Kaplan – Flashcard
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diabetes insipidus
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dec production of ADH (vasopressin) from posterior pituitary; extreme polyuria, polydipsia, dehydration nurse: keep I&O, monitor urine specific gravity, wt, administer Pitressin
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hydrocephalus
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inc in accumulation of CSF, inc in ventricular pressure nurse: assess for inc ventricular size, inc ICP, irritability, postop: position on unoperated side, keep flat, assess infection
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metabolic alkalosis
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pH>7.45, bicarb>28 tetany, paresthesia, hyperreflexia from prolonged vomiting, nasogastric suctioning nurse: monitor ABG levels for inc pH levels
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paresthesia
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abnormal skin sensations (as tingling, tickling, itching or burning) usually associated with peripheral nerve damage
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migraine HA
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last 4-72 hrs, unilateral pulsating pain, associated with nausea, vomiting, diarrhea, sometimes prodromal aura (lights, tingling), tx: ergotamine tartate (Ergomar), NSAIDs, antiemetics
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CVA tx
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thrombolytic agents (t-PA) dissolve obstructive bld clots, decreasing stroke severity
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addison's disease
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occurs when the adrenal glands do not produce enough of the hormones cortisol or aldosterone, adrenal gland destroyed; chronic, worsening fatigue, muscle weakness, loss of appetite & wt loss; with dec in aldosterone, there is inc excretion of sodium so sodium intake should be inc during periods of stress; tx: corticosteroid replacement (cortisone or hydrocortisone)
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parkinson's
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slowly spreading tremor, muscular rigidity, and altered gait nurse: finger exercises e.g. typing, piano playing; ROM, ambulation, goose-stepping walk, walk with wider base
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Clostridium difficile
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Gram-positive bacterium that causes antibiotic-associated colitis; abx depress natural intestinal flora
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lumbar puncture
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insertion of needle into subarachnoid space to obtain specimen, relieve pressure, inject dye or medications
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hypernatremia
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serum sodium>145, elevated temp, weakness, delusions, hallucinations, thirsty, tachy causes: diarrhea
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priorities
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hierarchy of human needs, pt preference, anticipation of future problems, discover what needs are most important to patient (if does not interfere with high priorities)
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stages of crisis
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denial, inc tension/anxiety, disorganization (inability to function), attempt to escape problem, blame others, general reorganization
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osteomyelitis
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infection of bone caused by Staph, carried by bld from primary site of infection (URI, otitis media, tonsillitis)
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cirrhosis
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chronic, progressive liver disease, most often due to alcoholism
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Rinne test
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compares bone conduction with air conduction; vibrating tuning fork place on mastoid process, when client no longer hears sound, position in front of ear canal; normal: should still be able to hear sound; air conduction > bone conduction by 2:1
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generativity vs. stagnation
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stage of development is appropriate for 45-64 years of age
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apraxia
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loss of purposeful movement in the absence of sensory or motor impairment, affects ability to perform ADLs
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perseveration
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the tendency to repeat a response inappropriately; often a result of deficits in executive control caused by prefrontal lesions
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Weber test
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stem of vibrating tuning fork is held in the middle of the forehead & the client's hearing is assessed in both ears
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VDRL
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veneral disease research laboratory (test for syphilis), tx: take penicillin
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conversion reaction
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a mental disorder characterized by the conversion of mental conflict into somatic forms (into paralysis or anesthesia having no apparent cause)
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sublimation
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diversion of unacceptable drives into socially acceptable channels
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cholecystitis
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right upper abdominal pain
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cortisol
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converts proteins and fats into glucuse, secreted by the adrenal cortex; it aids the body during stress by increasing glucose levels to provide energy, anti-inflammatory agent, also called hydrocortisone
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causes of constipation
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reduced GI motility due to dec. muscle tone and dec. exercise, prolonged use of laxatives, SE of meds, ignoring urge, emot'l problems, insufficient fluid intake, excessive dietary fat
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addisonian crisis
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acute adrenocortical insufficiency; characterized by acute hypotension, cyanosis, fever, classic signs of shock, N & V; precipitated by stress or abrupt withdrawal of therapeutic glucocorticoids
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extrapyramidal side effects
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akathisia (motor restlessness), dystonias (protrusion of tongue, abnormal posturing), pseudoparkinsonism (tremors, rigidity) & dyskinesia (stiff neck, difficulty swallowing)
