Flashcards
NCLEX part 2
Cards in this deck (144)
- 1S&S of glomerulonepritis: HAD STREPHypertension
Antistreptolysin titer positive
decreased GFR
Swelling in the face and eyes, esp. in the morning
Tea-colored urine
Recent strep infection
Elevated BUN and creatinine
Proteinuria (mild) - 2What happens to the body with proteinuria?Fluid shifts; pt will have edema and fluid overload
- 3What is lost in urine in nephrotic syndrome? Which complications result from it?Proteins:
hypoalbunemia - edema and hyperlipidemia
Immunoglobulins - infection risk
Clotting factors - bleeding risk - 4How does urine look when RBCs excreted?Tea colored
- 5How does urine looks when proteins excreted?Dark foamy/frothy
- 6What type of diet pts with nephrotic syndrome should have?Low Na, low fat
- 7What happens if a person is diagnosed with policystic kidney disease in adulthood and in infancyInfant poly cystic kidney disease results in death within a few months
adults polycystic kidney disease is diagnosed at 30 to 40 years old and progresses in end-stage kidney disease - 8What is renal calculi? Stones are made of? Which size of stones can be passed?Formation of renal stones in kidneys that abstract renal blood flow. Typically made from Utica acid, calcium oxalate calcium phosphate. If it is less than 5MM then it can be passed
- 9What is the priority nursing intervention in the client with renal calculiPain management around the clock
- 10Causes of renal calculi: CRYSTALConsumption of high amounts of pyrines, oxalates, salts, meds with Ca
Recurent UTIs
hYperCa, hyperparathyroidism, hypocitraturia
Structural blockage or statsis of urine
Too much uric acid
Absorption problems
Low activity - immobile - 11two types of pain in renal calculi: renal colic and ureteral colicRenal - deep, dull, aching pain in CVA. Stone in kidneys
Ureteral - tense, sharp, radiates to gential areas. Stone in ureter - 12Hydronephrosis is...Distension of renal pelvis
- 13Renal calculi interventions: pain? fluids? how to find a stone? mobility?Manage pain all the time
3-4L of fluids to dilute
strain urine each time
Increase mobility - 14Benign prostate hypertrophy: who is at the most risk?what is its early sign? How does it affect urination?Men older than 50
Dimished urine size
Urgency, frequency, hesistancy, incomplete bladder emptying - 15Fluoroquinolones end with... Used for? Have high risk of causing...? (greek mythology) Should be administered with...OXACIN
Antibiotic
Tendonitis and tendon rupture )achilles tendon most often involved)
With full glass of water d/t crystalloid urine - 16Sulfonamides are withheld if what is noted?Rash
- 17Antispasmodic medications should not be used in clients with which condition and wny?Open-angle glaucoma
They raise intraocular pressure - 18Normal IntraOcular pressure?10-21 mm
- 19Which condition is known for high IOP?Glaucoma
- 20When does variant angina occur?At the same time each day, usually in the morning
- 21Total cholesterol level should be..Less than 200
- 22LDL level should be...Less than 100
- 23HDL level should be...More than 40
- 24How does a prostate presents in a client with prostatitis?Warm to touch, swollen, tender, indurated
- 25What are the signs of disequilibrium syndrome during hemodyalisis? What are the complications of it?Solution is removed too quickly during dialysis, causing increased intracranial pressure and cerebral edema. Signs are mental status changes, headache, n&v, twitching, possible seizure activity
- 26After TURP, urine color in the bag should be... If it is not, the nurse...Pink colored
If it is dark red, then bladder irrigation should be increased - 27What is the difference between open-angle glaucoma and angle-closure glaucoma? What is the role of trabechular mechwork?Glauma is an incr in IOP as a result of aquious humour accumulation. In open type, t.m. get clogged and fluid does not move. In closed type, t.m. are open, but angle is closed. It is 911
- 28S&S of open-angle glaucoma?Asymptomatic
