy available for treatment of insomnia.
Valerian root.
Can also treat hyperactivity, stress, and nervous disorders like anxiety and restlessness.
Which informational category is of least importance during data collection for a patient scheduled for hernia repair?
Psychosocial.
Neurological, respiratory, and cardiovascular are important.
Common African American dietary requirement.
Fried foods.
In Hispanic culture what’s important to remember when gathering information about a child during examination?
Touch the child.
An evil eye can be placed by admiring the child without touching them.
After completing an incident report, notifying the nursing supervision and physician of the incident, the nurse should:
Docent a complete entry in the client’s record concerning the incident.
Incident reports should never be copied or placed into clients’ charts.
Two main instances for which informed consent is not needed:
- When an emergency is present and delaying treatment for the purpose of obtaining consent could risk injury or death.
- Client waives the right to give informed consent.
What does documentation on incident reports allow the nurses and administration to do?
Review the quality of care and to determine any potential risks present. Determining the effectiveness of interventions in relation to outcomes.
Normal PT time for an adult:
Male: 9.6 to 11.8 seconds
Female: 9.5 to 11.3 seconds
Normal therapeutic range for serum Digoxin (Lanoxin):
0.5 to 2.0 ng/mL
Normal serum sodium:
135 - 145 mEq/L
Normal serum potassium:
3.5 - 5.1 mEq/L
Normal serum chloride:
98 - 107 mEq/L
Normal serum bicarbonate (venous):
22 - 29 mEq/L
Sodium polystyrene sulfonate (Kayexalate)
Used in adult clients to bring critically high potassium levels down to normal range.
Normal fasting blood glucose level:
70 - 110 mg/dL
Critical fasting blood glucose level:
> 300 mg/dL
Normal platelet count range:
150,000 - 400,000 cells/uL
Normal adult magnesium level:
1.6 - 2.6 mg/dL
Normal serum creatinine:
0.6 - 1.3 mg/dL
Effect of renal insufficiency on serum creatinine level:
Renal insufficiency results in an increased serum creatinine level.
Therapeutic range for serum phenytoin (Dilantin):
10 - 20 mcg/mL
Normal range for protein level in adult:
6 - 8 g/dL
Normal serum lipase levels:
10 - 140 units/L
Troponins
Regulatory proteins found in striated muscle. They function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium.
Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium.
Normal hemoglobin level for an adult female:
12 - 15 g/dL
Iron deficiency anemia effect on hemoglobin levels:
hemoglobin levels are decreased due to the lack of available iron to produce usable hemoglobin.
Heart failure effect on hemoglobin levels:
Hemoglobin levels are elevated as a result of the body’s need for greater oxygen carrying capacity.
COPD effect on hemoglobin levels:
Hemoglobin levels are elevated as a result of the body’s need for greater oxygen carrying capacity.
Normal hematocrit level for an adult male:
42% - 52%
Effect of dehydration on hematocrit levels:
Dehydration causes an increase in hematocrit level resulting from an increased concentration of hematocrit and decreased volume for solution.
What does glycosylated hemoglobin (HbA1C) values indicate?
HbA1C measures the percent of glucose permanently bound to red blood cells.
Elevations in blood glucose levels will result in elevations in glycosylation.
Normal HbA1C levels for a diabetic in good control:
<7.5%
Normal WBC range:
4,500 - 11,000 cells/mm3
Foods high in Vitamin K:
Green, leafy vegetables.
Foods high in Vitamin E:
Vegetable oils.
Foods high in Folic Acid:
Legumes.
Foods high in Vitamin C:
Citrus fruits.
Diet therapy for diverticulitis:
Diet therapy is used for clients with diverticulitis to allow the bowels to rest.
Fiber is restricted. Fluids are encouraged. Seeds and nuts are to be avoided.
What should be avoided by a patient with gout?
Purine - especially found in scallops.
Food sources of riboflavin:
Milk
Lean meats
Fish
Grain
Nutrients and their sources that encourage and promote wound healing:
Protein and Vitamin C.
Meats with strawberries and broccoli.
Signs and symptoms of fluid overload:
Increased intravascular volume increases blood pressure. Pulse rate increases as the heart tries to pump the extra fluid volume.
Signs and symptoms of air embolus:
Confusion, pallor, light headedness, tachycardia, tachypnea, hypotension, anxiety and unresponsiveness.
Signs and symptoms of hyperglycemia:
Polyuris, polydipsia, and polyphagia.
Nutrient encouraged that helps prevent neural tube birth defects:
Folic acid (Folate).
Dietary sources of Folic acid:
Green, leafy vegetables
Liver, beef, and fish
Legumes
Grapefruit and oranges
Foods high in calcium not from dairy sources:
Tofu
Broccoli
Sardines
Mustard greens
Procedure for checking vital signs during blood transfusion:
Before the procedure to obtain a baseline.
Every 15 minutes for the first half hour after infusion begins.
Every half hour thereafter.
Respiratory reaction to fluid overload:
Crackles
Dyspnea
Signs and symptoms of transfusion reaction:
Flushed
Dyspnea
Generalized itching
Positive indication after receiving infusion of platelets:
Decrease in oozing from puncture sites and gums.
