Review

Question 1

age appropriate preparation for surgery

Answer 1

• newborn: include parents; mummy restraint “swaddling”; fears: loud noises and sudden movement
• infant 6-12 months: mummy and parental restraint; fears: strangers, heights; special consideration: distraction
• toddlers 1- 3 yo: simple explanations (no details), use distraction, allow choices (right or left hand first?); fears: separation, animals, change in routine; special consideration: do not ask permission (if they wanna have it done or not)
• pre-schoolers 3-5 yo: play with puppets/dolls, demonstrate equipment; fears: separation, ghosts, scary people (ex: wear PPE so they can see you); special consideration: let them disrobe
• school-age child 6-11 yo: allow questions, explain why something is done, allow child to handle equipment; fears: dark, injury, being alone, death; special consideration: proceed from head to toe
• adolescents 12-18 yo: explain long term benefits, accept regression, privacy; fears: social incompetence, war, accidents, death; special consideration: provide teaching

Question 2

traditional cholecystectomy

Answer 2

• surgical removal of gallbladder (storage and transportation of bile which helps in fatty food digestion in small intesting)
• T-tube: to ensure drainage of bile until edema diminishes), usual drainage 500-1000 mL/day, protect skin around incision from bile irritation with zinc oxide or water-soluble lubricant, keep drainage bag at same level as gallbladder (on bed), maintain in semi-Fowler’s position after T-tube removed

Question 3

hand hygiene

Answer 3

• with either antiseptic soap + water or ETOH-based waterless antiseptic
• water and soap: visibly dirty hands, before eating, after restroom, after contact with spore-producing organism
• ETOH-based waterless antiseptic: before and after client contact, before doning sterile or unsterile gloves, after contact with bodily fluids, before assisting clients, and after removing gloves
• nails short, wet and soap hands + wrists, wash hands below elbow level, rub hands for 10-15 secs, move rings up and down, pat dry, use emollient cream/lotion

Question 4

digoxin

Answer 4

0.5 - 2.0

monitor potassium levels, digitoxicity

Question 5

cirrhosis

Answer 5

• liver tissue replaced by scar tissue resulting in gradual loss of liver function
• complications: portal hypertension (persistent increase in pressure in portal vein that develops due to obstruction of flow), ascites (accumulation of fluid in peritoneal cavity that results from venous congestion of hepatic capillaries), bleeding esophageal varices, coag defects, jaundice (liver unable to metabolize bilirubin as interrupted edema, fibrosis, scarring of hepatic biles), hepatorenal syndrome, portal systemic encephalopathy (end stage hepatic failure)
• interventions: elevate HOB to minimize SOB, early stages – high protein and carb, advanced stages – fiber, protein, fat, and sodium restriction, (if ascites: give diuretics, Na and fluid restriction, paracentesis), monitor coag levels and F&E, avoid toxic drugs like opioids, sedatives, and barbiturates, try to decrease acid (give antiacids, lactulose to decrease pH and ammonia prod), give antibiotics (to inhibit protein synthesis in bacteria and decrease ammonia prod)

Question 6

placenta previa

Answer 6

• placenta partially or wholly blocks uterus neck, thus interfering with normal delivery of baby
• marginal, partial, total
• sudden onset of painless, bright red vaginal bleeding occurs in last half of pregnancy; usually soft and nontender abdomen
• interventions: maternal/fetus vital signs; US to confirm diagnosis; vaginal exams are contraindicated; bed rest in side-lying position as prescribed; monitor amount of bleeding (treat signs of shock); administer IV fluids; cesarean delivery if heavy bleeding occurs

Question 7

hypothyroidism

Answer 7

• hyposecretion of thyroid hormones T3, T4
• S/S: lethargy, fatigue, weakness, muscle aches, cold sensitivity, weight gain, bradycardia, constipation, generalized puffiness + edema around eyes and face (myxedema), cardiac enlargement with tendency to develop heart failure
• interventions: monitor V/S; administer thyroid replacement levothyroxine sodium (Synthroid); low calorie, cholesterol, low saturated fat diet; high protein, fiber, and cellulose diet to prevent constipation; warm environment; avoid sedatives and analgesics because of increased sensitivity

