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ATI CAPSTONE COMBO ASSESSMENT A, B. All the Information need to Pass exam.

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ATI CAPSTONE COMBO ASSESSMENT A&B 1. what is montelukast (singular) for? 2. what does advance directives contain? 3. what is the greatest risk to a pt receiving hemodialysis? 4. what is the clinic... al manifestation of disequilibrium? 5. what are expected findings in hemodialysis? 6. what should the nurse do when a pt feels lightheaded and begins to fall? 7. what are the characteristics of a pt with dependent personality disorder? 8. a pregnant pt who is bleeding is always? 9. what should a pregnant pt with urgency and frequent urination do? 10. what should a pregnant pt with odorless vaginal mucus do? 11. a pregnant pt with edema of the ankles do? 12. when should a colostomy bag be changed? 13. how large should the opening of the stoma pouch be? 14. what should the pt with a colostomy avoid? 15. what should the pt do with the pouch removing it? 16. where should drops be instill into? 17. what is a positive way of dealing with a terminal illness? 18. what are normal findings after a colonoscopy? 19. what are unexpected finding after a colonoscopy? 20. what do you do if an order is questioned? 21. what should pt with gastritis eat? 22. what is the cause autonomic dysreflexia? 23. what are s/s of icp? 24. what is late s/s of ICP? 25. when can a child with varicella(chickenpox) return school? 26. what is an appropriate behavior of a pt with hx of violence? 27. what is a skin cancer prevention? 28. what is the first thing you should do with excessive lochial discharge? 29. what is the nurse responsibility of the nurse when witnessing the pts signature on an informed consent? 30. who are at greater risk for std? 31. does trichomonas vaginalis increased the risk for cervical cancer? 32. Gonorrhea can lead to? 33. what should you do with postmortem care? 34. what can you not give to a pt with thickened liquids? 35. what can a pt with thickened liquids have? 36. oatmeal 37. what should a pt do with incentive spirometer? 38. they should elevate the cylinder by inhaling deeply assume semi fowlers or high fowlers position 39. in order to maintain sterile technique what should the nurse do? 40. should open all sterile packages prior to donning sterile gloves 41. what is psycho-motor learning? 42. have the pt demonstrate back the procedure 43. what places a newborn at risk for respiratory depression? 44. administration of an opioid analgesic exa: fentanyl (sublimaze) 45. what is an effective method of bowel retraining? 46. anal stimulation with a gloved finger after the evening meal, it will help stimulate the gastrocolic reflex 47. when inserting an NG tube? 48. the nurse should insert the tube into the airway that is patent and has greater airflow 49. what technique should be NG tube insertion? 50. clean technique 51. if NG tube meets resistance? 52. the nurse should rotate the tube without forcing it past the area of resistance 53. what kind of lubricant should be used during NG tube insertion? 54. water- based lubricant NOT petroleum jelly 55. what is pediculosis capitis management? 56. store child's clothing in a separate cubicle at school boil brushes and combs in water for 10 mins dry bed lines and clothing in a hot dryer for at least 20 mins 57. what can visual disturbances indicate? 58. preeclampsia 59. what is expected 24 hrs after surgery? 60. hypo active bowel sounds pain 61. what is an abnormal finding 24 hrs after surgery? 62. low HGB 63. what must be done in bucks traction? 64. the pt must be in proper alignment boots are secured by 3 straps, around pt leg weights must hang freely footplate is resting 15.24 cm (6inches) from the footboard 65. what does pts with delirium demonstrate? 66. a fluctuating LOC often at night or in am 67. pt with dementia demonstrate? 68. difficulty finding correct words to use 69. pt with anxiety disorders demonstrate? 70. obsessive behavior 71. how would the nurse determine progression of ascites? 72. abdominal girth should be measured daily 73. what is a food high in potassium? 74. cantaloupe 75. what is an indication of peripheral venous disease? 76. brown pigmentation around ankles 77. what is indication of peripheral arterial disease? 78. intermittent, leg muscle pain 79. what is some skin care for pts on radiation therapy? 80. pat area when drying use hand to wash do not use sunscreen 81. what can hydromorpone cause? 82. urinary retention 83. what does bethanechol (urecholine) causes? 84. it stimulates urinary out put 85. how is nystatin best absorb? 86. if given 1 hour before or after a feeding 87. what is a sign that a newborn has finished eating? 88. a slowed suck/swallow pattern is a sign that the newborn is finished eating 89. what not to do when breastfeeding? 90. is not necessary for the entire areola be in the mouth each feeding should start at the opposite breast do not push back of newborns head-toward the nipple 91. what should be included in a stool specimen? 92. visible blood, pus, or mucus 93. what is the first action in an infiltrated IV? 94. to d/c the saline lock 95. what is the first action when preparing to do a dressing change? 96. to determine the pts level of pain 97. what should a with hemonymous hemionopsia with right visual field, what will help pt eat better? 98. the pt should turn head to the right to see all food on tray 99. what are some side effect for theophylline (theo-dur)? 100. is used to prevent wheezing,sob, chest tightness in asthma irregular pulse and dysrhythmias seizures anxiety urinary frequency anorexia n/v diarrhea 101. what should you do when given enoxaparin (lovenox)? 102. it should be injected SUBQ do not aspirate do not massage do not inject in same area 103. what is the babinski reflex? 104. stroke sole of the foot upward, toward the great toe 105. what is the moro reflex? 106. startle the infant by clapping hands` 107. what is the stepping reflex? 108. hold infant upright and allow one foot to touch tables surface 109. what is the palmer grasp reflex? 110. place an object in the palm of infant hand 111. what should you do when catheterizing a male pt? 112. pt should be place in supine position penis should be at 90 degree angle retract the foreskin and clean the glans prior to catherization 113. what color is the meconium? 114. it is the first stool passed and it is dark green and viscous 115. what is an inportant thing to ask when pt having cardiac catherization? 116. if pt allergic to iodine 117. what should be done with nitroglycerin (nitrostat)? 118. if pt continues to have pain after taking 1 tab, they should call 911 and take a second tab 119. what is normal after taking a nitroglycerin (nitrostat) tab? 120. h/a change positions slowly it should be kept in original, dark colored bottle to avoid light exposure 121. what to do for restrains use? 122. observe skin condition before applying restrains use a quick release knot to secure the restraints belt restrains should be placed over pts waist able to insert two fingers under restraints do not use all four side of rails to restrain pt 123. what would indicate an active peristalsis? 124. the presence of vowel sounds 125. what does pt with COPD have? 126. increased metabolism due to work of labored breathing they have dry mouth/thick mucus constipation decreased peristalsis 127. how to use a cane? 128. pt should hold cane on the stronger side of the body place it forward 6-10 inches and move his weaker leg forward to the cane distributing his weight between the cane and the stronger leg then he should move the stronger leg forward beyond the cane and distribute his weight between the cane and weaker leg 129. what does the use of cardiac catherization required? 