ATI Comprehensive/ NCLEX Review 195 Questions with Verified Answers,100% CORRECT

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ATI Comprehensive/ NCLEX Review 195 Questions with Verified Answers Endometiral infection usually occurs - CORRECT ANSWER with a prolonged rupture of membranes, not vacuum-assisted births. Inten... stinal gas is a common side effect of - CORRECT ANSWER clients following a cesarean birth Cervical lacerations are common complications from - CORRECT ANSWER vacuum-assisted birth are rare but can include perineal, vaginal, or cervical lacerations When a client is experiencing a wound evisceration... - CORRECT ANSWER the nurse should initially stay with the client and call for help. Next, the nurse should place saline-soaked gauze on the exposed bowels to keep the internal organs moist. The nurse should then place the client in a supine position with his hips and knees bent to relieve pressure from the open wound. Last, the nurse should take the client's vital signs to assess for changes in hemodynamics. Valproic acid can cause - CORRECT ANSWER hepatic toxicity continuous passive motion (CPM) machine - CORRECT ANSWER Turn of the CPM machine during meals to promote comfort and dietary intake. -The affected extremity should maintain neutral alignment. Heparin - CORRECT ANSWER is an anticoagulant that inhibits the conversation of prothrombin to thrombin. Patients on an anticoagulant drug such as heparin are at an increased risk of bleeding. -Signs of bleeding: ecchymoses, tarry stools, mucosal bleeding, and pink/ red-tinged urine. Correct method for walking upstairs with crutches - CORRECT ANSWER 1. Hold to rail with one hand and crutches with the other hand. 2. Push down on the stair rail and the crutches and step up with the "unaffected" leg. 3. If not allowed to place weight on the "affected" leg, hop up with the "unaffected" leg. 4. Bring the "affected" leg and the crutches up beside the "unaffected" leg. 5.Remember, the "unaffected" leg goes up first and the crutches move with the "affected" leg. Droplet precautions - CORRECT ANSWER DROPLET: "SPIDERMAn" -Sepsis -Scarlet Fever -Strep -Pertussis -Pneumonia -Parvovirus -Influenza -Diphtheria -Epiglottitis -Rubella -Mumps -Adenovirus Management: Private room/mask -A private room a rom with other clients with the same infectious disease. -Masks for providers and visitors Airborne precautions: - CORRECT ANSWER AIRBORNE: "My Chicken Hez TB" -Measles -Chicken pox -Herpes zoster -TB Management: neg. pressure room, private room, mask, n-95 for TB. -A private room -Masks or respiratory protection devices for caregivers and visitors. -An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known or suspected to have TB. -Negative pressure airflow exchange in the room of at least six exchanges per hour. Contact precautions - CORRECT ANSWER CONTACT: "MRS WEE" -MRSA -RSV -Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, and staph) -Wound infections -Enteric infections (C-Diff) -Eye infections (conjunctivitis) Management: gown, gloves, goggles, private room VRSA - contact and airborne precautions (private room, door closed, negative pressure) -A private room or a room with other clients with the same infection. -Gloves and gowns worn by the caregivers and visitors. Stage I pressure ulcer - CORRECT ANSWER Intact skin with an area of persistent, nonblanchable redness, typically over a bony prominence, that may feel warmer or cooler than the adjacent tissue. The tissue is swollen and has congestion, with possible discomfort at the site. With darker skin tones, the ulcer may appear blue or purple. Stage II pressure ulcer - CORRECT ANSWER Partial-thickness skin loss involving the epidermis and the dermis. The ulcer is visible and superficial and may appear as an abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected, possibly with pain and scant drainage. Stage III pressure ulcer - CORRECT ANSWER Full-thickness tissue loss with damage to or necrosis of subcutaneous tissue. The ulcer may extend down to, but not through, underlying fascia. The ulcer appears as a deep crater with or without undermining of adjacent tissue and without exposed muscle or bone. Drainage and infection are common. Stage IV pressure ulcer - CORRECT ANSWER Full-thickness tissue loss with destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. There may be sinus tracts, deep pockets of infection, tunneling, undermining, eschar (black scab-like material), or slough (tan, yellow, or green scab-like material) Glasgow Coma Score - CORRECT ANSWER is calculated by using appropriate stimuli (a painful stimulus may be necessary) and then assessing the clients response in three areas. Eye opening (E) - The best eye response, with responses ranging from 4 to 1 4 = Eye opening occurs spontaneously. 3 = Eye opening occurs secondary to voice. 2 = Eye opening occurs secondary to pain. 1 = Eye opening does not occur. Verbal (V) - The best verbal response, with responses ranging from 5 to 1 5 = Conversation is coherent and oriented. 4 = Conversation is incoherent and disoriented. 3 = Words are spoken, but inappropriately. 2 = Sounds are made, but no words. 1 = Vocalization does not occur. Motor (M) - The best motor response, with responses ranging from 6 to 1 6 = Commands are followed. 5 = Local reaction to pain occurs. 4 = There is a general withdrawal to pain. 3 = Decorticate posture (adduction of arms, flexion of elbows and wrists) is present. 2 = Decerebrate posture (abduction of arms, extension of elbows and wrists) is present. 1 = Motor response does not occur. Responses within each subscale are added, with the total score quantitatively describing the client's level of consciousness. E + V + M = Total GCS When verifying NG tube placement, the pH of aspirated gastric fluid should - CORRECT ANSWER A good indication of appropriate placement is obtaining gastric contents with a pH between 0 and 4. Sodium - CORRECT ANSWER 136-145 Potassium - CORRECT ANSWER 3.5-5 Total Calcium - CORRECT ANSWER 9.0-10.5 Magnesium - CORRECT ANSWER 1.3-2.1 Phosphorus - CORRECT ANSWER 3.0-4.5 BUN - CORRECT ANSWER 10-20 Creatinine males - CORRECT ANSWER 0.6-1.2 Creatinine females - CORRECT ANSWER 0.5-1.1 Glucose - CORRECT ANSWER 70-105 HcbA1c - CORRECT ANSWER <6.5% WBC - CORRECT ANSWER 5,000-10000 RBC men - CORRECT ANSWER 4.7-6.1 million/mm3 RBC women - CORRECT ANSWER 4.2-5.4 millin/mm3 Hemoglobin men - CORRECT ANSWER 14-18 Hemoglobin women - CORRECT ANSWER 12-16 Hematocrit men - CORRECT ANSWER 42-52 Hematocrit women - CORRECT ANSWER 37-47 Platelet - CORRECT ANSWER 150,000-400,000 pH - CORRECT ANSWER 7.35-7.45 pC02 - CORRECT ANSWER 35-45 p02 - CORRECT ANSWER 80-100 HC03 - CORRECT ANSWER 21-26 Normal PT= - CORRECT ANSWER 11-12.5 seconds Normal INR= - CORRECT ANSWER 0.7-1.8 (Therapeutic INR 2-3) Normal PTT= - CORRECT ANSWER 30-40 seconds (Therapeutic PTT 1.5-2 x normal or control values) Digoxin - CORRECT ANSWER 0.5-2.0 Lithium - CORRECT ANSWER 0.8-1.4 Dilantin - CORRECT ANSWER 10-20 Theophylline - CORRECT ANSWER 10-20 Latex Allergies - CORRECT ANSWER Note that clients allergic to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes, and/or peaches may experience latex allergies as well. Order of Assessment - CORRECT ANSWER I-inspection P-palpation P-percussion A-auscultation Except with abdomen it is IAPP-inspect, auscultate, percuss and palpate. Cane Walking - CORRECT ANSWER C-cane O-opposite A-affected L-leg Crutch walking - CORRECT ANSWER Remember the phase "step up" when picturing a person going up stairs with crutches. The good leg goes up first followed by the crutches and the bad leg. The opposite happens going down the stairs....OR "up to heaven...down to hell" Delegation - CORRECT