Question 8

iron deficiency anemia

Answer 8

• hemoglobin under 11 g/dL female, 13 g/dL male
• S/S: can be asymptomatic, dyspnea, palpitations, diaphoresis, chronic fatigue, pale, exhausted all the time, cold sensitivity, loss of appetite, cardiac complications, “pins and needles” sensation, brown-ish colored stool and urine
• interventions: reverse deficiencies with iron preparations and diet; if bleeding, identify cause; frequent rest; prevent skin breakdown (no oxygenated blood through skin so protect from burns and chills); good oral hygiene (usually has sore mouth or tongue); IM iron may stain skin and cause pain

Question 9

inflammatory bowel disease

Answer 9

• Crohn’s disease (regional enteritis) and ulcerative colitis
• S/S: abdomainl pain, diarrhea, fluid imbalance, wt loss
• interventions: high-protein and calorie; low-fat and fiber; may require TPN to rest bowel; administer analgesics, anticholinergics, sulfonamides, corticosteroids, antidiarrheals, antiperistaltics; maintain F&E balance, monitor electrolytes, promote rest relieve anxiety

Question 10

hydrocephalus

Answer 10

• congenital or acquired condition characterized by an increase in accumulation of CSF within the ventricular system thus increase in ventricular pressure
• communication (impaired absorption within the subarachnoid space; no interference of CSF in ventr. system) vs. noncommunicating (obstruction of CSF flow in ventricular system)
• S/S: front-occipital circumference increases at fast rate, split sutures and widened, distended, tense fontanelles, prominent forehead, irritability, vomiting, unusal somnolence, convulsions, high-pitched cry, “setting eyes”; late signs: high, shrill cry and seizures
• interventions: shunting; post-op: position on unoperated side, keep flat to prevent complication due to rapid reduction of intracranial fluid, assess for increased ICP (HOB 15-30 degrees if necessary), s/s of infection, assess dressing for drainage

Question 11

blood administration

Answer 11

• intervention: identify pt; check for allergies and previous blood reactions; use 19-gauge needle and standard blood filter; start infusion slowly during first 15 mins and stay with pt; take V/S before and after the 15 mins, every hour or per protocol; check for reactions; infused over 2-4 hrs; changing administration set with every unit

Question 12

abdominal aortic aneurysm

Answer 12

• abnormal dilation/enlargement of arterial wall caused by localized weakness and stretching in medial layer of wall of aorta
• goal of treatment: limit progression by modifying risk factors, control BP to prevent strain on aneurysm, recognize s/s early, prevent rupture
• S/S: may be asymptomatic; prominent pulsating mass in abdomen, at or above umbilicus; systolic bruit over aorta; tenderness on deep palpation; abdominal or lower back pain; BP may lower in legs than arm
• interventions: monitor BP/hypovolume, kidney function, CBC (blood loss during surgery); instruct avoid bending, lifting, and constipation; monitor peripheral pulses and signs of graft occlusion: cool to cold extremities below graft, white or blue extremities or flanks, severe pain or abdominal distention; HOB at 45 degrees; urine output at 3-50 mL/hr; respiratory status, turn cough and deep breathe; bowel sounds; incision site

Question 13

lithium

Answer 13

• mood stabilizer used to control manic episodes of bipolar psychosis
• onset of action usually 5-7 days, may be as long as 2 weeks; normal level 0.5-1 or 0.6-1.2 mEw/L
• adverse effects: excessive thirst, unpleasant metallic-like taste, frequency of urination, fine head tremor, drowsiness, mild diarrhea, wt gain, elevated TSH
• interventions: monitor blood levels 2-3 a week when starting and monthly when on maintenance; no diuretics, avoid ETOH and OTC meds; monitor suicidal thoughts;
• pt ed: fluid intake of 2,500-3,000 mL/day and adequate salt intake
• lithium toxicity
– severe: deep tendon hyperreflexia, seizures
– mod: N/V, slurred speech, tinnitus, blurred vision, muscle twitching
– mild: lethargy, diminished concentration, mild ataxia
– V/S; LOC; cardiac status; suicidal tendency/precaution; F&E, BUN, Cr, CBC

Question 14

bipolar disorder

Answer 14

• episodes of mania + depression with periods of normal mood and activity in between
• S/S: mania-quickly angered, self-confidence, extroverted personality, grandiose and persecutory delusions, high and unstable affect, unlimited energy, dress colorfully or bizarre, sexually promiscuous, restlessness; depression-easily fatigued, poor concentration, lack of energy and initiative, suicidal thinking, anorexia
• interventions: lithium or anticonvulsant drug (watch for toxicity); maintain physical health and safety; orient pt to reality; limit stimuli, setting limits, being constant; assess for fatigue, monitor sleep patterns, provide frequent rest periods; focus on one conversation

