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~*~*~NCLEX Notes*~*~*~*~*~*~

Prednisone tx of inflammatory and immunologic conditions. o S.E.- hyperglycemia, gastric and duodenal ulcers, muscle wasting, fluid retention, potassium excretion, and moon face. o Nursing responsibilities include assessing for diabetes and ulcers, monitoring blood pressure and laboratory values, and checking for infections. Infant dx with PKU- offer Lofenalac o Lack enzyme to convert phenylalanine to tyrosine, accumulates in tissues, leads to mental retardation o Autosomal recessive Therapeutic Serum Lithium Lvl- Less than 1.5 mEq/L o Signs of lithium toxicity- diarrhea, over-sedation, ataxia, tinnitus, slurred speech, muscle weakness o EARLY SIGN TOXICITY- fine tremors of fingers, wrist, hands, N/V o SEVERE SIGNS- ataxia, confusion, seizures Raynauds phenomenon - cold temperatures or strong emotions cause blood vessel spasms that block blood flow to the fingers, toes, ears, and nose, tingling numbness Inderal (propanalol) contraindicated in pts with uncompensated Heart Failure and pulmonary edema o Proper meds- Digoxin, Lasix, O2 nasal cannula Range for IOP (intraocular pressure) 10-21 mmHg Postmortem care- wash the client, place pad under perineum o Dont pass buck to chaplain or supervisor Signs of hypoxia- increased RR, restlessness, cyanosis, anxiety, tachycardia Pt with Bells Palsy- protect face from cold and drafts bc trigeminal hyperesthesia. Heat on affected side 1

Acute Renal Failure (ARF)- inability of kidneys to concentrate urine o Check urine specific gravity Repair of detached retina- if gas or oil used to reattach, sleep on stomach for several days o Avoid jarring motion of head- increases ICP o Resume work after 3 weeks, avoid strenuous activity for 3 months

Evisceration- happens after surgery, underlying bowel visible, shiny pink area o Cover area with sterile gauze and soak in NS

Glaucoma- IOP is higher during the morning- early morning assessments more accurate in the morning o Lifelong eyedrop treatment needed to prevent blindness o Decreased visual acuity not corrected with glasses

Acute phase of CVA- HOB at 15-30 degrees, facilitates venous drainage from brain Pleur-Evac Drainage System o Suction control chamber- water bubbles constantly o Water seal chamber- bubbles when pt exhales and when coughing or sneezing Amount of fluid should fluctuate with respirations, rising with inspiration and falling with expiration If not fluctuating, either lung is expanded (desired) or obstruction of chest tube- kinked, looped, clots o First 24 hrs after surgery- 500-1,00mL drainage

Continuous Ambulatory Peritoneal Dialysis (CAPD) o Constipation common problem- stool softeners and high fiber diet o Cloudy dialysate output is first sign of peritonitis o Normal- clear and yellow

Ketonuria during pregnancy- ketoacidosis which contributes to intrauterine death JVD is symptom of cardiac tamponade, a complication after CABG from bleeding around the heart Hypoparathyroidism- diet high in CALCIUM and low in PHOSPEROUS Clomid (clomiphene citrate) works by inducing ovulation by altering estrogen and stimulating follicular growth to produce a mature ovumused for women having trouble conceiving

Eriksons stages: o Newborn-2: Trust vs. mistrust Feeding, attention, care lead to trust Toilet training leads to independence, personal control Assert power and control over environment to gain initiative o School-age 6-11: Industry vs. Inferiority School provides social and academic demands Developing sense of self Forming intimate, loving relationships Having children or legacy to leave behind, usefulness and accomplishment vs. shallow involvement in the world o Maturity 65-Death: Ego integrity vs. Despair Look back and feel sense of fulfillment o Adolescence 12-18: identity vs. Role Confusion o Young Adulthood 19-40: Intimacy vs. Isolation o Middle Adulthood 40-65: Generativity vs. Stagnation o Age 2-3: Autonomy vs. Shame and Doubt o Preschool 3-5: Initiative vs. Guilt