Steps for spiking an IV bag:
Clamp the IV tubing to prevent free flowing fluid, by using the roller.
Uncap the proximal (spike) portion of the tubing.
Attach spike to IV bag.
Roller clamp is opened slowly to allow fluid flow in a controlled manner.
What is an infiltrated IV site?
An IV that has dislodged from the vein and is lying in the subcutaneous tissue.
Signs and symptoms of an infiltrated IV site:
Pallor
Coolness
Swelling
*With increased swelling, the IV infusion will stop from the pressure.
How often should you monitor an IV infusion site?
At least once every hour.
Signs and symptoms of phlebitis:
Discomfort
Redness
Warmth
Swelling proximal to the IV catheter
Clients most likely to develop fluid volume excess problems:
Very young
Very old
Cardiac, respiratory, renal, or liver disease
Consent required prior to MRI?
Yes, consent is required.
But I don’t know why.
Emergency fire procedure:
Remove the client from the fire.
Activate the fire alarm.
Confine the fire by closing the door.
Extinguish the fire.
Frequency of assessing restraints and skin integrity:
Every 30 minutes.
Precautions when caring for a client with an internal radiation device:
Wearing gloves when emptying client’s bedpan
Keeping all linens in the room until the implant is removed
Wearing a lead apron when providing direct care for the client
Place the client in a private room with a private bathroom
Routes of transmission by Anthrax:
Skin contact
Inhalation
Gastrointestinal
*Cannot be transmitted from direct contact with an infected individual
Procedure for relieving an airway obstruction on an unconscious woman in an advanced stage of pregnancy:
Place the woman on her back.
Place a pillow or wedge under her right abdominal flank and hip to displace the uterus to the left side of her abdomen.
Procedure to open airway on a suspected neck injury victim:
Jaw-thrust maneuver.
CPR ratio for an Adult:
30 compressions : 2 Breaths
For a child between 1 and 8 years old, how many breaths per minute are given during CPR?
12 - 20 breaths per minute are delivered.
Chest compression rate for an infant during CPR:
100 compressions per minute.
Most appropriate place to assess the pulse of an infant <1 year old:
Brachial artery.
Infants have fatty necks, which makes palpating the carotid pulse difficult.
During CPR of an adult, the sternum should be depressed a depth of at least:
1.5 - 2 inches
Steps for performing adult CPR:
Determine unconsciousness.
Open the airway.
Determine breathlessness.
Initiate breathing.
Check for a pulse.
Perform chest compressions.
Done by the patient immediately before surgery:
Voiding to empty the bladder.
Aspirin should be discontinued how long before surgery?
48 hours
Common vital signs after surgery:
Slightly lower than normal BP.
Slightly elevated pulse.
Initial nursing check after client arrives post-op:
Check airway.
Check vital signs.
Check dressings, tubes, and drainage.
Normal urine output minimum:
30 mL/hour
Signs and symptoms of wound infection:
Warm
Red
Tender skin
Fever and chills
Purulent drainage
Nursing action for wound dehiscence:
Apply a sterile dressing soaked with sterile normal saline.
Contact physician.
The concept of “time out” in the perioperative area:
Allows the surgical team a chance to verify and agree on the client’s name, the procedure, and site before surgery begins.
Procedure for wound dehiscence and evisceration:
RN is notified who contacts the surgeon.
Client is placed in a low-Fowlers position, kept quiet, and instructed not to cough.
Protruding organs are covered with a saline soaked sterile dressing.
Patient positioning after cardiac catheterization:
The head of the bed is elevated to no more than 30 degrees.
The cardiac catheter line is inserted from the groin. This keeps the groin-leg area relatively straight and prevents arterial occlusion.
Bathroom privileges are not permitted in the immediate post-operative period of the cardiac catheterization.
Post-operative instructions for cataract removal surgery:
Should not sleep on affected side.
Do not take Aspirin or any medications that may contain aspirin.
Tylenol can be taken for mail pain.
Clients may wear their glasses.
Client position for administration of an enema:
Left Sims so the fluid can flow naturally into the colon.
Client position for thoracentesis:
Lying in bed on the unaffected side with the head of the bed elevated 45 degrees.
Patient positioning for NG-tube insertion:
High-Fowlers.
To reduce the risk of pulmonary aspiration should the client vomit during the procedure.
Patient positioning following craniotomy procedure:
Semi-Fowlers to Fowlers (30-45 degrees) with the head maintained at midline neutral position to facilitate venous drainage.
When is “log rolling” used:
To maintain a neutral neck and spinal alignment, especially after back or neck surgery, when repositioning patient.
Patient positioning after craniotomy with removal of cranial mass:
On the unaffected side to prevent shifting of the cranial contents.
Head of the bed elevated 30 degrees to promote venous drainage.
Head and spine maintained in neutral, midline orientation.
Patient instructions for the removal of an NG tube:
Take a deep breath and hold.
This causes the epiglottis to close and temporarily occludes the airway, thereby protecting it should any gastric fluid be released.