ANSWER RNs DO NOT delegate what they can EAT--evaluate, assess, teach Angina Precipitating Factors: 4 E's - CORRECT ANSWER Exertion: physical activity and exercise Eating Emotional distress Extreme temperatures: hot or cold weather Arterial occlusion: 4 P's - CORRECT ANSWER Pain Pulselessness or absent pulse Pallor Paresthesia Congestive Heart Failure Treatment: MADD DOG - CORRECT ANSWER Morphine Aminophylline Digoxin Dopamine Diuretics Oxygen Gasses: Monitor arterial blood gasses Heart Murmur Causes: SPASM - CORRECT ANSWER Stenosis of a valve Partial obstruction Aneurysms Septal defect Mitral regurgitation Heart Sounds: All People Enjoy the Movies - CORRECT ANSWER Aortic: 2nd right intercostal space Pulmonic: 2nd left intercostal space Erb's Point: 3rd left intercostal space Tricuspid: 4th left intercostal space Mitral or Apex: 5th left intercostal space Hypertension Care: DIURETIC - CORRECT ANSWER Daily weight Intake and Output Urine output Response of blood pressure Electrolytes Take pulse Ischemic episodes or TIAs Complications: CVA, CAD, CHR, CRF Shortness of Breath (SOB) Causes: 4 As+4Ps - CORRECT ANSWER Airway obstruction Angina Anxiety Asthma Pneumonia Pneumothorax Pulmonary Edema Pulmonary Embolus Stroke Signs: FAST - CORRECT ANSWER Face Arms Speech Time Compartment Syndrome Signs and Symptoms: 5 P's - CORRECT ANSWER Pain Pallor Pulse declined or absent Pressure increased Paresthesia Shock Signs and Symptoms: CHORD ITEM - CORRECT ANSWER Cold, clammy skin Hypotension Oliguria Rapid, shallow breathing Drowsiness, confusion Irritability Tachycardia Elevated or reduced central venous pressure Multi-organ damage Hypoglycemia Signs: TIRED - CORRECT ANSWER Tachycardia Irritability Restlessness Excessive hunger Depression and diaphoresis Hypocalcaemia Signs and Symptoms: CATS - CORRECT ANSWER Convulsions Arrhythmias Tetany Stridor and spasms Hypokalemia Signs and Symptoms: 6 L's - CORRECT ANSWER Lethargy Leg cramps Limp muscles Low, shallow respirations Lethal cardiac dysrhythmias Lots of urine (polyuria) Hypertension Complications: The 4 C's - CORRECT ANSWER Coronary artery disease (CAD) Congestive heart failure (CHF) Chronic renal failure (CRF) Cardiovascular accident (CVA): Brain attack or stroke Traction Patient Care: TRACTION - CORRECT ANSWER Temperature of extremity is assessed for signs of infection Ropes hang freely Alignment of body and injured area Circulation check (5 P's) Type and location of fracture Increase fluid intake Overhead trapeze No weights on bed or floor Cancer Early Warning Signs: CAUTION UP - CORRECT ANSWER Change in bowel or bladder A lesion that does not heal Unusual bleeding or discharge Thickening or lump in breast or elsewhere Indigestion or difficulty swallowing Obvious changes in wart or mole Nagging cough or persistent hoarseness Unexplained weight loss Pernicious Anemia Leukemia Signs and Symptoms: ANT - CORRECT ANSWER Anemia and decreased hemoglobin Neutropenia and increased risk of infection Thrombocytopenia and increased risk of bleeding Clients Who Require Dialysis: AEIOU (The Vowels) - CORRECT ANSWER Acid base imbalance Electrolyte imbalances Intoxication Overload of fluids Uremic symptoms Asthma Management: ASTHMA - CORRECT ANSWER Adrenergics: Albuterol and other bronchodilators Steroids Theophylline Hydration: intravenous fluids Mask: oxygen therapy Antibiotics (for associated respiratory infections) Hypoxia: RAT (signs of early) BED (signs of late) - CORRECT ANSWER Restlessness Anxiety Tachycardia and tachypnea Bradycardia Extreme restlessness Dyspnea Pneumothorax Signs: P-THORAX - CORRECT ANSWER Pleuretic pain Trachea deviation Hyperresonance Onset sudden Reduced breath sounds (& dyspnea) Absent fremitus X-ray shows collapsed lung Transient incontinence Causes: DIAPERS - CORRECT ANSWER Delirium Infection Atrophic urethra Pharmaceuticals and psychological Excess urine output Restricted mobility Stool impaction Dealing with Constipation - CORRECT ANSWER Constipation is difficult or infrequent passage of stools, which may be hard and dry. Causes include: irregular bowel habits, psychogenic factors, inactivity, chronic laxative use or abuse, obstruction, medications, and inadequate consumption of fiber and fluid. Encouraging exercise and a diet high in fiber and promoting adequate fluid intake may help alleviate symptoms. Dealing with Dysphagia: - CORRECT ANSWER Dysphagia is an alteration in the client's ability to swallow. Causes include: Obstruction Inflammation Edema Certain neurological disorders Modifying the texture of foods and the consistency of liquids may enable the client to achieve proper nutrition. Clients with dysphagia are at an increased risk of aspiration. Place the client in an upright or high-Fowler's position to facilitate swallowing. Provide oral care prior to eating to enhance the client's sense of taste. Allow adequate time for eating, utilize adaptive eating devices, and encourage small bites and thorough chewing. Avoid thin liquids and sticky foods. Dumping Syndrome - CORRECT ANSWER Dumping Syndrome occurs as a complication of gastric surgeries that inhibit the ability of the pyloric sphincter to control the movement of food into the small intestine. This "dumping" results in nausea, distention, cramping pains, and diarrhea within 15 min after eating. Weakness, dizziness, a rapid heartbeat, and hypoglycemia may occur. Small, frequent meals are indicated. Consumption of protein and fat at each meal is indicated. Avoid concentrated sugars. Restrict lactose intake. Consume liquids 1 hr before or after eating instead of with meals (a dry diet) Gastroesophageal Reflux Disease (GERD) - CORRECT ANSWER GERD leads to indigestion and heartburn from the backflow of acidic gastric juices onto the mucosa of the lower esophagus. Encourage weight loss for overweight clients. Avoid large meals and bedtime snacks. Avoid trigger foods such as citrus fruits and juices, spicy foods, and carbonated beverages. Avoid items that reduce lower esophageal sphincter (LES) pressure, such as alcohol, caffeine, chocolate, fatty foods, peppermint and spearmint flavors and cigarette smoking. Peptic Ulcer Disease (PUD) - CORRECT ANSWER PUD is characterized by an erosion of the mucosal layer of the stomach or duodenum. This may be caused by a bacterial infection with Helicobacter pylori or the chronic use of non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen. Avoid eating frequent meals and snacks, as they promote increased gastric acid secretion. Avoid alcohol, cigarette smoking, aspirin and other NSAIDs, coffee, black pepper, spicy foods, and caffeine. Lactose intolerance - CORRECT ANSWER Lactose intolerance results from an inadequate supply of lactase, the enzyme that digests lactose. Symptoms include distention, cramps, flatus, and diarrhea. Clients should be encouraged to avoid or limit their intake of foods high in lactose such as: milk, sour cream, cheese, cream soups, coffee creamer, chocolate, ice cream, and puddings. Diverticulosis and Diverticulitis: - CORRECT ANSWER A high-fiber diet may prevent diverticulosis and diverticulitis by producing stools that are easily passed and thus decreasing pressure within the colon. During acute diverticulitis, a low-fiber diet is prescribed in order to reduce bowel stimulation. Avoid foods with seeds or husks. Clients require instruction regarding diet adjustment based on the need for an acute intervention or preventive approach. Cholecystitis - CORRECT ANSWER Cholecystitis is characterized by inflammation of the gallbladder. The gallbladder stores and releases bile that aids in the digestion of fats. Fat intake should be limited to reduce stimulation of the gallbladder. Other foods that may cause problems include