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Kaplan Diagnostic exam A

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1. Addison's deficiency of adrenocortical hormones; cause: surgical removal of the adrenal cortex, destruction of it
disease idiopathically or by infections, inadequate pituitary ACTH, sudden stopping of exogenous adrenocortical hormone
therapy; indicates: weakness, hypoglycemia, hypotension, anorexia, GI symptoms, emaciation, dark, pigmentation of
skin, low serum sodium, low blood glucose, high serum K, dehydration; treatment: hormone replacement therapy;
nursing responsibility: monitor balance of fluid and electrolytes, VS, weight; client education: diet, medications,
activity level
2. adolescent during adolescence girls are coping with physical changes, changing relationships, and the increasing need for
pregnancy independence; less than age 15 years, girls still see parents as authority figures; age 15-17 years, look to peer group
for authority and decision making; age 17 years and older, are more comfortable with themselves and the ability to
make decisions; adolescents are at high risk for premature births, low birth weight infants, pregnancy-induced
HTN, and cephalopelvic disproportion
3. Agitation indicated by increased motor activity, decreased ability to relate to others, distorted perceptions, and loss of
rational thought; when interacting with an agitated client, it is important for the nurse to be supportive and
protective
4. Airborne Used with pathogens transmitted by airborne route; private room with monitored negative air pressure with 6-12 air
Precautions changes per hour, keep door closed and client in room can cohort or place client with another client with the same
organism but no other organism; place mask on client if being transported; examples of disease in category
include measles (rubeola), M. tuberculosis, varicella (chickenpox), disseminated zoster (shingles).
Airborne Infection Isolation Room (AIIR). PPE
5. Alcoholism occurs when drinking begins to cause problems in a person's life, drinking increases due to the problems, and a
physical and psychological dependence develops;
during counseling of an alcoholic, important to identify problems related to drinking, help person to see/admit
problem, establish control of drinking problem through Alcoholics Anonymous (AA), use disfulfram, assist person
to identify factors that trigger drinking.
6. Alcohol alcohol sedates the CNS; early S/S occur 4-6 hours after the last drink and include tremors, agitation, anxiety,
withdrawal insomnia, mild tachycardia; hypertension; Indications of delirium tremens include: tremors, anxiety, panic
disorientation, hallucination, vomiting, grand mal seizures (first 48 hours after withdrawal); nursing responsibilities
include administering sedation as needed, monitoring VS, seizure precautions, providing quiet, well-lighted
environment; alcoholic occurs 48 hours after last drink; indications include auditory, visual, or tactile hallucinations
in absence of other psychotic behavior
7. Alzheimer's Chronic, progressive, degenerative disease resulting in cerebral atrophy, decline in intellectual/cognitive
Disease functioning, motor, sensory, and affective decline. Risk- exact cause is unknown, repeated head injury, genetics.
Most common after age 65 years.
Indications: changes in personality, motor restlessness and pacing (in early stage of the disease).
Sometimes it is seen to occur in 3 stages: 1) memory loss 2) impaired language, motor ability, and object
recognition 3)loss of continence, ambulation, and all language skills
Nursing responsibilities: reorienting as needed, speaking slowly, providing clocks and calendars in patient's room,
promoting sleep, hygiene, grooming, nutrition. safety, protecting from self-injury and injury to others, encouraging
social interaction, increasing self-esteem, and assisting the family to understand and cope.
Safety: awaken at night, safety, and get lost. Allow as much independence as possible.
8. Aminophylline bronchodilator, relaxes smooth bronchial muscle, potentiates diaphragm contraction, and increase mucus
movement in airways; administered IV by continuous drip, dosage is based on body weight, used for asthma and
bronchospasm
9. Amitriptyline tricyclic antidepressant; adverse effects: drowsiness, dizziness, orthostatic hypotension, dry mouth, and
constipation; nursing considerations: monitoring VS for client diagnosed with cardiac disease, checking for urinary
retention and constipation; may take 3-4 weeks to achieve a therapeutic level, suicide risk high after 10-14 days;
sunblock required, take dose at bedtime
10. Amputation surgical removal of a part of the body; complications include phantom limb pain, infection, and hip contracture;
nursing responsibilities include preventing hip contracture by doing ROM, placing the client prone for 20-30 min
every 3-4 hr; dont elevate residual limb on a pillow after the immediate postoperative period; after the pressure
dressing and drains are removed, inspect the wound for inflammation; dressing changed daily until the suture are
removed; residual limb wrapped with an elastic bandage to shape the residual limb and keep the dressing in place;
observe for symptoms of inadequate tissue perfusion
11. Angina Pectoris chest pain is quick or slow in onset, caused by myocardial ischemia, and often related to coronary artery
disease
S/S: Burning, squeezing, or crushing tightness in the substernal or precordial chest, pain or discomfort may
radiate;
Treatment: nitrates reduce myocardial O2 consumption; beta-adrenergic blockers reduce workload and o2
demands;
Nursing care: monitor BP and HR
Expected Outcomes: increase in O2 supply and no signs of pain or SOB while at rest or with usual activity
12. anorexia nervosa eating disorder more common in females 8-10 years; indications: dramatic weight loss, distorted body image,
fear of obesity, anemia, amenorrhea, endocrine dysfunction, hypothermia, electrolyte imbalance, gastric
complications, denial/fear of sexuality, repression and regressions, strained family relationships, etc.
treatment: individual, group, family therapy, behavior modification, assessment and correction of an physiologic
abnormalities
Nursing responsibilities: monitoring weight intake, VS, implementing behavior modification, encouraging respon.
for self, exploring sexual issues, support groups, family interventions, client education
13. Basic Process of externally supporting circulation and respiration; failure to institute ventilation within 4-6 minutes
Cardiopulmonary results in brain damage; sequence is CAB (Compression-Airway-Breathing).
Resuscitation Purpose: supplies oxygen to the lungs, provides manual chest compressions circulate blood to the body
(CPR) systems, and preserves heart and brain function while waiting for defib and advanced cardiac life-support care.
1) establish unresponsiveness, breathing, pulse
2) activate EMS
3) start compressions at a rate of at least 100/min; depth depends on age, recoil, compression- ventilation rate
30:2 adult
4) establish airway by using the head-tilt chin lift; suspected trauma, use jaw thrust
5) begin breathing at 8-10 breaths/min, watch for visible chest rise. all chest compressions are at a rate at least
100/min.
