NURSING - STUDY GUIDE
2024/2025EDITION WITH COMPLETE
SOLUTION
barrel chest kawasaki syndrome strawberry tongue pernicious anemia red beefy tongue downs
syndrome protruding tongue cholera rice watery stool malaria stepladder like fever--with chills typhoid
rose spots on the abdomen diptheria pseudo membrane formation measles koplick's spots sle (systemic
lupus) butterfly rash pyloric stenosis olive like mass Addison's bronze like skin pigmentation Cushing's
moon face, buffalo hump hyperthyroidism/ grave's disease exophthalmos myasthenia gravis
descending musle weakness gullian-barre syndrome ascending muscle weakness angina
crushing, stabbing chest pain relieved by nitro
MI
crushing stabbing chest pain unrelieved by nitro cystic fibrosis salty skin
DM
polyuria, polydipsia,polyphagia
DKA
kussmal's breathing (deep rapid) Bladder CA painless hematuria
BPH
reduced size and force of urine retinal detachment floaters and flashes of light. curtain vision glaucoma
painful vision loss. tunnel vision. halo retino blastoma cat's eye reflex increased ICP hypertension,
bradypnea,, bradycarday (cushing's triad) shock
Hypotension, tachypnea, tachycardia Lymes disease bullseye rash intraosseous infusion often used in
peds when venous access can't be obtained. hand drilled through tibia where cryatalloids, colloids,
blood products and meds are administered into the marrow. one med that CANNOT be administered IO
is isoproterenol, a beta agonist.
sickle cell crisis two interventions to prioritize: fluids and pain relief.
glomuloneprhitis the most important assessment is blood pressure children 5 and up
should have an explanation of what will happen a week before surgery
Kawasaki disease
,(inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms.
ventriculoperitoneal shunt watch for abdominal distention. watch for s/s of ICP such as high pitch cry,
irritability and bulging fontanels. In a toddler watch for loss of appetite and headache. After shunt is
placed bed position is FLAT so fluid doesn't reduce too rapidly. If presenting s/s of ICP then raise the
HOB 15-30 degrees 3-4 cups of milk a day for a child?
NO too much milk can reduce the intake of other nutrients especially iron. Watch for ANEMIA
MMR and varicella immunizaions after 15 months!
cryptorchidism undescended testicles! risk factor for testicular cancer later in life. Teach self exam for
boys around age 12--most cases occur in adolescence
CSF meningitis
HIGH protein LOW glucose Head injury or skull fx no nasotracheal suctioning otitis media feed upright to
avoid otitis media!
positioning for pneumonia lay on affected side, this will splint and reduce pain. However, if you are
trying to reduce congestion, the sick lung goes up! (like when you have a stuffy nose and you lay with
that side up, it clears!) for neutropenic pts no fresh flowers, fresh fruits or veggies and no milk
antiplatelet drug hypersensitivity bronchospasm bowel obstruction more important to maintain fluid
balance than to establish a normal bowel pattern ( they cant take in oral fluids ) Basophils reliease
histamine during an allergic response Iatragenic
means it was caused by treatment, procedure or medication Tamoxifen
watch for visual changes--indicates toxicity post spelectomy
pneumovax 23 is administered to prevent pneumococcal sepsis
Alkalosis/ Acidosis and K+
ALKalosis=al K= low sis. Acidosis (K+ high) No phenylalanine to a kid with PKU. No meat, dairy or
aspartame never give potassium to a pt who has low urine output!
nephrotic syndrome characterized by massive proteinuria caused by glomerular damage. corticosteroids
are the mainstay the first sign of ARDS increased respirations! followed by dyspnea and tachypnea
normal PCWC (pulmonary capillary wedge pressure) is 8-13 readings 18-20 are considered high first sign
of PE
sudden chest pain followed by dyspnea and tachypnea Digitalis increases ventricular irritability ----could
convert a rhythm to v-fib following cardioversion
Cold stress and the newborn biggest concern resp. distress Parathyroid relies on vitamin D to work
Glucagon increases the effects of? anticoagulants Sucking stab wound
cover wound and tape on 3 sides to allow air to escape. If you cover and occlude it--it could turn into a
closed pneumo or tension pneumo! chest tube pulled out? occlusive dressing
,PE
Needs O2!
DKA
acetone and keytones increase! once treated expect postassium to drop! have K+ ready Hirschprung's
diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul
smelling stools
Intussusception
Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---
resolution=bowel movements laboring mom's water breaks? first thing--worry about prolapsed cord!
Toddlers need to express independence! Addison's causes sever hypotension!
pancreatitis
first pain relief, second cough and deep breathe CF chief concern? Respiratory problems a nurse makes
a mistake?
take it to him/her first then take up the chain
nitrazine paper turns blue with alkaline amniotic fluid. turns pink with other fluids up stairs with
crutches? down stairs with crutches?
good leg first followed by crutches(good girls go to heaven) crutches with the injured leg followed by the
good leg. dumping syndrome?
use low fowler's to avoid. limit fluids TB drugs are hepatotoxic! clozapine, Clozaril antipsychotic
anticholinergic clozapine s/e weight gain, hypotension, hyperglycemia, agranulocytosis dehydration
- hypovolemia
- elevated urine specific gravity flumazenil, Romazicon benzo overdose umbilical cord compression
reposition side to side or knee-chest short cord discontinue pictocin
TB
A positive Mantoux test indicates pt developed an immune response to TB.
Acid-fast bacilli smear and culture:(+suggests an active infection) the diagnosis is CONFIRM by a positive
culture for M TB
A chest x-ray may be ordered to detect active lesions in the lungs
QuantiFERON-TB Gold: DIAGNOSTIC for infection, whether it is active or latent Battery
performing procedure without consent
Assault
Threatening to give pt. medication putting another person in fear of a harmful or an offensive contact.
, Imprisonment
Telling the client you cannot leave the hospital Defamation is a false communication or careless
disregard for the truth that causes damage to someone's reputation. in writing(Libel) or
Verbally(Slander)
Sprain or Strain
RICE
Rest
Ice
Compress Elevate quad cane place of unaffected side of body
place it 6-12 in in front of the body before walking steps forward with affected leg first
bring the unaffected leg as well, bringing the foot past the cane hand roll in each hand maintains
functional position Fluoxetine (Prozac) report tremors, agitation, confusion, anxiety,
hallucinations=serotonin syndrome (risk in the first 2-72 hrs after given first time); client will stop the
meds; weight gain/diabetes/ hyperglicemia
asthma kid should participate in sports, inhaler prior to sports, stay inside when cold, use peak flow
meter every day same time, annual influenta vaccine important
RN COMPREHENSIVE PREDICTOR NURSING - STUDY GUIDE
What can be delegated to Assistive personnel (AP)?
- ADLs - bathing - grooming - dressing - ambulating - feeding (w/o swallow precautions) - positioning -
bed making - specimen collection - I&O - VS (stable clients
A nurse on a med surg unit has recieved change of shift report and will care for 4 clients. Which of the
following clients needs will the nurse assign to an AP? A. Feeding a client who was admitted 24 hours
ago with aspiration pneumonia
B. Reinforcing teaching with a client who is learning to walk with a quad cane
C. Reapplying a condom catheter for a client who has urinary incontinence D. Applying a sterile
dressing to a pressure ulcer
C
A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which
of the following info should the nurse share with the AP?