ATI comprehensive predictor

Study online at quizlet.com/_12moc3

1.

Do not
delegate

What you can EAT E-evaluate A-assess Tteach

2.

Addison's &
Cushings

Addison's = down down down up down

Cushings= up up up down up
hypo/hypernatremia, hypo/hypertension,
blood volume, hypo/hyperkalemia,
hypo/hyperglycemia

3.

Better
peripheral
perfusion?

EleVate Veins, DAngle Arteries

4.

APGAR

Appearance (all pink, pink and blue, blue

(pale)
Pulse (>100, <100, absent)
Grimace (cough, grimace, no response)
Activity (flexed, flaccid, limp)
Respirations (strong cry, weak cry, absent)

5.

6.

7.

8.

Airborne
precautions

MTV or My chicken hez tb measles,

chickenpox (varicella) Herpes zoster/shingles
TB

Airborne
precautions
protective
equip

private room, neg pressure with 6-12 air

exchanges/hr mask & respirator N95 for TB

Droplet
precautions

spiderman! sepsis, scarlet fever, streptococcal

pharyngitis, parvovirus, pneumonia,
pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or
meningeal pneumonia, adeNovirus
(Private room and mask)

Contact
precaution

MRS WHISE
protect visitors & caregivers when 3 ft of the
pt.
Multidrug-resistant organisms
RSV, Shigella, Wound infections, Herpes
simplex, Impetigo, Scabies, Enteric diseases
caused by micro-organisms (C diff),
Gloves and gowns worn by the caregivers
and visitors
Disposal of infectious dressing material into a
single, nonporous bag without touching the
outside of the bag
PMGG= Private room/ share same illness,
mask, gown and gloves

9.

Skin infection

VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies

10.

Air or
Pulmonary
Embolism

S/S chest pain, dyspnea, tachycardia,

pale/cyanotic, sense of impending doom.
(turn pt to LEFT side and LOWER the head
of bed.)

11.

Woman in
labor (unreassuring FHR)

(late decels, decreased variability, fetal

bradycardia, etc) Turn pt on Left side, give
O2, stop pitocin, Increase IV fluids!

12.

Tube feeding
with decreased
LOC

Pt on Right side (promotes emptying of the

stomach) Head of bed elevated (prevent
aspiration)

13.

After lumbar
puncture and
oil based
myelogram

pt is flat SUPINE (prevent headache and

leaking of CSF)

14.

Pt with heat
stroke

flat with legs elevated

15.

during
Continuous
Bladder
Irrigation (CBI)

catheter is taped to the thigh. leg must be

kept straight.

16.

After
Myringotomy

position on the side of AFFECTED ear, allows

drainage.

17.

After Cateract
surgery

pt sleep on UNAFFECTED side with a night

shield for 1-4 weeks

18.

after
Thyroidectomy

low or semi-fowler's position, support head,

neck and shoulders.

19.

Infant with
Spina Bifida

Prone so that sac does not rupture

20.

Buck's Traction
(skin)

elevate foot of bed for counter traction

21.

After total hip

replacement

don't sleep on side of surgery, don't flex hip

more than 45-60 degress, don't elevate
Head Of Bed more than 45 degrees.
Maintain hip abduction by separating
thighs with pillows.

22.

Prolapsed cord

Knee to chest or Trendelenburg

oxygen 8 to 10 L

23.

Cleft Lip

position on back or in infant seat to prevent

trauma to the suture line. while feeding
hold in upright position.

24.

25.

26.

To prevent dumping
syndrome

AKA (above knee

amputation)
BKA (below knee
amputation)

(post operative ulcer/stomach

surgeries) eat in reclining
position. Lie down after meals for
20-30 min. also restrict fluids
during meals, low CHO and fiber
diet. small, frequent meals.

41.

Myxedema/
hypothyroidism

slowed physical and mental function,

sensitivity to cold, dry skin and hair.

42.

Grave's Disease/
hyperthyroidism

accelerated physical and mental function.

Sensitivity to heat. Fine/soft hair.

43.

Thyroid storm

increased temp, pulse and HTN

elevate for first 24 hours on

pillow. position prone daily to
maintain hip extension.

