NCLEX RN 2024 Study Guide: Key Points for Nursing Exam Preparation, Exams of Nursing

Download NCLEX RN 2024 Study Guide: Key Points for Nursing Exam Preparation and more Exams Nursing in PDF only on Docsity! 1 NCLEX RN 2024 NEW UPDATED STUDY GUIDE REIEW SUCCESS ASSURED Evaluate Assess Teach Don’t delegate Unstable patients Initial Assessment, Teaching, IV drips, Evaluations only RN AIRBORNE TRANSMISSION-BASED PRECAUTIONS: MTV Measles TB Varicella-Chicken Pox/Herpes Zoster-Shingles Private Room: Negative pressure with 6-12 air exchanges/hr Mask: N95 for TB DROPLET TRANSMISSION-BASED PRECAUTIONS: Think of SPIDERMAN! Sepsis Scarlet fever Streptococcal Pharyngitis (Streptococcus group A/ Strep Throat): Can Lead to Glomerulonephritis & Rheumatic Parvovirus B19 Fever. Pneumonia Pertussis Influenza/ Haemophilus influenza type B Diphtheria (Pharyngeal): Serious bacterial infection. Epiglottitis: Medial Emergency! No Throat Inspection. Rubella/ German measles 2 Mumps Meningitis/ Neisseria 2 NCLEX RN STUDY GUIDE Meningitidis Mycoplasma/ Meningeal Pneumonia An - Adenovirus Private Room or Cohort Surgical mask PRN for Procedures Mask 3ft Distance CONTACT PRECAUTION TRANSMISSION-BASED PRECAUTIONS: MRS.WEE Multidrug resistant organism/ MRSA/ VRE Respiratory infection Skin infections Wound infection Enteric infection - Clostridium Difficile Eye infection – Conjunctivitis *MRSA - Contact precaution ONLY. Use Chlorhexidine Wipe! *VRSA - Contact & Airborne precaution (Private room, door closed, negative pressure) *SARS (Severe Acute Resp Syndrome) Airborne & Contact (just like Varicella) SKIN INFECTIONS- VCHIPS- CONTACT Varicella Zoster Cutaneous Diphtheria (Bacteria Infection in the Wound) Herpes Simplex Impetigo (Bacterial Skin Infection) Pediculosis (Lice) Scabies (Itchy Skin condition. Burrowing Trail of the Scabies Mite) Middle East Respiratory Syndrome (MERS): Viral respiratory illness caused by Coronavirus (MERS-CoV). 5 2 NCLEX RN STUDY GUIDE uction should be set at Medium Pressure (100-120 mm Hg for adults, 50-75 mm Hg for children) as Excess pressure will traumatize the mucosa and can cause hypoxia. Clients usually Cough as the catheter enters the trachea, and this helps loosen secretions. The catheter should be advanced until resistance is felt and then, to prevent mucosal damage, Retracted 1 cm before applying suction. You will ask every New Admission if he has an Advance Directive , and if not you will explain it, and he will have the option to sign or not. Alcohol: a Toxin that causes CNS Depression . Alcohol withdrawal generally starts within 8 hours after the last drink and peaks at 24-72 hours. Acute alcohol intoxication: Confusion, Coordination Impairment, Drowsiness, Slurred Speech, Mood Swings, and Uninhibited actions. Hypoglycemia. Chronic Alcohol Abuse/Alcoholism: Benzodiapepine (lorazepam, diazepam, chlordiazepoxide) – to Treat Gross Tremors, Seizures, Delirium symptom. Chlordiazepoxide: For Alcohol withdrawal. Don’t take with Alcohol (terrible N/V can occur) Thiamine (B 1): to treat Wernicke Encephalopathy, a Serious complication that manifests as altered mental status, oculomotor dysfunction, and ataxia. Also can lead to death or neurologic morbidity (Korsakoff Psychosis). Give before or with IV Glucose. Alzheimer’s Disease: Chronic, progressive, degenerative cognitive disorder that accounts for more than 60% of All Dementias. Memantine: Cognition Enhancing medication. It can treat Dementia associated with Alzheimer's disease. Improve symptoms cognition, Daily function, Behavioral problems. Donepezil: Cognition Enhancing medication. Amyotrophic Lateral Sclerosis (ALS): a condition in which there is a Progressive, Degeneration of Motor Neurons in both the Upper & Lower Motor Neuron systems. Upper Motor Neuron issue: Hyper Reflexes Lower Motor Neuron issure: Absent Reflexes 6 2 NCLEX RN STUDY GUIDE /S : Limb weakness, Dysarthria (difficulty speaking), and Dysphagia. Iron: IM: should be given Z-track so they don't leak into SQ tissues IV: Iron Dextran (Imferon). Can cause hypersensitivity reaction (anaphylaxis), test dose needs to be given First. PO: give with Vitamin C or on an Empty stomach or Btw Meals. Place it on the back of the Month (Stain teeth). Expect Black/Green Tarry Stools. Take iron elixir with juice or water....Never with milk (Vit D). Iron Poisoning: GI Bleed. Antidote: Deferoxamine Iron Deficiency Anemia: Microcytic anemia. S/S: Fatigue, Pallor, Fissures at the corner of the mouth, Spooning of the fingernail, Reduced exercise tolerance Thalassemia Major (Cooley’s Anemia): Microcytic anemia. S/S: Maxillary Hyperplasia, Frontal Bossing. Caused by: Defects in both Beta-chains of the Hgb molecule. Pernicious Anemia: Macrocytic anemia, Lack of required Intrinsic factor (B12 Deficiency) S/S: Pallor, Tachycardia, Sore Red Tongue (Beefy tongue), Enlarged Liver that can lead to R-sided HF. Take Vit. B12 for life. Shilling Test : Test for Pernicious Anemia. How well one absorbs Vit B12 Folate (Folic Acid) Deficiency: Macrocytic anemia. Risk: Alcoholism or Diet Low in Vegetables. 7 S/S: Stomatitis, Ulcerations on the tongue. Dysphagia, Flatulence, watery Diarrhea 10 2 NCLEX RN STUDY GUIDE (Descending)- Abrupt in Onset, “Worst Ever” “Tearing”, Ripping Pain, Moving Back Pain, Epigastric Pain Abdominal Aortic Aneurysm (AAA): Definitive Diagnosis- CT scan. Hypoactive BS for few days after the Surgery. Computed Tomography (CT) Scan: Assess Allergies Osteoarthritis: a Degenerative Disease, causing pain With Activity. Inflammation occurs, but the joint does Not usually become swollen or red. It commonly affects the Larger, weight-bearing joints and affects both genders equally. Rheumatoid Arthritis: causes Pain and Inflammation After periods of rest. It affects the Small joints (like fingers) and is more common in women. Pain is usually the Highest Priority. Heat for Chronic (Rheumatoid Arthritis): Warm Shower/Bath in the Morning. Swimming is the Best. Order of Assessment: Inspection, Palpation, Percussion and Auscultation. Except… Abdomen Assessment: Inspect, Auscultate, Percuss then Palpate (Last, bc it may induce pain) Assessment with Kids: Least invasive to Most invasive. An example of when you would Implement Before going through a bunch of Assessments is when someone is experiencing Anaphylaxis. Get the Ordered Epinephrine in them STAT, especially if they clearly States the S/S (Difficulty Breathing, Increasing Anxiety, etc.) Anaphylaxis is a Medical Emergency. Epinephrine Injection is the Only option for treating anaphylaxis. Asthma: 11 2 Wheezing on Expiration. NCLEX RN STUDY GUIDE Coughing Without other s/s is suggestive of asthma. If they stop Wheezing; it could mean it is Worsening. Hyperrsonance: Percussed over Hyperinflated (air) Lung (Asthma, Emphysema). Asthma and Arthritis: Swimming Best Avoid ASA, NSAID (ibuprofen), and Beta Blockers. Asthma has Intercostal Retractions (be Concerned) Exacerbation: Acute, Distress. Wheezing, Dyspnea, Sternal Retraction, Anxiety. Status Asthmaticus : Acute, Prolonged, and Severe Asthmatic Attack that is unresponsive to usual treatment. Hospitalization is usually required. When using a Bronchodilator inhaler in conjunction with a Glucocorticoid inhaler, administer the Bronchodilator First. Theophylline (Bronchodilator): Therapeutic Drug level: 10-20 Tx: of Asthma or COPD Increases the Risk of Digoxin Toxicity, Decreases the effects of Lithium and Phenytoin. Causes GI upset, give with food. Cromoglicic Acid (helps reduce Inflammation): an inhaler used to treat Allergy Induced Asthma. Not for acute asthma attack. Before Pulmonary Function Tests (PFT's): Hold the Bronchodilators. Stop Smoking for 4 hr prior. Incentive Spirometry: 1) Sit upright 2) Exhale 3) Insert mouthpiece 4) Inhale for 3 sec., then Hold for 10 sec. For Prevention of Atelectasis. Atropine: used to Decrease Secretions Atropine Blocks Acetylcholine (remember it reduces secretions). Atropine Overdose: Hot as a Hare (Temp), Mad as a Hatter (LOC), Red as a Beet (Flushed face) and Dry as a Bone (Thirsty) ADHD: Inattention, Hyperactivity, Impulsivity. 12 2 NCLEX RN STUDY GUIDE ethylphenidate / Ritalin: Assess for Heart related side effects report immediately. May need a Drug Holiday- it Stunts Growth. Dextroamphetamine: may alter Insulin needs, Avoid taking with MAOI's, take in Morning (Insomnia possible side effect) Atomoxetine: Norepinephrine-Specific Reuptake Inhibitor, and can be used for Depression. Autonomic Dysreflexia/Hyperreflexia: Neuro T6 or above. Life-threatening emergency. Uncompensated SNS stimulation (Inhibited Sympathetic Response) Tigger by : Bladder distention and Bowel impaction S/S: pounding/severe HA, profuse Sweating (Diaphoresis), Nasal Congestion, Bradycardia (30~40), Flushing, Piloerection (goose bumps), Nausea, Seizure, Uncontrolled HTN. Can occur weeks to years after the injury. Tx: Place client in sitting position (Elevate Hob ) first before any other implementation. High Fowler’s (90o): assist w/ventilation & prevention of HtN Stroke! Loosen constrictive clothing (Decr. skin stimulation) SBP> 300mmHg. Administer antihypertensive meds (may cause stroke, MI, seizure) Most spinal cord injuries are at the Cervical or Lumbar regions. Spinal Shock occurs Immediately after Spinal Injury Halo: remember Safety First; have a Screwdriver nearby. Myelogram: NPO 4-6hr, allergy hx, Phenothiazine, CNS depressants, and Stimulants withheld 48hr prior, table will be moved to various positions during test. Post: Neuro q2-4, Water Soluble HOB Up. Oil Soluble HOB Down (Lie Flat Supine, to prevent HA, and Leaking of CSF) oral analgesics for HA, encourage PO fluids, assess for Distended Bladder, Inspect Site. Benign Prostatic Hyperplasia (BPH): Enlarged Prostate. Reduced size & force of urine. 