Increased IOP, diminished accommodation
No pain
Optic disc cupping
Normal angles through gonioscope - 29S&S of angle closure glaucomaSvere eye pain
Nausea, vomiting
Increased IOP
vision changes: halos around eyes, blurred vision
Red eyes
Edema cornea - 30If open-angle glaucoma is untreated, it progresses to...Tunnel vision followed by blindness
- 31Surgical treatment for both types of glaucomaSelective laser trabeculpolasty/trabeculectomy
laser iridotomy/iridectomy - 32Post-op glaucoma teachingNo driving until allowed
Do not rub eyes, no contacts
Wear sunglasses
Avoid activities that increase eye pressure (vagal nerve stimulation) - 33Normal/abnormal signs post glaucoma surgeryNormal> watery, itching, blurred vision
Abnormal: severe pain and vision loss - 34Can medications for glaucoma return vision?No
- 35How to instill eye drops correctly? Which place? Blinking? Why and how to perform punctal occlusion?Into conjunctival sac
Close eyes, do not blink
Apply pressure for 2-3 min over lacrimal punctum to prevent it draining into nasolacrimal duct and produce systemic effects - 36What do you do if you have more than 1 type of eye drops to install?Wait 3-5 minutes between each installation
- 37Alpha agonist (eye drops) end with... Side effect?Idine
Drowziness - 38Beta-blockers (eye drops) end with... Which pt cannot use it? What to assess before installation?LOL
Pt with COPD, asthma, brady
Assess HR and BP before - 39Carbonic Anhydrase Inhibitors end with... Pt who are allergic to which drug cannot take it?ZOLAMIDE
Sulfonamide - 40Cholinergic (miotics) - example of med? Common SE?Pilocarpine
Bronchospasm, increased salivation, eye sensitivity to light, sweating - 41Which medications are not allowed to pts with glaucoma?Anticholinergic/mydriatics
Antispasmotics - 42Prostaglandin analogs end with ... Which unusual SE they have?POST
Longer and thinker eyelashes, change of iris color to brown - 43Factors that cause risk for glaucoma development: SAVESixty and over
Africans, Asians, Hispanics
Vascular problems (DM, HTN)
Elevated IOP - 44Antidote of cholinergic medicationsAtropine
- 45WHY MRI is contradicted in pregnant women?It increases amniotic fluid temperature and can be harmful to fetus
- 46When the lumbar puncture is contradicted?When pts have increased intracranial pressure, since it can cause brain herniation
- 47Which position a pt needs to have during lumbar puncture?Lateral recumbent, draw knees to the abdomen and chin to chest
- 48Cheyne-Stokes respirations are characterized by?Rhythmic respirations with periods of apnea
- 49Neurogenic hyperventilation chracterized by....Rapid and deep, regular RR
- 50Apneustic respirations characterized by....Irregular RR with pauses at the end of inspiration and expiration
- 51Ataxic respirations characterized by...?Totally irregular in rhythm and depth RR
- 52Unilateral pupil dilation indicates...Compression of cranial nerve 3
- 53Decorticate vs. decerebrate poistureDecorticate is flexor - flexing 1 or more arm on chest and may extend the legs stiffly
Decerebrate is extensor - extend 1 or both arms and possibly legs - 54Describe Babinski reflex and until which age it is normal to have itFirmly stroke lateral aspect of the sole of foot, which produces dorsiflexion of big toe and fanning of other toes
Normal until 2 y only - 55Describe Corneal (Blink) reflex? When is it lost?Involuntery closure of eyelids when cornea is stimulated
Lost in pts with dysfunction of cranial nerve 5 - 56Describe Gag reflex and when it can be lost?Contraction of pharyngeal muscles elicited by touch
Dusfunction of cranial nerves 9 and 10 - 57OLD OPERATORS OCASSIONALLY TROUBLESHOOT TRICKY ABDUCTED FAMILY VETERANS GALLOOPING VIOLENTLY ACROSS HISTORYOlfactory - smell
Optic
Oculomotor - pupils
Trochlear - eye movement
Trigeminal - facial muscles
Abduceous - moving eyeballs
Facial - tears, saliva, expressions
Vestibulotrochlear - hearing
Glossopharyngeal - swallowing
Vagus - GI
Accessory - movement