14. Bipolar Disorder Mood disorder; manic episode usually begin suddenly, with rapid escalation; Indications: elevated or expansive
mood, agitation, accelerated speech, thought, and movement, distractibility, self- confidence, aggression,
sarcasm, inappropriate dress, inattention to personal hygiene, anorexia, weight loss, constipation, insomnia;
Treatment: lithium or particular anticonvulsant medications; nursing responsibilities: maintaining physical health
and safety, monitoring for lithium or anticonvusant toxicity, orienting client to reality, limiting stimuli, setting limits
consistent
15. bradytherapy use of implants that are radioactive at the treatment site, usually a malignant lesion; internal radium implants;
internal radiation; mechanically positioned source of radioactive material placed in a body cavity or tumor;
source sealed; in the event that the implant becomes dislodged, radiology should be called immediately;
nursing considerations: save all dressings and bed linen until the source is removed and then discard the
dressings and linen as usual; this is done to assure that no radioactive source is in the linen or dressings; urine,
feces, and linen are not radioactive; nurse should not stand close to or in line with the radioactive source;
organize care so limited is spend in client's room; encourage client to do own care; client must remain on bed
rest while the implant is in place; position of the source of radiation is verified by radiography
16. Buck's traction Application of pulling force to part of the body to reduce, align, and immobilize fractures and relieve muscle
spasms.
It is a skin traction, pulling force applied to skin. Is utilized to exert partial or temporary immobilization of the
lower leg prior to surgical fixation of fractures to the proximal femur.
Nursing care: maintaining straight alignment of ropes and pulleys, assuring that weights hang free, frequently
inspecting skin for breakdown areas.
If no fracture, may turn to either side, with fracture, turn to unaffected side. Elevate foot of bed for
countertraction, use trapeze for moving. Do not elevate knee gatch.
17. Cardiac radiopaque catheter inserted through peripheral blood vessel into chamber of heart, usually used with
Catheterization angiography, purpose is diagnostic or can be used as intervention in some congenital heart deficits;
nursing considerations: pre-procedural: measure height to help determine correct catheter selection, hx of
allergic reactions, any infection present, assess and mark pedal pulses, age-appropriate preparation for
procedure; post-procedural nursing considerations include assess for pulses, temp, and color of affected
extremity, assess HR every 15 minutes for a full minute, assess for indications of hemorrhage, ensure adequate
hydration
18. Cast care immediate cast care- avoid covering cast until dry; handle with palms, not fingertips (plaster cast), avoid resting
cast on hard surfaces or sharp edges, keep affected limb elevated above heart on soft surface until dry.
Observe for blueness or paleness, pain, numbness on affected area. Teaching about possible heating while cast
dries.
Intermediate care- encourage client to perform prescribed exercises, report any break of foul odor, inform
client not to scratch skin underneath cast, don't put anything underneath cast. Compartment syndrome.
19. Chest tubes chest tubes are placed in the pleural space to drain air and blood so that the lung can re-expand; drainage
system consists of one or more chest tubes; collection container placed below the chest and a water seal is
used to keep air from entering the chest; nursing responsibilities: observing for constant bubbling in the
water-seal chamber (indicates a leak in the drainage system); if chest tube becomes dislodged, apply
pressure over teh insertion site with a dressing that is tented on one side to allow for the escape of air; if he
tube becomes disconnected from the drainage system, but 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 re-established.
20. Chronic Bronchitis Type of chronic obstructive pulmonary disease (COPD); caused by inflammation of the bronchi;
indications: change in color, weakness, dyspnea, productive cough, and adventitious breath sounds;
Nursing responsibilities: listening to breath sounds, administering low-flow oxygen, encouraging fluids,
providing small, frequent feedings, administering bronchodilators, antibiotics, corticosteroids
21. Chronic group of conditions associated with obstruction of airflow entering or leaving the lungs, asthma, emphysema,
Obstructive chronic bronchitis, and cystic fibrosis; indications: change in skin color, weakness, dyspnea, cough, and
Pulmonary Disease adventitious breath sounds; nursing care: administering bronchodilators, mucolytics, corticosteroids,
(COPD) anticholinergics, and atropine sulfate, administering low-flow oxygen, encouraging fluids, providing small
frequent feedings, listening to breath sounds, teaching the client about breathing exercises, and instructing to
stop smoking
22. Cocaine/crack stimulant; can be abused, also known as "crack" routes of use IV, intranasal, or smoking; highly addictive and
cocaine tolerance develops rapidly; use is demonstrated by pupillary dilation, tachycardia, altered blood pressure,
sweating, chills, N/V, weight loss, euphoria talkativeness, hypervigilance; pacing, psychomotor agitation,
impaired social or occupational functioning, episodes of violence, fighting grandiosity, visual or tactile
hallucinations, symptoms of withdrawal, anxiety, depression, irritability, fatigue, insomnia or hypersomnia,
perforation of nasal septum (if smoked); nursing interventions: keep in calm and quiet environment, monitor
respiratory and cardiac status, administer anticonvulsant if ordered, maintain cool ambient air, detoxify as
ordered
23. Colostomy Care pouch should be measured accurately to fit well; when changing the pouch, the client should assess the
color, moistness, presence of edema, tenderness, skin irritation; cleanse around stoma with water and soap;
apply skin barrier and pouch; client education about diet; immediately postoperatively low residue diet for
several weeks to allow for healing, then add foods as tolerated, avoid gas forming foods; utilize wound
ostomy continence nurse (WOCN) in client care
24. Crutch Walking Measure 2 fingers below axilla to measure crutch heights; support weight on hand piece rather than axilla;
keep crutches 8-10 inches out to side; elbows should be flexed at 20-30 degree for correct placement of
hang grip; ensure safety; remove throw rugs, make sure that crutches won't bump furniture causing client to
trip; instruct client not to walk on wet or slippery floors or sidewalks
25. Cuffed tube inserted through Surgical incision made into trachea by way of throat; balloon that encircles the trachea
Trachesotomy tube to form a seal between the outer cannula and the trachea; used to permit mechanical ventilation and
protect lower airways; should be inflated during and after eating. 1 hour after tube feeding, when client is
unable to handle oral secretions, during mechanical ventilation and any respiratory treatments; cuff pressure
should not exceed 20 mm H20
26. Cyclophosphamide alkylating agent; use: cancer
Action: interferes with RNA replication, causing an imbalance of growth that leads to cell death
side effects: cardiotoxiticity, N/V, leukopenia, anemia, reversible alopecia, hepatotoxicity
Nursing considerations: report hematuria, force fluids, monitor for infection, administer antibiotics, should be
administered by a nurse who is not pregnant
27. Cystic Fibrosis Heredity dysfunction of exocrine glands, causing obstructions because of flow of thick mucus; involves
dysfunction in sweat glands, respiratory, and GI systems; voracious appetite early in disease and loss of
appetite later; difficulties with eating due to respiratory difficulties; treatment: postural drainage, chest
physiotherapy, breathing exercises, expectorants, mucolytic agents, replacement of pancreatic enzymes,
aerosol therapy with bronchodilators, and mucolytics assists in loosening secretions so they may be removed,
provides relief of bronchospasm, decreases edema of he mucosa, and liquefies the bronchial secretions,
explusive coughing or postural drainage assists client to expectorate secretions.