2 Botox (Botulin Toxin): Used with Strabismus ( 15 NCLEX RN STUDY GUIDE Patch the Good eye, so the Weaker eye can get stronger). To relax Vocal Cords in Spasmodic Dysphonia. Bowel Sounds: Normal: High-Pitched, Gurgling sounds. Cardiovascular Bruits: (Swishing, Humming, Buzzing): usually indicate Arterial narrowing (Obstruction) or dilation (Aneurysm). After Surgery, BS are Absent first 24-48 hrs. Return to the Small intestine in 24hr; Large intestine may delayed 3~5 days. Borborygmi Sounds : are Loud, Gurgling sounds suggesting increased Peristalsis (Gastroenteritis, Diarrhea). Obstructed Ileostomy (Bowel Obstruction): S/S: N/V, Abd Distention, Decr. Stool. Ileostomy: Liquid Stool (Bypass the Colon). Low Fiber Diet: White rice, Pasta, Refined grains. Avoid High Fiber (Popcorn, Coconut, Brown Rice, Multigrain bread), Stringy Veg (Celery, Broccoli, Asparagus), Seeds or Pits (Strawberry, Raspberries, Olives), Edible Peels (Apple, Cucumber, Dried fruit). Colon: Fluid & Electrolyte Absorption, Vit K Production. Don’t Fall for ‘reestablishing a normal bowel pattern’ as a priority with Small Bowel Obstruction. Because the patient Can’t take in oral fluids ‘Maintaining Fluid Balance’ comes First. Small Bowel Follow-Through (SBFT): Sequential X-ray images to visualize the Structure and Function. Barium is Ingested, and X-ray images are taken every 15-60 minutes to visualize the barium as it passes through 16 2 NCLEX RN STUDY GUIDE he small intestine. Using this technique, Decreased Motility (eg, Ileus), increased motility (eg, Malabsorption Syndromes), Fistulas, or Obstructions are identified. Fast 8 hours Prior to the examination. The test usually takes 60-120 minutes, but if obstruction or decreased motility is present, it can take longer. Drink plenty of Fluids After the examination to facilitate barium Removal. Chalky stools may be present 24-72 hours after the examination. If brown stools do Not return after 72 hours or abdominal pain or fullness is present, contact the HCP. Burns: Rule of Nines Head and Neck= 9% Each upper ext= 9% Each lower ext= 18% Front trunk= 18% Back trunk= 18% Genitalia= 1% Assess for Smoke Inhalation/ Burns: 1st Degree - Red and Painful 2nd Degree - Blisters 3rd Degree - No Pain because of Blocked and Burned nerves. Tx: High-Flow O2 (100%) to displace CO & Cyanide from hgb. (1st 24 hour): Lactated Ringer’s: 4mL/kg HyperCalcemia: muscle weakness, lack of coordination, abd pain, confusion, absent tendon reflexes, sedative effect on CNS HypoCalcemia: CATS – Convulsions, Arrhythmias, Tetany, Spasms and Stridor. 17 2 rousseau’s & Chvostek’s. NCLEX RN STUDY GUIDE Ca2+ absorption is impaired when taken in excess of 500 mg per dose. Taken within an hour of meals as food incr. Ca2+ absorption. Constipation is a frequent side effect of Ca2+ supplements. For Chronic Kidney Disease take Ca2+ supplements before meals, to reduce Phosphorus levels Non-dairy sources of Ca2+: Rhubarb, Sardines, Collard Greens. Carbon Monxide (CO): More readily binds to Hemoglobin than O2. Pulse Oximeter: Can’t Differentiate between O2 & CO. CO Poisoning: S/S: HA, Dizziness, Fatigue, Nausea, Dyspnea. Tx: 100% O2. Serum CarboxyHemoglobin Test to Confirm Diagnosis. Normal Value: < 5% Non Smoker. < 10% Smoker. Carbon Dioxide (CO2) Narcosis: High K+ (Expected- Hydrogen floods the cell forcing K+ out). Causes Increased Intracranial Pressure. Cataract: S/S: Painless Vision Loss, Cloudy, Blurry vision, Opacity of the lens. Worst at Night. Tx: Lens Removal Surgery After Cataract Surgery: Sleep on Unaffected side with a Night Shield for 1~4 weeks. Celiac Disease: Barley, Rye, Oats, Wheat. Cephalhematoma (Caput Succinidanium): Resolves on its own in a few days. This is the type of Edema that Crosses the Suture lines. 20 2 NCLEX RN STUDY GUIDE Subarachnoid Hemorrhage: Emergent, Serious presentation often described as the "Worst Headache of My Life." The onset is usually Abrupt due to rupture of the vessel; High Mortality from recurrent bleeding. Chemotherapy: S/S: Oral mucosa, n/v (GI), Decr. Blood cell count (Bone Marrow) Neutropenic Precautions: No Yogurt (has Live Cultures), No Milk, No Fresh fruit or veggies. Radiation Therapy : Risk for Leukopenia. Infection kills cancer patients. Cisplatin: May cause Kidney injury. Vincristine: For Leukemia (Risk for Epistaxis bc of Low Platelets) Given IV only. Methotrexate: For RA & Psoriasis. Hepatotoxic Teratogenic. Immunosuppressant. Folate antimetabolite. (Risk for infection, No Live Vaccine). Infliximab, Adalimumab, Ehanercept (Tumor Necrosis Factor Inhibitors): For RA, Crohn disease, Psoriasis. Risk for infection, No Live Vaccine. Test for TB every year while on the medication. Cyclophosphamide: Complication: Hemorrhagic Cystitis (bladder inflammation/bloody urine). Tx: Drink plenty of fluids or IV hydration. Mesna: Detoxifying agent. Prophylactic agent in reducing the incidence of cyclophosphamide/ ifosfamide- induced Hemorrhagic Cystitis. Asparaginase: Test For Hypersensitivity Before the administration. Common sites for Metastasis: Liver, Brain, Lung, Bone, and Lymph. Lymphedema: Complication from Cancer. When the Lymph System is Blocked or Damaged. Fluid builds up in soft body tissues and causes Swelling Colorectal Cancer: Shouldn't have Cantaloupe before Fecal Occult Blood Test (FOBT), because Cantaloupe is high in vit C and vit C causes a False Positive for Occult Blood. FOBT: Detect blood. 1. Apple Stool first then dry. 2. Then Solution. Tamoxifen: For Breast cancer. Report changes in Visual Acuity, the Adverse effect could be Irreversible. 21 2 NCLEX RN STUDY GUIDE Risk for Endometrial Cancer (Heavy Period) & Thromboembolic Event. Hemovac: used after Mastectomy. Empty when Full or q8hr, remove plug, empty contents, place on flat surface, cleanse opening and plug with Alcohol sponge, compress evacuator completely to remove air, release plug, check system for operation. Don’t place Immunosuppressed pt With Any pt with an Infectious disease or Open wound. Basal Cell Carcinomas : Translucent, Raised, and Smooth. Rarely Metastasize or cause death. Most Common. Squamous Cell Carcinomas : characterized by Local Invasion. Fast Growing and Infrequent Metastasis. They are Red Nodules with Crust or Ulceration. Malignant Melanomas : Appears Black or Brown with Irregular Borders. Often Metastasize. Most Deathly form of Skin Cancer. Least Common. Chest Tube Drainage System: Placed in the Pleural space. If chest tube is dislodged, immediate action should be to apply a Sterile Occlusive Dressing (eg, petroleum jelly dressing) taped on 3 sides. This permits air to escape on exhalation and inhibits air intake on inspiration. Notify the HCP and arrange for the reinsertion of another chest tube. Suction Control Chamber: Set at -20 cm H2O to maintain Negative pressure in the system. Bubbling will occur when suction is applied. Water Seal Chamber of the chest tube drainage system is filled with Sterile water and acts as a One-Way Valve preventing air from entering the client's chest cavity. Tidaling: The water level in the water seal chamber Rises and Falls with Inspiration and Expiration. (Maintaining appropriate Negative pressure/ indicating Proper function of the chest tube drainage system) Air Leak Gauge: (part of the Water Seal Chamber) allows for assessment of air leaks. Continuous Bubbling : indicates an Air Leak in the system. Drainage Collection Chamber: which Fluid from the client's Pleural Cavity will collect; the nurse will assess the color and amount and record the output. Sucking Stab Wound: Immediately dress the wound and tape it on Three sides which allows air to Escape. Do not use an occlusive dressing, which could convert the wound from Open pneumo to Closed one. 22 2 NCLEX RN STUDY GUIDE ension Pneumothorax : develops when air enters the pleural space but Cannot escape. Increased intrapleural pressure and excessive accumulation of air can apply pressure to the heart and great vessels and drastically decrease cardiac output. An occlusive dressing taped on 4 sides would prevent the air in the pleural space from escaping on exhalation and would increase the risk for a tension pneumothorax. Tension pneumothorax trachea shifts to Opposite side. Tracheal Deviation: Reduce Cardiac Output & Hypotension. After that get your Chest Tube Tray, Labs, IV. Removal: Take a breath and hold it or Bare down by attempting to Exhale through the mouth and nose with your lips held Closed. Cholecystitis: Limit Fatty foods. Fat stimulates the release of Bile form the Gallbladder. N/V, Restlessness, Diaphoresis. Referred to the R Scapula & Epigastric tenderness. Murphy’s Sign : Pain w/ palpation of Gallbladder (RUQ) area. Cholera: Infection of the small intestine by some strains of bacterium Vibrio Cholerae. Acute Diarrheal Disease; Rice Watery Stool. Chronic Obstructive Pulmonary Disease (COPD): the Baroreceptors that detect the CO2 level are destroyed. Therefore, O2 level must be Low bc High O2 Conc. blows the patient’s Stimulus for Breathing. 