Pt with CVA- nursing care can PREVENT corneal abrasion- eye can no longer close voluntarily and produce moisture Tracheal tube suctioning- insert suction tube until resistance is met, then withdraw tube 1-2cm. Apply suction intermittently while 3

withdrawing in twirling motion. Never suction longer than 10-15 seconds Naproxen Sodium NSAID used as analgesic o SE- HA, dizziness, GI distress, pruritus, rash Thorazine- antipsych med o SE- akathesia (restlessness), dystonia (tongue protrusion), pseudoparkinsonian (tremors, rigid), dyskinesia (difficulity swallowing) Cogentin may be ordered for antiparkinsonian symptoms Dosage may be decreased if extrapyramidal symptoms

Post op cataract client- avoiding bending over, sudden movements, vomiting, constipation o Increase IOP- pressure on ocular suture line

Blood transfusion reactions o Circulatory overload- bounding peripheral pulses o Febrile- chills o Allergic- wheezing, hives, facial flushing, itching o Hemolytic- lower back pain

Process of adjustment o 1. Denial, isolation o 2. Anger o 3. Bargaining o 4. Depression o 5. Acceptance

Defense mechanisms used in phobias o Projection- attributing thoughts and impluses to something else o Displacement- shifting emotion concerning something to something else less dangerous o Symbolization- something representing something else

Other defense mechanisms

o Reaction formation- ex: treating someone you hate excessively nice in order to hide true feelings o Intellectualization- avoiding disturbing feelings with the use of logic or over-thinking o Sublimation- channeling unacceptable impulses into acceptable ones ex: anger to kick boxing o Internalization- using someone elses opinion as your own Infant barium swallow study- make NPO 3 hours prior Colostomy care o Irrigated at the same time every day o Once per day o Catheter inserted no more than 4 inches o Solution at body temperature Purpose of Digoxin- increase force of myocardial contraction During 4th stage of labor- uterus palpable at umbilicus SHARE- organization for parents who lost newborn Position of fractured hip- shortened, adducted, internally rotated Milestones for children o Posterior fontanelle closed at 2-3 months o Solid food (rice cereal) 4-5 months o Sitting with assist at 6 months o Pincer grasp at 9 months o Eating using fingers at 10-12 months o Tripling birth weight at 1 year o Anterior fontanelle closed at 1.5 years o Builds tower of blocks at 16-18 months o Discriminates between pictures of objects at 2 years Musculoskeletal milestones for children o Child stands without support 15 months o Child runs after ball- age 2 o Child climbs up and down stairs- age 2-4 5

o Child hops and skips- age 6 o Child neatly ties laces- above age 6 LTB- larygnotracheobronchitis edema and inflammation of upper airways, inspiratory stridor and restlessness Kussmaul respirations assoc. with DKA Hemophilia is SEX-LINKED- transmitted by mother to son IVP intravenous pyleogram o Looks at urinary tract by X-ray Cytoscopy o Looks at renal pelvis Lead Poisoning- increase calcium bc it binds to lead and inhibits absorption Rinne test- tuning fork held on mastoid until no longer heard then moved in front of the auditory canal. Air conduction should be better than bone conduction Osmitrol used in increased ICP bc it is osmotic diuretic and decreases ICP- UO will increase Hypothyroidism o Cannot tolerate cold temps o Sensitive to narcotics, barbiturates and anesthetics o Require high fiber high cellulose diet Cortisol- converts proteins and fats into glucose Amniocentesis indicates- spinal cord problems, blood problems, lung function US determines gestational age Addisons disease o Muscle weakness, fatigue, dark pigmentation of skin, GI disturbances, and anorexia o Addisonian crisis- restlessness, rapid and weak pulse Triad of preeclampsia o HTN 6