28. Deep Tender reflex within the body; to assess deep tendon reflexes the extremity should be relaxed and partially
Reflexes stretched, compare responses on the right and left side of the body, responses should be equal; reflexes
graded on a 4 point scale with 1+ being diminised and 4+ being hyperactive
29. Depression abnormal feelings of sadness, low self-esteem, helplessness or hopelessness, observe thoughts and fears, sense of
doom or failure; somatic complaints: GI distress, change in appetite, pain, irritability, sleep disturbances, lack of
energy, changes in sex drive, palpitations, dizziness
treatment: antidepressants, electroconvulsive therapy, individual or group therapy;
nursing responsibilities: being alert for signs of self-destructive behavior; assisting the client in meeting physical
needs, supporting self-esteem, and helping decrease social withdrawal
30. Diabetes disorder that results in abnormally high glucose levels in the blood; cause is absence or decrease of insulin from
Mellitus pancreas and/or decrease in ability of body to respond to insulin (insulin resistance, decreased sensitivity of tissues
to insulin); treatment: insulin injection or oral hypoglycemic agents, diet therapy, dietary management is very
important, as is consistency in total calories, carbohydrates, and the timing of food; client should lose weight is
obese and maintain the ideal weight; should have a high intake of complex carbohydrates, low intake of fat, high
intake of fiber, and some protein; meal planning includes meals with complex carbos, fat, and protein; insulin is a
pancreatic hormone that controls blood glucose levels, lowering them by promoting uptake and use of glucose by
cells, and inhibiting conversion of glycogen and amino acids to glucose; administered by injection
31. Digoxin and cardiac glycoside; action: decrease HR, increases force of contraction; side effects: bradycardia, anorexia, N/V,
Furosemide fatigue, dysrhthmias, and diaphoresis; nursing responsibilities: know baseline VS, check for signs of toxicity, take
apical pulse for 1 full minute noting rate and rhythm and quality, withhold the med and notify health care provider if
rate falls below 60, observe K levels;
Loop diuretic; action: inhibits reasborption of Na and Chloride in the loop of Henle and distal renal tubules; after
oral dose, diuresis occurs in about 30 minutes; side effects: hypotension, hypokalemia, GI upset, weakness; nursing
considerations: monitor BP and pulse and intake and output, monitor K, weigh client daily, do not give at hour of
sleep; client education: potassium containing foods
32. Disfunctional DUB is an excessive abnormal amount of menstrual flow related to anovulatory cycles.
Uterine Ask client to estimate the number of pads or tampons that are used in a specific time period, and ask if clots are
Bleeding preset in the flow. If clots are present, the nurse should ask the woman to estimate the size of the clots using coins
(DUB) for comparison.
Obtain a complete menstrual hx from the woman. Ask about recent illness, variations in weight, diet, or exercise,
drug ingestion, and the presence of pain.
Pelvic ultrasound and hysteroscope may be performed together with an endometrial biopsy by suction aspiration
or dilation and currettage (D & C).
33. Emphysema loss of lung elasticity and alveolar surface area, destruction of alveolar walls, enlargement of alveoli;
causes: smoking, exposure to secondhand smoke, chronic infections or inflammation, and alpha-one antitrypsin
deficiency;
symptoms: SOB with activity or at rest, orthopnea, decreased breath sounds, use of accessory muscles, tachypnea
with shallow respirations, weight loss, increased anterior-posterior chest diameter, decreased mental alertness;
complications: right HF, respiratory infections/failure;
treatment: removal of cause, cough enhancement techinques, graduated exercise program, beta-adrenergic
agonist and anticholingeric medications;
nursing care: education about prevention of infection and factors that cause pulmonary damage, potential
complications and when to call health care provider; administration of medications, education about meds,
administer oxygen therapy
34. Epilepsy chronic disorder characterized by recurrent seizure disorder, symptom of brain or CNS irritation;
classification: generalized seizure- tonic-clonic seizure; absence seizures; atonic seizures;
nursing responsibilities: observing and documenting type and progress of seizure activity and postictal behavior,
oxygen, and suction at bedside; postseizure: position on back with head turned to side or position on side to
prevent aspiration and promote drainage of secretions; treatment: medications :
35. Fetal lie describing fetal position-practice of defining position of baby, particualarly the presenting part, relative to the
mother's pelvis and its four quadrants: point of max. intensity (PMI) of fetus-point on the mother's abdomen where
the FHT is the loudest, is usually over the fetal back; divide the mother's pelvis into four parts of quadrants: right
and left anterior, which is the front, and right and left posterior, which is the back; abbreviated R and L for the Right
and left, and A and P for anterior and posterior; head, particularly the occiput, is abbreviated O; LOA is the most
common fetal presentation and the FHT is heard on the left side; in a vertex presentation, the FHT is heard below
the umbilicus; in breech presentation, the FHT is heard above the umbilicus.
