page 31-40 Flashcards
(165 cards)
1
Q
Immunizations
What do you get at each age?
BIRTH (1 vaccine)
A
Hep B #1
2
Q
Immunizations
What do you get at each age?
2 months (5 vaccines)
A
Hep B #2 (some resources say it can be given at 1 mo.) DTap Hib Haemophilus influenzae type b IPV Inactivated polio vaccine PCV Pneumococcal conjugate vaccine
3
Q
Immunizations
What do you get at each age?
4 months (4 vaccines)
A
All 2-month immunizations except Hep B
4
Q
Immunizations
What do you get at each age?
6 months (5 vaccines)
A
All 2-month immunizations: Hep B #2 DTap Hib IPV PCV
5
Q
Immunizations
What do you get at each age?
12 months
A
MMR #1
Hib Haemophilus influenzae type b
PCV
Varicella
6
Q
Immunizations
Tetanus & diptheria are optional vaccinations; what is the earliest age they can be given?
A
2 months
7
Q
Immunizations
What is a booster shot?
A
An additional dose of vaccination to increase effectiveness.
8
Q
Immunizations
What are the side effects of immunizations?
A
low-grade fever, tenderness, swelling at the site, child may become irritable
9
Q
Immunizations
What medications should be given for these effects?
A
Acetaminophen
10
Q
Immunizations
Never give ______ to children experiencing side effects of immunization.
A
Aspirin
11
Q
Immunizations
When should the meningitis vaccination be given?
A
Before going to college
12
Q
Immunizations
If an adult woman receives an MMR shot, what should you teach her?
A
Wait three months before pregnancy
13
Q
Immunizations
How soon can a child get the influenza vaccination?
A
Not until six months
14
Q
Immunizations
Do not give MMR if the client is allergic to _____ or _____.
A
Eggs or neomycin
15
Q
Immunizations
Do not give the influenza vaccination if the client is allergic to ______.
A
Eggs
16
Q
Immunizations
What is active immunity?
A
Stimulating the body to produce antibodies by giving a vaccine
17
Q
Immunizations
What is passive immunity?
A
Antibodies that are formed in another body but passed down for short-term use (breastmilk)
18
Q
Inflammatory Bowel Disease
Crohn’s Disease vs Ulcerative Colitis
Location: Anywhere in the digestive tract from mouth to anus
A
Crohn‘s Disease
19
Q
Inflammatory Bowel Disease
Crohn’s Disease vs Ulcerative Colitis
Location: Primarily colon
A
Ulcerative Colitis
20
Q
Inflammatory Bowel Disease (Crohn’s Disease vs Ulcerative Colitis)
Signs: 3-4 semi-soft stools, no blood, anorexia, fistulas
A
Crohn’s Disease
21
Q
Inflammatory Bowel Disease
Crohn’s Disease vs Ulcerative Colitis
Signs:
- Bloody diarrhea
- Weight loss
A
Ulcerative Colitis
22
Q
Inflammatory Bowel Disease
Crohn’s Disease vs Ulcerative Colitis
Lifestyle: Associated with smoking
A
Crohn’s Disease
23
Q
Inflammatory Bowel Disease
Crohn’s Disease vs Ulcerative Colitis
Lifestyle: Non-smokers
A
Ulcerative Colitis
24
Q
Inflammatory Bowel Disease
Treatment: Anti-inflammatory steroids
NPO Status- bowel rest
Surgery will not help; disease will reoccur
A
Crohn’s Disease
25
Inflammatory Bowel Disease
Treatment: Anti-inflammatory steroids
NPO Status -bowel rest
Surgery to remove affected area
Ulcerative Colitis
26
Incentive Spirometry
Incentive Spirometry is a method of _____ that helps maximize lung inflation.
Deep breathing
27
Incentive Spirometry
| Instruct the client to place _______ tightly around the mouth piece.
Lips
28
Incentive Spirometry is used after surgery to prevent _______.
Atelectasis
29
Increased intracranial pressure (ICP)
| what is the normal intracranial pressure range?
5-15 mmHg
30
Increased intracranial pressure (ICP)
| What are the common causes of ICP?
Trauma
Hemorrhage
Edema
Tumors
31
Increased intracranial pressure (ICP)
This the earliest sign of ICP.