When inserting an in-dwelling catheter, how do you determine placement?
Insert the catheter until urine flow is observed, then advance 2.5 to 5cm further.
Advancement ensures that the balloon (when inflated) will be in the bladder and not in the urethra (which could cause trauma), since the balloon-anchor is located behind the drainage holes.
Patient instruction when removing chest tube:
Valsalva’s maneuver, bear down, or hold breath.
Residual volume to hold NG-tube feeding:
> 100mL, hold feeding and notify physician. Delayed emptying of gastric contents puts the patient at risk for aspiration.
<100mL, replace contents back to stomach (to prevent electrolyte imbalance) and continue to administer feeding.
Subcutaneous emphysema:
Also known as crepitus. Presents as a puffed-up appearance that is caused by the leakage of air into the subcutaneous tissue. This is a complication of patients with chest tube drainage.
Monitoring for subcutaneous emphysema:
Palpating for the leakage of air into the subcutaneous tissues. This is felt like bubble wrap.
Fenestrated tracheostomy tube:
Tracheostomy tube with a small hole opening that allows the patients to speak.
Female structures that produce hormone Estrogen:
Ovarian follicles
Corpus luteum
Adrenal cortex
Placenta (during pregnancy)
Female structures that produce hormone Progesterone:
Corpus luteum
Adrenal glands
Placenta (during pregnancy)
Structure that releases FSH and LH, and their function:
Anterior pituitary gland.
Stimulates follicular growth and development, the growth of the follicle, and the production of progesterone.
Gynecoid pelvis:
Normal female pelvis and the most favorable for labor and delivery.
Fetal circulation consists of:
Two umbilical arteries and one vein.
Ductus venosus:
Connects the umbilical vein to the inferior vena cava.
Foramen ovale:
Temporary opening in the fetal heart between the Left and Right Atria.
Ductus arteriosus:
Joins the aorta and the pulmonary artery.
Fetal heart rate range:
110 - 160 BPM
Depending on gestational age.
Role of Estrogen:
Stimulates uterine development to provide an environment for the fetus, and it stimulates the breasts to prepare for lactation.
Role of Progesterone:
Maintains the uterine lining for implantation and relaxes all smooth muscle.
Functions of the amniotic fluid:
Allows for fetal movement.
Acts as a measurement of fetal kidney function.
Surrounds, cushions, and protects the fetus.
Maintains body temperature of the fetus.
Nagele’s Rule:
Subtract 3 months.
Add 7 days.
Gestation term when fetal movement can be felt:
16 - 20 weeks gestation.
GTPAL:
G = Gravida - Number of pregnancies.
T = Term Births - Born after 37 weeks.
P = Pre-term Birth - Born 20 - 37 weeks.
L = Live Births - Number of living children.
Goodell’s Sign:
Softening of the cervix.
During the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction.
Grava & Para:
Gravida = Number of pregnancies
Para = Number of live births >20 weeks.
Primipara:
First pregnancy.
Calculating fundal height:
The fundal height (in cm) is equivalent to the gestational age in weeks +/- 2cm.
Braxton Hicks contractions:
Irregular, painless contractions that occur intermittently throughout pregnancy.
Hegar’s sign:
Thinning of the lower uterine segment that occurs at about 6 weeks gestation.
Probable signs of pregnancy:
Uterine enlargement
Hegar’s sign
Goodell’s sign
Chadwick’s sign
Ballottement
Braxton Hicks contractions
Positive pregnancy test (that measures human chorionic gonadotropin)
Positive signs of pregnancy:
Detection of fetal heart rate
Palpation of active fetal movement
Positive ID using radiography or ultrasound
Chadwick’s sign
The violet coloration of the mucus membranes of the cervix, vagina, and vulva that occur at about 4 weeks gestation.
Ballottement:
Rebounding of the fetus against the examiners fingers during palpation.
What does the contraction stress test measure?
Assess placental oxygenation and function and determines the fetus’s ability to tolerate labor.
How is the contraction stress test performed?
The uterus is stimulated to contract by either small amounts of Oxytocin (Pitocin) or nipple stimulation.
What does Allen’s test assess?
Ulnar circulation.
Allen’s tests are performed before obtaining arterial specimens for ABG chemistries.
Normal PCO2
35 - 45 mm*Hg
Clinical manifestations of respiratory alkalosis
Tachypnea
Altered mental status
Dizziness
Pallor around the mouth
Muscle spasms
Hypokalemia
Troponin T level of 0.6
Indicates angina pectoris.
Presbycusis:
Age-related, irreversible, degenerative changes of the inner ear that leads to decreased hearing acuity.
As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched tones are more easily heard and interpreted.
Describe lesions of herpes zoster:
Clustered skin vesicles with erythmatous base base along a dermatone.
Characteristics of melanoma:
Irregularly shaped pigmented papule or plaque with a red, white, or blue color.
Findings related to frostbite:
White or blue skin color, and skin is hard, cold, and insensitive to touch.
Identification of scabies:
Multiple straight or wavy threadlike lines noted beneath the skin.
The skin lesions are caused by the female, which burrows beneath the skin to lay its eggs.
