Milestone 2-1 Flashcards

Question

NGT with decreased peristalsis

Answer 1

Turning side to side in bed Ambulation Bowel sounds Full Fowler's

Answer 2

Indication of infection, leakage of bile into peritoneal cavity, and obstruction of bile drainage; acute pain Note and report it

Answer 3

Elevated WBC in labs for diagnosis Stage I: Rest, oral fluids, analgesics, clear liquid diet Stage II: NPO, IV fluids, NG suctioning, antibiotics, oxycodone for pain

Answer 4

Fewer RBCs than normal, therefore, have lower hemoglobin (normal 12-18)

Answer 5

Manages symptoms of SLE (lupus) Retinal damage is most serious toxicity Discontinue at first sign of retinal injury

Answer 6

- Hypervolemia can occur - Diuretics administered prior to infusion (at risk) - Signs: dysnpea, orthopnea, tachy, HTN, anxiety, JVD, crackles, hypoxemia, pulmonary edema, pink/frothy sputum - If mild, slow rate and give diuretics - Iron-chelation therapy for iron toxicity

Answer 7

Primary osteoporosis after menopause Weight-bearing exercise, reduce caffeine, tobacco, alcohol, carbonated drinks

Answer 8

Knowledge of condition & treatment Pain relief Improved bowel elimination Absence of fractures

Answer 9

Overweight Sedentary lifestyle Assistive devices - remove stigma Give analgesic before exercise

Answer 10

Severe dieting not necessary Maintain normal weight Avoid purine-rich foods (shellfish, organ meat) Avoid trauma, stress, alcohol, red meat

Answer 11

Respiratory acidosis causes hypercapnia (excess CO2) which causes vasodilation of cerebral arteries, increasing intracranial pressure

Answer 12

Strict gluten-free diet for life (damages villi)

Answer 13

Modified Sims, Trendelenberg, knee-chest positions

Answer 14

Gestational diabetes lab

Answer 15

Presence of Group B streptococcus Indicates treatment of the mother with antibiotics (Penicillin G 4 hours prior to delivery) Women who at 36-37 weeks are screened

Answer 16

Maintain mom's cardiovascular status Deliver fetus quickly If partial - C-section If complete - vaginal, baby died

Answer 17

Reposition to left or right lateral, knee-chest, or hands and knees

Answer 18

Oxytocin first - dilute in NS If boggy uterus, fundal massage

Answer 19

- Can be an adverse reaction of spinal anesthesia - Semi-Fowler, IV hydration, O2

Answer 20

Undescended testes Palpated in inguinal canal Can be unilateral/bilateral If can't palpate, further investigation

Answer 21

Persistent cyanosis of fingers, hands, toes, and feet with mottled blue or red discoloration and coldness May be seen in newborns during the first few weeks of life in response to exposure to cold. Acrocyanosis is normal and intermittent.

Answer 22

Vitamin K, a fat-soluble vitamin, promotes blood clotting by increasing the synthesis of prothrombin by the liver Newborns are at risk for vitamin K deficiency and subsequent bleeding unless supplemented at birth Vitamin K is not produced in the intestine until after microorganisms have been introduced, such as with the first feeding

Answer 23

Dehydration can trigger sickling Other signs are elevated HR, pain, hyperthermia Promote hydration, give IV fluids

Answer 24

A hypoglycemic patient needs to be treated with sugar (i.e., milk, juice), followed by some form of protein intake

Answer 25

Nuchal rigidity-stiff neck Kernig's sign- hip flex causes pain in knee extension Brudzinskis- neck flex causes knee and hip flex

Answer 26

Aka cretinism Causes diminished physical and mental capacity Measure & record growth Measure thyroid levels Assess for hypo- or hyperfunction L-thyroxine (Synthroid) is treatment

Answer 27

Give IM to child < 2 yrs, once/month during RSV season - Prematurity - Chronic lung disease (bronchopulmonary dysplasia) requiring medication or oxygen - Certain congenital heart diseases - Certain neuromuscular disorders

Answer 28

Assess for hypo- or hyperglycemia in hospitalized child every 2 hours Child will need immediate access to rapid-acting insulin

Answer 29

- an absence of some or all of the major biliary ducts, resulting in obstruction of bile flow - causes cholestasis resulting in jaundice and eventual progressive fibrosis with end-stage cirrhosis of the liver - Assess: persistent jaundice, enlarged liver, chalky white stools - Management: vitamins ADEK, antibiotics, diuretics for ascites

