ATI comprehensive

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1.

Do not
delegate

What you can EAT E-evaluate A-assess T-teach

2.

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

3.

Better
peripheral
perfusion?

EleVate Veins, DAngle Arteries

4.

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)

11.

Woman in
labor (unreassuring FHR)

(late decels, decreased variability, fetal

bradycardia, etc) Turn pt on Left side, give
O2, stop pitocin, Increase IV fluids!

12.

Tube feeding
with decreased
LOC

Pt on Right side (promotes emptying of the

stomach) Head of bed elevated (prevent
aspiration)

13.

After lumbar
puncture and
oil based
myelogram

pt is flat SUPINE (prevent headache and

leaking of CSF)

14.

Pt with heat
stroke

flat with legs elevated

15.

during
Continuous
Bladder
Irrigation (CBI)

catheter is taped to the thigh. leg must be

kept straight.

5.

Airborne
precautions

My chicken hez tb (measles, chickenpox

(varicella) Herpes zoster/shingles TB

16.

After
Myringotomy

position on the side of AFFECTED ear, allows

drainage.

6.

Airborne
precautions
protective
equip

private room, neg pressure with 6-12 air

exchanges/hr mask N95 for TB

17.

After Cateract
surgery

pt sleep on UNAFFECTED side with a night

shield for 1-4 weeks

18.

Droplet
precautions

spiderman! sepsis, scarlet fever, streptococcal

pharyngitis, parvovirus, pneumonia,
pertussis,
influenza,
diptheria,
epiglottitis,
rubella,
mumps, meningitis, mycoplasma or
meningeal pneumonia, adeNovirus (Private
room or cohort mask!)

after
Thyroidectomy

low or semi-fowler's position, support head,

neck and shoulders.

19.

Infant with
Spina Bifida

Prone so that sac does not rupture

20.

Buck's Traction
(skin)

elevate foot of bed for counter traction

21.

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.

22.

Prolapsed cord

Knee to chest or Trendelenburg

23.

Cleft Lip

position on back or in infant seat to prevent

trauma to the suture line. while feeding
hold in upright position.

24.

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.

25.

AKA (above
knee
amputation)

elevate for first 24 hours on pillow. position

prone daily to maintain hip extension.

26.

BKA (below
knee
amputation)

foot of bed elevated for first 24 hours.

position prone to provide hip extension.

27.

detached
retina

area of detachment should be in the

dependent position

7.

8.

9.

10.

Contact
precaution

Skin
infection

Air or
Pulmonary
Embolism

MRS WEE
Multidrug resistant organism
Rresiratory infection
Skin infection
Wound infection
Enteric infection (C diff)
Eye infection (conjunctivitis)
VCHIPS
Varicella zoster
Cutaneous diptheria
Herpes simplez
Impetigo
Peduculosis
Scabies
S/S chest pain, dyspnea, tachycardia,
pale/cyanotic, sense of impending doom.
(turn pt to LEFT side and LOWER the head of
bed.)

28.

administration of enema

pt should be left side lying (Sim's)

with knee flexed.

29.

After supratentorial
surgery

30.

31.

32.

33.

46.

Hyperparathyroid

(incision behind hairline on

forhead) elevate HOB 30-40
degrees

fatigue, muscle weakness, renal calculi, back

and joint pain (increased calcium) give a low
calcium high phosphorous diet

47.

Hypovolemia

After infratentorial
surgery

(incision at the nape of neck)

position pt flat and lateral on
either side.

increased temp, rapid/weak pulse, increase

respiration, hypotension, anxiety. Urine
specific gravity >1.030

48.

Hypervolemia

During internal radiation

on bed rest while implant in

place

bounding pulse, SOB, dyspnea,

rales/crackles, peripheral edema, HTN,
urine specific gravity <1.010. semi fowler's

49.

Diabetes
insipidus
(decreased
ADH)

excessive urine output and thirst,

dehydration, weakness, administer Pitressin

50.

SIADH
(increased
ADH)

change in LOC, decreased deep tendon

reflexes, tachycardia. N/V HA administer
Declomycin, diuretics

51.

hypokalemia

muscle weakness, dysrhythmias, increase K

(rasins bananas apricots, oranges, beans,
potatoes, carrots, celery)

52.

