NCLEX 2

findings of hydrocephalus

-increased head circumference

-full or bulging fontanel

-setting sun eyes

-vomiting

salt substitutes increase/decrease potassium levels

increase

Cushings increases/decreases potassium levels

decrease

NG tubes increase/decreas potassium levels

decrease

When should corticosteroids be administered?

during the day because they can cause insomnia

Does a pt with cataracts need to quit drinking?

yes

Can LPNs do sterile procedures like dressing changes?

yes

What are plaque and nodules?

palpable, elevated, solid masses that may measure 1 cm or greater

What are macules and patches

circumscribed, flat, nonpalpable changes in skin color

-Macules are less than or equal to 1 cm

-Patches are more significant than 1 cm

What are bulla and pustules?

circumscribed, superficial skin elevations formed by free liquids in a cavity with skin layers

-Bulla is higher than 0.5 cm

-Pustules are filled with pus

What medication is used to manage chronic gout?

allopurinol

What medication is used for an acute gout attack?

colchicine

What is prolong labor with hypotonic contractions classified as?

labor dystocia

Interventions for labor dystocia

-encourage frequent voiding

-prepare for a prescribed infusion of oxytocin

-encourage frequent repositioning

-prepare for an infusion of IV fluids

Diet for diverticulosis

low fiber

What is conduct disorder?

a precursor to antisocial personality disorder

What findings would suppest a diagnosis of hemophilia A?

-prolonged aPTT

-hematuria

Does HSV and HPV need to be reported to the local health department?

no

What is variant angina?

chest pain that occurs about the same time every day, usually at rest

-treated with calcium channel blockers

When does the rooting reflex disappear?

3-4 months

When does the moro reflex disappear?

3-4 months

When does the palmar reflex disappear?

5-6 months

When does the tonic neck reflex disappear?

around 4 months

When does the plantar (babinski) reflex disapear?

12 months

When does the sucking reflex disapear?

12 months

When do you become concerned for orthostatic hypotension?

-systolic decreases by 20

-diastolic decreases by 10

Rule of Nines

mans of appendicitis

-n/v

-signs of dehydration

mans of pancreatitis

-n/v

-epigastric tenderness

-signs of dehydration

-pain triggered by alcohol intake

mans of cholecystitis

-n/v

-epigastric tenderness

-signs of dehydration

RF for breast cancer

-nulliparity

-early menarche

-overweight or obesity

Erikson’s stages of development

-trust vs mistrust

-autonomy vs shame and doubt

-initiative vs guilt

-industry vs inferiority

-identity vs role confusion

-intimacy vs isolation

-generativity vs stagnation

-integrity vs despair

What is Meniere’s disease?

condition that is caused by excessive endolymphatic fluid in the inner ear

mans of Meniere’s disease

-tinnitus

-vertigo

-hearing loss

What is homonymous hemianopia?

vision loss on the same sife of the visual field in both eyes

What is the best way to prevent a febrile reaction during a blood transfusion?

use leukocyte-reduced blood produces (not administering an antihistamine should be administered before a transfusion)

What is cyanosis?

the blue coloring of the skin and mucous membranes in the presence of poorly oxygenated blood

What type of isolation is required for rubeola?

airborne

What are the signs of vasovagal response?

bradycardia, hypotension, heart block, ventricular tachycardia

What do you need to monitor when administering carbamazepine?

CBC (can cause pancytopenia)

Med for exacerbation of rheumatoid arthritis

prednisone

The nurse in the emergency department (ED) is caring for a client experiencing agitation, anxiety, and hypertension. On assessment, the client has mydriasis and diaphoresis. The nurse suspects that this client may be intoxicated with which substance?

A) opioids

B) barbiturates

C) amphetamines

D) cannabis

amphetamines

Why do you need to administer warmed IVF slowly for a client with hypothermia?

ventricular fibrillation

What is an adverse effect of bumetanide?

leg cramps

What is Werneckie’s aphasia?

damage to the posterior one-third of the superior temporal gyrus causing the patient to have a normal speech rate and intonation but the content has semantic paraphasia errors

What med can help increase dietary fiber in the diet?

psyllium

ABCDE of melanoma detection

A: asymmetry

B: border

C: color

D: diameter

E: evolution

What should be monitored when taking clozapine?