Purpose of escharotomy procedure:
Alleviate compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential burn.
An anticipated therapeutic outcome is the return of distal pulses.
The most reliable indicator for determining the adequacy of fluid resuscitation:
Urine output measurement >30 mL/hr
Patient positioning for autograft on joint:
Extremity is often elevated and immobilized after surgery for 3 to 7 days.
Discharge instructions for patient following a biopsy:
Keep the dressing dry and clean for a minimum of 8 hours. After the dressing is removed, the site is cleaned once daily with tap water or saline to remove any dry blood or crusts. The physician may prescribe antibiotic ointment to minimize local bacterial colonization. The client is instructed to report any redness or excessive drainage. Sutures are usually removed 7 to 10 days after discharge from biopsy.
Cellulitis:
A skin infection into the deep dermis and subcutaneous fat tissue by Staphylococcus pyogenes.
Results in a deep red erythema without sharp borders, and it spreads widely through tissue spaces.
Prescribed treatment for acute cellulitis discomfort:
Warm compress followed by antibiotics.
Diagnosis of Herpes zoster is determined by:
Culture of the lesion.
Priority nursing intervention for multiple myeloma:
Encouraging fluids.
Hypercalcemia secondary to bone destruction is a priority concern in the client with multiple myeloma. The nurse should encourage adequate intake of fluids. The fluid is needed to not only dilute the calcium but prevent protein from precipitating in the renal tubules.
Restrictions for a client with internal radiation therapy:
Nurse spends maximum 30 minutes per 8 hour shift.
Dosimeter badge must be worn in the client’s room.
Children under 16 and pregnant women are not allowed in the client’s room.
Hodgkin’s disease:
Chronic progressive neoplastic disorder of the lymphoid tissue that is characterized by the painless enlargement of the lymph nodes with progression to extralymphatic sites (such as the spleen and liver).
Late decelerations:
fall in fetal heart rate after the peak of the contraction; indicates fetal hypoxia; position client on her left side, administer oxygen by mask, start IV or increase flow rate, stop oxytocin if appropriate
Early signs and symptoms of Addison’s disease:
Muscle weakness, hypotension, tachycardia, and moderate to severe dehydration.
Most important factor to maintain adequate circulation:
Blood volume.
To maintain adequate circulation, an adequate transport medium to carry nutrients and gases throughout the body is needed.
Normal glucose levels:
70 - 110
Contraindicated for viral hepatits:
Tylenol is contraindicated because it is hepatotoxic; instruct client to avoid all medications unless prescribed by the physician.
Action of oral hypoglycemics:
Hypoglycemics act by stimulating beta cells in the pancreas to release endogenous insulin; some oral hypoglycemics also facilitate insulin’s action on peripheral receptor sites; other oral hypoglycemics delay the absorption of glucose in the intestinal tract.
Diagnosis of schizophrenia:
Split between the thinking and the emotional aspects of the personality.
schizophrenic clients would have difficulty carrying out some the complex activities often performed by clients with impulse control disorders
difficulty in forming relationships with a marked inability to trust others is the main problem with schizophrenia
may exhibit acting-out behaviors such as anger and hostility toward those in the current environment, but is not the primary problem
Contraindicated medication with closed-angle glaucoma:
atropine is a mydriatic that results in pupillary dilation forcing the pupil against the cornea, resulting in a decreased angle; use of this type of medication in a client with narrow-angle glaucoma may result in blindness
Risk with elevated potassium levels:
normal potassium is 3.5 to 5.0 mEq/L; hyperkalemia causes fibrillation or ventricular dysrhythmias that can result in an immediate significant reduction in cardiac output and coronary circulation; is life-threatening and must be treated immediately
Stages of Labor:
Stage 1: 0-10cm dilation
Stage 2: birth of the baby
Stage 3: delivery of placenta
Stage 4: recovery (first 4 hours after delivery of the placenta)
Signs and symptoms of peritonitis:
peritonitis can be caused by ruptured appendix; signs and symptoms of peritonitis include severe abdominal pain, abdominal rigidity, decreased bowel sounds, nausea and vomiting, increased temperature, shock, paralytic ileus; monitor vital signs, administer antibiotics and IVs, NG tube to suction, NPO, surgery to correct cause
Following an esophagogastroduodenoscopy (EGD) to sclerose exposed blood vessels, it is MOST important action for the LPN/LVN to take?
Report vital sign changes and abdominal pain, which can indicate hemorrhage.
Medical purpose for a sitz bath:
Increase circulation to the area to promote wound healing.
Babinski reflex:
Babinski reflex disappears at 12 months; stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toe to dorsiflex and the toes to hyperextend.
Moro reflex:
Disappears by 4 months; sudden loud noise causes abduction of the arms with flexion of elbows.
Tonic neck reflex:
Disappears at 3 to 4 months; infant’s head is turned to one side, arm and leg extend on that side, and opposite arm and leg flex.
Palmar grasp reflex:
Palmar grasp lessens after 3 months; touching palms of hands near base of digits causes flexion of the hands.