44.

PostThyroidectomy

semi-fowler's. Prevent neck

flexion/hyperextension. Trach at bedside

45.

Hypoparathyroid

CATS---Convulsions, Arrhythmias, Tetany,

Spasms, Stridor. (decreased calcium) give
high calcium, low phosphorus diet

46.

Hyperparathyroid

fatigue, muscle weakness, renal calculi,

back and joint pain (increased calcium)
give a low calcium high phosphorous diet

47.

Hypovolemia

increased temp, rapid/weak pulse,

increase respiration, hypotension,
anxiety. Urine specific gravity >1.030

foot of bed elevated for first 24

hours. position prone to provide
hip extension.

27.

detached retina

area of detachment should be in

the dependent position

28.

administration of enema

pt should be left side lying (Sim's)

with knee flexed.

29.

After supratentorial
surgery

(incision behind hairline on

forhead) elevate HOB 30-40
degrees

48.

Hypervolemia

After infratentorial
surgery

(incision at the nape of neck)

position pt flat and lateral on
either side.

bounding pulse, SOB, dyspnea,

rales/crackles, peripheral edema, HTN,
urine specific gravity <1.010. semi fowler's

49.

During internal radiation

on bed rest while implant in

place

Diabetes
insipidus
(decreased ADH)

excessive urine output and thirst,

dehydration, weakness, administer
Pitressin

50.

SIADH (increased
ADH)

change in LOC, decreased deep tendon

reflexes, tachycardia. N/V HA administer
Declomycin, diuretics

51.

hypokalemia

muscle weakness, dysrhythmias, increase

K (rasins bananas apricots, oranges,
beans, potatoes, carrots, celery)

52.

Hyperkalemia

MURDER Muscle weakness, Urine (olig,

anuria) Resp depression, decreased
cardiac contractility, ECG changes, reflexes

53.

Hyponatremia

nausea, muscle cramps, increased ICP,

muscular twitching, convulsions. give
osmotic diuretics (Mannitol) and fluids

54.

Hypernatremia

increased temp, weakness, disorientation,

dilusions, hypotension, tachycardia. give
hypotonic solution.

55.

Hypocalcemia

CATS Convulsions, Arrythmias, Tetany,

spasms and stridor

56.

Hypercalcemia

muscle weakness, lack of coordination,

abdominal pain, confusion, absent
tendon reflexes, shallow respirations,
emergency!

57.

Hypo Mg

Tremors, tetany, seizures, dysthythmias,

depression, confusion, dysphagia, (dig
toxicity)

58.

Hyper Mg

depresses the CNS. Hypotension, facial

flushing, muscle weakness, absent deep
tendon reflexes, shallow respirations.
EMERGENCY

30.

31.

32.

33.

Autonomic
Dysreflexia/Hyperreflexia

Shock

S/S pounding headache, profuse

sweating, nasal congestion, chills,
bradycardia, hypertension. Place
client in sitting position (elevate
HOB) FIRST!
bedrest with extremities elevated
20 degrees. knees straight, head
slightly elevated (modified
Trendelenberg)

34.

Head Injury

elevate HOB 30 degrees to

decrease ICP

35.

Peritoneal Dialysis (when

outflow is inadequate)

turn pt from side to side BEFORE

checking for kinks in tubing

36.

Lumbar Puncture

After the procedure, the pt

should be supine for 4-12 hours
as prescribed.

37.

Myesthenia Gravis

worsens with exercise and

improves with rest

38.

Myesthenia Gravis

a positive reaction to Tensilon--will improve symptoms

39.

Cholinergic Crisis

Caused by excessive medication --stop giving Tensilon...will make it

worse.

40.

Liver biopsy (prior)

must have lab results for

prothrombin time

59.

Addison's

Hypo Na, Hyper K, Hypoglycemia,

dark pigmentation, decreased
resistance to stress fx, alopecia, weight
loss. GI stress.

69.

ICP and Shock

ICP- Increased BP, decreased pulse,

decreased resp
Shock--Decreased BP, increased
pulse, increased resp

60.