Answer 30

Epilepsy Febrile Neonatal

Answer 31

Control and reduce frequency Anticonvulsants Neuro exam Seizure precautions Relieve anxiety Monitor EEG changes in neonatal seizures

Answer 32

Most common renal tumor Occurs in kids 2-5 yrs Affects only one kidney Avoid palpating for initial pre-op assessment (metastasis)

Answer 33

“HOLE” in Ventricles Heart Failure and pulmonary hypertension: clammy sweating and occurs with activity like crying, activity, feeding etc. Often experiences lung infections (lung congestion) Low growth rate and loss of weight (inability to eat and burns calories due to difficulty breathing and increased workload on the heart) Extra heart sounds: holosystolic/pansystolic murmur (the mumur starts at S1 and goes into S2)…it may or may not be present at birth until pressure changes occur and is found at the lower left sternal border

Answer 34

Occurs most often in children with CHD Assess: VS, fatigue, weight gain, heart/resp function, apical pulse for 1 min Tests: Chest x-ray, ECG, echo Promote: O2, cardiac, nutrition, rest Tx: Digoxin, ACE, diuretics

Answer 35

Currant-jelly, bloody Palpate for sausage-shaped mass Treat with barium enema

Answer 36

Sweat chloride test: suspicious > 50 mEq/L, diagnostic if > 60 mEq/L Sweat is thick with salty taste and has more chloride

Answer 37

Recurrent bleeding into the joints can cause destruction Promote physical activity

Answer 38

No pelvic exam Painless, vaginal bleeding Diagnosed with ultrasound Treated with strict bedrest Monitor VS, FHR, bleeding (risk for hemorrhage)

Answer 39

Highest risk at ~2 weeks after starting antidepressant medication Correlated with bullying A form of PTSD

Answer 40

Avoid direct confrontation Instead, address environmental triggers

Answer 41

· electroconvulsive therapy (ECT) · Psychotherapy: o Interpersonal therapy - relationships, grief reactions, roles o Behavior therapy – positive/negative interactions, social skills o Cognitive therapy – how person thinks

Answer 42

When predictability of meetings or groups and staff–client interactions is lacking, clients often feel frustrated and bored, and aggression is more common and intense Triggering phase - the nurse should approach the client in a nonthreatening, calm manner in order to deescalate the client’s emotion and behavior Escalation phase - nurse should provide directions to the client in a calm, firm voice. The client should be directed to take a time-out for cooling off in a quiet area or his or her room Crisis phase – physically violent; staff must take charge of the situation for the safety of the client, staff, and other clients.

Answer 43

Family members and friends should be aware that clients who begin to revert to old behaviors, return to substance-using acquaintances, or believe they can “handle myself now” are at high risk for relapse, and loved ones need to take action.

Answer 44

To reverse negative views of the future Improve self-image Gain competence and self-mastery

Answer 45

Start multiple activities at once People in the manic phase are easily angered and irritated and strike back at what they perceive as censorship

Answer 46

Mental health clinicians may have a duty to warn identifiable third parties of threats made by clients, even if these threats were discussed during therapy sessions Must base his or her decision on the following: Is the client dangerous to others? Is the danger the result of serious mental illness? Is the danger serious? Are the means to carry out the threat available? Is the danger targeted at identifiable victims? Is the victim accessible?

Answer 47

Identify feelings that are related to self-mutilating or self-destructive behaviors Focus on self-responsibility and active approaches Identify strengths and successful coping behaviors

Answer 48

- Pressured speech - a classic hallmark of mania Interventions: - Decrease environmental stimuli - Use a firm yet calm, relaxed approach - Provide a consistent, structured environment

Answer 49

Belief that “others” are planning to harm him or her or are spying, following, ridiculing, or belittling (i.e., poisoned food) Don't support or challenge them Ask them to explain their belief

Answer 50

Believe them, listen, affirm safety, respect their decision, encourage them to develop a plan

Answer 51

Gentle inquiry about the family’s usual approach to resolving interpersonal difficulties

Answer 52

The fourth level involves esteem needs, which include the need for self-respect and esteem from others; confidence, achievement