coffee, broccoli, cauliflower, Brussels sprouts, cabbage, onions, legumes, and highly seasoned foods. Otherwise, the diet is individualized to the client's needs and tolerance. Acute Renal Failure (ARF): - CORRECT ANSWER ARF is an abrupt, rapid decline in renal function. It is usually caused by trauma, sepsis, poor perfusion, or medications. ARF can cause hyponatremia, hyperkalemia, hypocalcemia, and hyperphosphatemia. Diet therapy for ARF is dependent upon the phase of ARF and its underlying cause. Pre-End Stage Renal Disease (pre-ESRD): - CORRECT ANSWER Pre-ESRD, or diminished renal reserve/renal insufficiency, is a predialysis condition characterized by an increase in serum creatinine. Goals of nutritional therapy for pre-ESRD are to: Help preserve remaining renal function by limiting the intake of protein and phosphorus. Control blood glucose levels and hypertension, which are both risk factors. Protein restriction is key for clients with pre-ESRD. Slows the progression of renal disease. Too little protein results in breakdown of body protein, so protein intake must be carefully determined. Restricting phosphorus intake slows the progression of renal disease. High levels of phosphorus contribute to calcium and phosphorus deposits in the kidneys. Dietary recommendations for pre-ESRD: Limit meat intake. Limit dairy products to ½ cup per day. Limit high-phosphorus foods (peanut butter, dried peas and beans, bran, cola, chocolate, beer, some whole grains). Restrict sodium intake to maintain blood pressure. Caution clients to use vitamin and mineral supplements ONLY when recommended by their provider. End Stage Renal Disease (ESRD): - CORRECT ANSWER End Stage Renal Disease (ESRD): ESRD, or chronic renal failure, occurs when the glomerular filtration rate (GFR) is less than 25 mL/min, the serum creatinine level steadily rises, or dialysis or transplantation is required. The goal of nutritional therapy is to maintain appropriate fluid status, blood pressure, and blood chemistries. A high-protein, low-phosphorus, low-potassium, low-sodium, fluid restricted diet is recommended. Calcium and vitamin D are nutrients of concern. Protein needs increase once dialysis is begun because protein and amino acids are lost in the dialysate. Fifty percent of protein intake should come from biologic sources (eggs, milk, meat, fish, poultry, soy). Adequate calories (35 cal/kg of body weight) should be consumed to maintain body protein stores. Phosphorus must be restricted. The high protein requirement leads to an increase in phosphorus intake. Phosphate binders must be taken with all meals and snacks. Vitamin D deficiency occurs because the kidneys are unable to convert it to its active form. This alters the metabolism of calcium, phosphorus, and magnesium and leads to hyperphosphatemia, hypocalcemia, and hypermagnesemia. Calcium supplements will likely be required because foods high in phosphorus (which are restricted) are also high in calcium. Potassium intake is dependent upon the client's laboratory values, which should be closely monitored. Sodium and fluid allowances are determined by blood pressure, weight, serum electrolyte levels, and urine output. Achieving a well-balanced diet based on the above guidelines is a difficult task. The National Renal Diet provides clients with a list of appropriate food choices. Nephrotic Syndrome - CORRECT ANSWER Nephrotic syndrome results in serum proteins leaking into the urine. The goals of nutritional therapy are to minimize edema, replace lost nutrients, and minimize permanent renal damage. Dietary recommendations indicate sufficient protein and low-sodium intake. Nephrolithiasis (Kidney Stones) - CORRECT ANSWER Increasing fluid consumption is the primary intervention for the treatment and prevention of the formation of renal calculi. Excessive intake of protein, sodium, calcium, and oxalates (rhubarb, spinach, beets) may increase the risk of stone formation. Prioritization - CORRECT ANSWER Prioritization includes clinical care coordination such as clinical decision making, priority setting, organizational skills, use of resources, time management, and evaluation of care. Clinical decisions are made by completing a thorough assessment which will help you make good judgments later when you see a changing clinical condition. A poor initial assessment can lead to missed findings later on. Priority setting refers to addressing problems and prioritizing care. It is critical for efficient care. The RN uses his/her knowledge of pathophysiology when prioritizing interventions with multiple clients. Orders of prioritization: 1. Treat first any immediate threats to a patient's survival or safety. Ex. obstructed airway, loss of consciousness, psychological episode or anxiety attack. ABC's. 2. Next, treat actual problems. Ex. nausea, full bowel or bladder, comfort measures. 3. Then, treat relatively urgent actual or potential problems that the patient or family does not recognize. Ex. Monitoring for post-op complications, anticipating teaching needs of a patient that may be unaware of side effects of meds. 4. Lastly, treat actual or potential problems where help may be needed in the future. Ex Teaching for self-care in the home. Here are some great principles to help you as you prioritize: Systemic before local Acute before chronic Actual before potential Listen don't assume Recognize first then apply clinical knowledge Maslow's Hierarchy of Needs: Prioritize according to Maslow with physiological and safety issues before psychological esteem issues. Variant angina (Prinzmetal's angina) - CORRECT ANSWER Due to a coronary artery spasm, oftening occurring during periods of rest. Unstable angina - CORRECT ANSWER Occurs with exercise or emotional stress, but it increases in occurrence, severity, and duration over time. Stable angina - CORRECT ANSWER Occurs with exercise or emotional stress and is relieved by rest or nitroglycerin (Nitrostat). electrolyte imbalance manifestations: - CORRECT ANSWER hypocakelmia--> flat T waves on ECG hypercalcemia--> decreased deep tendon reflexes (DTRs) hypocalcemia--> tetany hyperkalemia--> tall peaked T waves on ECG Addison's disease - CORRECT ANSWER Decreased aldosterone and renin Hypothyroidism - CORRECT ANSWER Decreased triiodothyronine (T3) and thyroxine Cushing's disease - CORRECT ANSWER Elevated cortisol Diabetes Insipidus (DI) - CORRECT ANSWER Decreased urine specific gravity Diabetes melitus - CORRECT ANSWER Elevated glycosylated hemoglobin (HbA1c) Syndrome of Inappropriate Secretion of Antidiuretic Hormone - CORRECT ANSWER Increased urine osmolality Cataract - CORRECT ANSWER Progressive and painless loss of vision Angle-closure glaucoma - CORRECT ANSWER Rapid onset of elevated IOP macular degeneration - CORRECT ANSWER Central loss of vision Open-angle galucoma - CORRECT ANSWER Loss of peripheral vision Retinal detachment - CORRECT ANSWER Sudden loss of vision without pain Common disease's manifestations - CORRECT ANSWER Cholecystitis--> Murphy's sign Pancreatitis--> Turner's sign Peptic Ulcer Disease--> Upper epigastric pain 1-2 hours after meals Appendicits--> Pain at McBurney's point Decorticate - CORRECT ANSWER Decerebrate - CORRECT ANSWER Hepatitis disease transmissions - CORRECT ANSWER Hepatitis A--> Ingestions o contaminated food/water Hepatitis B--> Unprotected sexual contact Nonviral Hepatits--> Drug toxicity Heart Failure - CORRECT ANSWER Symptoms: Shortness of breath, fatigue, jugular vein distention, and an S3 are signs/symptoms of heart failure resulting from the decreased pumping ability of the heart and increased fluid volume. Hypovolemic shock - CORRECT ANSWER position: Supine with legs elevated (shock position) Below-the-knee amputation - CORRECT ANSWER Position: The client should be placed in the prone position several times a day to prevent hip flexion contractions. Chest tube - CORRECT ANSWER -Continuous bubling in the water seal champers indicates an air leak. If this is observed, the nurse should attempt to located the source of the air leak and intervene accordingly (tighten the connections, replace drainage system) Compartment syndrome - CORRECT ANSWER Symptoms: Pulselessness (late sign), Increased pain unrelieved with elevation or by pain medication Left homonymous hemianopsia - CORRECT ANSWER has lost the left visual field of both eyes. They are unable to visualize anything to the left of midline of the body. dialysis fistula - CORRECT ANSWER client teaching: avoid lifting heavy objects with access-site arm, avoid carrying objects that compress the extremity, avoid sleeping on top of the extremity with the access device, perform hand exercises that promote fistula maturation, check the access site at intervals following dialysis, apply light pressure if bleeding, notify the provider if the site continues to bleed after 30 min following dialysis. Chronic renal failure - CORRECT ANSWER Diet: low-protein, low-potassium, and high-carbohydrate, as well as low-sodium and low-phosphate Synchronized cardioversion - CORRECT ANSWER is the electrical management of choice for atrial fibrillation, supra ventricular tachycardia (SVT) and ventricular tachycardia with a pulse. Myoglobin - CORRECT ANSWER is the earliest marker of injury to cardiac or skeletal muscle and levels no longer evident after 24 hr. Troponin I - CORRECT ANSWER A positive Troponin I indicates damage to cardiac tissues and level are no longer evident in the blood after 7 days. Hyperglycemia - CORRECT ANSWER -Test urines for ketones and report if outside the expected reference range atropine - CORRECT ANSWER blocks the cardiac muscarinic receptors and inhibits the parasympathetic nervous system. The blockage of parasympathetic activity results in an increased heart rate. When the heart rate increases, cardiac output will also increase. Constant bubbling in a water seal chamber (of a chest tube) is an indication of - CORRECT ANSWER an air leak Cleft lip: nursing care plan (postoperative)—"CLEFT LIP" - CORRECT ANSWER Crying, minimize Logan bow Elbow restraints Feed with Brecht feeder Teach feeding techniques; two months of age (average age at repair) Liquid (sterile water), rinse after feeding Impaired feeding (no sucking) Position—never on abdomen Complication of severe preeclampsia—"HELLP" syndrome - CORRECT ANSWER Hemolysis Elevated Liver enzymes Low Platelet count Dystocia: general aspects (maternal)—"4P's" - CORRECT ANSWER Powers Passageway Passenger Psych Infections during pregnancy—"TORCH" - CORRECT ANSWER Toxoplasmosis Other (hepatitis B, syphilis, group B beta strep) Rubella Cytomegalovirus Herpes simplex virus IUD: potential problems with use—"PAINS" - CORRECT ANSWER Period (menstrual: late, spotting, bleeding) Abdominal pain, dyspareunia Infection (abnormal vaginal discharge) Not feeling well, fever or chills String missing Newborn assessment components—"APGAR" - CORRECT ANSWER Appearance Pulse Grimace Activity Respiratory effort Obstetric (maternity) history—"GTPAL" - CORRECT ANSWER Gravida Term Preterm Abortions (SAB, TAB) Living children Oral contraceptives: Signs of potential problems—"ACHES" - CORRECT ANSWER Abdominal pain (possible liver or gallbladder problem) Chest pain or shortness of breath (possible pulmonary embolus) Headache (possible hypertension, brain attack) Eye problems (possible hypertension or vascular accident) Severe leg pain (possible thromboembolic process) Preterm infant: Anticipated problems—"TRIES" - CORRECT ANSWER Temperature regulation (poor) Resistance to infections (poor) Immature liver Elimination problems (necrotizing enterocolitis [NEC]) Sensory-perceptual functions (retinopathy of prematurity [ROP]) VEAL CHOP-which relates to fetal heart rate. - CORRECT ANSWER Variable decels => Cord compression (usually a change in mother's position helps) Early decels => Head compression (decels mirror the contractions; this is not a sign of fetal problems) Accelerations => O2 (baby is well oxygenated-this is good) Late decels => Placental utero insufficiency (this is bad and means there is decreased perfusion of blood/oxygen/nutrients to the baby). Nine-point Postpartum Assessment...BUBBLEHER - CORRECT ANSWER B- Breasts U- Uterus B- Bladder B- Bowel function L- Lochia E- Episiotomy H- Hemorrhoids E- Emotional Status R- Respiratory System Considerations for the pregnant client - CORRECT ANSWER Admittance of a pregnant client to a medical-surgical unit: You may have a pregnant client admitted with a diagnosis unrelated to her pregnancy and, therefore, she may be admitted to a general medical-surgical floor. A mnemonic to assist you in performing important assessment elements for these clients is FETUS. * F: Document fetal heart tones every shift. To assess fetal heart tones, use a handheld Doppler ultrasound and place it in an area corresponding to uterine height. For example, for a client who's less than 20 weeks' pregnant, the most likely area to find fetal heart tones is at the pubic hairline or the symphysis pubis. For a client whose pregnancy is more advanced, such as at 24 weeks, the fetal heart rate can most probably be heard midline between the symphysis pubis and the umbilicus. As the pregnancy advances in weeks, fetal heart tones can be heard closer to and possibly above the umbilicus. * E: Provide emotional support. Pregnant women who are experiencing unexpected medical conditions are at a high level of anxiety related to how the current medical problem may affect the fetus. You should take extra care to alleviate and reduce your client's anxiety by explaining all medications and treatments. Additionally, be prepared to listen for fetal heart tones anytime the client requests it to further reduce her worry of the fetus' well being. * T: Measure maternal temperature. Because your client's core body temperature is higher than you can detect through oral or tympanic thermometers, be alert to the presence of a fever. A high maternal temperature can lead to fetal tachycardia and distress. An order for antipyretics on admission to ensure their quick availability will be a prudent request you should make to the admitting physician. * U: Ask about uterine activity or contractions. Make it Admittance of a postpartum client to a medical-surgical unit - CORRECT ANSWER There are times when a woman may be hospitalized during the postpartum period for a medical condition. When this occurs, she'll most likely be placed on a general medical-surgical unit. Her admission will cause you to ask: "What's normal during the weeks following the birth of a baby?" * Breasts. Within the first 24 hours postpartum, colostrum appears and is followed by breast milk within the first 72 hours. Breast engorgement is most likely to occur around day 4 postpartum. The engorged breast will appear full, taut, and even shiny. Although this is normal, it may be very uncomfortable for your client. In contrast, a woman with mastitis will usually run a fever higher than 100° F, report feeling "ill," and have one breast that's affected (firm, inflamed, swollen, and exquisitely tender to touch). If your client is breastfeeding her newborn, she'll require a breast pump. Depending on the medications ordered, the milk may need to be disposed of and not used for the baby. * Lochia. Sometimes women will experience lochia (vaginal discharge) until the time of their 6-week postpartum visit. Immediately after delivery, the lochia is red and heavy enough to require a pad change every 