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milk
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tx of lead poisoning
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nephrotic syndrome
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group of symptoms that occur due to loss of protein in the urine; sx: edema, hypoalbuminemia (loss of protein from the blood), heavy proteinuria & infection; also known as nephrosis
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hypoparathyroidism
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tetany, muscular irritability, carpopedal spasms, dysphagia, paresthesia & laryngeal spasms; encourage high calcium & low phosphorus diet because parathyroid controls calcium balance nurse: plan measures to deal with cardiac dysrhythmias r/t low serum calcium
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hemophilia
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rare hereditary X-linked recessive disorder causing a deficiency in specific blood clotting factor, almost exclusively affects males who get it from mother, prolonged bleeding, labs show decreased Factor VIII or IX and activated partial thromboplastin time, do NOT give aspirin
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ataxia
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inability to coordinate muscle activity during voluntary movements, resulting in shaky/tremor-like movements
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delusions of reference
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false belief that public events or people are directly related to the individual
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intravenous pyelogram (IVP)
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examines urinary tract by x-ray, evaluates kidney function; ask about allergies to iodine, give cleansing enemas night before to provide adequate visualization, NPO after midnight
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LPN
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assist with implementation of plans of care, perform procedures according to protocol, differentiate normal from abnormal, care for physiologically stable pts with predictable conditions, has knowledge of asepsis and dressing changes, ability to administer medications varies with ed. background and state nurse practice act
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RN cannot delegate
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pts who require assessment, teaching, or nursing judgement
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normative-reeducative strategies
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give information but pay attention to attitudes, values, skills, and relationships
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power-coercive strategies
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use of power to cause change, have less powerful people conform to plans and directives of the more powerful or when employees strike and exert their own power to coerce change
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duty to disclose
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obligation of HCPs to report certain acts, injuries, or practices to HCPs or authorities if there is a direct threat to social good (child abuse, elder abuse, etc.)
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failure to warn
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legal duty to warn others that they are at risk of injury to protect third-party victims of injury from potential harm
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carbon monoxide poisoning
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monitor for altered mental status, dec BP, depressed ST segment on EKG, coma, pale- to reddish-purple skin, convulsions, and death
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nonmaleficence
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a duty to not inflict harm
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Guillain-Barre syndrome
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autoimmune disease in which nerves don't transmit signals; trauma, surgery, acute illness, or immunizations often precede onset of neuro symptoms, onset is abrupt & can progress rapidly in ascending direction, put in ICU for resp muscle weakness; classic sx: resp failure & flaccidity due to paralysis of muscles & urinary retention due to loss of sensation
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early signs of inc ICP
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high-pitched cry in infants, confusion, restlessness, pupillary changes, altered LOC do not administer morphine: masks the signs nurse: assess for cough reflux & ability to swallow before administering oral fluids, elevate HOB to promote venous drainage
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glomerulonephritis
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type of kidney disease caused by inflammation of the glomeruli that causes RBCs & proteins to leak into the urine; occurs about 10 days after a skin or throat infection of Streptococcus; fever, chills, hematuria, dyspnea, wt gain, edema nurse: abx, corticosteroids, antihypertensives, immunosuppressive agents, restrict sodium intake, restrict water if oliguric, wts, I & O, bed rest, hi cal lo protein diet
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myringotomy
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incision in tympanic membrane to insert tympanostomy tubes due to recurrent & chronic otitis media; no diving, jumping, or submerging in water without earplugs, keep bath water and shampoo out of ear, inform parents that tubes will eventually fall out, notify practitioner when this occurs
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cataracts
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opacity of eye lens: blurred vision, annoying glare, pupils changing from black to gray to milky white; causes include age, trauma, use of corticosteroids, phenothiazines, or miotic agents & is related to some diseases; aging is most common cause
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stapedectomy
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removal of otosclerotic lesions & the creation of a tissue implant with a prosthesis to maintain adequate conduction; hearing may be impaired temporarily postop due to edema & packing
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meningitis
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mastoiditis can spread to the brain and cause chills, fever, N & V, and a sore neck
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Meniere's disease
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tinnitus, unilateral sensorineural hearing loss & vertigo occur; due to overproduction or dec. reabsorption of endolymphatic fluid
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detached retina
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the part of the eye that perceives light and transmits images to optic nerve separates from choroid causing flashes of light, blurred or "sooty" vision, sensation of particles moving in line of vision, delineated areas of vision, feeling of curtain coming up or down, painless loss of portion of vision, photophobia (sensitivity to light)