Cushings

Hyper Na, Hypo K, hyperglycemia,

prone to infection, muscle wasting,
weakness, edema, HTN, hirsutism,
moonface/buffalo hump

70.

Cor pumonae

Right sided heart failure caused by

left ventricular failure (edema,
jugular vein distention)

71.

Addesonian crisis

N/V confusion, abdominal pain,

extreme weakness, hypoglycemia,
dehydration, decreased BP

Heroin withdrawal
neonate

irritable, poor sucking

61.

72.

brachial pulse

pulse area on an infant

73.

lead poisoning

test at 12 months of age

74.

Before starting IV
antibiotics

obtain cultures!

75.

pt with leukemia may

have

epistaxis due to low platelets

76.

when a pt comes in
and is in active labor

first action of nurse is to listen to fetal

heart tones/rate

77.

for phobias

use systematic desensitization

78.

NCLEX answer tips

choose assessment first! (assess,

collect, auscultate, monitor, palpate)
only choose intervention in an
emergency or stress situation. If the
answer has an absolute, discard it.
Give priority to the answers that deal
with the patient's body, not
machines, or equipment.

79.

ARDS and DIC

are always secondary to another

disease or trauma

80.

In an emergency

patients with a greater chance to live

are treated first

81.

Cardinal sign of ARDS

hypoxemia

82.

Edema is located

in the interstitial space, not the

cardiovascular space (outside of the
circulatory system)

83.

the best indicator of

dehydration?

weight---and skin turgor

84.

heat/cold

hot for chronic pain; cold for accute

pain (sprain etc)

85.

When pt is in
distress....medication
administration

is rarely a good choice

86.

pneumonia

fever and chills are usually present.

For the elderly confusion is often
present.

87.

before IV antibiotics?

check allergies (esp. penicillin) make

sure cultures and sensitivity has
been done before first dose.

62.

63.

Pheochromocytoma

Tetrology of Fallot

hypersecretion of epi/norepi.
persistent HTN, increased HR,
hyperglycemia, diaphoresis, tremor,
pounding HA; avoid stress, frequent
bathing and rest breaks, avoid cold
and stimulating foods (surgery to
remove tumor)
DROP (Defect, septal, Right
ventricular hypertrophy, Overriding
aortas, Pulmonary stenosis)

64.

Autonomic
Dysreflexia

(potentially life threatening

emergency!) HOB elevate 90 degrees,
loosen constrictive clothing, assess for
full bladder or bowel impaction,
(trigger) administer antihypertensives
(may cause stroke, MI, seizure)

65.

FHR patterns for OB

Think VEAL CHOP!

V-variable decels; C- cord compression
caused
E-early decels; H- head compression
caused
A-accels; O-okay, no problem
L- late decels; P- placental
insufficiency, can't fill

66.

67.

68.

what to check with

pregnancy

Never check the monitor or machine

as a first action. Always assess the
patient first. Ex.. listen to fetal heart
tones with stethoscope.

Position of the baby

by fetal heart sounds

Posterior --heard at sides

Anterior---midline by unbilicus and
side
Breech- high up in the fundus near
umbilicus
Vertex- by the symphysis pubis.

Ventilatory alarms

HOLD
High alarm--Obstruction due to
secretions, kink, pt cough etc
Low alarm--Disconnection, leak, etc

88.

COPD and O2

with COPD baroreceptors that detect

CO2 level are destroyed, therefore, O2
must be low because high O2
concentration takes away the pt's
stimulation to breathe.

89.

Prednisone
toxicity

Cushings (buffalo hump, moon face,

high blood sugar, HTN)

90.

Neutropenic pts

no fresh fruits or flowers

91.

Chest tubes are

placed

in the pleural space

92.

Preload/Afterload

Preload affects the amount of blood

going into Right ventricle. Afterload is
the systemic resistance after leaving the
heart.

114.

DKA is rare

in DM II (there is enough insulin to prevent fat

breakdown)

115.

Glaucoma
patients
lose

peripheral vision.

116.

Autonomic
dysreflexia

patients with spinal cord injuries are at risk for

developing autonomic dyreflexia (T-7 or
above)

117.

