ATI comprehensive predictor 2 ALL ANSWERS 100% CORRECT SPRING FALL-2023/24 EDITION GUARANTEED GRADE A+

Do not delegate What you can EAT E-evaluate A-assess T-teach Addison's & Cushings Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, ...

Do not delegate What you can EAT E-evaluate A-assess T-teach Addison's & Cushings Addison's = down down down up down Cushings= up up up down up hypo/hypernatremia, hypo/hypertension, blood volume, hypo/hyperkalemia, hypo/hyperglycemia Better peripheral perfusion? EleVate Veins, DAngle Arteries APGAR Appearance (all pink, pink and blue, blue (pale) Pulse (>100, <100, absent) Grimace (cough, grimace, no response) Activity (flexed, flaccid, limp) Respirations (strong cry, weak cry, absent) Airborne precautions MTV or My chicken hez tb measles, chickenpox (varicella) Herpes zoster/shingles TB Airborne precautions protective equip private room, neg pressure with 6-12 air exchanges/hr mask & respirator N95 for TB Droplet precautions spiderman! sepsis, scarlet fever, streptococcal pharyngitis, parvovirus, pneumonia, pertussis, influenza, diptheria, epiglottitis, rubella, mumps, meningitis, mycoplasma or meningeal pneumonia, adeNovirus (Private room and mask) Contact precaution MRS WHISE protect visitors & caregivers when 3 ft of the pt. Multidrug-resistant organisms RSV, Shigella, Wound infections, Herpes simplex, Impetigo, Scabies, Enteric diseases caused by micro-organisms (C diff), Gloves and gowns worn by the caregivers and visitors Disposal of infectious dressing material into a single, nonporous bag without touching the outside of the bag PMGG= Private room/ share same illness, mask, gown and gloves Skin infection VCHIPS Varicella zoster Cutaneous diptheria Herpes simplez Impetigo Peduculosis Scabies Air or Pulmonary Embolism S/S chest pain, dyspnea, tachycardia, pale/cyanotic, sense of impending doom. (turn pt to LEFT side and LOWER the head of bed.) Woman in labor (un-reassuring FHR) (late decels, decreased variability, fetal bradycardia, etc) Turn pt on Left side, give O2, stop pitocin, Increase IV fluids! Tube feeding with decreased LOC Pt on Right side (promotes emptying of the stomach) Head of bed elevated (prevent aspiration) After lumbar puncture and oil based myelogram pt is flat SUPINE (prevent headache and leaking of CSF) Pt with heat stroke flat with legs elevated during Continuous Bladder Irrigation (CBI) catheter is taped to the thigh. leg must be kept straight. After Myringotomy position on the side of AFFECTED ear, allows drainage. After Cateract surgery pt sleep on UNAFFECTED side with a night shield for 1-4 weeks after Thyroidectomy low or semi-fowler's position, support head, neck and shoulders. Infant with Spina Bifida Prone so that sac does not rupture Buck's Traction (skin) elevate foot of bed for counter traction After total hip replacement don't sleep on side of surgery, don't flex hip more than 45-60 degress, don't elevate Head Of Bed more than 45 degrees. Maintain hip abduction by separating thighs with pillows. Prolapsed cord Knee to chest or Trendelenburg oxygen 8 to 10 L Cleft Lip position on back or in infant seat to prevent trauma to the suture line. while feeding hold in upright position. To prevent dumping syndrome (post operative ulcer/stomach surgeries) eat in reclining position. Lie down after meals for 20-30 min. also restrict fluids during meals, low CHO and fiber diet. small, frequent meals. AKA (above knee amputation) elevate for first 24 hours on pillow. position prone daily to maintain hip extension. BKA (below knee amputation) foot of bed elevated for first 24 hours. position prone to provide hip extension. detached retina area of detachment should be in the dependent position administration of enema pt should be left side lying (Sim's) with knee flexed. After supratentorial surgery (incision behind hairline on forhead) elevate HOB 30-40 degrees After infratentorial surgery (incision at the nape of neck) position pt flat and lateral on either side. During internal radiation on bed rest while implant in place Autonomic Dysreflexia/Hyperreflexia S/S pounding headache, profuse sweating, nasal congestion, chills, bradycardia, hypertension. Place client in sitting position (elevate HOB) FIRST! Shock bedrest with extremities elevated 20 degrees. knees straight, head slightly elevated (modified Trendelenberg) Head Injury elevate HOB 30 degrees to decrease ICP Peritoneal Dialysis (when outflow is inadequate) turn pt from side to side BEFORE checking for kinks in tubing Lumbar Puncture After the procedure, the pt should be supine for 4-12 hours as prescribed. Myesthenia Gravis worsens with exercise and improves with rest Myesthenia Gravis a positive reaction to Tensilon---will improve symptoms Cholinergic Crisis Caused by excessive medication ---stop giving Tensilon...will make it worse. Liver biopsy (prior) must have lab results for prothrombin time Myxedema/ hypothyroidism slowed physical and mental function, sensitivity to cold, dry skin and hair. Grave's Disease/ hyperthyroidism accelerated physical and mental function. Sensitivity to heat. Fine/soft hair. Thyroid storm increased temp, pulse and HTN Post-Thyroidectomy semi-fowler's. Prevent neck flexion/hyperextension. Trach at bedside Hypo-parathyroid CATS---Convulsions, Arrhythmias, Tetany, Spasms, Stridor. (decreased calcium) give high calcium, low phosphorus diet Hyper-parathyroid fatigue, muscle weakness, renal calculi, back and joint pain (increased calcium) give a low calcium high phosphorous diet Hypovolemia increased temp, rapid/weak pulse, increase respiration, hypotension, anxiety. Urine specific gravity >1.030 Hypervolemia bounding pulse, SOB, dyspnea, rales/crackles, peripheral edema, HTN, urine specific gravity <1.010. semi fowler's Diabetes insipidus (decreased ADH) excessive urine output and thirst, dehydration, weakness, administer Pitressin SIADH (increased ADH) change in LOC, decreased deep tendon reflexes, tachycardia. N/V HA administer Declomycin, diuretics hypokalemia muscle weakness, dysrhythmias, increase K (rasins bananas apricots, oranges, beans, potatoes, carrots, celery) Hyperkalemia MURDER Muscle weakness, Urine (olig, anuria) Resp depression, decreased cardiac contractility, ECG changes, reflexes Hyponatremia nausea, muscle cramps, increased ICP, muscular twitching, convulsions. give osmotic diuretics (Mannitol) and fluids Hypernatremia increased temp, weakness, disorientation, dilusions, hypotension, tachycardia. give hypotonic solution. Hypocalcemia CATS Convulsions, Arrythmias, Tetany, spasms and stridor Hypercalcemia muscle weakness, lack of coordination, abdominal pain, confusion, absent tendon reflexes, shallow respirations, emergency! Hypo Mg Tremors, tetany, seizures, dysthythmias, depression, confusion, dysphagia, (dig toxicity) Hyper Mg depresses the CNS. Hypotension, facial flushing, muscle weakness, absent deep tendon reflexes, shallow respirations. EMERGENCY Addison's Hypo Na, Hyper K, Hypoglycemia, dark pigmentation, decreased resistance to stress fx, alopecia, weight loss. GI stress. Cushings Hyper Na, Hypo K, hyperglycemia, prone to infection, muscle wasting, weakness, edema, HTN, hirsutism, moonface/buffalo hump Addesonian crisis N/V confusion, abdominal pain, extreme weakness, hypoglycemia, dehydration, decreased BP Pheochromocytoma hypersecretion of epi/norepi. persistent HTN, increased HR, hyperglycemia, diaphoresis, tremor, pounding HA; avoid stress, frequent bathing and rest breaks, avoid cold and stimulating foods (surgery to remove tumor) Tetrology of Fallot DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Autonomic Dysreflexia (potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) FHR patterns for OB Think VEAL CHOP! V-variable decels; C- cord compression caused E-early decels; H- head compression caused A-accels; O-okay, no