Decreased level of consciousness
32
Increased intracranial pressure (ICP)
| The client will often appear?
Restless, agitated, complaining of headaches
33
Increased intracranial pressure (ICP)
| What will babies physically present with?
Bulging fontanelles
34
Increased intracranial pressure (ICP)
| Late signs of ICP
Unilateral pupil dilation
Hypertension or hypotension
Bradycardia
35
Increased intracranial pressure (ICP)
| Client may complain of ________.
Projectile vomiting without nausea.
36
Increased intracranial pressure (ICP)
| How will the vital signs appear with ICP?
B/P (up)
Temp (up)
Resp (up then down)
HR (up)
37
Increased intracranial pressure (ICP)
| What is widening pulse pressure & how it is related?
When systolic bp goes up & diastolic continues to go down so that they become further apart (eg 135/40 is a bad sign)
38
Increased intracranial pressure (ICP)
| What is Cushing’s Triad?
3 things
Widening pulse pressure
Cheyne stokes respirations
Bradycardia
39
Increased intracranial pressure (ICP)
| Initiate _____ precautions.
Seizure
40
Increased intracranial pressure (ICP)
Elevate hob to?
10 to 30 degrees; to promote jugular venous outflow
41
Increased intracranial pressure (ICP)
| What medications will be prescribed?
Anti convulsants
BP medications
Corticosteroids
Diuretics
42
Increased intracranial pressure (ICP)
| Tell the client not to ________,_____,or ______.
Strain, cough or sneeze
43
Increased intracranial pressure (ICP)
| Nursing interventions would be to?
DECREASE environmental stimuli.
Maintain body temperature.
LIMIT fluid intake.
Monitor intake & output.
44
Instillation of Ear Medications
| Medication should be________ temperature?
Room - too hot or cold will have side effects (nausea dizziness etc)
45
Instillation of Ear Medications
| What position should the client be in when receiving ear medications?
Supine, with AFFECTED EAR UP
46
Instillation of Ear Medications
| When administering ear meds to an adUlt, draw the pinna back and ______.
Up
47
Instillation of Ear Medications
| When administering ear meds to an chilD, draw the pinna back and ______.
DOWN
48
Instillation of Ear Medications
| How long should the head be tilted to allow medication to travel the ear canal? _____ minutes
5 minutes
49
Instillation of Eye Medications
| When giving eye medications, do this to prevent meds from going into the nasal passage.
Apply pressure
50
Instillation of Eye Medications
| Pull the _____ eyelid down against the ______.
Lower, cheek
51
Instillation of Eye Medications
| Squeeze the drop in the _____.
Conjunctiva sac
52
Instillation of Eye Medications
| If more than one drop is prescribed, wait ___ to ___minutes before applying another drop.
3 to 5 minutes
53
Instillation of Eye Medications
| Do not let the ____ touch the ___.
Medication bottle, eyeball
54
Intravenous therapy
| Why are IV fluids used?
They are a quick way to replace nutrients, water, and electrolytes.
55
Instillation of Eye Medications
| What are the 3 types of IV fluid?
Isotonic
Hypotonic
Hypertonic
56
Increased intracranial pressure (ICP)
Initiate _____ precautions.
SEIZURE PRECAUTIONS
57
Increased intracranial pressure (ICP)
| Elevate hob to?
10-30 degrees, to promote jugular venous outflow
58
Increased intracranial pressure (ICP)
| What medications will be prescribed?
Anticonvulsants
Blood pressure medications
Corticosteroids
Diuretics
59
Increased intracranial pressure (ICP)
| Tell the px not to _____,____, or_____.
Strain, cough, or sneeze
60
Increased intracranial pressure (ICP)
| Nursing interventions would be to?
Decrease environmental stimuli
Maintain body temperature
Limit fluid intake
Monitor intake & output
61
Instillation of Ear Medications
| Medication should be ______ temperature?
Room
| -too hot or cold will have side effects (nausea, dizziness etc)
62
Intravenous Therapy
| Describe Isotonic fluid/give examples.
Isotonic fluid is the same as the inside of the cell.
0.9% normal saline
Lactated Ringer
D5W
63
Intravenous Therapy
| Why would you give isotonic fluids?
D.K.A, Burns to replace sodium chloride
| *0.9% NS always hung with blood
64
Intravenous Therapy
| Describe hypotonic fluids/give examples.