36. growth and climbs and jumps well, laves shoes, brushes teeth, 1500 word vocab, skips and hops on one foot, throws overhead;
development: age appropriate toys include playgrounds materials, housekeeping toys, coloring books, tricycles with the heart
4 year old
37. Growth and doubled birth weight, rests weight on forearms when prone, straightens head or back when propped or held in
development: 5- sitting position, sustains a portion of won weight when standing position, disappearance of tonic neck reflex;
month-old Moro reflex is fading, grasps objects with a whole hand, has some simple vowel sounds, plays with a variety of
objects is taken away; working on trust versus mistrust.
38. Growth and creeps from prone position; sits steadily and can lean forward (but not sidewards) and regains balance; stands
development: 9 holding onto table and may even pull up to that position; usually a first word; creeps; likes toys that go inside
month old each other (pots, pans); very aware of the changes in voice tone of others
39. Growth and ages 12-20 years; cognitive theory developed by Piaget views adolescence as a time when ability to reason
development: goes beyond concrete objects to symbols or abstractions; adolescents develop ability to deal with logic,
adolescence metaphors, and rational thought; can make conclusions and reflect on ideas. Male changes include increase in
genital size, breast swelling, appearance of pubic, facial, axillary, and chest hair deepening of the voice,
production of functional sperm, and nocturnal emissions; female changes include increase in pelvic diameter,
breast development, altered nature of vaginal secretions, appearance of axillary and pubic hair, menarche- first
menstrual period
40. growth and age 36-6 years; runs well; jumps rope; dresses without help; irritates adult patterns and roles; offer playground
development: materials housekeeping toys, coloring books, safety: used bicycle helmet, safety restraints in care, teach to look
preschool-aged ways before crossing street; 2100 word vocab, tolerates increasing periods of separations from parents,
child beginning of cooperative play, gender-specific behavior, skin of alternate feet, ties shoes
41. Growth and age 12-36 months: Time of slowed growth, profound activity, curiosity, and negativism, builds 2-7 block towers,
development: vocabulary increases from 10 to 200 words; fears include separation from parents, animals, and strangers, change
Toddler in the environment; anterior fontanelle closes at approximately 18 months; age-appropriate toys include: push-
pull toys, low rocking horses, dolls, stuffed animals, riding toys, blocks, finger-paints; engages in parallel play.
42. Heart Failure failure of the heart to pump blood to meet metabolic demands of tissues, left and right ventricles can fail
separately; left-sided failure indications; dyspnea, orthopnea, cough, crackles, tachycardia, fatigue, anxiety,
restlessness, confusion; right=sided failure indicates: jugular vein distention, dependent edema, hepatomegaly,
right upper quadrant tenderness, increasing hepatic dysfunction, ascites, anorexia, nausea, weight gain, weakness,
respiratory distress, abdominal pain, altered liver function and liver function tests, GI distress; treatment: O2,
digoxin, vasodilators, K supplements, low NA diet, bed rest; Nursing responsibilities: promoting physical and
emotional rest, high fowlers position, assessing VS, lung sounds, intake and output, good skin care and client
education
43. Hemodialysis Removes excessive fluids and waste products usually removed by the kidneys by circulating client's blood
through semi-permeable membrane that acts as an artificial kidney; client's circulation accessed through an
arteriovenous fistular (A-V), shunt, fistula, or graft; nursing care includes checking thrill and bruit every 8 hours,
don't use extremity for BP or to obtain blood specimens, monitored closely for hypotension, HA, N/V, malaise,
dizziness, muscle cramps
44. Hepatic a brain dysfunction and damage caused by increased ammonia in the blood, resulting from severe liver disease;
encephalopathy eliminating dietary protein administering antibiotics decreases serum;
indications: progressive mental and motor disturbances, including come;
Nursing Responsibilities: assessing neuro status, I & Os, VS, assessing for infection, monitoring electrolytes,
decreasing protein in diet, giving antibiotic as ordered.
45. Hepatitis A acute inflammatory disease of the liver resulting in liver cell damage. Hep A is transmitted by infectious feces via
fecal/oral route, shellfish from contaminated waters is a major source.
Indications: jaundice, anorexia, right upper quadrant abdominal pain, clay-colored stools, tea-colored urine,
pruritis; Liver function studies reveal evelated ALT, AST, prothrombin time is prolonged.
Interventions: prevention by improved sanitation, gamma globulin early postexposure
Nursing Interventions; bed rest for severe symptoms contact precautions is diapered or incontinent, diet low in
fat in calories, carbohydrates, and protein, no alcohol, use calamine lotion, antihistamines, maintain short, clean
nails for pruritus, administer medication as ordered, including vit K, antimetics, corticosteriods, avoid potentially
hepatotoxic prescription/OTC medications, teach to balance rest and activity periods, techniques to prevent
spread, cannot donate blood.
46. Hyperglycemic, occurs in type 2 diabetics over 50 years of age; indications: glucose levels greater than 800mg/dL,
hyperosmolar, hypotensions, dry mucous membranes, poor skin turgor, tachycardia, altered awareness, seizures, hemiparesis;
nonketotic ketosis and acidosis do not occur; nursing care: administration of normal saline, regular insulin, assess VS, blood
syndrome glucose, central venous pressure, LOC, urine output, and temperature
(HHNS)
47. hyperventilation patient breathes very rapidly over prolonged period of time, which causes an O2/CO2 imbalance; Indications:
tingling or numbness in the tip of nose, lips. fingers, or toes, dizziness, spots before eyes, carpal-pedal spasms;
Treatment: breathing into paper bag to rebreathe CO2
48. Hypoglycemia abnormally low blood glucose level; may occur at any time, but often occurs at the time the insulin is peaking;
usually occurring suddenly and as a complication of diabetes.
Indications: tremor, perspiration, anxiety, hunger, weakness, tachycardia, confusion, and HA;
Nursing care: if conscious offer 15 gram load of carbohydrate; if unconscious administer dextrose 50% follow with
additional carbohydrate or dextrose in 15 minute if blood glucose level not within normal range, determines cause.
administer a pack of protein and starch after symptoms resolve
49. Hypospdias congenital malformation; urethral opening is a groove on the ventral surface of the penis; treatment is surgery
50. Iieal conduit ureter is implanted into a portion of the ileum and brought through abdominal wall; nursing responsibilities: skin
barrier and transparent disposable urinary drainage bag applied could the conduit and connected to drainage;
appliance is changed as needed to prevent leakage of urine, usually every 3-5 days; stoma size is recalibrated
every 3-6 weeks postoperatively; appliance should be no larger than 1.6 mm larger than the stoma; skin around
stoma should be be cleaned with soap and water and thoroughly dried.