o Edema o Proteinuria Eclampsia- blurred vision, oliguria, epigastric pain and HA are signs of seizure Prolixin (fluphenazine decanoate) used in psychotic disorders, given IM or SQ every 1-6 weeks o Good for pts with poor med compliance Dilantin seizure med o SE- reddish-brown urine, constipation; longterm- acne, hirsutism (hairiness), gingival hyperplasia o Interferes with normal vit D metabolism= need supplement or osteomalacia may occur o Overdose/toxicity- ataxia, slurred speech, nystagmus Hemophiliac- at risk for crippling knee and joint deformities bc repeated bleeding episodes into joints Granular casts in UA = renal disease Hydralazine hydrochloride (Apresoline)-direct vasodilator, lowers BP and decreases peripheral resistence Atenolol (Tenormin)- beta blocker, slows HR and decreases cardiac contractility and CO, lowers BP o Less effective on blacks (also ACEs) Chlorothiazide (Diuril)- thiazide diuretic, sodium and water excretion, lowers BP o Especially effective in blacks Nifedipine (Procardia)- CCB, stops calcium from moving into cells, relaxes smooth muscles, causes vasodilation o Especially effective in elderly and blacks When angle between nail plate and proximal nail fold is straightened to 180 degrees, spongy on palpation= early clubbing= hypoxia Spoon nails (koilonychias)- iron deficiency anemia Small pits in nail plate seen in psoriasis 7

Horizontal depressions in nail plate- infection or severe malnutrition Signs and symptoms of air embolism- restless, complains of difficulty breathing o Place pt on left side in Trendeleberg position and initiate O2 therapy, contact physician o Increases likelihood air will pass into right atrium and dispersed by pulmonary artery

Fainting episode may be due to cardiac arrhythmia Sign patient is developing shock (could be from burns)- cool, clammy skin, and tachypnea o Body responds to early hypovolemic shock by adregnic stimulation o Vasoconstriction compensates for loss of fluid

Identifying PMI for fetal heart tone o If baby is BREECH (left/right sacrum anterior) it will be at or above the umbilicus

Rapid labor is risk factor for early postpartum hemorrhage and amniotic fluid embolism- labor pattern that progresses quickly ends in less than 3 hours

Hantavirus Pulmonary Syndrome (HPS) caused by rodent droppings o Symptoms- fever, aching, nausea o Can cause severe cardiopulmonary disease o Can cause thrombocytopenia Observe for hematuria, hematemesis, bleeding gums and melena

Polyarteritis nodosa- inflammation of the small arteries causing diminished blood o 90% remission rate with cortisone

Immunizations o DtaP- 2 months, 4 months, 6 months o Inactivated polio- 2 mo, 4 mo 8

o MMR- 15 months o TB skin testing- 12 months Pain in lower extremities not relieved by rest= peripheral artery disease o Numbness, burning, skin is dry, scaly, dusky, pale, mottled, cold o Pulses may be weak or absent Signs of HF- fatigue, SOB, tachycardia, edema, weight gain Left sided HF o Dyspnea o Orthopnea o Cough o Crackles o Tachycardia o Fatigue o Anxiety o Restlessness Right sided HF o JVD o Dependent edema o Hepatomegaly o Right upper quandrant tenderness o Ascities o Anorexia o Nausea o Weight gain o Weakness o GI distress Tx for Heart Failure o Oxygen therapy o Digoxin o Diuretics 9

o Vasodilators o Potassium supplements o Low sodium diet o High fowlers position Thiazide diuretics block reabsorption of sodium and increase excretion of water and potassium from body= can lead to hypokalemia After aortofemoral bypass keep pt in full supine position, bending of hip and knee contraindicated Digoxin increases the strength of the hearts contractions by slowing the HR and conduction through AV node o SE- bradycardia, anorexia, N/V, fatigue, dysrhythmias, diaphoresis o S&S of toxicity- N/V, diarrhea, confusion, visual disturbances o Hold med if HR below 60 Nitroglycerin dilates coronary arteries, decreases preload Lidocaine prevents premature ventricular contractions Atropine increases heart rate Dopamine used for hypotension and increases CO and urine output o SE- nausea, tachycardia, angina, dysrhythmias, increased IOP o Headache- early symptom of drug excess Propanolol (Inderal)- beta blocker used for HTN, dysrhythmias, angina, and MI o SE- bronchospasm, weakness, fatigue, CHF o Blocks signs of hypoglycemia