Spinal
shock
occurs

immediately after injury

118.

multiple
sclerosis

myelin sheath destruction. disruptions in

nerve impulse conduction

119.

Myasthenia
gravis

decrease in receptor sites for acetylcholine.

weakness observed in muscles, eyes
mastication and pharyngeal musles. watch for
aspiration.

120.

Gullian Barre
syndrome

ascending paralysis. watch for respiratory

problems.

121.

TIA

transient ischemic attack....mini stroke, no dead

tissue.

122.

CVA

cerebriovascular accident. brain tissue dies.

123.

Hodgkin's
disease

cancer of the lymph. very curable in early

stages

124.

burns rule
of Nines

head and neck 9%

each upper ext 9%
each lower ext 9%
front trunk 18%
back trunk 18%
genitalia 1%

125.

birth
weight

doubles by 6 months
triples by 1 year

126.

if HR is <100
(children)

Hold Dig

127.

early sign of
cystic
fibrosis

meconium in ileus at birth

128.

Meningitis-check for

Kernig's/ brudinski's signs

129.

wilm's
tumor

encapsulated above kidneys...causes flank

pain

130.

hemophilia
is x linked

passed from mother to son

93.

CABG

Great Saphenous vein in leg is taken

and turned inside out (because of
valves inside) . Used for bypass surgery
of the heart.

94.

Unstable Angina

not relieved by nitro

95.

PVC's

can turn into V fib.

96.

1 tsp

5 mL

97.

1 oz

30 mL

98.

1 cup

8 oz

99.

1 quart

2 pints

100.

1 pint

2 cups

101.

1 g (gram)

1000 mg

102.

1 kg

2.2 lbs

103.

I lb

16 oz

104.

centigrade to
Fahrenheit
conversion

F= C+40 multiply 5/9 and subtract 40

C=F+40 multiply 9/5 and subtract 40

105.

Angiotenson II

In the lungs...potent vasodialator,

aldosterone attracts sodium.

106.

Iron toxicity
reversal

deferoxamine

107.

S3 sound

normal in CHF. Not normal in MI

108.

After endoscopy

check gag reflex

109.

TPN given in

subclavian line

110.

pain with
diverticulitis

located in LLQ

111.

appendicitis pain

located in RLQ

112.

Trousseau and
Chvostek's signs
observed in

Hypocalcemia

131.

when
phenylaline
increases

brain problems occur

113.

never give K+ in

IV push

132.

buck's
traction

knee immobility

133.

russell traction

femur or lower leg

134.

dunlap traction

skeletal or skin

135.

bryant's traction

children <3 y <35 lbs with femur fx

136.

eclampsia is

a seizure

137.

perform
amniocentesis

before 20 weeks to check for cardiac

and pulmonary abnormalities

138.

Rh mothers receive
Rhogam

to protect next baby

139.

anterior fontanelle
closes
by...posterior by..

18 months, 6-8 weeks

140.

caput
succedaneum

diffuse edema of the fetal scalp that

crosses the suture lines. reabsorbes
within 1 to 3 days

141.

pathological
jaundice occurs:
physiological
jaundice occurs:

before 24 hours (lasts 7 days)

after 24 hours

142.

placenta previa s/s

placental abrution
s/s

there is no pain, but there is bleeding

there is pain, but no bleeding (board
like abd)

143.

bethamethasone
(celestone)

surfactant. premature babies

milieu therapy

taking care of pt and environmental

therapy

145.

cognitive therapy

counseling

146.

five interventions
for psych patients

safety
setting limits
establish trusting relationship
meds
least restrictive methods/environment

147.

SSRI's

take about 3 weeks to work

148.

patients with
hallucinations
patients with
delusions

redirect them
distract them

149.

Thorazine and
Haldol

can cause EPS

150.

Alzheimer's

60% of all dementias, chronic,

progressive degenerative cognitive
disorder.

151.

draw up regular
and NHP?

Air into NHP, air into Regular. Draw

regular, then NHP

144.

152.