51. Insert Indwelling double lumen catheter with inflatable balloon toward tip; used for urinary drainage; to female, place
Indwelling client in dorsal recumbent position or in Sims' position, drape with sterile technique; apply sterile gloves, lubricate
Urinary tip and place in sterile catheter tray, separate labia and wipe from meatus toward rectum with sterile povidone
Catheter iodine swab, insert catheter 2-3 inches into urethra, insert catheter an additional inch after urine begins to flow,
inflate balloon, gently apply traction to catheter and tape drainage tubing to thigh; to insert in male
(Uncircumcised); retract foreskin, cleanse glans and meatus with sterile povidone idoine swab, hold penis
peripendicular to body, insert catheter into urethra 6-7 inches or until urine flows out through end of catheter and
then advance another 2 inches, replace foreskin, inflate balloon, gently apply traction to catheter until resistance
felt, tape drainage tubing to thigh.
52. Isocarboxazid Monoamine inhibitor (MAOIs- a class of antidepressants).
(Marplan) Use: depression (only).
Side effects: constipation, dry mouth, dizziness, HA, drowsiness.
Nursing responsibilities: monitor BP during initial treatment, observing for suicidal tendencies. monitor vitals.
administer bedtime and with food (fiber/water).
Client education: instructing client to avoid foods high in tyramine. dry mouth.
53. IV infiltration infiltration occurs when the iV needle or catheter becomes dislodged from the vein and is the subcutaneous tissue;
IV fluid or medication administration into tissue; cause: dislodged cannula, perforation of vein; S/S: cool, pale,
clammy, edematous skin around site, fluid seeping from site, decreased flow rate, may be painful; if tissue is
irritating, sloughing might occur; nursing interventions: frequent, at least hourly, monitor IV insertion site; stop fluid
flow, discontinue site if medication/fluid is not a vesicant, apply site
54. Labor the first stage: 3 phases- phase 1 (latent): cervix is dilated 0-3 cm, contractions 10- 30 sec long, 5-30 min apart, mild
to moderate; phase 2 (active):cervix is dilated 4-7 cm, contractions 30-60 secs long, 3-5 min apart. moderate to
strong; phase 3 (transitional): cervix is dilated 8-10 cm, contractions are 45-90 secs long, 2-3 minutes apart, strong,
impending delivery marked by increase in ark red bloody show, increased urgency to bear down;
second stage: from full dilation of cervix to delivery of baby;
third stage: from birth of baby to expulsion of placenta;
fourth stage: the first 2 hours after the birth of the baby
55. Late begins after a contraction has been established (usually at or after the peak of contraction) and continues after the
deceleration contraction is over, with a gradual return to baseline; caused by uteroplacental insufficiency, cord compression,
and/or supine hypotensive syndrome in the pregnant client; fetal hypoxia and acidosis usually result; treatment
includes positioning client on left side; elevating the client's leg, giving the client oxygen, and notifying the health
care provider
56. Mantoux Test Tuberculin skin test, tubercle bacillus extract, purified protein derivative (PPD) given intradermally in the forearm;
read in 48-72 hours; induration (hard area under skin) of 5 or more considered positive HIV infected persons,
recent contact of a person with TB, persons with fribrotic changes on chest radiograph consistent with prior TB,
client with organ transplants, persons who are immunosuppressed for other reasons; Induration of 10 or more mm
is considered positive in recent immigrants from high-prevalence countries, injfection drug users, residents are
employees of high-risk, children less than 4 yrs old, infants and children and adolescents exposed to adults in
high-risk categories; induration of 15 or more mm is considered positive in any person, including persons with no
known risk factors fro TB; however, targeted skin testing programs should only be conducted among high-risk
groups; induration indicated exposure to TB or presence of inactive (dormant) disease.
57. Marijuana indications: injected (reddened) conjunctivae, tachycardia, dry mouth, and an increased appetite, especially for
"junk" food; indications of withdrawal are insomnia, hyperactivity, decreased appetite; nursing care includes: "talk
down" patient, reduce sensory stimuli
58. Maslow's 5 levels of needs:
Hierarchy of physicological needs,
Needs safety or security needs,
love and belonging needs,
esteem, and
self-actualization; client
progresses up the hierarchy when attempting to satisfy needs; low level needs must be met first
59. mastectomy modified mastectomy- a common surgical procedure for treatment of breast cancer; all the breast tissue is
removed together with axillary lymph nodes, pectoralis (chest) muscles are left intact; lymphedema is edema
caused by obstruction of lymphatics; can be prevented by positioning each joint higher than the more proximal
one
60. Meniere's caused by dilation of the endolyphatic system;
disease S/S: tinnitus, unilateral sensorieneural hearing loss, vertigo;
Treatment: salt and fluid restriction to decrease amount of endolymphatic fluid, antihistamines, antiemetics, and
surgery
61. Newborn newborn hypoglycemia occurs because of GDM, the moth was hyperglycemia and high levels of glucose cross
Hypoglycemia the placenta, stimulating the fetal pancreas to release insulin, hyperinsulinemia results: after infant is born, the
constant infusion of glucose is interrupted suddenly, causing hypoglycemia (blood sugar 40-50 mg/dL);
Indications: jitteriness, irregular respiratory effort, cyanosis, lethargy, twitching, seizures, Nursing Care: monitoring
glucose level soon after birth and repeating in 4 hour, administering glucose, initiating feedings
62. newborn stool first stool is black and tarry (meconium) passed within 12-24 hours; followed by thin green/brown transitional stools
(part maconium, part fecal) the next day or two; then 1-2 formed, pale yellow to light brown stools per day with
formula feeding or loose golden yellow stools with sour milk odor with every breast feeding
63. Nitroglycerin use: angina pectoris
(Nitrate) action: dilate veins and arteries and thereby reducing ischemia and relieving pain by decreasing myocardial O2
consumption
Side effects: throbbing HA, flushing, hypotension tachycardia
Client education: appropriate administration (time, technique, dosage), storage, expected pain relief, possible side
effects, ointment is applied to skin, rotate sites to avoid skin irritation; has a prolonged effect up to 24 hours
64. Nonsteroidal nonopioid analgesic, antipyretics; Use: pain, fever, inflammatory disorders; action: inhibit prostaglandin isythesis;
Anti- side effects: HA, eye chagnes, dizziness, GI disturbances and bleeding, rash; Nursing Considerations: monitor liver
inflammatory and renal function; Client education: take with food or after meals, avoid OTC medications that may contain similar
Drugs medications
(NSAIDs)
65. normal RR is 30 to 50 breathes per minute
newborn HR: 120-140 bpm
BP: 60-80/40-50 mmHg;
axillary temp less than a 97.6 may be caused by prematirty, infection, or environmental temperature
66. Orchitis acute inflammation of testes caused by trauma of infection;
Indications: scrotal pain and edema;
Treatment: bed rest with scrotal elevation, ice, analgesics, and antibiotics.
