NCLEX Review Multi1

  1. Simian crease
    straight crease lines across the palm of the hand and sometimes of the feet and are often a sign of Down Syndrome
  2. Down Syndrome
    chromosomal abnormality involving an extra chromosome (#21); indications include separated sagittal suture, eyes slanted upward and outward, small nose with depressed nasal bridge, muscle weakness, mild to moderate retardation, congenital heart diseas, hearing loss; care includes provide stimulation, OT, PT, special ed, adequate nutrition, parental education and support
  3. Care after pancreatoduodenectomy
    deep breathing and coughing to prevent atelectasis and pneumonia; splint the incision to aid in performing these as it hurts to deep breathe and client will breathe shallowly, allowing atelectasis to develop.
  4. Naegels rule
    • determine due date
    • count back 3 mo from first day of last menstrual period and add 7 days and 1 year; ultrasound fundal height-12-14 weeks, above the level of symphysis; 20 weeks, at the umbilicus or 20cm, rises approximately 1cm/wk until 36 weeks
  5. Orthopnea
    sitting position drops diaphragm and increases lung capacity; client may elevate head on pillows, sit in recliner or lean forward
  6. apnea
    absence of respirations
  7. Biot's respirations
    varying depth and rate, periods of apnea, irregular
  8. bradypnea
    less than 10 breaths/min, slow, regular rate and rhythm
  9. Cheyne-Stokes respirations
    alternating periods of apnea and deep, rapid breathing, regular rhythm
  10. hyperventilation
    increased rate and rythm
  11. hypoventilation
    decreased rate and rhythm
  12. Normal respirations
    12-20 breaths per minute, regular rhythm and rate
  13. tachypnea
    greater than 24 breaths per minute, shallow, fast rhythm
  14. Sodium level
  15. hyponatremia
    • less than 135
    • sodium is main extracellular ion, responsible for water balance
    • causes include vomitingg, diuretics, excessive administration of extrose and water IV's, prolonged low-sodium diet, excessive water intake
    • indications include nausea, muscle cramps, increased ICP, confusion, muscular twitching, convulsions
    • treatment includes oral administration of sodium rich foods such as beef broth, tomato juice, IV lactated ringers or 0.9% NaCl, water restriction, I&O daily weight.
  16. cimetidine
    • Tagament
    • used for gastritis
    • side effects, diarrhea, confusion and dizziness,headache, dysrhythmias
    • avoid antacids within 1 hour of dose, be alert to onset of confusion, bedtime dose suppresses nocturnal acid prodcution
  17. acute cholecystitis
    • inflammation of the gallbladder; acute or chronic
    • inflammation and obstruction stimulates abdominal pain receptors
    • pain may be intermittent or constant
    • pain radiates from right upper quadrant to right shoulder
    • indications include intolerance to fatty foods, indigestion, nausea, vomiting, severe pain in upper right quadrant of abdomen, elevated temp
    • risk factors include obesity, sedentary lifestyle, female ages 50-60
    • NSG considerations: administer antibiotics, analgesics, antispasmodics, NPO until acute symptoms subside, weight reduction if needed, instruct to avoid fatty, fried foods
  18. Acute Glomerulonephritis
    • is an inflammation of the tubules of the kidneys (glomeruli), which filter waste products from the blood
    • s/s: edema-initially in face around eyes then legs, changes in urine, including low urine output (oliguria), blood in urine (hematuria), protein in urine (proteinuria), and cola colored urine; high blood pressure, mild anemia, pallor, joint pain and stiffness, malaise and lethargy, anorexia, fever, H/A
    • treatment: antibiotics, antihypertensives, diuretics, corticosteroids, bed rest, dialysis in rare cases

    • damage to glomerulus caused by an immunologic reaction that results in proliferative and inflammatory changes with in the glomerular structure; usually caused by beta-hemolytic streptococcal infection elsewhere in the body, occurs 10 days after skin or throat infection; indications include hematuria, red cell casts, proteinuria, fever, chills, dyspnea, weight gain, lung rales, fluid overload, generalized and/or facial periorbital edema, oliguria with fixed specific gravity; complications include hypertensive encephalopathy, acute cardiac decomposition, acute renal failure
    • treatment includes antihypertensives, regular diet with limited sodium, restricted high potassium foods during oliguria, antibiotic therapy if an ongoing streptococcal infection
    • nsg considerations: frequent assessment of v/s, daily weight, monitor I&O, asses fro cerebral complications, record characteristics of urine, regular diet with NAS, divide prescribed intake throughout waking hours, bedrest.
