orthostatic hypotension - ANSWERcaused by DEHYDRATION from fluid loos and
electrolyte imbalance
gross motor skills - ANSWERphysical abilities involving large body movements, such as
walking and jumping
-EX: 9 month-old infant SHOULD be able to sit UNSUPPORTED for up to 10 MIN
Biofeedback - ANSWERtechnique that uses audio and visual signals that allow client to
reduce muscle tension by gaining control over autonomic physiologic functions.
How should phenytoin be administered? Why? - ANSWER-administered IV bolus at a
rate no greater than 50mg/min.
-to prevent HYPOTENSION and BRADYCARDIA
Manifestations of Parkinson's Disease - ANSWERtremor, rigidity, BRADYKINESIA,
postural instability, depression and other psychiatric changes, dementia, autonomic
symptoms, sleep disturbances
Non-Hodgkin's Lymphoma - ANSWERspreads ERRATICALLY through the
LYMPHATIC SYSTEM to other organs. It also manifest in PAINLESS, swollen lymph
nodes found in the CERVICAL, AXILLLARY, INGUINAL, & FEMORAL areas.
Hodgkin's lymphoma - ANSWERspreads SYSTEMICALLY from one group of lymph
nodes to the next group of nodes.
Important teachings for client with new prescription of a DIAPHRAGM. - ANSWER-
should remain in place for 6HR FOLLOWING INTERCOURSE
-should remove diaphragm NO MORE THAN 24HRS following intercourse
-insert diaphragm NO MORE THAN 6HR PRIOR to intercourse
-apply about 10ml (2tsp) of SPERMICIDE inside diaphragm prior to intercourse
-replace every 2 yrs.
-client should be refitted if their weight FLUCTUATE BY 20%
-client should be refitted following a ABDOMINAL SURGERY, PELVIC SURGERY, &
after each pregnancy
A client with fibrocystic breast condition will... - ANSWERhave BREAST PAIN and
tenderness as well ass LUMPS usually in the UPPER OUTER QUADRANT of the
breast.
Expected findings of INTRADUCTAL PAPILLOMA BREAST disorder? -
ANSWERfinding will include:
-mass in duct and NIPPLE DISCHARGE
Expected findings of DUCTAL EXTASIS BREAST DISORDER? - ANSWEREnlarged
axillary nodes and Nipple discharge.
,Client with COPD will experience... - ANSWERDIGITAL CLUBBING, which
DECREASES arterial O2 levels.
tophi with chronic gout - ANSWERhard, painless nodule on first toe, collection of NA
urate crystals due to chronic gout, sometimes bursts with chalky discharge
Swan neck deformity - ANSWER-hyperextension of PIP joint and flexion of DIP joint
-late manifestation of RHEUMATOID ARTHRITIS (RA)
scleroderma - ANSWERchronic progressive disease of the skin and internal organs with
hardening and shrinking of connective tissue
-EXPECT flexion or contracture of joints. (late manifestation)
Preferred meal plan for a patient with DIVERTICULITIS - ANSWER-advance to high-
fiber diet. Best source of fiber is a BANANA which yields 3.1g of FIBER.
Diverticulitis - ANSWERinflammation of the diverticula
What type of medication can increase a patient's risk for a stroke? - ANSWER-oral
contraceptives B/C this will INCREASE the risk for developing a
THROMBOEMBOLISM.
A client with HYPOPITUITARISM places the them at risk for developing what type of
condition? - ANSWER-osteoporosis
How does light to moderate drinking, (150ml or 5oz of wine each day) affect the client's
risk for having a stroke? - ANSWERit doesn't increase, it actually DECREASES the risk
for stroke.
What is Ewing Sarcoma? What are expected manifestations of this disease? -
ANSWER-rare malignant tumor arising in bone; most often occurring in children
-client will experience pain in the UPPER THIGH as well as LOCALIZED PAIN,
SWELLING, & PALPABLE MASS.
What are expected findings of Multiple Sclerosis (MS)? - ANSWER-decrease visual
acuity, diplopia, changes in peripheral vision, & nystagmus (repeat of uncontrolled
movements).
What are expected finding of Amyotrophic Later Sclerosis (ALS)? - ANSWER-
fascifulcations of the face, twitching of the face or tongue.