130. that the pt have normal renal functions for excretion of the dye 131. how should drops be apply? 132. the nurse should apply gently pressure to the inner canthus of the eye for 30-60 seconds 133. what are hyperthyroidism findings? 134. tachycardia 135. what are hypothyroidism findings? 136. cold intolerance constipation brittle hair 137. how much should infants grow? 138. 1 inch per month, during the first 6 months they should be able to double their birth weight between 4-6 months of age and gain approximately 150-210 (about 5-7oz) per week 139. what should you do when evaluating an infant? 140. the nurse should measure ht/wt separately, and not combine 141. what can reduce the anti hypertensive effect of anti hypertensives? 142. ibuprofen (advil) or any NSAIDS 143. what is the first action when IV pump alarm is beeping? 144. to observe the iv site for infiltration or phlebitis 145. how are normal bowel sounds? 146. high pitched, irregular gurgles that occur every 5-15 seconds, in a rage of 5-30 per/min 147. what is hypoactive? 148. infrequent less than 5/min 149. what is hyperactive? 150. every 3 seconds or greater 151. what is actinic keratosis? 152. a pre-malignant lesion flat, scaly area with red edges 153. what are cherry angiomas? 154. bright red, raised spots (expected skin changes with aging) 155. what does a change in color mole indicate? 156. indicates skin cancer 157. what happens in passive ROM? 158. the pt does not actively participates the nurse should support the pts extremities distal and proximal to the joints to facilitate passive ROM 159. what do you do when inserting a urinary catheter, and urine is seen in the tubing? 160. the catheter should be advance another 2.5-5 cm to ensure that the balloon is inflated in the bladder 161. what to do when addressing pt dilemma? 162. determine the facts related to dilema identify possible solutions consider clients wishes 163. what should a pt with peripheral vascular disease do? 164. walk until feel pain, rest for 3 min and continue until tired should sit with legs in a dependent position 165. what are s/s of a detached retina? 166. photopsia= bright flashes of light 167. what are s/s of macular degeneration? 168. loss of peripheral vision 169. what is a normal s/s of aging? 170. presbyopia= difficulty focusing on close objects 171. what should a pt with DM and influenza report? 172. temp higher than 101.5 or greater for 24 hours 173. what should be done with pts with closed head injury? 174. should be log roll only suction on prn basis maintain HOB at least 30 degrees do not use an incentive spirometer ICP might go up 175. what should a pt with cardiac catherization experience? 176. they should drink adequate fluids may need to cough during test may experience a feeling of heat "hot flash" only need bed rest for 4-6 hours 177. what should pt with COPD do? 178. should perform pursed- lip breathing alternate activities with rest eat high protein snacks practice relaxation techniques 179. turp care? 180. monitor pt for fluid volume over load remind pt that they will feel urge while catheter is in place calculate urinary out put every 2 hours measure pain level every 2-3 hours pt should get up to a chair asap, risk for dvt 181. how to administer ear drops to children under 3 yrs? 182. pull pinna down and back 183. how will ventricular fibrilation look on ekg? 184. irregular rate without P waves, bizarre and variable QRS 185. what are sinus tachycardia look on EKG? 186. regular rate greater than 100/min normal P and QRS waves 187. atrial ventricular (AV) block look on EKG? 188. regular rate between 60-100/min with extended PR intervals 189. premature atrial contractions look on EKG? 190. irregular rate with ectopic atrial beats earlier than expected 191. what are s/s of febrile transfussion reaction? 192. chills 193. what are s/s of circulatory overload transfussion reaction? 194. bounding pulse and hypertension 195. what are s/s of hemolytic transfussion reaction? 196. lower back pain 197. what foods are rich in iron? 198. red meats, liver 199. what to look for in HCTZ (Hydrodiuril)? 200. flunctuation in weight encourage increase of potassium should be taken with food or right after a meal 201. what are s/s of anaphalictic reactions? 202. increased respiratory effort hypotension bronchoconstriction (laryngeal stridor) 203. what does benzodiazepines (lorazepam/ativan) causes? 204. lethargic and somnolent 205. what are pt with preclampsia at risk for? 206. seizures 207. how should the formula be to prevent gastric cramping in an enteral feeding? 208. administer the formula at room temp 209. what is a s/s of bulemia nervosa? 210. hemoptysis 211. what is a s/s of anorexia nervosa? 212. amenorrhea acrocynosis 213. what are interventions for a salem sump tube? 214. the most common ng tube it is a double lumen (two-channeled) it irrigates the stomach and removes fluid and gas from stomach. -pt should be reposition every 2 hours to promote emptiying of stomach content -set suction 80-100 -never clamp air vent pt should be NPO 215. what might cause dry skin in older adults? 216. a decrease in elasticity of the skin which is an expected change associated with aging 217. what is a bronchoscope? 218. a tube that allows the doctor to see in the lungs and airways and remove objects 219. what are nursing interventions for pts with dementias? 220. should encourage verbal praise do not exceed 20 mins in tub may not be able to follow direction they should not disrobe until right before entering the bath to prevent chilling 221. what to do with ankle sprain? 222. check for pedal edema wrap with a compression dressing apply ice elevate 223. what promotes venous return? 224. using sequential compression device 225. what is an expected PR interval? 226. should be 0.12 to 0.20 seconds it should be one P wave prior to each QRS complex an expected QRS duration is 0.04 to 0.10 second an expected ventricular rate of 60 to 100/min 227. what are s/s of atorvastatin (lipitor) side effects? 228. muscle weakness which can lead to rhabdomyolysis, report muscle cramps, pain or tenderness 229. when should keflex (cephalexin) not be given? 230. if pt has PCN allergy 231. what will facilitate understanding in a pt with anxiety? 232. the use of short, concise sentenses because they have difficulty concentrating 233. what should be done to pts with expressive aphasia? 234. give them a picture board, or pen and paper, because pt cannot verbally express needs or wants should use simple statements and speak normal voice 235. what are risk factors for colorectal cancer? 236. obesity high consumption of alcohol cigaret smoking high protein diet older pt fam hx of colon cancer/ polyps hx of gastrectomy and inflammatory bowel disease 237. what is given for long term alcohol abuse? 238. disulfiram (antabuse), which is an adversion therapy 239. what is a bladder scan? 240. it is a non invasive procedure, and pt should not experience discomfort not a sterile procedure no consent necessary 241. how would the nurse explain a procedure to a school age child? 242. using simple diagram 243. what does concave shape nails indicate? 244. emphysema, prolonged hypoxemia 245. how many grams of protein does peanut butter contains? 246. 7g 247. what do you do with a boggy uterus? 248. promote involution of the uterus, massaging the fundus because of hemmorhage 249. what position is best for COPD pt? 250. orthopnea position because it increases lung expansion 251. phototherapy risks? 