NCLEX LVN EXAM
Mass casualty patient tagging: -ANS 1 Resuscitation/Red: airway/cardiovascular Class 2
Emergent/Yellow: immediate tx but not life threatening (fracture) Class 3 Urgent/Green: minor/not
immediate (laceration) Class 4 Less Urgent/Black: expected to die so divert attention to red and yellow
tags (penetrating head wound
Pt unresponsive no head trauma-
Pt unresponsive with head trauma-
Prevent hypothermia- -ANS Patient unresponsive without suspicion of head trauma the airway should
be opened with the head-tilt/chin-lift maneuver Patient unresponsive with suspected head trauma the
airway should be opened with modified jaw thrust maneuver Prevent hypothermia by removing wet
clothing, cover with warm blankets, increase room temp, heat lamp, warm IV fluids Tx poisoning with
activated charcoal, gastric lavage (if done within 1 hour of ingestion), and aspiration
Alpha 1 drugs
Beta 1 drugs
Beta 2 drugs
Dopamine drugs -ANS Alpha-1 drugs= vasoconstriction Beta-1 drugs= increases HR and conduction
through AV node Beta-2 drugs= bronchodilation Dopamine= renal blood vessel dilation
cerebral angiography -ANS visualization of cerebral blood vessels
Uses contrast dye Inform pregnant women dye can be harmful to fetus No food or water 4-6 hours prior
History or bleeding or anti-coagulation meds requires further considerations for monitoring after
procedure for possible bleeding Assess BUN and Creatinine to determine kidney's ability to excrete dye
EEG (electroencephalogram) -ANS Determine seizure activity, sleep disorder, behavioral changes No
prior fasting required Wash hair prior Instruct patient to be sleep deprived for procedure because it
promotes cranial stress and can induce seizures Increased electrical activity can be induced by flashing
lights or hyperventilation for 3-4 minutes
,Glascow Coma Scale (GCS) -ANS Best possible score is 15 Score < 8 associated with comatose and
severe head injuries Eye opening: best eye response (ranges 4-1) Verbal: best verbal response (ranges 5-
1) Motor: best motor response (ranges 6-1)
CP Monitoring: -ANS Placed by surgeon for patients with low Glascow Score Biggest risk is infection
Intraventricular catheter aka ventriculostomy Subarachnoid screw or bolt Epidural or subdural sensor
Increased ICP S/S: severe headache, decreased LOC, irritability, dilated/pinpoint pupils, Cheyne-Stokes
respirations, abnormal posturing (decerebrate, decorticate, flaccidity) Normal ICP= 10-15
lumbar puncture (LP) -ANS Tests for MS, Meningitis, Syphilis Patient should void prior to procedure
Patient should be in cannon ball position while on side or stretched over an overbed table Patient
should remain lying flat for several hours after procedure to ensure clots and to decrease risk of
headache Increase fluids after procedure PET scan determines tumor activity and response to tx Somatic
pain occurs in bones, joints, muscles, skin, or connective tissues Visceral pain occurs in organs
NSAIDs/Acetaminophen: -ANS Patients with healthy liver should take no more than 4g/day Monitor for
salicylism (tinnitus, vertigo, decreased hearing acuity) Prevent GI upset by taking them with food or
antacids Monitor for bleeding with long-term use
Opioid A/E: -ANS constipation, orthostatic hypotension, retention, nausea, vomiting, sedation,
respiratory depression
Meningitis
PREVENTION, VIRAL, S/S -ANS Prevention: Haemophilus Influenzae Type B vaccine and Meningococcal
vaccine Viral Meningitis: no vaccine S/S: excruciating constant headache, nuchal rigidity (neck stiffness),
photophobia, fever, chills, N/V, altered LOC, positive Kernig's and Brudzinski's signs, hyperactive deep
tendon reflexes, tachycardia, seizures, red macular rash
Meningitis: Kernig's sign -ANS Resistance and pain with extension of leg from flexed position (think
Kernig's= Knee)
, Meningitis: Brudzinski's sign -ANS flexion of knees and hips occurring with deliberate flexion of patient's
neck
Meningitis
CLOUDY CSF, CLEAR CSF, LABS -ANS Cloudy CSF= bacterial meningitis Clear CSF= viral meningitis Labs:
Elevated WBC and elevated protein; Decreased Glucose (bacterial) Isolate patient as soon as Meningitis
is suspected (contact precaution until antibiotics have been administered for 24 hours and oral/nasal
secretions are no longer infectious. Patients with bacterial meningitis might need to remain on droplet
precautions continuously
Meningitis
MGMT, TX, COMPLICATIONS -ANS Mgmt: Provide quiet environment and minimize exposure to bright
lights; maintain bed rest with HOB elevated to 30 degrees, monitor for increased ICP; avoid coughing
and sneezing to avoid increased ICP; seizure precautions Tx: Antibiotics (vancomycin with ceftriaxone or
cefotaxime), anticonvulsants (phenytoin) Complications: increased ICP, SIADH (dilute blood or
concentrated urine), septic emboli
Seizures
EPILEPSY
RISK FACTORS -ANS Seizures: abrupt and abnormal Epilepsy: chronic and reoccurring Risk factors:
genetics, acute febrile state especially with children under 2 years old, head trauma, cerebral edema,
infection, metabolic disorder (hypoglycemia or hyponatremia), exposure to toxins, brain tumor, hypoxia,
acute substance withdrawal, fluid and electrolyte imbalances Generalized seizures usually begin with
aura (alteration in smell, vision, hearing, or emotions)
Seizures: Tonic-Clonic -ANS few seconds of stiffening of muscles and loss of consciousness followed by
rhythmic jerking of extremities. Postictal phase follows tonic-clonic and is characterized by confusion
and sleepiness
Seizures