Cranial nerves

S=sensory M=motor B=both

Oh (Olfactory I) Some
Oh (Optic II ) Say
Oh (Oculomotor III) Marry
To (trochlear IV) Money
Touch (trigeminal V) But
And (Abducens VI ) My
Feel (facial VII) Brother
A (auditory VIII) Says
Girl's (glossopharyngeal IX) Big
Vagina (vagus X) Bras
And (accessory XI) Matter
Hymen (Hypoglossal XII) More

153.

Hypernatremia

S (Skin flushed)
A (agitation)
L (low grade fever )
T (thirst)

154.

Developmental

2-3 months: turns head side to side

4-5 months: grasps, switch and roll
6-7 months: sit at 6 and waves bye bye
8-9 months: stands straight at 8
10-11 months: belly to butt
12-13 months: 12 and up, drink from a cup

155.

Hepatitis A

Ends in a vowel, comes from the bowel

156.

Hepatitis b

B= blood and body fluids (hep c is the

same)

157.

Apgar
measures

HR RR Muscle tone, reflexes, skin color.

Each 0-2 points. 8-10 ok, 0-3 resuscitate

158.

Glasgow coma
scale

eyes, verbal, motor

Max- 15 pts, below 8= coma

159.

Addison's
disease:
Cushing's
syndrome:

"add" hormone
have extra "cushion" of hormone

160.

Dumping
syndrome

increase fat and protein, small frequent

meals, lie down after meal to decrease
peristalsis. Wait 1 hr after meals to drink

161.

Disseminated
herpes zoster
localized
herpes zoster

Disseminated herpes=airborne
precautions
Localized herpes= contact precautions. A
nurse with localized may take care of
patients as long as pts are not
immunosuppressed and the lesions must
be covered!

162.

Isoniazid

causes peripheral neuritis

163.

Weighted NI
(naso intestinal
tubes)

Must float from stomach to intestine. Don't

tape right away after placement. May leave
coiled next to pt on HOB. Position pt on
RIGHT to facilitate movement through
pyloris

164.

Cushings ulcers

r/t brain injury

165.

Cushing's
triad

r/t ICP (HTN, bradycardia, irritability, sleep,

widening pulse pressure)

186.

Transesophageal
fistula

esophagus doesn't fully develop. This is

a surgical emergency (3 signs in
newborn: choking, coughing, cyanosis)

166.

Thyroid
storm

HOT (hyperthermia)
187.

MMR

is given SQ not IM

167.

Myxedema
coma

COLD (hypothermia)

188.

codes for pt care

Red- unstable, ie.. occluded airway,

actively bleeding...see first
Yellow--stable, can wait up to an hour for
treatment
Green--stable can wait even longer to be
seen---walking wounded
Black--unstable, probably will not make
it, need comfort care
DOA--dead on arrival

168.

Glaucoma

No atropine

169.

Non Dairy
calcium

Rhubarb sardines collard greens

170.

Koplick's
spots

prodomal stage of measles. Red spots with

blue center, in the mouth--think kopLICK in
the mouth

171.

INH can
cause
peripheral
neuritis

Take vitamin B6 to prevent. Hepatotoxic

189.

Contraindication
for Hep B vaccine

anaphylactic reaction to baker's yeast

190.

what to ask
before flu shot

allergy to eggs

172.

pancreatitis
pts

put them in fetal position, NPO, gut rest,

Prepare anticubital site for PICC, they are
probably going to get TPN/Lipids

191.

what to ask
before MMR

allergy to eggs or neomycin

173.

Murphy's
sign

Pain with palplation of gall bladder (seen with

cholecystitis)

192.

when on
nitroprusside
monitor:

cyanide. normal value should be 1.

174.

Cullen's
sign

ecchymosis in umbilical area, seen with

pancreatitis

193.

William's
position

semi Fowler's with knees flexed to

reduce low back pain

175.

Turner's
sign

Flank--greyish blue. (turn around to see your

flanks) Seen with pancreatitis

194.

S/S of hip fx

External rotation, shortening adduction

McBurney's
point

Pain in RLQ with appendicitis

195.

Fat embolism

176.

blood tinged sputum r/t inflammations.

Increase ESR, respiratory alkalosis.
Hypocalcemia, increased serum lipids.

