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should feel soft and flat; fullness or bulging indicates? -closes when? | -increased intracranial pressure fontanelle is closed by 2 to 3 months | |
falls off within 1 to 2 weeks; no tub baths until the cord falls off | ||
extended her extremities and returned them to their previous position. disappears after 3 to 4 months | ||
sex-linked disorder bleeding disorder. transmitted to male by female carrier, recessive trait. (Mother recessive gene to son). Most common: Factor 8 deficiency -precautions? | avoid contact sports. tx joint pain, Do Not use aspirin avoid IM injections monitor for bleeding (bruising, pallor) | |
inserted until resistance is met never suction longer than 10–15 seconds withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion | ||
attributing one’s thoughts or impulses to another | ||
shifting of emotion concerning person or object to another neutral or less dangerous person or object | ||
diversion of unacceptable drives into socially acceptable channels | ||
incorporation of someone else’s opinion as one’s own | ||
attempt to make behavior appear to be the result of logical thinking | ||
excessive reasoning or logic used to avoid experiencing disturbing feelings | ||
development of conscious attitudes and behavior patterns into opposite of what one really wants to do | ||
Venereal Disease Research Laboratory test or VDRL is a blood test for syphilis. Instruct the client on the importance of taking the penicillin for the prescribed time. | ||
assists the elderly to carry out activities of daily living (ADLs). | ||
small head circumference low birth weight undeveloped cheekbones feeding difficulties and poor sucking ability respiratory distress related to preterm birth, neurologic damage, small trachea, floppy epiglottis | ||
narcotic analgesic used for moderate to severe pain, monitor vital signs frequently | ||
the level at which glucose starts to appear in the urine increases, leading to false-negative readings (may be 0-180); results in elevated glucose levels. | ||
lecithin/sphingomyelin (L/S) ratio by an amniocentesis. lecithin exceeds sphingomyelin by 2 to 1 | ||
-1% gamma benzene hexachloride (Kwell) shampoo -very hot water and a special detergent (RID) need to be used for cleansing clothing and personal belongings -repeated 5 to 7 days after first application. repeat after eggs hatch -tx w/ permethrin 1% crème rinse (Nix) kills both lice and nits after one application and does not need to be repeated. | ||
-tube should be inserted no more than 4 inches -patient left side-lying (Sim's) with knee flexed: allows solution to flow downward along the natural curve of the sigmoid colon and rectum, which improves retention of solution | ||
laryngotracheobronchitis (LTB) breathing looks like: | Inspiratory stridor and restlessness: characterized by edema and inflammation of upper airways | |
side effects include akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity), and dyskinesia (stiff neck, difficulty swallowing) if so: decrease med or give Cogentin | ||
priority nursing diagnosis for a client with a tracheostomy: | ineffective airway clearance because loss of the upper airway increases the amount and viscosity of secretions | |
decreased secretion of parathyroid hormone; indications include tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia, and laryngeal spasm diet? | diet for the client should provide high calcium and low phosphorus because the parathyroid controls calcium balance | |
complete triad seen with pre-eclampsia, (early pre-eclampsia s/s) | hypertension (140/90 or increase of 30/15) edema (generalized) proteinuria (1+ or 2+) | |
headache, epigastric pain, extreme irratibilty, sudden onset of edema, hemorrhage, pulmonary edema hyperflexia HELLP (hemolysis, elevated live enzymes, low platelet count) proteinuria (3+ to 4+) hypertension | ||
hypertension proteinuria oliguria, blurred vision SEIZURES, tonic clonic generalized | ||
CELLULITIS is a common complication because of skin popping or using an infected drug apparatus | ||
with a CVA things you cannot prevent as a nurse are: | Inability to talk. Loss of the gag reflex Inability to open the affected eye | |
with CVA things a nurse can help to prevent are: | Corneal abrasion: b/c client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect eye | |
side effects associated with antipsychotic agents: | Restlessness, shuffling gait, involuntary muscle movements Elevated white blood cell count, fever, orthostatic hypotension | |