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glaucoma
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inc. intraocular pressure leading to visual disability and blindness: blurred vision, headache, rainbow around lights, dec. peripheral vision
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hemolytic reaction
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most dangerous type of transfusion reaction: N & V, chills, headache, backache, dyspnea, hematuria nurse: stop blood, obtain urine specimen, maintain blood volume & renal perfusion
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late AIDS dementia complex
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65% of these patients have progressive dementia; late stage is cognitive confusion & disorientation
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positive Trousseau's sign
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indicative of neuromuscular hyperreflexia associated with hypocalcemia
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hypercalcemia
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constipation, depressed reflexes, decreased muscle strength
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Graves' disease
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autoimmune disease in which thyroid is overactive; inc metabolic rate causes wt loss even with inc appetite, heat intolerance & pt will be restless & have hyperactive reflexes
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pancreatic enzyme replacement
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pancreatin & pancrelipase helps digestion of starches, fats & protein
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total hip replacement
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keep hips abducted, don't cross legs, don't bend at the waist, HOB not elevated more than 45 degrees
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trendelenburg position
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patient's HOB is lower than foot of bed: facilitates venous return, used during postural drainage
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osteoporosis
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brittle bones that fracture easily; calcitonin causes calcium to be stored in the bone, parathyroid hormone causes release of calcium into the bloodstream
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phenylketonuria (PKU)
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a genetic disorder of metabolism; lack of the enzyme needed to turn phenylalanine into tyrosine results in an accumulation of phenylalanine in the body fluids which causes various degrees of mental deficiency; dietary restriction
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Mantoux test
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10 mm induration is positive reaction; if immunocompromised, > 5 mm indicates exposure to TB or presence of inactive (dormant) disease
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diverticulitis
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inflamed intestinal diverticula: LLQ abd pain that inc with coughing, lifting, straining, and bending
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full liquid diet
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includes all clear liquids & smooth textured dairy products, (yogurt, ice cream), milk & milk products (pudding, custards), all vegetable juices, all fruit juices, pureed vegetables, refined or strained cereals, eggs in custard, butter, margarine & cream
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bone scan
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must lie still for about an hour, interval btwn injection of tracer IV and scanning is 1-3 hrs; large amounts of fluid maintain hydration & dec radiation dose to bladder; void before scan to prevent distended bladder
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fluid volume deficit
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inc pulse rate with thready quality, inc rate & depth of respirations, dec BP, fever; daily weight is best way to evaluate for
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heat stroke
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105 degrees F or above; skin is hot & dry; behavior is bizarre, confused, delirious, or comatose
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gastric ulcer
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45 yrs & older, pain 1 h after meal or when fasting, food doesn't help with pain, pain relieved by vomiting, hematemesis
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MRI contraindication
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metal implanted objects; assess pt for claustrophobia; remove all metal jewelry & metal objects
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candidiasis
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soft, bland, nonacidic & cool liquids & foods will help eating process be more comfortable; spicy foods, hot liquids & citrus fluids cause mucosal irritation
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epiglottitis
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tx includes moist air & IV abx to dec epiglottal swelling; pulse ox; never insert tongue blade
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Hashimoto's disease
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autoimmune disease in which thyroid is underactive; body is run down, slow: fatigue, cold intolerance, wt gain, constipation, neck fullness, goiter
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myasthenia gravis
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a chronic progressive disease characterized by chronic fatigue and muscular weakness esp in the face and neck
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cerebellum
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maintains balance
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cystic fibrosis (CF)
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inherited condition of exocrine gland malfunction causing secretion of abnormally thick, viscous (sticky) mucus that obstructs passageways within the body, commonly affecting the lungs & GI tract; impaired intestinal absorption necessitates a hi-protein, hi-cal diet throughout the day; salt depletion during sweating, salty snacks recommended; both parents carry recessive trait
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minor head injury
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dizziness, nausea, headache for at least 24 hrs; if worsening: vomiting, blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache
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signs of hyperglycemia
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acetone odor to breath, lethargy, hot dry flushed skin, rapid deep respirations (Kussmaul), headache, nervousness, glucosuria, polyuria, polydipsia, polyphagia, tachycardia, anorexia, N & V
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signs of hypoglycemia
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confusion, cold clammy skin, irritability, headache, nervousness, weakness, hunger, slurred speech, tachycardia & diaphoresis