Hypotonic fluid is less concentrated than the cell.
This would cause water to move into the cell.
0.45% NS
65
Intravenous Therapy
| Why would you give hypotonic fluids?
Dehydration, HYPERnatremia; lowers blood pressure.
66
Intravenous Therapy
| Why should hypotonic fluids be closely monitored?
Because a rapid increase in fluid shifting into the cells can cause cellular & cerebral edema.
67
Intravenous Therapy
| Describe HYPERtonic fluid/give examples.
Hypertonic fluid is more concentrated than the cell.
This would cause water movement out of the cell.
5% NS
D5%NS
D5%LR
68
Intravenous Therapy
| WHY would you give HYPERtonic fluids?
Hyponatremia, nutrition
69
Intravenous Therapy
| Why would HYPERTONIC fluids be closely monitored?
Because it can cause electrolyte imbalance & dehydration.
70
Intravenous Therapy
| Before you start IV fluids, assess client's ______.
IV; make sure it is patent
71
Intravenous Therapy
| If the IV is infiltrated, what would you see?
Cool, swollen, tender, painful at the site
72
Laminectomy
| Surgery is the removal of ______ so the spinal cord can be seen.
Bone
73
Laminectomy
| To move the client after surgery, ______ this client!
Log roll
74
Lead Poisoning
| What is the highest risk factor in ingesting lead?
Age; younger kids put things in their mouth
75
Lead Poisoning
| What is the most likely ingested item to cause lead poisoning?
Lead paint chips
76
Lead Poisoning
| The MOST dangerous side effect of ingesting lead is ________.
Mental retardation
77
Lead Poisoning
| What are the signs of lead poisoning?
```
Signs more serious if larger amounts are ingested:
headache,
abdominal pain,
fatigue,
muscle weakness,
respiratory depression
```
78
Lead Poisoning
| How do you treat lead poisoning?
Chelating agents
79
Lead Poisoning
| How are these chelating agents given?
By receiving many IM injections
80
Lead Poisoning
| Do not give ______ to induce vomiting.
Ipecac
81
Legal Issues
| Negligence is when a nurse does _______.
NOT provide appropriate care according to set standards
82
Legal Issues
| If a nurse does a treatment without consent, it is example of ______?
Battery
83
Legal Issues
| If your client falls out of bed because you forgot to put up the side rails, this is _________.
Neglect
84
Legal Issues
| Any NCLEX question that has the word ''threat'', think?
Assault
85
Legal Issues
| Advanced directives are important because they _____.
Allow the client to direct how/what care they are to receive if they become unable to make decisions in the future.
86
Legal Issues
| Are advanced directives mandatory for a client?
NO
87
Legal Issues
| The document that specifically names a person to make decisions on another person's behalf is_______.
Durable power of attorney
88
Legal Issues
| The client must be of ______ to write a will.
Sound mind
89
Lung Sounds
| What is the cause of crackles?
Fluid or secretions in the airway
90
Lung Sounds
| When do you hear crackles?
On inspiration (sounds like Rice Crispies in milk)
91
Lung Sounds
| What are some possible causes of crackles?
pneumonia
edema
bronchitis
92
Lung Sounds
| What is another name for crackles?
Rales
93
Lung Sounds
| What are the characteristics of wheezes?
High-pitched musical sounds
94
Lung Sounds
| When do you hear wheezes ?
On inspiration & expiration
95
Lung Sounds
| What are possible causes of wheezing?
asthma
smoking
allergic reactions
96
Lung Sounds
| Wheezes can often be heard without a _______.
Stethoscope
97
Lung Sounds
| What are characteristics of stridor?
High-pitched harsh sound heard in UPPER airway.
98
Lung Sounds
| Stridor is often confused with _____.
Wheezing
99
Lyme Disease
| This type of infection is caused by?
Bite from a tick
100
Lyme Disease
| How long after a bite can you test for this disease?
Between 4 to 6 weeks
101
Lyme Disease
| What is the treatment plan?
Take antibiotics:
Doxycycline (Adults)
Amoxicillin (Children)
102
Maslow's Hierarchy of Needs
| What are the most important factors in order?