252. dehydration report decreased urine output infant may sleep longer should be kept on a regular feeding schedule of every 3-4 hrs may have loose green stool 253. what to teach with hepatitis B? 254. pt should use own utensils and dishes avoid tylenol (acetaminophen) 255. what should you teach a pt about exercising? 256. they should warm up for atleast 5 mins first 257. what should the nurse avoid when placing ekg lodes? 258. avoid scar tissue 259. post bronchoscopy care? 260. pt should not eat until gag reflex is checked blood in sputum is expected have a ride home report horseness or wheezing 261. what to do with a stage 5 alzheimers diasease pt? 262. increase stress level, provide a variety of foods that the pt is able to eat by himself to maintain independence 263. what does metoprolol affect? 264. heart rate is a beta adrenergic antagonist 265. car seat? 266. should be secure with a seat belt 267. where do we do blood draws? 268. in the antecubital fossa 269. crutch teaching? 270. instruct pt to hold crutches on the side opposite the injured leg, when sitting to improve balance and prevent falls 271. antidepressants (elavil) amitriptyline? 272. pt may not feel better for 7 to 28 days and may not experience full effect for 6 to 8 weeks 273. what should pt with leukemia not have in the room? 274. fresh flowers 275. what is an indication of hydration status? 276. mucus membranes 277. what is a low sodium food? 278. canned peaches 279. what is high sodium foods? 280. wheat crackers lean ham cottage cheese 281. how often is a tetanus booster? 282. every ten years 283. what are some risk for fall findings? 284. the pt walks barefoot medications stored on top shelf 285. what is the greatest risk for a thyroidectomy? 286. hypocalcemia with tingling around the mouth 287. what are strategies for teaching toddlers? 288. picture books and simple words 289. what are strategies for teaching preschoolers? 290. role playing/ short stories 291. what are strategies for teaching school age children? 292. discussing and participating in hands on demonstration 293. what are strategies for teaching adolescents? 294. collaborative process/ problem solving 295. what is priority in palliative care? 296. pharmacological pain management 297. what should peritoneal fluid in dialyses look like? 298. bloody, clear, straw color 299. what color should peritoneal fluid not look like? 300. cloudy or opaque, this might means infections 301. what is the glascow coma scale? 302. motor response 303. what are s/s of IV infiltration? 304. pallor surrounding the infusion site 305. what is a s/s of phlebitis? 306. redness along the vein 307. what is a s/s of an extravasation? 308. tissue sloughing 309. what to do with a child with rotavirus? 310. the diaper should fit snuggly avoid using a rectal thermometer apply skin barrier they are NOT contagious 311. where should the chest tube be placed? 312. below the level of the pts chest 313. what should be done with a pen rose drain? 314. a safety pin is placed at the distal end of the drain 315. what to do with a colonoscopy? 316. should not take NSAIDS 1 week prior should be NPO 6-8 hours before 317. what to report with albuterol (proventil)? 318. tremors 319. what should the nurse do when removing a pt IV catheter? 320. the nurse should maintain the catheter parallel to the vein to reduce the risk of trauma to the vein 321. what will the child need prior to an IV urography (IVP)? 322. the child will need to have a soapsud enema administered before the procedure to assist in visualization of the kidneys, ureters, and bladder 323. what diet should the child with nephrotic syndrome be in? 324. low sodium diet to assist with diuresis of extracellular fluid 325. what is normal findings in a turp? 326. yellow urine with red sediment 327. what is abnormal finding in a TURP? 328. LOWER ABD CRAMPING BLOODY URINE WITH LARGE CLOTS INCREASED BLADDER SPASMS 329. what pt should not take cephalexin (Keflex)? 330. pts with PCN allergy 331. what should be used to clean the inner cannula of a tracheostomy? 332. sterile hydrogen peroxide 333. what should the nurse consider when using an interpreter? 334. the nurse should ensure that the interpreter and the pt speak the same dialect and share similar cultural norms and practices 335. what should a pt with leukemia and stomatitis eat? 336. a cold, soft, bland, and liquid foods to prevent further irritation to the oral mucosa exa: oatmeal and applesauce 337. what should the nurse do after a pt has have a ECT electroconvulsive therapy? 338. the pt should be reoriented frequently 339. nursing interventions for pts in hypovolemic shock? 340. place pt in trendelengurg position elevate legs to promote venous return to heart increase IV fluids keep pt warm 341. nursing interventions for pts with vein ligation and stripping? 342. elevate feet (recliner is appropriate) perform ROM walk 5 to 10 min/hr while awake for first 24 hrs the nurse should wrap legs with an elastic bandage for prevention of clots 343. when would a pt on antidepressant (amitriptiline) feel the effect? 344. 10-14 days and experience full effect for 4-8 weeks 345. how is mono (infectious mononucleosis) acquired? 346. direct contact with droplets of saliva of an infected person 347. how long after giving insulin should a nurse check for hypoglycemia? 348. 4-14 after administration of NPH (novolin N) insulin 349. what should the pt do after taking iron preparation? 350. pt should rinse mouth immediately after taking med 351. in respiratory acidosis what is elevated? 352. the Paco2 is elevated greater than 45 353. what is the first thing a pt with prosthesis do? 354. applied immediately the prosthesis after waking 355. what should a pt on suicide precautions be told to do? 356. sign a no harm contract aka no suicide contract 357. what to avoid with theophylline (theochron)? 358. avoid caffeine due to tachycardia 359. what would you see with dehydration? 360. low potassium levels 361. how can hep B be contracted? 362. blood transfusion sexual contact sharing IV drug needles 363. what are the risks for colorectal cancer? 364. obesity high consumption of alcohol cigarette smoking high protein diet (red meat) fam hx of colon cancer hx of gastrectomy and IBS 365. what are right sided heart failure s/s? 366. edema ascites anorexia 367. what are left sided heart failure s/s? 368. dizziness 369. following rupture of the membranes what is the greatest risk? 370. fecal cord compression of prolapse, which is a medical emergency and obtaining a fetal heart tone is priority 371. what should be done to a pt with anxiety? 372. they will have trouble concentrating therefore the nurse should speak to the pt using simple sentenses 373. what is a manifestation of type 2 DM? 374. infection and poor wound healing 375. what to monitor with timolol (Timoptic)? 376. a decreased in BP 377. what is inhibit with spinal cord damage at T1 and T2? 378. it inhibits function below the waist 379. wheel chair precautions? 380. use a gell- filled seat cushion limit time to 2 hours at a time avoid donut-shaped pads shift weight every 15 minutes 381. what kind of mask should pt with COPD use? 382. a venturi mask 383. what is priority in a child with sickle cell crisis? 384. oxygenation 385. what should be avoided with a mastectomy? 386. avoid raising elbow above the shoulder until drain are removed avoid abduction return to work in 4 to 6 wks resume driving in 7 to 10 days 387. during the initial tx of acute diverticulitis what is done? 388. the pt receives parenteral nutrition and should be kept NPO 389. what do do for a child with juvenile idiopathic arthiritis? 