177.

LLQ

Diverticulitis

196.

pneumothorax, ulcers

178.

RLQ

appendicitis watch for peritonitis

179.

Guthrie test

Tests for PKU. Baby should have eaten protein

first

complications of
mechanical
ventilation

197.

Paget's disease

tinnitus, bone pain, elnargement of

bone, thick bones

198.

with allopurinol

no vitamin C or warfarin!

199.

IVP requires

bowel prep so bladder can be visualized

200.

acid ash diet

cheese, corn, cranberries, plums,

prunes, meat, poultry, pastry, bread

201.

alk ash diet

milk, veggies, rhubarb, salmon

202.

orange tag in
psych

is emergent psych

180.

shilling test

Test for pernicious anemia

181.

Peritoneal
dialysis

Its ok to have abd cramps, blood tinged

outflow and leaking around site if the cath
(tenkoff) was placed in the last 1-2 weeks.
Cloudy outflow is never ok

182.

183.

Hyper
reflexes
absent
reflexes

upper motor neuron issue (your reflexes are

over the top)
Lower motor neuron issue

Latex
allergies

assess for allergies to bananas, apricots,

cherries, grapes, kiwis, passion fruit, avocados,
chestnuts, tomatoes and peaches

203.

thyroid med side

effects

insomnia. body metabolism increases

204.

Tidal volume is

7-10 ml/kg

184.

Tensilon

used in myesthenia gravis to confirm diagnosis

205.

185.

ALS

(amyotrophic lateral sclerosis) degeneration of

motor neurons in both upper and lower
motor neuron systems

COPD patients
and O2

2LNC or less. They are chronic CO2

retainers expect sats to be 90% or less

206.

Kidney glucose
threshold

180

207.

Stranger
anxiety is
greatest at
what age?

7-9 months..separation anxiety peaks in

toddlerhood

222.

Myelogram

NPO for 4-6 hours. allergy hx

phenothiazines, cns depressants and
stimulants withheld 48 hours prior.
Table moved to various positions during
test. Post--neuro assessment q2-4 hours,
water soluble HOB UP. oil soluble HOB
down. oralanalgesics for HA. No po
fluids. assess for distended bladder.
Inspect site

208.

when drawing
an ABG

put in heparinized tube. Ice immediately,

be sure there are no bubbles and label if pt
was on O2

209.

Munchausen
syndrome vs
munchausen
by proxy

Munchausen will self inflict injury or illness

to fabricate symptoms of physical or mental
illness to receive medical care or
hospitalization. by proxy mother or other
care taker fabricates illness in child

223.

Liver biopsy

administer Vitamin K, NPO morning of

exam 6 hrs. Give sedative. Teach pt to
expect to be asked to hold breath for 510 sec. supide position, lateral with
upper arms elevated. Post--position on
RIGHT side. frequent VS. report severe
ab pain STAT. no heavy lifting 1 wk

210.

multiple
sclerosis

motor s/s limb weakness, paralysis, slow

speech. sensory s/s numbness, tingling,
tinnitis cerebral s/s nystagmus, atazia,
dysphagia, dysarthia

211.

hungtington's

50% genetic autosomal dominanat

disorder.. s/s uncontrolled muscle
movements of face, limbs and body. no cure

224.

Paracentesis

semi fowler's or upright on edge of bed.

Empty bladder. post VS--report elevated
temp. watch for hypovolemia

212.

WBC left shift

pt with pyelo. neutrophils kick in to fight

infections

225.

laparoscopy

CO2 used to enhance visual. general

anesthesia. foley. post--ambulate to
decrease CO2 buildup

213.

pancreatic
enzymes are
taken

with each meal!

226.

PTB

low grade afternoon fever

227.

pneumonia

rusty sputum

214.

infants IM site

Vastus lateralis

228.

asthma

wheezing on expiration

215.

Toddler 18
months+ IM
site

Ventrogluteal

229.

emphysema

barrel chest

230.

kawasaki
syndrome

strawberry tongue

216.

IM site for
children

deltoid and gluteus maximus

231.

pernicious
anemia

red beefy tongue

217.