1 to 2 hours. By 7 days postpartum, the lochia should be lighter in color (pink to red) and amount, requiring a pad change every 4 hours. Lochia that becomes heavier, has a foul odor, and is accompanied by pelvic pain isn't a normal finding and requires immediate intervention. * Perineal care. For the first 2 weeks following delivery, clients will need to perform perineal hygiene as taught during the immediate postpartum period. This may include perineal water rinses following elimination using warm water or medicinal rinses, use of sitz baths, and comfort medications to the perineal and anal area. * Cesarean section. If your cli Placenta Previa (PP) versus Abruptio Placenta (AP) - CORRECT ANSWER Problem: PP--> Low implantation of the placenta AP--> Premature separation of the placenta Incidence: PP--> It occurs in approximately 5 in every 1000 pregnancies AP--> It occurs in about 10% of pregnancies and is the most common cause of perinatal death Risk factors: PP--> increased parity, advanced maternal age, past cesarean births, past uterine curettage, multiple gestation, AP--> high parity, advanced maternal age, a short umbilical cord, chronic hypertensive disease, pregnancy-induced hypertension, direct trauma, vasoconstriction from cigarette use, thrombic conditions that lead to thrombosis such as autoimmune antibodies Bleeding: PP--> Always present AP--> May or may not be present Color of blood in bleeding episodes: PP--> Bright red AP--> Dark red Pain during bleeding: PP--> Painless AP--> Sharp, stabbing pain Management: PP--> Place the woman immediately on bed rest in a side-lyon position. Weight perineal pads. NEVER attempt a pelvic or rectal examination because it may initiate massive blood loss. AP--> Fluid replacement. Oxygen by mask. Monitor FHR. Keep the woman in a lateral position. DO NOT perform any vaginal or pelvic examinations or give enema. Pregnancy must be terminated because the fetus cannot obtain adequate oxygen and nutrients. If birth does not seem imminent, cesarean birth is method of choice for delivery. Common Thyroid Medications - CORRECT ANSWER Levo thyro xine (Syn thro id,Levo thro id) Lio thyro nien (Cytomel) Liotrix ( Thyro lar) Thyroid ( Thryoid USP) Antithyroid Medications (hyperthyroidism) - CORRECT ANSWER Antithyroid medications are used to block (anti) the thyroid hormones. Antithyroid medications block (anti) the conversion of T4 into T3. Used to treat clients with Graves Disease, thyro toxicosis. Antithryoid medications are prescribed for clients who have an overactive thyroid or hyperthyroidism. In hyperthyroidism....everything is HIGHHHHHHH(HYPERRRRRRRRR) Clients that are prescribed this medication need to take radioactivity precautions. Common Antithyroid Medications: Propylthiouracil (PTU) Thyroid-Radioactive Iodine (hyperthyroidism) - CORRECT ANSWER At high doses, thyroid radioactive iodine destroys thyroid cells. This drug is used for clients who have thyroid cancer and an over active thyroid (hyperthyroidism). Thyroid-NonRadioactive Iodine (hyperthyroidism) - CORRECT ANSWER This medication creates a high level of iodine that will reduce iodine uptake by the thyroid gland. It inhibits the thyroid hormone production and blocks the release of thyroid hormones into the bloodstream. This medication tastes nasty; has a metallic taste! Clients are to drink this medication through a straw to prevent tooth discoloration. Radioactivity precautions are not necessary due to this drug is nonradioactive. Oral Hypoglycemic Agents - CORRECT ANSWER These medications promote insulin release from the pancreas. Clients who are prescribed oral hypoglycemic agents do not produce enough insulin to lower their blood glucose (blood sugar) levels. Prescribed for clients with type 2 Diabetes Mellitus. Common Oral Hypoglycemic Agents: glipizide( Gluco trol, Gluco trolXL). See the form of glucose in the drug name? chlorpropamide ( Diab ines).See the form of Diabetes in the drug name? glyburide ( Diab inese,Micronase). See the form of Diabetes in the drug name? metforminHC1 ( Gluco phage). See the form of glucose in the drug name? For Insuline Overdose - CORRECT ANSWER Common medication for insulin overdose: Gluc agon (see the form of glucose in the drug name?) Glucagon (or glucose) is needed to increase blood glucose or blood sugar. Anterior Pituitary Hormons/Growth Hormones - CORRECT ANSWER These medications stimulate growth. Are used to treat growth hormone deficiencies. Use cautiously in clients who have Diabetes Mellitus since these medications cause hyperglycemia because of the decreased use of glucose. Common Anterior Pituitary Hormones/Growth Hormone Agents: somatropin somatrem(Protropin) Posterior Pituitary Hormones/Antidiuretic Hormone - CORRECT ANSWER This medication promotes the reabsorption of water within the kidneys; causes vaso constriction due to the contraction of vascular smooth muscle. Common Posterior Pituitary Hormones/Antidiruetic Hormones: desmopressin (DDAVP, stimate) vaso pressin (Pitressin synthetic) (See the form of vaso in the drug name, for vaso constriction) Anticonvulsants - CORRECT ANSWER The anticonvulsants are medications used for the treatment of epileptic seizures. These meds suppress the rapid and firing of neurons in the brain that start a seizure. Drugs for all types of seizures, except petit mal: CaPhe like cafe in French CA rbamazepine PHE nytoin/Phenobarbital Drugs for petit mal seizures: ValEt Val proic Acid Et hosuximide Phenytoin: adverse effects P - interactions H irsutism E nlarged gums N ystagmus Y ellow-browning of skin T eratogenicity O steomalacia I nterference with B metabolism (hence anemia) N europathies: vertigo, ataxia, headache All anti-epileptic drugs can be remembered by this mnemonic: Dr.BHAISAB's New PC. D ...Deoxy barbiturates B ...Barbiturates H ....Hydantoin A ....Aliphatic carb acids I ....Iminostilbenes S ....Succinimides B ....Benzodiazepines (BZD's) N ....Newer drugs P ....Phenyltriazines C ...Cyclic gaba analogues Antiparkinsonian - CORRECT ANSWER An antiparkinson, or antiparkinsonian medications are used for clients diagnosed with Parkinson's Disease. These medications increase dopamine activity or reduce acetylcholine activity in the brain. They do not halt the progression of the disease. These medications offer symptomatic relief. Anti-Parkinsonian Drugs include: A Cat Does Like Milk! A nticholinergic Agents C OMT Inhibitors (catechol-O-methyltransferase); An enzyme involved in degrading neurotransmitters. D opamine Agonists L evodopa M AO-B Inhibitors Opthalmic - CORRECT ANSWER Ophthalmic medications are drugs used for the eye. These medications are typically prescribed for clients who have Glaucoma, Macular Degeneration. Other ophthalmic medications are used to treat allergic conjunctivitis, inflammatory disorders, dyes to visualize the eye, and to treat infections or viruses. Beta-Adrenergic Blocking Agents Prescribed for clients who have open-angle glaucoma. These agents decrease the production of aqueous humor. Block beta 1and beta 2 receptors. Common Beta-Adrenergic Ophthalmic Blocking Agents: beta xolos ( Bet optic ) (see the form of beta in the drug names?) See optic in Betoptic? Opthalmic medication. levo beta xolol ( Beta xon) (see the form of beta in the drug names?) levobunolol ( Beta gan) (see the form of beta in the drug name?) timolol ( Bet imol) (see the form of beta in the drug name?) Prostaglandin Analogs First line treatment for glaucoma. Fewer side effects and just as effective as the beta-adrenergic Ophthalmic blocking agents. These drugs lower IOP by facilitating aqueous humor outflow by relaxing the ciliary muscle. Common Prostaglandin Analogs: latanoprost (Xal atan ) (see the suffix atan in