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1. Most common cause of hyperthyroidism Ans Grave's Disease 2. S/S of thyroid storm Ans hyperthermia, HTN, delirium, vomiting, abdominal pain, hyperglycemia, tachydysrhythmias 3. Antidote for Valium intoxication Ans Flumazenil (Romazicon) 4. Valium, monitor for what? Ans decreased respirations 5. Appropriate actions for bacterial meningitis Ans droplet precautions, decrease environmental stimuli, maintain best rest w/ HOB at 30, seizure precautions, replace fluid and electrolytes 6. position crutches on affected or unaffected side when sitting or rising from chair? Ans unaffected side 2-3 finger widths Crutches no weight bearing Tripod position weight on UNAFFECTED side. advance both crutches and affected extremity move unaffected forward (beyond crutches) advance both crutches then affected extremety continue sequence 1/37 (steps equal length) Crutches with weight bearing move crutches forward about 1 step length move AFFECTED leg forward level with crutches move unaffected leg forward continue sequence (steps equal length) 7. Intervention for sprain Ans (PRINCE) Protect, Rest, Ice, NSAIDs, Compress, Ele- vate 8. Airborne Precautions Ans Used to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). Airborne precautions require Ans - A private room - Masks/ respiratory protection devices for caregivers and visitors -Negative pressure airflow exchange in the room of at least six exchanges per hour. 9. Droplet Precautions Ans Protect against droplets larger than 5 mcg (streptococcal pharyngitis or pneumonia, scarlet fever, rubella, pertussis, mumps, mycoplasma, pneumonia, meingococcal pneumonia/sepsis, pneumonic plague). Droplet precau- tions require Ans - A private room or a room with other clients with the same infectious disease -Masks 10. Contact Precautions Ans MRS WEE) Multidrug resistant organism, respiratory infection, skin infection (varicella, diphteria, shingle, impetigo, scabies), wound infection, enteric infection (c- diff), eye infection isms, wound infections, herpes simplex, scabies, multi-resistant organisms). Contact precautions require Ans - Aprivate room or a room with other clients with the same infection - Gloves and gowns worn by the caregivers and visitors. - Disposal fo infectious dressing material into a single, nonporous bag without touching the outside of the bag. 11. use of restraints Ans provider must rewrite order every 24h, Toileting and ROM exercises and assessment of neurovascular and neurosensory status q2h, tie to bed frame (loose knots that are easily removed) 12. Care for Pt who has clostridium difficile Ans contact precautions, encourage increased fluid intake, antiemetics, antimicrobial therapy 13. clinical manifestations of smallpox Ans high fever, fatigue, sever headache, rash (starts centrally and spreads outward) that turns to pus-filled lesions, vomiting, delirium, excessive bleeding 14. sealed radiation implant Ans pt in private room, nurse should wear dosimeter film badge, visitors limited to 30m visits and maintain distance of 6ft, visitors who are pregnant or under 16yrs. should not contact Pt, lead container in room, instruct pt to call nurse for assistance with elimination 15. Latent phase of labor Ans 1st part of the 1st stage of labor, lasts 4-6h, cervix 0-3cm, contractions irregular, mild to mod frequency 5-30m and duration of 30-45s, some 4/37 dilation and effacement, pt talkative and eager Use slow/ deep breathing 16. Periodic FHR Changes Ans Variable Cord Compression Move client Early Head Compression Identify progress Acceleration Other (Okay) No action needed Late Placental Insufficiency Execute action fast 17. equation for calculating due date Ans 1st day of last period + 1yr - 3 months + 7d = due date 18. grains per day Ans6 oz whole grains (cereals , rice, pasta) 1 oz = one slice of bread, 1 cup cereal 1/2 cup cooked pasta 19. veggies per day Ans 2.5 cups (raw, cooked, or juice) broccoli, carrots dry beans and peas, corn, potatoes, tomatoes 20. fruits per day Ans 2 cups (1 small banana, orange, 1/4 cup dried apricots) 21. milk per day Ans 3 cups (2% milk, yogurt, cheese) 22. protein per day Ans 5.50z (one small chicken breast 3 0z, one egg 1 0z, 1/4 cup dried cooked beans 10z 23. nutrients for healthy nervous system Ans B complex vitamins (thiamine, niacin, B6 & B12, Ca, and Na 5/37 25. Lab Results of an MI Ans elevated troponin, CK-mb enzymes, elevated LDH 26. daily % calories from protein Ans 10% 27. daily % calories from carbs Ans 45-65% 28. daily % calories from fat Ans 20-35% 29. expected physiological changes of aging Ans decreased EVERYTHING (skin turgor, wt, chest wall movement, senses, ht, subQ fat) 30. measures to prevent injury with osteoporosis Ans Ca supplementation, ade- quate amounts of protein, mag, vit. K, Vit D, wt-bearing exercises, remove throw rugs, provide adequate lighting, clear walkways, mark thresholds, doorways and steps 31. African American women are at increased risk for what? Ans cervical cancer 32. African Americans are at increased risk for what? Ans heart disease and stroke 33. What populations are at greater risk for diabetes? Ans American Indians, Alaskan natives, African Americans & Hispanics 34. Discharge teaching on breast engorgement Ans Nonlactating Clients Ans avoid nip- ple stimulation & apply cold compresses 15m on and 45m off, cabbage leaves placed inside bra, pain meds, supportive bra. Lactating Clients Ans manually express some milk, frequent feeding or pumping, warm shower, beast massage, supportive bra, maternal meds after feed to avoid cross-over to breast milk. 35. to lose 1 lb of body fat per week, an adult must have an energy deficit of ____cals/day Ans 500 or 3,500 cal/wk 36. Positive symptoms of schizophrenia Ans hallucinations, delusions, alterations in speech, bizarre behavior 37. Negative symptoms of schizophrenia Ans flat, blunt affect; algoia (poverty of thought/speech); avolition (lack of motivation); anhedonia (lack of pleasure/joy); anergia (lack of energy) 38. Nursing interventions for domestic partner abuse Ans help Pt develop a safety plan, identify behaviors and situations that might trigger violence and provide infor- mation regarding safe places to live; encourage participation in support groups 39. Nursing interventions for Pt who is manic Ans decrease stimulation, frequent rest periods, observe for escalating behavior, provide outlets for physical activity, provide portable nutritious food, use a calm, matter- of-fact approach, give concise explanations 40. Nursing interventions for alcohol withdrawal syndrome Ans self-assess ones own feelings regarding abuses; use open-ended questions, close/one-on-one ob- servation; low-stimulation enviro, encourage attendance of self- help groups with fins and scales, NO PORK (hotdogs, sausage, gelatin), and no meats mixed with milk 49. Nutritional needs for Hepatic Encephalopathy Ans high carb, high cal, low to mod fat, and low to mod protein; small, frequent meals; supplement w/ vitamins (B complex), folic acid, and iron 50. Nursing intrvetions for Pt receiving TPN Ans monitor serum and urine glucose, monitor for "cracking" of solution, use sterile technique when changing central line, bag and tubing should be changed q24h 51. TPN fluid overload is evidenced by what? Ans weight gain > 1kg/day and edema 52. Interventions for chronic renal failure Ans diet high in carbs and mod. fat, control protein intake, restrict Na, K, Ph, and Mg 53. Sleep promotion Ans bedtime routine, min number of times pt is awakened, assist w/ personal hygiene or back rub, exercise 2hr before bed, limit fluids 2-4hr before bed 54. Intermittent tube feedings Ans HOB @ 45 degrees feed and thr after feeding, admin. solution at room temp, formula is administered q4-6h in equal portions of 200-300mL over a 30m-60m time frame Flush 30mL every 4 hours 