390. use heat therapy prior to physical activities because it promotes exercise they should attend school as much as possible promote exercise eat a well balanced diet 391. how often is a tetanus booster recommended? 392. every ten years 393. what to give prior to an NST? 394. administer 4 oz (120 ML) of orange juice to stimulate fetal movement 395. where should a cane be placed? 396. held in the hand of the stronger side of body 397. what is priority in a pt with anorexia nervosa? 398. record amount of food pt consumes weight daily restrict exercing 399. nitroglycerin (nitrostat)? 400. take up to 3 tabs during single episode place under tongue store in original container discard on expiration date 401. how should epoiten alfa be given? 402. sub Q 403. how should IM injections be given? 404. z tract method 405. what promotes drainage of stomach content in tubes/pumps? 406. turning pt every two hours 407. what should pt with cystic fibrosis eat? 408. a diet high in calories 409. what can long term use of corticosteroids induced? 410. osteoporosis 411. what should be priority when a pt with ketoacidosis come to hospital? 412. administer a 0.9 % sodium chloride becauses it replaces sodium looses 413. what is the greatest risk with a thyroidectomy? 414. hypocalcemia leading to tetany by s/s of tingling around mouth 415. what is a s/s of circulatory over load? 416. crackles, sob, jugular vein distention, cough 417. when taking care of a pt with meningitis what should the nurse wear? 418. a surgical mask within 3 feet ot the pt to prevent exposure 419. where would a pt with acute cholecystitis feel pain? 420. RUQ radiating to back 421. what to do first when IV pump is alarming? 422. observe the IV site for phlebitis 423. what should pt avoid before a colonoscopy? 424. NSAIDs because it increases risk for bleeding 425. when should a newborn repeat the hearing test if they fail the first time? 426. in 3 months 427. what helps pt with acute manic? 428. step by step direction 429. what is scleroderma? 430. is a chronic disease with skin changes causes thickening, hardening, or tightening of the skin, blood vessels, and internal organs 431. what is s/s of herpes zoster (shingles)? 432. results from reactivation of a dormant varicella virus, inflammation of the dorsal root ganglion. localized vesicular lesions unilateral localized, nodular skin lesions 433. genital herpes s/s? 434. fluid-filled vesicular rash in genital region 435. hepatitis A? 436. fecal-oral route, uncooked food 437. what is raynaud disease? 438. a disorder of the blood vessel that supply blood to the skin and causes the distal extremities and the tip of nose and ear to feel numb/cool in response to cold temps or stress s/s: tingling, swelling, painful throbbing attacks may last mins to hours the pt should not smoke 439. IGA? 440. associated with autoimmune diseases or chronic infections 441. IGE? 442. allergic manifestations, anaphylaxis, and asthma 443. IGM? 444. antibodies against ABO blood groups 445. IgG? 446. antibodies to all types of infections 447. what should the pt with SLE skin lesions do? 448. it affects any organ in the body is a chronic autoimmune disorder, pt should monitor body temp and report any elevations promptly apply moisturizer after bathing the lesions with warm water 449. what reduces exposure to allergens? 450. use a dehumidifier/ NOT humidifier no carpet bed linens should be washed weekly in hot water dont apply repellent to skin 451. what is pcp (pneumocystis carininii pneumonia? 452. it exist as part of the normal flora of the lungs, the infection results from an impaired immune system pt may need a bronchoscopy with biopsy of lung tissue 453. eosinophils? 454. usually with asthma 455. monocytes? 456. infection and several collagen disorders 457. lymphocytes? 458. cancers and malnourished pts 459. neutrophils? 460. infection, stress, and inflammation 461. RA s/s? 462. bilateral pain and swelling in fingers and joints with stiffness in morning, finger joints are erythematous and warm to touch 463. how to handle of an infant with HIV? 464. use disposable diapers, and discard in separate plastic bags use bleach solution and gloves to clean up blood spills hand washing is important anyone changing babies diaper should wear gloves 465. what should the pt with a desentization injection do? 466. must remain in clinic atleast 30 minutes 467. what are early manifestations of aids? 468. persistent fever swollen glands diarrhea weight loss fatigue 469. what does an elevated GFR indicate? 470. an acute inflammatory process pt will need thermal interventions (heat or cold) 471. what is an initial s/s of wound infection? 472. erythema (redness) at incision site 473. what is karposi sarcoma KS? 474. associated with aids it looks like hyperpigmented multicentric lesions that can be firm, flat, or nodular 475. what does histamine release causes? 476. increases mucus secretions bronchospasms bronchial constriction 477. what should a pt with active TB been transported wear? 478. a mask 479. what is early lyme disease characterized by? 480. fever influenza like manifestation erythema migrans distinct progressive circular rash (or bulls eye rash) 481. can pts with hepatitis a donate blood? 482. no 483. what does serum amylase has to do with? 484. pancreatitis 485. stoma care? 486. use mild soap apply skin sealant cut it 1/8 to 1/16 larger than the size measure it at least once a week 487. what is a early s/s of hepatitis A? 488. anorexia 489. what is a late s/s of hepatitis A? 490. pale feces dark urine jaundice 491. what to eat with peptic ulcer? 492. no soda eat as normal as possible eat 5-6 small meals a day 493. what foods to avoid with diverticulitis? 494. corn, strawberries, whole grain bread 495. what to do with spleenectomy? 496. promoting lung aeration is important 497. what is the position for an enema? 498. left lateral 499. TPN? 500. withdrawal look out for hypoglycemia (shakiness and diaphoresis) 501. SIADH? 502. is caused by excessive release of an antidiuretic hormone (ADH) as a result pt retains water creating a dilutional hyponatremia 503. what are dm type 2 manifestations of hyperglycemia? 504. increased urination and thirst 505. what are dm type 2 manifestations of hypoglycemia? 506. tremors cold, clammy skin 507. graves disease s/s? 508. difficulty slepping, diarrhea, increased appetite, heat intolerance 509. what does ketoacidosis causes? 510. dehydration by s/s of n/v 511. what are early s/s of hypoglycemia? 512. drowsiness clammy skin diaphoresis blurred vision 513. what are early s/s of hyperglycemia? 514. anorexia dry mouth urinary frequency 515. what are s/s of diabetes insipidus? 516. polydipsia polyuria 517. what does parathyroid hormone regulates? 518. calcium 519. what is the common cause of hyperthyroidism? 520. graves disease 521. what are s/s of thyroid storm? 522. fever hypertension pain tachycardia 523. what are s/s of diabetic ketoacidosis? 524. increased blood glucose levels positive urine acetone a low bicarbonate levels 525. what causes acromegaly? 526. excessive production of somatropin (growth hormone) after closing of the epiphyses 527. what is addisons disease? 528. hormone deficiency caused by damage to the outer layer of the adrenal gland they need diet high in salt, carbs, and protein low in potassium 529. what is primary therapy for a pt with JRA? 530. preservation of joint function 531. what is splitting? 532. a primitive ego defense mechanism that places people in good/bad categories 533. what is displacement? 534. transfer of feelings to a less threatening person 535. what is intellectualization? 