NCLEX

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TomWruble
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258973
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NCLEX
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2014-02-26 12:55:51
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NCLEX
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NCLEX
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  1. The nurse cares for a client 24 hours after a right pneumonectomy due to cancer. The client’s wife reports that the   client drinks a fifth of vodka daily. The nurse reports to the physician the client is restless, agitated, and irritable. The physician orders chlorpromazine (Thorazine), 25 mg IM now. Which of the following actions should the nurse take FIRST?

    A. Administer the medication as ordered.
    B. Continue to monitor the client.
    C. Ensure that the lights are on in the client’s room.
    D. Contact the physician.
    D. Contact the physician.

    Strategy: Think about the outcome of each answer.

    1) Thorazine is an antipsychotic/antiemetic; client has symptoms of alcohol withdrawal, contact the physician

    2) CORRECT— client has symptoms of alcohol withdrawal; other symptoms   include tremors, insomnia, alcoholic hallucinations; administer sedation as needed, monitor vital signs, seizure precautions;   place client in a quiet, well-lit room

    3) contact the physician regarding the order; usually administer benzodiazepines

    4) appropriate action; priority is to question the order
    (this multiple choice question has been scrambled)
  2. The nurse cares for a client receiving haloperidol (Haldol) by intramuscular injection. The client develops a fever of 103.6°F (40°C), pulse 110, muscle rigidity, and incontinence. The nurse knows that the client is experiencing which of the following?

    A. Tardive dyskinesia.
    B. Pseudoparkinsonism.
    C. Acute dystonic reaction.
    D. Neuroleptic malignant syndrome.
    D. Neuroleptic malignant syndrome.

    Strategy: Think about each answer.

    1) characterized by abnormal facial and tongue movements

    2) characterized by tremors, rigidity, and shuffling gait; administer an anticholinergic agent

    3) characterized by severe muscle contractions of the head and neck; administer diphenhydramine hydrochloride (Benadryl)

    4) CORRECT— severe reaction to antipsychotic medication as a result of dopamine blockade in the hypothalamus; fatal in approximately 10% of cases; stop medication; transfer to medical unit, cool body; administer bromocriptine (Parlodel) to treat muscle rigidity and dantrolene (Dantrium) to reduce muscle spasms
    (this multiple choice question has been scrambled)
  3. The nurse evaluates a client diagnosed with myxedema. The nurse determines that treatment is effective if which of the following is observed?

    A. The client takes his medication every day.
    B. The client becomes short of breath after climbing the stairs.
    C. The client wears multiple layers of clothing.
    D. The client discusses the family’s finances with his wife.
    D. The client discusses the family’s finances with his wife.

    Strategy: “Treatment is effective”    indicates an improvement in the client’s condition.            

    1) indicates client still feeling excessively cold, which indicates hypothyroidism

    2) CORRECT— hypothyroidism causes slowed mental functioning; improved thought processes indicate improvement

    3) indicates hypothyroidism

    4) vital that client takes medication as prescribed, but does not indicate that client’s condition is improving
    (this multiple choice question has been scrambled)
  4. risk factor for colorectal cancer
    age over 40

    history of ulcerative colitis

    diet high in fat, high in protein, and low in residue
  5. Meals for client diagnosed with cholecystitis
    all items are low in fat

    • gas-forming foods should be avoided
    • onions
    • cucumber
    • broccoli
    • beans
    • are gas-forming
  6. diverticulosis v. diverticulitis
    diverticulosis is diverticula in the colon without inflammation

    foods with seeds or indigestible material may block a diverticula; should avoid seeds, nuts, corn, popcorn, cucumbers, tomatoes, figs, strawberries, and caraway seeds            

    Diverticulitis results when one of these diverticula becomes inflamed

    fruits and vegetables are GOOD for diverticulosis but BAD for diverticulitis
  7. Lorenzo’s Oil
    a mixture of oleic and erucic acids

    given to children diagnosed with adrenoleukodystrophy (ALD), a hereditary disease of children
  8. risk factors for heart disease
    obesity and physical inactivity

    elevated blood glucose level

    positive family history for premature coronary artery disease

    history of alcoholism not a risk factor
  9. corticosteroids effect on K?
    hypokalemia
  10. diabetic ketoacidosis effect on K
    hyperkalemia
  11. total parenteral nutrition effect on K
    hypokalemia
  12. acute ulcerative colitis effect on K
    hypokalemia
  13. common complication of nephrotic syndrome
    venous thrombosis: S&S - swelling and redness
  14. client with a history of kidney stones, foods to avoid?
    avoid foods that are high in oxalates such as spinach, asparagus, and cabbage