Hypoglossal - speech - 58Normal ICP5-15
- 59Monro-Kellie HypothesisICP affected by CSF, brain mass and brain blood. Increase in volume of one o these structures, leads to decrease in volume of others
- 60Normal CPP? Why is it important to maintain it at this level? How is CPP calculated?60-100
To perfuse brain
CPP = MAP - ICP - 61Causes of ICPTrauma, bleeding, hematoma, meningitis, conditions that increase CSF, hydrocephalous, tumor, encephalitis
- 62Early sign of ICP? Late sign of ICP?Mental changes
Cushing Triad - 63S&S of ICP: MIND CRUSHEDMental status changes
Irregular breathing - Cheyne Stokes
Nerve changes to optic and oculomotor nerves
Decorticate/Decerebrate/Flaccid posture
Cushing triad
Reflex positive Babinski
Unconscious
Seizures
Headache
Emesis (but no nausea)
Deterioration of motor function - 64Which respirations an which reflex is present in ICP? What type of vision changes happens?Cheyne-Strokes
Babinski reflex
Abnormal dolls eyes, unequal pupils, double vision - 65How does Cushing Triad presentHigh SBP, but the same DBP, so that pulse pressure is wide
Low HR and low RR - 66Interventins in ICP: position? which Co2? temperature? Which activities to avoid? How to manage intracranial edema?HOD 30-40 degress. meck midline, avoid neck flexion and hip flexion
Keep CO2 lower end to promote vasoconstriction
Prevent elevated temp and do not check it orally or axillary in unconscious
Avoid straining activities - Valsalva
Mannitol - 67Which drugs are prescribed in ICP?Barbiturates
Vasopressors and Antihypertensive depending on BP
Antiseizure
Hyperosmotic drugs - 68What is the role of mannitol? When used? What are SE?It is osmotic diuretic. It promotes cerebral edema descrease by diuretic action. But, it pulls water and Na, so it can lead either to dehydration or hypervolemia.
Watch for HF, pulmonary edema, electrolyte changes - 69What are complications of hyperthermia?Increased metabolic needs, hypoxia and as a result ICP
- 70What is the difference between epidural and subdural hematoma?Epidural is caused by rupture of arteries, it is an emergency. Starts as a loss of consciousness, then a lucid period, then a coma
Subdural is caused by rupture of veins and it is slow - 71Signs of brain hematomaICP, CSF leakage, visual disturbances (papilloedema, pupillary changes), LOC, airway and breathing changes, Nuchal rigidity, seizure, decreased sensations
- 72How and why to test for Nuchal rigidity? When not to test?Tested to detect hematoma. Flex neck, if resistance felt, results are positive
Do not test it until spinal cord injury is ruled out - 73How to detect CSF leak?It will leak from nose or ears. CSF is tested positive for glucose and has concentric rings: bloody fluid surrounded by yellow stain
- 74Why a client after TURP may become suddenly confused and disoriented?Solution used during TURP is hypotonic, so the pt may experience hyponatremia
- 75Food high in oxalatesChocolate, tea, instant coffee, cola, beer, citrus, grapes, peanut
- 76If arteriovenous fistula is created on one of the arms for hemodialysis, a nurse is not allowed to...Take BP and venipuncture of the affected arm
- 77Which spinal cod injury is fatal?C2 and C3
- 78What is the result of spinal cord injury above C4?Tetraplegia
- 79What to do immediately for pt with spinal cord injury?Immobilize them. Use backboard, logrolling, maintain traction and alignment of head, no neck flexion
- 80What is spinal shock?It is a complete loss of reflexes, sensory, motor and autonomic function within 48 hours of spinal cord injury, but it goes away after
- 81What is neurogenic shock? What are VS?It is coomplete vasodilation of blood vessels, causing hypotension, bradycardia, hypothermia
- 82What is unique about hypothermia in neurogenic shock?Body is cold, pale, but extremities are warm and dry
- 83What is a complication of venous pooling in neurogenic shock?DVT
- 84Which fluids are administered in neurogenic shock?Crystalloids
- 85Autonomic dysreflexia happens in spinal cord injuries above...T6