Question 15

enoxaparin

Answer 15

• Lovenox – Partial Thromboplastin Time 1.5-2.5 times normal value, if too long then dosage should be lowered and vice versa; low molecular weight heparin used to prevent venous thromboembolism (VTE) and pulmonary emboli
• S/E: hemorrhage, tissue irritation/pain at injection site, anemia, thrombocytopenia, fever
• interventions: give deep SQ, NEVER administer IV or IM; does not require lab test monitoring; don’t expel bubble in pre-filled syringe, aspirate during injection, or rub; monitor coag labs and platelet levels; 25-28 gauge needle
• antidote: prostamine sulfate

Question 16

postural drainage

Answer 16

• chest physiotherapy uses gravity to facilitate remove of bronchial secretions; pt in variety of positions to loosen drainage into larger airways (lungs → bronchi → trachea); secretions may be removed by coughing or suctioning; prevents stasis complication of respiratory secretions (provides clearance and helps prevent/treat atelectasis and pneumonia)
• interventions: drink fluid; perform 2-4 times a day for 20-30 mins; stop if feeling weak or faintness occurs; avoid for 1-2 hours after meals to prevent nausea; if ordered, give bronchodilator and mist therapies before treatment; if pt has a diffuse disorder (bronchiectasis), start at lower lobes and work up; do not percuss over spine, sternum, liver, kidneys, or breasts (trauma)

Question 17

breastfeeding

Answer 17

• preferred for feeding newborns during baby’s 4-6 months (provides optimal infant nutrition, help build infant’s immunity, stimulates hormones that help uterine involution and reduce uterine cramping, gives mother and infant an opportunity to bond, protect against breast cancer in mother)
• interventions: being 1 hr w/in delivery; 8-12 in 24 hrs for first few months, 10-20 mins; promote feeding in comfortable position for both mother and baby (mother relaxed, pain free), hold in position that doesn’t put stress on C-section incision; cradle, sidelying or football position; help baby latch on nipple by ticking cheek/lips to open mouth on nipple/areola, if cracked/engorged infant may have trouble latching on (good latch: wide open mouth, audible sucking noise, tongue and jaw movement with swallowing); switch breasts (15-20 mins); self care-avoid use of soap or washcloths, break suction with finger or depress chin, let nipple air-dry after feeding, lubricate with drop of breastmilk, wear breast pads and replace often; minimize engorgement: ice/cool compress, snug supportive bra, warm shower before feeding; requires energy and whatever mom ingests can transfer to baby; mom’s cal intake increase by 200-500 cal/day with fluids; LATCH: latch by newborn, audible swallowing, type of nipple, comfort mother, hold/position of baby
• good feeding: 6 wet diapers/day, 2 loose yellow stools/day, pale yellow urine, steady wt gain, signs of contentment (sleeping well, healthy looking, alert when awake)

Question 18

preeclampsia

Answer 18

• pregnany induced HTN AKA gestational HTN develops during 20th week
• mild (BP 140+/90+, proteinuria 1+) severe (BP 160+/110+, proteinuria 3+, Cr and liver enzymes increased, Plt decreased, oliguria, visual disturbances, pain, N/V, severe headache) pre-eclampsia vs. eclampsia (deep tendon hyperreflexia (normal is 2+, 4+ hyperactive with clonus/feet jerking present), twitching → seizure, coma); life threatening
• risks: primigravida, hx of preeclampsia (self, mother, sister), excess placental tissue, lower socioeco status, DM HTN renal disease hx, African-American, obesity, younger than 17 yo or older than 35 yo
• interventions: complete bed rest preferably in left lateral position to enhance venous return; anti-HTN meds; magnesium to promote diuresis, reduce BP, and prevent seizures; if baby at risk, oxytocin labor induction or C-section; if seizures begin: immediate IV magnesium, oxygen therapy, fetal monitoring; well balanced, high-protein diet, limit Na intake, high fiber foods, fluids; quiet, darkened room, limited visitors until condition stabilizes

Question 19

C. diff

Answer 19

• gram +, spore forming, bacillus (rod) bacterium that causes antibiotic-associate colitis; antibiotics depress natural intestinal flora; anaerobic
• private room or cohort pt; use gloves and gown (PPE order gown, mask, goggle, gloves)