67. Osteoporosis Degenerative disease characterized by generalized loss of bone density and tensile strength; indications include
decreased height, low back pain kyphosis; risk factors include age greater than 60 years, small-framed and lean
body build. Caucasian and Asian race, inadequate intake of calcium or vitamin D, postmenopausal; Nursing care:
encouraging diet high in calcium, protein, and vitamin D, encouraging weight-bearing on long bones, instructing
about safety precautions to prevent to prevent pathologic fractures
68. Pancreatic Pancreatic enzymes (pancreatin and pancrelipase); action: aid in the digestion of starches, fats, protein; side
Enzyme effects: anorexia, N/V, diarrhea, hypersensitivity, sneezing, lacrimation, skin rashes; nursing responsibilities: do not
Replacement use with antacids, avoid inhaling powder, client education: take with meals
69. parenteral Intensive nutritional support, an excess of 2500 kcal/day; usually given when client is unable to ingest, digest, or
Nutrition (PN) absorb the nutrients in oral foods; centrally administered through catheter into subclavian or internal jugular vein;
contains high concentration of glucose and proteins; hypertonic solution; if given too rapidly client experiences
glucose overload and excessive diuresis with the excretion of glucose, client may develop dehydration and shock,
HA, nausea, postural hypotension, seizures
70. Percutaneous needle biospy of the liver under local anesthesia; preparation: administering vit K IM to decrease chance of
Liver Biopsy hemorrhage, NPO 6 hr before exam, teach client to hold breath 5-10 sec while tissue is removed; Nursing care
after biospy: taking VS hourly for 8-12 hr, positioning in the right lateral position for approximately 1-2 h after the
procedure, bedrest for 24 hours, checking clotting time, platelets, hematocrit, reporting severe pain immediately
as it may indicate perforation of bile duct and peritonitis
71. Peritoneal excessive fluids and waste products that are usually removed by the kidneys are removed through the
Dialysis peritoneal cavity; catheter surgically inserted into the abdominal cavity; nursing care before procedure:
obtaining baseline VS, breath sounds, weight, glucose, and electrolyte levels; during procedure: 1-2 L fluid is
infused into peritoneal space by gravity using sterile technique, the fluid stays in cavity for app. 20 min., then the
fluid is drained by gravity; nursing care during procedure: taking Vs, checking for resp. distress, pain, or
discomfort, checking abdominal dressing around the catheter for wetness; complications: peritonitis, abdominal
pain, and insufficient return of fluid
72. Phenylketonuria genetic disorder caused by a deficiency in liver enzyme phenylalanine hydroxlyase; body cannot metabolize the
(PKU) essential amino acid phenylalanine, which allows phenyl acid to accumulate in the blood; if not recognized,
resultant high levels of phenly ketone in the brain causes mental retardation; Guthrie test is screening test for
PKU; treatment includes: dietary restrictions of foods containing phenylalanine (meat, eggs, beans, bread). blood
levels of phenylalanine should be monitored to evaluate the effectiveness of the dietary restrictions.
73. Physical order of physical assessment:
Assessment Inspection, palpation, percussion, auscultation, smell; only variation is physical assessment of abdomen-order:
inspection, auscultation, percussion, palpation; includes head-to-toe examination, all body systems, height,
weight, VS
74. physical choose largest speculum that fits comfortably in the client's ear canal, tilt client's head slightly away and toward
assessment: the client's opposite shoulder to bring eardrum into view, pull the pinna up and back for the for an adult or older
tympanic child and down and back for an infant or a child under 3 years of age to straighten the ear canal, do not release
membrane traction on the ear until the examination has been completed, hold the otoscope "upside down" and rest the
hand holding the otoscope on the client's cheek to steady the equipment, speculum should be inserted slowly
and carefully into the ear canal, rotate the otoscope slightly to visualize the areas.
75. Placenta Previa placenta abnormally implanted near or over the cervical opening; indications: painless bright red vaginal
bleeding accompanied by a soft uterus usually in third trimester between 20-30 weeks; caused by scarring of
uterus from pregnancy, tumor; treatment: includes bed rest, ultrasounds to locate placenta, no vaginal/rectal
exams before fetal viability, amniocentesis for lung maturity, daily Hgb and Hct, 2 U cross-matched blood
available
76. pneumothorax lung collapse caused by accumulation of air in the pleural cavity; indications: pleuritic pain, tachypnea,
diminished breath sounds; treatment: chest tubes
77. Postpartum Nursing care during postpartum period: check lochia (color, volume) every 15 minute; lochia (endometrial
sloughing)-day 1-3 rubra (bloody with fleshy odor; may have clots); day 4-9 serosa (pink/brown with fleshy
odor); day 10+ alba (yellow-white); at no time should there be a foul odor (indicates infections); check vital signs
(blood pressure, pulse) every 15 minutes; follow protocol until stable, check fundus every 15 minutes; position-
should be at or 1 cm/finger breath above the umbilicus for the first 12 hours, then descend by one finger breath
each succeeding day; pelvic organ usually by day 10, check urinary output; measure first void; may urethral
edema, urine retention
78. Prednisone Shorting-acting synthetic steroid.
action: suppress severe inflammation or immune response, decrease release of inflammatory mediators,
decrease infiltration of inflammatory cells, decreases edema and hyperactivity of airways and mucous
production
79. Premature one or more ectopic foci stimulate a premature ventricular response, usually caused by firing of an irritable focus
Ventricular in the ventricle; caused by hypoxia, hypokalemia, hypocalcemia, acidosis, coronary artery disease, and HR;
Contraction dangerous when occurrence is more frequent than 6/min
(PVC)
80. Preoperative Preoperative checklist includes ensuring that informed consent is signed and attached to chart, all lab tests,
Care chest X-ray, EKG have been completed, performing skin and bowel prep, NPO, administering preoperative
medications (sedation, antibiotics), removing dentures, jewelry, and nail polish.