Actonel (risedronate sodium):
Decreases bone resorption, resulting in the prevention of osteoporosis; instruct to take 30 minutes before eating or taking other medication, remain upright for 30 minutes after taking medication to prevent esophageal irritation.
Type 1 Diabetes:
Insulin dependent diabetes.
Type 2 Diabetes:
Insulin independent diabetes.
Clinical manifestations of idiopathic hypopituitarism:
Idiopathic hypopituitarism is diminished or deficient secretions of pituitary hormone; height is below normal due to lack of growth hormone; height may be retarded more than weight, sexual development is usually delayed.
The LPN/LVN cares for a newborn delivered by a mother addicted to narcotics. When is the LPN/LVN MOST likely to observe symptoms of narcotic withdrawal?
Within 24 to 72 hours after birth.
Early symptom of gastric cancer:
Abdominal discomfort relieved with antacids, indigestion, loss of appetite, bloating feeling, and weight loss.
Early symptom of gastric cancer:
Abdominal discomfort relieved with antacids, indigestion, loss of appetite, bloating feeling, and weight loss.
Nursing interventions for patient with rheumatoid arthritis:
Assist with heat-application and range-of-motion exercises.
Goal is to reduce swelling, increase circulation, and diminish stiffness while preserving joint mobility.
Nursing interventions for patient with rheumatoid arthritis:
Assist with heat-application and range-of-motion exercises.
Goal is to reduce swelling, increase circulation, and diminish stiffness while preserving joint mobility.
Characteristics of Spastic Cerebral Palsy (CP):
spastic CP is the most common CP; characteristic signs include increased stretch reflex, increased muscle tone, and weakness; upper extremities will have increased tone in shoulder adductor and internal rotator muscles, increased tone in elbow flexor and pronator muscles, and increased tone in wrist and finger flexor muscles; poor control of posture, balance, and coordinated motion; is at risk for aspiration and poor gas exchange due to decreased respiratory muscle function; child may be predisposed to frequent infections because of malnutrition, risk of respiratory aspiration, or weakened respiratory muscles.
Developmental task for “middle-aged” patient:
middle adulthood is the time of guiding the next generation; this occurs not only in family life but also in one’s professional career; if this developmental task is not achieved, client becomes self-absorbed.
assisting heir children to grow into adulthood.
Actions to relieve gas and odor from colostomy pouch:
Place breath mint inside the colostomy pouch.
Cranberry juice, parsley, yogurt, and buttermilk.
Crackers, toast, and yogurt.
Commercially prepared deodorizer for the pouch.
Actions to relieve gas and odor from colostomy pouch:
Place breath mint inside the colostomy pouch.
Cranberry juice, parsley, yogurt, and buttermilk.
Crackers, toast, and yogurt.
Commercially prepared deodorizer for the pouch.
Interaction between sulfasalazine (Azulfidine) and oral hypoglycemics:
Sulfasalazine (Azulfidine) enhances action of oral hypoglycemics, may increase risk of toxicity.
Characteristics of obsessive-compulsive disorder:
clients with obsessive-compulsive disorder have an extreme need to control and predict outcomes; making decisions and adjusting to changes are anxiety-producing for these clients.
difficulty making decisions and adjusting to change.
Developmental task for “middle-aged” patient:
middle adulthood is the time of guiding the next generation; this occurs not only in family life but also in one’s professional career; if this developmental task is not achieved, client becomes self-absorbed.
assisting heir children to grow into adulthood.
Developmental task for “middle-aged” patient:
middle adulthood is the time of guiding the next generation; this occurs not only in family life but also in one’s professional career; if this developmental task is not achieved, client becomes self-absorbed.
assisting heir children to grow into adulthood.
Early symptom of gastric cancer:
Abdominal discomfort relieved with antacids, indigestion, loss of appetite, bloating feeling, and weight loss.
Nursing interventions for patient with rheumatoid arthritis:
Assist with heat-application and range-of-motion exercises.
Goal is to reduce swelling, increase circulation, and diminish stiffness while preserving joint mobility.
Characteristics of Spastic Cerebral Palsy (CP):
spastic CP is the most common CP; characteristic signs include increased stretch reflex, increased muscle tone, and weakness; upper extremities will have increased tone in shoulder adductor and internal rotator muscles, increased tone in elbow flexor and pronator muscles, and increased tone in wrist and finger flexor muscles; poor control of posture, balance, and coordinated motion; is at risk for aspiration and poor gas exchange due to decreased respiratory muscle function; child may be predisposed to frequent infections because of malnutrition, risk of respiratory aspiration, or weakened respiratory muscles.
Actions to relieve gas and odor from colostomy pouch:
Place breath mint inside the colostomy pouch.
Cranberry juice, parsley, yogurt, and buttermilk.
Crackers, toast, and yogurt.
Commercially prepared deodorizer for the pouch.
Characteristics of obsessive-compulsive disorder:
clients with obsessive-compulsive disorder have an extreme need to control and predict outcomes; making decisions and adjusting to changes are anxiety-producing for these clients.
difficulty making decisions and adjusting to change.
