Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Milestone 2 Remediation > Weaknesses > Flashcards

Weaknesses Flashcards

1
Q

What should the nurse do during the Triggering phase?

A

approach the client in a nonthreatening, calm manner in order to deescalate the
clients emotion and behavior.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What should the RN do if a patient has verbal threats, pacing, raised voice

A
  • Say in calm firm voice “lets go back to you room and take a time out.
  • stand in door way for easy access to leave
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What interventions for aggression response?

A
  • Assess verbal and nonverbal ques for escalating behavior.
  • nonauthoritative approach
  • “show of force” with a child who is out of control
  • Do not ask why questions
  • use “quiet room”
    What
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Aggression response

A
  • RN has to protect others from pts behavior
    set limits on unacceptable behavior
  • Limit setting: 1. Inform patient of rules, 2. explain consequences, 3. state
    expected behavior
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the aggression 5 phase response?

A

triggering (event), Escalation (movement toward a loss of control), Crisis (loss of
control), Recovery (regain control), Postcrisis (reconciliation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the Cycle of violence order?

A

Tension building, violence, honeymoon

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Domestic violence screening tool- priority/

A

Don’t probe, write evidence down verbatim, provide a safe environment
- violence is increased during pregnancy
- discharge with safety plan
-looks to another person when questions are asked
- Do not refer to legal council or pt will probably not go through with it and cycle
will repeat itself

safety- priority

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the highest priority for Maslow hierarchy of self care?

A

Physiologic, safety, love and belonging, self esteem , self- actualization

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

grief priority

A

based on shock

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

anorexia

A

powerlessness

encourage activities that don’t involve food

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What should you assess for a patient Bizarre social behavior

A

physical needs
suicide risk
ensure safety AT ALL TIMES
Patient may need a 1:1 sitter case.`]

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Bizarre social behavior-

A
  • Schizophrenia
  • Delusions
  • Hallucinations
  • How to respond: do not play with delusions
  • Speech patterns in schizo
  • Echolalia: repeating, imitating
  • Clang associations: words that sound similar
  • Preservation: Clinging to single ideas, topic and repeating same sentence over
    and over again.
  • Word salad: mixing up words that makes no sense.
  • Limit stimuli = 1:1 interaction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

arterial htn

A

pulmonary htn

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What Interventions are used for a patient taking allopurinol (zyloprim) for gout?

A
  • Increase fluid intake to prevent kidney stones
  • increase movement
  • avoid caffeine, alcohol, and dairy
  • may take several weeks to work
  • stop if rash develops.
    -reduce stress
  • NO HIGH PURINE FOODS (organ meats, shellfish, fructose)
  • avoid starting/ increasing med during active flare ups –> does NOT relieve active flare ups
  • bone marrow depression
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

important to acknowledge- hf

A

weight gain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the Five stages of grief in order

A

Denial, Anger, Bargaining, Depression, Acceptance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

contributes to risk of oa

A

history of high activity= long distance runner

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

sbo

A

maintain quiet environment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the first intervention for a patient with positive small bowel obstruction?
2nd line

A

NG tube to suction placement with X-ray to confirm correct placement

Barium enema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what should you assess for a small bowl obstruction?

A

ausculate bowel sounds
ive fluids to replace electrolytes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

sbo- immediately report

A

rebound tenderness in upper quadrants

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

improving rr- low

A

lower O2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

nutritional needs throughout recovery

A

Acute
phase: NPO, IV fluids
* Recovery phase: no fiber or foods that irritate the bowel
* Maintenance phase: high-fiber diet with bulk-forming laxatives

24
Q

What is the treatment for Diverticulitis?