Hyperkalemia

MURDER Muscle weakness, Urine (olig,

anuria) Resp depression, decreased cardiac
contractility, ECG changes, reflexes

Autonomic
Dysreflexia/Hyperreflexia

Shock

S/S pounding headache, profuse

sweating, nasal congestion, chills,
bradycardia, hypertension. Place
client in sitting position (elevate
HOB) FIRST!
bedrest with extremities elevated
20 degrees. knees straight, head
slightly elevated (modified
Trendelenberg)

34.

Head Injury

elevate HOB 30 degrees to

decrease ICP

35.

Peritoneal Dialysis (when

outflow is inadequate)

turn pt from side to side BEFORE

checking for kinks in tubing

53.

Hyponatremia

Lumbar Puncture

After the procedure, the pt

should be supine for 4-12 hours
as prescribed.

nausea, muscle cramps, increased ICP,

muscular twitching, convulsions. give
osmotic diuretics (Mannitol) and fluids

54.

Hypernatremia

increased temp, weakness, disorientation,

dilusions, hypotension, tachycardia. give
hypotonic solution.

36.

37.

Myesthenia Gravis

worsens with exercise and

improves with rest

38.

Myesthenia Gravis

a positive reaction to Tensilon--will improve symptoms

55.

Hypocalcemia

CATS Convulsions, Arrythmias, Tetany,

spasms and stridor

39.

Cholinergic Crisis

Caused by excessive medication --stop giving Tensilon...will make it

worse.

56.

Hypercalcemia

muscle weakness, lack of coordination,

abdominal pain, confusion, absent tendon
reflexes, shallow respirations, emergency!

40.

Liver biopsy (prior)

must have lab results for

prothrombin time

57.

Hypo Mg

41.

Myxedema/
hypothyroidism

slowed physical and mental

function, sensitivity to cold, dry
skin and hair.

Tremors, tetany, seizures, dysthythmias,

depression, confusion, dysphagia, (dig
toxicity)

58.

Hyper Mg

Grave's Disease/
hyperthyroidism

accelerated physical and mental

function. Sensitivity to heat.
Fine/soft hair.

depresses the CNS. Hypotension, facial

flushing, muscle weakness, absent deep
tendon reflexes, shallow respirations.
EMERGENCY

59.

Addison's

43.

Thyroid storm

increased temp, pulse and HTN

Hypo Na, Hyper K, Hypoglycemia, dark

pigmentation, decreased resistance to stress
fx, alopecia, weight loss. GI stress.

44.

Post-Thyroidectomy

semi-fowler's. Prevent neck

flexion/hyperextension. Trach at
bedside

60.

Cushings

Hyper Na, Hypo K, hyperglycemia, prone to

infection, muscle wasting, weakness, edema,
HTN, hirsutism, moonface/buffalo hump

45.

Hypo-parathyroid

CATS---Convulsions,
Arrhythmias, Tetany, Spasms,
Stridor. (decreased calcium) give
high calcium, low phosphorus
diet

61.

Addesonian
crisis

N/V confusion, abdominal pain, extreme

weakness, hypoglycemia, dehydration,
decreased BP

42.

62.

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)

63.

Tetrology of Fallot

DROP (Defect, septal, Right

ventricular hypertrophy, Overriding
aortas, Pulmonary stenosis)

64.

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)

65.

66.

67.

68.

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

69.

ICP and Shock

ICP- Increased BP, decreased pulse,

decreased resp
Shock--Decreased BP, increased
pulse, increased resp

70.

Cor pumonae

Right sided heart failure caused by

left ventricular failure (edema, jugular
vein distention)

75.

pt with leukemia may

have

epistaxis due to low platelets

76.

when a pt comes in
and is in active labor

first action of nurse is to listen to fetal

heart tones/rate

77.

for phobias

use systematic desensitization

78.

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.

79.

ARDS and DIC

are always secondary to another

disease or trauma

80.

In an emergency

patients with a greater chance to live

are treated first

81.

Cardinal sign of ARDS

hypoxemia

82.

Edema is located

in the interstitial space, not the

cardiovascular space (outside of the
circulatory system)

83.

the best indicator of

dehydration?

weight---and skin turgor

84.

heat/cold

hot for chronic pain; cold for accute

pain (sprain etc)

85.

When pt is in
distress....medication
administration

is rarely a good choice

86.

pneumonia

fever and chills are usually present.