What is Amyotrophic Lateral Sclerosis (ALS)? - ANSWERAlso known an Lou Gherig's
disease, ALS is a motor neuron disease which can lead to paralysis.
borderline personality disorder - ANSWERcondition marked by extreme instability in
mood, identity, and impulse control.
,-client's with this condition experience SUICIDAL IDEATION & SUBSTANCE ABUSE.
narcissistic personality disorder - ANSWERcharacterized by a grandiose sense of self-
importance, a preoccupation with fantasies of success or power, and a need for
constant attention or admiration or ARROGANCE
historonic personality disorder - ANSWERImpulsive attention seeking behavaior
paranoid personality disorder - ANSWERA personality disorder characterized by a
pervasive distrust and suspiciousness of the motives of others without sufficient basis
What are some complications of an infant born at or less than 32 weeks? - ANSWER-
apnea
-nectrotizing enterocolitis (due to intestinal ischemia and immature immune system)
-hypoglycemia
-anemia
-polycythemia
-hypothermia
What teachings should the nurse include for a client that underwent a UTERINE
ARTERY EMBOLIZATION? - ANSWER-client may experience flu-like symptoms for 7
days after procedure (embolectomy syndrome)
-inform client that a CLOSURE DEVICE or INJECTION that blocks blood flow to the
arteries of the FIBROID TUMOR is used
-inform client that SEVERE CRAMPING may occur in the first 24hr after the procedure
and can last up to 2 weeks.
What teachings should the nurse include for a client who has bipolar disorder and has a
new prescription of LITHIUM? - ANSWER-instruct client to take Li with meals to
decrease irritation of gastric mucosa.
-maintain adequate intake of salt (low Na can lead to Li retention, which can cause Li
toxicity).
-drink at least 1.5-3L of fluids each day (dehydration can lead to Li toxicity).
-expect WEIGHT GAIN (common adverse effect of Li).
Autism Spectrum Disorder (ASD) - ANSWERA disorder characterized by deficits in
social relatedness and communication skills that are often accompanied by repetitive,
ritualistic behavior.
Immunization schedule - ANSWERBirth: Hep B
2 mos: Hep B, ROTAVIUS, DTaP, Hib, Pneumococcal, Poliovirus
4 mos: Rotavirus, DTaP, Hib, Pneum, Poliovirus
6 mos: Hep B, DTaP, Hib, Pneum, Poliovirus
, 12 mos: MMR, VAR, Hep A, Influenza, Hib
11-12 YEARS: Tdap, Meningococcal, HPV
ADHD (Attention-Deficit Hyperactivity Disorder) - ANSWERa psychological disorder
marked by extreme inattention and/or hyperactivity and impulsivity
What should the nurse include in her planning for a patient who has ACUTE phase of
DIVERTICULITIS? - ANSWER-Instruct the client to AVOID COUGHING (this can
increase the intra-abdominal pressure and cause BOWEL PERFORATION).
-ADMINISTER OPIOID analgesics to relieve pain (this can decrease bowel motility)
-DO NOT administer EMEMAS or LAXITIVES (this will increase bowel motility and
places client at risk for bowel perforation)
-client should be NPO or on a clear liquid diet (this will decrease inflammation of the
bowels).
sickle cell crisis - ANSWERcondition in sickle cell anemia in which the sickled cells
interfere with oxygen transport, obstruct capillary blood flow, and cause fever and
severe pain in the joints and abdomen.
How should the nurse manage care for a client who is experiencing a sickle cell crisis? -
ANSWER-promote fluid intake to prevent dehydration
-monitor peripheral capillary refill, pulse O2, and skin temp every 1hr to assess
PERFUSION of EXTREMITIES.
-EXTEND client's knees to promote perfusion of lower extremities.
-elevate head or bed to 30 DEGREES or less to increase perfusion to lower extremities.
What are the depressive manifestation of low self-esteem? - ANSWER-hypersensitivity
to criticism
-guilt
-shame
-expression of helplessness
-lack of eye contact
-pessimistic outcome on life
What are the manifestations of spiritual distress? - ANSWER-express lack of meaning
in life
-anger
-refusing interactions with family
-discontinuing spiritual practice
What are the manifestations of disturbed thought process? - ANSWER-impaired
problem-solving skills
-confusion
-difficulty concentration
electrolyte imbalance
gross motor skills - ANSWERphysical abilities involving large body movements, such as
walking and jumping
-EX: 9 month-old infant SHOULD be able to sit UNSUPPORTED for up to 10 MIN
Biofeedback - ANSWERtechnique that uses audio and visual signals that allow client to
reduce muscle tension by gaining control over autonomic physiologic functions.