this drug and the drug below, they are the same) Travoprost (trav atan ) (see the suffix atan in this drug and the drug above; they are the same) Alpha2-Adrenergic Agonists These drugs lower IOP by reducing aqueous humor production and by increasing outflow. Also delays optic nerve degeneration and protects retinal neurons from death. Common Alpha2-Adrenergic Agonists: Brimon idine (Alphagan) (see the similarities with idine in the name of the drug) Apraclon idine (Iop idine ) (see the similarities with idine in both of the names of the drug) Direct Acting Cholinergic Agonist/Muscarinic Agonist (parasympathomimetic agent) These drugs stimulate the cholinergic rece Gestational diabetes mellitus - CORRECT ANSWER Impaired tolerance to glucose with the first onset or recognition during pregnancy Hyperemesis Gravidarum - CORRECT ANSWER Severe morning sickness with unrelenting, excessive nausea or vomiting that prevents adequate intake of food and fluids HELLP syndrome - CORRECT ANSWER A variant of gestational hypertension where hematologic conditions coexist with severe preeclampsia and hepatic dysfunction. Gestational hypertension - CORRECT ANSWER Hypertension beginning after the 20th week of pregnancy with no proteinuria. Mild preeclampsia - CORRECT ANSWER Hypertension beginning after the 20th week of pregnancy with 1 to 2+ proteinuria and a weight gain of more than 2 kg per week in the second and third trimesters. Eclampsia - CORRECT ANSWER Severe preeclampsia symptoms with seizure activity or coma Taking in phase - CORRECT ANSWER 24-48 hours after birth: dependent, passive; focuses on own needs; excited, talkative Taking hold phase - CORRECT ANSWER focuses on maternal role and care of the newborn; eager to learn; may develop blues Letting go phase - CORRECT ANSWER Focuses on family and individual roles Cephalopelvic disproportion - CORRECT ANSWER When the fetus has a head size, shape or position that does not allow for passage through the pelvis. Presentation - CORRECT ANSWER Includes cephalic, breech and shoulder. Longitudinal lie - CORRECT ANSWER The fetal long axis is parallel to the mother's long axis. The fetus is either in a breech or vertex presentation Duration - CORRECT ANSWER The amount of time elapsed from the beginning of one contraction to the end of the same contraction. Intensity - CORRECT ANSWER The strength of the uterine contraction. Transverse lie - CORRECT ANSWER The long axis of the fetus is at a right angle to the mother's long axis. This is incompatible with a vaginal delivery if the fetus remains in this position Frequency - CORRECT ANSWER The amount of time from the beginning of one contraction to the beginning of the next contraction Regularity - CORRECT ANSWER The amount of consistency in the frequency and intensity of contractions. Station - CORRECT ANSWER The relationship of the presenting part to the maternal ischial spines that measures the degree of descent of the fetus. missing birth control pills... - CORRECT ANSWER In the event of a client missing a dose the nurse should instruct the client that if one pill is missed to take as soon as possible. If two or three pills are missed the client should follow the manufacturer's instructions and use an alternative form of contraception. pediatric acetaminophen levels - CORRECT ANSWER >200 mcg/ml pediatric carbon dioxide - CORRECT ANSWER cord--> 14-22 premature 1 week --> 14-27 newborn --> 13-22 infant, child --> 20-28 pediatric chloride level - CORRECT ANSWER Cord --> 96-104 Newborn --> 97-110 Child --> 98-106 Conjugated direct Bilirubin level - CORRECT ANSWER 0.0-0.2 mg/dl pediatric creatinine level - CORRECT ANSWER cord --> 0.6-1.2 newborn --> 0.3-1.0 infant 0.2-0.4 child --> 0.3-0.7 adolescent --> 0.5-1.0 pediatric Digoxin toxic concentration - CORRECT ANSWER > 2.5 ng/ml pediatric Glucose (Serum) - CORRECT ANSWER Newborn, 1 day --> 40 to 60 Newborn, > 1 day --> 50 to 90 Child --> 60 to 100 pediatric Hematocrit levels - CORRECT ANSWER 1 day --> 48-69% 2 day --> 48-75% 3 day --> 44-72 % 2 month --> 28-42 % 6- 12 year --> 37-49% 12- 18 year Male --> 37-49% 12-18 year Female --> 36-46% Antigout Medications - What is gout? - CORRECT ANSWER Gout is a type of arthritis. In healthy people the body breaks down dietary purines and produces uric acid. The uric acid dissolves and is excreted via the kidneys. In individuals affected with gout the body either produces too much uric acid or is unable to excrete enough uric acid and it builds up. High uric acid levels results in urate crystals which can now collect in joints or tissues. This causes severe pain, inflammation and swelling. Treatment is both lifestyle adjustment and medication. Medications First Line: NSAIDs and prednisone (Deltasone) Purpose: Used as a first line defense to treat the pain and inflammation of gout attacks. Colchicine (Colgout): Purpose: Treat the inflammation and pain associated with gout. Just like NSAIDs, these meds can lead to GI distress and should be taken with foods. HINT: The word gout is right in the name Colgout. Allopurinol (Zyloprim): Purpose: This is the only medical preventative treatment for gout. Allopurinal prevents uric acid production. This can be an effective means of preventing gout attacks when diet alone is not effective. HINT: Examine the name allopurinol and you can see the word PURINE in the middle of the name. Note: There are many drug and food interactions associated with allopurinol: Potential serious interactions with the use of saliscylates, loop diuretics, phenylbutazamines and alcohol and potential for drug interactions with Warfarin (Coumadin). Teach client with gout to avoid the following: • Anchovies, sardine in oil, fish roe, herring • Yeast • Organ meat (liver, kidneys, sweetbreads) • Legumes (dried beans and peas) • Meathextracts (gravies and consommé) • Mushrooms, spinach, asparagus, cauliflower Anti-reabsorptives - CORRECT ANSWER What is anati-reabsorptive? Bone is a living organ which is continually being removed (resorbed) and rebuilt. Osteoporosis develops when there is more resorption than rebuilding. Antiresorptive medications are designed to slow bone removal and or improve bone mass. Treating and preventing osteoporosis can involve lifestyle changes and sometimes medication. Lifestyle change includes diet and exercise, and fall prevention. Prevention and treatment of osteoporosis involve medications that work by preventing bone breakdown or promote new bone formation. Medications Bisphosphonates prevent the loss of bone mass Alendronate (Fosamax) Monthly used to treat and prevent osteoporosis in menopausal women. Facts: The benefits of Fosamax can even be seen in elderly women over 75 years of age. Hint: Fosamax has been associated with severe esophagitis and ulcers of the esophagus. Should be avoided in clients with history of gastric ulcers. Risedronate (Actonel): This is a newer drug and less likely to cause esophageal irritation Hint: Teach clients taking either drug to take on an empty stomach with at least 8 ounces (240 ml) of water, while sitting or standing. This minimizes the chances of the pill being lodged in the esophagus. Clients should also remain upright for at least 30 minutes after taking these pills to avoid reflux in to the esophagus. For those clients who cannot tolerate the esophagus side effects of Fosamax, estrogen, etidronate (Didronel), and calcitonin are possible alternatives. Teriparatide (Forteo): It acts like parathyroid hormone and stimulates osteoblasts, thus increasing their activity. Promotes bone formation. Facts: This drug is associated with a risk of bone tumors so is only used when the benefits outweigh the risks. Antirheumatics - CORRECT ANSWER What is rheumatoid