For the elderly confusion is often
present.

87.

before IV antibiotics?

check allergies (esp. penicillin) make

sure cultures and sensitivity has
been done before first dose.

88.

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.

89.

Prednisone toxicity

Cushings (buffalo hump, moon face,

high blood sugar, HTN)

90.

Neutropenic pts

no fresh fruits or flowers

71.

Heroin withdrawal
neonate

irritable, poor sucking

91.

Chest tubes are

placed

in the pleural space

72.

brachial pulse

pulse area on an infant

92.

Preload/Afterload

73.

lead poisoning

test at 12 months of age

74.

Before starting IV
antibiotics

obtain cultures!

Preload affects the amount of blood

going into Right ventricle. Afterload is
the systemic resistance after leaving
the heart.

93.

CABG

Great Saphenous vein in leg is taken and

turned inside out (because of valves inside)
. Used for bypass surgery of the heart.

119.

Myasthenia
gravis

decrease in receptor sites for acetylcholine.

weakness observed in muscles, eyes
mastication and pharyngeal musles. watch
for aspiration.

94.

Unstable
Angina

not relieved by nitro

120.

Gullian -Barre
syndrome

ascending paralysis. watch for respiratory

problems.

95.

PVC's

can turn into V fib.

96.

1 tsp

5 mL

121.

TIA

transient ischemic attack....mini stroke, no

dead tissue.

97.

1 oz

30 mL

98.

1 cup

8 oz

122.

CVA

cerebriovascular accident. brain tissue dies.

99.

1 quart

2 pints

123.

Hodgkin's
disease

cancer of the lymph. very curable in early

stages

100.

1 pint

2 cups

124.

burns rule of
Nines

head and neck 9%

each upper ext 9%
each lower ext 9%
front trunk 18%
back trunk 18%
genitalia 1%

101.

1 g (gram)

1000 mg

102.

1 kg

2.2 lbs

103.

I lb

16 oz

104.

centigrade to
Fahrenheit
conversion

F= C+40 multiply 5/9 and subtract 40

C=F+40 multiply 9/5 and subtract 40

125.

birth weight

doubles by 6 months
triples by 1 year

105.

Angiotenson II

In the lungs...potent vasodialator,

aldosterone attracts sodium.

126.

if HR is <100
(children)

Hold Dig

106.

Iron toxicity
reversal

deferoxamine

127.

early sign of
cystic fibrosis

meconium in ileus at birth

107.

S3 sound

normal in CHF. Not normal in MI

128.

Kernig's/ brudinski's signs

After
endoscopy

check gag reflex

Meningitis-check for

108.

129.

wilm's tumor

109.

TPN given in

subclavian line

encapsulated above kidneys...causes flank

pain

110.

pain with
diverticulitis

located in LLQ

130.

hemophilia is
x linked

passed from mother to son

111.

appendicitis
pain

located in RLQ

131.

brain problems occur

112.

Trousseau and
Chvostek's
signs observed
in

Hypocalcemia

when
phenylaline
increases

132.

buck's
traction

knee immobility

133.

femur or lower leg

never give K+
in

IV push

russell
traction

134.

skeletal or skin

DKA is rare

in DM II (there is enough insulin to prevent

fat breakdown)

dunlap
traction

135.

bryant's
traction

children <3 y <35 lbs with femur fx

136.

eclampsia is

a seizure

137.

perform
amniocentesis

before 20 weeks to check for cardiac and

pulmonary abnormalities

138.

Rh mothers
receive
Rhogam

to protect next baby

113.

114.

Glaucoma
patients lose

peripheral vision.

116.

Autonomic
dysreflexia

patients with spinal cord injuries are at risk

for developing autonomic dyreflexia (T-7 or
above)

117.

Spinal shock
occurs

immediately after injury

118.

multiple
sclerosis

myelin sheath destruction. disruptions in

nerve impulse conduction

115.

139.

anterior fontanelle
closes
by...posterior by..

18 months, 6-8 weeks

153.

Hypernatremia

140.

caput
succedaneum

diffuse edema of the fetal scalp that

crosses the suture lines. reabsorbes
within 1 to 3 days

S (Skin flushed)
A (agitation)
L (low grade fever )
T (thirst)

154.