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turn, cough, deep breathe
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promotes ventilation, maintains good gas exchange, removed CO2 to prevent respiratory acidosis
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duodenal ulcer
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clients who experience psychological pressures, pain usually occurs 2-4 hrs after meals midmorning & midafternoon, melena (black, tarry feces), relieved by food or antacids
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early hypovolemic shock
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body responds by adrenergic stimulation: vasoconstriction compensates for loss of fluids: cool, clammy skin, tachycardia, tachypnea, pale
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dexamethasone suppression test
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test that determines presence of major depression
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drug toxicology screen
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screen test to see if client's symptoms are caused by excessive use of meds or alcohol
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myelogram
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lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal; identifies tumors, cysts, herniated vertebral discs
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reaction formation
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a defense mechanism in which a person unconsciously develops attitudes & behavior that are the opposite of unacceptable repressed desires & impulses & serve to conceal them; unconsciously expressing feelings opposite of true feelings
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Cushing's syndrome
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hypersecretion of adrenal hormones; respirations are 1st priority; clients are prone to fluid overload & CHF due to sodium & water retention; other indications include wt gain, buffalo hump, moon face, purple striae, osteoporosis, mood swings, high susceptibility to infections, hyperglycemia, hypernatremia
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manic phase of bipolar disorder
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gain control with a physically aggressive client in this phase; will need sedative meds & mood-stabilizing agents
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dementia
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unable to learn new skills; environment must be adapted for client with attention to safety & predictability
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cuffed tracheostomy tube
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seals trachea, helps to prevent aspiration
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hyperthermia
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inc the O2 requirements, which results in faster breathing as well as an inc in pulse rate: body's compensatory mechanism
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hiatal hernia
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classic sx: awakening at night with heartburn
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inguinal hernia
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bulge in lower right quadrant, pain at umbilicus radiating down to groin
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hypokalemia
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causes: vomiting, diarrhea, gastric suction, diuretics & steroids
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CVA
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assessment for this includes: ask to grasp hands, assessing muscle strength & client's consciousness, assess orientation to person place & time; assess pupillary response
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disseminated herpes zoster
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requires airborne & droplet precautions
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Z track method
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a variation of standard IM technique for administering meds that are highly irritating to subq & skin tissues
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Kaposi's sarcoma
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small painless purplish-brown spots on legs; use mild soap
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cocaine withdrawal
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severe cravings, depression, fatigue, hypersomnia
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physically assaultive client
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prority is to maintain milieu safety by restoring client's self-control
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dawn phenomena
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early morning hyperglycemia nurse: adjust evening diet, bedtime snack, insulin dose & exercise
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crave for sweets & carbs
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abusers of marijuana, hashish, and/or THC
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systemic lupus (SLE)
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increased maternal morbidity & mortality, should be in remission for at least 5 months prior to conceiving
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strabismus
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visual axes are not parallel, so brain receives two images; pt closes one eye to see
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intermittent peritoneal dialysis (IPD)
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moderate pain is frequently experienced as fluid is instilled (warm the bag) & blood tinged fluid is common during first few exchanges; there is peritonitis if if dialysate is cloudy, N & V, anorexia, abd pain, tenderness, rigidity
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post gastrectomy
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client should recline for 30 min after eating, fluids should be given btwn meals, intake of carbs & spicy foods should be reduced (prevents dumping syndrome)
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high residue diet
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prevents constipation
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renal transplant pts
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restricted visiting for at least 72 hrs postop
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myxedema
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slowing of all body functions
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Ewald tube
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large, orogastric tube designed for rapid lavage; insertion often causes gagging & vomiting; suction equipment must be immediately available to reduce the risk of aspiration
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penrose drain
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thin walled, collapsible latex tubes; prevents fluid from collecting and forming an abcess; remove dressing one layer at a time
