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Abuse: Co-Dependency - CORRECT ANSWERS -when the significant other gets positive self esteem from doing things for the abuser Co-Dependency/ Dependency: Nursing Intervention - CORRECT ANSWERS -Set Limits + enforce them -must work on self esteem Abuse: Manipulation - CORRECT ANSWERS -when abuser gets the significant other to do thin Manipulation: Nursing Intervention - CORRECT ANSWERS -Set Limits + enforce them Crutches: Length - CORRECT ANSWERS -2 to 3 finger widths below axillary fold -lateral & slightly in front of the foot Crutches: Hand Grip - CORRECT ANSWERS -should be in 30 degree flexion Calcium Channel Blockers - CORRECT ANSWERS -calms your heart •ends w/~dipine Calcium Channel Blockers: Indication - CORRECT ANSWERS -treats hypertension, angina, & Atrial Arrhythmia Calcium Channel Blockers: MOA - CORRECT ANSWERS -negative inotropic, chronotropic, + Dromotropic Calcium Channel Blockers: Adverse Effects - CORRECT ANSWERS -Hypotension -Headache
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Calcium Channel Blockers: Nursing Considerations - CORRECT ANSWERS -Hold if systolic BP= less than 100 2 Point Gait - CORRECT ANSWERS -move crutch + opposite foot together 2 Point Gait: Use - CORRECT ANSWERS -Mild Bilateral Problems QRS Depolarization - CORRECT ANSWERS -means ventricular P Wave - CORRECT ANSWERS -means atrial Lack of QRS - CORRECT ANSWERS -means asystole Chaotic - CORRECT ANSWERS -means fibrillation: •P Wave= A-Fib •QRS= V-Fib 3 Point Gait - CORRECT ANSWERS -move 2 crutches + bad leg together 3 Point Gait: Use - CORRECT ANSWERS -when only 1 leg is effected Bizarre - CORRECT ANSWERS -means tachycardia: •P Wave= Atrial Tachycardia •QRS= Ventricular Tachycardia Contact Precaution: RSV - CORRECT ANSWERS -effects babies 1 to 2yrs old -transmitted via droplet but we still use contact precautions
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Swing Through Gait - CORRECT ANSWERS -Plant crutches + Swing injured leg through Swing Through Gait: Use - CORRECT ANSWERS -non weight Bearing Injuries Non Psychotic Patient - CORRECT ANSWERS -has insight & is reality based -recognize what the problem is + how it effects their life Non Psychotic Patient: S&S - CORRECT ANSWERS -No delusions, hallucinations, or illusions Non Psychotic Patient: Treatment - CORRECT ANSWERS -Good therapeutic communication Crutches Stairs - CORRECT ANSWERS -Walk up w/the good leg -Walk down w/the bad leg •crutches move w/bad leg Canes - CORRECT ANSWERS -hold cane on the strong side Walker - CORRECT ANSWERS •1st~ Pick it Up •2nd~ Set it down •3rd~ Walk to it Ventilator: High Pressure Alarm - CORRECT ANSWERS -caused via blockage Ventilator High Pressure Alarm: Causes - CORRECT ANSWERS -water condensation in the tube -mucus secretions in the airway -Kinks in tubing
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Ventilator High Pressure Alarm: Nursing Interventions - CORRECT ANSWERS -mucus secretions= TCDB + PRN Suctioning -water condensation= Empty it -Kinks= Unkink it Wernicke - CORRECT ANSWERS -Encephalopathy Korsakoffs - CORRECT ANSWERS -psychosis that lose touch w/reality Vitamin B1 - CORRECT ANSWERS -thiamine Chest Tube: Pneumothorax - CORRECT ANSWERS -done to remove air -location= apical -Draining blood or NO Bubbling = Bad! Wernicke-Korsakoff Syndrome: Psychosis - CORRECT ANSWERS -induced by Vitamin B deficiency -lose touch w/reality Drug Trough - CORRECT ANSWERS -drug at the lowest Drug Trough: Procedure - CORRECT ANSWERS -draw 30min before next dose Chest Tube: Hemothorax - CORRECT ANSWERS -done to remove blood -location= Basilar -NO drained blood or bubbling!= Bad Confabulation - CORRECT ANSWERS -making up stories
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-Diarrhea Acidosis: Nursing Considerations - CORRECT ANSWERS -Kussmal Respirations= Metabolic Acidosis: Nursing Education - CORRECT ANSWERS -PCA Pump= Respiratory Acidosis Acidosis: Nursing Intervention - CORRECT ANSWERS -want Ambu bag @ the bedside Abuse: Dependency - CORRECT ANSWERS -abuser gets the significant other to do things for them -Abuser= Dependent Chest Tube: Pneumohemothorax - CORRECT ANSWERS -want 2 tubes: •Apical= pneumo •Hemo= basilar Wernicke-Korsakoff Syndrome - CORRECT ANSWERS 1)Psychosis 2)Amnesia w/Confabulation Wernicke-Korsakoff Syndrome: Nursing Care - CORRECT ANSWERS -70% of cases are irreversible Wernicke-Korsakoff Syndrome: Nursing Intervention - CORRECT ANSWERS -take vitamin B Chest Tube: Knocked Over - CORRECT ANSWERS -Set back up & instruct pt to take deep breaths -Non Emergency!