-weight

-CBC

-fasting blood glucose

-total cholesterol

Position for oral care of an unconscious client

on their side to prevent aspiration

What is isotretinoin?

used to treat moderate to sever acne

-highly teratogenic so need a negative pregnancy test prior to initiation

Treatment for hyperkalemia

-sodium polystyrene

-regular insulin

-hemodialysis

Causes of metabolic alkalosis

-vomiting

-antacids

-hypokalemia

What cardiac dysrhythmias can reduce CO?

-SVT

-bradycardia

-v tachy

-mobitz type 2 heart block

What meds can be given for systolic heart failure?

-furosemide

-lisinopril

(HF meds include diuretics, ACE-I, BB)

What is apraxia?

being unable to complete a purposeful movement

What is avolition?

lack of motivation

Mans of a gout flare

-low grade fever

-redness and warmth of the affected joint

-pain with movement of the affected joint

-reduced range of motion in the affected joint

-pain level

mans of RA

-low grade fever

-weight loss

-redness and warmth of the affected joint

-morning stiffness in the wrists that lasts throughout the day

-pain with movement in the affected joint

-reduced range of motion in the affected joint

-pain level

mans of osteoarthritis

-pain with movement in the affected joint

-reduced range of motion in the affected joint

-pain level

Placental abruption vs placenta previa vs preterm labor

Clinical Feature	Placental Abruption	Placenta Previa	Preterm Labor
Vaginal bleeding	x	x	x
Uterine tenderness or rigidity	x
Painless bleeding		x
Sudden onset of abdominal pain	x
Fetal heart rate abnormalities	x		x

Inability to comprehend any information signals _____ anxiety

severe

benzodiazepine toxicity vs bacterial meningitis vs influenza

Client Findings	benzodiazepine toxicity	bacterial meningitis	influenza
altered mental status	X	X
fever		X	X
petechial rash		X
altered speech pattern	X	X
neck stiffness		X

What is ceftriaxone?

antibiotic essential in the treatment of bacterial meningitis; administer immediately after the cultures are collected and LP is performed

Signs of metabolic syndrome

-elevated BP

-high fasting blood glucose

-abdominal obesity

-hyperlipidemia

The nurse cares for a client with a potassium of 3.2 mEq/L (mmol/L) [3.5-5 mEq/L, mmol/L]. Which of the following medications may cause this abnormality?

A) spironolactone

B) triamterene

C) prednisone

D) lisinopril

prednisone

What do expiratory wheezing indicate?

airway narrowing

What does flank pain when a client has nephrostomy tubes indicate?

pyelonephritis

Nursing care for a pavlik harness

-don’t apply moisturizing lotion under the straps

-dont remove during feedings

-wear 24 hours a day

-apply a diaper under the straps

-frequent skin assessments needed

-gently massage the skin to stimulate circulation

Mans of fifth disease

-erythema of the face

-maculopapular red spots distributed on the upper and lower extremities

-mild flu like symptoms (headache, fever, malaise)

Chest tube chambers

Expected findings of a child with lead poisoning

-headaches

-irritability

-abd pain

-peripheral neuropathy

Phases of labor

Sudden stop of wheezing can indicate

severe airway obstruction or impending respiratory failure

What is Cushing’s triad?

irregular respirations, bradycardia, and widening pulse pressure

What conditions can cause hypervolemia?

-heart failure

-renal failure

-hormonal imbalances

Factors that increase the risk for SIDS

-preterm

-peaks at 2-3 months and occurs before 12 months

-male sex

-sleeping in lateral/prone position

-formula feeding

Nursing interventions for valporic acid

-need follow up lab testing

-need to take a multivitamin

-notify provider if yellowing of eyes occurs

Hypomania vs mania