problem L- late decels; P- placental insufficiency, can't fill what to check with pregnancy Never check the monitor or machine as a first action. Always assess the patient first. Ex.. listen to fetal heart tones with stethoscope. Position of the baby by fetal heart sounds Posterior --heard at sides Anterior---midline by unbilicus and side Breech- high up in the fundus near umbilicus Vertex- by the symphysis pubis. Ventilatory alarms HOLD High alarm--Obstruction due to secretions, kink, pt cough etc Low alarm--Disconnection, leak, etc ICP and Shock ICP- Increased BP, decreased pulse, decreased resp Shock--Decreased BP, increased pulse, increased resp Cor pumonae Right sided heart failure caused by left ventricular failure (edema, jugular vein distention) Heroin withdrawal neonate irritable, poor sucking brachial pulse pulse area on an infant lead poisoning test at 12 months of age Before starting IV antibiotics obtain cultures! pt with leukemia may have epistaxis due to low platelets when a pt comes in and is in active labor first action of nurse is to listen to fetal heart tones/rate for phobias use systematic desensitization NCLEX answer tips choose assessment first! (assess, collect, auscultate, monitor, palpate) only choose intervention in an emergency or stress situation. If the answer has an absolute, discard it. Give priority to the answers that deal with the patient's body, not machines, or equipment. ARDS and DIC are always secondary to another disease or trauma In an emergency patients with a greater chance to live are treated first Cardinal sign of ARDS hypoxemia Edema is located in the interstitial space, not the cardiovascular space (outside of the circulatory system) the best indicator of dehydration? weight---and skin turgor heat/cold hot for chronic pain; cold for accute pain (sprain etc) When pt is in distress....medication administration is rarely a good choice pneumonia fever and chills are usually present. For the elderly confusion is often present. before IV antibiotics? check allergies (esp. penicillin) make sure cultures and sensitivity has been done before first dose. COPD and O2 with COPD baroreceptors that detect CO2 level are destroyed, therefore, O2 must be low because high O2 concentration takes away the pt's stimulation to breathe. Prednisone toxicity Cushings (buffalo hump, moon face, high blood sugar, HTN) Neutropenic pts no fresh fruits or flowers Chest tubes are placed in the pleural space Preload/Afterload Preload affects the amount of blood going into Right ventricle. Afterload is the systemic resistance after leaving the heart. CABG Great Saphenous vein in leg is taken and turned inside out (because of valves inside) . Used for bypass surgery of the heart. Unstable Angina not relieved by nitro PVC's can turn into V fib. 1 tsp 5 mL 1 oz 30 mL 1 cup 8 oz 1 quart 2 pints 1 pint 2 cups 1 g (gram) 1000 mg 1 kg 2.2 lbs I lb 16 oz centigrade to Fahrenheit conversion F= C+40 multiply 5/9 and subtract 40 C=F+40 multiply 9/5 and subtract 40 Angiotenson II In the lungs...potent vasodialator, aldosterone attracts sodium. Iron toxicity reversal deferoxamine S3 sound normal in CHF. Not normal in MI After endoscopy check gag reflex TPN given in subclavian line pain with diverticulitis located in LLQ appendicitis pain located in RLQ Trousseau and Chvostek's signs observed in Hypocalcemia never give K+ in IV push DKA is rare in DM II (there is enough insulin to prevent fat breakdown) Glaucoma patients lose peripheral vision. Autonomic dysreflexia patients with spinal cord injuries are at risk for developing autonomic dyreflexia (T-7 or above) Spinal shock occurs immediately after injury multiple sclerosis myelin sheath destruction. disruptions in nerve impulse conduction Myasthenia gravis decrease in receptor sites for acetylcholine. weakness observed in muscles, eyes mastication and pharyngeal musles. watch for aspiration. Gullian -Barre syndrome ascending paralysis. watch for respiratory problems. TIA transient ischemic attack....mini stroke, no dead tissue. CVA cerebriovascular accident. brain tissue dies. Hodgkin's disease cancer of the lymph. very curable in early stages burns rule of Nines head and neck 9% each upper ext 9% each lower ext 9% front trunk 18% back trunk 18% genitalia 1% birth weight doubles by 6 months triples by 1 year if HR is <100 (children) Hold Dig early sign of cystic fibrosis meconium in ileus at birth Meningitis--check for Kernig's/ brudinski's signs wilm's tumor encapsulated above kidneys...causes flank pain hemophilia is x linked passed from mother to son when phenylaline increases brain problems occur buck's traction knee immobility russell traction femur or lower leg dunlap traction skeletal or skin bryant's traction children <3 y <35 lbs with femur fx eclampsia is a seizure perform amniocentesis before 20 weeks to check for cardiac and pulmonary abnormalities Rh mothers receive Rhogam to protect next baby anterior fontanelle closes by...posterior by.. 18 months, 6-8 weeks caput succedaneum diffuse edema of the fetal scalp that crosses the suture lines. reabsorbes within 1 to 3 days pathological jaundice occurs: physiological jaundice occurs: before 24 hours (lasts 7 days) after 24 hours placenta previa s/s placental abrution s/s there is no pain, but there is bleeding there is pain, but no bleeding (board like abd) bethamethasone (celestone) surfactant. premature babies milieu therapy taking care of pt and environmental therapy cognitive therapy counseling five interventions for psych patients safety setting limits establish trusting relationship meds least restrictive methods/environment SSRI's take about 3 weeks to work patients with hallucinations patients with delusions redirect them distract them Thorazine and Haldol can cause EPS Alzheimer's 60% of all dementias, chronic, progressive degenerative cognitive disorder. draw up regular and NHP? Air into NHP, air into Regular. Draw regular, then NHP Cranial nerves S=sensory M=motor B=both Oh (Olfactory I) Some Oh (Optic II ) Say Oh (Oculomotor III) Marry To (trochlear IV) Money Touch (trigeminal V) But And (Abducens VI ) My Feel (facial VII) Brother A (auditory VIII) Says Girl's (glossopharyngeal IX) Big Vagina (vagus X) Bras And (accessory XI) Matter Hymen (Hypoglossal XII) More Hypernatremia S (Skin flushed) A (agitation) L (low grade fever ) T (thirst) Developmental 2-3 months: turns head side to side 4-5 months: grasps, switch and roll 6-7 months: sit at 6 and waves bye bye 8-9 months: stands straight at 8 10-11 months: belly to butt 12-13 months: 12 and up, drink from a cup Hepatitis A Ends in a vowel, comes from the bowel Hepatitis b B= blood and body fluids (hep c is the same) Apgar measures HR RR Muscle tone, reflexes, skin color. Each 0-2 points. 8-10 ok, 0-3 resuscitate Glasgow coma scale eyes, verbal, motor Max- 15 pts, below 8= coma Addison's disease: Cushing's syndrome: "add" hormone have extra "cushion" of hormone Dumping syndrome increase fat and protein, small frequent meals, lie down after meal to decrease peristalsis. Wait 1 hr after meals to drink Disseminated herpes zoster localized herpes zoster Disseminated herpes=airborne precautions Localized herpes= contact precautions. A nurse with localized may take care of patients as long as pts are not immunosuppressed and the lesions must be covered! Isoniazid causes peripheral neuritis Weighted NI (naso intestinal tubes) Must float from stomach to intestine. Don't tape right away after placement. May leave coiled next to pt on HOB. Position pt on RIGHT to facilitate movement through pyloris Cushings ulcers r/t brain injury Cushing's triad r/t ICP (HTN, bradycardia, irritability, sleep, widening pulse pressure) Thyroid storm HOT (hyperthermia) Myxedema coma COLD (hypothermia) Glaucoma No atropine Non Dairy calcium Rhubarb sardines collard