Obtain client knowledge and expectations: Hx of illness, purpose of surgery, type of procedure, and
expectations.
Go through the risks of surgery.
Assessment: age, mental stasis, knowledge about condition/procedure, client's exceptions after surgery, client
concerns, misconceptions.
Preoperative period: consent forms, lab/diagnostic tests, IV site, safety procedures, equipment, surgical site
marking, hair removal, hair/cosmetics/ prosthetic, jewelry, skin prep.
Cultural concerns: language, beliefs, health care practices, pain, dietary concerns.
81. Preterm labor labor that occurs between 20 and 38 weeks gestation;
nursing care: bed rest inside-lying position, uterine monitoring, daily weights, maintaining good nutrition,
instructing about relaxation techniques, administering medication
82. prolapsed Umbilical cord is below the presenting part of the fetus, compressing the cord, which causes fetal hypoxia
Umbilical Cord resulting in CNS damage and fetal death; causes: gravity pushing the cord in front of the presenting part after
rupture of membranes, long cord, malpresentation including unengaged presenting part, and placenta previa;
treatment: examiner putting direct finger pressure on presenting part, relieving pressure on cord, placing in
Trendelenburg or modified Sim' position with pillows under the right hip, preparing for an emergency
casesarean delievery if the cervix is not fully dilated.
83. Rheumatoid systemic, chronic, progressive inflammatory connective tissue disease that affects joints; vascular granulation
Arthritis tissue called pannus destroys cartilage and bone. autoimmune response, heredity, and smoking.
Indications: joints that are painful, swollen, red, warm, and stiff (especially in the morning), fatigue, anorexia,
weight loss, decreased mobility.
Treatment: salicylates of nonsteriodal anti-inflammatory drugs (NSAIDs), analgesics, preservation of joint and
muscle function, reconstructive surgery, corticosteriods, antidepressants (for depression, sleep, pain
management).
Nursing responsibilities: administering analgesics as ordered, encouraging balance between rest and activity,
promoting independence, addressing self-concept issues. Joint deformity.
84. Schizophrenia a chronic illness resulting in psychotic behavior; indications include autism (withdrawal from relationships and
the world), inappropriate or no display of feelings; hypochondriasis and depersonalization; hallucinations (false
sensory perceptions in the absence of external stimulus), delusions (persistent false beliefs), short attention
span, regression, inability to meet basic survival needs; nursing care: maintaining client safety (protecting from
altered thought processes and inappropriate behavior), administering antipsychotic medication as ordered,
decreasing risk for sensory stimuli, removing from areas of tension, validating reality, not arguing, recognizing
that client is experiencing hallucinations, responding to feeling or tone of hallucination of delusions
85. Septic Shock in any emergency situation, shock should be anticipated before it develops; hypovolemia is most common cause
of shock;
indications: increased pulse, decreased BP, pallor, diaporesis, most cold skin, oliguria, hyperpnea, metabolic
acidosis, and altered sensorium; treatment: correct physiologic abnormalities and restore and maintain tissue
perfusion;
nursing respons.; ensuring patent airway, maintaining breathing and circulation, restoring circulating blood
volume, inserting indwelling catheter, I & O every 15-30 minutes, determining cause of shock, lab test, elevating
feet slightly, medication as prescribed, maintaining body temp, avoiding to much heat
86. Shock in any emergency, shock should be anticipated before it develops; hypovolemia is the most common cause of
shock; indications: increased BP, pallor, diaphoresis, moist cold skin, oliguria, hyperpnea, metabolic acidosis, and
altered sensorium, treatment: correct physiologic abnormalities and restore and maintain tissue perfusion;
nursing responsibilities: ensuring patent airway, maintaining breathing and circulation, restoring circulation
blood volume, inserting indwelling catheter, I & O every 15-30 minutes, determining cause of shock, lab tests,
elevating feet slightly, medications as prescribed, maintaining body temperature, avoiding too much heat
87. Situational Crisis stages of a crisis include denial, increased tension/anxiety, disorganization (inability to function), attempt escape
from problem/pretend problem does not exist, blame other, general reorganization; nursing responsibilities:
focusing on client's immediate problems, exploring nurse's and client's understanding of the problem, and
helping client become aware of feelings and validating them
88. Stroke sudden disruption in blood supply loss of brain function that may be temporary or permanent; caused by
(cerebrovascular thrombosis, embolism, hemorrhage; indications: loss of movement, thought, memory, speech, or sensation;
accident) (CVA) nursing responsibility: encouraging the client to attain max. independence, stimulating multiple senses, repeating
directions and breaking down tasks into component, facing the client and speaking, facing the client and
speaking clearly and slowly, giving the client time to respond, maintaining skin integrity and providing exercise
(ROM and facial), self-care activities and teaching
89. Subtotal excision of thyroid gland; complications include hemorrhage, respiratory distress, tetany caused by parathyroid
Thyroidectomy injury, damage to laryngeal nerves; nursing responsibilities: checking Vs every 15 min until stable then every 30
minute until stable then every 30 minutes, checking the level of pain, sandbags are used support the neck to
prevent tension on the suture line, administering humidified air to promote easier respirations and liquefy
secretions, coughing and deep breathing the patient every 30 minute to 1 hour, suctioning PRN, checking neck
dressing and behind the head for bleeding initially every 1 hour then every 4 hour, monitoring respirations,
positioning in semi-Fowler's position, applying and ice bag to reduce swelling, asking the patient to speak every
2 h checking for a change in tone or hoarseness, checking for Chvostek's and Trousseau's sign, checking for
numbness or tingling of the extremities, keeping at bedside suction equipment, tracheostomy set, O2, suture
removal kit, and IV calcium
90. Supine During third trimester the large uterus compresses the inferior vena cava and aorta when the woman is supine,
Hypotension reducing cardiac output and causing a drop in material BP and fetal HR; sudden hypotensive episode due to
Syndrome gravid uterus pressing the inferior vena cava and aorta when the mother lies on her back; low venous return
cause decrease blood flow to fetus and mother and resulting signs and symptoms of hypotensions; indications:
dizziness, ringing in the ears, pallor, cold and clammy skin; nursing responsibilities: turning patient onto the left
side to prevent pressure on the vena cava and aorta, which facilitates cardiac output
91. Tamoxifen antineoplastic hormonal medication with potent antiestrogenic activity;
use: palliative treatment of breast cancer in postmenopausal women;
Side effects: thrombosis, N/ V, leukopenia, increased bone pain, photosensitivity, hot flashes;
Nursing Considerations: administer analgesics for increase in bone pain, monitor serum calcium and CBC;
Client education: wear suncreen and sun protective clothing.