- 86What are the causes of autonomic dysreflexia?3 Big Bs
Bladder (UTI, dilation)
Bowel (impaction)
Breakdown of skin - 87Pathophysiology of autonomic dysreflexiaTrigger (3 Big Bs) results in exaggerated sympathetic NS response, which fails to be compensated by parasympathetic NS
- 88S&S of autonomic dysreflexia? Skin changes? BP? early sign? HR? Pupils?Early sign is trobbing headache, check BP
Hypertension (20-40 more than baseline BP)
Bradycardia
Dilated pupils
Anxiety
Sweating - 89How to perform Foley insertion of fecal impaction in client with spinal cord injury above T6?Use anesthetic gel to decrease irritation to prevent autonomic dyreflexia
- 90What to do if autonomic dysreflexia is confirmed? HINT: positioningRapid response team
Place pt in 90 degrees with legs down
Check BP every 2-5min
Relieve from tight clothing
Give nitropaste if correcting the cause does not help - 91Client education in regards to halo fixation device: how to wash? How to get out of bed?Take baths, but no showers
To get out of bed, roll onto the side and push on mattress with arms, do not use metal frame for turning or lifting - 92Do not take temperatures from which place in patients with cerebral aneyrism?Rectally
- 93Stages of seizure and their characteristics1. Prodromal - days before - depression, anxiety, issues sleeping, anger
2. Aura - not always happens, initiate seizure precautions: altered vision/hearing, dizzy, dejavu, cannot speak, anxiety
3. Ictus - actual seiuzre, 1-3 min, if more than 5- emerg
4. Post ictus - recovery; tired, headache, confused - 94What is status epilepticus? Which medication would you administer? What is its reversal agent?Seizure for more than 5 mins or back-toback
Benzodiazepines (lorazepam)
Flumazenil - 95Generalized seizure: tonic-clonic. Characteristics> Meaning of tonic/clonic?Most common, the aura is present usually. Tonic - body stiffening: groan, cry, bronchospasm, bite tongue, apnea
Clonic - recurrent jorking (relax-spasm), leads to incontinence - 96Generalized: absence seizure: which population? what is a hallmark? Recovery period?Pediatric. Hallmark is staring like daydreaming. They would stop any activity, do not respond, but then come back to normal without any recovery period
- 97Generalized: atonic seizure: which population is often affected? What are they at risk for and what do they need to do in this case?Loss of muscle tone, so a person falls right away. Often affects kids. High risk of injury to head - wear a helmet.
- 98Focal: simple partial seizure. Awareness?Symptoms depend on location of neuron firing. A person is aware of seizure
- 99Complex partial seizure: awareness? Motor?A person is unaware of seizure. Automatism occurs: repetitive motor activity they are unaware of (lip making, rubbing hands)
- 100What to do during seizure activity?Pad bedrails
Remove restrictive clothing
Protect aiways: turn to side, give O2 and be ready to suction
Bed in lowest position
Note time and characteristics
Do not put anything in the mouth or restrain - 101Medications for seizure and how to take themBarbiturates; Hydantoins, Benzodiazepines, Valproates
Do not give them with milk or acidic products - 102Rule of nine: name % on each body part only front view4.5 arm
18 chest
9 leg
1 genitals
4.5 head - 103Normal Ca levels8.6-10.2
- 104What anemia in the person above 50 can signify? And what to perform immediately?It can signify colon cancer.
Perform colonoscopy - 105Sjogren syndrome results in....dry mouth and dry eyes
- 106What type of diet can be used in kids to treat seizures?Ketogenic diet: high fat, low carbs
- 107Which BP medication should be avoided in pregnancy?ACE inhbitors
- 108In how many hours after birth, meconium has to pass? If it does not, what it can be a sign of ?24 hours
Sign of imperforate anus - 109Preterm babies are born between how many weeks?20 to 36 and 6 days
- 110How to perform McRobert's maneuvr? What is it used for?Flex mothers knees to `bdomen to straighten sacrum.