    Many metal ions form insoluble precipitates with oxalate, a prominent example being calcium oxalate, the primary constituent of the most common kind of kidney stones.
  15. acute gout - limit the intake of
    should be on low-purine diet, should avoid red and organ meats, shellfish, oily fish with bones
  16. Odor Of Orangutan Terrified Tarzan After Forty Voracious Gorillas Viciously Attacked Him
    • I Olfactory - smell
    • II Optic - vision
    • III Oculomotor - EOM
    • IV Trochlear - down and laterally
    • V Trigeminal - Sensation of cornea, skin of face and nasal mucosa
    • VI Abducens - laterally
    • VII Facial - facial expression, taste, anterior two-thirds of tongue
    • VIII Vestibulocochlear - hearing & balance
    • IX Glossopharyngeal - swallowing ability, tongue movement, taste
    • X Vagus - sensation of pharynx and larynx, swallowing, vocal cord movement
    • XI Accessory - head & shrugging shoulders
    • XII Hypoglossal - protrusion of tongue, moves tongue up and down and side to side
  17. Olfactory
    I

    Smell
  18. I
    Olfactory

    Smell
  19. Optic
    II

    Vision and visual field
  20. II
    Optic

    Vision and visual field
  21. Oculomotor
    III

    Extraocular eye movement (EOM)
  22. III
    Oculomotor

    Extraocular eye movement (EOM)
  23. Trochlear
    IV

    EOM, movement of the eyeball downward and laterally
  24. IV
    Trochlear

    EOM, movement of the eyeball downward and laterally
  25. Trigeminal
    V

    Sensation of cornea, skin of face and nasal mucosa
  26. V
    Trigeminal

    Sensation of cornea, skin of face and nasal mucosa
  27. Abducens
    VI

    EOM, moves eyeball laterally
  28. VI
    Abducens

    EOM, moves eyeball laterally
  29. Facial
    VII

    Facial expression, taste, anterior two-thirds of tongue
  30. VII
    Facial

    Facial expression, taste, anterior two-thirds of tongue
  31. Vestibulocochlear
    VIII

    Equilibrium, Hearing
  32. VIII
    Vestibulocochlear

    Equilibrium, Hearing
  33. Glossopharyngeal
    IX

    Swallowing ability, tongue movement, taste
  34. IX
    Glossopharyngeal

    Swallowing ability, tongue movement, taste
  35. Vagus
    X

    Sensation of pharynx and larynx, swallowing, vocal cord movement
  36. X
    Vagus

    Sensation of pharynx and larynx, swallowing, vocal cord movement
  37. Accessory
    XI

    Head movement, shrugging of shoulders
  38. XI
    Accessory

    Head movement, shrugging of shoulders
  39. Hypoglossal
    XII

    Protrusion of tongue, moves tongue up and down and side to side
  40. XII
    Hypoglossal

    Protrusion of tongue, moves tongue up and down and side to side
  41. Mnemonic for remembering which cranial nerves are S=sensory, M=motor, or B=both.
    • Some
    • Say
    • Marry
    • Money
    • But
    • My
    • Brother
    • Says
    • Bad
    • Business
    • Marry
    • Money
  42. Runny nose, yawning, fever, muscle and joint pain, diarrhea
    narcotic (heroine) withdrawal is very much like the symptoms of the flu
  43. Nausea and vomiting, tachycardia, coarse tremors, seizures
    describes barbiturate withdrawal
  44. Depression, disturbed sleep, restlessness, disorientation
    describes amphetamine withdrawal
  45. Severe cravings, depression, fatigue, hypersomnia
    describes cocaine withdrawal
  46. synch button on debirillator?
    used for cardioversion to treat atrial flutter, atrial fibrillation, supraventricular tachycardial synchronizes shock with R wave
  47. V-fib joules settings?
    set at 200 joules, then 200–300 joules, then 360 joules