Answer 53

· identified and diagnosed in preschool or school · Symptoms interfere significantly with behavior and performance in school o impulsivity, inability to share or take turns, tendency to interrupt, and failure to listen to and follow directions. · The secondary complications of ADHD, such as low self-esteem and peer rejection · Tx: 1st line are stimulants (methylphenidate), 2nd line antidepressants (SSRIs)

Answer 54

A key feature of ADHD is the consistency of the child’s behavior Strategies for Home and School: · Medications, behavioral/environmental strategies · Giving stimulants during daytime combats insomnia

Answer 55

a condition that occurs when a person drinks enough water to significantly lower the concentration of sodium in the blood (hyponatremia)

Answer 56

Consistent interval between 0.12 and 0.20 seconds The PR Interval indicates atrioventricular conduction time. The interval is measured from where the P wave begins until the beginning of the QRS complex

Answer 57

Rate 120-200 bpm, irregular rhythm, no P-waves Increased risk for stroke, HF, myocardial ischemia

Answer 58

Unstable angina happens when a person still experiences pain even after stopping a stressful physical activity ANOM - aspirin, nitrogen, oxygen, morphine

Answer 59

Relieve pain or ischemic S/S Prevent further damage Respiratory Perfusion Reduce anxiety Self-care program Recognize complications

Answer 60

Avoid strenuous activity Alternate rest with activity

Answer 61

Chest pain, orthopnea, dyspnea on exertion, syncope Pillows needed to sleep, weight change, limited ADLs

Answer 62

With pulmonary edema, there is an extra layer of fluid in the alveoli that interferes with the lungs' ability to get rid of CO2. This leads to a rise in pCO2.

Answer 63

Dyspnea - common symptom Tachypnea - common sign Chest Pain, anxiety, fever, tachycardia, apprehension, cough, diaphoresis, hemoptysis, and syncope

Answer 64

Notify provider if PaO2 < 80 A rapid onset of severe dyspnea Arterial hypoxemia that does not respond to supplemental oxygen Respiratory acidosis can occur (PaCO2 > 45)

Answer 65

Born from mothers w/Hep C Health care and public safety workers Exposure Multiple sex partners, history of STIs IV/injection drug use Recipient of blood products or organ transplant before 1992 or clotting factor concentrates before 1987

Answer 66

Avoid risky behavior Avoid multi-dose vials Monitor cleaning, disinfection, and sterilization Barrier precautions with blood or body fluids. Use needleless IV and injection systems Standard precautions

Answer 67

In most cases, serum amylase and lipase levels are elevated within 24 hours of the onset of the symptoms (diagnostic)

Answer 68

Hematemesis is a key assessment for liver disease Interventions: Semi-fowler’s, give albumin

Answer 69

High-protein, high-calorie diet High carb Avoid potassium or phosphorus (e.g., bananas, citrus fruits and juices, coffee)

Answer 70

Withhold antihypertensive meds before dialysis to avoid hypotension

Answer 71

Severe hypoglycemia can result from Addison's Administer IV glucose

Answer 72

HTN, hyperglycemia

Answer 73

Hypokalemia & hypernatremia are signs Tx: Desmopressin (replaces ADH) Fluid deprivation test

Answer 74

Circulatory assessment consists of: Peripheral pulses, color, capillary refill, and temperature of the fingers or toes

Answer 75

Scheduled toileting Continence management Self-catheterization

Answer 76

Bulbar weakness can impair ability to swallow Suctioning may be needed to clear airway Assess for gag reflex and bowel sounds if resume oral feeding Gastrostomy/NG tube placed if can't swallow

Answer 77

Amplified pain sensation CNS's ascending & descending pathways (that regulate and moderate pain processing) function abnormally, turning up the “volume control setting” for pain

Answer 78

Administered for glaucoma as a miotic drug To assess for therapeutic effect: Check the intraocular pressure

Answer 79

Causes thrombocytopenia - increases risk for bleeding, use a soft toothbrush Bone marrow suppression causes anemia, leukopenia, and thrombocytopenia Anemia - low hemoglobin and hematocrit

Answer 80

The outer layers of the retina slowly break down, causing drusen to appear within the macula --> blurred vision, straight lines appear crooked Use Amsler grid several times a week Loss of central vision

Answer 81

Blurred vision Diplopia Ptosis

Answer 82

Resemble the tissue of origin, most likely benign

Milestone 2-1 Flashcards

(107 cards)