2L Nasal Cannula or less (Hypoxic Not Hypercapnic drive), PaO2 of ~60 Chronic CO2 retainer: SaO2 90% (Normal) CO2 causes Vasoconstriction. Venti Mask for Distress COPD pt. Tiotropium, Ipratropium, Benztropine. Bronchitis: Rhonchi: Continuous, Low-pitched Wheezes usually heard on Expiration that sound like moaning or snoring. 25 2 nd (Accessory XI) Matter Hymen (Hypoglassal XII) More NCLEX RN STUDY GUIDE Assessing Extraocular Eye Movements: Check Cranial Nerves 3, 4, and 6. Cystic Fibrosis: Salty Skin. Fatty Stools. Diet: Low Fat, High Sodium, Fat Soluble Vitamins ADEK. Pancreatic Enzymes are taken with each meal. Respiratory Problems are the Chief concern: Treat with Aerosol Bronchodilators, Mucolytic. Cystitis: Burning on Urination. Frequency, Urgency, Suprapubic Discomfort, Hematuria. CytoMegaloVirus: Ganciclovir: For CMV Retinitis. Pt will need regular Eye exams, report Dizziness, Confusion, or Seizures Immediately. DecortiCate: (Flexor) Toward the 'Cord'. Cortex involvement. Problem with Cervical Spinal Tract or Cerebral Hemisphere. DecerEbrate: (Extensor) The Other way (Out). Cerebellar, Brain Stem involvement. Problem w/in Midbrain or Pons. Weight is the Best indicator of Dehydration. 1kg = 1L Diagnose of Delirium: Acute Mental Changes, Inattention with disorganized thinking, Altered Level of Consciousness, Hallucination. Dengue Fever: Hemorrhagic. Petechiae or (+) Herman’s sign. 26 2 NCLEX RN STUDY GUIDE MonoAmine Oxidase Inhibitors (MAOI): Antidepressant. Isocarboxazid Phenelzine Selegiline Tranylcypromine Avoid Tyramine containing foods Don’t take it with SSRI; at least 14 days in between. Administered in the morning, as sleep dysfunction is common. Increased risk for Suicidal Ideation , particularly children, adolescents, and young adults. The risk of suicidal thoughts can be more prevalent when Starting the medication or with dose Increases. Feelings of hopelessness or despair must be evaluated to assess if suicidal ideation or thoughts of self-harm are present. Safety over Nutrition with a severely depressed client. Depression often manifests itself in Somatic (Relating to the Body) ways, such as Psychomotor retardation, GI complaints, and Pain. Amitriptyline: Tricyclic Antidepressant. Somatic Symptom Disorder (SSD): Mental disorder which manifests as physical symptoms but cannot explained fully by a general medical condition. Selective Serotonin Reuptake Inhibitors (SSRIs): Sertraline Fluoxetine Citalopram Paroxetine 27 2 ake about 3 weeks to Work. NCLEX RN STUDY GUIDE Sertraline: Agitation, Sleep disturb, and Dry mouth St John's Wort: used to treat Depression and Anxiety. Mimics the action of SSRI by Increasing available Serotonin in the brain. Taken in combination with an SSRI, may cause an Excess of Serotonin, resulting in Serotonin Syndrome. Serotonin Syndrome: characterized by Mental Status Changes (anxiety, agitation, disorientation) Autonomic Dysregulation (hyperthermia, diaphoresis, tachycardia/hypertension) Neuromuscular Hyperactivity (tremor, muscle rigidity, clonus, hyperreflexia) Mydriasis (dilation of pupil) Caused by : taking More Than One or an Overdose of Antidepressant med that incr. Serotonin levels. Diabetes Mellitus (DM): Polyuria, Polydipsia, Polyphagia. Metformin: Can’t be Given w/Contrast for CT Scan (Kidney Injury). Hold for 48hr. HbA1c - test to assess how well blood sugars have been controlled over the past 90-120 days. 4- 6 corresponds to a blood sugar of 70-110; 7 is ideal for a diabetic and corresponds to a blood sugar of 130. Diabetic ketoacidosis (DKA): when body is breaking down fat instead of sugar for energy. Fats leave Ketones (acids) that cause pH to decrease. DKA is rare in diabetes mellitus type II because there is enough insulin to prevent breakdown of fats. Serum acetone and serum ketones Rise in DKA. As you treat the Acidosis and Dehydration expect the potassium to Drop rapidly, so be ready, with K+ Replacement. While treating DKA, bringing the Glucose Down too far and too fast can result in Increased ICP due to water being pulled into the CSF. Wherever there is Sugar (Glucose) Water Follows. 30 2 NCLEX RN STUDY GUIDE nurse with a Localized herpes zoster can care for patients as long as the Patients are Not Immunosuppressed and the lesions must be Covered. Diverticulitis: Inflammation of the Diverticulum in the Colon. Often in the Sigmoid Colon. Pain is around LL quadrant. Low Residue (Low Fiber), No Seeds, Nuts, Peas. Complication: Peritonitis (LUQ Pain). Down Syndrome: Protruding Tongue. Floppy muscle tone. To Prevent Dumping Syndrome (Post-Operative ulcer/stomach surgeries): eat in Low-Fowler’s during meals, lie Down after meals for 20-30 minutes (Decrease Peristalsis), Restrict Fluids during meals (wait 1hr), Low CHO and Fiber diet, Incr. Fat and Protein, Small frequent meals, Eat slowly. S/S: Dizziness, Hypotension, Syncope, Generalized Sweating, Tachycardia, Palpitation, n/v, Diarrhea, Abd pain. Gastrojejunostomy (Roux-En-Y Surgery): Risk for Dumping Syndrome. Iron Deficiency Anemia. Cobalamin Deficiency. DVT (Homan’s Sign): who need Enoxaparin, should not be Delegate. Does Not Need to be on bed rest, unless they have Severe Edema or Leg Pain. Edema: is in the Interstitial Space Not in the Cardiovascular Space. Electrocardiogram (EKG): Atrial Fibrillation : Cardioversion: Anterior-Posterior Paddle Placement- One paddle is places just to the Right of the sternum at the Fourth Intracostal space and the Other paddle is placed between the scapulae on the Back. The Shock runs Diagonally through the chest. Cardiac Output Decreases with Dysrhythmias. Dopamine increases BP. 31 2 NCLEX RN STUDY GUIDE ed of choice for Vtach is Lidocaine/ Amiodarone (antiarrhythmic). Med of choice for SVT is Adenosine. Med of choice for Bipolar is Lithium. Med of choice for Asystole (no heart beat) is Atropine/ Epi Med of choice for Paroxysmal Atrial Tachycardia is Adenosine. Amiodarone is effective in both Ventricular and Atrial complications & Vfib/Vtach. V. Bigeminy. Flecainide (an antiarrhythmic): Limit Fluids and Na+ intake, because Na+ increases Water Retention which could lead to Heart Failure. PT/PTT are Elevated when patient is on Warfarin. No ASA & NSAID. Warfarin- Vitamin K Enoxaparin: LMWH. Monitor CBC to asses for Thrombocytopenia. Electroencephalogram (EEG): Before: Hold meds for 24-48 hrs prior, No Stimulants for 24hr Before, No caffeine or cigarettes for 24 hrs Prior, Can eat, pt Must Stay Awake night. During: Pt may be asked to Hyperventilate (3-4min) and watch a Bright flashing light. After: Assess pt for Seizures (Increased Risk) After Endoscopy Check Gag Reflex . Administration of Enema: position pt in Left side-lying (Sim's) with Knee Flexed. Fleet Enema : To Stimulate defecation & Relieve Constipation. Neomycin Enema: Administer before Bowel Surgery to decr. bacteria in the Colon. Epiglottitis: No Throat Inspection. 32 2 NCLEX RN STUDY GUIDE evere Inflammatory Obstruction. Drooling, Dysphonia (hoarse voice), Dysphagia (difficulty swallowing). Tripod Position. Inspiratory Stridor (Airway Distress). Caused by : Hib w/O Vaccine. Tx: Endotracheal Intubation w/ Tracheostomy Kit Standby. Dealing with Fire in Inpatient Setting (RACE): Rescue Activate the fire Alarm, Code Red Confine/ Close the Doors/Windows Extinguish the Fire. No Water. Using the Extingusher (PASS) Pull the Pin Aim the Nozzle Squeeze the Handle Sweep back and forth over the fire. Fractured Hip: S/S: External Rotation, Shortening, Adduction. Fat Embolism: Blood tinged sputum (r/t Inflammation), Incr. ESR, Respiratory Alkalosis (Not Acidosis r/t Tachypnea), Resp. Distress, Altered Mental Status, Hypocalcemia, Incr. serum Lipids, "Snow Storm" Effect on CXR. Petechiae (Treated w/ Heparin) in the chest, axillae, soft palate. Heparin Prevents Platelet Aggregation. No ASA & NSAID. Monitor PTT. Antidote: Protamine sulfate Reduce the Risk: Minimizing the move of a fractured long bone &early stabilization of the injury w/ surgery. Tx? Greenstick Fractures: usually seen in Kids bone breaks on one side and bends on the other 35 2 NCLEX RN STUDY GUIDE x of Duodenal Ulcers. Coats the ulcer/Mucosal Barrier (take one hour Before meals to Coat the stomach). Create Viscous Substance Forms a Protective Barrier. Misoprostol: Prevent Stomach Ulcers caused by NSAIDs. Give Antacid to a Mechanically Ventilated patient w/ NG tube if the pH of the Aspirate is < 5.0 , Checked at least every 12 hrs. Glasgow Coma Scale Eye opening (Maximum = 4) 4 - Spontaneous (open with blinking at baseline) 3 - To speech 2 - To pain only 1 - None (C - Not assessable [eg, trauma, edema]) Verbal response (Maximum = 5) 5 - Oriented 4 - Confused (converses but confused, disoriented) 3 - Inappropriate (inappropriate words) 2 - Incomprehensible (sounds, no words) 1 - None (T - Not assessable [intubated]) Motor response (Maximum = 6) 6 - Obeys commands for movement 5 - Localizes to pain 4 - Withdraws from pain 3 - Flexion in response to pain (decorticate posturing) 2 - Extension in response to pain (decerebrate posturing) 1 - None Use best response for each category (range, 3-15). Coma: Does not open eyes, does not follow commands, and does not utter understandable words; GCS 3-8. Head injury classification: Mild, GCS 13-15; moderate, GCS 9-12; severe, GSC ≤8. Below 8 you are in Coma. Intubated for Airway Protection. Dysphagia: Difficulty Swallowing (Risk for Aspiration) 36 2 NCLEX RN STUDY GUIDE ysarthria: Weakness of the Muscles for Speech (mumble, lisp) Aphasia: Impaired Communication (Words don’t make Sense) Apraxia: Loss of ability to perform a movement (clipping, whistling) Glaucoma: Intraocular Pressure is greater than the normal (22 mm Hg) Painful, Vision Loss, Tunnel/gun barrel/halo Vision (Peripheral Vision Loss) Pilocarpine/Miotics: to Constrict the pupils. Acetazolamide: Don’t take if allergic to Sulfa drug. Can cause HypoK+. Also can treat High altitude sickness. Timolol Maleate/Timoptic (Beta-adrenergic blocker): Eye drops. No Atropine. Primary Open-Angel Glaucoma : “Tunnel” Vision. Slow. Painless. Primary Angel-Closure Glaucoma : Medical Emergency! Apply eye drop to conjunctival sac and after wards apply pressure to nasolacrimal duct / inner canthus OU- both eyes OS- Left eye OD- Right eye (dominant Right eye- just a tip to remember) Gonorrhea is a Reportable Disease. Goodpasture’s Syndrome: Rare, Autoimmune Disease that affect’s Kidneys & Lungs. Gout: Probenecid: Uric Acid Reducer (Uricosuric and renal tubular blocking agent) Colchicine: Anti-inflammatory. (Pain improvement within 12 hours and subside within 24~48 hours) Common S/S: G.I. issue, Diarrhea, Abd Pain, n/v Allopurinol/Zyloprim: Uric acid reducer. It can also treat Kidney Stones. Push Fluids with Allopurinol - flush the uric acid out of system. No Vitamin C. 37 2 NCLEX RN STUDY GUIDE Indomethacine: to reduce pain and inflammation during acute attacks. Elevate the Inflamed Joints, Keep the area Bare, and apply Ice. Encourage Gradual weight loss. Guillain-Barre Syndrome (GBS): Ascending Paralysis. Ascending bilateral paralysis from segmental demyelination (remyelination eventually occurs). If the current level of paralysis is at the Knees and is therefore not the priority as it has not yet reached the Diaphragm. Keep eye on Respiratory System (absence of reflexes). Muscle weakness can lead to Resp. muscle paralysis, patient Unable to Cough effectively (Risk for Aspiration). Risk for Neuromuscular Respiratory Failure. Heart Failure: Anytime you see Fluid Retention. Think Heart problems first. Adding K+ to a diet, especially when substituting it for sodium, can Decrease BP and fluid retention. Avoid Sodium. S3 sound is Normal in CHF, not in MI. Fluid Volume Overload caused by IVC fluids infusing too quickly (or whatever reason) Nitroprusside (vasodilator): monitor Thiocyanate (Cyanide). Normal value should be 1. Greater than 1 is heading toward Toxicity ACE Inhibitor : Med of choice for CHF. Furosemide: May Cause Low K+, can Cause Anorexia due to Reduced K+. Give it slowly to prevent Ototoxicity, when giving more than 120mg. Digoxin (Cardiac Glycoside): check Pulse, Hold if hr < 60, (Children: Hold if hr <100). Check Dig levels (0.5-2.0) and K+ levels. Patient on Dig and Furosemide: Low K+ Potentiates Dig and can Cause Dysrhythmias. Digitalis Increases Ventricular Irritability, and could Convert a rhythm to V-Fib following Cardioversion. You better pick ‘Do Vitals’ Before administering that Dig. (Apical pulse for One full minute). Avoid salt substitutes when taken Dig and K-Supplements because many are Potassium based Antidote: Digoxin immune fab. 40 Resp. 41 2 NCLEX RN STUDY GUIDE ushing's Triad: Systolic Hypertension with Widened Pulse Pressure, Bradycardia, Resp. Depression Should be Less than 2, Measure Head Circumference. Infectious Mononucleosis: Hallmark- Sore Throat (Pharyngitis), Cervical Lymph Adenopathy (Node Swelling), Fever, Fatigue, Splenomegaly, Hepatomegaly. Caused by : Epstein-Barr Virus (EBV). Tx: Pain Control. Rest is Important. Serious Complication: Spleen Rupture (LUQ Sudden Onset of Abd Pain). Infective Endocarditis (IE): the Vegetation over the Valves can break off; Emboli to various Organs, resulting in Life-Threatening Complications. Stroke - paralysis on one side Spinal Cord Ischemia - paralysis of both legs Ischemia to the Extremities - pain, pallor, and cold foot or arm Intestinal Infarction - abdominal pain Splenic Infarction - left upper-quadrant pain Common S/S: Fever, Arthralgia (Joints Pains), Weakness, Murmur, Fatigue, Splinter hemorrhage, Osler’s Node (painful, red raised lesions), Janeway Lesion. Tx: IV Abx for 4-6 weeks. Fever may persist for several days after treatment is started. Risk Factor : Hx of Mechanical Heart Valve Replacement, Rheumatic Fever, Dental Procedures, IV Drug Use, and Immunosuppression. Irritable Bowel Syndrome: Dicyclomine (Antispasmodic): Assess for Anticholinergic side effects. Above Knee Amputation: Elevate for first 24 hours on pillow, position Prone daily to provide for hip extension. Do Not apply Lotions, Creams, or Oils. 42 2 NCLEX RN STUDY GUIDE Below Knee Amputation: foot of bed Elevated for first 24 hours, position Prone daily to provide for hip extension. Phantom Limb Pain: if the pain is High, Prioritized it. Total Knee Replacement: Common Complication is Blood Loss. Hemoglobin level of 7 g/dL (70 g/L) is very Low. Assess for Active Bleeding. For knee replacement use Continuous Passive Motion Machine. Laparoscopy: CO2 used to enhances visual, general anesthesia, foley. Post: Walk patient to Decrease CO2 build up used for procedure. LaryngoTracheitis/ LaryngoTracheoBronchitis (Coup): Upper Resp. Tract Symptoms followed by Hoarseness, Barking Cough, Stridor, and Resp. Distress. Inspiratory Stridor. Caused by : Parainfluenza Virus. Tx: Nebulized Racemic Epinephrine. Latex Allergies: Assess for allergies to Apricots, Avocados, Bananas, Cherries, Chestnuts, Grapes, Kiwi, Passion fruit, Peaches, Tomatoes. Lead Poisoning: Neurocognitive Impairment, Development Delays, Seizure, Kidney Damage. Tx: Chleation Therapy. Leprosy: Lioning face. Liver Cirrhosis: Spider Angiomas (eg, small, dilated blood vessels with bright red centers), Gynecomastia, Testicular atrophy, and Palmar erythema are Expected findings in cirrhosis due to altered metabolism of hormone in the liver. Jaundice. Esophageal Varices. Itching (Can give Cholestyramine). 45 2 NCLEX RN STUDY GUIDE Macular Degeneration: (Age Related) Progressive, Incurable disease of the eye in which the Central Portion of the Retina, the macula, begins to deteriorate with Age. S/S: Distortion (Blurred or Wavy disturbances) or Loss of the Central field of Vision; the Peripheral vision remains Intact. "Dry" Macular Degeneration: occurs when the microvasculature supplying the macula is Blocked, causing Ischemia. "Wet" Macular Degeneration: Abnormal blood vessels form and eventually Destroy the macula. Magnetic Resonance Imaging (MRI): Claustrophobia, No Metal, assess Pacemaker. Malaria: Step Ladder like Fever with Chills. Koplick's Spots are red spots with blue center characteristic of Prodromal stage of Measles. Usually in mouth. Complications of Mechanical Ventilation: Pneumothorax, Ulcers. Meniere's Disease: Administer Diuretics to Decr. Endolymph in the Cochlea, Restrict Na+, lay on Affected ear Triad: N/V, Tinnitus (Excess fluid inside the inner ear), Vertigo. Drop attacks. Aural Fullness. Fall Precaution. Salt Restriction. Meningitis: CSF- High Protein, Low Glucose. Nuchal Rigidity, Photophobia. Kernig’s Sign : Leg flex then leg Pain on extension. Brudzinski Sign : Neck flex; Lower Leg flex. Lumbar Puncture : pt is Positioned in Lateral Recumbent Fetal position. Post: Lay Flat Supine (4~12 hrs as prescribed), to prevent HA and Leaking of CSF. Sterile Dressing Applied, Frequent Neuro Assessments (q15-30 until stable). Encourage Fluids. Metabolic Acidosis: Diarrhea (Poo Bases) 2 Metabolic Alkalosis: Respiratory Acidosis: 46 NCLEX RN STUDY GUIDE Vomitus (Throwing up Acids) Respiratory Alkalosis: Hyperventilation (Blowing off CO2) In pH Regulation the Two Organs of concern are Lungs/Kidneys. Methicillin-Resistant Staphylococcus Aurea (MRSA): use Chlorhexidine wipes. 1.3- 2.1 mEq/L HyperMg: Depress CNS, Hypotension, Facial flushing, Muscle weakness, Absent deep tendon reflexes, Shallow respirations, Emergency (Can result in Cardiac Arrest!) HypoMg: Tremors, Tetany, Seizures, Depression, Confusion, Dysphagia; Dig Toxicity, Dysrhythmias (Torsades de Pointes) Multiple Myeloma (Blood Cancer): Bence-Jones Protein in the Urine Diagnose & Confirms. Forms from WBC (Plasma Cell) Malignant. Multiple Sclerosis: Chronic, Progressive disease with demyelinating lesions in the CNS which affect the White matter of the brain and spinal cord. Myelin Sheath Destruction, Disruption in nerve impulse conduction. S/S: Charcot’s Triad (NIS): Nystagmus, Intention tremor, Scanning or staccato speech. Bowel and/or Bladder Incontinence or Retention Hyperactive deep tendon reflexes, Vision changes, Fatigue and Spasticity. Motor S/S : limb weakness, paralysis, slow speech. Sensory S/S : numbness, tingling, tinnitus. Cerebral S/S : nystagmus, ataxia, dysphagia, dysarthria. Munchausen Syndrome: Psychiatric Disorder that causes an individual to Self-Inflict Injury or Illness or to Fabricate symptoms of physical or mental illness, in order to receive medical care or hospitalization. 