92. Thermal injury caused by energy transferring from heat source to body; classifications of burn depth; superficial partial-
thickness (first degree); deep partial thickness (second degree); full thickness (third degree)
93. Total Hip Surgical replacement of the head of the femur and acetabula with an artificial joint; used for diseased femoral
Arthroplasty joint or fracture of the head of the femur neck;
Complications: dislocation of hip prosthesis, excessive wound drainage, thromboembolism, infection
Nursing responsibilities: position leg in abduction splints or wedge or 2/3 pillows between the legs, hip should
not be flexed more than 90 degrees, head of the bed should not be elevated more than 45 degrees, turn from
back to unaffected side, use a fracture bedpan by having the client flex the unoperative hip while using a
trapeze to lit the pelvis of have the client ambulate to the bedroom or use a bedside commode, use of overbed
trapeze to reposition in bed, incision care, prevent complicatons of immobility by early ambulation, use semi-
reclining or elevated toilet seats and semi-recliner wheelchairs to prevent hip joint flexion, maintain hip
precautions as prescribed by surgeon.
94. toxic shock usually occurs in women less than 30 years of age who are menstruating using tampons; caused by Staph;
syndrome indications: sudden fever, vomiting, diarrhea, myalgia, hypotension, diffuse rash; treatment: fluid replacement
and antibiotics; nursing care: monitoring VS and blood gases, evaluating kidney function and hydration, teaching
about tampon use (change every 4 h, dont used super absorbent tampons, alternate use of pads and tampons)
95. Tracheostomy surgical incision made into trachea by way of throat; tube inserted through incision into trachea; care should be
performed every 8 h and PRN; hyperoxygenate or deep breathe client, suction tracheostomy tube, remove old
dressings, open sterile kit, put on sterile gloves, remove inner cannula, clean with hydrogen peroxide, rinse with
sterile water and dry, reinsert into outer cannula, clean stoma with hydrogen peroxide then sterile water and
then dry, change, ties as needed, apply new sterile dressing without gauze pads; indications for suctioning: noisy
respirations, restlessness, increased pulse and respirations, and presence of mucus in airway
96. traditional surgical removal of the gallbladder, monitorT-tube if present- inserted to ensure drainage of bile from common
cholecystectomy bile duct until edema in area diminished; check amount of drainage- usually 500-1000mL/day, decreases as fluid
begins to drain into duodenum, protect skin around incision from bile drainage irritation, zinc oxide or water
soluble lubricant; keep drainage bag at same level as gallbladder (on bed); maintain patient in semi-fowler
position after T-tube is removed; observe dressing for bile; notify physician drainage observed.
97. Tuberculosis infectious disease of insidious onset that primarily affects the lungs; s/s: fatigue, lethargy, anorexia, weight loss,
low-grade fever, and productive cough of mucopurulent sputum; diagnosis: Mantoux test, sputum positive for
acid-fast bacilli and chest X-ray; treatment: chemotherapy, 9-month regimen of isoniazed combined with
streptomycin, ethambutol, rifampin, or pyrazinamide; instruct client to cover mouth and nose with tissue when
coughing, sneezing, laughing, and burn tissues, good handwashing, good nutrients, must take full course of
medications, encourage to return to clinic for sputum smears
98. Venipuncture puncture of vein to insert IV catheter, explain procedure, gather equipment, apply tourniquet 8-10 inc above
the site to distend vein, tap on vessel, ask patient to open and close fist, or hang the arm over the side of the
bed, clean site with an alcohol swab starting at the center and moving outward in concentric circles, repeat
cleaning with povidone-iodine swab, hold skin taut to stabilize it and insert the catheter bevel up at 15-20
degree angle, decrease angle and advance the catheter watching for flashback; if flashback notes, advance
the catheter and remove the tourniquet; withdraw needle from the catheter and advance the catheter up to
the hub; secure catheter, attach the IV tubing and begin the IV infusion; check for infiltration or presence of a
hematoma
99. Venous Aggregate of platelets attached to a vein wall.
Thromboemoblism Risk factors: pregnancy, immediate postpartum period, prolonged immobility, use of oral contraceptives,
(VTE) sepsis, smoking, dehydration, HF, trauma.
Indication: calf pain, localized edema of one extremity, possible warm skin over the affected leg, possible
fever, chills, and perspiration.
Treatment: bedrest, elevating extremity, anticoagulants, possible thrombolytic drugs, possible surgery.
Nursing care: maintaining bedrest, raising extremity, elastic stockings after acute stage, administering
prescribed analgesics.
100. Wound Irrigation Warm irrigating solution to 90-95 degrees F; remove soiled dressing and discard in a plastic trash bag
together with the gloves, position client to allow for gravity drainage, establish a sterile field, pour the
irrigating solution into the sterile container, put on sterile gloves, fill syringe with solution, connect rubber
catheter to syringe to reduce force of solution, instill a low, steady stream of solution into the wound, make
sure the solution flows away from the wound to prevent contamination of clean tissues, withdraw catheter
without aspirating, refill syringe and repeat the irrigation, continue until solution is clear or prescribed amount
has been used.

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