DX TESTS
Mass casualty patient tagging: -ANS 1 Resuscitation/Red: airway/cardiovascular Class 2
Emergent/Yellow: immediate tx but not life threatening (fracture) Class 3 Urgent/Green: minor/not
immediate (laceration) Class 4 Less Urgent/Black: expected to die so divert attention to red and yellow
tags (penetrating head wound
Pt unresponsive no head trauma-
Pt unresponsive with head trauma-
Prevent hypothermia- -ANS Patient unresponsive without suspicion of head trauma the airway should
be opened with the head-tilt/chin-lift maneuver Patient unresponsive with suspected head trauma the
airway should be opened with modified jaw thrust maneuver Prevent hypothermia by removing wet
clothing, cover with warm blankets, increase room temp, heat lamp, warm IV fluids Tx poisoning with
activated charcoal, gastric lavage (if done within 1 hour of ingestion), and aspiration
Alpha 1 drugs
Beta 1 drugs
Beta 2 drugs
Dopamine drugs -ANS Alpha-1 drugs= vasoconstriction Beta-1 drugs= increases HR and conduction
through AV node Beta-2 drugs= bronchodilation Dopamine= renal blood vessel dilation
cerebral angiography -ANS visualization of cerebral blood vessels
Uses contrast dye Inform pregnant women dye can be harmful to fetus No food or water 4-6 hours prior
History or bleeding or anti-coagulation meds requires further considerations for monitoring after
procedure for possible bleeding Assess BUN and Creatinine to determine kidney's ability to excrete dye
EEG (electroencephalogram) -ANS Determine seizure activity, sleep disorder, behavioral changes No
prior fasting required Wash hair prior Instruct patient to be sleep deprived for procedure because it
promotes cranial stress and can induce seizures Increased electrical activity can be induced by flashing
lights or hyperventilation for 3-4 minutes
,Glascow Coma Scale (GCS) -ANS Best possible score is 15 Score < 8 associated with comatose and
severe head injuries Eye opening: best eye response (ranges 4-1) Verbal: best verbal response (ranges 5-
1) Motor: best motor response (ranges 6-1)
CP Monitoring: -ANS Placed by surgeon for patients with low Glascow Score Biggest risk is infection
Intraventricular catheter aka ventriculostomy Subarachnoid screw or bolt Epidural or subdural sensor
Increased ICP S/S: severe headache, decreased LOC, irritability, dilated/pinpoint pupils, Cheyne-Stokes
respirations, abnormal posturing (decerebrate, decorticate, flaccidity) Normal ICP= 10-15
lumbar puncture (LP) -ANS Tests for MS, Meningitis, Syphilis Patient should void prior to procedure
Patient should be in cannon ball position while on side or stretched over an overbed table Patient
should remain lying flat for several hours after procedure to ensure clots and to decrease risk of
headache Increase fluids after procedure PET scan determines tumor activity and response to tx Somatic
pain occurs in bones, joints, muscles, skin, or connective tissues Visceral pain occurs in organs
NSAIDs/Acetaminophen: -ANS Patients with healthy liver should take no more than 4g/day Monitor for
salicylism (tinnitus, vertigo, decreased hearing acuity) Prevent GI upset by taking them with food or
antacids Monitor for bleeding with long-term use
Opioid A/E: -ANS constipation, orthostatic hypotension, retention, nausea, vomiting, sedation,
respiratory depression
Meningitis
PREVENTION, VIRAL, S/S -ANS Prevention: Haemophilus Influenzae Type B vaccine and Meningococcal
vaccine Viral Meningitis: no vaccine S/S: excruciating constant headache, nuchal rigidity (neck stiffness),
photophobia, fever, chills, N/V, altered LOC, positive Kernig's and Brudzinski's signs, hyperactive deep
tendon reflexes, tachycardia, seizures, red macular rash
Meningitis: Kernig's sign -ANS Resistance and pain with extension of leg from flexed position (think
Kernig's= Knee)
, Meningitis: Brudzinski's sign -ANS flexion of knees and hips occurring with deliberate flexion of patient's
neck
Meningitis
CLOUDY CSF, CLEAR CSF, LABS -ANS Cloudy CSF= bacterial meningitis Clear CSF= viral meningitis Labs:
Elevated WBC and elevated protein; Decreased Glucose (bacterial) Isolate patient as soon as Meningitis
is suspected (contact precaution until antibiotics have been administered for 24 hours and oral/nasal
secretions are no longer infectious. Patients with bacterial meningitis might need to remain on droplet
precautions continuously
Meningitis
MGMT, TX, COMPLICATIONS -ANS Mgmt: Provide quiet environment and minimize exposure to bright
lights; maintain bed rest with HOB elevated to 30 degrees, monitor for increased ICP; avoid coughing
and sneezing to avoid increased ICP; seizure precautions Tx: Antibiotics (vancomycin with ceftriaxone or
cefotaxime), anticonvulsants (phenytoin) Complications: increased ICP, SIADH (dilute blood or
concentrated urine), septic emboli
Seizures
EPILEPSY
RISK FACTORS -ANS Seizures: abrupt and abnormal Epilepsy: chronic and reoccurring Risk factors:
genetics, acute febrile state especially with children under 2 years old, head trauma, cerebral edema,
infection, metabolic disorder (hypoglycemia or hyponatremia), exposure to toxins, brain tumor, hypoxia,
acute substance withdrawal, fluid and electrolyte imbalances Generalized seizures usually begin with
aura (alteration in smell, vision, hearing, or emotions)
Seizures: Tonic-Clonic -ANS few seconds of stiffening of muscles and loss of consciousness followed by
rhythmic jerking of extremities. Postictal phase follows tonic-clonic and is characterized by confusion
and sleepiness
Seizures
DX TESTS