Developmental

141.

pathological
jaundice occurs:
physiological
jaundice occurs:

before 24 hours (lasts 7 days)

after 24 hours

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

142.

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)

155.

Hepatitis A

Ends in a vowel, comes from the bowel

156.

Hepatitis b

B= blood and body fluids (hep c is the

same)

143.

bethamethasone
(celestone)

surfactant. premature babies

157.

Apgar
measures

HR RR Muscle tone, reflexes, skin color.

Each 0-2 points. 8-10 ok, 0-3 resuscitate

144.

milieu therapy

taking care of pt and environmental

therapy

158.

Glasgow coma
scale

eyes, verbal, motor

Max- 15 pts, below 8= coma

145.

cognitive therapy

counseling

159.

146.

five interventions
for psych patients

safety
setting limits
establish trusting relationship
meds
least restrictive methods/environment

Addison's
disease:
Cushing's
syndrome:

"add" hormone
have extra "cushion" of hormone

160.

Dumping
syndrome

increase fat and protein, small frequent

meals, lie down after meal to decrease
peristalsis. Wait 1 hr after meals to drink

161.

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!

162.

Isoniazid

causes peripheral neuritis

163.

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

164.

Cushings ulcers

r/t brain injury

165.

Cushing's triad

r/t ICP (HTN, bradycardia, irritability, sleep,

widening pulse pressure)

166.

Thyroid storm

HOT (hyperthermia)

167.

Myxedema
coma

COLD (hypothermia)

168.

Glaucoma

No atropine

169.

Non Dairy
calcium

Rhubarb sardines collard greens

170.

Koplick's spots

prodomal stage of measles. Red spots with

blue center, in the mouth--think kopLICK
in the mouth

147.

SSRI's

take about 3 weeks to work

148.

patients with
hallucinations
patients with
delusions

redirect them
distract them

149.

Thorazine and
Haldol

can cause EPS

150.

Alzheimer's

60% of all dementias, chronic,

progressive degenerative cognitive
disorder.

151.

draw up regular
and NHP?

Air into NHP, air into Regular. Draw

regular, then NHP

152.

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

171.

INH can cause

peripheral
neuritis

Take vitamin B6 to prevent. Hepatotoxic

172.

pancreatitis pts

put them in fetal position, NPO, gut rest,

Prepare anticubital site for PICC, they
are probably going to get TPN/Lipids

190.

what to ask
before flu shot

allergy to eggs

191.

what to ask
before MMR

allergy to eggs or neomycin

192.

when on
nitroprusside
monitor:

cyanide. normal value should be 1.

173.

Murphy's sign

Pain with palplation of gall bladder (seen

with cholecystitis)

193.

174.

Cullen's sign

ecchymosis in umbilical area, seen with

pancreatitis

William's
position

semi Fowler's with knees flexed to reduce

low back pain

194.

S/S of hip fx

External rotation, shortening adduction

175.

Turner's sign

Flank--greyish blue. (turn around to see

your flanks) Seen with pancreatitis

195.

Fat embolism

176.

McBurney's point

Pain in RLQ with appendicitis

blood tinged sputum r/t inflammations.

Increase ESR, respiratory alkalosis.
Hypocalcemia, increased serum lipids.

177.

LLQ

Diverticulitis

196.

pneumothorax, ulcers

178.

RLQ

appendicitis watch for peritonitis

179.

Guthrie test

Tests for PKU. Baby should have eaten

protein first

complications
of mechanical
ventilation

197.

Paget's disease

180.

shilling test

Test for pernicious anemia

tinnitus, bone pain, elnargement of bone,

thick bones

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

198.

with
allopurinol

no vitamin C or warfarin!

181.

199.

IVP requires

bowel prep so bladder can be visualized

200.

acid ash diet

cheese, corn, cranberries, plums, prunes,

meat, poultry, pastry, bread

182.

183.

Hyper reflexes
absent reflexes

upper motor neuron issue (your

reflexes are over the top)
Lower motor neuron issue

201.

alk ash diet

milk, veggies, rhubarb, salmon

202.

assess for allergies to bananas, apricots,

cherries, grapes, kiwis, passion fruit,
avocados, chestnuts, tomatoes and
peaches

orange tag in
psych

is emergent psych

Latex allergies

203.

thyroid med
side effects

insomnia. body metabolism increases

204.

Tidal volume
is

7-10 ml/kg

205.