greens Koplick's spots prodomal stage of measles. Red spots with blue center, in the mouth--think kopLICK in the mouth INH can cause peripheral neuritis Take vitamin B6 to prevent. Hepatotoxic pancreatitis pts put them in fetal position, NPO, gut rest, Prepare anticubital site for PICC, they are probably going to get TPN/Lipids Murphy's sign Pain with palplation of gall bladder (seen with cholecystitis) Cullen's sign ecchymosis in umbilical area, seen with pancreatitis Turner's sign Flank--greyish blue. (turn around to see your flanks) Seen with pancreatitis McBurney's point Pain in RLQ with appendicitis LLQ Diverticulitis RLQ appendicitis watch for peritonitis Guthrie test Tests for PKU. Baby should have eaten protein first shilling test Test for pernicious anemia Peritoneal dialysis Its ok to have abd cramps, blood tinged outflow and leaking around site if the cath (tenkoff) was placed in the last 1-2 weeks. Cloudy outflow is never ok Hyper reflexes absent reflexes upper motor neuron issue (your reflexes are over the top) Lower motor neuron issue Latex allergies assess for allergies to bananas, apricots, cherries, grapes, kiwis, passion fruit, avocados, chestnuts, tomatoes and peaches Tensilon used in myesthenia gravis to confirm diagnosis ALS (amyotrophic lateral sclerosis) degeneration of motor neurons in both upper and lower motor neuron systems Transesophageal fistula esophagus doesn't fully develop. This is a surgical emergency (3 signs in newborn: choking, coughing, cyanosis) MMR is given SQ not IM codes for pt care Red- unstable, ie.. occluded airway, actively bleeding...see first Yellow--stable, can wait up to an hour for treatment Green--stable can wait even longer to be seen---walking wounded Black--unstable, probably will not make it, need comfort care DOA--dead on arrival Contraindication for Hep B vaccine anaphylactic reaction to baker's yeast what to ask before flu shot allergy to eggs what to ask before MMR allergy to eggs or neomycin when on nitroprusside monitor: cyanide. normal value should be 1. William's position semi Fowler's with knees flexed to reduce low back pain S/S of hip fx External rotation, shortening adduction Fat embolism blood tinged sputum r/t inflammations. Increase ESR, respiratory alkalosis. Hypocalcemia, increased serum lipids. complications of mechanical ventilation pneumothorax, ulcers Paget's disease tinnitus, bone pain, elnargement of bone, thick bones with allopurinol no vitamin C or warfarin! IVP requires bowel prep so bladder can be visualized acid ash diet cheese, corn, cranberries, plums, prunes, meat, poultry, pastry, bread alk ash diet milk, veggies, rhubarb, salmon orange tag in psych is emergent psych thyroid med side effects insomnia. body metabolism increases Tidal volume is 7-10 ml/kg COPD patients and O2 2LNC or less. They are chronic CO2 retainers expect sats to be 90% or less Kidney glucose threshold 180 Stranger anxiety is greatest at what age? 7-9 months..separation anxiety peaks in toddlerhood when drawing an ABG put in heparinized tube. Ice immediately, be sure there are no bubbles and label if pt was on O2 Munchausen syndrome vs munchausen by proxy Munchausen will self inflict injury or illness to fabricate symptoms of physical or mental illness to receive medical care or hospitalization. by proxy mother or other care taker fabricates illness in child multiple sclerosis motor s/s limb weakness, paralysis, slow speech. sensory s/s numbness, tingling, tinnitis cerebral s/s nystagmus, atazia, dysphagia, dysarthia hungtington's 50% genetic autosomal dominanat disorder.. s/s uncontrolled muscle movements of face, limbs and body. no cure WBC left shift pt with pyelo. neutrophils kick in to fight infections pancreatic enzymes are taken with each meal! infants IM site Vastus lateralis Toddler 18 months+ IM site Ventrogluteal IM site for children deltoid and gluteus maximus Thoracentesis: CONTINUED..