Developmental task for “middle-aged” patient:
middle adulthood is the time of guiding the next generation; this occurs not only in family life but also in one’s professional career; if this developmental task is not achieved, client becomes self-absorbed.
assisting heir children to grow into adulthood.
Normal WBC count range:
4,500 - 11,000
Signs and symptoms of hypovolemic shock:
Hypovolemic shock is caused by an inadequate volume of blood caused by hemorrhage, severe dehydration, or burns; skin will be cold and clammy because the body redirects blood from the skin, kidneys, and GI tract to the brain and heart; urine output decreases; blood pressure will be decreased and pulse will be elevated.
Interaction between sulfasalazine (Azulfidine) and oral hypoglycemics:
Sulfasalazine (Azulfidine) enhances action of oral hypoglycemics, may increase risk of toxicity.
Diet for a client with Cushing’s Syndrome:
Low calories
Low Carbohydrates
Low Sodium
High Potassium
High Protein
Cause of Lipodystrophy:
Occurs in some diabetic clients when the same injection site is used for prolonged periods of time.
Signs and symptoms indicating lithium toxicity:
Vomiting, diarrhea, slurred speech, and decreased coordination.
When does the posterior fontanel close:
8 - 12 weeks
Behavior commonly associated with anxiety:
Somatizing, anger, and withdrawal.
All serve to reduce emotion.
Clinical manifestations of ovarian cancer:
Abdominal distention
Urinary urgency and frequency
Pain from pressure caused by the growing tumor
Pain from urinary or bowel obstruction
Constipation
Normal findings following a modified radical mastectomy:
Mild pain at the incisional site
Sanguineous drainage in the drainage tube
Complaints of decreased sensation at the operative site
Dietary instructions to prevent dumping syndrome:
Decrease the amount of fluids taken at meals
Avoid high-carbohydrate foods
Assume low-Fowlers position during meals
Lay down for 30 minutes after eating to delay gastric emptying.
Discharge instructions following prostatectomy:
Small pieces of tissue or clots may be found in the urine for up to two weeks following surgery
Driving a car or sitting for long periods of time are restricted for at least 3 weeks
Daily fluid intake of 2-2.5 L/day are encouraged to limit clot formation and prevent infection
Avoid lifting objects heavier than 20 pounds for at least 6 weeks.
Most common symptom among cancer of the bladder:
Hematuria
Expected findings assessing the stoma following a ureterostomy:
A red and moist stoma
Client position which aggravates pain associated with pancreatitis:
Lying flat.
Sitting up, leaning forward, and flexing the left leg all help alleviate some of the discomfort.
When to perform BSE:
7 days after menstruation.
Multiple myeloma:
Neoplastic condition that is characterized by the abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow.
Assessment findings that are consistent with multiple myeloma:
Increased number of plasma cells in the bone marrow, anemia, hypercalcemia as a result of the release of calcium from the deteriorating bone tissue, and an elevated BUN level.
Syndrome of Inappropriate Antidiuretic Hormone (SIADH):
Excessive amounts of water are reabsorbed by the kidneys and put back into systemic circulation. The increased water causes hyponatremia and some degree of fluid retention.
Common signs of hyperglycemia:
Fruity breath odor
Polyuria
Blurred vision
Diet for a client with Cushing’s Syndrome:
Low calories
Low Carbohydrates
Low Sodium
High Potassium
High Protein
Cause of Lipodystrophy:
Occurs in some diabetic clients when the same injection site is used for prolonged periods of time.
Complications of Pheochromocytoma:
Hypertensive retinopathy
Nephropathy
Myocarditis
Congestive heart failure
Increased platelet aggregation
Stroke
Assessment indicative of CHF:
Congestion heard upon auscultation of the lungs.
Clinical manifestations of Thyroid Storm:
High fever (106 F)
Severe tachycardia
Profuse diarrhea
Extreme vasodilation
Hypertension
A-Fib
Hyperreflexia
Abdominal pain
Dehydration
*Can rapidly progress to coma and cardiovascular collapse.
Classic symptoms of diabetes insipidus:
Polydipsia
Polyuria
Urine is pale in color and the specific gravity is low. Anorexia and weight loss occur.
Common manifestations of Addison’s disease:
Postural hypotension from fluid loss
Syncope
Muscle weakness
Anorexia
Nausea
Vomiting
Abdominal cramps
Weight loss
Depression
Irritability
Dietary instructions to prevent dumping syndrome:
Decrease the amount of fluids taken at meals
Avoid high-carbohydrate foods
Assume low-Fowlers position during meals
Lay down for 30 minutes after eating to delay gastric emptying.
Early manifestations of dumping syndrome:
Occur 5 to 30 minutes after eating.
Vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lay down.
Bowel movement characteristics of Crohn’s disease:
Non-bloody diarrhea, over time the episodes increase in frequency, duration, and severity.
Patient positioning for paracentesis procedure:
Upright
*Floats the intestines backward so as to deter from puncture during catheterization.
Client position which aggravates pain associated with pancreatitis:
Lying flat.
Sitting up, leaning forward, and flexing the left leg all help alleviate some of the discomfort.