COPD patients
and O2

2LNC or less. They are chronic CO2

retainers expect sats to be 90% or less

206.

Kidney
glucose
threshold

180

207.

Stranger
anxiety is
greatest at
what age?

7-9 months..separation anxiety peaks in

toddlerhood

208.

when drawing
an ABG

put in heparinized tube. Ice immediately,

be sure there are no bubbles and label if pt
was on O2

209.

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

184.

Tensilon

used in myesthenia gravis to confirm

diagnosis

185.

ALS

(amyotrophic lateral sclerosis)

degeneration of motor neurons in both
upper and lower motor neuron systems

186.

Transesophageal
fistula

esophagus doesn't fully develop. This is

a surgical emergency (3 signs in
newborn: choking, coughing, cyanosis)

187.

MMR

is given SQ not IM

188.

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

189.

Contraindication
for Hep B vaccine

anaphylactic reaction to baker's yeast

210.

multiple
sclerosis

motor s/s limb weakness, paralysis, slow

speech. sensory s/s numbness, tingling,
tinnitis cerebral s/s nystagmus, atazia,
dysphagia, dysarthia

211.

hungtington's

50% genetic autosomal dominanat

disorder.. s/s uncontrolled muscle
movements of face, limbs and body. no cure

212.

WBC left shift

pt with pyelo. neutrophils kick in to fight

infections

213.

pancreatic
enzymes are
taken

with each meal!

214.

infants IM site

Vastus lateralis

215.

Toddler 18
months+ IM
site

Ventrogluteal

216.

IM site for
children

deltoid and gluteus maximus

217.

Thoracentesis:

position pt on side or over bed table. no

more than 1000 cc removed at a time. Listen
for bilateral breath sounds, V.S, check
leakage, sterile dressing

218.

219.

220.

221.

222.

Cardiac cath

Cerebral angio
prep
lumbar
puncture
ECG

Myelogram

NPO 8-12 hours. empty bladder, pulses, tell

pt may feel heat, palpitations or desire to
cough with injection of dye. Post: V.S.--keep
leg straight. bedrest for 6-8 hr
well hydrated, lie flat, site shaved, pulses
marked. Post--keep flat for 12-14 hr. check
site, pulses, force fluids.
fetal position. post-neuro assess q15-30
until stable. flat 2-3 hour. encourage fluids,
oral analgesics for headache.
no sleep the night before, meals allowed, no
stimulants/tranquilizers for 24-48 hours
before. may be asked to hyperventilate 3-4
min and watch a bright flashing light. watch
for seizures after the procedure.
NPO for 4-6 hours. allergy hx
phenothiazines, cns depressants and
stimulants withheld 48 hours prior. Table
moved to various positions during test. Post-neuro assessment q2-4 hours, water
soluble HOB UP. oil soluble HOB down.
oralanalgesics for HA. No po fluids. assess
for distended bladder. Inspect site

223.

Liver biopsy

administer Vitamin K, NPO morning of

exam 6 hrs. Give sedative. Teach pt to
expect to be asked to hold breath for 510 sec. supide position, lateral with
upper arms elevated. Post--position on
RIGHT side. frequent VS. report severe
ab pain STAT. no heavy lifting 1 wk

224.

Paracentesis

semi fowler's or upright on edge of bed.

Empty bladder. post VS--report elevated
temp. watch for hypovolemia

225.

laparoscopy

CO2 used to enhance visual. general

anesthesia. foley. post--ambulate to
decrease CO2 buildup

226.

PTB

low grade afternoon fever

227.

pneumonia

rusty sputum

228.

asthma

wheezing on expiration

229.

emphysema

barrel chest

230.

kawasaki
syndrome

strawberry tongue

231.

pernicious
anemia

red beefy tongue

232.

downs syndrome

protruding tongue

233.

cholera

rice watery stool

234.

malaria

stepladder like fever--with chills

235.

typhoid

rose spots on the abdomen

236.

diptheria

pseudo membrane formation

237.

measles

koplick's spots

238.

sle (systemic
lupus)

butterfly rash

239.

pyloric stenosis

olive like mass

240.

Addison's

bronze like skin pigmentation

241.