arthritis? Rheumatoid arthritis (RA) is a chronic disease that results in inflammation of the joints and surrounding tissues. RA affects the lining of the joints and the painful swelling can result in bone erosion and joint deformities. It is the small joints in hands and feet are most often affected. Treatment is designed to provide symptom relief and some delay in progression of the disorder but not a cure. Medications Disease-modifying Antirheumatic drugs (DMARDs), glucocorticoids, and non-steroidal anti-inflammatory drugs (NSAIDs) may be used individually or in combination to manage this chronic disorder. The major categories of antirhematics are: DMARDs I - Major Nonbiologic DMARDs • Cytotoxic medications: Methotrexate (Rheumatrex), leflunomide (Arava) • Antimalarial agents: Hydroxychloroquine (Plaquenil) • Anti-inflammatory medication: Sulfasalazine (Azulfidine) • Tetracycline antibiotic: Minocycline (Minocin) DMARDs II - Major Biologic DMARDs • Etanercept (Enbrel) • Infliximab (Remicade) • Adalimumab (Humira) • Rituximab (Rituxan) • Abatacept (Orencia) DMARDs III - Minor nonbiologic and biologic DMARDs • Gold salts: Aurothioglucose (Solganal) • Penicillamine (Cuprimine, Depen) • Cytotoxic medications: Azathioprine (Imuran), cyclosporine (Sandimmune, Gengraf, Neoral) • Glucocorticoids: • Prednisone (Deltasone), prednisolone (Prelone) ● NSAIDs Hints: DMARDs slow joint degeneration and progression of rheumatoid arthritis. Glucocorticoids and NSAIDs provide symptom relief from inflammation and pain. Rheumatrex ( methotrexate ) is the most commonly used DMARD. This is because it has been shown to work as well or better than any other single medicine. It is also relatively inexpensive and generally safe. Methotrexate has many food and drug interactions esp Antineoplastics - CORRECT ANSWER Antineoplastics are used combat cancerous cells. There are many kinds of anti-cancer drugs with a variety of actions. But in simple terms this category of drugs attack cells that multiply and divide. This very action which can kill cancer cells can also do the same to healthy dividing cells. This is especially true of cells that need a steady supply of new cells such as skin, hair and nails. There are over 90 different kinds of chemotherapy agents and different drugs cause different side effects Chemotherapy is associated with a variety of side effects: § Nausea and vomiting § Diarrhea and or constipation § Alopecia § Anorexia § Fatigue and exhaustion § Mouth sores § Easy bruising Medications Fluorouracil (5-fluorouracil, 5-FU) Warning - Hazardous drug! 5-FUis one of the oldest chemotherapy drugs and is used against a variety of cancers. Following are some of the most common and important ill effects: • Soreness of the mouth, difficulty swallowing • Diarrhea • Stomach pain • Low platelets • Anemia • Sensitive skin (to sun exposure) • Excessive tear formation from the eyes Nursing Hints: Be aware of the importance of leucovorin rescue with fluorouracil therapy, if prescribed. • The best treatment for extravasation is prevention. • Extravasation can cause pain, reddening, or irritation on the arm with the infusion needle. In severe cases in can lead to tissue necrosis and even loss of an extremity. • Check infusion site frequently • Stop infusion immediately if suspected • Slowly aspirate back blood back from the arm • Elevate arm and rest in elevated position • Check institution policies on how to remove catheter Oral hypoglycemics - CORRECT ANSWER What is diabetes? Diabetes is a disorder that affects glucose metabolism. Type 1 diabetes: The client either makes no insulin or not enough insulin. Type 2 diabetes: The client makes enough insulin at least early in the disease but is unable to transport glucose from the blood into the cells. In both cases, the individual is unable to metabolize glucose. The purpose of oral hypoglycemics is to assist with glucose metabolism. Medications There are four classes of hypoglycemic drugs: • Sulfonylureas Tolbutamide (Orin ase); glyburide; Micron ase Stimulates insulin production Associated with weight gain • Biguanide: Metformin o First line drug in type 2 diabetes o Reduces the production of glucose within the liver o Associated with modest weight loss o Less likely to cause hypoglycemia. o Significant lipid-lowering activity. • Thiazolidinediones o Reverses insulin resistance o Increases glucose uptake and decreased glucose production o Associated with severe liver damage • Alpha-glucosidaseinhibitors. o Acarbose (Precose) o Reduces the absorption of dietary glucose o Associated with flatulence and diarrhea Hints: No matter which class the client will be taking there is always the risk of hypoglycemia Be sure to teach client how to recognize early signs and symptoms of hypoglycemia as well as appropriate interventions. Mental Status Exam - CORRECT ANSWER All clients should have a Mental Status Exam, which includes: Level of consciousness Physical appearance Behavior Cognitive and intellectual abilities The nurse conducts the MSE as part of his or her routine and ongoing assessment of the client. Changes in Mental Status should be investigated further and the provider notified. There are two types of mental health hospitalizations: Voluntary commitment and involuntary or civil commitment. Involuntary commitment is against the client's will. Despite that, unless proven otherwise, clients are still considered competent and have the right to refuse treatment. Use the following communication tips when answering questions on NCLEX: - CORRECT ANSWER * If the client is anxious or depressed - use open-ended, supportive statements * If the client is suicidal - use direct, yes or no questions to assess suicide risk * If the client is panicked - use gentle guidance and direction * If the client is confused - provide reality orientation * If the client has delusions / hallucinations / paranoia - acknowledge these, but don't reinforce * If the client has obsessive / compulsive behavior - communicate AFTER the compulsive behavior * If the client has a personality or cognitive disorder - be calm and matter-of-fact ECT - CORRECT ANSWER The most common type of brain stimulation therapy is electronconvulsive therapy or ECT. ECT is generally performed for major depressive disorders, schizophrenia or acute manic disorders. Most clients receive therapy three times a week for two to three weeks. Prior to ECT, carefully screen the client for any home medication use. Lithium, MAOIs and all seizure threshold medications should be discontinued two weeks prior to ECT. After therapy, reorient the client as short term memory loss is common. Anxiety disorders - CORRECT ANSWER Anxiety disorders are common mental health disorders. Generalized Anxiety Disorder, Panic Disorder, Phobias, Obsessive Compulsive Disorder, and Posttraumatic stress disorder (PTSD) are all considered types of anxiety disorders. Assess the client for risk factors, triggers and responses. Depressive disorders - CORRECT ANSWER A classic symptom of depression is change in sleep patterns, indecisiveness, decreased concentration, or change in body weight. Any client who shows these signs or symptoms should be asked if they have suicidal ideation. Teach clients to never discontinue anti-depressants suddenly. Bipolar disorders - CORRECT ANSWER Bipolar disorders are mood disorders with periods of depression and mania. Clients have a high risk for injury during the manic phase related to decreased sleep, feelings of grandiosity and impulsivity. Hospitalization is often required and nurses should provide for client safety. abuse - CORRECT ANSWER There are several different types of abuse, including physical, sexual, or emotional. Abuse tends to be