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Flashcards in Nclex final test tutorial Deck (25)
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1

Planning activities for p w/ acute exacerbation of schizophrenia. Wotf is appropriate?
a. walking w/ a staff member on gated grounds
b. playing Ping-Pong in the dayroom w/ another p
c. shooting baskets w/ several other p's in the gym
d. riding on a bike alone in the fitness room

a. P. should participate in nonthreatening, noncompetitive physical activities. B and C are both high levels of stimulation and competitive options which require concentration and socialization (something the p might not be able to handle right now). D - p's should never be alone w/ acute schizophrenia

2

Child w/ strabismus . RN explains that to prevent amblyopia (lazy eye) it will be necessary to do wotf?
a. patch the unaffected eye
b. administer mydriatic eye drops daily
c. obtain Rx eyeglasses
d. give IV antibiotics

a. patch the unaffected eye. Amblyopia is a d/o of the eye in which unilateral central blindness occurs as a result of another condition, like strabismus. W/ strabismus, muscle weakness allows one eye to wander and the brain eventually ignores signals coming from this eye. This results in central blindness if not treated by 6 years of age. Patching the unaffected eye strengthens the other eye's muscles

3

Teaching p undergoing laser assisted in situ keratomileusis (LASIK) surgery, include that he?
a. may need to wear reading glasses after the surgery
b. can drive home after the procedure
c. should continue to wear his contact lenses until the day of surgery
d. will not have to wear glasses after the surgery

a. LASIK surgery corrects the refractive lens w/ myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, many ppl develop presbyopia (farsightedness) w/ age and may need reading glasses despite having had the LASIK surgery. P's should not drive home after LASIK surgery (blurry vision, tearing, and photophobia common SEs). P's should not wear contacts for two weeks prior to LASIK (limits O2 intake to the cornea).

4

astigmatism

refractive error of vision due to diffs in curvature of refractive surfaces of the eye (cornea and lens). Other words, the curvature of the cornea is not perfect and one cannot focus their vision on particular objects. This includes myopia and presbyopia

5

strabismus

deviation in the axis of the eye (crossed eyes)

6

amblyopia

lazy eye, failure of one eye to develop central vision. This is an untreatable condition

7

nystagmus

involuntary, rapid, rhythmic movement of the eyeball

8

Reinforcing teaching for child w/ Asperger's syndrome. Wotf is true?
a. Aricept may slow the progression of the d/o
b. grp therapy is important for children w/ cognitive d/os
c. it will help our child if we keep a structured daily routine
d. this d/o is r/t our child's prematurity

c. Asperger's syndrome is a high functioning form of autism. Children w/ this have nml to high cognitive skills and they may have problems with sudden schedule changes, socialization requirements and preferences for ritualistic behaviors. Donepezil (Aricept) is used to slow the progression of Alzheimer's disease. Prematurity is not r/t Asperger's syndrome

9

Receiving p. who had a thyroidectomy from PACU. Which emergency equipmt should be available on unit?
a. cardiac monitor
b. defibrillator
c. thoracotomy tray
d. tracheostomy tray

d. In the event of laryngeal edema or tetany, resp distress could result in airway obstruction. Emergency intubation may be difficult due to laryngeal swelling, and endotracheal intubation may increase the risk for hemorrhage by increasing tension on the incision during insertion. A trach tray should be easily accessible. A and B - thyroidectomy pts are not at increased risk for dysrhythmias.

10

P w/ tracheostomy and receiving mech ventilation. Low pressure alarm sounds indicating?
a. excessive airway secretions
b. a leak w/in the ventilator circuitry
c. decreased lung compliance
d. p. is coughing or attempting to talk

b. low pressure alarm = p is disconnected from tubing or that tubing has come apart.
a - a high pressure alarm would sound from excess secretions due to increased resistance of air movement into the p's lungs
c - decreased lung compliance would increase resistance to air movement, causing a high pressure alarm
d - coughing/talking causes increased resistance for the ventilator to deliver air, causing high pressure alarm

11

P. to have EEG in the am. teaching includes?
a. you will be given a sedative, so you wont feel the small electrical shock
b. after midnight you will not be able to ear or drink
c. you need to shampoo your hair tonight, and avoid applying hair products
d. its common to exp. temporary short-term memory loss following the procedure

c. EEG is a painless test that records the electrical activity of the brain. During the test, electrodes are attached to the scalp and will not adhere properly if the p's hair is not clean and free of oil/products. Sedatives are not given for an EEG, p's are not required to be NPO as anesthetics are not used, and short-term memory loss is r/t electroconvulsive therapy.