tx bipolar disorder; mainly to control mainc episodes normal blood target level? Check serum levels when? dose during depressive state? should not take/ or take with? early vs. severe s/s of toxicity? | -Normal blood target level: 1-1.5 -Check serum levels: 2-3 weekly when started, then 1x month when on maintaince. Draw in the AM prior to dose -1/2 dose during depressive state -Drink 2,500 to 3,000 fluid intake -get adequate sodium intake -GI effects reduced if taken with meals -early toxic s/e: Fine tremors, nausea, vomiting, diarrhea. -severe toxic s/e: Ataxia, confusion, seizures--require promt tx! | |
toxicity is very similar DI, need to increase water and increase Na, therefore you do not want alot of K+ | ||
withhold food and fluids just before going to bed b/c You are less likely to awaken during the night with heartburn if the stomach is empty. | ||
elderly adults have problems with constipation b/c | reduced gastrointestinal motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, side effect of medications, emotional problems, insufficient fluid intake, and excessive dietary fat | |
adrenal glands produce too little cortisol and often insufficient levels of aldosterone as well AKA: adrenal insufficiency or hypocortisolism s/s? tx: ? | muscle weakness/fatigue weight loss, pathologic fractures darking of skin= hyperpigmentation low BP low blood sugar low sodium low blood volume high potassium tx: hormone replacement | |
could lead to shock: Restlessness and rapid, weak pulse n/v ab pain fever and extremeness of all s/s of disease tx: give hydrocortisone fluids glucose k+ binding with excretion meds | ||
mother’s fourth stage of labor, the nurse should palpate the client’s fundus where? | uterus is normally contracted and palpable at the umbilicus descends on finger breath each day should be at pelvic organ by day 10! | |
sudden changes in position, constipation, vomiting, stooping, or bending over is not advised b/c? | increase the INTROCULAR pressure and put pressure on the suture line. *not all pts get implants! | |
objects blurred decrease color glares pupil changes from BLACK to GRAY to WHITE if implant do what? if no implant do what? | if implant= pupil remains constricted! if no implant (aphakic)= pupil remains dialted! | |
cataract EXTRAcapsular vs. INTRAcapsular extraction? | e: cut through anterior capsule to expose the opaque lens: most common i: cut out entire lens and capsule: greater risk for retinal detachment. | |
BEST indication of an alcohol problem in a client hospitalized for another physical illness is? | client who has several complaints of pain that do not appear to be correlated to the admissions problem requires further investigation; tremors, elevated temperature, and pain symptoms are indicative of an alcohol-related problem | |
pituitary dwarfism looks like? (hypopituitarism) | -small size but normal body proportions -delayed sexual maturity: appear younger than chronological age -fine, smooth skin -features delicate! what is it c/b? | hyposecretion of growth hormone, occurs before maturity. complication: diabetes (?) tx: human growth hormone replacement, thyroid growth replacement, testosterone |
osmotic diuretic; increases urinary output and decreases intracranial pressure | ||
cephalosporin: antibiotic What is important to monitor? | long-term use of Rocephin can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended | |
-cannot tolerate cold temperatures -very sensitive to narcotics, barbiturates, and anesthetics -requires high fiber, high cellulose foods to prevent constipation | ||
The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal. | ||
The stem of a vibrating tuning fork is held in the middle of the forehead, and the pts hearing is assessed in both ears. | ||
gradual destruction occurs because of deterioration of the retinal vessels | ||
induces ovulation by altering estrogen and stimulating follicular growth to produce a mature ovum | ||
NSAID (nonsteroidal anti-inflammatory drug) used as analgesic s/e: ? | headache, dizziness, gastrointestinal distress, pruritus, and rash Fluid retention nephrotoxicity | |
DM pt post-op gets SQ insulin (when they are only on oral meds) means: | inability to control diabetes mellitus by diet and oral agents, coupled with surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids necessitates temporary control by insulin. | |
Most important info for a rehab nurse to KNOW on a new admission? | The client’s personal goals for rehabilitation: it is important for the nurse to understand what the client expects from the rehabilitation program for future success | |
hormone that produces the 'flight or fight' response? | ||
hormone that regulating the calcium metabolism is? | ||
hormone that converts proteins and fat into glucose is? | ||