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Droplet Precautions - CORRECT ANSWERS -infections travel 3 feet on large particles via coughing/sneezing Droplet Precautions: H Flu - CORRECT ANSWERS -Never stick anything down throat -can cause epiglottis Droplet Precautions: Diseases - CORRECT ANSWERS -Meningitis or H Flu Droplet Precaution: Nursing Education - CORRECT ANSWERS -Dedicated Supples + Disposable Equipment -pt wears masks when out of the room Droplet Precaution: Nursing Care - CORRECT ANSWERS -Private Room Preferred -Gloves or Mask -Hand Washing Chest Tube: Broken Water Seal - CORRECT ANSWERS •1st~ Clamp •2nd~ Cut tube away from broken device •3rd~ Stick open end into sterile water •4th~ Unclamp Psychotic Patient - CORRECT ANSWERS -Has no insight & isn't reality based -think everyone else is the problem Psychotic S&S: Hallucinations - CORRECT ANSWERS -false fixed 5 senses experience Auditory Hallucinations - CORRECT ANSWERS -Most Common -hearing things that are not there
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-onset= 1hr -Peak= 2hr Chest Tube: Clamping Tubes - CORRECT ANSWERS -Never Clamp a tube for more than 15secs •w/out Doctors Order -Continuous= Higher Risk of Infections! -use rubber tipped double clamps Psychotic S&S: Delusions - CORRECT ANSWERS -no sensory component= all in their brain -false fixed idea or belief Paranoid Delusions - CORRECT ANSWERS -believe people are out to harm them Grandiose Delusions - CORRECT ANSWERS -believe they are superior NPH - CORRECT ANSWERS -intermediate acting cloudy Insulin NPH: Ranges - CORRECT ANSWERS -peak= 8 to 10hrs -duration= 12hrs -onset= 6hrs Somatic Delusions - CORRECT ANSWERS -are about a body part Delusion: Types - CORRECT ANSWERS -Grandiose -Paranoid -Somatic
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Hatial Hernia - CORRECT ANSWERS -regurgitation of acid into the esophagus -gastric contents move in wrong direction @ the correct rate Hatial Hernia: S&S - CORRECT ANSWERS -Heartburn + Indigestion= when you lie down after eating Hatial Hernia: Nursing Considerations - CORRECT ANSWERS -Goal= want stomach to empty faster Hatial Hernia: Nursing Interventions - CORRECT ANSWERS -⬆️Fluids + ⬆️Carbs -High Fowlers
- ⬇️Protein Psychotic S&S: Illusions - CORRECT ANSWERS -when the patient refers to something that exists in reality as something else Psychotic Patient: S&S - CORRECT ANSWERS -Hallucinations -Delusions -Illusions Psychotic Patient: Management - CORRECT ANSWERS -must determine which type of psychosis the patient has Calcemia - CORRECT ANSWERS -do the opposite of the prefix Hypercalcemia - CORRECT ANSWERS -Everything ⬇️ Trousseau Sign - CORRECT ANSWERS -put BP cuff on arm & it spams
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PVC: Nursing Intervention - CORRECT ANSWERS -Amiodarone -Lidocaine Ventilator: Low Pressure Alarm - CORRECT ANSWERS -causes via Disconnection Ventilator Low Pressure Alarm: Causes - CORRECT ANSWERS -Tubing Disconnection Ventilator Low Pressure Alarm: Nursing Interventions - CORRECT ANSWERS -Priority= Reconnect It -O2 Sensory Tubing on floor= bag them + call RT Aminoglycosides - CORRECT ANSWERS •end w/-mycin Aminoglycosides: MOA - CORRECT ANSWERS -treats serious life threatening gram negative bacteria Aminoglycosides: Bowel Sterilization - CORRECT ANSWERS -Neomycin or Kanamycin= PO Aminoglycosides: Admin - CORRECT ANSWERS -Bowel Sterilization= PO -Usually given IM or IV Aminoglycosides: PO - CORRECT ANSWERS -Hepatic Encephalopathy -Pre Op Bowel Surgery -E Coli Ototoxicity - CORRECT ANSWERS -mice ears