  19. Gastroesophageal Reflux Disease
    • GERD
    • syndrome resulting from esophageal reflux, which is backward flow of gastric contents into esophagus
    • esophageal mucosa breaks down
    • often associated with hiatal hernia, but not necessarily
    • indications include odynophagia (severe sensation of burning, squeezing pain while swallowing),acid regurgitation, dysphagia, dyspepsia (gastric discomfort after eating, sucha as fullness, heartburn, bloating, nausea)
    • symptoms may mimic heart attack symptoms
    • interventions include surgery if pt does not respond to medical management
    • nursing interventions include administer medications to decrease reflux (antacids, histamine receptor antagonist, cholinergics,¬†gastrointestinal stimulants, proton pump inhibitors), instruct about dietary changes (small frequent meals, adequate fluids with meals, chew slowly and thoroughly, avoid irritating foods such as very hot or cold, spicy, fatty, citrus juices, coffee), NPO for 3 hours before sleep, instruct about lifestyle changes (elevate HOB 6-8 inches at night, lose weight if overweight, avoid tobacco, salicylates, alcohol).
  20. BP Medications
    • ACE inhibitors: lowers production of angiotensin II
    • Calcium Channel Blockers: blocs calcium channels in the circulatory system
    • Diuretics: decreases fluid volume
    • Beta-adrenergic blockers: decreasing HR and contractions force
  21. Pneumothorax
    • lung collapse caused by accumulation of air or fluid in the pleural cavity; indications include pleuritic pain, tachypnea, diminished breath sounds
    • treatment includes chest tubes
    • S/S: sudden sharp chest pain; may be worse with coughing; decreased or no breath sounds on the affected side; asymmetrical chest wall movement; SOB, tympanic sounds with chest wall percussion; rapid shallow respirations, tachycardia, anxiety, subcutaneous emphysema
    • Treatment: bedrest, needle aspiration, Heimlich valve, thoracotomy tube with underwater seal, pleurodesis, pleural staling, pleurectomy
    • NSG care: assess breath sounds, care of client with thoracotomy tube, instruct use of IS, pulmonary hygiene measures, evaluate the pt response to therapy
  22. nitroglycerin
    • used in the treatment of angina pectoris to reduce ischemia and relieve pain by decreasing myocardial oxygen consumption, acts to dilate veins and arteries
    • S/E: throbbing H/A, flushing, hypotension, and tachycardia
  23. defensive or coping mechanisms
    • Denial: failure to acknowledge reality
    • Displacement: redirection of feeling away from real target to safer but innocent person
    • Dissociation: temporary change in consciousness (to deal with emotional conflict)
    • Projection: a person attributes to others his unacceptable thoughts and feelings
    • Rationalization: making excuses for short comings
    • Reaction formation: behaving the opposite of the way a person feels
    • Repression: unconsciously blocking out upsetting or unacceptable thoughts and feelings
    • undoing: trying to undo the harm a person believes he has done
  24. Levothyroxine sodium
    • Synthroid
    • thyroid hormone, increases metabolic rate of body
    • S/E: nervousness, tremors, tachycardia, palpitations, arrhythmias, angina, weight loss, sweating
    • NSG considerations: monitor pulse before each dose during dosage adjustment, monitor weight, teach to report toxicity signs.
  25. Bowel Obstruction
    • partial or complete blockage of lumen of large or small intestines.
    • S/S: abdominal pain, nausea, vomiting, inability to pass gas or stool, and tympanitic and tender abdomen
    • treatment: NPO, nasogastric or intestinal tube placement, fluid and electrolyte replacement, enema, disimpaction, colectomy possibly including temporary or permanent colostomy or ileostomy
    • NSG Car: monitor abdominal girth, V/S, and fluid and electrolyte balance, provide oral hygiene, administer fluids, electrolytes, antibiotics, antiemetics and analgesics, opiods are avoided because they decrease peristalsis. Monitor for ferforation and ischemic bowel. encourage high fiber and fluids.
Card Set
NCLEX Review Multi1
test 1 review