47 2 NCLEX RN STUDY GUIDE Munchausen by proxy (MSBP): an Individual, typically a mother, Intentionally Causes or Fabricates illness in a child or other person under her care. Myasthenia Gravis: Disorder in the transmission of impulses from Nerve to Muscle Cell. Worsens w/ Exercise (Fatigue of voluntary muscles), Improves with Rest. Muscle stronger in the morning AM. Decrease in Receptor Sites for Acetylcholine. Since smallest concentration of ACTH receptors are in cranial nerves, expect fatigue and weakness in Eye, Mastication, Pharyngeal muscles. Descending muscle weakness (Not enough Acetylcholine), Bulbar Signs (Difficulty speaking or swallowing) Pyridostigmine: Incr. Muscle strength, give before meal AC. Neostigmine: Give to pt about 45 min. Before eating, so it will help with Chewing and Swallowing. Neostigmine/Atropine (anticholinergic)- Pancuronium Bromide (Antidote) Edrophonium/ Tensilon: Prevents the breakdown of the chemical acetylcholine, a neurotransmitter that nerve cells release to stimulate your muscles. (Acetylcholinesterase Inhibitor) Tensilon Test: To Confirm the Diagnosis; Positive if muscle is Improved. Myasthenia Crisis: a Positive reaction to Tensilon--will improve symptoms (Edrophonium) Cholinergic Crisis: Caused by Excessive medication (anticholinesterase). Stop Med. Giving Tensilon will make it Worse. Myocardial Infarction: Dead Heart Tissue Present. Crushing stubbing pain which Radiates to left shoulder, neck, arms, Unrelieved by NTG. Atypical symptoms (eg, Shoulder Pain, Nausea). ST Elevation. Unstable Angina : is Not relieved by NTG. Myocardial Ischemia : ST Depression. Angina: Low Oxygen to Heart Tissues (No dead heart tissues). Crushing stubbing pain Relieved by NTG. 50 Gastrointestinal upset (eg, dyspepsia, pain) can be reduced if the medicine is taken with food. 51 2 NCLEX RN STUDY GUIDE idney injury - long-term use is associated with kidney injury Hypertension and heart failure - can cause fluid retention, which can exacerbate conditions such as heart failure, cirrhosis/ascites, and hypertension Indomethacine: Tx of Arthritis (Osteo, Rhematoid, Gout), Bursitis, and Tendonitis. Use Cold for Acute pain (eg. Sprain ankle) and Heat for Chronic (Rheumatoid Arthritis) Guided imagery is great for Chronic Pain. When patient is in Distress, medication administration is Rarely a good choice. Statin (Anticholesterol med): must be given with Evening meal (most cholesterol is Synthesized by the Liver during the fasting state, at night). Contraindicated severe Liver or Muscle injury. Simvastatin, for hyperlipidemia, take on Empty stomach to enhance absorption, report any unexplained muscle pain, especially if fever. Ezetimibe: Inhibits the intestinal absorption of Cholesterol and is often Combined with a Statin to treat hyperlipidemia. After Myringotomy (Ear Tube): position on side of Affected Ear after surgery (allows drainage of secretions). Nasogastric (NG) Tube: connect the main lumen of the NG tube (using an adaptor) to the suction apparatus and leave the blue pigtail lumen Open to air to facilitate gastrointestinal decompression. Regular flushing of the NG tube with water prevents clogging and allows the suction apparatus a clear pathway to decompress the suction. An NG tube can be Irrigated with Cola, and should be taught to family when a client is going Home with an NG tube. Flush and Aspirate the tube w/ Warm water. Then try it w/ Digestive Enzyme Solution. Weighted Nasointestinal Tube: must float From Stomach to Intestine. Don't tape the tube right away after placement, may leave coiled next to pt on HOB. Position patient on Right to facilitate movement through Pylorus. 52 2 NCLEX RN STUDY GUIDE After G-Tube placement: the Stomach contents are Drained by Gravity for 24 hours Before it can be used for feedings. HyperNatremia: increased temp, weakness, disorientation/delusions, hypotension, tachycardia, hypotonic solution Skin flushed Agitation Low grade fever Thirst Hyponatremia: nausea, muscle cramps, increased ICP, muscular twitching, convulsion; osmotic diuretics, fluids NephrOtic Syndrome: is caused by glomerular damage, which allows the Leakage of Proteins into urine. S/S: Generalized edema, Weight gain (fluid overload), Hypotension, massive Proteinuria (urine looks dark and frothy), Hyperlipidemia, Albuminuria, Hypoalbuminemia. WBC shift to the left in a patient with Pyelonephritis (Neutrophils kick in to fight infection) Turn and Reposition (risk for impaired skin integrity) Tx: Corticosteroids (In general are started at High Dose & Slowly Tapered to Reduce the Risk of Sudden Adrenal Crisis. Glomerulonephritis: take VS q 4hr and daily weights. Consider BP to be your most important assessment parameter. Dietary Restrictions: Fluids, Protein, Na+, K+. Gross Hematuria (Expected) IVP: requires Bowel Prep so they can Visualize the Bladder better. A Laxative is given the night before in order to better visualize the organs. Acute Glomerulonephritis (AGN): 55 Chronic Pancreatitis, Pancreatic Enzymes are given with meals. 56 2 NCLEX RN STUDY GUIDE fter pain relief, Cough and Deep breathe. Bc of fluid pushing up in the Diaphragm. Beta Cells of pancreas produce Insulin. TPN (Total Parenteral Nutrition): given in Subclavian line. Turner’s sign : flank grayish blue (turn around to see your flanks) pancreatitis. Cullen’s Sign : Ecchymosis in Umbilical area. (+) Grey turners spots. ARDS is the most Severe form of these complications and can rapidly progress to respiratory failure within a few hours. The presence of Inspiratory Crackles in this client could indicate early ARDS and needs to be assessed further for progression. Parkinson: (RAT): Rigidity, Akinesia (loss of muscle), Pill Rolling Tremors. Carbidopa/Levodopa: Dry Mouth, Postural Hypotension, Psychosis, Reddish -brown Urine. Causes Drowsiness. Contraindicated: Pt with glaucoma, Avoid B6. Also Contraindicated with MAOI's Trihexyphenidyl: Treat Stiffness, Tremors, Spasms, Poor muscle control. Also Sedative effect. Benztropine Injection: Extrapyramidal effects of other drugs. Ropinirole, Pramipexole: Sleep attacks, Extreme Drowsiness. Pemphigus Vulgaris (Autoimmune): Painful Blistering on the Skin and Mucous Membranes. Nikolsky’s Sign: Separation of epidermis caused by rubbing of the skin. (Blister) Pericarditis: Inflammation of Visceral and/or Parietal Pericardium. Cardiac Output is Diminished. S/S: Pericardial Friction Rub, Pleuritic Chest Pain (Sharp), Aggravated during Inspiration & Coughing, Fever, Leukocytosis, ST-segment Elevation. Lean Forward : will pull the heart Away from the lungs, Preventing Pericardial Irritation caused by friction and contact with the lungs. Tx: NSAID/ ASA & Colchicine (Gout med). Pericardiocentesis: a procedure where fluid is Aspirated from the Pericardium. Positioned the pt Supine with the HOB 30O ~ 60O. Complication: Cardiac Tamponade (Paradoxical Pulse). 57 2 NCLEX RN STUDY GUIDE Cardiac Tamponade : (Beck’s Triad) Hypotension, Muffled Heart Sounds, Distended Neck Veins. Paradoxical Pulse: Stroke Volume or Sbp > 10mmHg during Inspiration. PVD remember DAVE (Legs are Dependent for Arterial & for Venous Elevated) EleVate Veins; dAngle Arteries for better perfusion. Pheochromocytoma (PCC) (Benign Tumor on the Adrenal Gland/Medulla): Hypersecretion of Epi/Norepi, persistent HTN, Tachycardia, Palpitations, Hyperglycemia, Diaphoresis, Tremor, Pounding HA; Stress, Frequent rest breaks, Avoid Cold and Stimulating foods. Weight loss Tx: Surgery to remove Tumor Adrenal Medulla : Secrete Catecholamine (Epinephrine and Norepinephrine) and Dopamine. Adrenal Cortex: Secrete Glucocorticoids (Cortisol), Mineralocorticoids (Aldosterone), Androgens (Testosterone) Anterior Pituitary Gland: Prolactin, Growth Hormone, ACTH, Follicle-Stimulating Hormone (TSH), Thyroid-Stimulating Hormone (TSH), Luteinising Hormone (LH), Melanocyte-Stimulating Hormone (MSH). Posterior Pituitary Gland: ADH and Oxytocin. Removal of Pituitary Gland, watch for Hypocortisolim and Temporary Diabetes Inspidus . Polycythemia: Elevated Hgb levels and Hct levels. Compensatory mechanism due to prolonged tissue hypoxia. Increase Blood Viscosity (risk for stroke or thromboembolism). Tx: Hydration. Polycythemia Vera (PV): Slow growing Blood Cancer. Chronic Myeloproliferative Disorder. Incr. RBC. 60 2 NCLEX RN STUDY GUIDE se ABC’s & Maslow for Priority Need Bleeding is part of the ‘Circulation’ assessment of the ABCD’s in an Emergent Situation. Therefore, if Airway and Breathing are accounted for, a compound fracture requires assessment before Glasgow coma scale and a neuro check (D=disability, or Neuro check) Priapism: Painful Erection lasting longer than 6 hrs. Promethazine (an antihistamine): used to treat Allergic reactions and to treat or prevent Nausea and Vomiting from illness or motion sickness. It is also used to make you Sleep before surgery, and to help treat Pain or Nausea after surgery. AntiPsychotic Medications: Typical: Chlorpromazine/Thorazine, Haloperidol, Thiothixene. First Generation Med. Can cause Extrapyramidal Symptoms (Motor control). More Side Effects. Fewer Withdrawal. Atypical: Aripiprazole/Abilify, Clozapine, Olanzapine, Quetiapine, Risperidone, Ziprasidone. Clozapine: agranulocytosis, tachycardia and seizures. Tx Severe Schizophrenia. Don’t Mix antipsychotics with Caffeine and Apple juice. Haloperidol: Preferred antipsychotic in Elderly. Monitor for early signs of EPS and give IM Benadryl. Risperidone: Doses over 6mg can cause Tardive Dyskinesia, first line antipsychotic in Children All Psych meds (except Lithium) side effects are the same as SNS but the BP is decreased. SNS: Increase in BP, HR and RR (dilated bronchiole), dilated pupils (blurred vision), Decreased GUT (urinary retention), GIT (constipation), Constricted blood vessels and Dry mouth. New Generation Med. Less likely to cause EPS. Less Side Effects. More withdrawal. ExtraPyramidal Symptoms (Motor Control): Parkinsonism, Dystonia, Akathisia (Motor restlessness), Tardive Dyskinesia (Protrusion of the tongue, Difficulty Swallowing) 61 2 NCLEX RN STUDY GUIDE ardive Dyskinesia (Irreversible): Involuntary movements of the tongue, face and extremities, may happen after prolonged use of antipsychotics Akathisia (Motor restlessness): Need to keep going, tx with antiparkinsons meds, can be mistaken for agitation. Tx: With Anticholinergics (Benztropine, Trihexyphenidyl, and Diphenhydramine/ Antihistamine) Neuroleptic Malignant Syndrome (NMS): Life-Threatening Condition! S/S: Hyperpyrexia (High fever), Stiff (increased muscle tone/ muscle rigidity), Diaphoresis, Incr. BP, Incr. pulse, Incr. respirations, Drooling, Altered mental status, Caused by : Antipsychotic Meds. Cognitive therapy: Counseling Crisis intervention: Short term. Five Interventions: Safety, Set limits, Establish trusting relationship, Meds, Least restrictive methods/environment. Hallucinations: Redirect them; In Delusions Distract them. Milieu therapy: Taking care of patient/environment Obsession is to Thought. Compulsion is to Action Phobic Disorder: use Systematic Desensitization. Lithium: Mood Stabilizer. (Therapeutic affect is 0.6-1.2mmol/L). It is salt preparation & replaces Na+ in the cells. Risk for Dehydration, Decr. Renal Function (elderly pt). Drug-drug interactions (eg, NSAIDS and thiazide Diuretics). Tx: Hydrate 2~3L of H2O; Maintain Na+ 2~3g/day. Low Na+ diet will precipitate Li+ toxicity (> 1.5). Chronic Toxicity (Toxic Level is 2-3mmol/L): N/V, diarrhea Neurologic manifestations: Ataxia, Confusion or Agitation, and Neuromuscular Excitability (Tremor, Myoclonic Jerks) 62 2 NCLEX RN STUDY GUIDE ephrogenic Diabetes Insipidus : Polyuria and Polydipsia (increased thirst) Tx: Mannitol and Acetazolamide Atelectasis (Diminished Lung Sounds): Common Complication after Heart Surgery. Encourage Deep Breathing. Fine crackles are a series of distinct, discontinuous, and high-pitched snapping sounds usually heard on inspiration. The sound originates as small atelectatic bronchioles quickly reinflate and can be expected in clients who have undergone abdominal surgery due to shallow breathing related to pain. Although the presence of fine crackles requires treatment (eg, ambulation, deep breathing). Fremitus: Palpable vibration felt on the chest wall. Sound travels faster in solids (Consolidation) than in an aerated lung, resulting in increased fremitus in pneumonia. The presence of egophony, bronchophony, or whispered pectoriloquy also suggests a consolidative process. Fluid or air outside the lung interrupts the transmission of sound, resulting in decreased fremitus in Pleural effusion and Pneumothorax. Hemothorax: Collection of Blood in the Pleural Space. Risk of Empyema. 65 2 NCLEX RN STUDY GUIDE ormal Pulmonary Artery Wedge Pressure (PAWP): 6-12 mmHg. Normal Pulmonary Capillary Wedge Pressure (PCWP): Left Ventricular Preload. is 8-13. Readings of 18-20 are considered High. Normal Central Venous Pressure (CVP): Right Ventricular Preload. 2-8 mmHg. Normal Tidal Volume : 7 – 10mL/kg Ambient Air (Room Air) contains 21% oxygen. Radial Arterial Line: Risk for hemorrhage, could lose a large amount of arterial blood in a short period of time. Low Pressure Alarm: Could be Hypotension/ Disconnected Tubing. Phlebostatic Axis: Midaxillary Line at 4th Intercostal Space. If your Normally Lucid patient starts Seeing Bugs you better check his Respiratory Status First. Signs of Hypoxia: Restless, Anxious, Cyanotic, Tachycardia, Increased Resp. (also monitor ABG's) The First Sign of Hypoxia is Restlessness, followed by Agitation, and things go Downhill from there all the way to Delirium, Hallucinations, and Coma. So check the O2 Stat, and get ABG’s if possible. Lung Biopsy: Position pt Lying on Side of bed or with arms Raised up on pillows over bedside table, have pt Hold Breath in Midexpiration, Chest X-ray done Immediately Afterwards to check for Complication of Pneumothorax, Sterile Dressing Applied. Pulmonary Sarcoidosis: leads to Right sided heart failure. During Internal Radiation: on Bedrest while Implant in place. Criteria for Activating Rapid Response Team: (Any Staff can Call) (Acute Change) HR < 40/min or > 130/min 2 BP < 90mmHg RR < 8/min or > 28/min 66 NCLEX RN STUDY GUIDE O2 < 90% despite O2 Urine Output <50mL in 4 hours Change in LOC Recovery Position: for unconscious pt who is still breathing. Side Position (Prone) w/ top leg Flexed. Detached Retina: area of detachment should be in the Dependent position. S/S: Curtain appearing in the vision/ Shadow, loss of vision, Visual Floaters, Flashes of light Rhabdomyolysis: breakdown of muscle tissue that leads to the release of myoglobin/ muscle fiber contents into the blood. These substances can be harmful to the Kidney. Medical Emergency. Rapid IV Fluid Resuscitation to presume kidney function. Rocky Mountain Spotted Fever: transmitted by Ticks. Most common Rickettsial Disease Start with a Fever, HA, Myalgia (muscle pain), a Maculopapular Rash (develops 2 ~ 6 after the onset of the fever) that begins on the wrists and ankles and spreads Centripetally to the trunk. Rotavirus: Contagious Virus. Leading cause of Diarrhea (<5yo). Spread via Fecal-Oral Route. Breast feeding should be maintained. Scabies: Lindane/Kwell: tx of Scabies and Lice. Scabies- apply Lotion once and leave on for 8-12 hours. Lice- use the Shampoo and leave on for 4 minutes with hair uncovered then rinse with warm water and comb with a fine tooth comb. 67 2 NCLEX RN STUDY GUIDE cleroderma: Overproduction of Collagen. No Cure. Tx: Control Symptoms. Prevent Further Complications. Sedation: Midazolam/Versed (Benzodiazepine): given for Conscious Sedation. Risk for Resp. Depression & Hypotension. Diazepam (Benzodiazepine): commonly used tranquilizer given to reduce Anxiety before surgery. Four Side-Rails Up: can be considered a form of restraint. Even in LTC facility when a client is a fall risk, keep lower rails down, and one side of bed against the wall, lowest position, wheels locked. Seizure: Phenytoin: Drug Level 10-20. Should Not Stop abruptly. Stop the feeding for 1 to 2 hours before and after administering phenytoin as products containing Ca2+ (eg, antacids, calcium supplements) and/or nutritional enteral tube feedings can Decr. absorption. Flushing the tube with 30-50 mL of water before and after. Can cause Liver damage. Monitoring of Liver function test. (Yellow of the skin) Can cause Gingival Hyperplasia, maintain Oral hygiene. Rash. Stop med. Oral contraceptives effectiveness is Decr., use alternative birth control methods. Teratogenicity. IV Phenytoin can cause Hypotension and Arrhythmias (Bradycardia) Phenytoin Toxicity : Nystagmus, Diplopia, Slurred Speech, Rash, Dizziness, Nausea, Ataxia (Gait Unsteadiness & Coordination), Lethargy, Coma. Carbamazepine: Can be used for Trigeminal Neuralgia (CN V) for Neuropathic Pain. Associated w/ Agranulocytosis (Leukopenia). Risk for Infection. Don’t take with Grapefruits Valproic Acid : Seizure (epilepsy) and Bipolar med. 2 Anaphylactic Shock: 70 NCLEX RN STUDY GUIDE has an acute onset, and manifestations usually develop quickly (20-30 minutes). Caused by a systemic IgE-mediated hypersensitivity allergic reaction to drugs, foods, and venom. Results hypotension and respiratory manifestations, including laryngeal edema (from inflammation) and bronchoconstriction (primarily from release of histamine); these can lead to cardiac and respiratory arrest. Tx: Maintain Airway & Breathing (High Flow O2). Elevate legs. Volume Resuscitation w/ IV Fluids. Albuterol. Antihistamine/ Diphenhydramine. Corticosteroids. Epinephrine: Always given in TB Syringe (IM). Norepinephrine: Vasopressor used to Increase Stroke Volume, Cardiac Output, and MAP. Titrating a norepinephrine infusion upward to maintain the MAP within normal limits (>65 mm Hg). Remember the action of Vasopressin because it sounds like “Press In”, or VasoConstriction. Hydroxyzine (Antihistamine): Use for itching or hives. Also used as a Sedative to treat Anxiety. Give to PreOp (Commonly). S/S: Dry Mouth. Basophils: release Histamine during an allergic response. Sickle Cell Crisis: Two Interventions to Prioritize: Fluids & Pain Relief & Folic Acid/ Blood Transfusion. Maintain Bed Rest. Do Not give Demerol. Hydroxyurea (chemotherapy drug): report GI symptoms immediately, could be Sign of Toxicity. Help to Prevent Formation of Sickle-Shaped RBC. Vasocclusive Crisis : Leads to Ischemia & Severe Pain. Bilirubin released, results in Jaundiced brownish hue to the urine. Stomas: Dusky stoma means Poor blood supply. Protruding means Prolapsed. Mucus in Ileal Conduit is Expected. Change in color is always a Late sign. Peritonitis: Sharp pain & Rigidity. 71 2 NCLEX RN STUDY GUIDE neumococcal Vaccine / Pneumovax 23 gets administered Post-Splenectomy to prevent Pneumococcal Sepsis. Streptococcal Pharyngitis (Strep Throat): can lead to Glomerulonephritis/ Rheumatic Fever. 24hr After Starting Antibiotic, can Return to school. Rheumatic Fever : can Lead to Cardiac Valves Malfunctions. Group A Strep Precedes Rheumatic Fever. Chorea (Neurological Disorder) is part of this sickness (Grimacing, Sudden Body Movements, etc.) and it Embarrasses kids. They have Joint Pain. Watch for Elevated AntiStreptolysin O (ASO). Tx: Penicillin. Systemic Lupus Erythematosus (SLE): Butterfly rashes. Leukopenia (WBC < 4,000) & (Serious Complication) Thrombocytopenia Lupus Nephritis : Plat < 150,000 & Incr. Cr & Incr. BUN. Hypertension: Secondary HTN have Identifiable causes. A newly diagnosed hypertension patient should have BP assessed in Both arms. Angiotensin II in the lungs: potent Vasodilator. Aldosterone attracts Sodium. Hydralazine (vasodilator): Tx of HTN or CHF. Report Flu-like symptoms, Rise slowly from sitting/lying position; Take with meals. Verapamil (Ca2+ Channel Blocker): affects the Afterload. Diltiazem Tx: HTN, Angina. S/S: Constipation, Gingival Hyperplasia, Edema, Fatigue, Dizziness, HA. For afib pt, to Decr. Ventricular Rate to Prevent Stroke. Hypertension Emergency: SBP> 180mmHg, DBP> 120mmHg Hypotension: 72 2 NCLEX RN STUDY GUIDE opamine (Intropine): Tx of Shock, Low Cardiac Output, Poor Perfusion to vital organs. Hypotension due to bradycardia. Monitor EKG for Arrhythmias, Monitor BP. Hypotension and Vasoconstricting Meds may alter the Accuracy of O2 Saturation. Tetanus: Risus Sardonicus (spasm of facial muscles, grinning), Trismus (Lockjaw), Spasms of the Jaw, and Arching of the back. After SupraTentorial Surgery (incision Behind hairline): Elevate HOB 30-45 degrees After InfraTentorial Surgery (incision at Nape of neck): position Flat and Lateral on either side. Malignant HyperThermia: S/S: Tachypnea, Tachycardia, Rigid Jaw (generalized rigidity), Muscle stiffness, Hypercapnia (excess), Incr. K+, Incr. Temp. Triggered by: PeriOperative setting in response to Anesthesia. Dantrolene Sodium (Muscle Relaxant): for Spasticity, may take a Week or more to be effective. HypoThermia: Medical Emergency. Alterations in acid-base balance, coagulation values, and cardiac function may also occur; can lead to Cardiac and Respiratory Failure and Coma. Should anticipate a workup for Sepsis and various types of Shock. S/S: Core Temp (eg, rectal) < 95 F (35 C), Mental status changes, Shivering, and Impaired coordination. HyperThyroidism: Elevated T4, Low TSH level. Graves’ Disease: Accelerated physical and mental function; sensitivity to heat. Fine/soft hair. Exophthalmos. Elevated T4, and Low TSH (the pituitary gland will try to compensate for excess T3 and T4). Thyroid Storm: Trigger by Stress Event. Life-Threatening! S/S: Tachycardia, Fever, Cardia Dysrhythmia (A. Fib), n/v, Diarrhea, Altered Mental Status/Confusion, Seizure, and HTN (Thyrotoxicosis) 2 Triage: 75 NCLEX RN STUDY GUIDE In an emergency, patients with Greater chance to live are treated First Triage the person who is most likely to Not survive Last. Red (Immediate): Injuries are Life-Threatening but survivable with Minimal intervention. Ex: Hemothrax, Tension Pneumothorax, Unstable Chest and Abdominal Wounds, Incomplete Amputations, Open Fx's of Long Bones, Occluded Airway, Actively Bleeding. 2nd/3rd degree Burn w/ 15%-40% of total body surface. Yellow (Delayed): Injuries are Significant, Require Medical Care, but can Wait Hours w/o Threat to Life/Limb. Ex: Stable Abd Wounds w/o evidence of hemorrhage, Fx requiring open reduction, debridement, external fixation, most Eye and CNS injuries, Burns. Green (Minimal): Injuries are Minor and Treatment can be Delayed to Hours or Days. Individuals in this group should be Moved Away from the main triage area. Ex: Upper Extremity Fx, Minor Burns, Sprains, Small Lacerations, Behavior Disorders. "Walking Wounded" Black (Expectant): Injuries are Extensive and Chances of Survival are Unlikely. Separate but Don’t Abandoned, Comfort Measures if possible. Ex: Unresponsive, Spinal Cord Injuries, Wounds with Anatomical Organs, Seizures, Profound Shock with Multiple Injuries, No Pulse/ BP, Pupils Fixed or Dilated. Head Injury w/ Fixed Pupils. Broken neck w/ Agonal Breaths. 2nd/3rd degree Burn with 60% of body surface area. DOA: Dead on Arrival Orange: NON-Emergent Psych Tuberculosis (TB): If a TB patient is Unable/Unwilling to Comply with Tx they may need Supervision (Direct Observation). TB is a public health risk. PPD is positive if area of induration is: >5 mm in an immunocompromised patient >10 mm in a normal patient 76 >15 mm in a patient who lives in an area where TB is very rare. 77 2 NCLEX RN STUDY GUIDE ositive ppd Confirms Infection, not just exposure. Sputum Test will Confirm Active Disease. Pulmonary TB : Low-grade afternoon Fever. Isoniazid (INH): Do Not give with Phenytoin. Can cause Phenytoin Toxicity. Monitor LFT's. (Hepatotoxic) Can cause Peripheral Neuritis , take Vit B6 with it. Hypotension will occur initially, then resolve. R ifampin & Rifapenine : (Bactericidal) Red orange Tears and Urine, also Oral Contraceptives don't work as well. Take it with Meals. E thambutol : messes with your Eyes. TB drugs are Liver Toxic. (Does your patient have hepB?) Adverse reaction is Peripheral Neuropathy. Pulmonary TB: Low-grade Afternoon Fever. Tube Feeding w/ Decr. LOC: position pt on Right side (promotes Emptying of the Stomach) w/ HOB Elevated (to Prevent Aspiration) Critically Ill clients are at Increased risk for Aspiration of oropharyngeal secretions and gastric content; Administering Continual rather than Bolus tube feeding. Other than Initially to Test Tolerance, G-tube and J-tube feedings are usually given as Continuous feedings. Typhoid: Rose Spots in Abdomen. Ulcerative Colitis: Recurrent Bloody Diarrhea Varicella: Very Contagious disease caused by the Varicella-Zoster Virus (VZV). It causes a Blister-like Rash, Itching, Tiredness, and Fever. Vesicular Rash (Central to Distal) dew drop on rose petal Ventilator Alarms: HOLD High alarm- Obstruction due to Incr. Secretions, Kink. (pt Coughs, Gag or Bites) Low press alarm- Disconnection or Leak in ventilator or in pt. airway cuff, pt. Stops Spontaneous Breathing 2 80 NCLEX RN STUDY GUIDE 2 81 NCLEX RN STUDY GUIDE Active Labor: First Action is to Listen to Fetal Heart Tone/Rate. Never check the monitor or a machine as a first action. Always Assess the patient First. 82 2 NCLEX RN STUDY GUIDE isten to the Fetal Heart Tones with a Stethoscope in NCLEX land. Sometimes it's hard to tell who to check on first, the mother or the baby; it's usually easy to tell the right answer if the mother or baby involves a machine. If you're not sure who to check first, and one of the choices involves the Machine, that's the Wrong answer. Perform Amniocentesis Before 20 weeks gestation to check for Cardiac and Pulmonary abnormalities. Amniotic Fluid is Alkaline, and turns Nitrazine paper Blue. Urine and normal Vaginal Discharge are Acidic, and turn it Pink. Yellow Amniotic Fluid with Particles: Meconium-Stained. Betamethasone (Corticosteroid): Causes Immature Fetus's Lungs to Produce Surfactant; to Speed up a preterm fetus's lung development. Caput Succedaneum: Diffuse Edema of the Fetal scalp that Crosses the Suture lines. Swelling Reabsorbs within 1 to 3 days. Patient with a Vertical C-section Surgery will more likely have another C-section. Treatment for Torsades de Pointes and Seizures associated with Eclampsia: Mg2+ Preeclampsia: Headache, Visual Disturbances, and Facial Swelling. Complications of Preeclampsia may include Thrombocytopenia, Liver Dysfunction, and Renal Insufficiency. HELLP Syndrome: Severe form of Preeclampsia. Hemolysis, Elevated Liver enzymes, Low Platelets. S/S: RUQ Pain/ epigastric pain, n/v, malaise. Complication: Placental Abruption, Liver failure, Stroke, Maternal/Fetal death. Hypotension, Bradypnea, Bradycardia are Major Risks and Emergencies. 