    emergency treatment of ventricular fibrillation; completely   depolarizes myocardial cells so SA node can reestablish as pacemaker
  48. average head circumference of newborn?
    33–35 cm

    increased size may indicate hydrocephaly or increased intracranial pressure          
  49. clients at highest risk for developing Dupuytren contracture?
    Dupuytren contracture is a slow progressive contracture of the palmar fascia causing flexion of the fourth and fifth fingers

    results from inherited autosomal dominant trait; occurs most often in

    • men over 50 years of age
    • Scandinavian or Celtic descent
    • associated with diabetes
    • gout
    • arthritis
    • alcoholism
  50. location where the nurse expects to palpate the client’s fundus 8 hours after delivery
    Fundus rises to level of umbilicus 6 to 12 hours after delivery; beginning with day 1, the fundus descends about 1 fingerbreadth per day.

    So, 8 hrs, at umbilicus...
  51. All require standard precautions except?

    infectious mononucleosis
    Legionnaires’disease
    pneumococcal meningitis
    disseminated herpes zoster
    disseminated herpes zoster requires airborne and contact precautions            
  52. Blurred vision (can be caused by)
    hypoglycemia

    normal FBS is 60 to 110 mg/dL
  53. Edema (can be caused by)
    albumin deficit decreases oncotic pressure and fluids shift from vascular area to tissue

    normal serum albumin is 3.5 to 5.5 g/dL
  54. Nausea (can be caused by)
    hypokalemia or hyponatremia

    Norm sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.0 mEq/L
  55. client diagnosed with conversion reaction utilizes which defense mechanism?
    Repression: instinctive drives and their accompanying anxiety are repressed and converted into a physical symptomRepression
  56. risk factors for pneumonia?
    • advanced age
    • underlying lung disease
    • bedridden
    • postop
  57. foods allowed on a renal diet
    • increased calories
    • high biological protein
    • low potassium
    • low sodium

    • beets are a high-potassium vegetable
    • orange is a high-potassium fruit
    • peanut butter, nuts, vegetables are considered protein sources of low biological value
    • eggs, lean meat, fish, and poultry are high biological protein

    protein intake determined on basis of kidney impairment (glomerular filtration rate)
  58. standard precautions
    • client diagnosed with cancer
    • CMV (cytomegavirus)
  59. contact precautions
    wear a gown and gloves

    • abscess that is not covered with a dressing
    • Bronchiolitis
    • C. difficile
    • Congenital rubella
    • Conjunctivitis, Acute viral (acute hemorrhagic)
    • Diphtheria, Cutaneous
    • Furunculosis, staphylococcal
    • herpes zoster
    • Rotavirus
    • Hepatitis, viral Type A
  60. droplet precautions
    • private room
    • maintain spatial separation of 3 feet between patient and visitors
    • wear a mask (a respirator is not necessary)

    • rubella
    • pertussis
    • Diphtheria, Pharyngeal
    • Epiglottitis, due to Haemophilus influenzae type b
    • influenza
    • Mumps
    • Mycoplasma pneumonia
  61. airborne precautions
    • room that is equipped with special air handling and ventilation
    • N95 or higher level respirators

    • tuberculosis
    • Measles
    • SARS
    • Smallpox
    • Varicella Zoster
  62. gestation
    needs supplementation with folic acid (vitamin B9) to prevent neural tube defects in the fetus;
  63. Contraindications for thrombolytic therapy
    • trauma in last two months
    • active internal bleeding
    • history of hemorrhagic stroke
    • intracranial or intraspinal surgery
    • intracranial neoplasm
    • arteriovenous malformation
    • aneurysm
    • severe uncontrolled hypertension            
  64. Blood Transfusion reactions
    febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin

    hemolytic reaction; most dangerous type of transfusion reaction, symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen, and maintain blood volume and renal perfusion

    allergic reaction; symptoms include urticaria, pruritus, fever; treatment is to stop blood, give Benadryl, and administer oxygen

    circulatory overload (client with neck vein distention); treatment is to stop blood, position in an upright position, and administer oxygen

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