12

Receiving IV ampicillin and p. develops urticaria and dyspnea?
a. give diphenhydramine (Benadryl)
b. call the HCP
c. obtain pulse ox reading
d. stop the infusion

d. stop the infusion. Then monitor pulse ox, call HCP, and give Benadryl

13

Body mechanics

sit with your back supported, knees should be at the hip level, wrist and forearms should be parallel to the ground (also, arms kept close to body, head should be level when looking at computer screen)

14

P. suspected of SLE, RN expects to note an increased?
a. aPTT
b. RBC count
c. Hgb and Hct
d. ESR

d. ESR - SLE is a chronic autoimmune disease that causes skin, heart, lung, and renal inflammation and is characterized by exacerbations and remissions. P's typically die from end stage renal disease. Most p's will have an increased ESR. Most SLE p's have anemia, so decreased RBCs, Hct, and Hgb

15

cataracts

clouding of the lens of the eyes that causes gradual visual impairment, decreased contrast and blurred vision

16

angle-closure glaucoma

caused by a sudden shift in the position of the iris of the eye that blocks the outflow of aqueous humor. This leads to an acute increase in IOP and pain. (emergency) S&S include redness, reduced vision, colored halos and headache

17

detached retina

Retina is a thin layer of light sensitive tissue on the back of the eye. Detached retina is an emergency in which the retina peels away from its underlying support tissue, if entirely detached it will lead to permanent vision loss. S&S = sudden onset of decreased peripheral and central vision, dark floaters, flashes of light, and a curtain being pulled over visual field

18

macular degeneration

Results in loss of vision in the central visual field (the macula) bc of damage to the retina. S&S= gradual reduction of central vision

19

P. w/ Addison's comes to ER c/o N/V, diarrhea and abd pain. Prevent addisonian crisis by IV administration of?
a. calcium
b. potassium
c. insulin
d. corticosteroids

d. Addison's = adrenal gland hypofunction and inadequate production of corticosteroids. This can lead to severe/fatal F&E imbalances. Rapid infusions of NS boluses and high doses of hydrocortisone sodium succinate (Solu-cortef) are started as soon as venous access is established

20

RN helping with breastfeeding immediately following birth of NB. Wotf is the most important benefit of breastfeeding at this time?
a. RN is available to assist the mother
b. Maternal- NB bonding is promoted while NB is in alert phase
c. warmth is provided for the NB being held against the mom
d. oxytocin secretion is stimulated causing UCs

d. Oxytocin causes UCs, promoting involution and decreasing the risk for hemorrhage. This represents a physiological need.
a- not most important benefit
b- this promotes bonding, which would be a love/belonging need and is not the most important benefit
c - this is a physiological need but not the most important benefit

21

Manifestations of an MI

N/V, diaphoresis, dizziness, chest and left arm pain, anxiety, feelings of impending doom

22

Toddler to undergo insertion of pressure equalization tubes (tympanoplasty tubes). Parents asks "When will these tubes be removed?"
a. When the doctor determines it is time to remove the tubes
b. unless they need to be replaced, they are permanent
c. the tubes remain in place for 1-2 years until they fall out on their own
d. you don't need to worry about that now. The doctor will decide what to do when the time comes

c. Children generally outgrow the tubes and they usually fall out on their own a couple years after insertion

23

Expected txmt for a p admitted w/ SIADH?
a. increased fluids w/ hypertonic NaCl and fludrocortisone (Florinef)
b. fluid restriction plus hypertonic NaCl and furosemide
c. physiological amts of hypotonic NaCl and vasopressin
d. isotonic 0.9% NaCl to replace UOP and desmopressin

b. fluid restriction plus hypertonic NaCl and furosemide. SIADH causes water intoxication (and hyponatremia) b/c the posterior pituitary gland continually secretes ADH.
a. this is used to treat cerebral salt wasting disease (hyponatremia and hypovolemia)
c & d - these interventions treat DI

24

Hypovolemic shock, expected lab values?
a. urine spec grav 1.026
b. Hct 35%
c. Hct 55%
d. urine spec grav 1.001

c. hct 55%. An elevated Hct indicates hypovolemia, along with a weak pulse, hypotension, decreased CVP, decreased CO, elevated BUN and serum osmolality and decreased UOP.
A low spec gravity indicates hypervolemia

25

Wotf is consistent with celiac disease?
a. elevated sweat chloride
b. foul-smelling stool
c. clubbing of the fingernails
d. jaundice

b. foul smelling stool.