A

NPO diet or clear liquid diet to decrease exacerbations to decrease inflammation –> highest priority
- low fiber may be progressed from there
- antibiotics

25
Q

digoxin toxity

A

take vs first

  • Loss of appetite
  • Lower stomach pain
  • diarrhea
  • Weakness
  • Blurred or yellow vision
  • headache
  • Rash
26
Q

antidote digoxin

A

potassium and Digifab

27
Q

ex of hypertonic fluids

A

Saline 3% or 5%
3% NaCl
5% Nacl
D10W
‘D20W
D50W
D5LR

28
Q

ng tube- Confirmation that obstruction is the cause of pt discomfort

A

us done by assessing
the amount of of fluid aspirated a residual of >400 mL indicated obstruction

can be placed during sx for aspirationg fluid

29
Q

meds not to give- bph

A

BPH - don’t give antihistamines - do not give decongestant, anticholinergics,
antidepressants

30
Q

copd interventions

A

low concentrated oxygen
<2-3L nasal canula
No petroleum-based lip products
DO NOT WANT Ph TO FALL.- resp acidosis
ORAL OR IV CORTICOSTEROIDS
avoid infection

31
Q

ibs- who has highest risk

tx

A

women

  • Fluids
  • antibiotic therapy
  • colloid
  • electrolyte replacement
32
Q

arterial insufficienty- who has highest risk

sx

A

men- legs

  • weak pedal pulses
    -shiny and cool skin
  • intermittent claudication
  • aching/cramping
    -induced fatigue
  • diminished pulse
  • diminished hair growth
33
Q

monitoring- lithotropsy

A

urine output

34
Q

What should be assessed for post anesthesia

A

vitals should be q15. if systolic is under 90 REPORT IMMEDIATELY.

35
Q

thrombocytopenia labs- bleeding

A

-under 50,000 /LOW PLATELET COUNT
normal PT/PTT
prolonged Bleeding time
Thrombocytopenia: Low platelet count
Bleeding and petechiae usually do not occur
with platelet counts greater than
50,000/mm3, although excessive bleeding can follow surgery or other trauma.
-When the platelet count drops to less than 20,000/mm3, petechiae can appear,
along with nasal and gingival bleeding, excessive menstrual bleeding, and
excessive bleeding after surgery or dental extractions.
-When the platelet count is
less than 5000/mm3, spontaneous, potentially fatal central nervous system or GI
hemorrhage can occur

36
Q

sickle cell crisis

prevention

first signs

A

Vaccinations to prevent infections
-hydration to prevent crisis.

  • Pain
  • Fatigue
  • swollen hands and feet
  • dehydration
  • Give oxygen, fluids, pain medications, infection prevention**
37
Q

duchenne muscular dystrophy

characterstics

electromyogram

A

human genetic disease caused by X-linked recessive allele; characterized by
progressive weakening and a loss of muscle tissue

life extectancy usually around 30

delayed motor/speech, cognitive impairment, muscle weakness, waddle, calf
enlargement, cardiomyopathy.
-walk on tipy toes
-trips easily

soreness after test is normal- temporary

38
Q

congenital heart defect

assess

interventions

risk

A

Daily weight
- watch for fluid gain
color change
diminished pulses- femoral

  • small frequent meals
  • oxygen
  • high calorie formula
    -KNEE TO CHEST IF CYaNOTIC

suscpectible to resp infections

39
Q

rsv

assess

interventions

A
  • Grunting
  • Use of accessory muscle breathing
  • Nose flaring
  • increased respirations
  • prolonged expirations
  • nasal suctioning
  • hydration
  • calm
  • o2 as needed
    -standard precautions/contact
40
Q

s/s pyloris stenosis vs intussuscpetion

A

Olive RUQ
- Opening between stomach and small intestine is thickened
- Projectile vomiting’s –> electrolyte imbalance
- dehydration
- colic- crying
- lethargic
- Limp in belly
- Failure to thrive
-

Sausage
– Part of intestine fold into the section next to it causing obstruction.
- severe crampy abdomen
- RUQ sausage shaped mass in upper abd
- jelly stool
- bloody mucus stool
- fever
- Weight loss

41
Q

The 6-week-old infant diagnosed with pyloric stenosis has recently developed
projectile vomiting. Which assessment finding indicates to the nurse that the infant
is becoming dehydrated

A

weak cry wo tears

42
Q

electrolyte imbalance- vomiting

A

met alk

43
Q

The nurse is caring for an infant scheduled for reduction of intussusceptions. The
day before the scheduled procedure the infant passes a soft-formed brown stool.
Which intervention should the nurse implement?