Common signs of acute viral hepatitis:
Weight loss
Dark urine (excess bilirubin ex created from the kidneys)
Fatigue
Anorexic
Finds food distasteful
Clinical manifestation of paralytic ileus:
Inability to pass flatus.
Interventions nurse would expect for diagnosis of acute pancreatitis:
NPO (to rest the pancreas and suppress GI secretions)
Pain medication such as meperidine, due to abdominal pain discomfort
Side-laying position with knees flexed to chest to ease tension on abdominal cavity
Antacids and anticholinergics prescribed to suppress GI secretions
Definitive diagnosis of TB:
Confirmed through sputum culture and isolation of Mycobacterium tuberculosis.
A presumptive diagnosis is made from a TB skin test, positive sputum smear for acid fast bacteria, chest X-ray, and histologic evidence.
Purpose of pursed lip breathing:
Promote carbon dioxide elimination.
Especially used with clients with obstructive lung disease, by increasing airway pressure, which keeps airway passages open during exhalation.
Signs of allergic reaction to the contrast medium used for pulmonary angiography:
Localized itching and edema
Respiratory distress
Stridor
Decreased blood pressure
Early sign of exacerbation of pulmonary sarcoidosis:
Shortness of breath
Also chest pain, hemoptysis, and pneumothorax.
Later systemic signs include weakness and fatigue, malaise, fever, and weight loss.
Hemoptysis:
Expectoration of blood or of blood stained sputum from the bronchi, larynx, trachea, or lungs.
Positive Mantoux reading:
Induration measuring 10mm or more.
How long is a TB client contagious for while on medication therapy?
2 to 3 consecutive weeks.
However the client must take the full course of therapy for 6 months or longer to prevent reinfection of drug resistant TB.
When can a TB patient return to work?
After three consecutive sputum cultures return negative.
Histoplasmosis:
An opportunistic fungal infection that can occur in the client with AIDS. Begins as a respiratory infection and and progress to disseminated infection.
Typical signs and symptoms include fever, dyspnea, cough, and wight loss. There may be enlargement of the clients lymph nodes, liver, and spleen as well.
Basic symptoms of a closed pneumothorax:
Shortness of breath
Chest pain
A larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema.
Hypocapnia
Level of CO2 in the blood is lower than normal.
Can result from deep or rapid breathing.
Clinical manifestations of COPD:
Hypoxemia
Hypercapnia
Dyspnea on exertion and at rest
Oxygen desaturation with exercise
Use of accessory muscles of respiration
Chest X-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.
Common side effects of Chlorpromazine (Thorazine):
Photosensitivity
Hypotension
Common side effects of Vancomycin:
Ototoxicity
Nephrotoxicity
Carotid Massage:
One maneuver used for Vagus nerve stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia.
Common life-threatening complication of DVT or Thrombophlebitis:
Pulmonary embolism:
Sudden chest pain is the most common symptom. Dyspnea, cough, diaphoresis, and apprehension.
Raynaud’s Disease:
The feeling of numbness or cold in response to cool climate.
Characteristics of Pulmonary Edema:
Extreme breathlessness, dyspnea, air hunger, production of frothy pink-tinged sputum. Auscultation of the lungs reveals crackles.
Hallmark sign with Right-Sided Heart Failure:
Dependent edema
Hallmark sign with Left-Sided Heart Failure:
Crackles upon auscultation of lungs.
*Pressure buildup from Right side pushing harder against weaker Left side causes fluid to leach out.
Stable Anginal Pain:
Induced by exercise and relieved by Nitroglycerin.
Unstable Anginal Pain:
Occurs at lower and lower levels of physical activity or at rest, is less predictable, and usually a precursor to the big MI.
Variant Anginal Pain:
Prolonged and severe, and occurs at the same time each day, most often in the morning.
Characteristics of Disequilibrium Syndrome:
Headache, mental confusion, decreasing LOC, nausea, vomiting, twitching, and possible seizure activity.
Signs and symptoms of Epididymitis:
Scrotal pain and edema.
Sometimes fever, nausea, and vomiting
Post-op client positioning following cataract extract:
On their backs in Semi-Fowlers
or
On their UNOPERATIVE side
Miotic medications:
Lower the intraocular pressure, increasing blood flow to the retina and decreasing retinal damage and loss of vision.
Mydriatic medications:
Dilate the pupils and relax the ciliary muscles.
Vital Signs changes for increased ICP:
Increasing temperature
Decreasing pulse
Decreasing respirations
Increasing BP
Myasthenic Crisis vs. Cholinergic Crisis:
Myasthenic crisis caused by too LITTLE medication.
Cholinergic crisis caused by too MUCH medication.
Kaposi’s Sarcoma:
Vascular malignancy that appears as a skin disorder. Common symptom as an AIDS indicator.
Pemphigus:
An autoimmune disease causing blistering of the epidermis. The patient has large flaccid blisters (bullae). Because they are on the epidermis, they have only a thin covering of skin and rupture easily, leaving large denuded areas of the skin.
Presents with Nikolsky’s signs.
Systemis Lupus Erythematosus (SLE):
An inflammatory disease of collagen contained in connective tissue. Typically presents as a butterfly rash on the face.