Thoracentesis:

position pt on side or over bed table. no

more than 1000 cc removed at a time. Listen
for bilateral breath sounds, V.S, check
leakage, sterile dressing

232.

downs syndrome

protruding tongue

233.

cholera

rice watery stool

234.

malaria

stepladder like fever--with chills

NPO 8-12 hours. empty bladder, pulses, tell

pt may feel heat, palpitations or desire to
cough with injection of dye. Post: V.S.--keep
leg straight. bedrest for 6-8 hr

235.

typhoid

rose spots on the abdomen

236.

diptheria

pseudo membrane formation

237.

measles

koplick's spots

well hydrated, lie flat, site shaved, pulses

marked. Post--keep flat for 12-14 hr. check
site, pulses, force fluids.

238.

sle (systemic
lupus)

butterfly rash

239.

pyloric stenosis

olive like mass

lumbar
puncture

fetal position. post-neuro assess q15-30

until stable. flat 2-3 hour. encourage fluids,
oral analgesics for headache.

240.

Addison's

bronze like skin pigmentation

241.

Cushing's

moon face, buffalo hump

ECG

no sleep the night before, meals allowed, no

stimulants/tranquilizers for 24-48 hours
before. may be asked to hyperventilate 3-4
min and watch a bright flashing light. watch
for seizures after the procedure.

242.

hyperthyroidism/
grave's disease

exophthalmos

243.

myasthenia gravis

descending musle weakness

244.

gullian-barre
syndrome

ascending muscle weakness

218.

219.

220.

221.

Cardiac cath

Cerebral angio
prep

245.

angina

crushing, stabbing chest pain

relieved by nitro

266.

cryptorchidism

undescended testicles! risk factor for

testicular cancer later in life. Teach self
exam for boys around age 12--most cases
occur in adolescence

246.

MI

crushing stabbing chest pain

unrelieved by nitro

247.

cystic fibrosis

salty skin

267.

CSF meningitis

HIGH protein LOW glucose

248.

DM

polyuria, polydipsia,polyphagia

268.

no nasotracheal suctioning

249.

DKA

kussmal's breathing (deep rapid)

Head injury or
skull fx

Bladder CA

painless hematuria

269.

otitis media

feed upright to avoid otitis media!

250.

BPH

reduced size and force of urine

270.

251.

positioning for
pneumonia

252.

retinal detachment

floaters and flashes of light. curtain

vision

253.

glaucoma

painful vision loss. tunnel vision. halo

lay on affected side, this will splint and

reduce pain. However, if you are trying to
reduce congestion, the sick lung goes up!
(like when you have a stuffy nose and you
lay with that side up, it clears!)

retino blastoma

cat's eye reflex

271.

254.

hypertension, bradypnea,,
bradycarday (cushing's triad)

no fresh flowers, fresh fruits or veggies

and no milk

255.

increased ICP

for neutropenic
pts

272.

bronchospasm

256.

shock

Hypotension, tachypnea,
tachycardia

antiplatelet
drug
hypersensitivity

273.

257.

Lymes disease

bullseye rash

bowel
obstruction

258.

intraosseous
infusion

often used in peds when venous

access can't be obtained. hand
drilled through tibia where
cryatalloids, colloids, blood products
and meds are administered into the
marrow. one med that CANNOT be
administered IO is isoproterenol, a
beta agonist.

more important to maintain fluid balance

than to establish a normal bowel pattern
(they cant take in oral fluids)

274.

Basophils
reliease
histamine

during an allergic response

275.

Iatragenic

means it was caused by treatment,

procedure or medication

276.

Tamoxifen

watch for visual changes--indicates toxicity

259.

sickle cell crisis

two interventions to prioritize: fluids

and pain relief.

277.

post
spelectomy

pneumovax 23 is administered to prevent

pneumococcal sepsis

260.

glomuloneprhitis

the most important assessment is

blood pressure

278.

Alkalosis/
Acidosis and K+

ALKalosis=al K= low sis. Acidosis (K+ high)

261.

children 5 and up

should have an explanation of what

will happen a week before surgery

279.

No
phenylalanine

to a kid with PKU. No meat, dairy or

aspartame

262.