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Ototoxicity: Nursing Education - CORRECT ANSWERS -Tinnitus + Vertigo/ Dizziness=Monitor Hearing Nephrotoxicity: Nursing Education - CORRECT ANSWERS •1st~24hr Creatinine Clearance •2nd~ Serum Creatinine Aminoglycosides: Adverse Effects - CORRECT ANSWERS -Nephrotoxicity -Ototoxicity Drug Peak - CORRECT ANSWERS -drug at the lowest Drug Peak: Procedure - CORRECT ANSWERS -draw after drug admin Drug Peak: Drawing Routes - CORRECT ANSWERS -Sublingual= 5 to 10min -IM= 30 to 60min -IV= 15 to 30min Delirium Tremens - CORRECT ANSWERS -occurs @72hrs -doesn't always follow Alchol withdrawal syndrome Delirium Tremens: Diet - CORRECT ANSWERS -Clear Liquids -NPO Delirium Tremens: Room - CORRECT ANSWERS -Want Private room by the nurses station Delirium Tremens: Ambulation - CORRECT ANSWERS -Want Restricted bed rest Delirium Tremens: Restraints - CORRECT ANSWERS -use vest or 2 point locked leathers
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CHD Trouble: Shunting - CORRECT ANSWERS -Right to Left CHD Trouble: Cyanosis - CORRECT ANSWERS -cyanotic= Blue Congenital Heart Defects: All Kids - CORRECT ANSWERS -Echocardiogram= done to detect defect or murmur -Murmur= Shunting of blood 3 Types of Psychosis - CORRECT ANSWERS -Functional -Dementia -Delirium Functional Psychosis - CORRECT ANSWERS -Schizo Schizo Major Manic -Pt has potential to learn reality + function in everyday life Functional Psychosis: Nursing Teaching - CORRECT ANSWERS -want to teach reality Functional Psychosis: Nursing Intervention - CORRECT ANSWERS •1st~ Acknowledge Feelings •2nd~ Present Reality •3rd~ Set a Limit •4th~ Enforce the limit Lispro - CORRECT ANSWERS -called humalog -Fastest acting insulin -want to give w/meals Lispro: Ranges - CORRECT ANSWERS -duration= 3hrs
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-onset= 15mins -peak= 30mins Hypocalcemia - CORRECT ANSWERS -Trousseau + Chovsteks -Everything ⬆️ Dementia Psychosis - CORRECT ANSWERS -psychosis due to actual damage in the brain -can't learn reality Dementia Psychosis: Nursing Considerations - CORRECT ANSWERS -Don't set limits or present reality Dementia Psychosis: Nursing Interventions - CORRECT ANSWERS •1st~ Acknowledge feelings •2nd~ Redirect from something they can't do to something they can do Asystole - CORRECT ANSWERS -no cardiac output or brain perfusion -Can kill w/in 8 mins= High Priority! Asystole: Pharm - CORRECT ANSWERS •1st~ Epinephrine •2nd~ Atropine Downers - CORRECT ANSWERS -⬇️Vitals + ⬇️Consciousness Lithium: Range - CORRECT ANSWERS -0.6 to 1. Lithium: Indication - CORRECT ANSWERS -used to treat bipolar mania Lithium: Nursing Considerations - CORRECT ANSWERS -Toxic= 2 or more
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Phenytoin - CORRECT ANSWERS -Dilantin -used to treat seizures Phenytoin: Nursing Considerations - CORRECT ANSWERS -Range= 10 to 20 -Toxic= over 20 Diabetes Type 2: Diet - CORRECT ANSWERS -Calorie Restriction= Best! •1200 to 1500 calories -want 6 small meals Diabetes Type 2: Treatment - CORRECT ANSWERS -Oral Hypoglycemic -Diet= Priority! -Activity Lantus - CORRECT ANSWERS -called glargine Lantus: Ranges - CORRECT ANSWERS -Duration= 12 to 24hrs -No Peak! Lantus: Teach Proper Storage - CORRECT ANSWERS -unopened vials refrigerated@ the hospital -refrigerate @ home Lantus: Expiration Date - CORRECT ANSWERS -want to write down date w/new expiration -have 30 days from opening -Teach Proper Storage Lantus: Nursing Considerations - CORRECT ANSWERS -opening the bottle invalidates the manufacturers expiration date
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-only insulin you can safely + routinely give @ bedtime V-Tach - CORRECT ANSWERS -Potentially life threatening -Does have cardiac output V-Tach: Pharm - CORRECT ANSWERS -Amiodarone -Lidocaine Overdose - CORRECT ANSWERS -Upper + Downer= ⬆️Vitals + ⬆️Consciousness Overdose Downer: Priority - CORRECT ANSWERS -Respiratory Depression Overdose Upper: Priority - CORRECT ANSWERS -Seizure= Suction Diabetes: Exercise - CORRECT ANSWERS -⬆️exercise= ⬇️Insulin Needed -does the same thing as insulin Diabetes: Sick Day Rules - CORRECT ANSWERS -⬆️water intake= Prevent Dehydration -take insulin even if you're not eating -Stay Active Diabetes: Sick Days - CORRECT ANSWERS -when your sick your glucose ⬆️ -remember sick day rules! Digoxin - CORRECT ANSWERS -Lanoxin -used to treat A.Fib + CHF Digoxin: Nursing Considerations - CORRECT ANSWERS -Hold if apical pulse= less then 60