Question 20

suctioning

Answer 20

• removal of secretions with aspiration device (cannot cough or simply remove secretions); helps maintain a patent airway, stimulate cough reflex, collect sputum or sample of respiratory secretions
• interventions: determine facility policy if need MD’s order; early morning; rinse mouth with water before collection; obtain 15 mL of sputum; always collect specimen before client begins antibiotic therapy; explain procedure to pt, assess baseline, wash hands, semi or high Fowler’s unless contraindicated, waterproof pad on pt’s chest, gloves, prepare suction equipment and test, hyperoxygenate pt (give oxygen to ask to take deep breaths), insert catheter w/o suction and once inserted apply suction intermittently while rotating catheter for up to 10 secs, after deep breaths, listen to breath sounds, document procedure pt’s response/toleration and effectiveness
• complications: hypoxia, cardiac dysrhythmias, hypoTN, mucosal trauma, atelectasis, death

Question 21

phenytoin

Answer 21

• Dilantin – 10-20 mcg/mL; anticonvulsant/antiepileptic used to depress abnormal neuronal discharges and prevent the spread of seizures to adjacent neurons; Dilantin also used for dysrhythmias (so give slowly to prevent hypoTN and cardiac dysrhythmias; caution combo use with anticoag, ASA, sulfonamides, and antipsychotic
• interventions: seizure precautions; urinary output, liver and renal function tests, med blood serum level; s/s of med toxicity (CNS depression, ataxia, N/V, drowsiness, restlessness, visual disturbances); S/E: ataxia (loss of body control/staggering gait), GI upset, gingival hypertrophy (practice good oral hygiene), nystamus; Dilantin IV 25-50 mg/min and dilute in normal saline or med can precipitate; never mix w/ other IV meds or dextrose; take w/ meals; urine may turn red brown or pink (harmless)

Question 22

allergy

Answer 22

• hypersensitivity caused by allergen exposure; allergic rxn caused by high amount of histamine throughout circulatory system, resulting in extensive vasodilation and severe edema of bronchial tissue
• intervention: detailed history; establish airway; administer epipen or diphenhydramine (Benadryl), aminophylline for severe bronchospasm; pt ed: inhaler and epipen, how to avoid allergens, paint walls, toys should be wood, plastic or metal, remove rugs, use allergen proof covers, do not store anything under bed, keep bedu from forced air vent, decrease exposure to smoke/latex/chems/animals

Question 23

OCD

Answer 23

• anxiety disorder; obsession: preoccupation w/ persistent intrusive thoughts and ideas; compulsion: performance of rituals/repetitive behaviors designed to prevent some event and decrease anxiety
• interventions: accept ritualistic behavior; structured environment; guide decisions; minimize choices; don’t interrupt unless safety risk
• if OCD? anxiety when cannot do compulsion or think obsession; repetitive; hand washing; checking behavior; counting; organization; unwanted sexual thoughts

Question 24

buspirone

Buspar

Answer 24

• nonbenzodiazepine for anxiety

* contraindications: MAO med (14 days); renal/hepatic failure

Question 25

schizophrenia

Answer 25

• severe psychiatric disorder (withdrawal from reality, illogical thinking, delusions/hallucinations)

types:

1. catatonic (motionless/excessive motor activity)
2. disorganized (can’t perform ADL; disorganize/disrupted behavior/thinking)
3. paranoid (hostile; persecutory; suspicious)
4. residual (dx in past; social isolation)
5. undifferentiated (s/s of other types)

\+ = hallucinations/delusions
- = apathy, lack of motivation, flat/blunted affect

Question 26

AIDS

Answer 26

• caused by HIV retrovirus attaches to T lymphocytes; 2nd phase: T cells + CD4 cells greatly decrease (organ dysfunction)
• transmitted: bleeding, vaginal/semen secretions, breast milk
• detect? ELISA (presence of antibodies to HIV); Western blot test (confirm HIV dx); IFA
• meds:

Question 27

ultrasound

Answer 27

• outlines/identifies fetal/maternal structures as early as 5 wks
• drink fluid to fill bladder before, to get better fetus image

Question 28

vegetarian diet

Answer 28

• vegetarian: no animal source of protein
- tofu, tempeh, soy milk/prods, legumes, nut/seeds, sprouts
• lactovegetarian: milk products
• ovovegetarian: milk prods + egg

Question 29

anorexia nervosa

Answer 29

• self-starvation syndrome