Typical medications are anti-inflammatory, corticosteroids, and immunosuppressant drugs.
Latex allergy food cautions:
Kiwis, bananas, pineapples, tropical fruits, grapes, avocados, potatoes, hazelnuts, and water chestnuts.
Common side effect of AIDS anti-retro-viral therapy:
Leukopenia
Anemia
Adverse effects of aminoglycosides:
Ototoxicity
Confusion
Disorientation
GI irritation
Palpatations
Blood pressure changes
Nephrotoxicity
Hypersensitivity
Oral Hypoglycemic Agents:
Administered to decrease the serum glucose level and REDUCE the signs and symptoms of HYPER-glycemia.
Normal serum ammonia levels:
35 - 65
Common side effects of INH:
Peripheral neuritis:
Numbness, tingling, paresthesias in the extremities.
Common infectious agent responsible for Rheumatic endocarditis:
Streptococcal infection
Normal WBC count:
4,500 - 11,000
Diet prescribed for Addison’s disease:
High sodium
High complex carbohydrates
High protein
Adult CPR Ratio:
30:2
Clinical manifestations of the stages of Lyme disease:
Stage 1: Rash
Stage 2: Cardiac problems and neurological deficits
Stage3: Arthralgia and joint enlargement
Paronychia:
Infection around the nail. Characterized by red, shiny skin, often associated with painful swelling.
Confrontational eye examination:
Examine visual fields or peripheral vision.
The Cerebellum is responsible for what?
Balance
Coordination
Thermoregulatory Center:
Hypothalamus
Late signs and symptoms of Ovarian Cancer:
Pelvic pain
Anemia
Ascites
Late signs and symptoms of Ovarian Cancer:
Pelvic pain
Anemia
Ascites
Classic signs of HYPER-glycemia:
POLY-dipsia
POLY-phagia
POLY-uria
Alkaline-ash Diet:
All fruits are allowed EXCEPT:
Cranberries
Prunes
Plums
Normal components in CSF:
WBC
Glucose
Protein
Crush injury with positive myoglobin urine test:
Risk of acute tubular necrosis; myoglobin get’s clogged in the renal tubules and causes necrosis of the kidney.
Laboratory indication of disseminated intravascular coagulopathy (DIC):
Severe drop in fibrinogen levels necessary for clotting.
Hyphema:
Bleeding into the anterior chamber of the eye that occurs postoperatively as a complication of cataract surgery:
Treatment includes bed rest and bilateral eye patching for 2 - 5 days. Myotics and cycloplegics may be prescribed. Position client in semi-Fowler’s position.
Clinical manifestations of ovarian cancer:
Abdominal distention
Urinary frequency and urgency
Pleural effusion
Malnutrition
Pain from pleasure
Constipation
Ascites with dyspnea are late signs
Clinical manifestations of ovarian cancer:
Abdominal distention
Urinary frequency and urgency
Pleural effusion
Malnutrition
Pain from pleasure
Constipation
Ascites with dyspnea are late signs
Most common initial symptom of Pulmonary Embolism (PE):
Sudden chest pain.
Most common initial symptom of Pulmonary Embolism (PE):
Sudden chest pain.
Histoplasmosis:
Opportunistic fungal infection that generally occurs in clients who have AIDS.
Typical signs and symptoms include fever, dyspnea, cough, and weight loss.
Patient positioning following lumbar puncture:
Prone, with a pillow under the abdomen to retard the leakage of CSF by increasing intra-abdominal pressure.
Digital subtraction angiography:
Radiographic method of studying blood vessels.
Classic signs of cardiogenic shock:
Increased pulse
Weak and thready pulse
Decreased blood pressure
Decreased urine output
Confusion and agitation
Cool and clammy skin
Clinical manifestations of tonic clonic seizures:
Violent extension spasm of the entire body interrupted by muscular relaxation and accompanied by strenuous hyperventilation.
The face is contorted and the eyes roll. There is excessive salivation resulting in frothing from the mouth, profuse sweating, protruding of the tongue, and rapid pulse.
Common clinical manifestations of early Alzheimer’s disease:
Forgetfulness interferes with the daily routine.
Early symptoms of Huntington’s Disease:
Restlessness, forgetfulness, clumsiness, falls, balance and coordination problems, altered speech and handwriting.
Difficulty with swallowing occurs in the later stages.
Lumbar puncture signs of a bacterial infection:
Cloudy appearance, pressure greater than 200 mm H2O, protein greater than 15 mg/dL, increased WBC, and reduced glucose levels.
Anosognosia:
Condition where the patient is unaware of their own disability.
Typically, they neglect the area of body that is effected.
Clinical manifestations of adrenal insufficiency following adrenalectomy:
Weakness
Hypotension
Fever
Altered mental status
Key features of pulmonary emphysema:
Dyspnea
Late cough (after dyspnea)
Scant mucous production
Weight loss
Typical signs of hiatal hernia:
Typically asymptomatic
Difficulty swallowing
Acid reflux
Heartburn
The three classic signs of preeclampsia:
Proteinuria
Hypertension
Generalized edema