false belief that public events or people are directly related to the individual | ||
elusion is a strongly held belief that is not validated by reality; the idea that his brother is trying to steal his property is a belief not validated by reality | ||
tx for supraventricular tachcardias Antihypertensive: CaChannel Blocker Most important tocheck for what prior to giving? Avoid? | ||
out of these four which is most often used intravenously: Benzodiazepines. Barbiturates. Narcotics. | ||
Breast feeding mother should increase their calorie intake by ? | ||
1st tube There is continuous bubbling in the suction control chamber. fill with sterile water to the 20cm level, or as ordered by doc. | ||
3rd tube postop, more than 100cc/hr would be expected | ||
2nd tube fluctuates with respirations: -inspiration=increased negative pressure in the pleural cavity= increases the water level. -expiration=decreased pleural pressure =decreases the water level. | ||
chest tubes: If chest tube becomes dislodged..? | apply pressure over the insertion site with a dressing that is tented on one side to allow for the escape of air. | |
chest tubes: If the tube becomes disconnected from the drainage system...? | cut the contaminated tip off the tubing using sterile scissors, and immerse the end of the chest tube in 2 cm sterile water until system can be reestablished. Cut off the contaminated tip of the tubing before inserting it into sterile saline. This will prevent air from returning to the chest by maintaining the water-seal. | |
Chest tubes are clamped ONLY MOMENTARILY to check for air leaks and to change the drainage apparatus. | ||
continuous bubbling in the water-seal chamber means? | This indicates a leak in the drainage system. need to check for location of leak; clamp tubing close to chest and check for bubbling, and then clamp tubing close to container and check for bubbling | |
Are placed in the pleural space to drain air and blood so the lung can re-expand. The drainage system consists of one or more chest tubes. The collection container is placed below the chest and a water seal is used to keep air from entering the chest. | ||
if fluctuations in the chamber stop moving, this could mean..? | 1. lund re-expanded 2. tubing is obstructed 3. loop hangs below rest of tubing 4. suction is not working. | |
wheezing, urticaria (hives), facial flushing, and epiglottal edema | ||
action of cardiac glycosides such as digoxin is? | ||
acts to regulate cardiac rhythm= Increases the cardiac output. | ||
Prevents premature ventricular contractions (PVCs) | ||
-normal diet the week before -avoid alcohol -only sips of water are permitted for 12 hours before plasma cholesterol screening to achieve accurate results | ||
High in calcium and vit D= help body absorb less lead High in iron=' ' High in Vit C= helps the body absorbs more iron=which will them absorb less lead. | ||
5 stages: 1. Denial and isolation 2. Anger 3. Bargaining 4. Depression 5. Acceptance | ||
provides x-ray visualization of kidneys, ureters, and bladder pre-op? post-op? | preop: bowel prep, npo after midnight, check allergies for iodine or shellfish, eggs, milk -may have c/o of salty taste or burning post-op: watch for s/s of reactions to dye (edema, itching, wheezing, dyspnea. | |
occurs when antibodies are passed from mother to fetus via placenta, colostrum, and breast milk | ||
small amounts of specific antigens are used for vaccination; body responds by actively making antibodies | ||
antigen enters the body without human assistance; body responds by actively making antibodies | ||
involves injection with antibodies that were produced in another person or animal; used to protect person exposed to serious disease. | ||
a support group for parents who have lost a newborn or have experienced a miscarriage | ||
support group for parents who have had an infant die from sudden infant death syndrome. | ||
support group for families who have lost a child to cancer. | ||
-do at SAME time each day=helps create normal pattern of elmination -do Once a day -catheter is never inserted more than 4inches -should be at body temp. | ||
is loss of purposeful movement in the absence of motor or sensory impairment; when it affects an ADL, such as dressing, the client may not be able to put clothes on properly | ||
describes a lack of muscle coordination during voluntary movements, such as walking or picking up objects. it can affect your movements, your speech, your eye movements and your ability to swallow. | ||
The leg appears to be shortened and is adducted and externally rotated. |
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