```
Physiological Needs
Safety & Security
Love & Belongingness
Self-Esteem
Self-Actualization
```
103
Mastectomy
| This surgery is to remove ______ or _____.
Breast tissue or nipple
104
Mastectomy
| After surgery, ______ the affected arm to prevent _______.
Elevate, lymphedema
105
Mastectomy
| No ______ or _____ in the affected arm.
BP, venipuncture
106
Mastectomy
| Always assess site for signs of _____ after surgery.
Infection
107
Mastectomy
| List signs of infection.
```
● swelling
● redness
● fever
● chills
● elevated WBC count
```
108
Mastectomy
| Encourage client to do ______ on the remaining breast.
Self breast exam
109
Medication Administration
| What are the six rights of medication administration?
Right:
1. Client
2. Medication
3. Time
4. Documentation
5. Dose
6. Route
110
Medication Administration
| What two verifiers do you ask a client before giving a medication?
Name & birthdate
111
Medication Administration
| Do not give medication if _____.
You don't know what it does.
| Clients will ask. If you can't answer them, they won't trust you!
112
Medication Administration
| DO NOT STORE medications _____.
At the bedside
113
Medication Administration
| Can you give medication prepared by other RN?
No, never do this. This is ILLEGAL!
114
Medication Administration
| What does it mean if a medication is PRN?
It means to give only when necessary.
115
Medication Administration
| Do not _______ sustained-release capsules or enteric-coated tablets.
Crush
116
Medication Administration
| What should a nurse do if she/he administers the wrong medication?
Notify physician
DO NOT document on px's chart & complete an incident form.
This is not part of client records.
117
Meniere's Syndrome
| What are the symptoms?
Tinnitus
Unilateral hearing loss
dizziness
118
Meniere's Syndrome
| What are the causes?
Viral, bacterial infections & allergic reactions
119
Meniere's Syndrome
| Describe Meniere's attacks.
Severe, sudden attacks that may cause permanent hearing loss.
Nausea & vomiting can also be present.
120
Meniere's Syndrome
| What is the best environment for a client with this syndrome?
Bed rest in a quiet room, moving head slowly, sedatives can be given to keep client calm.
Low playing music helps with tinnitus.
121
Meniere's Syndrome
| What diet should be?
Low sodium
122
Meningitis
| What is meningitis?
Inflammation of arachnoid & pia mater of the brain/spinal cord
123
Meningitis
| How it is transmitted?
Direct Contact
Droplet
124
M E N I N G I T I S
| What are the signs & symptoms?
```
M E N I N G I T I S
● nuchal rigidity (Brudzinki's sign)
● tachycardia
● headache
● nausea & vomiting
```
125
Meningitis can also cause ______.
Increased intracranial pressure
126
Meningitis
| What two physical signs are positive?
Positive Kernig's & Brudsinki's
127
M E N I N G I T I S
| What are the nursing interventions?
1. Monitor LOC
2. Vitals
3. Initiate seizure precautions
4. Maintain isolation
5. Elevate HOB
128
Meningitis
| What medications are prescribed?
Antibiotics & analgesics
129
Mongolian Spots
| What do these spots look like?
Bluish-black spots on body
130
Mongolian Spots
| Where can you find these spots?
On the back & buttocks of newborns
131
Mongolian Spots
| In what race are these spots mostly seen?
Asian & African American
132
Mongolian Spots
| Are they harmful & how long do they appear?
No. They are normal in newborns & they gradually
133
```
Multiple Sclerosis (MS)
True or false? MS is a chronic, progressive, degenerative disease of the nervous system.
```
True
134
```
Multiple Sclerosis (MS)
What part of the nervous system is affected?
```
The problem is with demyelinization of the white matter of the brain & spinal cord.
135
```
Multiple Sclerosis (MS)
Is there a cure for MS?
```
No
136
```
Multiple Sclerosis (MS) - is a chronic, progressive, degenerative disease of the nervous system
What are the signs of MS?
```
* muscle spasms
* weakness
* bowel/bladder dysfunction
* numbness in the extremities
* visual disturbances
MULTIPLE SCLEROSIS
137
```
Multiple Sclerosis (MS)
What medication will be given for spasms?
```
Baclofen
138
```
Multiple Sclerosis (MS)
What medication will be given to reduce amount of time a client experiences exacerbated symptoms?