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gout
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deposition of urate crystals in joints, leading to painful arthritis; encourage partial wt bearing while ambulating, immobility aggravates pain, low-purine diet: avoid red & organ meats, shellfish, oily fish with bones
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tuberculosis (TB)
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necessary to take meds for 6-9 mo's
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T-tube
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tube placed in the bile duct for drainage into a small pouch (bile bag) on the outside of the body; bile drainage expected, change dressing to keep wound clean & dry
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dissociative disorder
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sudden or gradual disruption in integrative functions of identity, memory, or consciousness
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multiple sclerosis
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progressive damage to nerves in the brain & spinal cord; causes weakness and problems with sensation and vision
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phlebitis
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characterized by inflammation & reddened areas around site & up length of vein
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continuous ambulatory peritoneal dialysis (CAPD)
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daily wt necessary with peritoneum empty to assess fluid volume status; strict aseptic technique required; drainage by gravity; eat high-protein diet
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fixed & dilated pupil
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neurological emergency, contact physician
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rheumatoid arthritis
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chronic autoimmune disease affecting connective tissue, especially in joints, causing pain, swelling & deformity nurse: assist with heat application & ROM exercises to reduce swelling, inc circulation & diminish stiffness while preserving joint mobility
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total laryngectomy
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esophageal speech: swallows air & eructates it while forming words with mouth
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CSF otorrhea
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indicates rupture of meninges & presents potential complication of meningitis
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burn wound sepsis
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inc resp rate & dec BP; life-threatening complication of thermal injury
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aphasia
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impairment of language, usually caused by left hemisphere damage either to Broca's area (impairing speaking) or to wernicke's area (impairing understanding)
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elderly diet
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inc protein intake to slow down degeneration process of aging
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Buck's traction
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common orthopedic mechanism by which pull is exerted on lower extremity with system of ropes, wts & pulleys; relieves muscular spasm of legs and back (may or may not be a fx); no fx: turn to either side; fx: turn to unaffected side (immobility causes complications); 8-20 lb normal, 40 lb scoliosis; don't elevate knee gatch, use trapeze to move, don't place pillow under heels (elevate food of bed = counter-traction)
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Glasgow coma scale
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used for head trauma: score 3-15, based on eye opening, verbal response & motor response
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droplet precautions
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hands should be washed before removing mask to prevent transfer of microbes to face, gown not necessary, pathogens spread primarily by coughing, sneezing, talking, suctioning & procedures such as bronchoscopy; pt should be in a private room; wear protective mask when within 3 feet of patient; only leave room when necessary, for transport, the patient should wear mask; keep door closed to prevent pathogens from being carried out of room
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anemia
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fatigue, pallor, exertional dyspnea (because of tissue hypoxia as a result of dec RBCs)
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liver biopsy
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position client supine with arms raised above head: elevates ribs to allow access to liver, needle is inserted btwn two of the lower ribs or below the rt rib cage; position on rt side with small pillow under puncture site for 3 hrs after procedure
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flaccid bladder
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prune juice, cranberry juice, tomato juice & bouillon promote acidic urine, minimize risk of UTI & stone formation
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parathyroidectomy
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low-calcium diet is recommended preop
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chronic renal failure
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peripheral edema; tx: fluid & sodium restrictions
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sensorineural hearing loss
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hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves
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conductive hearing loss
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hearing loss caused by interference with sound transmission in the external auditory canal, middle ear, or ossicles
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akathisia
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motor restlessness such as fidgeting, rocking, or pacing due to the neuromuscular or neurologic adverse effects associated with the use of antipsychotics
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dystonia
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involuntary muscular movements (spasms) of the face, arms, legs & neck; may occur as an extrapyramidal SE of some antipsychotic medications
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pseudoparkinsonism
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drug-induced parkinsonism: stiff, stooped posture, mask-like face, dec arm swing, shuffling gait, cogwheel rigidity, drooling, tremor, bradycardia & coarse pill-rolling movements of the thumb & fingers while at rest
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dyskinesia
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difficult movement m/b stiff neck or difficulty swallowing; the distortion or impairment of voluntary movement such as in a tic or spasm