cyclic, following a pattern on tension building, battering and honeymoon phase. When test questions appear related to abuse, look for the phase to determine the correct response. violent clients - CORRECT ANSWER For the aggressive or violent client, setting boundaries and limits on behavior are important. The nurse should maintain a calm approach and use short, simple sentences. SSRI's - CORRECT ANSWER SSRIs: Selective Serotonin Reuptake Inhibitors. These medications include Citalopram (Celexa), Fluoxetine (Prozac), or Sertraline (Zoloft). The client should avoid using St. John's Wort with these medications, and should eat a healthy diet while on these medications. TCAs - CORRECT ANSWER TCAs: Tricyclic Antidepressants. Amitriptyline (Elavil) is an example. Anticholinergic effects and orthostatic hypotension may occur. MAOIs - CORRECT ANSWER MAOIs: Monoamine Oxidase Inhibitors. Phenelzine (Nardil) is an example. Hypertensive crisis may occur with tyramine food ingestion, so care must be taken to avoid these substances. Educate the client to avoid all medications until discussed with provider. Atypical antidepressants - CORRECT ANSWER Atypical antidepressants. Bupropion (Wellbutrin) is the most common example. Appetite suppression is a common side-effect. Headache and dry mouth may be severe and client should notify the provider if this occurs. Atypical antidepressants should not be used with clients with seizure disorders. SNRI's - CORRECT ANSWER Serotonin Norepinephrine Reuptake Inhibitors. Common SNRIs include Venlafaxine (Effexor) and Duloxetine (Cymbalta). Adverse effects may include nausea, weight gain, and sexual dysfunction. Antagonists - CORRECT ANSWER In order to understand how antagonist drugs work, you need to understand how agonist drugs produce therapeutic effects. Agonists are simply drugs that allow the body's neurotransmitters, hormones, and other regulators to perform the jobs they are supposed to perform. Morphine sulfate, codeine, and meperidine (Demerol) are opioids agonists that act on the mu receptors to produce analgesia, respiratory depression, euphoria, and sedation. These drugs also work on kappa receptors, resulting in pain control, sedation and decreased GI motility. Antagonists, on the other hand, are drugs that prevent the body from performing a function that it would normally perform. To quote William Shakespeare & the US Army, these drug classes allow the body's functions "to be or not to be...all that they can be". Common uses of antagonists: • Treatment of opioids overdose, reversal of effects of opioids, or reversal of respiratory depression in an infant • Example: a post-operative client receiving morphine sulfate for pain control experiences respiratory depression and is treated with naloxone (Narcan) Nursing Interventions for antagonists: • Monitor for side/adverse effects • Tachycardia and tachypnea • Abstinence syndrome in clients who are physically dependent on opioids agonists • Monitor for symptoms to include cramping, hypertension, and vomiting • Administer naloxone by IV, IM or subcutaneous routes, not orally • Be prepared to address client's pain because naloxone will immediately stop the analgesia effect of the opioid the client had taken • When used for respiratory depression, monitor for return to normal respiratory rate (16-20/min for adults; 40-60/min for newborns) Antidotes - CORRECT ANSWER Antidotes are agents given to counteract the effects of poisoning related to toxicity of certain drugs or substances. Antidotes are extremely valuable, however most drugs do not have a specific antidote. Atropine--> is the antidote for muscarinic agnostic and cholinesterase inhibitors: Bethanechol (Urecholine), Neostigmine (Prostigmin) Phyosostigmine (Antillirium)--> is the antidote for anticholinergic drugs, atropine. Digoxin immune Fab (Digibind)--> is the antidote for digoxin, digitoxin Vitamin K--> is the antidote for Warfarin (Coumadin) Protamine sulfate--> is the antidote for Heparin Glucagon--> is the antidote for insulin-induced hypoglycemia Acetylcysteine (Mucomyst)--> is the antidote for acetaminophen (tylenol) Bronchodilators - CORRECT ANSWER Bronchodilators are used to treat the symptoms of asthma that result from inflammation of the bronchial passages, but they do not treat the inflammation. Therefore, most clients with asthma take an inhaled glucocorticoid concurrently to provide the best outcomes. The two most common classes of bronchodilators are beta2-adrenergicagonists and methylxanthines. Beta2-adrenergic agonists : act upon the beta2-receptors in the bronchial smooth muscle to provide bronchodilation and relieve spasm of the bronchial tubes, inhibit release of histamines and increase motility of bronchial cilia. These short-acting preparations provide short-term relief during an asthma exacerbation, while the long-acting preparations provide long-term control of asthma symptoms. The generic names for the inhaled form of these drugs end in"terol" = " T aking E ases R espiratory distress o r L abored breathing" • Albu terol (Proventil, Ventolin) • Formo terol (Foradil Aerolizer) • Salme terol (Serevent) The brand names of some drugs in this class provide a hint as well because they contain the words "vent " or " breth " referring to ventilation or breathing: • Albuterol (Pro vent il, Vent olin) • Salmeterol (Sere vent ) • Terbutaline ( Breth ine) Nursing interventions and client education: • Short-acting inhaled preparations of albuterol (Proventil, Ventolin) can cause systemic effects of tachycardia, angina, and tremors. • Monitor client's pulse rate before, during, and after nebulizer or inhaler treatments • Long-acting inhaled preparations can increase the risk of severe asthma or asthma-related death if used incorrectly—mainly if used without concurrent inhaled glucocorticoid use • Oral preparations can cause angina pectoris or tachydysrhythmias with excessive use • Instruct clients to report chest pain or changes in h ACE inhibitors - CORRECT ANSWER ACE inhibitors block the production ofangiotensin II which results in vasodilation, sodium and water excretion, and potassium retention. Drugs in this class are used for treating heart failure, hypertension, myocardial infarction, and diabetic or nondiabetic nephropathy. Clients taking captopril (Capoten) should be instructed to take med at least 1 hour before meals; all other ACE inhibitors are not affected by food. The generic names of ACE inhibitors end in "pril": • Capto pril (Capoten) • Enala pril (Vasotec) • Fosino pril (Monopril) • Lisino pril (Prinivil) • Rami pril (Altace) Side/adverse effects include: • Orthostatic hypotension with first dose • Instruct client to monitor BP for at least 2 hours after first dose • Cough, rash or altered or distorted taste (dysgeusia) • Instruct client to notify health care provider • Angioedema • Treated with epinephrine and symptoms will resolve once medication is stopped • Neutropenia is rare but serious with captopril (Capoten) • Instruct client to report signs of infection Hyperkalemia can be life-threatening Monitor potassium levels to maintain normal range of 3.5-5.0 mEq/L Medication/food interactions: • Concurrent use with diuretics can lead to first-dose orthostatic hypotension • Concurrent use with other antihypertensives can lead to increase effect resulting in hypotension • Concurrent use with potassium supplements or potassium-sparing diuretics increases the risk of hyperkalemia • Concurrent use with lithium can increase serum lithium levels, leading to lithium toxicity • Concurrent use with NSAIDs can decrease the therapeutic effects of the ACE inhibitor Vasodilators - CORRECT ANSWER [Show More]

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