Kawasaki disease

(inflammation of blood vessles,

hence the strawberry tongue)
causes coronary artery aneurysms.

280.

never give
potassium

to a pt who has low urine output!

281.

nephrotic
syndrome

characterized by massive proteinuria

caused by glomerular damage.
corticosteroids are the mainstay

282.

the first sign of

ARDS

increased respirations! followed by

dyspnea and tachypnea

283.

normal PCWC
(pulmonary
capillary wedge
pressure)

is 8-13 readings 18-20 are considered high

284.

first sign of PE

sudden chest pain followed by dyspnea

and tachypnea

285.

Digitalis

increases ventricular irritability ----could

convert a rhythm to v-fib following
cardioversion

263.

264.

265.

ventriculoperitoneal
shunt

3-4 cups of milk a

day for a child?
MMR and varicella
immunizaions

watch for abdominal distention.

watch for s/s of ICP such as high
pitch cry, irritability and bulging
fontanels. In a toddler watch for loss
of appetite and headache. After
shunt is placed bed position is FLAT
so fluid doesn't reduce too rapidly. If
presenting s/s of ICP then raise the
HOB 15-30 degrees
NO too much milk can reduce the
intake of other nutrients especially
iron. Watch for ANEMIA
after 15 months!

286.

Cold stress and

the newborn

biggest concern resp. distress

307.

dehydration

-hypovolemia
- elevated urine specific gravity

287.

Parathyroid
relies on

vitamin D to work

308.

flumazenil,
Romazicon

benzo overdose

288.

Glucagon
increases the
effects of?

anticoagulants

309.

umbilical
cord
compression

reposition side to side or knee-chest

289.

Sucking stab
wound

cover wound and tape on 3 sides to allow

air to escape. If you cover and occlude it--it
could turn into a closed pneumo or
tension pneumo!

310.

short cord

discontinue pictocin

311.

TB

290.

chest tube
pulled out?

occlusive dressing

291.

PE

Needs O2!

292.

DKA

acetone and keytones increase! once

treated expect postassium to drop! have
K+ ready

A positive Mantoux test indicates pt

developed an immune response to TB.
Acid-fast bacilli smear and
culture:(+suggests an active infection) the
diagnosis is CONFIRM by a positive culture
for M TB
A chest x-ray may be ordered to detect
active lesions in the lungs
QuantiFERON-TB Gold: DIAGNOSTIC for
infection, whether it is active or latent

293.

Hirschprung's

diagnosed with rectal biopsy. S/S infantfailure to pass meconium and later the
classic ribbon-like/foul smelling stools

312.

Battery

performing procedure without consent

313.

Assault

Threatening to give pt. medication

putting another person in fear of a harmful
or an offensive contact.

314.

Imprisonment

Telling the client you cannot leave the

hospital

315.

Defamation

is a false communication or careless

disregard for the truth that causes damage
to someone's reputation. in writing(Libel) or
Verbally(Slander)

316.

Sprain or
Strain

RICE
Rest
Ice
Compress
Elevate

294.

Intussusception

Common in kids with CF. Obstruction may

cause fecal emesis, current jelly stools.
enema---resolution=bowel movements

laboring mom's
water breaks?

first thing--worry about prolapsed cord!

296.

Toddlers need
to express

independence!

297.

Addison's

causes sever hypotension!

298.

pancreatitis

first pain relief, second cough and deep

breathe

299.

CF chief
concern?

Respiratory problems

300.

a nurse makes a
mistake?

take it to him/her first then take up the

chain

301.

nitrazine paper

turns blue with alkaline amniotic fluid.

turns pink with other fluids

302.

up stairs with
crutches?
down stairs
with crutches?

good leg first followed by crutches(good

girls go to heaven)
crutches with the injured leg followed by
the good leg.

303.

dumping
syndrome?

use low fowler's to avoid. limit fluids

304.

TB drugs are

hepatotoxic!

305.

clozapine,
Clozaril

antipsychotic
anticholinergic

306.

clozapine s/e

weight gain, hypotension, hyperglycemia,

agranulocytosis

295.