Cushing's

moon face, buffalo hump

242.

hyperthyroidism/
grave's disease

exophthalmos

243.

myasthenia gravis

descending musle weakness

244.

gullian-barre
syndrome

ascending muscle weakness

245.

angina

crushing, stabbing chest pain relieved

by nitro

246.

MI

crushing stabbing chest pain

unrelieved by nitro

247.

cystic fibrosis

salty skin

248.

DM

polyuria, polydipsia,polyphagia

249.

DKA

kussmal's breathing (deep rapid)

250.

Bladder CA

painless hematuria

251.

BPH

reduced size and force of urine

270.

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!)

252.

retinal detachment

floaters and flashes of light. curtain

vision

253.

glaucoma

painful vision loss. tunnel vision. halo

254.

retino blastoma

cat's eye reflex

271.

255.

increased ICP

hypertension, bradypnea,,
bradycarday (cushing's triad)

for neutropenic
pts

no fresh flowers, fresh fruits or veggies

and no milk

272.

antiplatelet
drug
hypersensitivity

bronchospasm

273.

bowel
obstruction

more important to maintain fluid balance

than to establish a normal bowel pattern
(they cant take in oral fluids)

274.

Basophils
reliease
histamine

during an allergic response

275.

Iatragenic

means it was caused by treatment,

procedure or medication

276.

Tamoxifen

watch for visual changes--indicates toxicity

277.

post
spelectomy

pneumovax 23 is administered to prevent

pneumococcal sepsis

256.

shock

Hypotension, tachypnea,
tachycardia

257.

Lymes disease

bullseye rash

258.

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.

259.

260.

261.

262.

263.

sickle cell crisis

two interventions to prioritize: fluids

and pain relief.

glomuloneprhitis

the most important assessment is

blood pressure

278.

ALKalosis=al K= low sis. Acidosis (K+ high)

children 5 and up

should have an explanation of what

will happen a week before surgery

Alkalosis/
Acidosis and K+

279.

Kawasaki disease

(inflammation of blood vessles,

hence the strawberry tongue)
causes coronary artery aneurysms.

No
phenylalanine

to a kid with PKU. No meat, dairy or

aspartame

280.

never give
potassium

to a pt who has low urine output!

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

281.

nephrotic
syndrome

characterized by massive proteinuria

caused by glomerular damage.
corticosteroids are the mainstay

282.

the first sign of

ARDS

increased respirations! followed by

dyspnea and tachypnea

283.

normal PCWC
(pulmonary
capillary wedge
pressure)

is 8-13 readings 18-20 are considered high

284.

first sign of PE

sudden chest pain followed by dyspnea

and tachypnea

285.

Digitalis

increases ventricular irritability ----could

convert a rhythm to v-fib following
cardioversion

286.

Cold stress and

the newborn

biggest concern resp. distress

287.

Parathyroid
relies on

vitamin D to work

288.

Glucagon
increases the
effects of?

anticoagulants

264.

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

265.

MMR and varicella

immunizaions

after 15 months!

266.

cryptorchidism

undescended testicles! risk factor for

testicular cancer later in life. Teach
self exam for boys around age 12-most cases occur in adolescence

267.

CSF meningitis

HIGH protein LOW glucose

268.

Head injury or skull

fx

no nasotracheal suctioning

269.

otitis media

feed upright to avoid otitis media!

289.

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!

290.

chest tube pulled out?

occlusive dressing

291.

PE

Needs O2!

292.

DKA

acetone and keytones increase! once treated expect postassium to drop! have K+ ready

293.

Hirschprung's

diagnosed with rectal biopsy. S/S infant-failure to pass meconium and later the classic ribbon-like/foul
smelling stools

294.

Intussusception

Common in kids with CF. Obstruction may cause fecal emesis, current jelly stools. enema---resolution=bowel
movements

295.

laboring mom's water

breaks?

first thing--worry about prolapsed cord!

296.

Toddlers need to
express

independence!

297.

Addison's

causes sever hypotension!

298.

pancreatitis

first pain relief, second cough and deep breathe

299.

CF chief concern?

Respiratory problems

300.

a nurse makes a
mistake?

take it to him/her first then take up the chain

301.

nitrazine paper

turns blue with alkaline amniotic fluid. turns pink with other fluids

302.

up stairs with
crutches?

crutches first followed by good leg

303.

dumping syndrome?

use low fowler's to avoid. limit fluids

304.

TB drugs are

hepatotoxic!