536. a logical aproach 537. what is projection? 538. attribute her faults to others 539. what is the play mode in toddlers? 540. parallel play with each child performing similar activities 541. when are liver enzymes elevated? 542. in pts with HELLP 543. what to do with magnesium toxicity? 544. give calcium gluconate s/s of toxicity: loss of deep tendon reflex respiratory depression oliguria if left untreated can lead to cardiac and respiratory arrest 545. when taking iron supplement what would counteract with constipation? 546. eating raw fruit and vegetables 547. s/s of coarctation of the aorta? 548. unequal upper and lower extremity pulses 549. SSRI Side effects 550. Side effects of SSRIs may include, among others: Nausea Nervousness, agitation or restlessness Dizziness Reduced sexual desire or difficulty reaching orgasm or inability to maintain an erection (erectile dysfunction) Drowsiness Insomnia Weight gain or loss Headache Dry mouth Vomiting Diarrhea 551. MAOI Side effects 552. The most common side effects of MAOIs include: Dry mouth Nausea, diarrhea or constipation Headache Drowsiness Insomnia Skin reaction at the patch site Dizziness or lightheadedness Other possible side effects include: Involuntary muscle jerks Low blood pressure Reduced sexual desire or difficulty reaching orgasm Sleep disturbances Weight gain Difficulty starting a urine flow Muscle aches Prickling or tingling sensation in the skin (paresthesia 553. Opioid 554. Other side effects of opioid analgesics include: Euphoria, dysphoria, agitation, seizures, hallucinations Lowered blood pressure and heart rate Muscular rigidity and contractions Nausea and vomiting Non-allergic itching Pupil constriction Sexual dysfunction Urinary retention 555. Do not delegate 556. What you can EAT E-evaluate A-assess T-teach 557. Addison's & Cushings 558. Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia 559. Better peripheral perfusion? 560. EleVate Veins, DAngle Arteries 561. APGAR 562. Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) 563. Airborne precautions 564. My chicken hez tb (measles, chickenpox (varicella) Herpes zoster/shingles TB 565. Airborne precautions protective equip 566. private room, neg pressure with 6-12 air exchanges/hr mask N95 for TB 567. Droplet precautions 568. spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room or cohort mask!) 569. Contact precaution 570. MRS WEE Multidrug resistant organism Rresiratory infection Skin infection Wound infection Enteric infection (C diff) Eye infection (conjunctivitis) 571. Skin infection 572. VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies 573. Air or Pulmonary Embolism 574. S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) 575. Woman in labor (un-reassuring FHR) 576. (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! 577. Tube feeding with decreased LOC 578. Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) 579. After lumbar puncture and oil based myelogram 580. pt is flat SUPINE (prevent headache and leaking of CSF) 581. Pt with heat stroke 582. flat with legs elevated 583. during Continuous Bladder Irrigation (CBI) 584. catheter is taped to the thigh. leg must be kept straight. 585. After Myringotomy 586. position on the side of AFFECTED ear, allows drainage. 587. After Cateract surgery 588. pt sleep on UNAFFECTED side with a night shield for 1-4 weeks 589. after Thyroidectomy 590. low or semi-fowler's position, support head, neck and shoulders. 591. Infant with Spina Bifida 592. Prone so that sac does not rupture 593. Buck's Traction (skin) 594. elevate foot of bed for counter traction 595. After total hip replacement 596. don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. 597. Prolapsed cord 598. Knee to chest or Trendelenburg oxygen 8 to 10 L 599. Cleft Lip 600. position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. 601. To prevent dumping syndrome 602. (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. 603. AKA (above knee amputation) 604. elevate for first 24 hours on pillow. position prone daily to maintain hip extension. 605. BKA (below knee amputation) 606. foot of bed elevated for first 24 hours. position prone to provide hip extension. 607. detached retina 608. area of detachment should be in the dependent position 609. administration of enema 610. pt should be left side lying (Sim's) with knee flexed. 611. After supratentorial surgery 612. (incision behind hairline on forhead) elevate HOB 30-40 degrees 613. After infratentorial surgery 614. (incision at the nape of neck) position pt flat and lateral on either side. 615. During internal radiation 616. on bed rest while implant in place 617. Autonomic Dysreflexia/Hyperreflexia 618. S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! 619. Shock 620. bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) 621. Head Injury 622. elevate HOB 30 degrees to decrease ICP 623. Peritoneal Dialysis (when outflow is inadequate) 624. turn pt from side to side BEFORE checking for kinks in tubing 625. Lumbar Puncture 626. After the procedure, the pt should be supine for 4-12 hours as prescribed. 627. Myesthenia Gravis 628. worsens with exercise and improves with rest 629. Myesthenia Gravis 630. a positive reaction to Tensilon---will improve symptoms 631. Cholinergic Crisis 632. Caused by excessive medication ---stop giving Tensilon...will make it worse. 633. Liver biopsy (prior) 634. must have lab results for prothrombin time 635. Myxedema/ hypothyroidism 636. slowed physical and mental function, sensitivity to cold, dry skin and hair. 637. Grave's Disease/ hyperthyroidism 638. accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. 639. Thyroid storm 640. increased temp, pulse and HTN 641. Post-Thyroidectomy 642. semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside 643. Hypo-parathyroid 644. CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet 645. Hyper-parathyroid 646. fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet 647. Hypovolemia 648. increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030 649. Hypervolemia 650. bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's 651. Diabetes insipidus (decreased ADH) 652. excessive urine output and thirst, dehydration, weakness, administer Pitressin 653. SIADH (increased ADH) 654. change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics 655. hypokalemia 656. muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery) 657. Hyperkalemia 658. MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes 659. Hyponatremia 660. nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids 661. Hypernatremia 662. increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. 663. Hypocalcemia 664. CATS Convulsions, Arrythmias, Tetany, spasms and stridor 665. Hypercalcemia 666. muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! 667. Hypo Mg 668. Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) 669. Hyper Mg 670. depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY 671. Addison's 672. Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. 673. Cushings 674. Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump 675. Addesonian crisis 676. N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP 677. Pheochromocytoma 678. hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) 679. Tetrology of Fallot 680. DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) 681. Autonomic Dysreflexia 682. (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) 683. FHR patterns for OB 684. Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill 685. what to check with pregnancy 686. Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. 