How should phenytoin be administered? Why? - ANSWER-administered IV bolus at a
rate no greater than 50mg/min.
-to prevent HYPOTENSION and BRADYCARDIA
Manifestations of Parkinson's Disease - ANSWERtremor, rigidity, BRADYKINESIA,
postural instability, depression and other psychiatric changes, dementia, autonomic
symptoms, sleep disturbances
Non-Hodgkin's Lymphoma - ANSWERspreads ERRATICALLY through the
LYMPHATIC SYSTEM to other organs. It also manifest in PAINLESS, swollen lymph
nodes found in the CERVICAL, AXILLLARY, INGUINAL, & FEMORAL areas.
Hodgkin's lymphoma - ANSWERspreads SYSTEMICALLY from one group of lymph
nodes to the next group of nodes.
Important teachings for client with new prescription of a DIAPHRAGM. - ANSWER-
should remain in place for 6HR FOLLOWING INTERCOURSE
-should remove diaphragm NO MORE THAN 24HRS following intercourse
-insert diaphragm NO MORE THAN 6HR PRIOR to intercourse
-apply about 10ml (2tsp) of SPERMICIDE inside diaphragm prior to intercourse
-replace every 2 yrs.
-client should be refitted if their weight FLUCTUATE BY 20%
-client should be refitted following a ABDOMINAL SURGERY, PELVIC SURGERY, &
after each pregnancy
A client with fibrocystic breast condition will... - ANSWERhave BREAST PAIN and
tenderness as well ass LUMPS usually in the UPPER OUTER QUADRANT of the
breast.
Expected findings of INTRADUCTAL PAPILLOMA BREAST disorder? -
ANSWERfinding will include:
-mass in duct and NIPPLE DISCHARGE
Expected findings of DUCTAL EXTASIS BREAST DISORDER? - ANSWEREnlarged
axillary nodes and Nipple discharge.
,Client with COPD will experience... - ANSWERDIGITAL CLUBBING, which
DECREASES arterial O2 levels.
tophi with chronic gout - ANSWERhard, painless nodule on first toe, collection of NA
urate crystals due to chronic gout, sometimes bursts with chalky discharge
Swan neck deformity - ANSWER-hyperextension of PIP joint and flexion of DIP joint
-late manifestation of RHEUMATOID ARTHRITIS (RA)
scleroderma - ANSWERchronic progressive disease of the skin and internal organs with
hardening and shrinking of connective tissue
-EXPECT flexion or contracture of joints. (late manifestation)
Preferred meal plan for a patient with DIVERTICULITIS - ANSWER-advance to high-
fiber diet. Best source of fiber is a BANANA which yields 3.1g of FIBER.
Diverticulitis - ANSWERinflammation of the diverticula
What type of medication can increase a patient's risk for a stroke? - ANSWER-oral
contraceptives B/C this will INCREASE the risk for developing a
THROMBOEMBOLISM.
A client with HYPOPITUITARISM places the them at risk for developing what type of
condition? - ANSWER-osteoporosis
How does light to moderate drinking, (150ml or 5oz of wine each day) affect the client's
risk for having a stroke? - ANSWERit doesn't increase, it actually DECREASES the risk
for stroke.
What is Ewing Sarcoma? What are expected manifestations of this disease? -
ANSWER-rare malignant tumor arising in bone; most often occurring in children
-client will experience pain in the UPPER THIGH as well as LOCALIZED PAIN,
SWELLING, & PALPABLE MASS.
What are expected findings of Multiple Sclerosis (MS)? - ANSWER-decrease visual
acuity, diplopia, changes in peripheral vision, & nystagmus (repeat of uncontrolled
movements).
What are expected finding of Amyotrophic Later Sclerosis (ALS)? - ANSWER-
fascifulcations of the face, twitching of the face or tongue.