55. Bariatric surgeries Dietary planning Ans limited to liquids or pureed foods for first 6wks, meal size shouldn't exceed 1c, vit & min supplements 56. Foods that can cause odor for ostomy Ans fish, eggs, asparagus, garlic, beans, and dark green leafy veggies 57. Foods that can cause gas for ostomy pt Ans dark green leafy veggies, beer, carbonated beverages, dairy products, and corn 58. What type of diet should a client who has dysphasia be on? Ans Pureed or mechanical soft diet 59. Contraindications for the use of Isosorbide Mononitrate (IMDUR) For Angina Ans Headache hypersensitivity to nitrates, traumatic head injury b/c med can increase ICP, use cautiously in Pt taking Hypotension Ans antiHTN meds or have renal or liver dysfucntion 60. If Pt develops reflex tachycardia from taking Imdur give what? Ans metoprolo! (Lopressor) 61. Atorvastatin (lipitor) purpose Ans decrease manufacture of LDL and VLDL and increase HDLs; promotes vasodilation, decreased plaque site inflammation, and decreased risk of thromboembolism 62. S/E of Atorvastatin (Lipitor) Ans Hepatotoxicity (liver fxn tests after 12wks then q6m); myopathy (obtain baseline CK levels); peripheral neuropathy (notify provider) 11/37 DRINK FLUIDS AVOID SUNLIGHT New onset diabetes/loss of glucose control (report s/s of increased thirst, urination, appetite), wt gain, hypercholesterolemia, orthostatic hypotension, anticholinergic effects, symptoms of agitation, dizziness, sedation, and sleep disruption, mild EPS such as tremor, risk for dyslipidemia, risk for fatal agranulocytosis (baseline & wkly monitor of WBC, notify of S/S of infection) Stop med for signs of neuroleptic malignant syndrome 68. Therapeutic effect of Levothyroxine (Synthroid) Ans For Hypothyroidism Ans de- creased TSH 0.3-3.0, normal T4 levels, absence of hypothyroidism symptoms (de- pression, wt gain, bradycardia, anorexia, cold intolerance, dry skin, menorrhagia); takes several wks to notice a therapeutic effect 69. Long-term adverse effects of Haloperidol (Haldol) Ans Tardive dyskinesia (invol- untary movements of tongue and face, lip smacking, involuntary movments of arms, legs, and trunk) 70. Effectiveness of Allopurinal (Zyloprim) is evidenced by Ans Improvement in pain caused by gout attack (decreased joint swelling, redness), decreased number of gout attacks, decreased uric acid levels 71. Leukotrien Modifiers Montelukast (Singulair) Ans suppress inflammation, bronchoconstriction, airway ede- ma, and mucus production long-term therapy for asthma and to prevent exercise-induced bronchospasm Take once daily at bedtime 72. Assessment of DI Ans Decreased urine specific gravity and osmolality Hypernatremia Hypokalemia Increased urinary output Dehydration, weight loss and dry skin 73. Desmopressin (DDAVP) For Diabetes Insipidus Ans promote absorption of water within the kidneys; cause vasoconstriction; tx of diabetes insipidus Effectiveness of DDAVP is evidenced by Ans reduction in the large volumes of urine output associated with diabetes insipidus to normal levels 74. Contraindications to MMR Immunization Ans pregnancy, allergy to gelatin and neomycin, hx of thrombocytopenia, immunosuppression, recent blood transfusion; common cold NOT a contraindication Ans Use cautiously with mental depression avoid with alcohol and medications with CNS depression S/E Dry mouth, decreased libido, respiratory depression 81. Opioids (relief and sedation) Ans Duragesic, Dilaudud, Morphine, Demerol, Codeine, oxycodone 82. Opioid antagonist nalaxone (Narcan) Ans used for respiratory depression 83. Ace Inhibitors (end in "pril") Ans Used for Ans HTN, HF, MI, diabetic neuropathy Monitor potassium levels K+ persistent non-productive cough 84. SSRI (Duloxetine, Fluoxetine, Escitalopram, Fluvoxamine, Paroxetine, Ser- traline) Teaching Ans Avoid alcohol, do not discontinue abruptly, monitor for agitation, confusion and halluciations within the first 72 hours. S/E Weight gain, sexual