687. Position of the baby by fetal heart sounds 688. Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. 689. Ventilatory alarms 690. HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc 691. ICP and Shock 692. ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp 693. Cor pumonae 694. Right sided heart failure caused by left ventricular failure (edema, jugular vein distention) 695. Heroin withdrawal neonate 696. irritable, poor sucking 697. brachial pulse 698. pulse area on an infant 699. lead poisoning 700. test at 12 months of age 701. Before starting IV antibiotics 702. obtain cultures! 703. pt with leukemia may have 704. epistaxis due to low platelets 705. when a pt comes in and is in active labor 706. first action of nurse is to listen to fetal heart tones/rate 707. for phobias 708. use systematic desensitization 709. NCLEX answer tips 710. choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. 711. ARDS and DIC 712. are always secondary to another disease or trauma 713. In an emergency 714. patients with a greater chance to live are treated first 715. Cardinal sign of ARDS 716. hypoxemia 717. Edema is located 718. in the interstitial space, not the cardiovascular space (outside of the circulatory system) 719. the best indicator of dehydration? 720. weight---and skin turgor 721. heat/cold 722. hot for chronic pain; cold for accute pain (sprain etc) 723. When pt is in distress....medication administration 724. is rarely a good choice 725. pneumonia 726. fever and chills are usually present. For the elderly confusion is often present. 727. before IV antibiotics? 728. check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. 729. COPD and O2 730. with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. 731. Prednisone toxicity 732. Cushings (buffalo hump, moon face, high blood sugar, HTN) 733. Neutropenic pts 734. no fresh fruits or flowers 735. Chest tubes are placed 736. in the pleural space 737. Preload/Afterload 738. Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart. 739. CABG 740. Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart. 741. Unstable Angina 742. not relieved by nitro 743. PVC's 744. can turn into V fib. 745. 1 tsp 746. 5 mL 747. 1 oz 748. 30 mL 749. 1 cup 750. 8 oz 751. 1 quart 752. 2 pints 753. 1 pint 754. 2 cups 755. 1 g (gram) 756. 1000 mg 757. 1 kg 758. 2.2 lbs 759. I lb 760. 16 oz 761. centigrade to Fahrenheit conversion 762. F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 763. Angiotenson II 764. In the lungs...potent vasodialator, aldosterone attracts sodium. 765. Iron toxicity reversal 766. deferoxamine 767. S3 sound 768. normal in CHF. Not normal in MI 769. After endoscopy 770. check gag reflex 771. TPN given in 772. subclavian line 773. pain with diverticulitis 774. located in LLQ 775. appendicitis pain 776. located in RLQ 777. Trousseau and Chvostek's signs observed in 778. Hypocalcemia 779. never give K+ in 780. IV push 781. DKA is rare 782. in DM II (there is enough insulin to prevent fat breakdown) 783. Glaucoma patients lose 784. peripheral vision. 785. Autonomic dysreflexia 786. patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) 787. Spinal shock occurs 788. immediately after injury 789. multiple sclerosis 790. myelin sheath destruction. disruptions in nerve impulse conduction 791. Myasthenia gravis 792. decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. 793. Gullian -Barre syndrome 794. ascending paralysis. watch for respiratory problems. 795. TIA 796. transient ischemic attack....mini stroke, no dead tissue. 797. CVA 798. cerebriovascular accident. brain tissue dies. 799. Hodgkin's disease 800. cancer of the lymph. very curable in early stages 801. burns rule of Nines 802. head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1% 803. birth weight 804. doubles by 6 months triples by 1 year 805. if HR is <100 (children) 806. Hold Dig 807. early sign of cystic fibrosis 808. meconium in ileus at birth 809. Meningitis--check for 810. Kernig's/ brudinski's signs 811. wilm's tumor 812. encapsulated above kidneys...causes flank pain 813. hemophilia is x linked 814. passed from mother to son 815. when phenylaline increases 816. brain problems occur 817. buck's traction 818. knee immobility 819. russell traction 820. femur or lower leg 821. dunlap traction 822. skeletal or skin 823. bryant's traction 824. children <3 y <35 lbs with femur fx 825. eclampsia is 826. a seizure 827. perform amniocentesis 828. before 20 weeks to check for cardiac and pulmonary abnormalities 829. Rh mothers receive Rhogam 830. to protect next baby 831. anterior fontanelle closes by...posterior by.. 832. 18 months, 6-8 weeks 833. caput succedaneum 834. diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days 835. pathological jaundice occurs: physiological jaundice occurs: 836. before 24 hours (lasts 7 days) after 24 hours 837. placenta previa s/s placental abrution s/s 838. there is no pain, but there is bleeding there is pain, but no bleeding (board like abd) 839. bethamethasone (celestone) 840. surfactant. premature babies 841. milieu therapy 842. taking care of pt and environmental therapy 843. cognitive therapy 844. counseling 845. five interventions for psych patients 846. safety setting limits establish trusting relationship meds least restrictive methods/environment 847. SSRI's 848. take about 3 weeks to work 849. patients with hallucinations patients with delusions 850. redirect them distract them 851. Thorazine and Haldol 852. can cause EPS 853. Alzheimer's 854. 60% of all dementias, chronic, progressive degenerative cognitive disorder. 855. draw up regular and NHP? 856. Air into NHP, air into Regular. Draw regular, then NHP 857. Cranial nerves 858. S=sensory M=motor B=both Oh (Olfactory I) Some Oh (Optic II ) Say Oh (Oculomotor III) Marry To (trochlear IV) Money Touch (trigeminal V) But And (Abducens VI ) My Feel (facial VII) Brother A (auditory VIII) Says Girl's (glossopharyngeal IX) Big Vagina (vagus X) Bras And (accessory XI) Matter Hymen (Hypoglossal XII) More 859. Hypernatremia 860. S (Skin flushed) A (agitation) L (low grade fever ) T (thirst) 861. Developmental 862. 2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup 863. Hepatitis A 864. Ends in a vowel, comes from the bowel 865. Hepatitis b 866. B= blood and body fluids (hep c is the same) 867. Apgar measures 868. HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate 869. Glasgow coma scale 870. eyes, verbal, motor Max- 15 pts, below 8= coma 871. Addison's disease: Cushing's syndrome: 872. "add" hormone have extra "cushion" of hormone 873. Dumping syndrome 874. increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink 875. Disseminated herpes zoster localized herpes zoster 876. Disseminated herpes=airborne precautions Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered! 877. Isoniazid 878. causes peripheral neuritis 879. Weighted NI (naso intestinal tubes) 880. Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris 881. Cushings ulcers 882. r/t brain injury 883. Cushing's triad 884. r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure) 885. Thyroid storm 886. HOT (hyperthermia) 887. Myxedema coma 888. COLD (hypothermia) 889. Glaucoma 890. No atropine 891. Non Dairy calcium 892. Rhubarb sardines collard greens 893. Koplick's spots 894. prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth 895. INH can cause peripheral neuritis 896. Take vitamin B6 to prevent. Hepatotoxic 897. pancreatitis pts 898. put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids 899. Murphy's sign 900. Pain with palplation of gall bladder (seen with cholecystitis) 901. Cullen's sign 902. ecchymosis in umbilical area, seen with pancreatitis 903. Turner's sign 904. Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis 905. McBurney's point 906. Pain in RLQ with appendicitis 907. LLQ 908. Diverticulitis 909. RLQ 910. appendicitis watch for peritonitis 911. Guthrie test 912. Tests for PKU. Baby should have eaten protein first 913. shilling test 914. Test for pernicious anemia 915. Peritoneal dialysis 916. Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok 917. Hyper reflexes absent reflexes 918. upper motor neuron issue (your reflexes are over the top) Lower motor neuron issue 919. Latex allergies 920. assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches 921. Tensilon 922. used in myesthenia gravis to confirm diagnosis 923. ALS 924. (amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems 925. Transesophageal fistula 926. esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis) 927. MMR 928. is given SQ not IM 929. codes for pt care 930. Red- unstable, ie.. occluded airway, actively bleeding...see first Yellow--stable, can wait up to an hour for treatment Green--stable can wait even longer to be seen---walking wounded Black--unstable, probably will not make it, need comfort care DOA--dead on arrival 931. Contraindication for Hep B vaccine 932. anaphylactic reaction to baker's yeast 933. what to ask before flu shot 934. allergy to eggs 935. what to ask before MMR 936. allergy to eggs or neomycin 937. when on nitroprusside monitor: 938. cyanide. normal value should be 1. 939. William's position 940. semi Fowler's with knees flexed to reduce low back pain 941. S/S of hip fx 942. External rotation, shortening adduction 943. Fat embolism 944. blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids. 945. complications of mechanical ventilation 946. pneumothorax, ulcers 947. Paget's disease 948. tinnitus, bone pain, elnargement of bone, thick bones 949. with allopurinol 950. no vitamin C or warfarin! 951. IVP requires 952. bowel prep so bladder can be visualized 953. acid ash diet 954. cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread 955. alk ash diet 956. milk, veggies, rhubarb, salmon 957. orange tag in psych 958. is emergent psych 959. thyroid med side effects 960. insomnia. body metabolism increases 961. Tidal volume is 962. 7-10 ml/kg 963. COPD patients and O2 964. 2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less 965. Kidney glucose threshold 966. 180 967. Stranger anxiety is greatest at what age? 968. 7-9 months..separation anxiety peaks in toddlerhood 969. when drawing an ABG 970. put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2 971. Munchausen syndrome vs munchausen by proxy 972. Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child 973. multiple sclerosis 974. motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia 975. hungtington's 976. 50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure 977. WBC left shift 978. pt with pyelo. neutrophils kick in to fight infections 979. pancreatic enzymes are taken 980. with each meal! 981. infants IM site 982. Vastus lateralis 983. Toddler 18 months+ IM site 984. Ventrogluteal 985. IM site for children 986. deltoid and gluteus maximus 987. Thoracentesis: 988. position pt on side or over bed table. no more than 1000 cc removed at a time. Listen for bilateral breath sounds, V.S, check leakage, sterile dressing 989. Cardiac cath 990. NPO 8-12 hours. empty bladder, pulses, tell pt may feel heat, palpitations or desire to cough with injection of dye. Post: V.S.--keep leg straight. bedrest for 6-8 hr 991. Cerebral angio prep 992. well hydrated, lie flat, site shaved, pulses marked. Post--keep flat for 12-14 hr. check site, pulses, force fluids. 993. lumbar puncture 994. fetal position. post-neuro assess q15-30 until stable. flat 2-3 hour. encourage fluids, oral analgesics for headache. 995. ECG 996. no sleep the night before, meals allowed, no stimulants/tranquilizers for 24-48 hours before. may be asked to hyperventilate 3-4 min and watch a bright flashing light. watch for seizures after the procedure. 997. Myelogram 998. NPO for 4-6 hours. allergy hx phenothiazines, cns depressants and stimulants withheld 48 hours prior. Table moved to various positions during test. Post--neuro assessment q2-4 hours, water soluble HOB UP. oil soluble HOB down. oralanalgesics for HA. No po fluids. assess for distended bladder. Inspect site 999. Liver biopsy 1000. administer Vitamin K, NPO morning of exam 6 hrs. Give sedative. Teach pt to expect to be asked to hold breath for 5-10 sec. supide position, lateral with upper arms elevated. Post--position on RIGHT side. frequent VS. report severe ab pain STAT. no heavy lifting 1 wk 1001. Paracentesis 1002. semi fowler's or upright on edge of bed. Empty bladder. post VS--report elevated temp. watch for hypovolemia 1003. laparoscopy 1004. CO2 used to enhance visual. general anesthesia. foley. post--ambulate to decrease CO2 buildup 1005. PTB 1006. low grade afternoon fever 1007. pneumonia 1008. rusty sputum 1009. asthma 1010. wheezing on expiration 1011. emphysema 1012. barrel chest 1013. kawasaki syndrome 1014. strawberry tongue 1015. pernicious anemia 1016. red beefy tongue 1017. downs syndrome 1018. protruding tongue 1019. cholera 1020. rice watery stool 1021. malaria 1022. stepladder like fever--with chills 1023. typhoid 1024. rose spots on the abdomen 1025. diptheria 1026. pseudo membrane formation 1027. measles 1028. koplick's spots 1029. sle (systemic lupus) 1030. butterfly rash 1031. pyloric stenosis 1032. olive like mass 1033. Addison's 1034. bronze like skin pigmentation 1035. Cushing's 1036. moon face, buffalo hump 1037. hyperthyroidism/ grave's disease 1038. exophthalmos 1039. myasthenia gravis 1040. descending musle weakness 1041. gullian-barre syndrome 1042. ascending muscle weakness 1043. angina 1044. crushing, stabbing chest pain relieved by nitro 1045. MI 1046. crushing stabbing chest pain unrelieved by nitro 1047. cystic fibrosis 1048. salty skin 1049. DM 1050. polyuria, polydipsia,polyphagia 1051. DKA 1052. kussmal's breathing (deep rapid) 1053. Bladder CA 1054. painless hematuria 1055. BPH 1056. reduced size and force of urine 1057. retinal detachment 1058. floaters and flashes of light. curtain vision 1059. glaucoma 1060. painful vision loss. tunnel vision. halo 1061. retino blastoma 1062. cat's eye reflex 1063. increased ICP 1064. hypertension, bradypnea,, bradycarday (cushing's triad) 1065. shock 1066. Hypotension, tachypnea, tachycardia 1067. Lymes disease 1068. bullseye rash 1069. intraosseous infusion 1070. often used in peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids, blood products and meds are administered into the marrow. one med that CANNOT be administered IO is isoproterenol, a beta agonist. 1071. sickle cell crisis 1072. two interventions to prioritize: fluids and pain relief. 1073. glomuloneprhitis 1074. the most important assessment is blood pressure 1075. children 5 and up 1076. should have an explanation of what will happen a week before surgery 1077. Kawasaki disease 1078. (inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. 1079. ventriculoperitoneal shunt 1080. watch for abdominal distention. watch for s/s of ICP such as high pitch cry, irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the HOB 15-30 degrees 1081. 3-4 cups of milk a day for a child? 1082. NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA 1083. MMR and varicella immunizaions 1084. after 15 months! 1085. cryptorchidism 1086. undescended testicles! risk factor for testicular cancer later in life. Teach self exam for boys around age 12--most cases occur in adolescence 1087. CSF meningitis 1088. HIGH protein LOW glucose 1089. Head injury or skull fx 1090. no nasotracheal suctioning 1091. otitis media 1092. feed upright to avoid otitis media! 