What is Amyotrophic Lateral Sclerosis (ALS)? - ANSWERAlso known an Lou Gherig's
disease, ALS is a motor neuron disease which can lead to paralysis.
borderline personality disorder - ANSWERcondition marked by extreme instability in
mood, identity, and impulse control.
,-client's with this condition experience SUICIDAL IDEATION & SUBSTANCE ABUSE.
narcissistic personality disorder - ANSWERcharacterized by a grandiose sense of self-
importance, a preoccupation with fantasies of success or power, and a need for
constant attention or admiration or ARROGANCE
historonic personality disorder - ANSWERImpulsive attention seeking behavaior
paranoid personality disorder - ANSWERA personality disorder characterized by a
pervasive distrust and suspiciousness of the motives of others without sufficient basis
What are some complications of an infant born at or less than 32 weeks? - ANSWER-
apnea
-nectrotizing enterocolitis (due to intestinal ischemia and immature immune system)
-hypoglycemia
-anemia
-polycythemia
-hypothermia
What teachings should the nurse include for a client that underwent a UTERINE
ARTERY EMBOLIZATION? - ANSWER-client may experience flu-like symptoms for 7
days after procedure (embolectomy syndrome)
-inform client that a CLOSURE DEVICE or INJECTION that blocks blood flow to the
arteries of the FIBROID TUMOR is used
-inform client that SEVERE CRAMPING may occur in the first 24hr after the procedure
and can last up to 2 weeks.
What teachings should the nurse include for a client who has bipolar disorder and has a
new prescription of LITHIUM? - ANSWER-instruct client to take Li with meals to
decrease irritation of gastric mucosa.
-maintain adequate intake of salt (low Na can lead to Li retention, which can cause Li
toxicity).
-drink at least 1.5-3L of fluids each day (dehydration can lead to Li toxicity).
-expect WEIGHT GAIN (common adverse effect of Li).
Autism Spectrum Disorder (ASD) - ANSWERA disorder characterized by deficits in
social relatedness and communication skills that are often accompanied by repetitive,
ritualistic behavior.
Immunization schedule - ANSWERBirth: Hep B
2 mos: Hep B, ROTAVIUS, DTaP, Hib, Pneumococcal, Poliovirus
4 mos: Rotavirus, DTaP, Hib, Pneum, Poliovirus
6 mos: Hep B, DTaP, Hib, Pneum, Poliovirus
, 12 mos: MMR, VAR, Hep A, Influenza, Hib
11-12 YEARS: Tdap, Meningococcal, HPV
ADHD (Attention-Deficit Hyperactivity Disorder) - ANSWERa psychological disorder
marked by extreme inattention and/or hyperactivity and impulsivity
What should the nurse include in her planning for a patient who has ACUTE phase of
DIVERTICULITIS? - ANSWER-Instruct the client to AVOID COUGHING (this can
increase the intra-abdominal pressure and cause BOWEL PERFORATION).
-ADMINISTER OPIOID analgesics to relieve pain (this can decrease bowel motility)
-DO NOT administer EMEMAS or LAXITIVES (this will increase bowel motility and
places client at risk for bowel perforation)
-client should be NPO or on a clear liquid diet (this will decrease inflammation of the
bowels).
sickle cell crisis - ANSWERcondition in sickle cell anemia in which the sickled cells
interfere with oxygen transport, obstruct capillary blood flow, and cause fever and
severe pain in the joints and abdomen.
How should the nurse manage care for a client who is experiencing a sickle cell crisis? -
ANSWER-promote fluid intake to prevent dehydration
-monitor peripheral capillary refill, pulse O2, and skin temp every 1hr to assess
PERFUSION of EXTREMITIES.
-EXTEND client's knees to promote perfusion of lower extremities.
-elevate head or bed to 30 DEGREES or less to increase perfusion to lower extremities.
What are the depressive manifestation of low self-esteem? - ANSWER-hypersensitivity
to criticism
-guilt
-shame
-expression of helplessness
-lack of eye contact
-pessimistic outcome on life
What are the manifestations of spiritual distress? - ANSWER-express lack of meaning
in life
-anger
-refusing interactions with family
-discontinuing spiritual practice
What are the manifestations of disturbed thought process? - ANSWER-impaired
problem-solving skills
-confusion
-difficulty concentration