dys- function, fatigue, drowsiness May cause serotonin syndrome (2-72 hrs after start of treatment) Anstremors, agitation, confusion, anxiety and hallucinations 85. When should admin RhoGAM Ans when mom is Rh-negative and had Rh-positive infant; admin w/n 28 weeks (3rd trimeter) and 72h after birth Spontaneous abortion, amneoscentesis 86. Does does Magnesium Sulfate do? Ans relaxes smooth muscle of the uterus and inhibits uterine activity by suppressing contractions 87. What are s/s of Mag sulfate toxicity? What is the antidote for Mag Sulfate? Ans loss of Deep Tendon Reflexes, urinary output < 30ml/hr, resp depression, pulmonary edema, and/or chest pain Calcium Gluconate to fix! 88. What are the contraindications for Mag sulfate? Ans active vagninal bleeding, dilation of cervix is > 6cm, chorioamnionitis, > 34 wks gestation, acute fetal distress, severe pregnancy induced HTN or eclampsia 89. Indications to withhold Propranolol (inderal) Beta Blocker Ans bradycardia, SOB, edema, fatigue, AV block, Pt has asthma 90. ANGINA Containdications for vasodilators Nitros Ans CLIENTS WITH A HEAD INJURY Hypotensive risk with antihypertensive meds Erectile dysfunction meds (life threatening hypotension) 91. Uses for methadone (Dolophine) Ans relief of mod to severe pain; sedation; re- duction of bowel motility 92. Equation for calculating pulse pressure Ans systolic - diastolic = pulse pressure 120-80=40 93. When should a trough level be scheduled for a once daily dosing of 17/37 101. S/S of hyperkalemia Ans slow, irregular pulse; hypoTN, restlessness, irritability, weakness with ascending flaccid paralysis, N/V/D, hyperactive bowel sounds 102. S/S of hypocalcemia Ans muscle twitches/tetany, hyperactive DTRs, positive Chvostek's sign (tapping on the facial nerve triggering facial twitching), positive Trousseau's sign (hand/finger spasms with sustained blood pressure cuff inflation), seizures 103. S/S of hypomagnesaemia Ans hyperactive DTRs, muscle tetany, positive Chvostek's and Trousseau's signs, hypoactive bowel sounds, paralytic ileus 104. Complications following a hypophysectomy (removal of pituitary gland)- Ans monitor for bleeding and nasal drainage for possible CSF leak (assess drainage for glucose or halo sign); assess neurological condition every hour for first 24h and every 4h after 105. Nursing Interventions for preventing delays in healing Ans encourage an in- take of 2-3L of fluid/d, increase protein, keep serum albumin levels above 3.5 106. Meds for Sinus Tachycardia Ans amiodarone, adenosine, and verapmil; synchronized cardioversion 107. S/S of hyperglycemia Ans BG > 250, thirst, freq. urination, hunger; warm, dry flushed skin; weakness; malaise; rapid, weak pulse; hypoTN, deep rapid respirations 108. Complication of pericarditis Ans cardiac tamponade (hypoTN, muffled heart sounds, JVD, paradoxical pulse) 109. Pericarditis commonly follows a Ans respiratory infection 110. S/S of pericarditis Ans chest pressure/pain, friction rub, SOB, pain relieved when sitting and leaning forward 111. Fasting blood glucose Ans post pone admin of antidiabetic med until after levels are drawn; ensure pt has fasted for 8hr prior to blood draw 112. Oral glucose tolerance test Ans fasting blood glucose level drawn at start then pt consumes a specified amount of glucose. Blood glucose levels drawn every 30m for 2hrs; instruct client to consume balanced diet for 3d prior then fast 10-12hr 113. Glycosylate hemoglobin (HgA1c) Ans best indicator for average blood glucose level for the past 120d; normal range is 4- 6%, diabetic range is 6.5-8% 114. Evaluating proper placement of NG tube Ans aspirate to collect gastric contents and test pH (4 or less) before feeding. Hold if residual is >100 mL, X-Ray Injecting air into tube to listen over abdomen is NOT an acceptable practice 115. IV Urography Procedure Ans used to detect obstruction, assess for a parenchy- mal mass, and assess size of kidney 