A

tell dr

44
Q

What are the signs of placenta abruption

A

uterine irritability
- Dark red blood
- knife like pain
-broad rigid abdomen
- hypovolemic shock

45
Q

what should the nurse do for a placental abrution

A

c-section, bedrest
start 2 large IV lines. one for fluid and medications and the other for blood
replacement.

-IMMEDIATELY NOTIFY HCP, & NO ABD OR VAG MANIPULATION OR
EXAMS
-ADMIN O2 BY FACEMASK
-MONITOR FOR BLEEDING AT IV SITE & GUMS B/C OF ↑ RISK FOR DIC

46
Q

What is not good when looking fetal heart tracings?

A
  • Recurrent decelerations
47
Q

While in labor at 39 weeks’ gestation, a primigravida develops a temperature of
38.2°C (100.7°F), and fetal tachycardia is noted at 170 beats per minute. The
student nurse asks the experienced nurse what this could indicate. How should the
experienced nurse respond?

A

ANSWER- A temperature of 38.2°C (100.7°F) may
indicate an infection such as chorioamnionitis, and the practitioner should be
notified

48
Q

What should the nurse do for a patient with prolapse cored

A

push up on fetal presenting part to remove pressure.
- look for cord in vagina
- use hand to remove pressure
- KNEE TO CHEST POSITION
- TRINDELINBURG POITION
- IF CORD IS CLAMPED BABY LOOSING O2
- DO NOT PUT ON LEFT SIDE( FOR BP)

How should the nurse handle a patient with a prolapsed cord?
1. Call for assistance- medical emergency
2. Sterile gloves, insert 2 fingers into vagina & elevate the fetal presenting part off
cord.
3. Apply warm sterile saline soaked towels over cord.
4. Oxygen
5. Prepare for birth

49
Q

Shoulder dystocia actions

How can you tell a patient is experiencing shoulder dystocia?

A

supra pubic pr and mcroberts maneuver

Delivery of the head and then retracts immediately.

50
Q

Variable deceleration actions

A
  1. Change maternal position TO SIDE
  2. Stimulate fetus if indicated.
  3. Discontinue oxytocin (Pitocin) if infusing.
  4. Administer oxygen (O2) at 10 L by tight facemask.
  5. Perform a vaginal examination to check for cord prolapse.
  6. Report findings to physician and document.
51
Q

What should the nurse do for a patient with a boggy uterus?

assessment?

A

empty bladder
uterine massage
MEDICAL EMERGENCY
give oxytocin

fundus is higher than expected when palpated
-excessive lochia

52
Q

Mother brings infant complaining of vomiting and diarrhea to ER that’s been
breastfeeding and introducing formula

A

ANSWER- Ask what kind of water are
you mixing with formula

53
Q

How is symmetric IUGR diagnosed

signs

A

By serial ultrasound, which is the
reason for 1st trimester ultrasound

amniotic fluid levels.
assess babies growth and cord prolapse
fetal size
fetal weight under 10th %
fetal distress

54
Q

what should a patient do if they have engorged breasts but wants to breast feed?
pump, and skin to skin contact

What should a patient do for engorged breasts but doesnt want to breast feed?t

A

pump, and skin to skin contact

cold compress and tight clothing
what

55
Q

A new mother reports breast engorgement and nipple pain on day 2 after the
delivery of a healthy newborn. The mother tells the nurse, “I’m not sure that
breastfeeding the baby is for me.” What should the nurse advise the mother to do to
help relieve discomfort and encourage persevering with breastfeeding? -

A

ANSWER- Inform the mother that breastfeeding the newborn more frequently will
help treat these symptoms

56
Q

A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce
breast engorgement. Which instruction should the nurse provide?

A

breastfreed q2hr

57
Q
A

Milestone 2 Remediation (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions