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138 Cards in this Set
- Front
- Back
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What are emergency situations for CHF/Pulmonary edema?
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Give o2, diuretics, Sit up-right
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Why is a patient made NPO before an invasive procedure?
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To prevent aspiration and help prevent nausea and vomiting
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CBI (Continuous Bladder Irrigation) Interventions?
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Monitor color and amount (light red to pink), check for kinks in tubing often
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What are Maslows Hierarchy of needs?
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Physiologic, Safety and security, Love and belongingness, Esteem, Self-actualization
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What is the use of NTG (Nitroglycerin)?
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Used for Angina Pectoris, which reduces pain and severity of angina attacks
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What are the side effects of NTG?
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Prolonged headache, hypotension
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What are the signs and symptoms of parkinsons disease?
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Tremors, shuffling gait, loss of postural reflexes, change in speach patterns, pill rolling
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What are Nephrostomy tube interventions?
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Meticulous skin care, assess for hemorrhage, accurate I&O
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What are the signs and symptoms of hyperglycemia?
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Dry mucous membranes, fruity breath, polydipsia, polyuria
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What are the signs and symptoms of hypoglycemia?
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T=tachycardia
I=Irritability R=Restlessness E=excessive hunger D=Diapharesis, dehydration |
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What are the signs and symptoms of appendicitis?
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vomiting, low-grade fever, elevated white blood cell count, right lower quadrant pain, decreased or abscent bowel sounds
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What are some interventions for appendicitis?
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bed rest, NPO, comfort measures for pain relief, monitor VS, fluid/electrolyte replacement, NO HEAT APPLIED
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Maintenance care for CHF patients?
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Daily weights, diuretics, frequent rest periods, o2, sodium restricted diets, fluid restriction
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What are the signs and symptoms of increased intracranial pressure?
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Changes in LOC, headache, pupillary changes, pupil edema, doll's eyes, decreased sensory/motor function, changes in VS (I Bp, D pulse, D RR), vomiting
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What are the interventions for Increased intracranial pressure?
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Elevate head of bed to 30 to 45 degrees to promote venous return, restrict fluid intake, o2 via mask
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What are the Signs and symptoms of Cataracts?
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blurred vision, diplopia, photo sensitivity, glare, dif. driving at night
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What are the post-op cataract surgery instructions?
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Antibiotic and corticosteriod drops, avoid bending, stooping, coughing, wear an eye patch at night
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What are COPD interventions?
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Low flow o2 (1-2 L), bronchodilators, albuterol, atrovert, increased protein and calorie intake, frequent small meals
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What are some interventions to prevent, treat pressure ulcers?
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turn and position every 2 hours, frequent skin assessment, topical barriers, special mattresses
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What are the signs and symptoms of Right sided CVA?
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Paralyzed left side, left sided neglect, short attention span, safety problems, impaired judgement
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What are signs and symptoms of Left sided CVA?
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Paralyzed right side, impaired speech/language, slow performance, cautious, depression
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Why do we check for bowel sounds?
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To listen or check for problems with the bowels. Listen for 1 minute in 4 quadrants
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What are some indications that there are no bowel sounds present?
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No bowel movement or gargling with in 1 min.
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How should Prednisone be taken?
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tablets, solution
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What is the minimal amount of urine output per hour?
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30 mL
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What is the minimal amount of urine output per day?
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1000-2000 mL per day
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What are analgesics used for?
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Used to relieve pain without causing loss of consciousness or reflex activity
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What are antipyretics used for?
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used to reduce a fever
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What are post-pneumonectomy interventions/assessment?
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place patient in comfortable sitting position, cough/deep breathe, explain important of changing positions, admin. o2 prn, assess incision, prevent infection, assess lung sounds, pain meds, monitor VS
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What are some cast care/handling instructions?
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Do not put anything under the cast, support cast with pillows, inspect skin for erythema or skin impairment, report complaints of pain under cast, perform neurovascular checks
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What are some risks of having a cast?
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infection, irritation, neurovascular pressure, edema, compartment syndrome, DVT
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What are some reasons for an amputation?
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Crushing injury, trauma, disease. (blood flow cannot be restored to affected area)
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What are some types of amputations?
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Above the knee, below the knee
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What are some interventions for amputations?
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observe for signs of hemorrhage or bleeding, monitor and document drainage, neurovascular checks, prevent contractures, educate pt. about phantom limb sensation
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What are some post-op complications of amputations?
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phantom limb pain, infection, feelings of loss and anger
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What are the signs and symptoms of shock?
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tachycardia, restlessness, apprehension, cold moist skin, cyanosis
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What is the treatment for Shock?
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Admin. o2, raise pts. legs above the level of the heart, increase rate of IV fluids
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What does ABC stand for?
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Airway, breathing, circulation
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What is the cause of hyperparathyroidism?
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increased PTH d/t tumor, chronic renal failure
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What are the signs and symptoms of hyperparathyroidism?
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increased blood calcium levels, weight loss, bone pain, lethargy
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What are some interventions for hyperparathyroidism?
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Surgical removal, diuretics, strain urine for stones
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What is the cause of hypoparathyroidism?
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Decreased blood calcium d/t low PTH levels d/t accidental removal during thryoidectomy
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What are the signs and symptoms of hypoparathyroidism?
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Decreased blood calcium levels, muscle spasms, tetany, kidney stones
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What are some interventions for hypoparathyroidsim?
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Respiratory assessment, increase calcium intake, teach s&s of hypocalcemia
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What is the cause of cushings disease?
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Excessive corticosteriods caused by adrenal hyperplasia/tumor of adrenal cortex. Also can be caused by prolonged steriod use
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What are the signs and symptoms of cushings disease?
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weight gain, moon face, buffalo hump, thin arms and legs d/t muscle wasting, low potassium levels, back problems, mood swings, depression
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What are some interventions for cushings disease?
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adrenalectomy, low salt diet, good skin care, support with ADL's
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What is the cause of addisons disease?
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d/t not enough corticoids. The most common cause is autoimmune response. Destruction of adrenal tissue
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What are the signs and symptoms of addisons disease?
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n/v/d, anorexia, weight loss, dry mucous membranes, hypoglycemia, dark pigmented areas on the skin
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What are some interventions for addisons disease?
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decrease potassium, increase sodium, watch for adrenal crisis
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What are some risks for a thyroidectomy?
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bleeding, vocal paralysis, hypoparathyroidism
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What are some pre-op interventions for a thryroidectomy?
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rest, keep room cool, teach deep breathing
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What are some post-op interventions for a thyroidectomy?
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HOB up (semi-fowlers), avoid hyperextension of neck, must have trach kit at bedside, airway assessment, make sure gag reflex returns
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What are some tests for Diabetes Mellitus?
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Fasting blood sugar (FBS), oral glucose tolerance test, serum insulin, glycosuria, C-PEPTIDE test, glycosylated hemoglobin, postparndial blood sugar (PPBS)
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What is Type 1 diabetes?
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Insulin dependent
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What are the signs and symptoms of type 1 diabetes?
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polyphasia, polyuria, polydipsia, dehydration, weight loss, fatigue, progressive destruction of beta cells
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What are some interventions for type 1 diabetes?
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insulin, diet, exercise, knowledge of disease process
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What are some complications of type 1 diabetes?
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risk for cardiovasuclar disease, infections, slow healing rate, renal failure, damaged blood vessels
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What are the signs and symptoms of type 2 diabetes?
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blurred vision, increased UTI's, hypertension, yeast infections, decrease healing rate
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What are some interventions for type 2 diabetes?
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diet, exercise, oral agents
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What are some meds for post-op bladder spasms??
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anticholinergic agents, neostigmine (prostigmine)
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What are some super pubic catheter care interventions and complications?
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Check for leaks and kinks, check for blood or exudate, assess for infection
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What are some interventions for constipation?
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increase fiber intake, increase fluid intake, ambulation
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What is a papsear?
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method of examining stained exfoliative peeling and sloughed off tissue or cells
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What is a pelvic exam?
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Visualization and palpation of the vulva, perineum, vagina, cervix, ovaries and uterine surfaces
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What are some risks for cervical cancer?
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Multiple sexual partners, multiple births, lower socioeconomic status, smoking, chronic infections
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What are the signs and symptoms of cervical cancer?
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luekorrhea, irregular vaginal bleeding or spotting between menstration periods, severe pain in the back, upper thighs and legs
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What are some interventions for cervical cancer?
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Verbal reassurance, position comfortably, maintain body alignment, provide pain relief measures, change dressing frequently, monitor skin
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What is SBE?
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This is a self breast exam. The entire breast should be examined systemically, clockwise, in a circular motion
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What is chemotherapy used for?
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to reduce or slow the growth of metastic cancer
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What are the complications of chemotherapy?
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destruction of normal cells, n/v/d, can result in other problems
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What are some interventions of musculoskeletal injuries?
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restricted activities, check for sensation, assess for edema
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What is involved in the assessment of a musculoskeletal injuries?
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patient description of injury and pain, signs of edema, limited function, ecchymosis of soft tissue around injury
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What is muscular atrophy?
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muscle wasting causing weakness from not being used
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What are the signs and symptoms of rheumatoid arthritis?
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joint stiffness that is worse in the morning, fatigue, anorexia, weight loss, fever. red, swollen, warm joints
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What is rheumatoid arthritis?
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inflammatory disease of connective tissue
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What is osteoarthritis?
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wear and tear disease from overuse or injury
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What are the signs and symptoms of osteoarthritis?
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stiffness and pain in joint, may become enlarged over time
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What is the treatment for rheumatoid arthritis?
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meds, heat and cold applications, rest and stress reduction, pain management
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What is the treatment of osteoarthritis?
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rest of joint, weight loss if overweight, meds to reduce pain and inflammation, joint replacement
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What are the signs and symptoms of salicylate toxicity?
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Tinnitus, impaired hearing, sweating, fever, lethargy, dizziness, mental confusion, N/V, can lead to respiratory depression and coma
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Compound or open fracture
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through the skin
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Simple or closed fracture
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not through the skin
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complete fracture
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broke all the way
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incomplete fracture
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hairline or crack in bone
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communuted fracture
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crushing break
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displaced fracture
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moved from origin
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spiral fracture
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twisted
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greenstick fracture
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break from a bend in the bone
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Pathological fracture
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unknown reason for the break
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compression fracture
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splinters from compression
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impacted fracture
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jammed
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What is ORIF?
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open-reduction with internal fixation. Surgical procedure allowing fracture alignment under direct visualization while using various internal fixation devices applied to the bone
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What is closed reduction of fractures?
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manual manipulations, moving bony fragments into position by applying traction and pressure to distal fragments
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What are the signs and symptoms of ulcerative colitis?
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rectal bleeding, abdominal cramping, lethargy, weight loss, abd. distention, fever, tachycardia
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What are some interventions for ulcerative colitis?
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antidiarrheals, antiinflammatores, diet therapy, stess control, surgery
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What are some complicaitons of ulcerative colitis?
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dehydration, abdominal pain
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What are the signs and symptoms of crohns disease?
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diarrhea, fatigue, abd. pain, weight loss, fever, anemia, dehydration, weakness, stress
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What are some interventions for chohns disease?
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drug therapy, antiinflammatory agents, corticosteriods, vit. b12 injections, immunosuppressants, surgery
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what are some complications of chrohns disease?
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electrolyte imbalance, sleeplessness d/t diarrhea
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What are the signs and symptoms of thrombophlebitis?
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pain, edema, positive homans signs, erythema, warmth and tenderness along the vein
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What are some interventions for thrombophlebitis?
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early mobilization, changing position, skin checks
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What is a complication of thrombophlebitis?
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Can cause a pulmonay embolus
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What is a colostomy?
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Part of the colon is removed or disconnected and the colon is brought through the abd. wall to form a stoma
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What types of colostomys are there?
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Sigmoid, transverse, descending
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What are some colostomy complications?
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infections
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What signs and symptoms indicate that bowels are working?
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Bowel sounds, bowel movements, gurgling in all four quadrants
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What is PUD?
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excess of gastric acid, decrease in natural ability of GI mucosa to protect itself from acid and pepsin
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What are the signs and symptoms of PUD?
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weight loss, burning left epigastric area, food leads to pain frequently
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What are some complications of cholecysteectomy?
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jaundice, hemorrhage, increased HR, increased Temp
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What are the post-op instructions for a cholecystectomy?
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care of the tube, follow up care, stones may reaccur
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What is the actual cause of ascites?
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the damaged live can't metabolize protein normally
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What is the appearance of ascites?
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veins in the upper part of the body distend
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What are the signs and symptoms of Cirrhosis?
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enlarged liver, pain in RUQ, dyspepsia, change in bowel habits, weight loss, ascites, jaundice
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What is the most common cause of Cirrhosis?
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alcohol consumption
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What are some complications of Cirrhosis?
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Portal hypertension, ascites, esophageal varices
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What is the treatment for Cirrhosis?
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eliminate ETOH and hepatic toxins, high protein/calorie diet, low fat/sodium diet, antiemetics, fluid restriction
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What are some organic brain disorders?
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Meningitis, Guillain-Barre Syndrome, Encephalitis, West nile
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What could indicate possible abuse in children?
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burns, falls, MVA, ingestion, frequent injuries explained as accidents, conflicting stories, fear of parents
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What are some of the focuses for a terminally ill patient?
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Pain management, palliative care, quality of life
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What is Pentobarbital (Drug)
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HIGH ALERT DRUG
(barbitone) depresses activity in the brain cells. It is used for insomnia, sedation, Pre-op, IICP, dental anesthetic (can be given PO, IM, IV |
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What are the stages of anxiety?
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Mild, Moderate, Severe
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What are the signs and symptoms of the mild stage of anxiety?
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increased vs, awareness of danger, able to think and make corrections, heightened awareness, motivated
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What are the signs and symptoms of the Moderate stage of anxiety?
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tense, decreased perception, alert to specific information only, HA, N/V/D, back pain
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What are the signs and symptoms of the Severe stage of anxiety?
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Feelings of impending danger, distorted perception, communication distored and dif. to understand, fatigue
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What is the use for Digitalis?
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treat mild to severe systolic heart failure where the patient does not respond to diuretics or beta blockers
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What are the side effects of Digitalis use?
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decreased pulse rate, casoconstriction
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What are the toxicity signs and symptoms of Digitalis overdoes?
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pulse defecit, bigeminy, loss of appetite, N/V/D, extreme fatigue, blurred vision
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What med is admin. during CPR to reverse acidosis?
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Sodium Bicarbonate
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What is the dif. between Angina and an MI?
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agina is spasmatic cramplike chest pain that resembles an MI, and an MI is an occlusion of a major artery
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What is the cause of anemia?
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delivery of insufficient amounts of o2 to tissues and cells
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What are the signs and symptoms of anemia?
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anorexia, cardiac dialation, disorientation, vertigo, dyspepsia, dyspnea, fatigue, HA, insomnia, pallar, shortness of breath, tachy
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What are some of the diagnostic tests used for cardiac d/o's?
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cardiac catheritization, angiography, ECG, EKG, thallium scanning
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What is pulse defecit?
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Difference between apical and radial pulse
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What is thrombocytopenia?
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an abnormal hematological condition in which the number of platelets is reduced to fewer than 150,000/mm3
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What are the signs and symptoms of thrombocytopenia?
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the s&s correlate with the platelet count (petechiae and ecchymoses on the skin)
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What are some complications of thrombocytopenia?
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if the level drops to less than 100,000/mm3 then the risk for bleeding becomes a factor
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What is the tx for thrombocytopenia?
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corticosteroid therapy and splenectomy
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