1093. positioning for pneumonia 1094. lay on affected side, this will splint and reduce pain. However, if you are trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with that side up, it clears!) 1095. for neutropenic pts 1096. no fresh flowers, fresh fruits or veggies and no milk 1097. antiplatelet drug hypersensitivity 1098. bronchospasm 1099. bowel obstruction 1100. more important to maintain fluid balance than to establish a normal bowel pattern (they cant take in oral fluids) 1101. Basophils reliease histamine 1102. during an allergic response 1103. Iatragenic 1104. means it was caused by treatment, procedure or medication 1105. Tamoxifen 1106. watch for visual changes--indicates toxicity 1107. post spelectomy 1108. pneumovax 23 is administered to prevent pneumococcal sepsis 1109. Alkalosis/ Acidosis and K+ 1110. ALKalosis=al K= low sis. Acidosis (K+ high) 1111. No phenylalanine 1112. to a kid with PKU. No meat, dairy or aspartame 1113. never give potassium 1114. to a pt who has low urine output! 1115. nephrotic syndrome 1116. characterized by massive proteinuria caused by glomerular damage. corticosteroids are the mainstay 1117. the first sign of ARDS 1118. increased respirations! followed by dyspnea and tachypnea 1119. normal PCWC (pulmonary capillary wedge pressure) 1120. is 8-13 readings 18-20 are considered high 1121. first sign of PE 1122. sudden chest pain followed by dyspnea and tachypnea 1123. Digitalis 1124. increases ventricular irritability ----could convert a rhythm to v-fib following cardioversion 1125. Cold stress and the newborn 1126. biggest concern resp. distress 1127. Parathyroid relies on 1128. vitamin D to work est tube pulled out? 1134. occlusive dressing 1135. PE 1136. Needs O2! 1137. DKA 1138. acetone and keytones increase! once treated expect postassium to drop! have K+ ready 1139. Hirschprung's 1140. diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul smelling stools 1141. Intussusception 1142. Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel movements 1143. laboring mom's water breaks? 1144. first thing--worry about prolapsed cord! 1145. Toddlers need to express Respiratory problems 1153. a nurse makes a mistake? 1154. take it to him/her first then take up the chain 1155. nitrazine paper 1156. turns blue with alkaline amniotic fluid. turns pink with other fluids 1157. up stairs with crutches? 1158. crutches first followed by good leg 1159. dumping syndrome? 1160. use low fowler's to avoid. limit fluids 1161. TB drugs are 1162. hepatotoxic! 1163. clozapine, Clozaril 1164. antipsychotic anticholinergic 1165. clozapine s/e 1166. weight gain, hypotension, hyperglycemia, agranulocytosis 1167. dehydration 1168. -hypovolemia - elevated urine specific gravity reposition side to side or knee-chest 1173. short cord 1174. discontinue pictocin 1175. Discontinue oxypocin 1176. Discontinue oxytocin if uterine hyperstimulation occurs. Symptoms of uterine hyperstimulation include: ☐ Contraction frequency more often than every 2 min. ☐ Contraction duration longer than 90 seconds. ☐ Contraction intensity that results in pressures greater than 90 mm Hg as shown by IUPC. ☐ Uterine resting tone greater than 20 mm Hg between contractions. ☐ No relaxation of uterus between contractions 1177. Airborne Precautions 1178. My - Measles Chicken - Chicken Pox/Varicella Hez - Herpez Zoster/Shingles TB 1179. Droplet 1180. think of SPIDERMAN! S - sepsis S - scarlet fever S - streptococcal pharyngitis P - parvovirus B19 P - pneumonia lottitis R - rubella M - mumps M - meningitis M - mycoplasma or meningeal pneumonia An - Adenovirus Private Room or cohort Mask 1181. Contact 1182. MRS.WEE M - multidrug resistant organism R - respiratory infection S - skin infections * W - wound infxn E - enteric infxn - clostridium difficile E - eye infxn - conjunctivitis 1183. Hypokalemia 1184. muscle ewakness, dysrhythmias, increase K (raisins, bananas, apricots, oranges, ontractility, ECG changes, reflexes 1187. Hyponatremia 1188. nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids 1189. Hypernatremia 1190. increased temp, weakness, disorientation/delusions, hypotension, tachycardia; hypotonic solution 1191. MAOI 1192. pirates say arrrr, so think; pirates take MAOI's when they're depressed. - explanation; MAOI's used for depression all have an arrr sound in the middle (Parnate, Marplan, Nardil) 1193. FHR patterns 1194. V = variable decels; C = cord compression caused E = early decels; H = head compression caused A = accels; O = okay, not a problem! L = late decels = placental insufficiency, can't fill 1195. Cord Compression 1196. place the mother in the TRENDELENBERG position because this removes pressure of the presenting part off the cord. (If her head is down, the baby is no longer being pulled out of hte body by gravity) If the cord is prolapsed, cover it with sterile saline gauze to prevent drying of the cord and to minimize infection. 1197. Late decelerations 11ased BP, decreased pulse, decreased resp 1201. shock 1202. decreased BP, increased pulse, increased resp 1203. Conversions 1204. 1 t (teaspoon)= 5 ml 1 T(tablespoon)= 3 t = 15 ml 1 oz= 30 ml 1 cup= 8 oz 1 quart= 2 pints 1 pint= 2 cups 1 gr (grain)= 60 mg 1 g (gram)= 1000 mg 1 kg= 2.2 lbs 1 lb= 16 oz 1205. Antidotes 1206. heparin= protamine sulfate coumadin= vitamin k ammonia= lactulose acetaminophen= n-Acetylcysteine. Iron= deferoxamine Digitoxin, digoxin= digibind. Alcohol withdraw= Librium. 12asps, switch & roll 6-7 months: sit at 6 and waves bye-bye 8-9 months: stands straight at eight 10-11 months: belly to butt (phrase has 10 letters) 12-13 months: twelve and up, drink from a cup 1209. Hepatitis 1210. Hepatitis: -ends in a VOWEL, comes from the BOWEL (Hep A) Hepatitis B=Blood and Bodily fluids Hepatitis C is just like B 1211. Give NSAIDS, Corticosteroids, drugs for Bipolar, Cephalosporins, and Sulfanomides 1212. with food 1213. Valium is treatment of 1214. status epilepticus (Ativan may be used also) 1215. Allopurinol arin 1217. Rifampin 1218. Red orange tears and urine, also contraceptives don't work as well 1219. LLQ 1220. diverticulitis , low residue, no seeds, nuts, peas 1221. Kayexalate 1222. Don't use with hypoactive bowel sounds 1223. Anticholinergic effects 1224. dry mouth==can't spit urinary retention=can't **** constipated =can't **** blurred vision=can't see 1225. TCA end in mine, pine or line 1226. ● Therapeutic Uses ◯ Depression ◯ Depressive episodes of bipolar disorders Orthostatic hypotension, Anticholinergic effects, Sedation, sweating, increased chance of seizure ----- Avoid use of MAOI and TCA Avoid TCA and anti-histamines 1227. SSRI (ends in pram, tine, line) 1228. ● Therapeutic Uses ◯ Major depression ◯ Obsessive compulsive disorder ◯ Bulimia nervosa ◯ Premenstrual dysphoric disorders ◯ Panic disorders ◯ Posttraumatic disorder --- Decreased sex libido CNS stimulation (inability to sleep, anxiety) Weight loss / gain --- Do not use St. Johns Wart MAOI must be discontinued for 14 days --- May increase warfarin levels or NSAID levels 1229. MAOI (zine, zid, mine, line) 1230. ● Therapeutic Uses ◯ Atypical depression ◯ Bulimia nervosa ◯ Obsessive compulsive disorder --------- Side effects CNS stimulation, orthostatic hypotension, hypertensive crisis (with tyramine) ------able to tolerate the sexual dysfunction side effects ◯ Aid to quit smoking ◯ Prevention of seasonal affective disorder --- Weight loss, sz, headache dry mouth [Show More]

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