85 2 NCLEX RN STUDY GUIDE If the baby is a Posterior Presentation, the Sounds are heard at the Sides. If the baby is Anterior, the Sounds are heard closer to Midline, between the Umbilicus and Sides. If the baby is Breech, the Sounds are High up in the Fundus near the Umbilicus . If the baby is Vertex, they are a little bit Above the Symphysis Pubis . RhoGAM: given at 28 weeks & 72 hours Post Partum, IM. Only given to Rh Neg. Mother. Rh- mothers receive RhoGAM to Protect Next baby. Positive Indirect Coomb’s Test: Don’t Need to give RhoGAM bc she has antibody. Negative Coomb’s Test: Need to Give. Never get pregnant with a German Measles (Rubella). “bella” No MMR (Live Vaccine). Shoulder Dystocia: baby Cannot make it down to canal. Nursing actions to Improve Fetal Perfusion and Oxygenation include: Discontinue Uterotonic Drugs (eg, oxytocin [Pitocin]) to Reduce Uterine Activity- First Action Change the Maternal Position to the Left side to Relieve Compression of the Inferior Vena Cava Administer Oxygen at 8-10 L/min via nonrebreather face mask 86 2 NCLEX RN STUDY GUIDE ive prescribed intravenous (IV) bolus of Lactated Ringer's or Normal Saline Notify the HCP Woman in Labor w/ Non-Reassuring FHR (Late Decels, Decreased Variability, Fetal Bradycardia): Turn On Left side (and give O2, stop Pitocin, Increase IV fluids). For Cord Compression, place the mother in the Trendelenburg Position because this Removes Pressure of the presenting part off the cord. (If her head is down, the baby is no longer being pulled out of the body by gravity). Prolapsed Cord (Umbilical cord comes out of the Uterus): Knee-Chest position or Trendelenburg. Cover it with Sterile Saline Gauze to Prevent Drying of the cord and to Minimize Infection. If the Water Breaks and she is Any Minus Station, there is a Risk of Prolapsed Cord . For Late Decels, turn the mother to her Left side, to allow More Blood flow to the Placenta. For any kind of Bad Fetal Heart Rate Pattern, you give O2, often by mask. 2 87 NCLEX RN STUDY GUIDE 2 1 0 Appearance (Color) all pink pink and blue blue/pale Pulse >100 < 100 absent Grimace cough grimace no response Activity/Refle x Irritability flexed flaccid limp Respirations strong cry weak cry absent Normal: 8~10 Give O 2: 4~7 Require Rescue : 0~3 Babinski Sign: Toes fan out. Disappear around 1 years-old. Bacterial Meningitis is inflammation of the meninges of the brain and spinal cord caused by infection. General manifestations in infants and children age <2 include Fever, possible hypothermia, Restlessness, Irritability frequent Seizures, High-Pitched Cry, Poor Feeding and Vomiting, and Nuchal Rigidity. 90 2 NCLEX RN STUDY GUIDE Barium Enema : may be used to Hydrostatically Reduce the Telescoping. Resolution is Obvious, with Onset of Bowel Movements. Developmental: 2-3 months: turns Head Side to Side 4-5 months: Grasps, Switch & Roll 6-7 months: Sit at 6 and Waves bye- bye 8-9 months: Stands Straight at 8 10-11 months: Belly to Butt (phrase has 10 letters) 12-13 months: twelve and up, Drink from a Cup Birth Weight: Doubles by 6 month and Triple by 1 year of age. Head and Chest Circumference are Equal. Able to sit down from a standing position WithOut assistance. Lower Central Incisors usually between age 6-10 months. The following is a quick assessment formula to calculate the expected # of teeth during the first 24 months: Age of child (in months) – 6 = Expected number of teeth A 12-month-old should have approximately 6 teeth, and by age 30 months all primary teeth (20) should have erupted. Stranger Anxiety is greatest 7 - 9 months. Separation Anxiety peaks in Toddlerhood: Protest, Despair, Detachment. Toddlers need to express Autonomy (Independence) If you gave a Toddler a Choice about taking medicine and he says No, you should leave the room and come back in five minutes, because to a toddler it is another episode. Next time, don’t ask. 91 2 NCLEX RN STUDY GUIDE Years- old kids Cannot interpret Time. Need to explain time in relationship to a known Common Event (eg: "Mom will be back after supper"). School-age kids (5 and up) are old enough, and should have an Explanation of what will happen a week before surgery such as tonsillectomy. An Ill child Regresses in Behaviors BSA is considered the Most Accurate Method for Medication dosing with kids Interpersonal model (Sullivan): Behavior motivated by need to Avoid Anxiety and Satisfy Needs 1. Infancy 0-18 months others will satisfy needs 2. Childhood >6yrs learn to delay need gratification 3. Juvenile 6-9 years learn to relate to peers 4. Preadolescence 9-12 yrs learns to relate to friends of opposite sex 5. Early adolescence12-14yrs:learn independence and how to relate to opposite sex 6. Late adolescence 14-21yrs: develop intimate relationship with person of opposite sex is this not about communication. HR is <100 do not give Digoxin to children. Duchenne’s Muscular Dystrophy: Gowers’ Sign. Use of hands to Push one’s self from the floor. Assess Resp. Pull Pinna Down and Back for kids < 3 yrs. when Instilling Eardrops. 92 2 NCLEX RN STUDY GUIDE etal Alcohol Syndrome: Intellectual disability and Developmental delay. Growth deficiency (Small for Gestational age), Neurological symptoms (eg, Microcephaly), or specific facial characteristics (indistinct Philtrum, Thin upper lip, Epicanthal folds, Flat midface/nasal bridge, and Short palpebral fissures) Greek Heritage: they put an Amulet or any other use of Protective Charms around their baby's neck to avoid "evil eye" or envy of others. Heart defects. Remember for Cyanotic -3T’s (ToF, Truncus Arteriosus, Transposition of the great vessels). Prevent blood from going to heart. If problem does not fix or cannot be corrected surgically, CHF will occur following by death. CHF in an Infant: watch for Tachycardia, Not Cough. Congenital Cardiac Defects result in Hypoxia which the body attempts to Compensate for (Influx of Immature RBC). Labs supporting this would show Increased Hematocrit, Hemoglobin, and RBC count. Prolonged Hypoxemia is a likely Cause of Cardiac Arrest in a child. In a Five-year old: Breathe once for every 5 compressions doing CPR. Hypercyanotic Spell (Tet spells): Treated with Morphine, Calm the child, Oxygen. Coarctation of the Aorta (Narrowed Aorta): Causes Incr. Blood Flow and Bounding Pulses in the arms. Elevated Pulse Pressure in the Upper extremities. Diminished Pressure in the Lower extremities. Patent Ductus Arteriosus (PDA): Machine like Murmur. Systolic. Poor feeding. Tetralogy of Fallot: Children will exhibit Bluish skin during episodes of Crying or Feeding. Ventricular Septal Defect : Excess blood to the Lungs. Higher pressure (L) to Lower pressure (R), Incr. Pulmonary Blood Flow (Pulmonary Congestion) Risk for CHF & Pulmonary HTN. 95 Subacute - Skin begins to Peel from the hands and feet. The child remains very irritable. 96 2 NCLEX RN STUDY GUIDE kin discomfort can be eased with Cool compresses and Lotions. No treatment is needed, but the new skin might be very tender. Convalescent - symptoms disappear Slowly. The child's temperament returns to normal. Systemic Vasculitis : Irritablity, Knee Pain, Skin Peeling. Tx: IV Gamma Globulin (IVIG) and AcetylSalicylic Acid (ASA) to prevent Coronary Artery Aneurysms. IVIG (IV Immunglobulin) creates high plasma oncotic pressure, and signs of fluid overload and pulmonary edema develop if it is given in large quantities. Monitored for symptoms of Heart Failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing). No Live Vaccine 11 months after receiving IVIG. AcetylSalicylic Acid (ASA) can cause Reye’s syndrome (Encephalopathy- Swelling of the Liver and Brain), when given to Children. Lead Poisoning Test: around 12 months of age. Anemia with Milk-aholics: Too much Milk Reduces Intake of other Essential Nutrients, Especially Iron. Mother should Not put anything But Water in that kid’s bottle During naps/over-night. Juice or milk will Rotten that kids Teeth right out of his head. Watch out for questions suggesting a child drinks More than 3-4 cups of milk each day. It is essential to Maintain Nasal Patency with children < 1 yr. because they are Obligatory Nasal Breathers . Neonatal Abstinence Syndrome: Autonomic Nervous System Symptoms : stuffy nose, sweating, frequent yawning and sneezing, tachycardia, and tachypnea. Tx: swaddling and keeping nasal passages clear. Central Nervous System Symptoms : irritability, restlessness, high-pitched crying, abnormal sleep pattern, and hypertonicity/hyperactive primitive reflexes. Tx: medication and protecting the skin. Gastrointestinal symptoms – poor feeding, vomiting, and diarrhea. 97 2 x: small, frequent feedings NCLEX RN STUDY GUIDE With Omphalocele (Sealed by Peritoneal Layer) and Gastroschisis (No Peritoneal Layer): (Herniation of Abdominal Contents) Dress with Loose Saline Dressing covered with Plastic Wrap, and keep eye on Temp. Kid can Lose Heat quickly. Parvovirus B19 (Contagious): Fifth disease causes a distinctive red rash on the face that makes a child appear to have a "slapped cheek.". Pertussis (Whooping Cough): Highly Contagious Respiratory disease and requires Droplet Precautions. Can be Deadly if contracted in infancy Before Vaccination is started. This client should be placed in Isolation Immediately to Prevent the spread of disease. S/S: Paroxysms of Rapid Coughing that lead to Vomiting (can Last up to 6 weeks) Tx: can be Prevent w/ DTaP. If pt already have Pertussis, treat with Abx Therapy. Preterm Newborns: Lanugo: fine, downy hair found mostly on the backs and shoulders of, begins disappearing around 36 weeks gestation. Smooth, pink skin with visible veins as Skin is Thin and Transparent with Lack of Subcutaneous Fat. Areolae are barely visible, with No raised breast buds. Very smooth Soles with only Faint red marks or possibly a Single Anterior Transverse Crease. Undescended Testes, palpable in the Upper Inguinal Canal. Lungs are not fully developed. Incr. the Risk for Acute and Chronic Respiratory Illnesses. Low Birth Weight. May cause Delays in growth patterns, must "catch up" in their developmental milestones. PhenylKetonUria (PKU): When Phenylalanine Increases, Brain problems occur. No Phenylalanine with a kid Positive for PKU (no Meat, no Dairy, no Aspartame).