It is used to correct shoulder dysclocia - 111What are two options on how to relieve umbilical cord prolapse?Insert glove hands and lift presenting part of umbiicus
Assist mother in knee-chest position or Trendelenburg position - 112What is pica? What is the other condition that often accompanies it?Pica is craving for non-edible products during pregnancy (paper, cornstarch, chalk, clay).
Often accompanied by iron-deficiency anemia - 113What is the only treatment of syphilis during pregnancy?Penicillin
- 114When does quickening happen?18-20 week of gestation
- 115What is normal head cirumeference of newforn?33-35 cm
- 116IS breastfeeding allowed in hepatitis B patients? Or HIV patients?Allowed in hep. B
Not allowed in HIV - 117What is tetralogy of Fallot? Which lab value we should watch for?A disease in pediatric population in which there is congenital heart defect and decreased pulmonary blood flow, resulting in chronic hypoxemia.
Body initiates increases erhytropoetin production, which increases RBC and Hbg. High Hbg increases risk for clots. - 118When do you see a lanugo on an infant?Before 36 weeks of gestation
- 119Creases on the entire sole and/or skin desquamatization (peeling) is expected in infant who is....Full-term or post-term newborn
- 120Is mucoid vaginal discharge, which is bloody to brownish normal during pregnancy? When it can occur?It is normal
It can precede days before true labor - 121Tuft of hair, hemangloma, nevus or dimple across the base of the spine are signs of...Spina bifida - a neural tube defect
- 122Why would a pregnant woman get IM glucocorticoids during preterm delivery?To increase surfactant production
- 123What is turtle sign?If shoulder dyslocia occurs, a head may present through vagina, but then retract back to mother's perineum
- 124Chest tube output of which amount should be reported to HCP?More than 100 in hour
- 125Normal triglyceride levels?Less than 150
- 126Which laboratory value should be checked in pt taking anticholisterols/statin medications and wny?CK
It has SE of muscle wasting - myopathy - 127Which assessment is contradicted in a child with the suspected epiglottis and why?Throat culture or examination
It may cause laryngospasm - 128A client with meningitis should be on which precautions?Droplet
- 129What would CSF of person with meningitis look like?Positive for protein, WBCs
- 130Do not take anti seizure medications with which items?Milk and antacids
- 131Signs of Addison diseaseLow BP, weight loss, hypoglycemia, low Na, high K, muscle weakness, hyperpigmented skin
- 132Which skin changes happen with Addison disease?Hyperpigmented skin
- 133What is hirsutism? What are common causes?Condition in women resulting in hair growing like in men
Polycystic ovary disease and Cushing - 134How urine specific gravity changes if the urine is too dilute?It is low
- 135What are acinthosis nigricans? What do they signify?Symmetric, hyperpygmented, velvety plaques on skin
- 136What are signs of thyroid storm? What are causes?Fever (monitor for any increase), chills, tachy
Causes are hyperthryodism, manipulation with tyhroid gland (thyroidectomy), meds - 137What is serum osmolality in client with hypervolemia?Low
- 138Signs of Myxedema coma?Hypoventilation, hypotension, bradycardia, hypothermia
- 139What type of shoes are preffered in pts with diabetes?Closed-toe, leather based
- 140Normal Ca levels? Signs of hypocalcemia?8.6 - 10.2
Chovstek, Trousseau, tetany, tingling, numbing - 141What is the DKA issue that needs to be corrected first of all?Dehydration
- 142Which assessment technique should be avoided in patient with pheochromocytoma?Abdomen palpation as it can cause release of cathecolomines and cause hypertensive crisis
- 143Signs of ototoxicityvertigo, tennitis
- 144When a child should be taken to the dentist for the first time?After the first tooth appears (usually around 6 months) or by their first birthday
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- Flashcards on NCLEX part 2, created by Kristina Tsvygun on 20/06/2021.
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