```
Corticosteroids
139
```
Multiple Sclerosis (MS)
If you were at a MS conference, what would you teach?
```
1. start regular bladder bowel program
2. avoid stressful situations
3. eat a well-balanced diet
4. initiate speech/physical therapy
5. remove safety hazards in home
140
Munchausen Syndrome
| What is the definition of this syndrome?
A psychiatric disorder that causes a person to self-inflict injury/harm to his/her own body.
The person may also say that he/she has a mental disorder.
141
Munchausen Syndrome
| What is Munchausen by proxy?
An individual, typically a mother, intentionally causes or makes up an illness in a child under their care for attention.
142
Munchausen Syndrome
| Notes for NCLEX
The child will have issues with no explained etiology.
Treatment of the issue does not help.
Assessments indicate child is healthy, symptoms get better when child is away from the caregiver.
Nursing priority: Protect the child
143
Myasthenia Gravis
True or false?
It is an autoimmune disease that results in extreme fatigue & muscle weakness.
true
144
Myasthenia Gravis
| What is the malfunction of the body?
Body produces antibodies that block acetylcholine receptors
145
Myasthenia Gravis
| Is there a cure for myasthenia gravis?
No
146
Myasthenia Gravis
| What are the signs & symptoms?
```
S/Sx MG
• difficulty talking
• chewing
• weak eye muscles
• visual disturbances
• unsteady gait
```
147
Myasthenia Gravis
| Do the symptoms of myasthenia gravis worsen with activity?
YES, they do.
148
Myasthenia Gravis
| The _______ test is performed to diagnosis Myasthenia Gravis.
Tensilon
149
Myasthenia Gravis
| If the px muscle strength is increased, the test is ______.
Positive
150
Myasthenia Gravis
| What medication will be given?
Anticholinesterase/Plasmapheresis
151
Myasthenia Gravis
| What would you teach at a myasthenia gravis conference?
M G
• Take meds 30 mins before eating.
• Cough/deep breathe
• Exercise
• Conserve energy by doing multiple short tasks
• Try to decrease stress, infections, & unhealthy habits.
152
```
Myocardial Infarction (MI)
What is the cause of MI?
```
Decreased oxygen supply to heart
153
```
Myocardial Infarction (MI)
Where is the pain felt?
```
Substernal (sudden, crushing radiating to jaw, shoulders, back) & lasting longer than 30 minutes
154
```
Myocardial Infarction (MI)
The pain is not relieved by ______ or ______.
```
Rest or nitroglycerin
155
```
Myocardial Infarction (MI)
What changes would you see on an EKG?
```
ST elevation, inverted T waves
156
```
Myocardial Infarction (MI)
What lab values will be elevated?
```
1. CK-MB Creatine kinase-MB
2. CPK Creatine kinase
3. Troponin
4. LDH Lactate dehydrogenase
5. WBC
157
```
Myocardial Infarction (MI)
What medications are given for an MI?
```
```
MONA
Morphine
O2
Nitroglycerin
Aspirin
```
*MI=MONA
158
```
Myocardial Infarction (MI)
What activity is prescribed for this client?
```
bed rest
159
```
Myocardial Infarction (MI)
What is angina pectoris?
```
Chest pain due to heart not receiving enough oxygen
160
```
Myocardial Infarction (MI)
Where is the pain located? (angina pectoris)
```
The same area of the chest as seen in MI
161
```
Myocardial Infarction (MI)
What are common causes of angina pectoris?
```
early-morning activity (shoveling snow), heavy meals, stress, exercise and smoking
162
```
Myocardial Infarction (MI)
How is stable angina different from an MI?
```
Chest pain that has a typical onset location, lasts for 3 to 5 minutes & is relieved by nitroglycerin/rest
163
```
Myocardial Infarction (MI)
What is UNSTABLE angina?
```
It is chest pain that occurs while the client is resting.
164
```
Myocardial Infarction (MI)
How is angina diagnosed?
```
1. cardiac cath
2. coronary artery bypass
3. exercise/thallium stress test
4. EKG with no ST elevation
165
```
Myocardial Infarction (MI)
What should you teach a client who has angina?
```
* How to take nitro for pain (can take up to 3 tablets SL)
* Diet modification (low cholesterol)
* Exercise & stop smoking
